Propensity Score-matched Cohort Of Patients Research Articles

β-Blocker Use and Delayed Onset and Progression of Huntington Disease

Huntington disease (HD) is characterized by motor, cognitive, and psychiatric decline. β-Blockers may play a therapeutic role by decreasing enhanced sympathetic tone in HD. To evaluate the impact of β-blockers on the timing of motor diagnosis onset and progression of HD symptoms. This observational, longitudinal multicenter study used the Enroll-HD platform database (initiated September 2011 to present), including propensity score-matched cohorts of patients with premanifest HD (preHD) and early motor-manifest HD (mmHD) who were either users or nonusers of β-blockers. Participants included patients with genetically confirmed preHD (n = 4683 eligible participants) or mmHD (n = 3024 eligible participants) who were taking a β-blocker and were matched to similar non-β-blocker users. Uninterrupted use of a β-blocker for more than 1 year. For PreHD: risk of receiving a motor diagnosis of HD over time. For mmHD: progression rate of total motor score, total functional capacity score, and the symbol digit modalities test. Post hoc analyses were performed to test additional clarifying hypotheses after the primary analyses were completed. This study included 174 preHD β-blocker users (59 males; 115 females) with a mean age of 46.4 (SD, 13.1) years and a mean cytosine-adenine guanine repeat length of 41.1 (SD, 2.4) who were well matched to 174 preHD non-β-blocker users. The preHD β-blocker users showed a statistically significant reduction in the annualized hazard of receiving a motor diagnosis compared with nonusers (n = 174) (hazard ratio, 0.66; 95% CI, 0.46-0.94; P = .02). There were 149 mmHD β-blocker users (86 males; 60 females) with a mean age of 58.9 (SD, 11.3) years and a mean cytosine-adenine guanine repeat length of 42.0 (SD, 2.3) matched to 149 mmHD non-β-blocker users. The β-blocker users had a slower mean annualized worsening in total motor score (mean difference [MD], -0.45; 95% CI, -0.85 to -0.06; q = 0.025), total functional capacity score (MD, 0.10; 95% CI, 0.02-0.18; q = 0.025), and symbol digit modalities test (MD, 0.33; 95% CI, 0.10-0.56; q = 0.017) compared with matched nonusers. In this study, β-blocker use was associated with delayed motor onset in preHD and reduced the rate of worsening of symptoms in mmHD. These findings demonstrated that β-blockers may have a therapeutic role in HD but further studies are required.

GLP-1 receptor agonists and pancreatic cancer risk: target trial emulation using real-world data.

Data on the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on pancreatic cancer incidence are limited and inconsistent. Here we evaluate the association of GLP-1RAs, alone and in combinations, with incident pancreatic cancer risk in a real-world population, stratified by obesity and smoking status. This retrospective cohort included patients with T2DM who were prescribed GLP-1RAs or other non-GLP-1RA anti-diabetes medications between January 2013 and March 2019 and had no prior diagnosis of pancreatic cancer. The incident (first-time) diagnosis of pancreatic cancer during a 5-year follow-up was compared between propensity-score matched cohorts of patients prescribed GLP-1RAs vs other non-GLP-1RA anti-diabetes medications. Subgroup analyses were performed in patients stratified by the status of obesity and tobacco use disorder. We also compared GLP-1RA combination therapies with monotherapies. Time-to-first-event analysis was performed using Cox proportional hazards and Kaplan-Meier survival analysis, with the hazard ratio (HR) and 95% confidence interval (CI) calculated. The study population comprised 1,636,056 eligible patients including 167,091 prescribed GLP-1RAs and 1,468,965 prescribed other anti-diabetes medications. GLP-1RAs were associated with a significantly decreased risk for pancreatic cancer incidence compared with each of six non-GLP-1RA anti-diabetes medications with HR ranging from 0.42 to 0.82. The reduction was greater in patients with obesity and tobacco use disorder than in those without. GLP-1RA combination therapies were associated with lower pancreatic cancer risk compared with monotherapies. GLP-1RAs were associated with reduced pancreatic cancer incidence in patients with T2DM. Further studies and trials are needed to explore mechanisms and confirm causal effects.

ARE COGNITIVELY IMPAIRED PATIENTS SUITABLE CANDIDATES FOR HIP ARTHROPLASTY? A PROPENSITY SCORE-MATCHED COHORT STUDY

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results.This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols.We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences.Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups.Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either.To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols.

Economic burden of recurrent hyperkalemia in patients with chronic kidney disease.

Hyperkalemia is a common complication of chronic kidney disease (CKD) and can become recurrent in half of cases. However, the incremental economic burden associated with recurrent hyperkalemia is unknown. To evaluate all-cause health care resource utilization (HRU) and medical costs in patients with stage 3/4 CKD with recurrent hyperkalemia vs normokalaemia and vs nonrecurrent hyperkalemia. Data were from Optum's de-identified Market Clarity Data (January 1, 2016, to August 1, 2022). This retrospective observational cohort study compared patients with stage 3/4 CKD with recurrent hyperkalemia (≥2 hyperkalemia events within 1 year [hyperkalemia event: hyperkalemia diagnosis or potassium [K+]>5 mmol/l]; index was the first hyperkalemia event) with an exact- and propensity score-matched cohort of patients with normokalemia (K+ ≥3.5 to ≤5 mmol/l; random K+ as index) and separately with a matched cohort of patients with nonrecurrent hyperkalemia (1 hyperkalemia event within 1 year; index was hyperkalemia event). Patient characteristics, medication use, HRU, and medical costs were compared between cohorts using standardized mean differences during the 12-month baseline period. All-cause HRU and medical costs during the 12-month follow-up were compared using Wilcoxon rank sum tests for continuous variables and McNemar tests for categorical variables. Substudies of recurrent hyperkalemia vs normokalemia were conducted for patients with Medicare coverage and renin-angiotensin-aldosterone system inhibitor (RAASi) use. The recurrent hyperkalemia vs normokalemia sample comprised 4,549 matched pairs (Medicare substudy: 3,151; RAASi substudy: 3,535) and the recurrent hyperkalemia vs nonrecurrent hyperkalemia sample comprised 1,599 matched pairs. Baseline characteristics, HRU, and medical costs of the cohorts were similar after matching. During follow-up, patients with recurrent hyperkalemia had a mean of 11.2 more health care encounters (0.5 more inpatient admissions, 0.3 more emergency department visits, and 7.2 more outpatient visits) than patients with normokalemia. Patients with recurrent hyperkalemia also had double the total annual medical costs vs normokalemia ($34,163 vs $15,175; P < 0.001), mainly driven by inpatient costs ($21,250 vs $7,392), which accounted for 62.2% and 48.7% of total costs, respectively. Results were similar in the RAASi and Medicare substudies. Recurrent hyperkalemia was associated with a mean 4.3 more all-cause health care encounters and $14,057 higher medical costs (both P < 0.001) than nonrecurrent hyperkalemia. Recurrent hyperkalemia in patients with stage 3/4 CKD was associated with higher all-cause HRU and medical costs compared with normokalemia (including in patients with Medicare coverage and RAASi use) and nonrecurrent hyperkalemia. Research is needed to understand if long-term treatment strategies aimed at preventing hyperkalemia recurrence may alleviate this economic burden.

Impact of proton versus photon adjuvant radiotherapy on overall survival in the management of skull base and spinal chordomas: a National Cancer Database analysis.

Chordomas are rare tumors that originate from undifferentiated remnants of the notochord. Currently, there are no established guidelines regarding the choice of adjuvant radiation modality for patients surgically treated for chordomas. Using a nationwide, multicenter database, the authors aimed to compare long-term survival outcomes associated with the use of proton or photon adjuvant therapy for the management of chordomas of skull base and spine. The National Cancer Database (NCDB) was queried for chordoma cases from 2004 to 2017. Patient, tumor, and treatment characteristics were extracted from the database. The primary outcome was overall survival (OS). Kaplan-Meier survival analyses were conducted to investigate differences in outcome on propensity score-matched cohorts of patients treated with proton or photon adjuvant radiotherapy. Of the 3490 patients available, 424 met the inclusion criteria for this study. In the prematching analysis, patients receiving adjuvant photon therapy were significantly older (median age 57.0 vs 45.0 years, p < 0.001) and were more commonly male (61% vs 43%, p < 0.001) compared with those receiving proton therapy. Races were equally distributed among radiotherapy modalities (p = 0.64). Patients with chordomas of the mobile spine or sacrum were less likely to receive proton compared with photon therapy (37% vs 58%). Patients receiving proton therapy were more often represented among private insurance holders (69% vs 52%, p < 0.001) as well as in the highest income quartile (52% vs 40%, p = 0.008). Patients traveled farther to receive proton, as opposed to photon, therapy (median 59.0 vs 34.9 miles, p < 0.001). On postmatching Kaplan-Meier analysis encompassing all chordoma cases, no difference in OS between photon and proton therapy was revealed (HR 0.75, 95% CI 0.39-1.44; p = 0.39). A Kaplan-Meier analysis only including patients with skull base chordomas reached similar results (HR 0.83, 95% CI 0.31-2.22; p = 0.71). In patients with spine chordomas, however, a significant difference was found, as proton therapy exhibited a superior OS over photon therapy (HR 0.28, 95% CI 0.09-0.81; p = 0.012). Based on this nationwide analysis, patients with private insurance and higher income were more likely to receive proton adjuvant radiotherapy, while those with spinal or sacral chordomas were less likely to receive this modality. Despite this disparity, an OS benefit was observed in patients with chordomas of the spine and sacrum who received adjuvant proton therapy, in comparison with a matched cohort of patients treated with photon therapy. Conversely, this advantageous outcome was not evident in cases of chordomas located at the skull base.

Postoperative Complications and Readmission Rates in Robotic-Assisted Versus Manual Total Knee Arthroplasty: Large, Propensity Score-Matched Patient Cohorts.

There is a paucity of research comparing postoperative complication rates between manual total knee arthroplasty (M-TKA) and robotic-assisted total knee arthroplasty (RA-TKA). This study aims to compare 90-day postoperative complication, readmission, and emergency department rates between RA-TKA and M-TKA. A retrospective review of a multihospital database identified patients who underwent TKA between January 2016 and May 2023. Surgeons who used the robotic-assisted surgery technique in <10% or >90% of their cases annually were excluded. This resulted in 15,999 cases (8,853 RA-TKAs; 7,146 M-TKAs) from 282 surgeons. RA-TKA and M-TKA cohorts were one-to-one matched based on patient sex, age, body mass index, hospital setting, surgeon experience, primary payer, and anesthesia type. Each cohort consisted of 7,146 patients (N = 14,292). 90-day revisits, specifically readmissions, readmissions with >23 hours of observation, and ED visit rates were compared between cohorts. Complications were classified according to the Clinical Classification Software schema and compared between cohorts. Mann-Whitney U, chi-squared, and Fisher exact tests, along with Bonferroni correction, were used to statistically compare cohorts. All-cause 90-day readmission rates were 2.4% for RA-TKA and 2.6% for M-TKA (P = 0.36). RA-TKA had fewer revisits (RA-TKA: 7.8%; M-TKA: 8.8%, P = 0.027) and rates of readmission with >23 hours of observation (RA-TKA: 1.4%; M-TKA: 2.0%, P = 0.003). RA-TKA had fewer hospital revisits due to joint stiffness (RA-TKA: 17 revisits; M-TKA: 42 revisits, P = 0.002) and chronic pain (RA-TKA: 1 revisit; M-TKA: 8 revisits, P = 0.039). Fewer readmissions were observed for acute injuries (lower extremity muscle/tendon strains) in the RA-TKA cohort (RA-TKA: 1; M-TKA: 9, P = 0.021). RA-TKA had fewer ED visits due to hematomas (RA-TKA: 0 visits; M-TKA: 7 visits, P = 0.016). In this retrospective matched cohort analysis, RA-TKA was associated with markedly fewer revisits and readmissions with >23 hours of observation compared with M-TKA. No differences in all-cause 90-day readmission were observed between cohorts. Level III. Retrospective review.

Association of dipeptidyl peptidase-4 inhibitor initiation at glycated haemoglobin

Therapeutic inertia, hypoglycaemia and poor treatment persistence can lead to glycaemic fluctuation and poor outcomes in type 2 diabetes (T2D). We compared glycated haemoglobin (HbA1c) variability, insulin initiation, severe hypoglycaemia and clinical events in patients with T2D initiated dipeptidyl peptidase-4 inhibitors (DPP4is) at low versus high HbA1c thresholds. Using territory-wide electronic medical records in Hong Kong, we curated a propensity score-matched cohort of patients initiated DPP4i at HbA1c <7.5% versus ≥7.5% in 2007-2019. We expressed the HbA1c variability score (HVS) as a proportion of HbA1c varied by ≥0.5% compared with preceding values. We used the Cox model to compare the risks of insulin initiation and clinical outcomes, adjusted for time-varying variables between the two groups. Mediation analysis estimated the effects of HbA1c variability on outcomes. Among 6874 insulin-naïve patients who initiated DPP4i, 88.7% were treated with metformin and 79.6% with sulphonylureas at baseline (54.9% men; mean age 65.2 ± 11.4 years). After a median follow-up of 4.6 years, compared with the high-threshold plus high-HVS group (≥50%), the low-threshold plus low-HVS (<50%) group had reduced hazard ratios (95% confidence interval) of insulin initiation (0.35, 0.31-0.40), severe hypoglycaemia (0.38, 0.34-0.44), major adverse cardiovascular endpoints (0.76, 0.66-0.88), heart failure (0.42, 0.36-0.49), end-stage kidney disease (0.65, 0.36-0.49) and mortality (0.45, 0.35-0.57). Reduced HbA1c variability explained 31.1%-81.2% of the effect size of DPP4i initiation at HbA1c <7.5% versus ≥7.5% on outcomes. In Chinese patients with T2D, avoiding therapeutic inertia with intensified glycaemic control at HbA1c <7.5% using drugs with low risk of hypoglycaemia and good tolerability, such as DPP4i, delayed insulin treatment, reduced HbA1c variability and improved clinical events.

Outcomes of Conversion Surgery for Patients With Low-Risk Papillary Thyroid Carcinoma

The outcomes of patients with low-risk thyroid cancer who undergo surgery following a period of active surveillance (AS) are not well-defined. To evaluate surgical, pathologic, and oncologic outcomes among patients undergoing conversion surgery (CS) following AS for low-risk papillary thyroid carcinoma. In this cohort study, patients who underwent CS for disease progression were compared with patients who underwent CS without disease progression and with a propensity score-matched cohort of patients who underwent initial surgery (IS). The median (IQR) postsurgical follow-up time was 40.3 (18.0-59.0) months. Patients were treated at a quaternary cancer referral center in the United States. Surgery. Surgical complications, pathologic characteristics, overall survival (OS), and recurrence-free survival (RFS). Of 550 patients who underwent AS, 55 (10.0%) had CS, of whom 39 (7.1%) had surgery due to suspected disease progression (median [IQR] age, 48 [39-56] years; 32 [82.1%] female). There were no clinically meaningful differences in rates of surgical sequalae between the progression CS group (12 of 39 [30.7%]) and the nonprogression CS group (7 of 16 [43.8%]) (Cramer V, 0.2; 95% CI, 0.01-0.5). The 5-year OS was 100% (95% CI, 100%-100%) in both the disease-progression CS cohort and the IS cohort. Although the cohort of patients undergoing CS after disease progression was by definition a subset with more aggressive tumor behavior, no clinically meaningful differences were observed in the rates of regional recurrence (2 of 39 [5.1%] vs 0 of 39 patients with IS), local recurrence (0 patients), distant metastasis (0 patients), or disease-specific mortality (0 patients) when compared with the matched IS group. Five-year RFS rates were similar: 100% in the IS group and 86% (95% CI, 70%-100%) in the CS group. In this cohort study, CS for suspected disease progression was associated with surgical and oncologic outcomes similar to IS, supporting the feasibility and safety of AS for patients with low-risk papillary thyroid carcinoma.

Does intensity-modulated radiation therapy by helical tomotherapy for prostate cancer increase the subsequent risk of bladder cancer? A propensity score-matched analysis.

This study aimed to evaluate the risk of bladder cancer after intensity-modulated radiation therapy (IMRT) using helical tomotherapy for prostate cancer in comparison to the risk post-radical prostatectomy (RP) using propensity score-matched analysis and to assess the risk factors for bladder cancer. This retrospective study included 2067 patients with non-metastatic prostate cancer treated at our institution between June 2007 and December 2016. Of these, 1547 patients were treated with IMRT and 520 underwent RP. The propensity scores were calculated using age, National Comprehensive Cancer Network risk classification, prostate volume, Brinkman index, and follow-up time as matched covariates. A propensity score-matched patient cohort (n = 718; IMRT: 359, RP: 359) was created, and the risk of bladder cancer after treatment was compared. In total, bladder cancer was detected in 33 patients. Five patients in the IMRT group and one in the RP group died of bladder cancer. In the propensity score-matched analysis, the 5-year bladder cancer-free survival rate was significantly lower in the IMRT group than in the RP group (91.7% and 96.2%, respectively; p < 0.001). Multivariate analysis revealed that IMRT and the Brinkman index were the risk factors for bladder cancer in this cohort (odds ratio = 5.085, 95% confidence interval = 1.436-18.008, p = 0.012 and odds ratio = 1.001, 95% confidence interval = 1.000-1.001, p = 0.010, respectively). IMRT for prostate cancer using helical tomotherapy increases the subsequent risk of bladder cancer compared with RP and is an independent risk factor for bladder cancer similar to smoking.

Are sleep disorders associated with the risk of gastrointestinal cancer?-A case-control study.

Sleep disorders are among the most common health problems worldwide and are linked to a variety of physical and mental health problems. Recently, there has been increasing evidence of an association between sleep disorders and cancer risk. We aimed to investigate this association specifically for cancers of the gastrointestinal (GI) tract. Using the DA database (IQVIA), adult patients diagnosed with GI cancer between January 2010 and December 2022 were retrospectively compared to a 1:1 propensity score-matched cohort of patients without cancer. The outcome of the study was the association between sleep disorders and subsequent diagnosis of GI cancer. To determine whether sleep disorders were more common in patients with GI cancer than in patients without GI cancer, logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (95% CI). After matching, 37,161 cases with GI cancer and 37,161 controls without cancer were available for analysis. No association with cancer was found for sleep disorders in the overall history before the index date (OR 1.04; 95% CI 0.96-1.12), but considering sleep disorders documented within 1year before the index date showed a positive association with GI cancer overall (OR 1.20; 95% CI 1.08-1.34). Stratified analyses by cancer site revealed higher odds of sleep disorders prior to diagnosis of gastric, pancreatic, and colorectal cancer. Our findings suggest that sleep disorders might be indicative of short-term health outcomes, including GI cancer, suggesting a role for sleep disorder screening in the context of cancer prevention efforts.

Association of a Remote Blood Pressure Monitoring Program With Postpartum Adverse Outcomes.

To use administrative claims data to evaluate the association of a remote blood pressure monitoring program with adverse postpartum clinical outcomes in patients with a hypertensive disorder of pregnancy. This was a retrospective cohort study of Independence Blue Cross members with a hypertensive disorder of pregnancy diagnosis across three obstetric hospitals from 2017 to 2021. Patients who were enrolled in twice-daily text-based blood pressure monitoring for 10 days postpartum were compared with two propensity-score matched cohorts of patients who met the program criteria: an asynchronous cohort (cohort A), consisting of patients at any of the three participating hospitals before remote monitoring program implementation, and a contemporaneous cohort (cohort C), consisting of patients at other hospitals during the same time period as clinical use of the program. Patients with less than 16 months of continuous insurance enrollment before delivery were excluded. Claims for adverse clinical outcomes after delivery discharge were evaluated. Health care service utilization and total medical costs were evaluated. The 1,700 patients in remote blood pressure monitoring program were matched to 1,021 patients in cohort A and 1,276 in cohort C. Within the first 6 months after delivery, patients enrolled in remote monitoring were less likely to have the composite adverse outcome than those in cohort A (2.9% vs 4.7%; OR 0.61, 95% CI 0.40-0.98). There was no statistically significant difference relative to cohort C (3.2% vs 4.5%; OR 0.71, 95% CI 0.47-1.07). The remote monitoring group had more cardiology visits and fewer postnatal emergency department (ED) visits and readmissions compared with both comparison cohorts. Reductions in ED visits and readmissions drove overall lower total medical costs for the program cohort. Patients enrolled in a remote blood pressure monitoring program were less likely to experience an adverse outcome in the first 6 months after delivery. Reductions in ED visits and readmissions resulted in lower postpartum total medical costs compared with both control cohorts. Broad implementation of evidence-based remote monitoring programs may reduce postpartum adverse outcomes, thereby reducing morbidity and mortality in populations such as the one studied here.

Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection for Patients with Poor-Risk, Locally Advanced, Mid-to-Low Rectal Cancer May Improve Oncologic Outcomes: A Propensity Score-Matched Analysis.

This study aimed to investigate whether the addition of induction chemotherapy before chemoradiotherapy (CRT) and total mesorectal excision (TME) with selective lateral lymph node dissection improves disease-free survival for patients with poor-risk, mid-to-low rectal cancer. The authors' institutional prospective database was queried for consecutive patients with clinical stage II or III, primary, poor-risk, mid-to-low rectal cancer who received neoadjuvant treatment followed by TME from 2004 to 2019. The outcomes for the patients who received induction chemotherapy before neoadjuvant CRT (induction-CRT group) were compared (via log-rank tests) with those for a propensity score-matched cohort of patients who received neoadjuvant CRT without induction chemotherapy (CRT group). From 715 eligible patients, the study selected two matched cohorts with 130 patients each. The median follow-up duration was 5.4 years for the CRT group and 4.1 years for the induction-CRT group. The induction-CRT group had significantly higher rates of 3-year disease-free survival (83.5 % vs 71.4 %; p = 0.015), distant metastasis-free survival (84.3 % vs 75.2 %; p = 0.049), and local recurrence-free survival (98.4 % vs 94.4 %; p = 0.048) than the CRT group. The pathologically complete response rate also was higher in the induction-CRT group than in the CRT group (26.2 % vs 10.0 %; p < 0.001). Postoperative major complications (Clavien-Dindo classification ≥III) did not differ significantly between the two groups (12.3 % vs 10.8 %; p = 0.698). The addition of induction chemotherapy to neoadjuvant CRT appeared to improve oncologic outcomes significantly, including disease-free survival, for the patients with poor-risk, mid-to-low rectal cancer who underwent TME using selective lateral lymph node dissection.

PD44-03 EVALUATION OF GENDER SPECIFIC DIFFERENCES IN HEALTH-RELATED QUALITY OF LIFE FOR BLADDER CANCER PATIENTS AFTER RADICAL CYSTECTOMY - RESULTS FROM A LARGE PROSPECTIVE PROPENSITY SCORE-MATCHED COHORT

You have accessJournal of UrologyCME1 Apr 2023PD44-03 EVALUATION OF GENDER SPECIFIC DIFFERENCES IN HEALTH-RELATED QUALITY OF LIFE FOR BLADDER CANCER PATIENTS AFTER RADICAL CYSTECTOMY - RESULTS FROM A LARGE PROSPECTIVE PROPENSITY SCORE-MATCHED COHORT Thilo Westhofen, Josephine Coleman, Lennert Eismann, Alexander Buchner, Raphaela Waidelich, Christian G. Stief, Severin Rodler, and Alexander Kretschmer Thilo WesthofenThilo Westhofen More articles by this author , Josephine ColemanJosephine Coleman More articles by this author , Lennert EismannLennert Eismann More articles by this author , Alexander BuchnerAlexander Buchner More articles by this author , Raphaela WaidelichRaphaela Waidelich More articles by this author , Christian G. StiefChristian G. Stief More articles by this author , Severin RodlerSeverin Rodler More articles by this author , and Alexander KretschmerAlexander Kretschmer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003354.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Previous studies have shown gender specific differences in diagnosis and oncologic outcome for patients with bladder cancer (BC). However, in BC patients, gender specific differences in health-related quality of life (HRQOL) outcomes following radical cystectomy (RC) remain unclear. We aimed to assess gender specific differences in HRQOL by providing data from a large prospective propensity score (PS)-matched cohort of patients undergoing RC with a systematic follow-up of up to 10 yrs. METHODS: 1498 consecutive BC patients [n=421 female, n=1077 male] who underwent RC at a large tertiary care center were included. PS-matching of 794 patients [n=397 women, n=397 men] was conducted applying matching variables “age at RC”, “BMI”, “pT-stage” and “type of urinary diversion. HRQOL was assessed systematically, applying EORTC QLQ-C30- as well as the bladder cancer-specific QLQ-BLM30- and FACT-BL-questionnaires. Separate modeling of longitudinal HRQOL for women and men was performed. Spearman’s rank correlation was applied to identify gender specific factors influencing HRQOL. RESULTS: At baseline, female and male patients showed no difference in general HRQOL assessed by the global health status domain (GHS) (p=.162). In longitudinal analysis, a similar course of GHS for women and men was observed till 36mo after RC (p-range: .107 - .856). Between 48mo and 96mo after RC, GHS was significantly better for males (p-range: .002-.045). Spearman’s rank correlation revealed a significant correlation between physical functioning or urinary continence and increased general HRQOL equally for male and female patients (each p<.05). No correlation was found between sexual functioning and increased general HRQOL. While a strong correlation between Social/Family wellbeing and increased general HRQOL was found for women (p=.001), no correlation was shown for male patients (p=.103). CONCLUSIONS: The current study provides prospective data from a large propensity score-matched contemporary patient cohort, which displays gender specific differences in the natural course of general HRQOL and its subdomains. These data might play an important role in guiding gender specific treatment decision-making for patients with BC. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1124 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thilo Westhofen More articles by this author Josephine Coleman More articles by this author Lennert Eismann More articles by this author Alexander Buchner More articles by this author Raphaela Waidelich More articles by this author Christian G. Stief More articles by this author Severin Rodler More articles by this author Alexander Kretschmer More articles by this author Expand All Advertisement PDF downloadLoading ...

A comparison of clinical thresholds for revision following total and unicompartmental knee arthroplasty

Unicompartmental knee arthroplasty (UKA) has higher revision rates than total knee arthroplasty (TKA). As revision of UKA may be less technically demanding than revision TKA, UKA patients with poor functional outcomes may be more likely to be offered revision than TKA patients with similar outcomes. The aim of this study was to compare clinical thresholds for revisions between TKA and UKA using revision incidence and patient-reported outcomes, in a large, matched cohort at early, mid-, and late-term follow-up. Analyses were performed on propensity score-matched patient cohorts of TKAs and UKAs (2:1) registered in the New Zealand Joint Registry between 1 January 1999 and 31 December 2019 with an Oxford Knee Score (OKS) response at six months (n, TKA: 16,774; UKA: 8,387), five years (TKA: 6,718; UKA: 3,359), or ten years (TKA: 3,486; UKA: 1,743). Associations between OKS and revision within two years following the score were examined. Thresholds were compared using receiver operating characteristic analysis. Reasons for aseptic revision were compared using cumulative incidence with competing risk. Fewer TKA patients with 'poor' outcomes (≤ 25) subsequently underwent revision compared with UKA at six months (5.1% vs 19.6%; p < 0.001), five years (4.3% vs 12.5%; p < 0.001), and ten years (6.4% vs 15.0%; p = 0.024). Compared with TKA, the relative risk for UKA was 2.5-times higher for 'unknown' reasons, bearing dislocations, and disease progression. Compared with TKA, more UKA patients with poor outcomes underwent revision from early to long-term follow-up, and were more likely to undergo revision for 'unknown' reasons, which suggest a lower clinical threshold for UKA. For UKA, revision risk was higher for bearing dislocations and disease progression. There is supporting evidence that the higher revision UKA rates are associated with lower clinical thresholds for revision and additional modes of failure.

Gender specific differences in health-related quality of life for patients with bladder cancer following radical cystectomy.

437 Background: Previous studies have shown pronounced gender specific differences regarding diagnosis and oncological outcome for patients with bladder cancer (BC). Current literature lacks evidence on gender specific differences in health-related quality of life (HRQOL) outcomes for patients with BC following radical cystectomy (RC). We aimed to assess those gender specific differences by providing HRQOL data from a large prospective propensity score-matched cohort of patients undergoing RC with a systematic follow-up of up to 10 yrs. Methods: 1498 consecutive patients [n=421 women, n=1077 men] who underwent RC at a large tertiary care center were included. A propensity-score matched analysis of 794 patients [n=397 women, n=397 men] was conducted applying the matching- variables “patient age”, “BMI”, “pT-stage” and “type of urinary diversion”. Exclusion criteria encompassed age &lt;30 yr and RC due to benign diseases. HRQOL was assessed preoperatively, at 3 mo, then annually until a maximum follow-up of 120 months applying the validated EORTC QLQ-C30- as well as the bladder cancer-specific QLQ-BLM30- and FACT-BL-questionnaires. Separate modeling of longitudinal HRQOL for women and men was performed. Spearman’s rank correlation was applied to identify gender specific factors influencing HRQOL. Results: At baseline women and men showed no significant difference in general HRQOL assessed by the global health status domain (GHS) (p=.162). Women presented with worse mean emotional (p=.001) and cognitive (p=.007) functioning subscale. In the longitudinal analysis, a similar natural course of the GHS for women and men could be observed up to 36mo after RC (p-range: .107 - .856). Between 48mo and 96mo after RC, general HRQOL was significantly higher for men compared to women (p-range: .002-.045). At 12month a significant correlation between physical functioning or urinary continence and increased general HRQOL could equally be observed for men and women (each p&lt; .05). No significant correlation was found between sexual functioning and increased general HRQOL. While a strong correlation between Social/Family wellbeing and increased general HRQOL was found for women (p=.001), no correlation was found for men (p=.103). Conclusions: The current study provides prospective data from a unique propensity score-matched contemporary patient cohort, which displays gender specific differences in the natural course of general HRQOL and its subdomains. Those data are important to guide gender specific treatment decision-making for patients with BC.

Distal embolic protection use during transfemoral carotid artery stenting is associated with improved in-hospital outcomes

ObjectiveDespite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter. MethodsWe identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome. ResultsAmong 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052). ConclusionstfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered.

Clinical characteristics and outcomes of COVID-19 in patients with autoimmune hepatitis: A population-based matched cohort study.

Patients with autoimmune hepatitis (AIH) require life-long immunosuppressive agents that may increase the risk of poor coronavirus disease 2019 (COVID-19) outcomes. There is a paucity of large data at the population level to assess whether patients with AIH have an increased risk of severe diseases. To evaluate the impact of pre-existing AIH on the clinical outcomes of patients with COVID-19. We conducted a population-based, multicenter, propensity score-matched cohort study with consecutive adult patients (≥ 18 years) diagnosed with COVID-19 using the TriNeTx research network platform. The outcomes of patients with AIH (main group) were compared to a propensity score-matched cohort of patients: (1) Without chronic liver disease (CLD); and (2) Patients with CLD except AIH (non-AIH CLD) control groups. Each patient in the main group was matched to a patient in the control group using 1:1 propensity score matching to reduce confounding effects. The primary outcome was all-cause mortality, and secondary outcomes were hospitalization rate, need for critical care, severe disease, mechanical ventilation, and acute kidney injury (AKI). For each outcome, the risk ratio (RR) and confidence intervals (CI) were calculated to compare the association of AIH with the outcome. We identified 375 patients with AIH, 1647915 patients with non-CLD, and 15790 patients with non-AIH CLD with COVID-19 infection. Compared to non-CLD patients, the AIH cohort had an increased risk of all-cause mortality (RR = 2.22; 95%CI: 1.07-4.61), hospitalization rate (RR = 1.78; 95%CI: 1.17-2.69), and severe disease (RR = 1.98; 95%CI: 1.19-3.26). The AIH cohort had a lower risk of hospitalization rate (RR = 0.72; 95%CI: 0.56-0.92), critical care (RR = 0.50; 95%CI: 0.32-0.79), and AKI (RR = 0.56; 95%CI: 0.35-0.88) compared to the non-AIH CLD patients. Patients with AIH are associated with increased hospitalization risk, severe disease, and all-cause mortality compared to patients without pre-existing CLD from the diagnosis of COVID-19. However, patients with AIH were not at risk for worse outcomes with COVID-19 than other causes of CLD.

Trends in Healthcare Resource Use Preceding Diagnosis of Alzheimer's Disease Dementia.

An Alzheimer's disease (AD) dementia diagnosis is often preceded by an extended period of cognitive decline. Few studies have examined healthcare resource use (HRU) during an extended period before AD dementia diagnosis. In a historical claims-based cohort study, propensity score-matched cohorts of patients with and without AD dementia were observed for a 5-year prediagnosis period and a 1-year postdiagnosis period. Demographics, clinical characteristics, and HRU were compared between groups. Individuals in the AD dementia group displayed a greater level of medical complexity in the year before diagnosis of AD dementia relative to those in the matched cohort. Both all-cause and AD dementia complication-related HRU increased gradually, with a marked spike at the time of initial AD dementia diagnosis. Discussion. Further research into the natural history of patients with AD dementia is necessary to improve identification of early AD and to better understand its broader impact.

Statin therapy is associated with improved perioperative outcomes and long-term mortality following carotid revascularization in the Vascular Quality Initiative.

Statin therapy is the standard of care for patients with carotid artery stenosis given its proven cardiovascular benefits. However, the impact of statin therapy on outcomes in patients undergoing carotid revascularization in the Vascular Quality Initiative has not yet been evaluated. Therefore, our aim was to investigate the association of statin therapy with outcomes following carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR). We identified all patients who underwent CEA, tfCAS, or TCAR in the Vascular Quality Initiative registry from January 2016 to September 2021. To compare outcomes, we stratified patients by procedure type and created 1:1 propensity score-matched cohorts of patients who received no preoperative statin therapy (within 36hours of procedure) versus those who received preoperative statin therapy. Propensity scores incorporated demographic characteristics, comorbidities, carotid symptom status, preoperative medications, and physician and hospital procedural experience. The primary outcome was a composite end point of in-hospital stroke and/or death. As a secondary analysis, we performed repeat propensity score-matching by postoperative statin use (prescribed at discharge) and assessed 5-year mortality. Relative risks (RR) and hazard ratios (HR) were calculated using log binomial regression and Cox regression, respectively. Among 97,835 CEA, 20,303 tfCAS, and 22,371 TCAR patients, 15%, 17%, and 10% of patients did not receive preoperative statin therapy, respectively. Compared with statin use, no statin use was associated with a higher risk of in-hospital stroke or death among 13,434 matched CEA patients (no statin, 1.7% vs statin, 1.4%; RR, 1.2; 95% confidence interval [CI], 1.02-1.5) and among 2707 matched tfCAS patients (4.8% vs 2.8%; RR, 1.7; 95% CI, 1.3-2.3). However, there was no difference for this outcome by statin use among 2089 matched TCAR patients (1.8% vs 1.6%; RR, 1.1; 95% CI, 0.7-1.8). At5years, no statin therapy at discharge was associated with higher 5-year mortality after CEA (15% vs 10%; HR, 1.8; 95% CI, 1.6-2) and tfCAS (18% vs 14%; HR, 1.5; 95% CI, 1.2-1.8), but there was no difference after TCAR (14% vs 11%; HR, 1.3; 95% CI,0.9-1.8). Compared with statin use, no statin use was associated with a higher risk of in-hospital stroke or death and 5-year mortality among CEA and tfCAS patients. Although there was no significant difference in outcomes among TCAR patients, this may in part be due to lower statistical power in this cohort. Overall, statin therapy is essential in the short- and long-term management of patients undergoing carotid revascularization. Our findings not only support current Society for Vascular Surgery recommendations for statin therapy in patients undergoing carotid revascularization, but they also highlight an important opportunity for quality improvement.

Distinct course of portal hypertension in patients with cirrhosis with gastric variceal bleeding as their first decompensation: a propensity score-matched study.

Limited data exist on course of portal hypertension in patients with cirrhosis with gastric variceal (GV) bleeding as their index decompensation. We evaluated long-term outcomes in this subgroup and compared them with a propensity score-matched cohort of patients with esophageal variceal (EV) bleeding. Patients with cirrhosis with GVs (IGV-1 and GOV-2) bleeding as their index decompensation were analyzed in this retrospective study. Incidence of new-onset clinical decompensations and survival were estimated and compared with a cohort of patients with EVs bleeding matched for etiology and disease severity using competing risk analysis. Baseline characteristics of patients with GVs related bleeding (n = 51) (mean age-48.1 ± 12.9years, 80% males, non-viral cirrhosis: 80.3%) were similar to the cohort of EVs bleeding (n = 51) (mean age-45.9 ± 14.2, 88% males, non-viral cirrhosis: 78.4%). The 1-year and 3-year rates of new-onset ascites were (17.9%, 34.2%) and (23.9%, 49%) in patients with GVs and EVs related index bleeding, respectively (Gray's test, p = 0.035). The 1-year and 3year rate of rebleed was (35.6%, 46.3%) and (13.9%, 35.7%) in patients with GVs and EVs related index bleeding, respectively (Gray's test, p = 0.1). While overall survival was similar across both the groups (GV: 29.6% vs EV: 21.6%, p = 0.495), rebleeding-related deaths occurred exclusively in patients with GV (rebleeding-related deaths: GV: 40% vs EVs: 0%; non-bleeding liver-related deaths: GV: 60% vs EV: 100%; p = 0.048). Rebleeding predominates the course of portal hypertension in patients with cirrhosis presenting with GVs related bleeding, whereas ascites is the most significant event on follow-up in those with EVs related bleeding.