Relative Risk Of Death Research Articles

Colon cancer survival after radical surgery performed in hospitals of the Arkhangelsk region: a population-based analysis

Background. surgery is the main method of treatment of colon cancer (cc). Radical surgery performed in non-specialized hospitals can lead to the adverse outcomes.The aim of this study was to assess CC survival after radical surgery performed in state hospitals of the arkhangelsk region (North-West Russia) in 2010–21.Material and Methods. data on all the 2142 cases of radical surgery of CC were obtained from the arkhangelsk regional cancer registry (ARCR). One- and five-year cancer-specific survival rates were estimated by the survival tables; cumulative survival function was calculated by the Kaplan–meier method. Univariate and multiple cox regression analysis was carried out to identify independent predictors associated with CC death risk after radical surgery in state hospitals (incl. sex, age at the time of diagnosis, topography, morphology and stage of CC).Results. less than half (42.8 %) of patients underwent surgery at the arkhangelsk clinical cancer center (accc), a single specialized hospital. one- and five-year survival rates of all patients were 86.5 % (95 % CI: 84.9–87.9 %) and 65.1 % (95 % ci: 62.7–67.4 %), respectively. The 5-year survival rate of patients who underwent surgery in the accc was significantly higher than that in patients who underwent surgery in other state non-specialized hospitals (76.0 % (95 % ci: 72.5–79.0 % versus 49.3–73.8 %, p<0.0001). The relative risk of death of CC patients depended on the state hospital where radical surgery was performed and the stage of CC; it did not depend on patients’ sex, morphology and topography of CC.Conclusion. our results demonstrate the need to search for specific reasons for the relatively low survival in patients after radical surgery performed in non-specialized hospitals.

High-sensitivity troponin-T concentrations and long-term risk of death in patients with acute pulmonary embolism

Abstract Background Cardiac troponin elevation is associated with adverse short-term prognosis in patients with pulmonary embolism (PE). However, it is unknown whether high-sensitivity troponin concentrations predict long-term outcomes and whether serial measurements offer additional prognostic information in this setting. Purpose To determine short- and long-term prognostic implications of high-sensitivity troponin-T (hsTnT) concentrations and their changes from baseline, in patients with acute PE. Methods Retrospective cohort study based on Danish national registries. We identified all patients discharged from the hospital with a PE from 2013 through 2019 and merged them with all records of at least one hsTnT (99th percentile upper reference limit, 13.5 ng/l) measurement obtained during the same hospitalization. Absolute and relative risks for death from any cause at days 0-30 and 31-365 were calculated through multivariable logistic regression with average treatment effect modeling. Moreover, we tested whether hsTnT changes (in those who had a second measurement available ≥1 hour and ≤7 hours after the first measurement) were associated with additional prognostic information. Results At least one hsTnT measurement was available in 4611 individuals. Median age (25th-75th percentile) was 70.8 (58.6-79.5) years, and 2312 (50.1%) were women. One-hundred and forty-one (3.1%) patients had a prior venous thromboembolic event, 731 (15.9%) had known coronary artery disease, and 1001 (21.7%) had a history of cancer. Median baseline hsTnT was 29 (25th-75th percentile, 14-79) ng/l, and 1082 (76.5%) had an elevated concentration. Four-hundred and thirty-one (9.3%) individuals had died at 30 days, while an additional 614 (14.7% of 30-day survivors) died between days 31-365. hsTnT concentration displayed a significant, non-linear association with death (P<0.001). Figure 1 shows the unadjusted 30-day risk of death stratified for hsTnT quartiles, while Figure 2 shows the risk at days 31-365 (with 0 on the x-axis representing day 30 from the index event). Upon multivariable adjustment (including absence or presence of acute cor pulmonale), the risk of death at both timepoints remained significantly higher among individuals in each of quartiles 3 and 4 versus quartile 1 (P<0.05), with quartile 2 showing a trend (P=0.06 and P=0.07 for short- and long-term death, respectively). In 1247 subjects with two hsTnT measurements available, absolute and relative changes from baseline did not appear to carry additional prognostic information, nor did switching from normal to elevated hsTnT or vice versa, though the latter was only observed in very few persons. Conclusions In patients with acute PE, elevated hsTnT concentrations were associated with both short- and long-term mortality, but unlike in acute coronary syndromes, the utility of drawing a second sample appeared limited.Figure 1Figure 2

The risk and cause of death according to prevalent atrial fibrillation and the role of CHA2DS2-VASc score to stratify the risk of all-cause and cardiovascular death

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is rapidly increasing. AF is associated with increased risks of stroke and all-cause death. Understanding the causes of death (COD), the relative risks of each cause in AF patients compared to non-AF population, and finding out modalities to stratify the risk of death among AF patients is essential to plan optimal care of AF patients. Purpose We aimed to analyze the COD of AF patients and the relative risk of death from specific causes in AF patients compared to non-AF population using a nationwide population based cohort. Also, we identified the role of CHA2DS2-VASc score to stratify the risk for all-cause death and death from cardiovascular causes in AF patients. Methods Using the Korean nationwide claims database, subjects who received nationwide health screening examination at 2009 and aged 40 or older were included (n=7,240,800). Patients with missing values in health examinations were excluded. Finally, 6,87,929 patients were included: 40,585 patients with AF and 6,837,344 subjects without AF. COD were classified by diagnostic codes. Results A total of 490,807 deaths were reported during follow-up (incidence rate of all-cause death: non-AF group, 19.1 and AF group, 34.2 per 1000 person-years). In AF group, cardiovascular diseases were the most common COD occupying 39.8% of all-death, whereas only 19% of non-AF subjects died due to cardiovascular diseases (Figure A). The proportion of death from cerebrovascular diseases in the AF group was two times higher than that of the non-AF group (15.1% vs. 7.5%, respectively). Compared to non-AF group, AF group was associated with a significantly higher risk of all-cause death (hazard ratio [HR] 1.739, 95% confidence interval [CI] 1.708-1.771, p <0.001) (Figure B). AF group was associated with higher risks of death from cardiovascular diseases and death from cerebrovascular diseases by almost 3-fold than non-AF group (HR [95% CI], 2.899 [2.814-2.985] for death from cardiovascular diseases; 2.899 [2.814-2.985] for death from cerebrovascular diseases, all p <0.001) (Figure B). Among AF patients, the risks of all-cause, cardiovascular, and cerebrovascular death were well-stratified by CHA2DS2-VASc scores (Figure C). The increases of HRs by increases of CHA2DS2-VASc score were more prominent in the risk of death from cerebrovascular diseases, followed by death from cardiovascular causes, and all-cause death. Conclusions Compared to non-AF subjects, AF patients showed higher risks of death from cardiovascular and cerebrovascular diseases. The risks of death from cardiovascular and cerebrovascular diseases were clearly stratified according to CHA2DS2-VASc score. Integrated management for AF patients should be focused on to prevent death from cardiovascular and cerebrovascular causes. CHA2DS2-VASc score could help to stratify the risk of all-cause death and death from specific causes in AF patients.

External validation of a lung cancer-based prediction model for two-year mortality in esophageal cancer patient cohorts

Purpose/objectiveChemo-radiotherapy can improve the oncological outcome of esophageal cancer (EC) patients, but may cause long term radiation-induced toxicity, including an increased risk of non-cancer related death. For lung cancer patients, a model to predict 2-year total mortality using mean heart dose (MHD) and gross tumor volume (GTV) has previously been developed and validated. This project aimed to externally validate this model in EC patients. MethodsFive EC patient cohorts from 3 different Dutch centres were used for model validation. External validity of the model was assessed separately in definitive (n = 170) and neo-adjuvant (n = 568) chemoradiotherapy (dCRT and nCRT) patients. External validity was assessed in terms of calibration by calibration plots, calibration-in-the-large (CITL) and calibration slope (CS), and discrimination by assessment of the c-statistic. If suboptimal model performance was observed, the model was further updated accordingly. ResultsFor the dCRT patients, good calibration was found after adjustment of the intercept (CITL 0.00; CS 1.08). The c-statistic of the adjusted model was 0.67 (95%CI: 0.58 to 0.75). For nCRT patients the model needed adjustment of both the slope and the intercept because of initial miscalibration in the validation population (CITL 0.00; CS 1.72). After recalibration, the model showed perfect calibration (i.e., CITL 0, CS 1), as is common after recalibration. The c-statistic of the recalibrated model equaled 0.62 (95%CI: 0.57 to 0.67). ConclusionThe existing model for 2-year mortality prediction in lung cancer patients, based on the predictive factors MHD and GTV, showed good performance in EC patients after updating the intercept and/or slope of the original model.

Long-term aspirin adherence and risk of cardiovascular events and death after myocardial infarction: A nationwide cohort study

Abstract Background Aspirin is mandatory in the acute phase after myocardial infarction (MI); however, the efficacy of aspirin for long-term secondary prevention is less established and may have changed with the addition of modern therapies and diagnostics methods. Purpose To investigate the effectiveness of adherence to long term aspirin therapy at different timepoints following MI. Methods Using Danish nationwide registries, we included patients ≥40 years with a first time MI undergoing percutaneous coronary intervention from 2004 through 2017, who were alive, not treated with anticoagulants, and had stayed adherent to aspirin at one year after the index event (Figure 1). We evaluated adherence to aspirin therapy as proportion of days covered (PDC) ≤80% and >80% at four landmarks (2, 4, 6, and 8 years after MI, respectively). At each landmark, patients were excluded from the analysis if they had suffered a recurrent MI or stroke, died, emigrated or were on anticoagulant or P2Y12-inhibitor therapy. The absolute and relative risks of a composite of death, recurrent MI, or ischemic stroke at 2 years from each landmark were calculated through multivariable logistic regression analysis with average treatment effect modelling standardized to the distribution of age, sex, diabetes, hypertension, hypercholesterolemia, chronic kidney disease, cancer, peptic ulcer, former bleeding, and chronic obstructive pulmonary disease (as a proxy for smoking). Non-CVD death was used as a neutral comparator. Results A total of 40,114 individuals were included in the analysis. Suboptimal adherence to aspirin (PDC≤80%) increased from 10% at first landmark 2 years after MI to 19% at fourth landmark 8 years after MI (Figure 1). The standardized absolute risk of death, recurrent MI, or ischemic stroke was highest at the first landmark 2 years after MI for both PDC-groups (PDC>80%: 8.34%, 95% confidence interval [CI]: 8.04-8.63% and PDC≤80%: 10.75%, 95% CI: 9.80-11.69%) (Figure 2). The standardized relative risk of the composite endpoint was significantly higher for patients with PDC≤80% at all landmarks. A trend towards a diminished protective effect of long-term aspirin therapy appeared from 4 years after the index MI and onwards, decreasing from 1.40 (95% CI: 1.26-1.53) at second landmark 4 years after MI to 1.20 (95% CI: 1.04-1.35) at fourth landmark 8 years after MI. Overall, we found no difference in the relative risk of non-CV death between PDC-groups. Conclusion Suboptimal adherence to long-term aspirin therapy following MI was associated with an increased risk of recurrent MI, ischemic stroke, or death, but the relative risk appeared to decrease slightly over time from 4 years after the index MI and onwards.Figure 1Figure 2

Pharmacologic and Genetic Downregulation of Proprotein Convertase Subtilisin/Kexin Type 9 and Survival From Sepsis

OBJECTIVES: Treatments that prevent sepsis complications are needed. Circulating lipid and protein assemblies—lipoproteins play critical roles in clearing pathogens from the bloodstream. We investigated whether early inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) may accelerate bloodstream clearance of immunogenic bacterial lipids and improve sepsis outcomes. DESIGN: Genetic and clinical epidemiology, and experimental models. SETTING: Human genetics cohorts, secondary analysis of a phase 3 randomized clinical trial enrolling patients with cardiovascular disease (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab [ODYSSEY OUTCOMES]; NCT01663402), and experimental murine models of sepsis. PATIENTS OR SUBJECTS: Nine human cohorts with sepsis (total n = 12,514) were assessed for an association between sepsis mortality and PCSK9 loss-of-function (LOF) variants. Incident or fatal sepsis rates were evaluated among 18,884 participants in a post hoc analysis of ODYSSEY OUTCOMES. C57BI/6J mice were used in Pseudomonas aeruginosa and Staphylococcus aureus bacteremia sepsis models, and in lipopolysaccharide-induced animal models. INTERVENTIONS: Observational human cohort studies used genetic PCSK9 LOF variants as instrumental variables. ODYSSEY OUTCOMES participants were randomized to alirocumab or placebo. Mice were administered alirocumab, a PCSK9 inhibitor, at 5 mg/kg or 25 mg/kg subcutaneously, or isotype-matched control, 48 hours prior to the induction of bacterial sepsis. Mice did not receive other treatments for sepsis. MEASUREMENTS AND MAIN RESULTS: Across human cohort studies, the effect estimate for 28-day mortality after sepsis diagnosis associated with genetic PCSK9 LOF was odds ratio = 0.86 (95% CI, 0.67–1.10; p = 0.24). A significant association was present in antibiotic-treated patients. In ODYSSEY OUTCOMES, sepsis frequency and mortality were infrequent and did not significantly differ by group, although both were numerically lower with alirocumab vs. placebo (relative risk of death from sepsis for alirocumab vs. placebo, 0.62; 95% CI, 0.32–1.20; p = 0.15). Mice treated with alirocumab had lower endotoxin levels and improved survival. CONCLUSIONS: PCSK9 inhibition may improve clinical outcomes in sepsis in preventive, pretreatment settings.

Abstract 17301: C-Reactive Protein and Long-Term Risk of Death in Patients With Myocardial Infarction

Introduction: The long-term prognostic value of C-reactive protein (CRP) in patients with myocardial infarction (MI) is unknown. Purpose: To assess the association between the first CRP measured during hospitalization and long-term mortality in patients with MI. Methods: Using Danish nationwide registries, we identified patients with a first diagnosis of MI from 2012 through 2020 who underwent a CRP measurement during index hospitalization. The primary outcome was death from any cause. The association between CRP levels and death was examined stratifying the patients into quartiles of CRP concentrations. Absolute and relative risks (RR) for death at days 0-30 and 31-365 were calculated through multivariable Cox regression with average treatment effect modeling. Models were standardized for demographic and clinical features, including high-sensitivity troponin (hsTn). Results: We included 36,021 patients with MI and a CRP measurement within 24 hours before or after the time of admission. Median age was 69.7 years and 35.2 % were women. Median CRP in the entire cohort was 4.9 mg/l, and quartile (Q) intervals were: Q1: <3 mg/l, Q2: 3 to <5 mg/l, Q3: 5 to <17 mg/l, and Q4: >=17 mg/l. CRP was significantly and nonlinearly associated with the primary outcome (p<0.001). At 0-30 days, 2694 patients had died, and another 2566 had died between days 31-365. Figure 1 shows the Kaplan Meier curves. The standardized absolute risk of death at both 0-30 and 31-365 days was lowest among patients in Q1 (0-30 days: 4.1%, 31-365 days: 4.8%) and highest among patients in Q4 (0-30 days: 12.1%, 31-365 days: 10.6%). The standardized RR of death compared with Q1 were: 0-30 days 1.01 (95% CI 0.84;1.71), 1.45 (1.26;1.63) and 2.96 (2.61;3.29) in Q2, Q3 and Q4 and at days 31-365, the RR were 1.18 (1.02;1.34), 1.61 (1.42;1.79) and 2.19 (1.95;2.42), respectively. Conclusion: In patients with MI, higher CRP levels were significantly associated with a higher risk of death, independently of hsTn concentrations.

Exploring the Prognostic and Predictive Roles of Ki-67 in Endometrial Cancer

Background: Up to now, endometrial cancer (EC) treatments are mainly represented by surgery followed by adjuvant chemotherapy or radiotherapy. The updated guidelines give a 2A recommendation for the use of hormone therapy only in advanced low-grade ECs, underlying the need for more data on the role of hormone therapy in the adjuvant setting. Methods: The clinicopathological data of 158 early-stage EC patients was retrospectively collected. A Ki-67 cut-off value of 40% was established based on literature data. Disease-free survival (DFS) and Overall survival (OS) were evaluated. Results: Results: Multivariate analysis of DFS and OS showed a significantly increased risk of progression in patients with >40% Ki-67 [HR = 3.13 (95% CI; 1.35–7.14); p = 0.007] and a significantly higher relative risk of death [HR = 3.70 (95% CI; 1.69–8.33); p = 0.001]. The predictive role of the Ki-67 index was highlighted by the clinical benefit of adjuvant hormone in patients with high Ki-67. Conclusions: Our results suggest a positive role of the Ki-67 index as a prognostic and potentially predictive marker in EC, although further studies are warranted to reach a definitive conclusion.

Comparative Survival Analysis of Dialysis and Renal Transplantation in HBV-Infected End-Stage Renal Disease Patients

The potential risks and benefits of kidney transplantation in patients with end-stage renal disease (ESRD) infected with hepatitis B virus (HBV) have been a subject of debate. This study aimed to provide real-world data on the relative risks of death and clinical outcomes associated with kidney transplantation in this context. We conducted a longitudinal cohort study using the National Health Insurance Research Database from 1997 to 2013, extracting cohorts of patients who are HBV-infected ESRD. The main outcome measure was overall survival, whereas the secondary measure was the relative risk of death and survival benefit through propensity-score matching (1:1). Of the 4895 patients who are HBV-infected with ESRD, 172 renal transplant recipients were enrolled for analysis. There was a numeric trend towards higher overall survival rates in renal transplant recipients, although this was not statistically significant (P=.057). A significant survival benefit was observed in the renal transplant group if the follow-up was longer than one year (P = 0.007). The relative risks of death among renal transplant recipients were initially higher at 2.0 times that of patients on chronic dialysis, presenting in a hyperbolic pattern with equal risks at 462 days. The likelihood of survival became equal until 1649 days. Our study suggests that kidney transplantation may be a viable option for patients who are HBV-infected with ESRD, given the significant improvement in quality of life and reduction of death risks observed four to five years after successful transplantation. This real-world data can help clinicians make informed decisions regarding the management of ESRD in patients who are HBV-infected.

THE RISK OF PERINATAL LOSSES DUE TO PARVOVIRUS INFECTION DURING PREGNANCY AND WAYS TO PREVENT THEM

THE RISK OF PERINATAL LOSSES DUE TO PARVOVIRUS INFECTION DURING PREGNANCY AND WAYS TO PREVENT THEM

Association of EEG Background and Neurodevelopmental Outcome in Neonates With Hypoxic-Ischemic Encephalopathy Receiving Hypothermia.

Predicting neurodevelopmental outcome for neonates with hypoxic-ischemic encephalopathy (HIE) is important for clinical decision-making, care planning, and parent communication. We examined the relationship between EEG background and neurodevelopmental outcome among children enrolled in a trial of erythropoietin or placebo for neonates with HIE treated with therapeutic hypothermia. Participants had EEG recorded throughout hypothermia. EEG background was classified as normal, discontinuous, or severely abnormal (defined as burst suppression, low voltage suppressed, or status epilepticus) at 5 1-hour epochs: onset of recording, 24, 36, 48, and 72 hours after birth. The predominant background pattern during the entire continuous video EEG monitoring recording was calculated using the arithmetic mean of the 5 EEG background ratings (normal = 0; discontinuous = 1; severely abnormal = 2) as follows: "predominantly normal" (mean = 0), "normal/discontinuous" (0 < mean<1), "predominantly discontinuous" (mean = 1), "discontinuous/severely abnormal" (1 < mean<2), or "predominantly severely abnormal" (mean = 2). Primary outcome was death or neurodevelopmental impairment (NDI) defined as cerebral palsy, Gross Motor Function Classification Score ≥1, or cognitive score <90 on Bayley Scales of Infant Toddler Development, third edition at age 2 years. Neurodevelopment was also categorized into a 5-level ordinal measure: no, mild, moderate, severe NDI, or death for secondary analysis. We used generalized linear regression models with robust standard errors to assess the relative risk of death or NDI by EEG background in both unadjusted and adjusted analyses controlling for the effects of treatment group, sex, HIE severity, and study recruitment site. Among 142 neonates, the predominant background EEG pattern was predominantly normal in 35 (25%), normal/discontinuous in 68 (48%), predominantly discontinuous in 11 (7.7%), discontinuous/severely abnormal in 16 (11%), and predominantly severely abnormal in 12 (8.5%). Increasing severity of background across monitoring epochs was associated with increasingly worse clinical outcomes. Children with severe EEG background abnormality at any time point (n = 36, 25%) were significantly more likely to die or have severe NDI at 2 years (adjusted relative risk: 7.95, 95% CI 3.49-18.12). EEG background is strongly associated with NDI at age 2 years. These results can be used to assist health care providers to plan follow-up care and counsel families for decision-making related to goals of care.

Post Mastectomy Radiation Therapy Impact on Clinical Outcomes of Male Breast Cancer: A Meta-Analysis of Comparative Studies

Male breast cancer accounts for less than 1 percent of all cancer diagnoses in men. Because it is rare, it does not lend itself to large, randomized trials. In general, the approach to the treatment of early, non-metastatic male breast cancer has largely been extrapolated from female breast cancer trials though it is deemed to be a different disease. Data on early-stage post mastectomy radiation therapy (PMRT) is limited, and its benefits remain unclear. We conducted this meta-analysis to determine the impact of PMRT on recurrence patterns and survival outcomes using the available male breast cancer data. A review of the medical literature was conducted using online databases. Inclusion criteria consisted of English language, diagnosis of invasive non-metastatic male breast cancer (MBC), comparative studies of PMRT versus none, and studies that reported the incidence of local and distant recurrences as well as survival data in the compared arms. A meta-analysis using the Mantel-Haenszel method for calculating the weighted pooled relative risk (RR) under the fixed effects model was conducted. Subsequently, the heterogeneity statistic was incorporated to calculate the summary RR under the random effects model. Ten retrospective comparative studies with 3912 patients were included and analyzed. Eight studies reported survival data. Six and three studies reported local and distant recurrence incidence, respectively. PMRT did not have an impact on overall survival or distant recurrences. However, PMRT significantly lowered the RR of locoregional recurrences (RR = 0.53, 95% CI 0.31-0.92). In addition, when survival was analyzed by TNM stage and N status, PMRT was found to have a significant reduction in RR of death in stage III (RR = 0.85, 95% CI 0.75-0.97), N1 (RR = 0.77, 95% CI 0.61-0.98), and N2 (RR = 0.61, 95% CI 0.49-0.78) disease. This is the first meta-analysis to show that PMRT is associated with a lower relative risk of death in stage III MBC as well as N1 and N2 disease. It also demonstrates a significant reduction in RR of locoregional recurrences. In the absence of randomized clinical trials, it represents the most compelling data supporting the use of PMRT in this MBC patient population using MBC data.

Urinary peptides provide information about the risk of mortality across a spectrum of diseases and scenarios

BackgroundThere is evidence of pre-established vulnerability in individuals that increases the risk of their progression to severe disease or death, although the mechanisms causing this are still not fully understood. Previous research has demonstrated that a urinary peptide classifier (COV50) predicts disease progression and death from SARS-CoV-2 at an early stage, indicating that the outcome prediction may be partly due to vulnerabilities that are already present. The aim of this study is to examine the ability of COV50 to predict future non-COVID-19-related mortality, and evaluate whether the pre-established vulnerability can be generic and explained on a molecular level by urinary peptides.MethodsUrinary proteomic data from 9193 patients (1719 patients sampled at intensive care unit (ICU) admission and 7474 patients with other diseases (non-ICU)) were extracted from the Human Urinary Proteome Database. The previously developed COV50 classifier, a urinary proteomics biomarker panel consisting of 50 peptides, was applied to all datasets. The association of COV50 scoring with mortality was evaluated.ResultsIn the ICU group, an increase in the COV50 score of one unit resulted in a 20% higher relative risk of death [adjusted HR 1.2 (95% CI 1.17–1.24)]. The same increase in COV50 in non-ICU patients resulted in a higher relative risk of 61% [adjusted HR 1.61 (95% CI 1.47–1.76)], consistent with adjusted meta-analytic HR estimate of 1.55 [95% CI 1.39–1.73]. The most notable and significant changes associated with future fatal events were reductions of specific collagen fragments, most of collagen alpha I (I).ConclusionThe COV50 classifier is predictive of death in the absence of SARS-CoV-2 infection, suggesting that it detects pre-existing vulnerability. This prediction is mainly based on collagen fragments, possibly reflecting disturbances in the integrity of the extracellular matrix. These data may serve as a basis for proteomics-guided intervention aiming towards manipulating/ improving collagen turnover, thereby reducing the risk of death.

Medical follow-up and long-term survival of patients with cerebrovascular accident: data from the REGION-M registry

Aim. To assess the survival rate of patients after cerebrovascular accident (CVA), depending on the visits to the local outpatient clinic and the type of medical supervision, and in the first year after hospital discharge.Material and methods. The outpatient part of the REGION-M registry included 684 patients assigned to the City Polyclinic № 64 of Moscow, discharged from the F. I. Inozemtsev City Clinical Hospital (Moscow) in the period from January 1, 2012 to April 30, 2017 with a confirmed diagnosis of cerebral stroke/transient ischemic attack.Results. During the first year after the CVA, 451 (65,9%) patients visited the local clinic on their own (group 1), while 166 (24,3%) patients was consulted by house call (group 2), and 67 (9,8%) did not see the physician (group 3). Patients visited by house call were more likely to have prior coronary artery disease and stroke, and the age of men was older than in other groups. Patients who did not see a doctor were less likely to have comorbidities and disabilities, and were less likely to visit the clinic before stroke. The mortality of patients in group 3 was significantly higher throughout the entire follow-up period (55,2%, 70,1% and 77,6% at stages 1, 2 and 3 (p&lt;0,001), respectively) than in group 2 (31,2%, 55,4% (p&lt;0,001)) and group 1 (23,7%, 37,0% and 54,3% (p&lt;0,001)). Mortality of patients in group 1 was lower than group 2 (p&lt;0,05-0,01). The relative risk of death in clinic visitors was 0,450 (95% confidence interval (CI), 0,333-0,608, p&lt;0,0001), while in those visited by a doctor at home — 0,668 (95% CI, 0,482-0,927, p&lt;0,05). In multivariate analysis and adjustment for sex and age (relative risk (RR) of death, 0,08 (95% CI, 0,048-0,133), p&lt;0,0001 and 1,036 (95% CI, 1,031-1,042), p&lt;0,001, respectively), the independent contribution of the factor of clinic visits was preserved. Thus, the RR of death in visitors was 0,996 (95% CI, 0,994-0,999), p&lt;0,001 and 0,998 (95% CI, 0,995-1,0), p&lt;0,05.Conclusion. The lower mortality among those visited the local clinic in the first year after CVA and among those who were visited by a doctor at home, compared with patients who were not observed, confirms the important role of medical supervision in the post-hospital period.

Relative Risk of Death in Bulgarian Cancer Patients during the Initial Waves of the COVID-19 Pandemic.

The COVID-19 pandemic has led to millions of documented deaths worldwide, with diverse distribution among countries. Surprisingly, Bulgaria, a middle-income European Union member state, ranked highest in COVID-19 mortality. This study aims to assess whether Bulgarian cancer patients experienced a higher relative risk (RR) of death compared to the general Bulgarian population during the pandemic. Data from the Bulgarian National Statistical Institute and the Bulgarian National Cancer Registry were analyzed to estimate monthly RR of death in cancer patients compared to the general population before and during the first two years of the pandemic. The impact of the COVID-19 waves and predominant SARS-CoV-2 variants on RR was evaluated on various cancer types and age groups using a multiple linear regression approach. During the COVID-19 waves, both the general population and cancer patients experienced a significant increase in mortality rates. Surprisingly, the RR of death in cancer patients was lower during pandemic waves. The results from the statistical modeling revealed a significant association between the COVID-19 waves and reduced RR for all cancer patients. Notably, the effect was more pronounced during waves associated with the Alpha and Delta variants. The results also showed varying impacts of the COVID-19 waves on RR when we analyzed subsamples of data grouped depending on the cancer type, age and sex. Despite increased overall mortality in Bulgarian cancer patients during the pandemic, the RR of death was lower compared to the Bulgarian general population, indicating that protective measures were relatively effective in this vulnerable group. This study underscores the importance of implementing and encouraging preventive measures, especially in cancer patients, to mitigate the impact of future viral pandemics and reduce excess mortality.

Analysis of compound health impacts of heatwave and COVID-19 in Korea from May to September in 2020

The number of non-accidental deaths and heat-related illnesses due to the co-occurrence of heatwaves and COVID-19 has been identified to estimate compound health impacts between two risks. We have analyzed data from historical years (2013–2019) to calculate the baseline values of the number of non-accidental deaths and heat-related illness patients from May to September using a quasi-Poisson generalized linear model and compared them to data from 2020 in Korea. We also assessed the relative risk and absolute cumulative number of non-accidental deaths and heat-related illnesses in the summer of 2020 in Seoul, Daegu, and Gyeongnam region of Korea. In the Summer of 2020, Korea experienced 0.8% of non-accidental excess deaths, with the highest in August, and 46% of reduction was observed in heat-related throughout the study period, except in Daegu, where excess of heat-related illness occurred in August. The relative risk (RR) of non-accidental deaths at 33.1 °C, was 1.00 (CI 0.99–1.01) and 1.04 (CI 1.02–1.07) in 2013–2019 and 2020, respectively. The RR of heat-related illness at 33.1 °C, was 1.44 (CI 1.42–1.45) and 1.59 (CI 1.54–1.64) in 2013–2019 and 2020, respectively. The absolute cumulative trends of non-accidental deaths and heat-related illnesses were similar in the three regions, indicating increased non-accidental deaths and decreased heat-related illnesses at similar temperatures in 2020. During the COVID-19 pandemic, the fear of infection by the virus and the limited access to healthcare services led to changes in health-seeking behaviors. These results indicate social distancing could have had adverse impacts on other health conditions. A comprehensive health risk assessment is important when facing simultaneous risks, such as heatwaves and pandemics, in the implementation of effective countermeasures.

Neck radiation is not associated with increased risk of perioperative adverse events after transcarotid artery revascularization or transfemoral carotid artery stenting

ObjectiveIt is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort. MethodsData were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ2 test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events. ResultsA total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001). ConclusionsPatients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.

Risk of Stroke, Myocardial Infarction, Deep Vein Thrombosis, Pulmonary Embolism, and Death After Retinal Vein Occlusion

To examine rates of stroke, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE), and death in patients after retinal vein occlusion (RVO) compared to controls. Retrospective cohort study. An aggregated electronic health records research network, TriNetX, was used to identify patients with diagnosis of RVO and a control group of patients with cataract. Patients were excluded if they had history of stroke, MI, DVT, or PE within 2 years of diagnosis of RVO or cataract. Propensity score matching was performed to control for baseline demographics and medical comorbidities. Main outcomes included relative risk (RR) of death, stroke, MI, DVT, and PE after RVO compared to those in matched controls. A total of 45,304 patients were included in each cohort. There was elevated risk of death in the RVO cohort compared to the control cohort at 1 year (RR=1.30, P < .01), 5 years (RR=1.22, P < .01), and 10 years (RR=1.08, P < .01). There was elevated risk of stroke at 1 year (RR=1.61, P < .01), 5 years (RR=1.31, P < .01), and 10 years (RR=1.18, P < .01). There was elevated risk of MI at 1 year (RR=1.26, P < .01) and 5 years (RR=1.13, P < .01), but not at 10 years (RR=1.06, P=.12). There was mildly elevated risk of DVT at 1 year (RR=1.65, P < .01) but not at 5 years (RR=0.94, P=.94) or 10 years (RR=1.05, P=.37). There was no elevated risk of PE at 1 year (RR=0.98, P=0.80), 5 years (RR=0.95, P=.42), or 10 years (RR=0.85, P =.40). There is an increased rate of death, stroke, and MI after RVO compared to those in matched controls. We emphasize the need for long-term systemic evaluation after RVO.

1210 Network Meta-Analysis of Associated Mortality with Transfusion Strategies for Major Haemorrhage in Adults

Abstract Aim The aetiology of a large proportion of mortality in trauma patients is attributed to acute major haemorrhage. Damage control resuscitation and surgery have been developed as part of management, which often includes large volume blood product transfusion. The aim of this meta-analysis was to investigate differences in mortality between transfusion strategies used in major haemorrhage in adults (18+ years). Method A frequentist random effects network meta-analysis (NMA) using the netmeta package in R 4.0.5 of the eligible papers in the systematic review “Optimal dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a systematic review” compared a 1:1:1 ratio of red blood cells (RBC), fresh frozen plasma (FFP) and platelets (P) to a ratio of 2:1:1, whole blood, and laboratory-guided replacement. Homogeneity and heterogeneity were assessed with Cochran’s Q. Results Mortality at one month by group was 21.8% (12/55) for whole blood, 17.0% (58/342) for 2RBC:1FFP:1P, 14.3% (5/35) for laboratory-guided transfusion and 22.3% (96/43) for standard 1RBC:1FFP:1P ratio. The NMA showed no significant differences between groups, with relative risk of death when compared to 1RBC:1FFP:1P by one month of 1.42 (0.631; 3.19, p = 0.398) for whole blood, 0.7643 (0.562; 1.04, p = 0.0871) for 2RBC:1FFP:1P and 0.4396 (0.1741; 1.1099, p = 0.0820) for laboratory-guided transfusion. Conclusions The results demonstrated no significant differences in mortality between transfusion strategies in major haemorrhage - however, some arms of the NMA contain few patients and so may be underpowered to detect differences between groups. On this evidence, current use of component therapy is not inferior to another transfusion strategy.

Divergent androgenic modulation of SARS-CoV-2 infection cooperates with dysregulated immune response to dictate worse COVID-19 outcomes in men

BackgroundSex-determined differences are rarely addressed in the management of diseases, despite well-known contrasting outcomes between female and male patients. In COVID-19 there is a remarkable disparity, with higher rates of mortality and more severe acute disease in men compared to women, who are mostly affected by long COVID-19. Furthermore, whether androgens play a protective or detrimental role in COVID-19 is still a matter of debate. Hence, the adequate management of the disease, especially regarding men presenting acute disease aggravation, still needs important data to elucidate the interplay between sex hormones and host immune responses that drive the worse evolution in male patients. MethodsA cohort of 92 controls and 198 non-severe and severe COVID-19 patients, from both sexes, was assessed for clinical outcomes, plasma steroids, gonadotropins, sex hormone binding globulin (SHBG) and immune mediators, before vaccination. These data were correlated with the global gene expression of blood leukocytes. The androgen receptor (AR) signaling pathway was investigated by transcriptomics and tracheal aspirate was obtained from severe patients for SARS-COV-2 quantification in the respiratory tract. The interplay among clinical, endocrine and immunological data deciphered the sex differences in COVID-19. Importantly, statistical analyses, using 95% confidence interval, considered confounding factors such as age and comorbidities, to definitely parse the role of androgens in the disease outcome. ResultsThere were notable contrasting levels of testosterone and dihydrotestosterone (DHT) throughout the disease course in male but not female patients. Inflammatory mediators presented significant negative correlations with testosterone, which was partially dependent on age and diabetes in men. Male subjects with severe COVID-19 had a significant up regulation of the AR signaling pathway, including modulation of TMPRSS2 and SRD5A1 genes, which are related to the viral infection and DHT production. Indeed, men had a higher viral load in the tracheal aspirate and levels of DHT were associated with increased relative risk of death. In contrast, the testosterone hormone, which was notably reduced in severe disease, was significantly related with susceptibility to COVID-19 worsening in male patients. Secondary hypogonadism was ruled out in the male severe COVID-19 subjects, as FSH, LH, and SHBG levels were not significantly altered. Instead, these subjects tended to have increased gonadotropin levels. Most interestingly, in this study we identified, for the first time, combined sets of clinical and immunoendocrine parameters that together predicted progression from non-severe to severe COVID-19 in men. One of the limitations of our study was the low or undetectable levels of DHT in many patients. Then, the evaluation of enzymes related to biosynthesis and signaling by androgens was mandatory and reiterated our findings. ConclusionsThese original results unraveled the disease immunoendocrine regulation, despite vaccination or comorbidities and pointed to the fundamental divergent role of the androgens testosterone and DHT in the determination of COVID-19 outcomes in men. Therefore, sex-specific management of the dysregulated responses, treatments or public health measures should be considered for the control of COVID-19 pandemic.