Score-adjusted Cox Regression Analysis Research Articles

The long-term outcomes of surgical ablation for atrial fibrillation during redo left-sided valvular surgery.

This study evaluated the outcome of surgical ablation (SA) for atrial fibrillation (AF) concomitant with redo left-sided valvular surgery. The study enrolled 224 AF patients (paroxysmal: 13 patients, persistent: 76 patients, long-standing persistent AF: 135 patients) undergoing redo open heart surgery for left-sided valve disease. The early results and long-term clinical outcomes were compared between those who underwent concomitant SA for AF (SA group) and did not (NSA group). Propensity score adjusted Cox regression analysis of overall survival and competing risk analysis of the other clinical outcomes were performed. Seventy-three patients were classified as the SA group and 151 as the NSA group. The median follow-up duration was 124 (1.0-249.5) months. The median ages of the patients in the SA and NSA groups were 54.1±11.3 and 58.4±11.1 years, respectively. There were no significant differences between the groups in the early in-hospital mortality rate (5.5% vs. 9.3%, P=0.474) or postoperative complications, except for low cardiac output syndrome (11.0% vs. 23.8%, P=0.036). Overall survival was better in the SA group [hazard ratio, 0.452; 95% confidence interval (CI): 0.218-0.936, P=0.032]. The incidence of recurrent AF was significantly higher in the SA group on multivariate analysis [hazard ratio, 3.440; 95% CI: 1.987-5.950, P<0.001]. The cumulative incidence of the composite of thromboembolism and bleeding was lower in the SA than NSA group [hazard ratio, 0.338; 95% CI: 0.127-0.897, P=0.029]. The concomitant surgical arrhythmia ablation with redo cardiac surgery for left-sided heart disease resulted in a better overall survival, higher incidence of sinus conversion, and lower incidence of a composite of thromboembolism and major bleeding. Concomitant SA procedure should be considered in patients undergoing redo cardiac surgery.

MP57-16 IMPACT OF EXTENT OF LYMPHADENECTOMY ON ALL CAUSE MORTALITY IN PATIENTS WITH INTERMEDIATE AND HIGH-RISK PROSTATE CANCER MANAGED WITH RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 May 2022MP57-16 IMPACT OF EXTENT OF LYMPHADENECTOMY ON ALL CAUSE MORTALITY IN PATIENTS WITH INTERMEDIATE AND HIGH-RISK PROSTATE CANCER MANAGED WITH RADICAL PROSTATECTOMY Furkan Dursun, Ahmed Elshabrawy, Hanzhang Wang, Michael A. Liss, Ronald Rodriguez, Dharam Kaushik, and Ahmed M. Mansour Furkan DursunFurkan Dursun More articles by this author , Ahmed ElshabrawyAhmed Elshabrawy More articles by this author , Hanzhang WangHanzhang Wang More articles by this author , Michael A. LissMichael A. Liss More articles by this author , Ronald RodriguezRonald Rodriguez More articles by this author , Dharam KaushikDharam Kaushik More articles by this author , and Ahmed M. MansourAhmed M. Mansour More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The role of limited versus extended pelvic lymph node dissection (PLND) in the surgical management of prostate cancer (PCa) remains controversial. We sought to evaluate the impact of the extent of PNLD on survival outcomes for patients with intermediate and high-risk PCa. METHODS: The NCDB was queried for patients with intermediate and high-risk PCa (according to AUA guidelines risk stratification), who were treated by radical prostatectomy (RP) and PLND from 2004 to 2013. We limited our cohort to men <70 years of age with a CCI=0. Patients were divided into 3 groups according to the number of excised LN as a surrogate for the extent of PLND (Group 1:1–9, Group 2:10–19, and Group 3:≥20 nodes). Primary outcome was overall survival (OS). All-cause mortality was evaluated using propensity score weighted Kaplan-Meir (KM) Curves and Cox regression models. RESULTS: 103,250 men had a new diagnosis of PCa, and 25.8% of those had high-risk PCa. The number of LN excised was <10 for 80.5%, 10-19 for 15.9%, and ≥20 for 3.6% of the patients. Figure 1 illustrates the KM curves in the propensity score-weighted cohorts. In intermediate-risk PCa patients, propensity score adjusted cox regression analysis showed OS benefit for group 2 compared to group 1 (HR0.86, CI0.79-0.93, p <0.001). Similarly, in high-risk patients, group 3 had better OS compared to group 1 (HR0.61, CI 0.47-0.78, p <0.001) (Table 1). pN+ disease rates were significantly higher in group 3 compared to group 1 and 2 in both intermediate and high-risk diseases. (Intermediate risk 9.3% vs. 1.5% and 4.5%, p <0.001; high risk 25.3% vs. 5.7% and 15.5%, p <0.001, respectively). CONCLUSIONS: Removal of ≥20 LNs during RP was associated with better OS for men with high-risk PCa. Similar survival benefit was noted in the intermediate-risk group with removal of 10-19 lymph nodes. Increased number of removed nodes was associated with increased likelihood of lymph node positivity and more accurate pathologic staging. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e988 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Furkan Dursun More articles by this author Ahmed Elshabrawy More articles by this author Hanzhang Wang More articles by this author Michael A. Liss More articles by this author Ronald Rodriguez More articles by this author Dharam Kaushik More articles by this author Ahmed M. Mansour More articles by this author Expand All Advertisement PDF DownloadLoading ...

Optimal dual antiplatelet therapy duration for bioresorbable scaffolds: an individual patient data pooled analysis of the ABSORB trials.

Compared with everolimus-eluting metallic stents, the Absorb bioresorbable scaffold (BRS) results in increased rates of myocardial infarction (MI) and scaffold thrombosis (ST) during its three-year bioresorption phase. It is unknown whether prolonged dual antiplatelet therapy (DAPT) duration might decrease the risk of ischaemic events. We sought to evaluate the impact of DAPT duration on ischaemic and bleeding outcomes following BRS implantation. We conducted an individual patient data pooled analysis from four ABSORB randomised trials and one prospective ABSORB registry. Study endpoints were MI, ST, bleeding, and death up to three-year follow-up. Propensity score-adjusted Cox regression analysis was used to account for baseline differences related to DAPT duration. The five ABSORB studies included 2,973 patients. DAPT use was 91.7%, 53.2%, and 48.0% at 1, 2, and 3 years, respectively. DAPT use within the first year after BRS implantation was associated with markedly lower risks of MI (adjusted hazard ratio [aHR] 0.17, 95% CI: 0.10-0.32; p<0.0001) and ST (aHR 0.08, 95% CI: 0.03-0.19; p<0.0001). Conversely, DAPT use between 1 and 3 years did not significantly affect the risk of MI (aHR 1.04, 95% CI: 0.70-1.55; p=0.84) or ST (aHR 0.86, 95% CI: 0.42-1.75; p=0.67). DAPT did not have major effects upon bleeding or death in either period. DAPT use during the first year after BRS implantation was strongly associated with lower risks of ST and MI. However, a benefit of ongoing DAPT use between 1 and 3 years after BRS implantation was not apparent.

Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia - A nationwide propensity score adjusted analysis.

The risk of major amputation is higher after urgently planned endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients with diabetes mellitus (DM). The aim of this nationwide cohort study was to compare outcomes between patients with and without DM following urgently planned open revascularization for CLTI from 2010 to 2014. Out of 1537 individuals registered in the Swedish Vascular Registry, 569 were registered in the National Diabetes Register. A propensity score adjusted Cox regression analysis was conducted to compare outcome between the groups with and without DM. Median follow-up was 4.3 years and 4.5 years for patients with and without DM, respectively. Patients with DM more often had foot ulcers (p = 0.034) and had undergone more previous amputations (p = 0.001) at baseline. No differences in mortality, cardiovascular death, major adverse cardiovascular events (MACE), or major amputation were observed between groups. The incidence rate of stroke was 70% higher (95% CI: 1.11–2.59; p = 0.0137) and the incidence rate of acute myocardial infarction (AMI) 39% higher (95% CI: 1.00–1.92; p = 0.0472) among patients with DM in comparison to those without. Open vascular surgery remains a first-line option for a substantial number of patients with CLTI, especially for limb salvage in patients with DM. The higher incidence rates of stroke and AMI among patients with DM following open vascular surgery for infrainguinal CLTI require specific consideration preoperatively with the aim of optimizing medical treatment to improve cardiovascular outcome postoperatively.

The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis.

To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM). In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively. The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14). Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.

Contemporary outcomes of aortic and mitral valve surgery for rheumatic heart disease in sub-Saharan Africa

ObjectivesRheumatic heart disease is endemic in sub-Saharan Africa. There is a paucity of data on the outcomes of valvular surgery for rheumatic heart disease in the developing world. The objective of this study was to evaluate the outcomes of aortic and mitral valve surgery for rheumatic heart disease in Ethiopia. MethodsBetween 2009 and 2017, 240 consecutive patients with rheumatic heart disease underwent aortic and/or mitral surgery at the Cardiac Center of Ethiopia in Addis Ababa. These surgeries were performed in the context of 22 international humanitarian missions. Median follow-up was 2.3 (interquartile range, 0.5-4.0) years and 96% complete. Outcomes were compared between patients who underwent mechanical valve implantation (n = 90, 38%), bioprosthetic valve implantation (n = 58, 24%), and valve repair (n = 92, 38%). ResultsMean age of patients was 19 ± 8 years, and 136 patients (57%) were female. Operative mortality occurred in 5 patients (2.1%) and was not significantly different between the groups. Eleven additional patients (5%) died at follow-up, and 55 patients (23%) had at least 1 major adverse valve-related event. Propensity score–adjusted Cox regression analysis demonstrated higher rates of death in the bioprosthetic group compared with the mechanical group (hazard ratio, 8.82; 95% confidence interval, 1.64-47.39; P = .011). Survival was not significantly different between the repair and mechanical groups (hazard ratio, 1.09; 95% confidence interval, 0.17-7.16; P = .93). Likewise, rates of major adverse valve-related event were higher in the bioprosthetic group compared with the mechanical group (hazard ratio, 2.71; 995% confidence interval, 1.13-6.49; P = .025), but not significantly different between the repair and mechanical groups (hazard ratio, 1.98; 95% confidence interval, 0.89-4.39; P = .092). ConclusionsLeft-sided valve surgery for rheumatic heart disease in sub-Saharan Africa is associated with acceptable perioperative outcomes, but a high incidence of major adverse valve-related event at follow-up. The use of bioprosthetic valves is associated with poor outcomes in this patient population.

Postoperative Small Bowel Obstruction Following Laparoscopic or Open Fundoplication in Children: A Retrospective Analysis Using a Nationwide Database.

Postoperative small bowel obstruction (SBO) is one of the most serious adverse events resulting in deteriorated quality of life in children. Numerous studies have shown that laparoscopic surgery significantly reduces the occurrence of SBO compared with open surgery in adults. However, evidence of the advantages of laparoscopic surgery over open surgery in terms of reducing SBO is lacking in children. Fundoplication is a common abdominal procedure in children. This study was performed to compare the occurrence of SBO after laparoscopic fundoplication (LF) versus open fundoplication (OF). Using the Diagnosis Procedure Combination database, a national inpatient database in Japan, we retrospectively identified patients aged 0-18years who underwent LF or OF from July 2010 to March 2016. Propensity score adjustment was used to compare the occurrence of SBO between the groups. We identified 1838 eligible patients who underwent LF (n = 1362) or OF (n = 476). The median age at surgery was 4.0 and 1.5years in the LF and OF group, respectively (P < 0.001). The median weight at admission was 11.4 and 7.5kg, respectively (P < 0.001). Nineteen (1.4%) patients in the LF group and 13 (2.7%) in the OF group had at least one episode of SBO (P = 0.11, log-rank test). In the propensity score-adjusted Cox regression analysis, SBO was significantly less likely to occur in the LF than OF group (hazard ratio, 0.36; 95% confidence interval 0.16-0.82; P = 0.01). In this retrospective nationwide study, LF was significantly associated with a reduction in SBO compared with OF in children.

Early and late results of surgical treatment for isolated active native mitral valve infective endocarditis.

Native mitral valve infective endocarditis (IE) is a complicated disease with high mortality and morbidity rates. Mitral valve repair (MVRep) is feasible when limited valve destruction is present. However, recurrent valve dysfunction and reintervention are common. Between January 2000 and March 2016, 83 patients underwent surgery for isolated active native mitral valve IE. We applied an early surgery, MVRep-oriented approach with progressive utilization of patch techniques to secure a durable repair; MVRep was attempted in 67% of patients. Fifty-one (61%) patients underwent MVRep (including full-ring annuloplasty in 94%) and 32 (39%) patients underwent mitral valve replacement. Early mortality was 13%. No cases of early recurrent IE occurred. Predischarge echocardiography demonstrated good MVRep function in all, except 1 patient with residual (Grade 2+) regurgitation. The mean duration of follow-up was 3.7 years (interquartile range 1.5-8.4). For hospital survivors, 8-year overall survival rates were 92.4% (95% confidence interval 84.0-100%) and 74.2% (95% confidence interval 53.8-94.6%) for the MVRep and mitral valve replacement groups, respectively. Propensity score-adjusted Cox regression analysis revealed no significant difference in survival between the 2 groups (hazard ratio 0.359, 95% confidence interval 0.107-1.200; P = 0.096). Four reinterventions occurred, 2 in each group. Echocardiographic follow-up demonstrated excellent MVRep durability; no cases of mitral regurgitation and 1 case of mitral valve stenosis were seen. Native mitral valve IE is linked to high mortality and morbidity rates. A durable MVRep is feasible in most patients and provides excellent mid-term durability. Mitral valve replacement is a reasonable alternative when a durable repair is not likely.

Staging of pancreatic cancer based on the number of positive lymph nodes.

The International Study Group on Pancreatic Surgery has stated that at least 12 lymph nodes should be evaluated for staging of pancreatic cancer. The aim of this population-based study was to evaluate whether the number of positive lymph nodes refines staging. Patients who underwent pancreatectomy for stage I-II pancreatic cancer between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. The predictive value of the number of positive lymph nodes for survival was assessed by generalized receiver operating characteristic (ROC) curve analysis and propensity score-adjusted Cox regression analysis. Some 5036 patients were included, with a median of 18 (i.q.r. 15-24) lymph nodes examined. Positive lymph nodes were found in 3555 patients (70·6 per cent). The median duration of follow-up was 15 (i.q.r. 8-28) months. ROC curve analysis revealed that two positive lymph nodes best discriminated overall survival. Patients with one or two positive lymph nodes (pN1a) and those with three or more positive lymph nodes (pN1b) had an increased risk of overall mortality compared with patients who were node-negative (pN0): hazard ratio (HR) 1·47 (95 per cent c.i. 1·33 to 1·64) and HR 2·01 (1·82 to 2·22) respectively. These findings were confirmed by propensity score-adjusted Cox regression analysis. The 5-year overall survival rates were 39·8 (95 per cent c.i. 36·5 to 43·3) per cent for patients with pN0, 21·0 (18·6 to 23·6) per cent for those with pN1a and 11·4 (9·9 to 13·3) per cent for patients with pN1b disease. The number of positive lymph nodes in the resection specimen is a prognostic factor in patients with pancreatic cancer.

Impact of aprepitant on emesis control, dose intensity, and recurrence-free survival in a population-based cohort of head and neck cancer patients receiving high-dose cisplatin chemotherapy

Standard care for locally advanced head and neck cancer (HNC) patients consists of high-dose cisplatin with radiation to prolong recurrence-free survival (RFS). However, poorly controlled emesis can compromise optimal dose intensity (DI) and affect disease control. To evaluate the impact of aprepitant on emesis control, DI, and RFS. HNC patients treated at the British Columbia Cancer Agency were analyzed. Kaplan-Meier method and adjusted Cox proportional hazard models were used to evaluate RFS in aprepitant users. To control for selection bias, a propensity score analysis was conducted. A total of 192 HNC patients were included: 141 received aprepitant prophylaxis. The aprepitant-treated and untreated groups were comparable in mean age (56.3 vs 58.1 years), male gender (82.3% vs 86.3%), tumor location, and number of metastatic sites. However, more patients in the aprepitant group than in the untreated group had surgically resectable disease (31.2% vs 15.7%, respectively) and better performance status (ECOG 0/1, 87.9% vs 76.4%). Less emesis was reported in the aprepitant group (21.3% vs 28.0%). Patients in the treated group were also more likely to complete 3 cycles of high-dose cisplatin (OR, 2.3; P = .03). The propensity score adjusted Cox regression analysis suggested a reduced risk of disease recurrence in patients who received aprepitant (HR, 0.47; 95% CI, 0.17- 1.28). Potential confounders such as other diseases or treatments that may have influenced the presence of nausea/emesis symptoms. Aprepitant contributed to improved emesis control, enhanced DI, and better adherence to cisplatin chemotherapy.

Long-Term Outcomes of Neointimal Hyperplasia Without Neoatherosclerosis After Drug-Eluting Stent Implantation

ObjectivesThe aim of this study was to investigate the correlation between in-stent neointimal tissue without features of neoatherosclerosis and long-term clinical outcomes. BackgroundRecent studies have reported differential morphological characteristics of in-stent neointimal tissue assessed by optical coherence tomography (OCT). MethodsThe study population consisted of 336 patients with 368 drug-eluting stent-treated lesions. Patients received a follow-up OCT examination without any intervention. OCT-based neointima was categorized as homogeneous (n = 227 lesions in 208 patients), heterogeneous (n = 79 lesions in 73 patients), or layered (n = 62 lesions in 55 patients). Major adverse cardiac events (MACE) (a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization) were assessed according to neointimal patterns during long-term clinical follow-up after OCT examination. ResultsThe time interval between stent implantation and OCT examination was similar among the 3 groups (p = 0.64). On multivariate logistic regression analysis, the significant determinant for the heterogeneous neointima was age (odds ratio [OR]: 1.037, 95% confidence interval [CI]: 1.007 to 1.068, p = 0.015) and an initial clinical presentation of acute coronary syndrome (OR: 1.967, 95% CI: 1.159 to 3.339, p = 0.012). The overall median follow-up duration for all patients after follow-up OCT examination was 31.0 months, and this was statistically different among the heterogeneous group (22.0 months), the homogeneous group (34.0 months), and the layered group (28.0 months, overall p = 0.002). MACE occurred more frequently in patients with heterogeneous neointima over a median 31-month follow-up period after OCT examination (13.7% vs. 2.9% in homogeneous vs. 7.3% in layered, p = 0.001). A propensity score–adjusted Cox regression analysis showed that independent risk factors for MACE were inclusion in the heterogeneous neointima (hazard ratio: 3.925, 95% CI: 1.445 to 10.662, p = 0.007) and minimal lumen cross-sectional area (hazard ratio: 0.368, 95% CI: 0.242 to 0.560, p < 0.001). ConclusionsDetermination of neointimal characteristics is helpful in predicting long-term clinical outcomes. Our data suggest that heterogeneous lesions are linked to poor long-term clinical prognoses.

Blood transfusion does not adversely affect survival after elective colon cancer resection: a propensity score analysis

The aim of this study was to assess the putative impact of perioperative blood transfusions on overall survival in patients undergoing curative resection for stage III colon cancer by applying propensity scoring methods. In a single-center study, a total of 309 patients who underwent open curative resection for stages I-III colon cancer from 1996-2008 were assessed. The mean follow-up period was 47 ± 38months. Transfused and non-transfused patients were compared using both Cox regression and propensity score analyses. Overall, 148 patients (47.9%) received blood transfusions. The patient characteristics were highly biased toward transfusions (propensity score 0.68 ± 0.22 vs. 0.30 ± 0.22, p <0.001). In the unadjusted analysis, blood transfusions were associated with a 90% increased risk of overall mortality (hazard ratio 1.90, 95% CI: 1.19-3.04, p = 0.001). The 5-year survival for patients receiving blood transfusions was 64.5% (95% CI: 56.0-74.3%) compared with 80.1% (95% CI: 72.8-88.2%) in those not receiving blood transfusions. In the propensity score-adjusted Cox regression analysis (hazard ratio: 0.85, 95% CI = 0.53-1.37, p = 0.501), blood transfusions did not increase the risk of overall mortality. After risk adjustment, the 5-year survival rate for patients receiving blood transfusions was 66.6% (95% CI: 57.4-77.3%) compared with 61.8% (95% CI: 51.9-73.7%) for those who did not. This study is the first propensity score-based analysis that provides evidence that poor oncological outcomes after curative colon cancer resection in patients receiving perioperative blood transfusions are due to the clinical circumstances that require the transfusions and are not due to the blood transfusions.