Survival Relative Risk Research Articles

Custo-Efetividade da Oxigenação por Membrana Extracorpórea Venoarterial no Choque Cardiogênico Refratário: Um Estudo na Perspectiva Brasileira

Abstract Background Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. Methods We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. Results In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Conclusions Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Cost-Utility of Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock: A Brazilian Perspective Study.

Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest.

The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes. In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes. We identified 562 index in-hospital cardiac arrests (median [Q1, Q3] age 2.9 years [0.6, 10.0], 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (adjusted risk ratio, 0.97 [95% CI, 0.95-0.99]; P=0.02). Longest CC pause duration was also associated with survival to hospital discharge (adjusted risk ratio, 0.98 [95% CI, 0.96-0.99]; P=0.01) and return of spontaneous circulation (adjusted risk ratio, 0.93 [95% CI, 0.91-0.94]; P<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with adjusted risk ratio of return of spontaneous circulation, but not survival or neurological outcomes. Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.

Abstract 125: The Association of Racial Residential Segregation and Survival to Discharge After Out-of-Hospital Cardiac Arrest in the United States

Introduction: Racial and economic segregation is associated with poor health outcomes, including out-of-hospital cardiac arrest (OHCA) survival. Prior work identified disparities in OHCA survival for Medicare beneficiaries associated with residential segregation. We sought to use registry data to evaluate this association of racial and economic segregation with OHCA survival to discharge. Methods: We conducted a retrospective analysis of the 2013-2021 Cardiac Arrest Registry toEnhance Survival OHCA dataset. Arrests with missing data, pediatric patients, or EMS-witnessed were excluded. Our primary predictor, the index of concentration at the extremes(ICE), is a validated measure of racial and economic segregation. We examined three ICE measures (race, income, and race + income) calculated from US Census data and binned into tract-level quintiles. The primary outcome was survival to discharge. We performed multi-levelPoisson regression, with hospital random effect, and adjusted for age, gender, race and ethnicity, witness status, location, and bystander CPR to predict relative risk of survival to discharge and good neurological outcome. Results: We identified 624,626 adult OHCA patients with median age 64 years (SD 17), 38%female, 22% Black/African American, 50% White, 6.8% Hispanic/Latino. Overall, 156,712 (25%)survived to hospital admission, 10% survived to hospital discharge and 6.3% had good neurological outcome. Patients residing in the most segregated White and higher income tracts(Q5) had a 7-10% higher likelihood of survival to discharge compared to the most segregatedBlack and lower income communities (Q1) across all three measures (race RR: 1.09, CI 1.05-1.12; income RR: 1.07, CI 1.04-1.10; race + income RR: 1.10, CI 1.06-1.13). Similarly, neurological recovery was higher in Q5 (race RR: 1.20, CI 1.15-1.25; income RR: 1.12, CI 1.08-1.16; race + income RR: 1.19, CI 1.15-1.23) compared to Q1. Conclusion: We identified outcome disparities across three ICE measures for residents of the most segregated and lowest income Black census tracts compared to those in most segregated higher income White census tracts. Future work should focus on interventions for these disparities to improve survival and address health inequities.

Mix-supervised multiset learning for cancer prognosis analysis with high-censoring survival data

High censoring phenomenon usually occurs in cancer prognosis analysis, which, however, would introduce bias for model construction and limit generalization performance. In this paper, we first explore and identify an appropriate censoring range for cancer prognosis evaluation, upon which we present a mix-supervised multiset learning framework to cope with high-censoring data. Specifically, we construct multiple subsets with the specified censoring proportion, followed by a multiset representation learning method to learn subset-specific representations, which equips with adversary integrality preservation and dependency limitation constraints to ensure the unbiasedness of subsets and eliminate the redundancy among subsets, respectively. Furthermore, a mix-supervised multiset fusion model is proposed to estimate the relative survival risk, in which teacher model can make full use of the survival time of uncensored samples and the prognosis-related attributes of censored ones to generate reliable pseudo-labels and latent-space for student model. We evaluate the proposed method on three public datasets, and extensive experimental results demonstrate its superiority.

Survival benefit of active surveillance for papillary thyroid carcinoma: a propensity score matching analysis based on SEER database.

Over-treatment of papillary thyroid microcarcinoma (PTMC) has become a common issue. Although active surveillance (AS) has been proposed as an alternative treatment to immediate surgery for PTMC, its inclusion criteria and mortality risk have not been clearly defined. The purpose of this study was to investigate whether surgery can achieve significant survival benefits in patients with larger tumor diameter of papillary thyroid carcinoma (PTC), in order to evaluate the feasibility of expanding the threshold for active surveillance. This study retrospectively collected data of patients with papillary thyroid carcinoma from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2019. The propensity score matching (PSM) method was used to minimize confounding factors and selection bias between the surgery and non-surgery groups, and to compare the clinical and pathological characteristics between the two groups based on the SEER cohort. Meanwhile, the impact of surgery on prognosis was compared using Kaplan-Meier estimates and Cox proportional hazard models. A total of 175,195 patients were extracted from the database, including 686 patients who received non-surgical treatment, and were matched 1:1 with patients who received surgical treatment using propensity score matching. The Cox proportional hazard forest plot showed that age was the most important factor affecting overall survival (OS) of patients, while tumor size was the most important factor affecting disease-specific survival (DSS) of patients. In terms of tumor size, there was no significant difference in DSS between PTC patients with tumor size of 0-1.0cm who underwent surgical treatment and those who underwent non-surgical treatment, and the relative survival risk began to increase after the tumor size exceeded 2.0cm. Additionally, the Cox proportional hazard forest plot showed that chemotherapy, radioactive iodine, and multifocality were negative factors affecting DSS. Moreover, the risk of death increased over time, and no plateau phase was observed. For patients with papillary thyroid carcinoma (PTC) staged as T1N0M0, AS is a feasible management strategy. As the tumor diameter increases, the risk of death without surgical treatment gradually increases, but there may be a threshold. Within this range, a non-surgical approach may be a potentially viable management strategy. However, beyond this range, surgery may be more beneficial for patient survival. Therefore, it is necessary to conduct more large-scale prospective randomized controlled trials to further confirm these findings.

Abstract 255: Association Of Hospital Market Area Dominance With Out-of-hospital Cardiac Arrest Survival To Admission

Introduction: Access to care has been measured by geographic distance, transport time or provider density. For emergency care sensitive conditions, like out-of-hospital cardiac arrest (OHCA), market area coverage may be associated with short-term outcomes due to the need for access to definitive care. Our objective was to evaluate the association of market area dominance with survival to hospital admission. Methods: ED-treated OHCA were identified in age-eligible Medicare fee-for service claims using ICD 9/10 codes and ED charges. Hospital market shares were defined as the cumulative proportion of all OHCA claims treated at the hospital of interest within a group of ZIP code tabulation areas (ZCTAs) centered around the hospital. Market share was calculated using sequential addition of ZCTAs. Hospital Market Areas (HMAs) included all ZCTAs where the cumulative market share exceeded a threshold (&lt;50% 50-74% 75-89% ≥90%). Survival to admission was determined using in-patient claims and vital status data. The primary predictor, maximum HMA threshold, is the highest market share proportion covering that ZCTA. A ZCTA with a 90% max HMA has one hospital treating 90% of OHCA case in that ZCTA or closer. Relative risk of survival was calculated using modified Poisson regression with hospital random effect and patient characteristics (age, sex, race, comorbidity). Results: Of the 194,914 claims treated at 4,436 hospitals between 2013 and 2015, 45% were female, 16% Black, 77% White, and 50% from large metro areas. 28% of claims were from a ZCTA with &lt;50% max HMA (an area where no single hospital treats the majority of OHCA). Relative risk of survival to admission decreased as the max HMA increased [RR[95%CI] 50-74%: 0.97[0.95, 0.99]; 75-89%: 0.94 [0.91, 0.98]; ≥90%: 0.90 [0.83, 0.98]. Small and non-metro areas were associated with lower survival likelihood. Interactions were not significant between max HMA and small metro areas; non-metro areas saw a greater reduction in survival likelihood for ZCTAs with max HMAs &gt;75%. Conclusion: For OHCA, market dominance was associated with lower likelihood of survival to hospital admission. The likelihood of survival decreased as market dominance increased. Further study is needed to develop strategies to mitigate this disparity.

Death or survival, which you measure may affect conclusions: A methodological study.

Background and AimsConsidering the opposite outcome—for example, survival instead of death—may affect conclusions about which subpopulation benefits more from a treatment or suffers more from an exposure.MethodsFor case studies on death following COVID‐19 and bankruptcy following melanoma, we compute and interpret the relative risk, odds ratio, and risk difference for different age groups. Since there is no established effect measure or outcome for either study, we redo these analyses for survival and solvency.ResultsIn a case study on COVID‐19 that ignores confounding, the relative risk of death suggested that 40–49‐year‐old Mexicans with COVID‐19 suffered more from their unprepared healthcare system, using Italy's system as a baseline, than their 60–69‐year‐old counterparts. The relative risk of survival and the risk difference suggested the opposite conclusion. A similar phenomenon occurred in a case study on bankruptcy following melanoma treatment.ConclusionTo increase transparency around this paradox, researchers reporting one outcome should note if considering the opposite outcome would yield different conclusions. When possible, researchers should also report or estimate underlying risks alongside effect measures.

Effect of multidisciplinary team care on survival of oesophageal cancer patients: a retrospective nationwide cohort study

Oesophageal cancer is the sixth leading cause of cancer death worldwide. This nationwide study analyses the survival results of oesophageal cancer under multidisciplinary team (MDT) care. We enrolled oesophageal cancer patients diagnosed between 2010 and 2015 with follow-up for at least 1 year. This study performed propensity score matching with a ratio of 1:1 between MDT participants and non-MDT participants. We performed conditional Cox proportional hazards model to research relative risk of survival and associated factors of survival. The adjusted survival curves were plotted. 8184 newly diagnosed oesophageal cancer patients were included. The favourable survival factors include participant status of MDT, gender, monthly salary, urbanization level, other catastrophic illness, stage of cancer, treatment methods, and service volume of physicians (P < 0.05). MDT participants showed lower risk of death (HR = 0.73; 95% CI 0.67–0.79). Further stratification analysis revealed that the incorporation of an MDT reduced the death risk of patients with stages 2, 3, and 4 cancer, with the greatest reduction observed in patients with stage 3 cancer (HR = 0.72; 95% CI 0.67–0.79). The risk of death was lower for oesophageal cancer patients who enrolled in MDT care.

Patient survival in severe low-flow, low-gradient aortic stenosis after aortic valve replacement or conservative management.

Background and aimClassical and paradoxical low‐flow, low‐gradient (LFLG) aortic stenosis (AS) are the most challenging subtypes of AS. The current therapeutic options are aortic valve replacement (AVR) and conservative management: AVR promotes long‐term survival but is invasive, while conservative management yields a poor prognosis but is noninvasive since it uses no aortic valve replacement (noAVR). The present meta‐analysis investigated the rate of survival of patients with LFLG AS undergoing either AVR or noAVR interventions.MethodsThe meta‐analysis compared the outcomes of AVR with those of noAVR in terms of patient survival. In both groups, a meta‐regression was conducted to investigate the impact on patient survival of the left ventricular ejection fraction (LVEF), either preserved (paradoxical LFLG AS) or reduced (classical LFLG AS).ResultsThe relative risk of survival between the AVR and noAVR groups was 1.99 [1.40, 2.82] (p = .0001), suggesting that survival tends to be better in AVR patients than in noAVR patients. The meta‐regression revealed that a reduced LVEF may be related to a higher survival in AVR patients when compared to a preserved LVEF (p = .04). Finally, the analysis indicated that LVEF seems not to be prognostic of survival in noAVR patients (p = .18).ConclusionsPatients with LFLG AS have better survival if they undergo AVR. In AVR patients, reduced LVEF rather than preserved LVEF is related to better survival, whereas there seems to be no difference in prognostic value between reduced and preserved LVEF in noAVR patients.

Prognostic value of ephrin B receptors in breast cancer: An online survival analysis using the microarray data of 3,554 patients.

The roles of Ephrin B (EphB) receptors in cancer are relatively unknown as these receptors are associated with complex signaling pathways. A limited number of studies have investigated the association between EphB receptors and prognosis. Using the Kaplan-Meier plotter database, the present study investigated the associations between the mRNA expression levels of five EphB receptors and the outcomes of 3,554 patients with breast cancer who had been followed-up for 20 years. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated to assess the relative risk of survival. The results demonstrated that high mRNA expression levels of EphB2 (HR, 0.74; 95% CI, 0.66–0.84; P=2.1×10-6), EphB4 (HR, 0.82; 95% CI, 0.72–0.93; P=0.0023) and EphB6 (HR, 0.69; 95% CI, 0.61–0.78; P=3×10-9) were significantly associated with improved survival, while a high mRNA expression level of EphB3 (HR, 1.14; 95% CI, 1.01–1.28; P=0.029) was associated with worse survival for patients with breast cancer. High expression levels of all EphB receptors, including EphB1 (HR, 1.4; 95% CI, 1.02–1.94; P=0.039), EphB2 (HR, 1.34; 95% CI, 1.07–1.67; P=0.011), EphB3 (HR, 1.39; 95% CI, 1.11–1.73, P=0.0038), EphB4 (HR, 1.33; 95% CI, 1.06–1.67; P=0.013) and EphB6 (HR, 1.32; 95% CI, 1.05–1.65; P=0.016), were associated with an increased risk of mortality in patients with lymph-node-positive breast cancer. High mRNA expression levels of EphB1 were not associated with survival for all patients with breast cancer (HR, 0.85; 95% CI, 0.72–1.01; P=0.058). The results of the present suggested that EphB receptors may be useful as prognostic biomarkers of breast cancer.

Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury \u2013 a multicentre prospective cohort study and systematic review

BackgroundIntracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT.MethodsWe included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016.ResultsAmong the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99–2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36–2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4–5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04–1.95), p = 0.03, I2 = 15%).ConclusionsCHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.

The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis

BackgroundThe optimal prehospital fluid for the treatment of hypotension is unknown. Hypertonic fluids may increase circulatory volume and mute the pro-inflammatory response of the body to injury and illness. The purpose of this systematic review is to determine whether in patients presenting with hypotension in the prehospital setting (population), the administration of hypertonic saline (intervention), compared to an isotonic fluid (control), improves survival to hospital discharge (outcome).MethodsSearches were conducted in Medline, Embase, CINAHL, and CENTRAL from the date of database inception to November, 2016, and included all languages. Two reviewers independently selected randomized control trials of hypotensive human participants administered hypertonic saline in the prehospital setting. The comparison was isotonic fluid, which included normal saline, and near isotonic fluids such as Ringer’s Lactate. Assessment of study quality was done using the Cochrane Collaborations’ risk of bias tool and a fixed effect meta-analysis was conducted to determine the pooled relative risk of survival to hospital discharge. Secondary outcomes were reported for fluid requirements, multi-organ failure, adverse events, length of hospital stay, long term survival and disability.ResultsOf the 1160 non-duplicate citations screened, thirty-eight articles underwent full-text review, and five trials were included in the systematic review. All studies administered a fixed 250 ml dose of 7.5% hypertonic saline, except one that administered 300 ml. Two studies used normal saline, two Ringer’s Lactate, and one Ringer’s Acetate as control. Routine care co-interventions included isotonic fluids and colloids. Five studies were included in the meta-analysis (n = 1162 injured patients) with minimal statistical heterogeneity (I2 = 0%). The pooled relative risk of survival to hospital discharge with hypertonic saline was 1.02 times that of patients who received isotonic fluids (95% Confidence Interval: 0.95, 1.10). There were no consistent statistically significant differences in secondary outcomes.ConclusionsThere was no significant difference in important clinical outcomes for hypotensive injured patients administered hypertonic saline compared to isotonic fluid in the prehospital setting. Hypertonic saline cannot be recommended for use in prehospital clinical practice for the management of hypotensive injured patients based on the available data.PROSPERO registration # CRD42016053385.

Survival and Neurodevelopmental Outcomes among Periviable Infants

BackgroundData reported during the past 5 years indicate that rates of survival have increased among infants born at the borderline of viability, but less is known about how increased rates of survival among these infants relate to early childhood neurodevelopmental outcomes.MethodsWe compared survival and neurodevelopmental outcomes among infants born at 22 to 24 weeks of gestation, as assessed at 18 to 22 months of corrected age, across three consecutive birth-year epochs (2000–2003 [epoch 1], 2004–2007 [epoch 2], and 2008–2011 [epoch 3]). The infants were born at 11 centers that participated in the National Institute of Child Health and Human Development Neonatal Research Network. The primary outcome measure was a three-level outcome — survival without neurodevelopmental impairment, survival with neurodevelopmental impairment, or death. After accounting for differences in infant characteristics, including birth center, we used multinomial generalized logit models to compare the relative risk of survival without neurodevelopmental impairment, survival with neurodevelopmental impairment, and death.ResultsData on the primary outcome were available for 4274 of 4458 infants (96%) born at the 11 centers. The percentage of infants who survived increased from 30% (424 of 1391 infants) in epoch 1 to 36% (487 of 1348 infants) in epoch 3 (P<0.001). The percentage of infants who survived without neurodevelopmental impairment increased from 16% (217 of 1391) in epoch 1 to 20% (276 of 1348) in epoch 3 (P=0.001), whereas the percentage of infants who survived with neurodevelopmental impairment did not change significantly (15% [207 of 1391] in epoch 1 and 16% [211 of 1348] in epoch 3, P=0.29). After adjustment for changes in the baseline characteristics of the infants over time, both the rate of survival with neurodevelopmental impairment (as compared with death) and the rate of survival without neurodevelopmental impairment (as compared with death) increased over time (adjusted relative risks, 1.27 [95% confidence interval {CI}, 1.01 to 1.59] and 1.59 [95% CI, 1.28 to 1.99], respectively).ConclusionsThe rate of survival without neurodevelopmental impairment increased between 2000 and 2011 in this large cohort of periviable infants. (Funded by the National Institutes of Health and others; ClinicalTrials.gov numbers, NCT00063063 and NCT00009633.)

Trends in ethnic and socioeconomic inequalities in cancer survival, New Zealand, 1991–2004

Improvements in cancer survival may be distributed inequitably throughout populations and across time. We assessed trends in cancer survival inequalities in New Zealand by ethnic and income group. 126,477 people diagnosed with cancer between 1991 and 2004, followed-up to 2006, were included. First, inequalities pooled over time were measured with excess mortality rate ratios (EMRRs). Second, interpretation of changes in inequalities over time can differ depending on whether one uses EMRRs, excess mortality rate differences (EMRD) or absolute differences in relative survival risks (RSRD); we estimated all three by cancer-site and (for EMRRs only) pooled across all sites. We found that pooled over time and all sites, Māori had an EMRR of 1.29 (95% CI, 1.24–1.34) compared to non-Māori. The low compared to high-income EMRR was 1.12 (95% CI, 1.09–1.15). Pooled over cancers, there was no change in the ethnic EMRR over time but the income EMRR increased by 9% per decade (1–17%). Changes over time in site-specific inequalities were imprecisely measured, but the direction of change was usually consistent across EMRRs, EMRDs and RSRDs. There were persistent ethnic inequalities in cancer survival over time, and slower improvements for low-income people.

Increasing Sibling Relative Risk of Survival to Older and Older Ages and the Importance of Precise Definitions of "Aging," "Life Span," and "Longevity".

The lack of a formal definition of human longevity continues to generate confusion about its genetic and nongenetic determinants. In order to characterize how differences in birth year cohorts and percentiles of survival are associated with familial contribution to variation in survival, we estimated sibling relative risk of living to increasingly rare percentiles of survival based on a dataset of 1,917 validated sibships each containing at least one individual living to age 90 years. About 1,042 of the sibships included at least one individual who survived to age 100 and 511 included at least one individual who survived to age 105 and older. We show that sibling relative risk increases with older ages, sex, and earlier birth year cohorts of the proband and siblings of male 90-year-olds (5th percentile of survival) have 1.73 (95% CI: 1.5; 2.0) times the chance of living to age 90, while siblings of both male and female probands who survived to age 105 years (~0.01 percentile of survival) have 35.6 (95%CI: 15.1; 67.7) times the chance of living to age 105 compared with population controls. These results emphasize the importance of consistently defining the longevity phenotype in terms of rarity of survival for appropriate comparisons across studies.

Cerebral Performance Category and Long-Term Prognosis Following Out-of-Hospital Cardiac Arrest*

Although measures of functional status are often advocated when assessing short-term survival following cardiac arrest, little is known about how these measures predict long-term prognosis. We sought to determine whether the Cerebral Performance Category (CPC) was associated with long-term outcome following resuscitation from out-of-hospital cardiac arrest. The study was a retrospective cohort investigation of adults who suffered out-of-hospital cardiac arrest in the study community between January 1, 2001 and December 31, 2009, and were successfully resuscitated and discharged alive from the hospital following the event. The CPC at the time of hospital discharge was ascertained through review of the hospital record. The primary outcome was survival following hospital discharge. Survival status was determined using state and national death indexes. We used Kaplan-Meier curves and Cox regression to evaluate the association between CPC and survival. Among the 980 eligible subjects, 606 of 980 (62%) had a CPC of 1; 227 of 980 (23%) had a CPC of 2; 97 of 980 (10%) had a CPC of 3; and 50 of 980 (5%) had a CPC of 4. There were 336 deaths during 3,713 person-years of follow-up. Overall, 1-year survival was 82% and 5-year survival was 64%. Favorable CPC predicted better long-term prognosis. Compared with CPC 1, the relative risk of survival was 0.61 (0.47-0.80) for CPC 2, 0.43 (0.31-0.59) for CPC 3, and 0.10 (0.06-0.15) for CPC 4. The CPC at hospital discharge is a useful surrogate measure of long-term survival and can be an informative tool for programmatic evaluation and research of resuscitation.

Age determines the prognostic role of the cancer stem cell marker aldehyde dehydrogenase-1 in breast cancer

BackgroundThe purpose of this study was to compare the expression and the prognostic effect of the breast cancer stem cell marker aldehyde dehydrogenase-1 (ALDH1) in young and elderly breast cancer patients.MethodsThe study population (N = 574) consisted of all early breast cancer patients primarily treated with surgery in our center between 1985 and 1994. Median follow-up was 17.9 years (range: 0.1 to 23.5). Tissue microarray slides were immunohistochemically stained for ALDH1 expression and quantified by two independent observers who were blinded to clinical outcome. Assessment of the prognostic effect of ALDH1 expression was stratified according to age and systemic treatment.ResultsComplete lack of expression of ALDH1 was found in 40% of tumors. With increasing age more tumors showed complete absence of ALDH1 expression (P < .001). In patients aged > 65 years, ALDH1 status was not associated with any clinical outcome. Conversely, in patients aged < 65 years, ALDH1 positivity was an independent risk factor of worse outcome for relapse free period (hazard ratio = 1.71 (95% CI, 1.09 to 2.68); P = .021) and relative survival (relative excess risks of death = 2.36 (95% CI, 1.22 to 3.68); P = .016). Ten-year relative survival risk was 57% in ALDH1-positive patients compared to 83% in ALDH1-negative patients.ConclusionALDH1 expression and its prognostic effect are age-dependent. Our results support the hypothesis that breast cancer biology is different in elderly patients compared to their younger counterparts and emphasizes the importance of taking into consideration age-specific interactions in breast cancer research.

Season of diagnosis and prognosis in breast and prostate cancer

Patients with breast or prostate cancer diagnosed during the summer season have been observed to have better survival. The extent to which this is due to biological and/or health care system related factors is unclear. Using the Swedish Cancer Register and clinical databases, we analyzed overall survival by month of diagnosis among the incident cases of breast (n = 89,630) cancer and prostate (n = 72,375) cancer diagnosed from 1960 to 2004. We retrieved data on tumor stage from 1976 for breast cancer and 1997 for prostate cancer. Cox proportional hazards models were used to calculate relative risk of survival by the season of diagnosis. There was a higher hazard ratio of death in men and women diagnosed with cancer in the summer with a relative hazard of 1.20 (95% confidence interval 1.15-1.25) for July for prostate cancer and 1.14 (95% confidence interval 1.09-1.19) for August for breast cancer when compared to being diagnosed in January. This difference coincided with a lower mean number of cases diagnosed per day, and a higher proportion of advanced cases diagnosed in the summer. This pattern of presentation was stronger in the later years. The difference in stage distribution explains the seasonal variation in prognosis seen in this study. The variation may be because of structure of the health care system and a strong tradition of vacationing from mid June to mid August. Thus, the health care infrastructure and the late presentation of symptomatic disease may influence cancer survival studied by season of diagnosis substantially.

Clinical Outcomes Improve with Highly Active Antiretroviral Therapy in Vertically HIV Type‐1–Infected Children

Background. Use of antiretroviral therapy has resulted in a decrease in morbidity and mortality rates in human immunodeficiency virus type 1 (HIV-1)-infected children.Methods. We performed a retrospective study involving 427 children to determine the effectiveness of different antiretroviral therapy protocols on clinical outcome. The follow-up period was divided into 5 calendar periods (CPs): CP1 (1980-1989), before antiretroviral therapy was administered; CP2 (1990-1993), when monotherapy was administered; CP3 (1994-1996), when combined therapy was administered; CP4 (1997-1998), when </=50% of children were receiving highly active antiretroviral therapy (HAART); and CP5 (1999-2003), when >/=60% of children were receiving HAART.Results. Children experienced a progressive increase in the CD4(+) cell count and decrease in the viral load from 1997 onwards. A lower number of AIDS cases and deaths occurred during CP5 than during the other CPs (P<.01), with a relative risk of an absence of AIDS of >20 and a relative risk of survival of >30. The AIDS rate was >50% in CP1; we observed a very strong decrease to 14% in CP2, to 16% in CP3, to 7% in CP4, and to 2% in CP5. The mortality rates in CP2 and CP3 were >6% and thereafter decreased to 0.5% in CP5. The relative risks for no hospital admission in CP4 and CP5 were >3.5. The total rates of hospital admission in CP1, CP2, and CP3 were >30%; we observed a decrease in CP4 and CP5. The duration of hospitalization decreased during the follow-up period, and it was higher in CP1 (~30 days) than in the other periods.Conclusions. We observed that HAART produces a decrease in adverse clinical outcomes (i.e., hospital admission, AIDS, and death) in children with vertical HIV-1 infection in Madrid, Spain.