Propensity Score-weighted Analysis Research Articles

Effects of intravenous hydration in preventing post-contrast acute kidney injury in patients with eGFR < 30mL/min/1.73 m2.

To investigate the effects of intravenous hydration in preventing post-contrast outcomes in patients with estimated glomerular filtration rate (eGFR) < 30mL/min/1.73 m2 undergoing intravenous administration of iodinated contrast media (ICM). Hospitalized patients with eGFR < 30mL/min/1.73 m2 and intravenous ICM exposure between 2015 and 2021 were included. Post-contrast outcomes include post-contrast acute kidney injury (PC-AKI) (defined by 2012 Kidney Disease: Improving Global Outcomes (KDIGO) or European Society of Urogenital Radiology (ESUR)), chronic dialysis at discharge, and in-hospital mortality. Confounding effects between the two groups were reduced to a minimum using propensity score-based matching and overlap weighting. Association between intravenous hydration and outcomes was analyzed using logistic regression. In total, 794 patients were included in the study, with284 receiving intravenous hydration, and 510 not. After 1:1 propensity score matching, 210 pairs were generated. No significant differences were found in the outcomes between the intravenous hydration and no intravenous hydration groups: PC-AKI by KDIGO, 25.2% vs 24.8% (odds ratio (OR), 0.93; 95% confidence interval (CI), 0.57-1.50); PC-AKI by ESUR, 31.0% vs 25.2% (OR, 1.34; 95% CI, 0.86-2.08); chronic dialysis at discharge, 4.3% vs 3.3% (OR, 1.56; 95% CI, 0.56-4.50); in-hospital mortality, 1.9% vs 0.5% (OR, 4.08; 95% CI, 0.58-81.08). Overlap propensity score-weighted analysis alsoshowed no significant effects of intravenous hydration on the incidences of the post-contrast outcomes. Intravenous hydration was not associated with lower risks of PC-AKI, chronic dialysis at discharge, and in-hospital mortality in patients with eGFR < 30mL/min/1.73 m2 undergoing intravenous administration of ICM. This study provides new evidence in supporting that intravenous hydration is not beneficial to patients with eGFR < 30mL/min/1.73 m2 before and after intravenous administration of iodinated contrast media. • Intravenous hydration before and after intravenous administration of ICM is not associated with lower risks in PC-AKI, chronic dialysis at discharge, and in-hospital mortality in patients with eGFR < 30mL/min/1.73 m2. • Withholding intravenous hydration may be considered in patients with eGFR < 30mL/min/1.73 m2 around intravenous administration of ICM.

Association between delirium and statin use in patients with congestive heart failure: a retrospective propensity score-weighted analysis.

The relationship between statin use and delirium remains controversial; therefore, we aimed to study the association between statin exposure and delirium and in-hospital mortality in patients with congestive heart failure. In this retrospective study, patients with congestive heart failure were identified from the Medical Information Mart for Intensive Care database. The primary exposure variable was statin use 3 days after admission to the intensive care unit, and the primary outcome measure was the presence of delirium. The secondary outcome measure was in-hospital mortality. Since the cohort study was retrospective, we used inverse probability weighting derived from the propensity score to balance various variables. Of 8,396 patients, 5,446 (65%) were statin users. Before matching, the prevalence of delirium was 12.5% and that of in-hospital mortality was 11.8% in patients with congestive heart failure. Statin use was significantly negatively correlated with delirium, with an odds ratio of 0.76 (95% confidence interval: [0.66-0.87]; P < 0.001) in the inverse probability weighting cohort and in-hospital mortality of 0.66 (95% confidence interval: [0.58-0.75]; P < 0.001). Statins administered in the intensive care unit can significantly reduce the incidence of delirium and in-hospital mortality in patients with congestive heart failure.

P-236 Aflibercept-based and bevacizumab-based second-line regimens in patients with RAS mutant metastatic colorectal cancer: Propensity score weighted-analysis from a multicenter cohort

P-236 Aflibercept-based and bevacizumab-based second-line regimens in patients with RAS mutant metastatic colorectal cancer: Propensity score weighted-analysis from a multicenter cohort

P-249 Aflibercept-based and bevacizumab-based second-line regimens in patients with RAS/BRAF wild type metastatic colorectal cancer: Propensity score weighted-analysis from a multicenter cohort

P-249 Aflibercept-based and bevacizumab-based second-line regimens in patients with RAS/BRAF wild type metastatic colorectal cancer: Propensity score weighted-analysis from a multicenter cohort

Frailty Among Total Hip and Knee Arthroplasty Recipients: Epidemiology and Propensity Score-Weighted Analysis of Effect on In-Hospital Postoperative Outcomes.

From the Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, MI (Zalikha), and the Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY (El-Othmani). Correspondence to Abdul K Zalikha, MD, Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, MI; email: [email protected].

Causal inference between aggressive extrathyroidal extension and survival in papillary thyroid cancer: a propensity score matching and weighting analysis.

Extrathyroidal extension is a major risk factor for poor prognosis in papillary thyroid cancer. However, the effect of different degrees of extrathyroidal extension on prognosis remains controversial. We performed a retrospective study to elucidate how the extent of extrathyroidal extension in papillary thyroid cancer affected the clinical prognosis of patients and its covariates. The study included 108,426 patients with papillary thyroid cancer. We categorized the extent of extension into none, capsule, strap muscles, and other organs. Three causal inference methods for retrospective studies, namely, inverse probability of treatment weighting, standardized mortality ratio weighting, and propensity score matching analysis, were used to minimize potential selection bias. Kaplan-Meier analysis and univariate Cox regression analyses were applied to analyze the precise effect of ETE on survival in papillary thyroid cancer patients. In the Kaplan-Meier survival analysis, only extrathyroidal extension into or beyond the strap muscles was statistically significant for both overall survival (OS) and thyroid cancer-specific survival (TCSS). In univariate Cox regression analyses before and after matching or weighting based on causal inference, extrathyroidal extension into soft tissues or other organs is a high-risk factor for both overall survival and thyroid cancer-specific survival. Sensitivity analysis revealed that lower overall survival was observed in patients with older age (≥55) and larger tumor size (>2cm) of papillary thyroid cancer with extrathyroidal extension into or beyond the strap muscles. Our study indicates that extrathyroidal extension into soft tissues or other organs is a high-risk factor in all papillary thyroid cancer. Even though invasion into the strap muscles did not seem to be a marker for poor prognosis, it still impaired the overall survival of patients with older age (≥55 years old) or larger tumor size (>2cm). Further investigation is needed to confirm our results and to clarify further risk factors independent of extrathyroidal extension.

Is the use of bipolar hemiarthroplasty over monopolar hemiarthroplasty justified? A propensity score-weighted analysis of a multicentre randomized controlled trial.

Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA). This study is a secondary analysis of patients aged 50 years or older with a displaced femoral neck fracture who were enrolled in the HEALTH trial and underwent monopolar and bipolar HA. Scores from the Western Ontario and McMaster University Arthritis Index (WOMAC) and 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and (MCS) were compared between the two HA groups using a propensity score-weighted analysis. Of 746 HAs performed in the HEALTH trial, 404 were bipolar prostheses and 342 were unipolar. After propensity score weighting, adequate balance between the bipolar and unipolar groups was obtained as shown by standardized mean differences less than 0.1 for each covariable. A total of 24 months after HA, the total WOMAC score and its subcomponents showed no statistically significant difference between the unipolar and bipolar groups. Similarly, no statistically significant difference was found in the PCS and MCS scores of the SF-12 questionnaire. In participants aged 70 years and younger, no difference was found in any of the functional outcomes. From the results of this study, the use of bipolar HA over unipolar design does not provide superior functional outcomes at 24 months postoperatively. The theoretical advantage of reduced acetabular wear with bipolar designs does not appear to influence functional outcomes in the first two years postoperatively.

The prognostic impact of lymphovascular invasion for upper urinary tract urothelial carcinoma: A propensity score-weighted analysis.

Lymphovascular invasion (LVI) predicts poor survival in patients with pathologically localized or locally advanced upper urinary tract urothelial carcinoma (UT-UC). However, LVI is associated with high tumor grade, tumor necrosis, advanced tumor stage, tumor location, concomitant carcinoma in situ, lymph node metastasis, and sessile tumor architecture. These factors might interfere with the analysis of the impact of LVI on oncological prognosis. To address this, this study aimed to clarify the relationship between LVI and patient prognosis in UT-UC using propensity score weighting. Data were collected from 789 patients with UT-UC treated with radical nephroureterectomy without chemotherapy. We evaluated the significance of LVI in predicting metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) using propensity score weighting. All weighted baseline characteristics included in the propensity score model were balanced between the LVI (+) and LVI (-) groups. The MFS, CSS, and OS were all significantly poorer in the LVI (+) group. For patients without LVI, the 5-year MFS, CSS, and OS rates were 65.3%, 73.1%, and 67.3%, respectively, whereas the corresponding rates were 50.2%, 63.8 %, and 54.6%, respectively, for patients with LVI. (all P < .001). For patients without LVI, the 10-year MFS, CSS, and OS rates were 61.5%, 69.6%, and 59.2%, respectively, whereas those for patients with LVI were 44.5%, 57.0%, and 42.7%, respectively (all P < .001). LVI is an important pathological feature that predicts metastasis development and worse survival outcome after radical surgery in UT-UC patients.

Is being a refugee associated with increased 30-day mortality after visiting the emergency department? A register-based cohort study using Danish data.

Refugees face many challenges that could lead to disparity in quality of care from the health-care system compared with native Danes. These challenges could be language barriers, cultural differences, mental health co-morbidities and socio-economic status (SES). The aim of this study was to compare the 30-day mortality of refugees and native Danes after visiting the emergency department (ED) at Aarhus University Hospital, Denmark. In this register-based cohort study linking clinical and socio-demographic data, we included all visits to a major Danish ED from 1 January 2016 to 31 December 2018. According to the predefined analysis plan, we present non-parametric Kaplan-Meier plots and propensity score-weighted analysis. We included 29,257 eligible unique patients of whom 631 were refugees. In the 30-day time period after discharge from the ED, 11 deaths occurred in the group of refugees, resulting in a Kaplan-Meier estimate of 1.8% (95% confidence interval (CI) 0.7-2.8), and 1638 deaths occurred in the group of Danes, resulting in a Kaplan-Meier estimate of 5.9% (95% CI 5.6-6.1). The adjusted 30-day mortality risk difference was 1.6 percentage points (95% CI -2.0 to -1.2 percentage points) lower for refugees compared to native Danes. The 30-day mortality risk difference decreased from approximately 4 to 1.6 percentage points in the adjusted analysis. Thus, there were 16 fewer deaths among refugees within 30 days per 1000 discharged from the ED compared with native Danes when adjusting for age, sex, SES and co-morbidities. This study shows that refugees had a lower 30-day mortality after visiting the ED compared with native Danes.

General anesthesia versus regional anesthesia in patients undergoing obliterative vaginal procedures for pelvic organ prolapse.

The objective was to compare outcomes in patients receiving general versus regional anesthesia when undergoing obliterative vaginal surgery for pelvic organ prolapse. Obliterative vaginal procedures performed from 2010 to 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgeries were categorized into general anesthesia (GA) or regional anesthesia (RA). Rates of reoperation, readmission, operative time, and length of stay were determined. A composite adverse outcome was calculated including any of the following: nonserious or serious adverse events, 30-day readmission, or reoperation. Propensity score-weighted analysis of perioperative outcomes was performed. The cohort included 6,951 patients, of whom 6,537 (94%) underwent obliterative vaginal surgery under GA and 414 (6%) received RA. When comparing outcomes under the propensity score-weighted analysis, operative times were shorter (median 96 vs 104 min, p<0.01) in the RA group versus GA. There were no significant differences between composite adverse outcomes (10% vs 12%, p=0.06), or readmission (5% vs 5%, p=0.83) and reoperation rates (1% vs 2%, p=0.12) between the RA and GA groups. Length of stay was shorter in patients receiving GA than in those receiving RA, especially when undergoing concomitant hysterectomy (67% discharged within 1 day in GA vs 45% in RA, p<0.01). Composite adverse outcomes, reoperation rates, and readmission rates were similar in patients who received RA for obliterative vaginal procedures compared with GA. Operative times were shorter in patients receiving RA than in those receiving GA, and length of stay was shorter in patients receiving GA than in those receiving RA.

Triplets versus doublets in the treatment of right-sided metastatic colorectal cancer in real-world setting: A propensity-score weighting analysis.

55 Background: Right-sided metastatic colorectal cancer (mCRC) has a worse prognosis and the best first-line treatment is still uncertain. The aim of this study was to analyze progression-free survival (PFS) and overall survival (OS) comparing triplet versus doublet backbone chemotherapy in first-line setting for right-sided mCRC. Methods: Retrospective study evaluating 510 patients with mCRC who were treated in a private institution in Brazil from January 2011 to December 2019. Information of 118 patients with right-sided primary tumor was analyzed in this study. Demographic and clinical data were retrieved from electronic medical records. PFS and OS were calculated in months (m) using propensity-score weighting analysis (PSWA) due to expected disparity between the number of patients treated with triplet and doublet regimens. Variables used to balance patient groups were age; metastasectomy; primary tumor resection; bevacizumab use; BRAF and RAS mutation status. Results: The median follow-up was 31 months. Our population was mostly composed of elderly (64%) and female (52%) patients. First-line treatment with triplet backbone chemotherapy was done in 16 patients (14%). Primary tumor resection was done in 14% of the cases, 55% underwent metastasectomy, and 57% received anti-VEGF treatment. BRAF mutation was found in 9% of the patients and RAS mutation in 46%. After PSWA we found a significant better median PFS among patients treated with triplet regimen: 12.7m versus 8.9m compared to those receiving doublet backbone chemotherapy, with a hazard ratio of 0.64 (CI 95%: 0.42 – 0.97); p-value: 0.037. No significant difference was found in OS (29.8m versus 45.5m) between triplet and doublet therapy groups, respectively. Conclusions: In our study we found a significantly better PFS with triplet backbone chemotherapy in first-line setting for right-sided mCRC, encouraging the use of this regimen in treatment-naive selected patients. However, no difference in OS was found, probably due to subsequent treatments. PSWA is an acceptable and needed tool to enable retrospective real world studies involving treatments with expected uneven distribution. More studies are needed to answer the best strategy to target right-sided mCRC, which remains a challenge for oncologists, with unmet needs.

Combined transarterial chemoembolization and external beam radiotherapy for identifying surgical candidates for hepatocellular carcinoma with macroscopic vascular invasion: A propensity score-weighted analysis.

562 Background: To evaluate the role of hepatic resection in patients with objective responses after combined transarterial chemoembolization (TACE) and radiotherapy (RT) for hepatocellular carcinoma (HCC) with macroscopic vascular invasion (MVI). Methods: We retrospectively reviewed the patients treated with combined TACE and RT as a first-line treatment for HCC with MVI between 2010 and 2015. Some patients with objective responses underwent hepatic resection or liver transplantation. Surgical resectability was determined by the hepatobiliary and transplant surgeons of the multidisciplinary team for liver cancer. To investigate the role of surgery, patients with objective responses who did not undergo surgery were selected as a control group. The survival outcomes between the patients who received surgery and those who did not were compared using a propensity score-based stabilized inverse probability of treatment weighting method to minimize selection bias. Time-dependent survival analysis by surgery was performed. Results: Of the 170 patients with objective responses after combined TACE and RT, surgery was performed for 41 patients, including 8 liver transplantations. The unweighted surgery group was younger and had a higher proportion of solitary tumor and unilateral vascular involvement. After adjustment, the overall survival rates at 3 years were 61.0% and 28.6% in surgery and non-surgery groups, respectively. The most important prognostic factor for overall survival was surgery (adjusted Cox hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.17–0.46; p-value &lt; 0.001). Complete response after TACE and RT was also a significant prognostic indicator for overall survival (adjusted HR, 0.41; 95% CI, 0.27–0.61; p-value &lt; 0.001). There was no surgical mortality. Four patients (9.8%) required additional surgery for postoperative bleeding or graft failure. Conclusions: Hepatic resection was significantly associated with improved overall survival in patients with objective responses after combined TACE and RT for HCC with MVI.

Frailty Among Total Hip and Knee Arthroplasty Recipients: Epidemiology and Propensity Score-weighted Analysis of Effect on In-hospital Postoperative Outcomes.

Total joint arthroplasty (TJA) is one of the most successful and frequently performed procedures in the United States. The number of these procedures is projected to continue growing rapidly in the coming years, and with it comes the demand for more sophisticated perioperative risk and complication assessment. This study examines the effect of frailty on postoperative inpatient complications and hospital resource utilization after TJA. Discharge data from the National Inpatient Sample were used to identify all patients aged 50 years or older who underwent TJA between 2006 and 2015. Nonelective admissions and hip fractures were excluded. Patients were stratified into two groups with and without concomitant ICD-9 diagnostic criteria that qualified them has having frailty. An analysis comparing the 2 groups' epidemiology, medical comorbidities, and propensity score-weighted postoperative clinical and economic outcomes was done. A total of 7,854,890 TJAs were included in this analysis, with 136,516 meeting the criteria for frailty and 7,718,374 being nonfrail. Among these patients, the average age was 67.3 years and the female distribution was 61.1%. Frail patients were found to have markedly higher rates of all but two individual comorbidities constituting the Modified Elixhauser Profile compared with nonfrail patients. Compared with the control group, frail patients were found to have increased risk of any postoperative complication, central nervous system complications, hematoma/seroma, wound dehiscence, infection, and postoperative anemia. Frail patients also had longer length of stay, higher discharge to rehabilitation facilities, and higher hospital charges. Patients with frailty undergoing TJA procedures are at a markedly higher risk for developing postoperative complications and worse hospital economic outcomes. As this patient population continues to increase, it is imperative for clinicians to use their risk factors in optimizing their perioperative care and support.

Hepatocellular carcinoma risk in patients with chronic hepatitis B receiving tenofovir- vs. entecavir-based regimens: Individual patient data meta-analysis

The comparative risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB) receiving tenofovir disoproxil fumarate (TDF) vs. entecavir (ETV) remains controversial. In this individual patient data (IPD) meta-analysis, we aimed to compare HCC risk between the two drugs and identify subgroups who may benefit more from one treatment than the other. Published meta-analyses, electronic databases and congress proceedings were searched to identify eligible studies through January 2021. We compared HCC risk between the two drugs using a multivariable Cox proportional hazards model with anonymised IPD from treatment-naïve patients with CHB receiving TDF or ETV for ≥1 year. Treatment effect consistency was explored in propensity score matching (PSM), weighting (PSW) and subgroup analyses for age, sex, hepatitis B e-antigen (HBeAg) positivity, cirrhosis and diabetes status. We included 11 studies from Korea, Taiwan and Hong Kong involving 42,939 patients receiving TDF (n= 6,979) or ETV (n= 35,960) monotherapy. Patients receiving TDF had significantly lower HCC risk (adjusted hazard ratio [HR] 0.77; 95% CI 0.61-0.98; p= 0.03). Lower HCC risk with TDF was consistently observed in PSM (HR 0.73; 95% CI 0.59-0.88; p <0.01) and PSW (HR 0.83; 95% CI 0.67-1.03; p= 0.10) analyses and in all subgroups, with statistical significance in the ≥50 years of age (HR 0.76; 95% CI 0.58-1.00; p <0.05), male (HR 0.74; 95% CI 0.58-0.96; p= 0.02), HBeAg-positive (HR 0.69; 95% CI 0.49-0.97; p= 0.03) and non-diabetic (HR 0.79; 95% CI 0.63-1.00; p <0.05) subgroups. TDF was associated with significantly lower HCC risk than ETV in patients with CHB, particularly those with HBeAg positivity. Longer follow-up may be needed to better define incidence differences between the treatments in various subgroups. Previous aggregate data meta-analyses have reported inconsistent conclusions on the relative effectiveness of tenofovir disoproxil fumarate and entecavir in reducing hepatocellular carcinoma risk in patients with chronic hepatitis B (CHB). This individual patient data meta-analysis on 11 studies involving 42,939 patients from Korea, Taiwan and Hong Kong suggested that tenofovir disoproxil fumarate-treated patients have a significantly lower hepatocellular carcinoma risk than entecavir-treated patients, which was observed in all subgroups of clinical interest and by different analytical methodologies. These findings should be taken into account by healthcare providers when determining the optimal course of treatment for patients with CHB and may be considered in ensuring that treatment guidelines for CHB remain pertinent.

Impact of Transfusion Program during Pregnancy on the Obstetrical Outcomes in Sickle Cell Disease Women

Introduction: Pregnancy in sickle cell womenis associated with adverse maternal outcomes. Studies evaluating the effects of the transfusion program (TP) during pregnancy are contradictory. The objective of this retrospective study was to evaluate the effect of the transfusion program on maternal and neonatal outcomes in Sickle cell disease (SCD) . Since the publications highlighting the frequency of delayed hemolysis transfusion reaction (DHTR) in SCD patients and particularly in pregnant women, transfusion(TF) indications have changed in the management of pregnancies. Transfusion indications have been limited since 2015 in view of the risks of alloimmunization and DHTR, associated with the lack of evidence of obstetrical benefit, in SCD pregnancies (10). Our objective was to evaluate the impact of the transfusion program during pregnancy on obstetric and neonatal outcomes with a propensity score to account for potential biases. Method: This is a retrospective cohort study based on analysis of electronic and paper medical records including all pregnancies in women with SCD (Hb SS, SC, S beta-thalassemia phenotypes) who received prenatal care delivered in a French tertiary care academic center (CHI-Créteil) and in Henri Mondor SCD referral center between January 2004 and December 2017. The DHTR risk score was defined for all patients. Confounding factors considered in a propensity score were delivery period, SCD genotype, history of acute chest syndrome (ACS), and delayed hemolytic transfusion reaction (DHTR) risk score. Results: We analyzed 246 pregnancies in 173 patients. Twenty-two pregnancies with a history of DHTR were analyzed separately. We found a higher frequency of TP before 2013 (119/148 [80.4%] vs 38/76 [50%], p<0.001). Patients with a history of ACS and a low DHTR risk score were significantly more represented in the transfusion program group. There was no difference between the two groups in the frequency of preeclampsia, eclampsia, Hellp syndrome, term of delivery , births <37 weeks, birth weight, and cesarean section. Punctual transfusions were more frequent in the group without TF program. Rates of preterm birth before 34 weeks, vaso-occlusives crisis(VOC) and ACS during pregnancy were significantly more frequent in the group without a transfusion program. There were 4 inaugural DHTRs in each of the 2 groups and 4 deaths in the TF Program group; this difference was not significant. Multivariate analysis weighted by propensity score showed that TF program was associated only with a significant reduction in the risk of preterm delivery before 34 weeks (OR= 0.05 95% CI [0.01-0.31], p = 0.001). Of the 22 pregnancies with a history of DHTR, 4 were complicated by a new DHTR event after emergency transfusion. The rates of delivery before 34 and 37 Weeks of gestation, neonatal death, frequency of ACS, hospitalization during pregnancy and in intensive care unit, and composite adverse obstetric outcome were significantly different between the group with a history of DHTR and all patients without known DHTR, confirming the potential seriousness of these patients. Conclusion: This study shows a trend toward reduced routine use of the transfusion program during pregnancy. There was no difference between the two groups( TP and without TP) in the frequency of pre-eclampsia, eclampsia, Hellp syndrome, term of delivery and births <37 weeks, birth weight and caesarean section. Propensity score-weighted analysis reveals an independent protective effect of the transfusion program on prematurity before 34 weeks as well as composite obstetric criteria (birth <34 weeks and/or preeclampsia and/or SGA and/or abruption and/or IUFD and/or maternal death and/or neonatal death). Although the benefit/risk balance of the transfusion program should be considered on a case-by-case basis with the DHTR risk score in early pregnancy. In patients with low transfusion risk, transfusions may be recommended upon discontinuation of HU or in case of VOC complications. Prospective studies are still needed on large homogeneous patient populations and the evaluation of alternative treatments to transfusion such as hydroxycarbamide seems important.

Anticholinergic drugs for death rattle in dying patients with cancer: multicentre prospective cohort study

BackgroundThis study aimed to investigate the effectiveness of anticholinergics (AC) for death rattle in dying patients with cancer.MethodsThis is a prospective cohort study enrolled Terminally ill adult (20 years or...

Robotic Approach for Lymphadenectomy in Biliary Tumors: The Missing Ring Between the Benefits of Laparoscopic and Reproducibility of Open Approach?

This study aimed to evaluate the oncological adequacy of lymphadenectomy (LND) for biliary tumors and surgical outcomes of resections performed using robotic, laparoscopic, and open approaches and to compare the techniques within a weighted propensity score analysis. The need to perform formal LND is considered a limit for the applicability of minimally invasive liver surgery. Overall, 25 robotic resections with LND (2021-2022) from a single-center constituted the study group (Rob group), matched by inverse probability treatment weighting with 97 laparoscopic (Lap group) and 113 open (Open group) procedures to address the primary endpoint. A "per-period" analysis was performed comparing the characteristics and outcomes of the Rob group with the first 25 consecutive laparoscopic liver resections with associated LND (LapInit group). Minimally invasive techniques performed equally well regarding the number of harvested nodes, blood transfusions, functional recovery, length of stay, and major morbidity and provided a short-term benefit to patients when compared with the open technique. A better performance of the robotic approach over laparoscopic approach (and both approaches over the open technique) was recorded for patients achieving LND with retrieval of >6 nodes. The open approach reduced both the operative time and time for LND, and robotic surgery performed better than laparoscopic surgery. Minimally invasive techniques are excellent tools for the management of LND in patients with biliary tumors, showing feasibility, and oncological adequacy. Robotics could contribute to the large-scale diffusion of these procedures with a high profile of complexity.

Association of ventilator-free days with respiratory physiotherapy in critically ill patients with Coronavirus Disease 2019 (COVID-19) during the first pandemic wave. A propensity score-weighted analysis.

BackgroundRespiratory physiotherapy is reported as safe and feasible in mechanically ventilated patients with severe Coronavirus Disease (COVID-19) admitted to Intensive Care Unit (ICU), but the short-term benefits remain unclear.MethodsWe performed a retrospective observational study in four ICUs in Northern Italy. All patients with COVID-19 admitted to ICU and under invasive mechanical ventilation (MV) between March 1st and May 30th, 2020, were enrolled into the study. Overlap weighting based on the propensity score was used to adjust for confounding in the comparison of patients who had or had not been treated by physiotherapists. The primary outcome was the number of days alive and ventilator-free (VFDs). The secondary outcomes were arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio (P/F) at ICU discharge, ICU length of stay, ICU and hospital mortality, and survival at 90 days. The trial protocol was registered on clinicaltrials.gov (NCT 05067907).ResultsA total of 317 patients were included in the analysis. The median VFDs was 18 days [interquartile range (IQR) 10; 24] in patients performing physiotherapy and 21 days (IQR 0; 26) in the group without physiotherapy [incidence rate ratio (IRR) 0.86, 95% confidence interval (CI): 0.78; 0.95]. The chance of 0 VFDs was lower for patients treated by physiotherapists compared to those who were not [odds ratio (OR) = 0.36, 95% CI: 0.18–0.71]. Survival at 90 days was 96.0% in the physiotherapy group and 70.6% in patients not performing physiotherapy [hazard ratio (HR) = 0.14, 95% CI: 0.03–0.71]. Number of VFDs was not associated with body mass index (BMI), sex, or P/F at ICU admission for individuals with at least 1 day off the ventilator.ConclusionIn patients with COVID-19 admitted to ICU during the first pandemic wave and treated by physiotherapists, the number of days alive and free from MV was lower compared to patients who did not perform respiratory physiotherapy. Survival at 90 days in the physiotherapy group was greater compared to no physiotherapy. These findings may be the starting point for further investigation in this setting.

Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis

BackgroundThe mortality rate for a patient with a refractory cardiogenic shock on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains high, and hyperoxia might worsen this prognosis. The objective of the present study was to evaluate the association between hyperoxia and 28-day mortality in this setting.MethodsWe conducted a retrospective bicenter study in two French academic centers. The study population comprised adult patients admitted for refractory cardiogenic shock. The following arterial partial pressure of oxygen (PaO2) variables were recorded for 48 h following admission: the absolute peak PaO2 (the single highest value measured during the 48 h), the mean daily peak PaO2 (the mean of each day’s peak values), the overall mean PaO2 (the mean of all values over 48 h), and the severity of hyperoxia (mild: PaO2 < 200 mmHg, moderate: PaO2 = 200–299 mmHg, severe: PaO2 ≥ 300 mmHg). The main outcome was the 28-day all-cause mortality. Inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in baseline characteristics.ResultsFrom January 2013 to January 2020, 430 patients were included and assessed. The 28-day mortality rate was 43%. The mean daily peak, absolute peak, and overall mean PaO2 values were significantly higher in non-survivors than in survivors. In a multivariate logistic regression analysis, the mean daily peak PaO2, absolute peak PaO2, and overall mean PaO2 were independent predictors of 28-day mortality (adjusted odds ratio [95% confidence interval per 10 mmHg increment: 2.65 [1.79–6.07], 2.36 [1.67–4.82], and 2.85 [1.12–7.37], respectively). After IPW, high level of oxygen remained significantly associated with 28-day mortality (OR = 1.41 [1.01–2.08]; P = 0.041).ConclusionsHigh oxygen levels were associated with 28-day mortality in patients on VA-ECMO support for refractory cardiogenic shock. Our results confirm the need for large randomized controlled trials on this topic.

The impact of infectious diseases consultation for children with Staphylococcus aureus bacteremia.

Despite clear benefit of improved outcomes in adults, the impact of infectious diseases (ID) consultation for Staphylococcus aureus bacteremia in children remains understudied. To assess the impact of pediatric ID consultation on management and outcomes, we conducted a cohort study of children with S. aureus bacteremia at St. Louis Children's Hospital from 2011 to 2018. We assessed adherence to six established quality-of-care indicators (QCIs). We applied propensity score methodology to examine the impact of ID consultation on risk of treatment failure, a composite of all-cause mortality or hospital readmission within 90 days. Of 306 patients with S. aureus bacteremia, 193 (63%) received ID consultation. ID consultation was associated with increased adherence to all QCIs, including proof-of-cure blood cultures, indicated laboratory studies, echocardiography, source control, targeted antibiotic therapy, and antibiotic duration. Obtaining proof-of-cure blood cultures and all indicated laboratory studies were associated with improved outcomes. In propensity score-weighted analyses, risk of treatment failure was similar among patients who did and did not receive ID consultation. However, the number of events was small and risk estimates were imprecise. For children with S. aureus bacteremia, ID consultation improved adherence to QCIs, some of which were associated with improved clinical outcomes. In children with Staphylococcus aureus bacteremia, consultation by an infectious diseases (ID) physician improved adherence to established quality-of-care indicators (QCIs). The current literature regarding ID consultation in pediatric S. aureus bacteremia is sparse. Three prior international studies demonstrated improved quality of care with ID consultation, though results were disparate regarding clinical outcomes. This article impacts the current literature by strengthening the evidence that ID consultation in children improves adherence to QCIs, and demonstrates that adherence to QCIs improves clinical outcomes.