Short-term Survival Benefit Research Articles

Multi-dimensional assessment of long-term outcomes in patients treated with extracorporeal cardiopulmonary resuscitation during refractory cardiac arrest

Abstract Background Recent randomised controlled trials showed short-term survival benefits with extracorporeal cardiopulmonary resuscitation (ECPR) compared to standard cardiac arrest treatment in selected patients with refractory cardiac arrest. Only limited data exist on multi-dimensional long-term outcomes after ECPR. Purpose To investigate multi-dimensional long-term outcomes of ECPR survivors, that is general health status, as well as cardiac, cognitive and psychological functions. Methods This is a multicenter, mixed-method clinical study conducted by cardiologists, neurologists and psychologists between May 2021 and December 2023. Adult patients who survived ECPR with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (i.e., VA-ECMO plus percutaneous left-ventricular assist device) in two German tertiary care centers were included. A comprehensive set of functional outcomes across multiple dimensions were assessed at approximately 18 months after the index cardiac arrest event (see Figure for stations A to E and explanation of abbreviations). Results Long-term outcomes were assessed in 32 ECPR survivors, out of whom 15 patients (46%) had received VA-ECMO and 18 (54%) ECMELLA treatment. 23 patients (70%) were male and the average age was 55 years (±13). Vital signs and laboratory markers were unremarkable. Most patients denied heart failure symptoms although the average EQ-5D-5L score was 52 (±8). The left-ventricular ejection fraction was 51% (±9), which improved by 14% (±11) in the ECMO group and 31% (±15) in the ECMELLA group since the index cardiac arrest event. Bicycle exercise (on average 6 minutes duration with a power of up to 100 Watts) and 6-minute walk test (average distance of 394 meters ±145) revealed physical impairments. 29 patients (88%) had a good cerebral performance (i.e., Cerebral Performance Category scale of 1) and the average mental status was good (mini–mental state examination score 29 ±1). 22 patients (56%) perceived (partial) impairments in activities of daily living although the average Barthel index was 100 (±5) and modified Rankin scale was 1 (±1). 12 patients (36%) were unable to return to their jobs. Remarkably, 17 (51%) and 4 (12%) patients reported depressive symptoms and suicidal thoughts, respectively. Conclusion Although ECPR remains a highly complex procedure, cardiac and neurologic functions in survivors have almost recovered, while physical and psychological impairments still persisted at 18 months after cardiac arrest. Physical rehabilitation and psychological care appear to be important measures for ECPR survivors.

Survival benefit of IABP in pre- versus post-primary percutaneous coronary intervention in patients with cardiogenic shock

BackgroundCardiogenic shock (CS) remains a major cause of in-hospital mortality in the setting of acute myocardial infarction (AMI). However, little evidence is available regarding the optimal order of intra-aortic balloon counter-pulsation (IABP) insertion and primary percutaneous coronary intervention (PPCI). The aim of this study was to assess the hospital and short-term survival benefits of two different IABP insertion approaches, before versus after PPCI in patients with acute myocardial infarction and cardiogenic shock.ResultsTotal mortality was 80 patients representing 48.4% of the total 165 studied patients; 60 patients died during the hospital admission period, while the remaining 20 patients died post-discharge. In-hospital mortality was significantly higher in Post-PPCI–IABP group 40 (49.4%) versus Pre-PPCI–IABP group 20 (23.8%) (P = 0.001). Moreover, the mortality difference between the two groups was sustained over six-month follow-up period, where 15 patients (18.5%) died in the Post-PPCI–IABP group, while only 5 patients 6.0% died in the Pre-PPCI–IABP (P = 0.001).ConclusionsEarly IABP insertion before PPCI is associated with improved in-hospital and long-term survival when used for patients presenting with AMI complicated by hemodynamic instability.

Clinical outcomes and short-term survival of neoadjuvant immunochemotherapy for resectable esophageal cancer: a multi-center retrospective cohort study

Objective: The present retrospective cohort study aims to evaluate the efficacy and safety of neoadjuvant immunochemotherapy for resectable esophageal cancer and report the preliminary short-term survival. Methods: A multi-center, retrospective study was conducted concerning patients who received neoadjuvant PD-1 agents plus platinum-based chemotherapy between January, 2019 to January, 2022. The primary endpoint was the tumor pathologic complete response (pCR) rate. Results: Two hundred and thirteen patients with initial stage cI-IVA esophageal cancer who received neoadjuvant immunochemotherapy were identified. Complete tumor resection(R0) rate was 99.1%. The pCR rate was 31.9%, and the overall major pathological response rate was 49.8%. The 2-year DFS rate was 78.9% (95%CI: 72.9%-85.4%) and 2-years OS rate was 80.9% (95%CI: 75.3%-86.9%). The incidence of TRAEs and surgical complications rate were 68.5% and 35.2%, respectively. Conclusion: The PD-1 agents combined with chemotherapy in the neoadjuvant treatment for resectable stage I–IVA esophageal cancer had a high pCR rate as well as good short-term survival benefit and tolerable toxicity.

Vascular reconstruction provides short-term and long-term survival benefits for patients with hilar cholangiocarcinoma: A retrospective, multicenter study

BackgroundIn patients with hilar cholangiocarcinoma (HCCA), radical resection can be achieved by resection and reconstruction of the vasculature. However, whether vascular reconstruction (VR) improves long-term and short-term prognosis has not been demonstrated comprehensively. MethodsThis was a retrospective multicenter study of patients who received surgery for HCCA with or without VR. Variables associated with overall survival (OS) and recurrence-free survival (RFS) were identified based on Cox regression. Kaplan-Meier curves were used to explore the impact of VR. Restricted mean survival time (RMST) was used for comparisons of short-term survival between the groups. Patients’ intraoperative and postoperative characteristics were compared. ResultsTotally 447 patients were enrolled. We divided these patients into 3 groups: VR with radical resections (n = 84); non-VR radical resections (n = 309) and non-radical resection (we pooled VR-nonradical and non-VR nonradical together, n = 54). Cox regression revealed that carbohydrate antigen 242 (CA242), vascular invasion, lymph node metastasis and poor differentiation were independent risk factors for OS and RFS. There was no significant difference of RMST between the VR and non-VR radical groups within 12 months after surgery (10.18 vs. 10.76 mon, P = 0.179), although the 5-year OS (P < 0.001) and RFS (P < 0.001) were worse in the VR radical group. The incidences of most complications were not significantly different, but those of bile leakage (P < 0.001) and postoperative infection (P = 0.009) were higher in the VR radical group than in the non-VR radical group. Additionally, the levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) up to 7 days after surgery tended to decrease in all groups. There was no significant difference in the incidence of postoperative liver failure between the VR and non-VR radical groups. ConclusionsRadical resection can be achieved with VR to improve the survival rate without worsening short-term survival compared with resection with non-VR. After adequate assessment of the patient's general condition, VR can be considered in the resection.

Prolonged vs intermittent intravenous infusion of β-lactam antibiotics for patients with sepsis: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis

BackgroundThe prolonged β-lactam antibiotics infusion has been an attractive strategy in severe infections, because it provides a more stable free drug concentration and a longer duration of free drug concentration above the minimum inhibitory concentration (MIC). We conducted this systematic review of randomized clinical trials (RCTs) with meta-analysis and trial sequential analysis (TSA) to compare the effects of prolonged vs intermittent intravenous infusion of β-lactam antibiotics for patients with sepsis.MethodsThis study was prospectively registered on PROSPERO database (CRD42023447692). We searched EMBASE, PubMed, and Cochrane Library to identify eligible studies (up to July 6, 2023). Any study meeting the inclusion and exclusion criteria would be included. The primary outcome was all-cause mortality within 30 days. Two authors independently screened studies and extracted data. When the I2 values < 50%, we used fixed-effect mode. Otherwise, the random effects model was used. TSA was also performed to search for the possibility of false-positive (type I error) or false-negative (type II error) results.ResultsA total of 4355 studies were identified in our search, and nine studies with 1762 patients were finally included. The pooled results showed that, compared with intermittent intravenous infusion, prolonged intravenous infusion of beta-lactam antibiotics resulted in a significant reduction in all-cause mortality within 30 days in patients with sepsis (RR 0.82; 95%CI 0.70–0.96; P = 0.01; TSA-adjusted CI 0.62–1.07). However, the certainty of the evidence was rated as low, and the TSA results suggested that more studies were needed to further confirm our conclusion. In addition, it is associated with lower hospital mortality, ICU mortality, and higher clinical cure. No significant reduction in 90-day mortality or the emergence of resistance bacteria was detected between the two groups.ConclusionsProlonged intravenous infusion of beta-lactam antibiotics in patients with sepsis was associated with short-term survival benefits and higher clinical cure. However, the TSA results suggested that more studies are needed to reach a definitive conclusion. In terms of long-term survival benefits, we could not show an improvement.

Short-course blinatumomab for refractory/relapse precursor B acute lymphoblastic leukemia in children.

To evaluate the clinical efficacy and safety of a short course of blinatumomab in children with refractory or relapsed precursor B-cell acute lymphoblastic leukemia (R/R-BCP-ALL). The clinical data of 33 R/R BCP-ALL children aged 0-18 years who underwent a short course of blinatumomab (14 days) between August 2021 and November 2022 were retrospectively collected and analyzed. Among 33 patients with BCP-ALL, 26 achieved complete remission (CR), with a total remission rate of 78.8% (26/33). The duration of remission was approximately 14 days. Of the 7 children without CR, 5 were still in remission at 28 days. In 11 patients with refractory disease and 22 with recurrence, the remission rates were 90.9% (10/11) and 72.7% (16/22), respectively. The overall survival (OS) rates of the 26 patients with CR and seven patients without CR were 96.1% and 57.1% (p = 0.002), respectively, and the disease-free survival (DFS) rates were 96.1% and 42.9% (p < 0.001), respectively. Among the 26 patients with CR, 15 underwent bridging hematopoietic stem cell transplantation (HSCT) and 11 did not receive HSCT; with OS rates of 93.3% and 100% (p = 0.40) and DFS rates of 93.3% and 100% (p = 0.400), respectively. The OS for all patients was 87.9% (29/33) and the DFS was 84.8% (28/33). There were 18 cases (54.5%) of cytokine release syndrome (CRS), 2 cases (6.1%) of severe CRS (all grade 3), 1 case (3.0%) of immune effector cell-associated neurotoxicity syndrome (ICANS), 0 cases (0%) of ICANS ≥ grade 3, and no deaths caused by treatment. Short-term follow-up revealed a high R/R BCP-ALL remission rate in children treated with a short course of blinatumomab. The toxicity was low and controllable. No significant short-term survival benefits were observed after bridging HSCT with blinatumomab. In developing countries, a short course of blinatumomab can achieve satisfactory outcomes, while reducing household costs and saving medical resources.

Head-to-head effectiveness and safety of pembrolizumab plus axitinib vs. nivolumab plus ipilimumab in metastatic renal cell carcinoma in the United States.

4532 Background: Two main first-line combination therapies for metastatic renal cell carcinoma (mRCC) are pembrolizumab plus axitinib (P+A) and nivolumab plus ipilimumab (N+I). No head-to-head clinical trial comparing these treatments has been performed, and the available real-world data (RWD) on their effectiveness is limited. Here, we used RWD to compare the overall survival and posttreatment hospitalization rates of mRCC patients receiving P+A vs. N+I. Methods: We included mRCC patients treated with N+I or P+A between 6/2018 and 3/2022, utilizing data from Elevance Health administrative claims and clinical data from AIM Cancer Care Quality Program. Inverse probability of treatment weighting (IPTW) was used to adjust for age, sex, socioeconomic deprivation index (SDI), ECOG performance status (PS), Charlson Comorbidity Index (CCI), and metastatic sites. Real-world overall survival (rwOS) was defined from first treatment until death or last claim and was estimated using weighted Kaplan-Meier method. Favorable risk was defined based on PS (&lt;2) and with a treatment initiated less than 1 year from diagnosis. Results: We identified 764 mRCC patients, of them 483 were treated with N+I (63%). The P+A group was slightly older (p=0.08), while other features were similar in both groups. Survival analysis using IPTW showed a borderline significant advantage of P+A vs. N+I (p-value=0.07). Inspection of the Kaplan-Meier curves suggested that P+A provides short-term survival benefit: 12-month rwOS was 86% for P+A vs. 77.8% for N+I (p&lt;0.001), while at 24-months, where power was lower, the curves almost converged (rwOS: 68% in P+A vs. 65% in N+I; p=0.52). In a subset of patients with favorable risk (N=69 P+A, N=68 N+I), the P+A survival improvement extended to at least 24-months (p=0.06). Finally, the N+I group had significantly higher rates of posttreatment hospitalizations (3-months after treatment initiation) compared to the P+A group (31.9% vs. 19.6%; p-value&lt;0.001). Conclusions: Our retrospective cohort study suggests that P+A may provide short-term survival benefits over N+I, and this benefit is extended in patients with favorable risk. P+A is also associated with fewer post-treatment hospitalizations. We argue that the higher toxicity of N+I may explain its lower short-term effectiveness and may also explain its lower effectiveness in patients with favorable risk. [Table: see text]

The Impact of Heparin on Mortality Following Open Ruptured Abdominal Aortic Aneurysm Repair

Systemic administration of heparin is widely used in patients undergoing open elective abdominal aortic aneurysm (AAA) repair. However, no clear consensus exists in the use of intraoperative heparin during open ruptured AAA (rAAA) repair. In this study, we assessed the safety of intravenous heparin administration in patients undergoing open rAAA repair. A retrospective cohort study comparing patients who received and did not receive heparin during open rAAA repair in the Vascular Quality Initiative database between 2003 and 2020 was conducted. The primary outcomes were 30-day and 10-year mortality. The secondary outcomes included estimated blood loss, number of packed red blood cells transfused, early postoperative transfusions, and postsurgical complications. Propensity score matching was used to adjust for potentially confounding variables. The outcomes were compared between the 2 groups using relative risk for binary outcomes and paired t-test and the Wilcoxon rank-sum test for normally and non-normally distributed continuous variables, respectively. Survival was examined using Kaplan-Meier curves and compared using a Cox proportional hazards model. A total of 2,410 patients who underwent open rAAA repair between 2003 and 2020 were studied. Of the 2,410 patients, 1,853 patients received intraoperative heparin and 557 did not. Propensity score matching on 25 variables yielded 519 pairs for the heparin to no heparin comparison. Thirty-day mortality was lower in the heparin group (risk ratio: 0.74; 95% confidence interval [CI]: 0.66-0.84) and in-hospital was also lower in the heparin group (risk ratio: 0.68; 95% CI: 0.60-0.77). Furthermore, estimated blood loss was 910mL (95% CI: 230mL to 1,590mL) lower in the heparin group and the mean number of packed red blood cells transfused intraoperatively and postoperatively were 17 units lower in the heparin group (95% CI: 8-42). Ten-year survival was higher for patients who received heparin, and their rate of survival was approximately 40% higher than those who did not receive heparin (hazard ratio: 0.62; 95% CI, 0.53-0.72; P<0.0001). In patients who received systemic heparin administration at the time of open rAAA repair, there were significant short-term and long-term survival benefits within 30days and at 10years. Heparin administration may have afforded a mortality benefit or been a surrogate for healthier and less moribund patients at the time of the procedure.

Predictors of anemia response to momelotinib therapy in myelofibrosis and impact on survival.

We retrospectively reviewed 72 anemic patients with myelofibrosis (MF; median age 68 years), who were JAK2 inhibitor-naïve at the time of study entry to a phase-1/2 momelotinib clinical trial. Driver mutation profile included JAK2 69%, CALR 17%, MPL 8%, and triple-negative 6%; other mutations included ASXL1 39% and SRSF2 17%. Momelotinib was administered at a median dose of 300 mg daily. Anemia response was assessed by formal criteria and documented in 44% of all patients with hemoglobin levels below the sex-adjusted reference range (n =72), 48% of those with hemoglobin <10g/dl (n =54), and 46% of those who were transfusion-dependent at the time of study entry (n =28). Anemia response was more likely with post-essential thrombocythemia MF (83% vs 37%; p=.001), lower serum ferritin (p=.003), and shorter time from diagnosis to momelotinib therapy (p= .001); the first two variables were also predictive in transfusion-dependent patients. Post-momelotinib median survival was 3.2 years; in univariate analysis, survival was superior in anemia responders (median 3.8 vs. 2.8 years; p=.14) and in the presence of type 1/like CALR mutation and inferior in the presence of age > 65 years, ASXL1/SRSF2 mutation, unfavorable karyotype, DIPSS-plus high risk, red cell transfusion need and higher serum ferritin. Multivariable analysis confirmed the favorable impact of anemia response on survival (p=.02; HR 0.5, 3/5/10-year survival; 69%/38%/25%). This survival advantage was also noted in transfusion-dependent patients (3.7 vs. 1.9 years; p=.01; HR 0.3) and appeared to be restricted to patients with an unfavorable genetic profile. The current study suggests a short-term survival benefit associated with anemia response in momelotinib-treated patients with MF.

Staphylococcus aureus bacteraemia and mortality: a population-based study in Olmsted County, Minnesota, from 2006 to 2020

Objectives To provide an evaluation of predictors of 6-month mortality in incident Staphylococcus aureus bacteraemia cases. Methods A retrospective population-based study of 541 adult residents of Olmsted County, MN with monomicrobial S. aureus bacteraemia from 1 January 2006 through 31 December 2020. Multivariable Cox regression was used to investigate risk factors of 6-month mortality. Results The median (interquartile range [IQR]) age of 541 patients with S. aureus bacteraemia was 66.8 (54.4–78.5) years and 39.6% were female. The median (IQR) Charlson Comorbidity Index was 6 (3–9). Overall, 144 patients died during the six-month period following their initial episode (30-day and 6-month mortality = 16.5% and 26.7%, respectively). In a multivariable analysis, older age, ICU admission, and unknown source of infection were significant predictors of increased 6-month mortality. In contrast, having an infectious diseases (ID) consultation was associated with reduced mortality in the first 2 weeks of follow-up. Secondary analyses revealed an early benefit of ID consultation during the first 30 days of follow-up and that infective endocarditis was an additional predictor of 6-month mortality. Conclusions To our knowledge, this investigation represents the only US population-based study evaluating predictors of mortality in patients with S. aureus bacteraemia. The finding of a short-term survival benefit associated with early ID consultation may be due to more extensive diagnostic efforts.

S1315 Are We Following the Guidelines in the Treatment of Patients With Alcoholic Hepatitis?

Introduction: Alcoholic liver disease is one of the leading causes of chronic liver disease worldwide and accounts for up to 48% of cirrhosis-associated deaths in the United States. Corticosteroids provide a short-term survival benefit in about half of treated patients with Severe Alcoholic Hepatitis. The decision is made on the basis of risk stratification by Maddrey or Meld scoring system. We hope to assess how well we are at identifying and treating the patient population at Crozer Chester Medical Center Methods: We did a retrospective review of patients admitted to Crozer Chester Medical Center from October 2021 to January 2017. We filtered patients based on ICD-10 codes for Alcoholic Hepatitis. We included the patient 18 years and above hospitalized at Crozer Chester Medical Center with the diagnosis of alcoholic hepatitis. We excluded the patients who had sepsis on admission, had active hepatitis B or C, had acute kidney injury present on admission, had upper gastrointestinal bleed present on admission, patients requiring steroids due to some other condition. Results: We had an initial sample of 431 patients. After clearing duplicates or missing data entries, we were left with 321 patients. After applying the exclusion criteria, we were left with 60 patients, those who did not have any contraindications to steroid use. 90% (N=54) of those patients had no risk calculation score documented. There was no statistically significant difference between the teaching and non-teaching service regarding risk score documentation (p=0.43). We identified 20 patients from the sample who would have benefited from steroids. Out of those, only 47%(N=8) received steroids. Out of those, only 5 (29%) received prednisolone (Figure). Conclusion: Currently, the American College of gastroenterology guideline recommends using steroids in the high-risk patient population. (2)Various risks calculating criteria like Maddrey's Discriminant Function and MELD score have been developed to determine the patients who fulfill the criteria for severe disease and can benefit from a course of steroids Various strategies can be implemented to improve adherence to guidelines. The scoring system should be documented when admitting patients with alcoholic hepatitis Changes in the electronic medical records can be considered as displaying a popup reminder to calculate the appropriate risk score, to consult a specialist, or to automatically calculate the risk score can be made as it would be beneficial in this maintaining adherence to guidelines.Figure 1.: Steroids given to patients with high Maddrey/Meld score with no contraindications

Can albumin reduce the mortality of patients with cirrhosis and ascites? A meta-analysis of randomized controlled trials.

Albumin therapy in patients with decompensated liver cirrhosis has always been a controversial issue. This study aimed to investigate the efficacy and safety of albumin in reducing mortality and controlling complications in patients with liver cirrhosis and provide a reference for relevant decision-making. Databases such as PubMed, EMBASE, and Web of Science were searched to collect eligible articles published before January 2022, which were analyzed by Revman 5.3. A total of 10 randomized controlled trials (2040 patients) were included. Based on the meta-analysis results, no significant difference in mortality was shown between the albumin administration group and the control group (HR = 1.01; 95% CI, 0.97-1.05; P = 0.62). Subgroup analysis showed that albumin administration had no significant short-term or long-term survival benefits in patients with decompensated liver cirrhosis and increased the risk of pulmonary edema adverse reactions (RR = 3.14; 95% CI, 1.48-6.65; P = 0.003). Subgroup analysis based on albumin administration time showed that short-term (HR = 0.93; 95% CI, 0.76-1.13; P = 0.47) or long-term (HR = 0.97; 95% CI: 0.87-1.08; P = 0.58) administration of albumin could not significantly reduce the mortality of patients with decompensated liver cirrhosis. In contrast, albumin administration could significantly reduce the recurrence rate of ascites (RR = 0.56; 95% CI, 0.46-0.68; P = 0.000). Short-term(<1 month) or long-term (>1 month) administration of albumin can not significantly reduce the mortality of patients with decompensated liver cirrhosis, and a large amount of albumin infusion will increase the risk of pulmonary edema.

Artificial liver support in patients with liver failure: a modified DELPHI consensus of international experts.

The present narrative review on albumin dialysis provides evidence-based and expert opinion guidelines for clinicians caring for adult patients with different types of liver failure. The review was prepared by an expert panel of 13 members with liver and ntensive care expertise in extracorporeal liver support therapies for the management of patients with liver failure. The coordinating committee developed the questions according to their importance in the management of patients with liver failure. For each indication, experts conducted a comprehensive review of the literature aiming to identify the best available evidence and assessed the quality of evidence based on the literature and their experience. Summary statements and expert's recommendations covered all indications of albumin dialysis therapy in patients with liver failure, timing and intensity of treatment, efficacy, technical issues related to the device and safety. The panel supports the data from the literature that albumin dialysis showed a beneficial effect on hepatic encephalopathy, refractory pruritus, renal function, reduction of cholestasis and jaundice. However, the trials lacked to show a clear beneficial effect on overall survival. A short-term survival benefit at 15 and 21 days respectively in acute and acute-on-chronic liver failure has been reported in recent studies. The technique should be limited to patients with a transplant project, to centers experienced in the management of advanced liver disease. The use of extracorporeal albumin dialysis could be beneficial in selected patients with advanced liver diseases listed for transplant or with a transplant project. Waiting future large randomized controlled trials, this panel experts' statements may help careful patient selection and better treatment modalities.

Early Statin Therapy and In-Hospital Outcomes in Acute Coronary Syndrome Patients Presenting with Advanced Killip Class at Admission: Findings from the CCC-ACS Project.

It is unknown if acute coronary syndrome (ACS) patients presenting with advanced Killip class (III/IV) would benefit from early statin therapy. Therefore, we aimed to explore the relationship between statin therapy within the first 24 h of medical contact and in-hospital outcomes in this patient population in a nationwide registry. In the Improving Care for Cardiovascular Disease in China-ACS project, among ACS patients presenting with Killip class III/IV, we performed the following three analyses: (i) the associations between early statin therapy and risks for in-hospital mortality and ischaemic events; (ii) the dose effect of statins on mortality and (iii) the interaction between low-density lipoprotein cholesterol (LDL-C) levels and statins on mortality. Among 104,516 ACS patients, 12,149 presented with advanced Killip class and 89.3% received early statins. Multivariable-adjusted logistic regression models revealed a 69% reduction in mortality in the statin group (adjusted odds ratio [OR] 0.31; 95% confidence interval [CI] 0.25-0.39), parallel with a reduction in ischaemic events (adjusted OR 0.50, 95% CI 0.33-0.74), compared with those not receiving early statins, which was consistent in multiple sensitivity analyses. Additionally, the protective association of early statins on in-hospital mortality was observed even among patients that received a low-to-moderate dose. Finally, the short-term survival benefit of early statins was independent of LDL-C. In a nationwide ACS registry, statin therapy initiated within the first 24 h of medical contact was associated with a reduced risk of in-hospital mortality in ACS patients presenting with advanced Killip class.

Impact of stereotactic body radiation therapy volume on surgical patient selection, short-term survival, and long-term survival in early-stage non–small cell lung cancer

ObjectivesStereotactic body radiation therapy (SBRT) is increasingly used to treat non–small cell lung cancer. The purpose of this study is to analyze relationships between facility SBRT utilization and surgical patient selection and survival after surgery. MethodsData on patients with TI/T2N0M0 lesions and treatment facility characteristics were abstracted from the National Cancer Database, 2008 to 2017. Facilities were stratified using an SBRT/surgery ratio previously associated with short-term survival benefit for patients treated surgically, and by a previously identified surgical volume threshold. Multiple regression analyses, Cox proportional-hazard regressions, and Kaplan–Meier log rank test were employed. ResultsIn total, 182,610 patients were included. Proportion of high SBRT:surgery ratio (≥17%) facilities increased from 118 (11.5%) to 558 (48.4%) over the study period. Patients undergoing surgery at high-SBRT facilities had comparable comorbidity scores and tumor sizes to those at low-SBRT facilities, and nonclinically significant differences in age, race, and insurance status. Among low-volume surgical facilities, treatment at a high SBRT-using facility was associated with decreased 30-day mortality (1.8% vs 1.4%, P < .001) and 90-day mortality (3.3% vs 2.6%, P < .001). At high-volume surgical facilities, no difference was observed. At 5 years, a survival advantage was identified for patients undergoing resection at facilities with high surgical volumes (hazard ratio, 0.91; confidence interval, 0.90-0.93 P < .001) but not at high SBRT-utilizing facilities. ConclusionsDifferences in short-term survival following resection at facilities with high-SBRT utilization may be attributable to low surgical volume facilities. Patients treated at high volume surgical facilities do not demonstrate differences in short-term or long-term survival based on facility SBRT utilization.

Sources of Human’s Aggression, Violence, Antisocial and Addictive Behaviors

In the 21st century hunger, starvation and malnutrition is still a scourge of mankind. According to World Bank reports a rise of millions of people lacked year-round access to adequate food in 2020 compared to 2019. Malnutrition, poverty, lack of quality education and insufficient health care are causes and consequences of each other. Preconceptual, prenatal and early postnatal malnutrition have life-long negative consequences on human’s health and behavior via epigenetic processes that regulate gene expression providing short-term survival benefits but predispose to various pathological conditions in adulthood. Based on scientific research there is not any doubt that early epigenetic changes play a major role in the development of excessive aggression, violence, antisocial and addictive behaviors. A body of evidence shows that clinical pictures like oppositional defiant disorders (ODD), conduct disorders (CD) and antisocial personality disorders (APD) have a neurodevelopmental origin based on epigenetic changes of gene expression. It is suggested that only early intensive therapeutic interventions focusing on autonomy, sense of competence and social connectedness in an individualistic, systemic and tightly structured positive and safe environment including healthy lifestyle and nutrition could prevent the progression of ODD into CD and eventually into APD. Quality nutrition, quality education and adequate health care for every human, starting at the very first days of life, are claimed to be unconditional premises to transform humanity into a peaceful species able to deal with the future challenges and dangers of life on planet earth.

Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients.

The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization. A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2 ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis. A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p= 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p= 0.007) when compared to non-diabetic patients. Early initiation of HD at eGFR >5ml/min/1.73 m2 had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.

Survival Benefit of Lung Transplant in Septuagenarians: A United Network of Organ Sharing Database Analysis

<h3>Purpose</h3> The benefit of lung transplant in septuagenarians is questioned on the grounds that recipients must be so highly selected that their baseline survival negates any benefit of transplant. This study evaluated the short-term outcomes and survival benefit of lung transplant in septuagenarians compared to waitlist patients that did not receive a transplant. <h3>Methods</h3> Using the United Network for Organ Sharing database, lung transplant recipients and waitlist candidates from 1991-2021 were analyzed. Dual organ transplant candidates/recipients and those without validated records were excluded. The cohort consisted of 3109 patients, 12.9% (400) were waitlist candidates and 87.1% (2709) were lung transplant recipients all seventy years of age and older. Propensity matching on eleven demographic characteristics, year of waitlist/surgery, and waitlist time produced 384 pairs with correction of baseline differences. Short-term survival was compared with a Cox regression model. Median follow-up of the lung transplants was 2 years (interquartile range (IQR) 0.8-4) versus 0.3 (IQR 0.1-0.6) for waitlist candidates. <h3>Results</h3> Lung transplants in septuagenarians increased from 0.14% (1) in 1991 to 12.2% (193) transplants in 2021, p<0.001. The median age of the unmatched waitlist candidates and recipients was 71 (IQR 70-73), with a listing lung allocation score of 38.7 (IQR 34-48.5) and 37.8 (IQR 34.1-44.8), respectively, all p>0.5. In the unmatched cohort, there was a higher proportion of females in the waitlist group (37.3% (149) vs 25% (677)), p<0.0001. In matched patients, six-month survival was lower in the waitlist group 42% (95% CI 36.4-47.4) versus 91.1% (95% CI 87.6-93.7), p<0.0001 (Figure). <h3>Conclusion</h3> Lung transplant can be offered in septuagenarians with survival benefit in those eligible for lung transplant. These findings may inform the transplant community that selection bias due to age should be reconsidered.

Acetylsalicylic acid use is associated with improved survival in bacteremic pneumococcal pneumonia: A long-term nationwide study.

BackgroundPneumonia is commonly caused by Streptococcus pneumoniae (pneumococcus) and associated with subsequent cardiovascular complications and increased mortality. Potential short‐term survival benefits conferred by acetylsalicylic acid (ASA) use in pneumonia remain controversial, and long‐term outcomes have not been studied.ObjectivesTo evaluate the association between ASA use and survival for up to 1 year following bacteremic pneumococcal pneumonia.MethodsAll bacteremic pneumococcal episodes in Iceland from 1975 to 2019 were reviewed. The study cohort consisted of individuals at least 18 years of age with symptoms and imaging results consistent with pneumonia. Differences in survival were assessed at 30 days, 90 days and 1 year using propensity score weighting (inverse probability weighting). Splitting and stratifying on survival at 7 days was done for the 30‐day survival, because of nonproportionality.ResultsIn total, 815 bacteremic pneumococcal pneumonia episodes (median age 67 years, females 48%) were identified. Cox regression using propensity score weighting on the association of ASA with survival at 30 days showed an average hazard ratio (HR) of 0.60 (95% confidence interval [CI] 0.34–1.05). A significantly improved survival was observed within 7 days (HR = 0.42, 95% CI 0.19–0.92) but not during days 7–30 (HR = 1.08, 95% CI 0.46–2.55). ASA was associated with survival at 90 days (HR = 0.53, 95% CI 0.32–0.87) and 1 year (HR = 0.48, 95% CI 0.31–0.75).ConclusionUse of ASA upon admission for bacteremic pneumococcal pneumonia is associated with significantly reduced mortality for up to 1 year after diagnosis. ASA therapy in patients with pneumonia and other infectious syndromes warrants further study.

Real‐world experience with venetoclax and hypomethylating agents in myelodysplastic syndromes with excess blasts

Real‐world experience with venetoclax and hypomethylating agents in myelodysplastic syndromes with excess blasts