Propensity Score-matched Sample Research Articles

Maternal and neonatal outcomes after metabolic and bariatric surgery among women with severe obesity.

Earlier evidence indicated that metabolic and bariatric surgery (MBS) may adversely affect neonatal outcomes among patients conceiving soon after MBS, but recent studies demonstrated conflicting results, especially for new surgical techniques. The aim of this study was to assess the effects of MBS types and surgery to birth interval on maternal, birth, and nonbirth outcomes in women with severe obesity. New York State's all-payer hospital discharge database (2008-2019). We identified women with severe obesity who underwent MBS (Post-MBS, n = 5001) or did not undergo MBS (No-MBS, n = 74,515), and examined maternal, neonatal, and nonbirth outcomes by MBS type and time since surgery in a propensity score-matched sample. Compared with No-MBS mothers, Post-MBS mothers had a lower incidence of stillbirths, ectopic pregnancies, and miscarriages (nonoverlapping confidence intervals). Post-MBS mothers were also significantly less likely to have pregnancy hypertension, gestational diabetes, and cesarean deliveries, but were more likely to experience vaginal bleeding during early pregnancy and deliver low birthweight newborns compared with No-MBS mothers (P < .05). Among Post-MBS mothers, deliveries within 18 months after surgery were associated with higher rate of cesarean sections and neonatal deaths compared with deliveries 18+ months after MBS (P < .05). Pregnancies after gastric bypass (RYGB) were more likely to result in cesarean deliveries compared with pregnancies after sleeve gastrectomy (P < .01). Although weight loss surgery in women with obesity may reduce the rates of adverse maternal nonbirth outcomes and pregnancy complications, neonates born to women who conceived during the first year after MBS, especially RYGB, may be at higher risk for adverse outcomes.

Precision medicine in type 1 diabetes: comparing metabolic outcomes of Control-IQ and MiniMed 780G according to patient characteristics.

This study aimed to compare 12-month metabolic outcomes in patients with type 1 diabetes (T1D) treated with either MiniMed 780G (Guardian 4) or Control-IQ (Dexcom G6) automated insulin delivery (AID) systems and identify interaction with patient characteristics. We conducted a single-centre, retrospective study including all patients (aged ≥16) with T1D who were started on either MiniMed 780G or Control-IQ between January 2021 and October 2022 and continued for ≥12 months. We used propensity score matching to compare the average marginal effects between MiniMed 780G and Control-IQ regarding the primary outcome (time in range [TIR]) and secondary outcomes (time below range [TBR], glucose monitoring indicator [GMI] and coefficient of variation [CV]) after 12 months. We tested for interaction effects between baseline characteristics (age, sex, socio-professional background, body mass index, insulin daily dose, carbohydrate counting practice) and treatment effect. We included 245 patients (58% women): 178 treated with Control-IQ and 67 with MiniMed 780G. The mean ± SD age and haemoglobin A1c were 39 ± 15 years and 8.7 ± 1.8% (72 ± 20 mmol/mol) respectively. In the propensity score-matched sample (n = 221), we observed significant differences in 12-month TIR (MiniMed 780G minus Control-IQ [95% CI]: 6.4 [3.4;9.5]), GMI (-0.42 [-0.59; -0.25]) and CV (-2.12 [-3.68; -0.55]), while TBR showed no significant difference (-0.04 [-0.47; +0.40]). The 12-month TIR difference was consistent across subgroups, including baseline carbohydrate counting characteristics. MiniMed 780G is associated with moderate metabolic superiority compared to Control-IQ, without interaction with patient characteristics. These results suggest that neither model is more appropriate for certain populations, particularly patients without carbohydrate counting practice.

Sexual behaviours and risk of SARS-CoV-2 infection among MSM during the first COVID-19 lockdown

BackgroundThe social distancing measures associated with the COVID-19 pandemic had far reaching effects on sexual behavior worldwide. However, it remains unclear whether sexual contact with non-steady partners was a contributor to the spread of SARS-CoV-2. The aim of this study was to (i) describe risk factors for SARS-CoV-2 seropositivity after the first pandemic wave among people using HIV Pre-Exposure Prophylaxis (PrEP) in Zurich, Switzerland, including sexual contact with non-steady partners, and (ii) assess whether the SARS-CoV-2 seropositivity among PrEP users in this time period differed from that of a demographic matched population level comparison group.MethodsThe study was conducted between July 2020 and October 2020 as a nested cross-sectional study within two ongoing cohort studies, SwissPrEPared (all eligible PrEP users in Switzerland ≥ 18 years old) and Corona Immunitas (a series of cross-sectional and longitudinal studies measuring the SARS-CoV-2 seroprevalence across Switzerland, beginning in April 2020). All SwissPrEPared participants were recruited from Checkpoint Zurich (the main PrEP clinic in Zurich) and were men having sex with men or transgender women. Data were collected on participants’ SARS-CoV-2 antibody status, social characteristics and behavioral data after the first wave of the pandemic in Switzerland, and seroprevalence was compared with a propensity score-matched sample from the general Zurich population.ResultsOf the 218 participants enrolled, 8.7% (n = 19, 95% CI: 5.5–13.5%) were seropositive for SARS-CoV-2 during the first pandemic wave, higher than that of the general male population in Zurich aged 20–65 (5.5%, 95% CI: 3.8–8.2%). Participants on average reduced their social outings, but the seronegative were more socially active before, during, and after the first lockdown period. In a logistic model, increasing mean sexual partner count was not associated with seropositivity (OR: 1.02, 95% CI: 0.95, 1.07). The estimated risk ratio for seropositivity for the participants compared to the general Zurich population after propensity score matching was 1.46 (95% CI: 0.53, 3.99).ConclusionsOur study suggests that SARS-CoV-2 seropositivity was slightly elevated among people taking PrEP in Zurich during the first wave of the pandemic, but that socializing and sexual activity were less important than other factors in contributing to risk.

Relationship Between Insurance Status and Receipt of Cardiac Tests and Procedures During Hospitalization: A Cross-Sectional Study.

Prior analyses of the relationship between insurance status and receipt of tests and procedures have yielded conflicting findings and have focused on outpatient care. We sought to characterize the relationship between primary payer and diagnostic and procedural intensity, comparing rates of cardiac tests and procedures in matched hospitalized Medicaid and commercially insured patients. We created a propensity score-matched sample of Medicaid and commercially insured adults hospitalized at all acute care hospitals in Kentucky, Maryland, New Jersey, and North Carolina from 2016 to 2018. The main outcome was receipt of a cardiac test or procedure: echocardiogram, stress test, cardiac catheterization (elective, in acute coronary syndrome, in ST-segment-elevation myocardial infarction), and pacemaker and subcutaneous cardiac rhythm monitor implantation. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds of a commercially insured patient receiving a given test or procedure relative to a Medicaid patient. Models controlled for race, ethnicity, and zip code income quartile. Commercially insured patients were more likely to receive each cardiac test or procedure, with adjusted odds ratios ranging from 1.16 (95% CI, 1.00-1.34) for cardiac catheterization in ST-segment-elevation myocardial infarction to 1.40 (95% CI, 1.27-1.54) for pacemaker implantation. Hospitalized commercially insured patients were more likely to undergo a range of cardiac tests and procedures, some of which may represent low-value care. This may be driven by a combination of physician and patient preference, financial incentives, and social determinants of health. Our findings support the need for hospital payment models focused on increasing value and reducing inequities.

Sacubitril-Valsartan in Patients Requiring Hemodialysis.

Randomized clinical trials have shown that sacubitril-valsartan reduces the risks of mortality and hospitalization in patients with heart failure with reduced ejection fraction (HFrEF), but patients with kidney failure requiring dialysis were excluded. To investigate the comparative effectiveness of sacubitril-valsartan vs angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs or ARBs) in patients with HFrEF requiring hemodialysis. This retrospective, 1:1 propensity score-matched comparative effectiveness study included patients who were 18 years or older with HFrEF, enrolled in Medicare Parts A, B, and D, and survived at least 90 days receiving in-center hemodialysis from July 8, 2015, to December 31, 2020. Patients were excluded for less than 180 days of continuous Medicare Parts A, B, and D primary payer coverage or prior dispensing of sacubitril-valsartan. Data analysis was conducted from September 23, 2023, to June 25, 2024. New use of sacubitril-valsartan vs new or continued use of ACEIs or ARBs. The associations between initiation of sacubitril-valsartan therapy and all-cause mortality, cardiovascular mortality, all-cause hospitalization, and HF hospitalization were assessed using Cox proportional hazards regression models in a propensity score-matched sample. Participants included 1:1 matched pairs of 1434 sacubitril-valsartan users and 1434 ACEI or ARB users (mean [SD] age, 64 [13] years). Of the 2868 matched participants, 996 (65%) were male; 987 (34%) were Black or African American and 1677 (58%) were White; and median dialysis vintage was 3.8 (IQR, 1.8-6.3) years. The median follow-up was 0.9 (IQR, 0.4-1.7) years. Sacubitril-valsartan (vs ACEI or ARB) therapy was associated with a reduction in all-cause mortality (hazard ratio [HR], 0.82 [95% CI, 0.73-0.92]) and all-cause hospitalization (HR, 0.86 [95% CI, 0.79-0.93]) but not cardiovascular mortality (HR, 1.01 [95% CI, 0.86-1.19]) or HF hospitalization (HR, 0.91 [95% CI, 0.82-1.02]). There was a decrease in hyperkalemia (HR, 0.71 [95% CI, 0.62-0.81]) and no difference in hypotension (HR, 0.99 [95% CI, 0.83-1.19]). Only 195 participants (14%) ever received the maximum combination dose of sacubitril (97 mg twice daily) and valsartan (103 mg twice daily). In this comparative effectiveness study of patients with HFrEF requiring hemodialysis, sacubitril-valsartan therapy was associated with beneficial effects in all-cause mortality and all-cause hospitalization.

Evaluation of Posthospital Brain Injury Rehabilitation Outcomes With Quasi-Experimental Controls.

To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study (n =2120). Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI). Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating. Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating. Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category. Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score (F =77.21, P <.001; partial η2=0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group. These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

Association of Previous Cardiac Surgery With Postoperative Pneumonia in Infants Undergoing Abdominal Operations: A Cohort Study

BackgroundChildren with congenital heart disease (CHD) often require other, non-cardiac related surgical procedures following their initial cardiac surgery. After full or partial CHD repair, they remain at increased risk of postoperative complications. We examined the association of previous cardiac intervention (surgery or percutaneous catheterization intervention) with postoperative pneumonia in infants undergoing abdominal general surgery. MethodsA 1:1 propensity score-matched study was conducted using a retrospective cohort of 104,820 infants (<12 months) who had general abdominal surgeries between 2012 and 2022 in U.S. hospitals participating in the National Surgical Quality Improvement Program. The primary outcome was postoperative pneumonia within 30 days. Secondary outcomes included unplanned reintubation, prolonged mechanical ventilation (>72 h), and extended hospital stay (>75th percentile for the study cohort). ResultsOf the study cohort, 9736 infants (9.3%) had previous cardiac interventions. In the propensity score-matched sample, infants with previous cardiac surgery had increased risks of postoperative pneumonia (1.3% vs 0.8%; adjusted relative risk [RRadj]: 1.64, 95% CI: 1.22, 2.18, p = 0.001), unplanned reintubation (57.8% vs 32.6%; RRadj: 1.77, 95% CI: 1.77, 1.85, p < 0.001), prolonged mechanical ventilation (5.0% vs 2.3%; RRadj: 2.14, 95% CI: 1.83, 2.52, p < 0.001), and prolonged hospital stays (61.0% vs 53.8%; RRadj: 1.13, 95% CI: 1.10, 1.17, p < 0.001). ConclusionsA history of previous cardiac intervention carries an increased risk of postoperative pneumonia, unplanned tracheal reintubation, prolonged mechanical ventilation, as well as longer hospital stays following intra-abdominal surgery. Clinicians should closely monitor these patients for respiratory complications after surgery. Level of evidenceII.

Laparoscopic versus robotic-assisted primary bariatric-metabolic surgery. Are we still expecting to overcome the learning curve? A propensity score–matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BackgroundRobotic surgery is becoming increasingly popular in bariatric-metabolic surgery. However, its superiority regarding postoperative outcomes compared with conventional laparoscopy has not been clearly proven. With growing adoption of robotic surgery and improved technologies, benefits should become more evident. ObjectivesEvaluate readmission and reoperation rates after bariatric-metabolic surgery performed by conventional laparoscopy versus robotic-assisted from 2015 to 2021. SettingAcademic institution. MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was reviewed for primary bariatric operations performed with conventional laparoscopy versus robotic-assisted. Postoperative outcomes were compared in a propensity score-matched sample. ResultsOf 1,059,348 cases meeting inclusion criteria, 921,322 (87%) were conventional laparoscopic bariatric-metabolic surgeries, which were matched 1:1 with robotic-assisted cases (138,026). Reoperation (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.00–1.15, P = .0463), postoperative morbidity (OR 1.07; 95% CI 1.01–1.12, P = .0193), readmission (OR 1.14; 95% CI 1.09–1.18, P < .0001), and emergency department visits (OR 1.06; 95% CI 1.03–1.09, P = .0003) at 30 days postoperatively were significantly greater for robotic-assisted cases. Robotic-assisted cases had a similar mortality rate at 30 days postoperatively and length of stay >3 days when compared with conventional laparoscopic cases. Similar results were observed in cases from 2020 to 2021, except for reoperation and emergency department visits, which showed no difference between groups and length of stay >3 days, which was greater in robotic-assisted cases. ConclusionsOur results show a greater readmission and reoperation rate and greater morbidity at 30 days postoperatively in robotic-assisted bariatric-metabolic surgery compared with conventional laparoscopy. Analyzing only cases performed between 2020 and 2021, robotic surgery also does not show superiority over conventional laparoscopy.

Effect of off-label targeted drugs on long-term survival in chronic thromboembolic pulmonary hypertension: Insights from a national multicentre prospective registry.

Off-label pulmonary arterial hypertension (PAH)-targeted drugs are commonly prescribed for non-operated chronic thromboembolic pulmonary hypertension (CTEPH), but their effect on the long-term prognosis of CTEPH remains unknown. This study investigated the effect of off-label PAH-targeted drugs on the long-term survival of CTEPH patients. CTEPH patients were enrolled from a prospective multicentre national registry. Except for licensed riociguat and treprostinil, other PAH-targeted drugs were off-label. In the original and propensity score-matched (PSM) samples, five-year survival was compared in two groups: (a) patients not receiving off-label PAH-targeted drugs (control) versus (b) patients receiving off-label PAH-targeted drugs (treatment). The latter group was investigated for the effect of started off-label PAH-targeted drugs at baselines (initial) or during follow-up (subsequent). Of 347 enrolled patients, 212 were treated with off-label PAH-targeted drugs initially (n = 173) or subsequently (n = 39), and 135 were untreated. The 1-, 2-, 3- and 5-year survival of the treatment group was significantly higher than that of the control group (97.1% vs. 89.4%, 92.3% vs. 82.1%, 83.2% vs. 75.1% and 71.1% vs. 55.3%, respectively, log-rank test, p = 0.005). Initial treatment was correlated with better 5-year survival after excluding patients with subsequent treatment to reduce the immortal-time bias (hazard ratio: 0.611; 95% CI: 0.397-0.940; p = 0.025). In PSM samples, patients given initial treatment showed significantly better 5-year survival than untreated patients (68.9% vs. 49.3%, log-rank test, p = 0.008). Off-label targeted drugs contributed to improved long-term survival in CTEPH patients receiving pharmacotherapies.

Bidirectional associations between workplace bullying and sickness absence due to common mental disorders – a propensity-score matched cohort study

BackgroundThe link between workplace bullying and poor mental health is well-known. However, little is known about the prospective and potentially reciprocal association between workplace bullying and mental health-related sickness absence. This 2-year prospective study examined bidirectional associations between exposure to workplace bullying and sickness absence due to common mental disorders (SA-CMD) while controlling for confounding factors from both work and private life.MethodsThe study was based on propensity score-matched samples (N = 3216 and N = 552) from the Swedish Longitudinal Occupational Survey of Health, using surveys from years 2012, 2014 and 2016. Self-reported exposure to workplace bullying was linked to registry-based information regarding medically certified SA-CMD (≥ 14 consecutive days). The associations were examined by means of Cox proportional hazards regression and via conditional logistic regression analysis. Hazard ratios and odds ratios with 95% confidence intervals were estimated.ResultsExposure to workplace bullying was associated with an increased risk of incident SA-CMD (HR: 1.3, 95% CI: 1.0–1.8), after accounting for the influence of job demands, decision authority, previous SA-CMD, as well as other sociodemographic covariates. However, we found no statistically significant association between SA-CMD and subsequent workplace bullying (OR 1.2, 95% CI 0.7–1.9).ConclusionsThe results support an association between self-reported workplace bullying and SA-CMD, independent of other sociodemographic factors and workplace stressors. Preventing workplace bullying could alleviate a share of the individual and societal burden caused by SA globally.

Nonsteroidal anti-inflammatory drug “allergy” labeling is associated with increased postpartum opioid utilization

Current guidelines recommend a stepwise approach to postpartum pain management, beginning with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with opioids added only if needed. Report of a prior NSAID-induced adverse drug reaction (ADR) may preclude use of first-line analgesics, despite evidence that many patients with this allergy label may safely tolerate NSAIDs. We assessed the association between reported NSAID ADRs and postpartum opioid utilization. We performed a retrospective cohort study of birthing people who delivered within an integrated health system (January 1, 2017, to December 31, 2020). Study outcomes were postpartum inpatient opioid administrations and opioid prescriptions at discharge. Statistical analysis was performed on a propensity score-matched sample, which was generated with the goal of matching to the covariate distributions from individuals with NSAID ADRs. Of 38,927 eligible participants, there were 883 (2.3%) with an NSAID ADR. Among individuals with reported NSAID ADRs, 49.5% received inpatient opioids in the postpartum period, compared to 34.5% of those with no NSAID ADRs (difference= 15.0%, 95% confidence interval 11.4-18.6%). For patients who received postpartum inpatient opioids, those with NSAID ADRs received a higher total cumulative dose between delivery and hospital discharge (median 30.0 vs 22.5 morphine milligram equivalents [MME] for vaginal deliveries; median 104.4 vs 75.0 MME for cesarean deliveries). The overall proportion of patients receiving an opioid prescription at the time of hospital discharge was higher for patients with NSAID ADRs compared to patients with no NSAID ADRs (39.3% vs 27.2%; difference= 12.1%, 95% confidence interval 8.6-15.6%). Patients with reported NSAID ADRs had higher postpartum inpatient opioid utilization and more frequently received opioid prescriptions at hospital discharge compared tothose without NSAID ADRs, regardless of mode of delivery.

Measurement invariance and differential item functioning of the PHQ-9 and GAD-7 between working age and older adults seeking treatment for common mental disorders

BackgroundThe nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalised Anxiety Disorder (GAD-7) scale are widely used clinically and within research, and so it is important to determine how the measures, and individual items within the measures, are answered by adults of differing ages. This study sought to evaluate measurement invariance and differential item functioning (DIF) of the PHQ-9 and GAD-7 between working age and older adults seeking routine psychological treatment. MethodsData of working age (18–64 years old) and older (≥65) adults in eight Improving Access to Psychological Therapies (IAPT) services were used. Confirmatory factor analysis (CFA) was used to establish unidimensionality of the PHQ-9 and GAD-7, with multiple-group CFA to test measurement invariance and The Multiple Indicators, Multiple Causes Models approach to assess DIF. The employed methods were applied to a propensity score matched (PSM) sample in sensitivity analyses to control for potential confounding. ResultsData from 166,816 patients (159,325 working age, 7491 older) were used to show measurement invariance for the PHQ-9 and GAD-7, with limited evidence of DIF and similar results found with a PSM sample (n = 5868). LimitationsThe localised sample creates an inability to detect geographical variance, and the potential effect of unmeasured confounders cannot be ruled out. ConclusionsThe findings support the use of the PHQ-9 and GAD-7 measures for working age and older adults, both clinically and in research settings. This study validates using the measures for these age groups to assess clinically significant symptom thresholds, and monitor treatment outcomes between them.

Modeling Longitudinal Outcomes in a Small Matched-Pair Sample Motivated by Cardiovascular Data: A Simulation Study

Introduction: In cardiovascular research, matched pairs with longitudinal outcomes are used to assess time and treatment effects on relevant cardiovascular parameters of interest. Generalized estimating equations (GEE) with independent working correlation are commonly employed for unbiased estimation, but their consistency depends on large sample properties. This study investigates the validity of independent GEE for small sample matched pair data under various working correlations, comparing the results with quasi-least squares (QLS) estimates through simulation. Methods: We simulate a hospital cohort with longitudinal outcomes for two exposure groups and individual random effects. After obtaining the propensity score-matched sample, we performed different simulation scenarios across various mortality rates and the random effect. We compare results from GEE and QLS methods under independence, exchangeable, and AR1 working correlation structures. Results: The independence structure often yields a wider range of relative biases and higher standard errors when there is considerable drop-out. Conversely, the exchangeable structure appears as the true correlation structure, providing more accurate and reliable estimates. No significant discrepancies are observed between the results generated by GEE and QLS methods in this study, and the performance of both approaches is significantly influenced by mortality rates and the standard deviation of the random intercept. Conclusion: Our findings suggest that GEE with an independent working correlation structure is misspecified due to incorrect correlation assumptions and is less efficient. Therefore, correctly specifying the working correlation structure is important for small sample data.

Patient-reported swallowing outcomes after transoral robotic thyroidectomy: Comparison with conventional transcervical thyroidectomy.

This study aimed to evaluate the swallowing outcomes after transoral robotic thyroidectomy (TORT) and compare them with those of conventional transcervical thyroidectomy. We enrolled 146 patients who underwent thyroidectomy (73 TORT; 73 conventional approach). We prospectively analyzed swallowing outcomes using the Swallowing Impairment Index-6 (SIS-6) questionnaire, a patient-reported measure, before and 1, 3, and 6 days; 1, 3, and 6 months; and 1 year after surgery. Propensity score-matched analysis was performed using three covariates: age, sex, and extent of thyroidectomy. SIS-6 scores worsened significantly immediately after surgery and progressively recovered 1 year postoperatively in both groups. Propensity score matching generated two matched groups of 22 patients each. In the propensity score-matched samples, the SIS-6 scores did not differ between the TORT and conventional groups, except at 1 day postoperatively. Patient-reported swallowing outcomes of TORT were comparable to those of the conventional transcervical procedure.

Effect of sacubitril/valsartan on cardiac remodeling compared with other renin–angiotensin system inhibitors: a difference-in-difference analysis of propensity-score matched samples

BackgroundIn patients with heart failure with reduced ejection fraction (HFrEF), treatment with sacubitril–valsartan (S/V) may reverse left ventricular remodeling (rLVR). Whether this effect is superior to that induced by other renin–angiotensin system (RAS) inhibitors is not well known.MethodsHFrEF patients treated with S/V (n = 795) were compared, by propensity score matching, with a historical cohort of 831 HFrEF patients (non-S/V group) treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (RAS inhibitors). All patients were also treated with beta-blockers and shared the same protocol with repeat echocardiogram 8–12 months after starting therapy. The difference-in-difference (DiD) analysis was used to evaluate the impact of S/V on CR indices between the two groups.ResultsAfter propensity score matching, compared to non-S/V group (n = 354), S/V group (n = 354) showed a relative greater reduction in end-diastolic and end-systolic volume index (ESVI), and greater increase in ejection fraction (DiD estimator = + 5.42 mL/m2, P = 0.0005; + 4.68 mL/m2, P = 0.0009, and + 1.76%, P = 0.002, respectively). Reverse LVR (reduction in ESVI ≥ 15% from baseline) was more prevalent in S/V than in non-S/V group (34% vs 26%, P = 0.017), while adverse LVR (aLVR, increase in ESVI at follow-up ≥ 15%) was more frequent in non-S/V than in S/V (16% vs 7%, P < 0.001). The beneficial effect of S/V on CR over other RAS inhibitors was appreciable across a wide range of patient’s age and baseline end-diastolic volume index, but it tended to attenuate in more dilated left ventricles (P for interaction = NS for both).ConclusionIn HFrEF patients treated with beta-blockers, sacubitril/valsartan is associated with a relative greater benefit in LV reverse remodeling indices than other RAS inhibitors.Graphical abstract

Cyclosporine vs. tacrolimus after liver transplantation for primary sclerosing cholangitis – a propensity score-matched intention-to-treat analysis

There is controversy regarding the optimal calcineurin inhibitor type after liver transplant(ation) (LT) for primary sclerosing cholangitis (PSC). We compared tacrolimus with cyclosporine in a propensity score-matched intention-to-treat analysis based on registries representing nearly all LTs in Europe and the US. From the European Liver Transplant Registry (ELTR) and Scientific Registry of Transplant Recipients (SRTR), we included adult patients with PSC undergoing a primary LT between 2000-2020. Patients initially treated with cyclosporine were propensity score-matched 1:3 with those initially treated with tacrolimus. The primary outcomes were patient and graft survival rates. The propensity score-matched sample comprised 399 cyclosporine-treated and 1,197 tacrolimus-treated patients with PSC. During a median follow-up of 7.4 years (IQR 2.3-12.8, 12,579.2 person-years), there were 480 deaths and 231 re-LTs. The initial tacrolimus treatment was superior to cyclosporine in terms of patient and graft survival, with 10-year patient survival estimates of 72.8% for tacrolimus and 65.2% for cyclosporine (p <0.001) and 10-year graft survival estimates of 62.4% and 53.8% (p <0.001), respectively. These findings were consistent in the subgroups according to age, sex, registry (ELTR vs. SRTR), time period of LT, MELD score, and diabetes status. The acute rejection rates were similar between groups. In the multivariable Cox regression analysis, tacrolimus (hazard ratio 0.72, p <0.001) and mycophenolate use (hazard ratio 0.82, p= 0.03) were associated with a reduced risk of graft loss or death, whereas steroid use was not significant. Tacrolimus is associated with better patient and graft survival rates than cyclosporine and should be the standard calcineurin inhibitor used after LT for patients with PSC. The optimal calcineurin inhibitor to use after liver transplantation in patients with primary sclerosing cholangitis has yet to be firmly established. Since randomized trials with long follow-up are unlikely to be performed, multicontinental long-term registry data are essential in informing clinical practices. Our study supports the practice of using tacrolimus instead of cyclosporine in the initial immunosuppressive regimen after liver transplantation for patients with primary sclerosing cholangitis. The retrospective registry-based design is a limitation.

Association between intraoperative starch use and postoperative kidney dysfunction in patients undergoing major gastro-intestinal surgery: A propensity score-matched analysis.

The impact of intraoperative starch-based fluid therapy on postoperative kidney dysfunction in patients undergoing major abdominal surgery is uncertain. Low molecular weight starch is expected to cause less postoperative kidney dysfunction. This retrospective study evaluated the impact of intraoperative 6% hydroxyethyl starch on postoperative renal dysfunction. The primary outcome of this study was postoperative acute kidney injury as per KDIGO definition within 72 hours of surgery. This study analysed data from 461 patients with a median (interquartile range) age of 45 (33-58) years, and 48.2% of all patients were female. The proportion (95% confidence interval) of patients who developed acute kidney injury was 0.18 (0.14-0.21); 62.9% of patients had acute kidney injury stage I, 32% had acute kidney injury stage II, and the rest were acute kidney injury stage III. In the propensity score-matched sample, the average treatment effect of intraoperative colloid use on postoperative serum creatinine at day 3 (p = 0.32), duration of postoperative intensive care unit stay (p = 0.97), duration of hospital stay (p = 0.37), postoperative worst international normalised ratio (p = 0.92), and postoperative transfusion requirement (p = 0.40) were not statistically significant. Intraoperative use of low molecular weight hydroxyethyl starch use was not associated with postoperative kidney dysfunction and coagulopathy in adult patients undergoing major open abdominal surgery.

Aspirin reduces the mortality risk of sepsis-associated acute kidney injury: an observational study using the MIMIC IV database.

Introduction: Sepsis-associated acute kidney injury (SA-AKI) is a complication of sepsis and is characterized by high mortality. Aspirin affects cyclooxygenases which play a significant role in inflammation, hemostasis, and immunological regulation. Sepsis is an uncontrolled inflammatory and procoagulant response to a pathogen, but aspirin can inhibit platelet function to attenuate the inflammatory response, thus improving outcomes. Several studies have generated contradictory evidence regarding the effect of aspirin on patients with sepsis-associated acute kidney injury (SA-AKI). We conducted an analysis of the MIMIC IV database to investigate the correlation between aspirin utilization and the outcomes of patients with SA-AKI, as well as to determine the most effective dosage for aspirin therapy. Materials and methods: SA-AKI patients' clinical data were extracted from MIMIC-IV2.1. Propensity score matching was applied to balance the baseline characteristics between the aspirin group and the non-user group. Subsequently, the relationship between aspirin and patient death was analyzed by Kaplan-Meier method and Cox proportional hazard regression models. Results: 12,091 patients with SA-AKI were extracted from the MIMIC IV database. In the propensity score-matched sample of 7,694 individuals, lower 90-day mortality risks were observed in the aspirin group compared to the non-users group (adjusted HR: 0.722; 95%CI: 0.666, 0.783) by multivariable cox proportional hazards analysis. In addition, the Kaplan-Meier survival curves indicated a superior 90-day survival rate for aspirin users compared to non-users (the log-rank test p-value was 0.001). And the median survival time of patients receiving aspirin treatment was significantly longer than those not receiving (46.47days vs. 24.26days). In the aspirin group, the average ICU stay length was shorter than non-users group. (5.19days vs. 5.58days, p = 0.006). There was no significant association between aspirin and an increased risk of gastrointestinal hemorrhage (p = 0.144). Conclusion: Aspirin might reduce the average ICU stay duration and the 30-day or 90-day mortality risks of SA-AKI patients. No statistically significant difference in the risk of gastrointestinal hemorrhage was found between the aspirin group and the control group.

Clinical characteristics and outcomes of injuries in agricultural and nonagricultural workers visiting the emergency department: a propensity-matched analysis.

Agriculture is a hazardous industry. However, previous studies have focused on injuries to agricultural workers without comparison with injuries to nonagricultural workers. Therefore, we compared the clinical characteristics and outcomes of injuries reported at an emergency department (ED) between agricultural workers and nonagricultural workers. We established a prospective ED-based agricultural injury surveillance system at a tertiary university hospital. Adult patients visiting the ED for an injury were divided into farmer and non-farmer groups depending on their engagement with agriculture. Using an adjusted multivariate analysis and propensity score matching (age, sex, inhabitant, and insurance type), we compared the clinical characteristics and outcomes of injuries between the farmer and non-farmer groups. In total, 38,556 injured adult patients (37,746 in the non-farmer group and 810 in the farmer group) were available for the unmatched sample analysis. The 1,620 matched subjects were equally classified after one-to-one nearest-neighbor propensity score matching. A multivariate logistic regression analysis of the unmatched sample revealed higher adjusted odds ratios (ORs) for intensive care unit admission (adjusted OR, 1.752; P=0.003) and overall surgery (adjusted OR, 1.870; P<0.001) in the farmer group. In contrast, univariate logistic regression analyses of the propensity score-matched sample found a higher OR in the farmer group only for overall surgery (OR, 1.786; P<0.001). Injuries of agricultural workers had higher odds only of requiring surgery; differences in injury-related mortality between groups were not statistically significant in either the matched or unmatched sample analyses.

Association of Reported Nonsteroidal Anti-Inflammatory Drug (NSAID) Adverse Drug Reactions With Opioid Prescribing After Total Joint Arthroplasty.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for postoperative pain management, but use may be precluded by the report of adverse drug reactions (ADRs). The effect of NSAID ADR labeling on opioid prescribing after total joint arthroplasty (TJA) is unknown. To assess the association between NSAID ADRs and postoperative opioid prescribing after TJA, a common surgical procedure. We performed a retrospective cohort study of adults who underwent total joint (knee or hip) replacement in a single hospital network between April, 1, 2016, and December 31, 2019. Demographic information, clinical and surgical characteristics, and prescription data were obtained from the electronic health record. We studied the association between reported NSAID ADRs and postoperative opioid prescribing in a propensity score-matched sample over 1 year of follow-up. NSAID ADRs were reported by 9.6% of the entire cohort (n= 584/6091). NSAID ADR was associated with 41% higher odds of receipt of opioid prescriptions at 181 to 365 days after hospital discharge (95% confidence interval: 13%-75%) in a propensity score-matched sample. Over 98% of individuals received an opioid prescription at the time of hospital discharge, with no difference in overall median opioid dose prescribed by NSAID ADR status. However, more patients with NSAID ADRs(7.6% vs 4.7%) received cumulative opioid doses ≥ 750 morphine milligram equivalents (MME) at discharge (P=.004). Reported NSAID ADR was associated with increased risk for prolonged receipt of opioids at 181 to 365 days postoperatively. Patients with NSAID ADRs more frequently received cumulative opioid doses ≥ 750 MME at discharge after TJA. Clarification and evaluation of reported NSAID ADRs may be particularly beneficial for surgical patients at high risk for prolonged receipt of opioids.