Unmatched Cohort Research Articles

Mortality after emergency unit fluid bolus in febrile Ugandan children.

Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda. This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria. The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase. This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.

Long and Short-Term Effects of Hypothermic Machine Perfusion vs. Cold Storage on Transplanted Kidneys from Expanded Criteria Donors-A Matched Comparison Study.

Hypothermic machine perfusion (HMP) has been shown to reduce delayed graft function (DGF)-rates in kidneys from expanded criteria donors (ECD) and may increase graft survival compared with static cold storage (SCS). This single-center, retrospective observational study aimed to evaluate this effect. The primary endpoint was the DGF-rate, defined as the use of dialysis in the first postoperative week, excluding the first 24 h. The main secondary endpoint was graft survival at 5 years. Recipients of ECD-kidneys between 2013 and 2021 with ≤2 grafts were included (n = 438). The SCS-kidneys were marginal-matched by propensity score to the HMP-group for donor age, cold ischemia time, and graft number. Multivariable adjusted analysis for confounders in the unmatched cohort and caliper-based ID-matching constituted sensitivity analyses. HMP showed a trend to lower DGF-rate in the marginal-matched comparison (9.2% vs. 16.1%, p = 0.063). This was strengthened by a significant benefit observed for HMP in both the sensitivity analyses: an adjusted OR of 0.45 (95% CI: 0.24; 0.84; p = 0.012) in the multivariable analysis and DGF-rate of 8.7% vs. 17.4% (p = 0.024) after ID-matching. The 5-year graft survival rate was >90% in both groups, with no benefit using HMP (HR = 0.79; 95% CI:0.39-1.16; p = 0.52). Our results suggest that HMP may be effective in decreasing DGF-rates, however, without any significant benefit in graft survival.

Laparoscopic vs open repair for primary midline ventral hernia: a prospective cohort study

BackgroundThe optimal operative treatment for umbilical and epigastric hernia, i.e., primary midline ventral hernia (PMVH), is debatable. The most common techniques are the primary suture and open repair with mesh, while laparoscopic approach using intraperitoneally placed onlay mesh (IPOM) is less frequent. The aim of this study was to examine the outcomes of IPOM in PMVH. Perioperative results, recurrence, pain, and functional status were studied.MethodsThis single-center prospective cohort study included consecutive patients with PMVH operated between September 2006 and December 2015. Systematic follow-up was conducted 6 months and 2 and 5 years postoperatively.ResultsSeven hundred fifty-four patients underwent PMVH repair. Open repair without mesh, open repair with mesh, and IPOM were performed in 251 (34.9%), 273 (38%), and 195 (27.1%) patients, respectively. In the unmatched cohort, the incidence of postoperative complications was similar except postoperative seroma, which was more frequent after IPOM. The latter was also associated with longer length of stay. Open repair with mesh was associated with significantly lower recurrence compared with open repair without mesh and IPOM (5.2 vs 18.2 vs 13.8%, p=0.001, respectively). No differences were seen between the groups in terms of visual analog scale used for registering postoperative pain. These observations persisted after applying propensity score matching. In the multivariable analysis, open repair without mesh and IPOM significantly correlated with recurrence.ConclusionsIn PMVH, open repair with mesh is associated with lower recurrence compared with open repair without mesh and IPOM. Pain, postoperative complications (except for seroma), and functional status are similar.

Development and internal validation of a Neonatal Healthcare-associated infectiOn Prediction score (NeoHoP score) for very low birthweight infants in low-resource settings: a retrospective case–control study

Background and objectivesEarly diagnosis of neonatal infection is essential to prevent serious complications and to avoid unnecessary use of antibiotics. The prevalence of healthcare-associated infections (HAIs) among very low birthweight...

Are outcomes for emergency index-admission laparoscopic cholecystectomy performed by hepatopancreatobiliary surgeons better compared to non-hepatopancreatobiliary surgeons? A 10-year audit using 1:1 propensity score matching

BackgroundEmergency index-admission cholecystectomy (EIC) is recommended for acute cholecystitis in most cases. General surgeons have less exposure in managing “difficult” cholecystectomies. This study aimed to compare the outcomes of EIC between hepatopancreatobiliary (HPB) versus non-HPB surgeons. MethodsThis is a 10-year retrospective audit on patients who underwent EIC from December 2011 to March 2022. Patients who underwent open cholecystectomy, had previous cholecystitis, previous endoscopic retrograde cholangiopancreatography or cholecystostomy were excluded. A 1:1 propensity score matching (PSM) was performed to adjust for confounding variables (e.g. age ≥ 75 years, history of abdominal surgery, presence of dense adhesions). ResultsThere were 1409 patients (684 HPB cases, 725 non-HPB cases) in the unmatched cohort. Majority (52.3%) of them were males with a mean age of 59.2 ± 14.9 years. Among 472 (33.5%) patients with EIC performed ≥ 72 hours after presentation, 40.1% had dense adhesion. The incidence of any morbidity, open conversion, subtotal cholecystectomy and bile duct injury were 12.4%, 5.0%, 14.6% and 0.1%, respectively. There was one mortality within 30 days from EIC. PSM resulted in 1166 patients (583 per group). Operative time was shorter when EIC was performed by HPB surgeons (115.5 min vs. 133.4 min, P < 0.001). The mean length of hospital stay was comparable. EIC performed by HPB surgeons was independently associated with lower open conversion [odds ratio (OR)= 0.24, 95% confidence interval (CI): 0.12–0.49, P < 0.001], lower fundus-first cholecystectomy (OR= 0.58, 95% CI: 0.35–0.95, P= 0.032), but higher subtotal cholecystectomy (OR= 4.19, 95% CI: 2.24–7.84, P < 0.001). Any morbidity, bile duct injury and mortality were comparable between the two groups. ConclusionEIC performed by HPB surgeons were associated with shorter operative time and reduced risk of open conversion. However, the incidence of subtotal cholecystectomy was higher.

Aortic valve cusp repair does not affect durability of modified aortic valve reimplantation for tricuspid aortic valves

ObjectiveDuring aortic valve reimplantation, cusp repair may be needed to produce a competent valve. We investigated whether the need for aortic valve cusp repair affects aortic valve reimplantation durability. MethodsPatients with tricuspid aortic valves who underwent aortic valve reimplantation from January 2002 to January 2020 at a single center were retrospectively analyzed. Propensity matching was used to compare outcomes between patients who did and did not require aortic valve cusp repair. ResultsCusp repair was performed in 181 of 756 patients (24%). Patients who required cusp repair were more often male, were older, had more aortic valve regurgitation, and less often had connective tissue disease. Patients who underwent cusp repair had longer aortic clamp time (124 ± 43 minutes vs 107 ± 36 minutes, P = .001). In-hospital outcomes were similar between groups and with no operative deaths. A total of 98.3% of patients with cusp repair and 99.3% of patients without cusp repair had mild or less aortic regurgitation at discharge. The median follow-up was 3.9 and 3.2 years for the cusp repair and no cusp repair groups, respectively. At 10 years, estimated prevalence of moderate or more aortic regurgitation was 12% for patients with cusp repair and 7.0% for patients without cusp repair (P = .30). Mean aortic valve gradients were 6.2 mm Hg and 8.0 mm Hg, respectively (P = .01). Ten-year freedom from reoperation was 99% versus 99% (P = .64) in the matched cohort and 97% versus 97%, respectively (P = .30), in the unmatched cohort. Survival at 10 years was 98% after cusp repair and 93% without cusp repair (P = .05). ConclusionsAortic valve reimplantation for patients with tricuspid aortic valves has excellent long-term results. Need for aortic valve cusp repair does not affect long-term outcomes and should not deter surgeons from performing valve-sparing surgery.

1000-P: The Economic Impact of Reducing Hospitalizations and Amputations in Patients with Diabetic Foot Ulcers

The purpose of this real-word evidence (RWE) cohort study was to evaluate whether utilization of Cyclical Pressurized Topical Oxygen (TWO2) therapy had any impact on the incidence of Diabetic Foot Ulcer related hospitalizations and amputations over a 12-month period in patients with hard to heal Diabetic foot Ulcers (DFU). An IRB approved retrospective review of deidentified DFU patient medical records was conducted at 2 US Veterans Affairs Medical Centers in Illinois and Virginia, which included demographic information on wound characteristics, clinical characteristics, neuropathy, cardiovascular disease (CVD), peripheral vascular disease (PVD), pain levels and kidney disease etc. Within the unmatched cohorts of the 202 DFU patients (91 TWO2, 111 NO TWO2)there was an 88% reduction in hospitalizations and a 71% reduction in amputations over a 12-month period for the patients treated with TWO2 therapy compared to those that did not receive TWO2 therapy. Propensity score matching was conducted showing similar outcomes and a regression analysis as preformed along with a budget impact model which demonstrated significant cost saving to the payor system. This large RWE study demonstrates the TWO2 therapy positively impacts patients quality of life and the costs associated with treating their DFU by forcing them into remission, resulting in significantly reduced rates of hospitalizations, amputations and cost outlay. Disclosure M.G.Garoufalis: Consultant; Uluru, Employee; AOT Inc., Speaker's Bureau; 3M/KCI, Horizon Therapeutics plc.

Cusp overlap versus standard three-cusp technique for self-expanding Evolut transcatheter aortic valves.

Reducing rates of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is important for achieving the best procedural outcomes. The cusp overlap technique (COT) implements procedural steps including an overlap angulation of the right and left coronary cusp to mitigate this complication. We investigated the incidence of PPI and complication rates following the COT compared to the standard three-cusp implantation technique (3CT) in an all-comers cohort. Atotal of 2,209 patients underwent TAVI with the self-expanding Evolut platform from January 2016 to April 2022 at five sites. Baseline, procedural and in-hospital outcome characteristics were compared for both techniques before and after one-to-one propensity score matching. Atotal of 1,151 patients were implanted using the 3CT and 1,058 using the COT. At discharge, the rates of PPI (17.0 vs 12.3%; p=0.002) and moderate/severe paravalvular regurgitation (4.6% vs 2.4%; p=0.006) were significantly reduced with the COT compared with 3CT within the unmatched cohort. Overall procedural success and complication rates were similar; major bleeding was less common in the COT group (7.0% vs 4.6%; p=0.020). These results remained consistent after propensity score matching. In multivariable logistic regression analysis, right bundle branch block (odds ratio [OR] 7.19, 95% confidence interval [CI]: 5.18-10.0; p<0.001) and diabetes mellitus (OR 1.38, 95% CI: 1.05-1.80; p=0.021) emerged as predictors of PPI, whereas the COT (OR 0.63, 95% CI: 0.49-0.82; p<0.001) was protective. The introduction of the COT was associated with asignificant and relevant reduction of PPI and paravalvular regurgitation rates without an increase in complication rates.

Outcomes and reoperation rates of adult spinal deformity patients with baseline sagittal malalignment based on the cranial axis to the hip at 2 years postoperatively.

The aim of this study was to discern whether patients with a cranial sagittal vertical axis to the hip (CrSVA-H) > 2 cm at 2 years postoperatively exhibit significantly worse patient-reported outcomes (PROs) and clinical outcomes compared with patients with CrSVA-H < 2 cm. This was a retrospective, 1:1 propensity score-matched (PSM) study of patients who underwent posterior spinal fusion for adult spinal deformity. All patients had a baseline sagittal imbalance of CrSVA-H > 30 mm. Two-year patient-reported and clinical outcomes were assessed in unmatched and PSM cohorts, including Scoliosis Research Society-22r (SRS-22r) and Oswestry Disability Index scores as well as reoperation rates. The study compared two cohorts based on 2-year alignment: CrSVA-H < 20 mm (aligned cohort) vs CrSVA-H > 20 mm (malaligned cohort). For the matched cohorts, binary outcome comparisons were carried out using the McNemar test, while continuous outcomes used the Wilcoxon rank-sum test. For unmatched cohorts, categorical variables were compared using chi-square/Fisher's tests, while continuous outcomes were compared using Welch's t-test. A total of 156 patients with mean age of 63.7 (SEM 1.09) years underwent posterior spinal fusion spanning a mean of 13.5 (0.32) levels. At baseline, the mean pelvic incidence minus lumbar lordosis mismatch was 19.1° (2.01°), the T1 pelvic angle was 26.6° (1.20°), and the CrSVA-H was 74.9 (4.33) mm. The mean CrSVA-H improved from 74.9 mm to 29.2 mm (p < 0.0001). At the 2-year follow-up, 129 (78%) of 164 patients achieved CrSVA-H < 2 cm (aligned cohort). Patients who had CrSVA-H > 2 cm (malaligned cohort) at the 2-year follow-up had worse preoperative CrSVA-H (p < 0.0001). After performing PSM, 27 matched pairs were generated. In the PSM cohort, the aligned and malaligned cohorts demonstrated comparable preoperative patient-reported outcomes (PROs). However, at the 2-year postoperative follow-up, the malaligned cohort reported worse outcomes in SRS-22r function (p = 0.0275), pain (p = 0.0012), and mean total score (p = 0.0109). Moreover, when patients were stratified based on their magnitude of improvement in CrSVA-H (< 50% vs > 50%), patients with > 50% improvement in CrSVA-H had superior outcomes in SRS-22r function (p = 0.0336), pain (p = 0.0446), and mean total score (p = 0.0416). Finally, patients in the malaligned cohort had a higher 2-year reoperation rate (22% vs 7%; p = 0.0412) compared with patients in the aligned cohort. Among patients who present with forward sagittal imbalance (CrSVA-H > 30 mm), patients with CrSVA-H exceeding 20 mm at the 2-year postoperative follow-up have inferior PROs and higher reoperation rates.

Difference in the cumulative incidence of aneurysmal occlusion by Flow Re-direction Endoluminal Device and Pipeline Embolization Device in the treatment of unruptured internal carotid artery aneurysms: a propensity score-matched cohort study.

The introduction of flow diverters (FDs) has represented a paradigm shift in the management of unruptured cerebral aneurysms (UCA). Flow Re-direction Endoluminal Devices (FREDs) and Pipeline Embolization Devices (PEDs) have gained widespread popularity. We aimed to investigate the cumulative incidence of aneurysm occlusion. A total of 195 patients with 199 UCAs were analyzed retrospectively. The outcomes were aneurysmal occlusion during the follow-up, a modified Rankin Scale score of 0-2 at 90days, additional treatment, major stroke, and steno-occlusive events of FD. Propensity score-matched analysis was performed, controlling for age, sex, aneurysmal size, and location of the internal carotid artery (ICA) aneurysm. Non-ICA aneurysms were excluded from matching. During the follow-up period (median, 366days), complete and satisfactory aneurysmal occlusions were observed in 128 (68%) and 148 (78%) of 189 UCAs in the unmatched cohort. The 142 (71 each) propensity score-matched cohort was complied. The FRED group had a higher cumulative incidence of ICA aneurysm occlusion (complete: HR 2.7, 95% CI 1.4-5.1, p = 0.0025; satisfactory: HR 2.4, 95% CI 1.1-5.2, p = 0.025). The proportion of additional treatment was significantly smaller in the FRED group (OR 0.077, 95% CI 0.010-0.57, p = 0.0007). Other outcomes showed no significant differences. Propensity score-matched analysis indicated that FRED might have a higher cumulative incidence of aneurysmal occlusion in the treatment of unruptured ICA aneurysms. Whether a cumulative incidence of aneurysmal occlusion may differ by the type of FDs warrants further investigation.

Association between input/weight ratio and acute kidney injury in obese critical ill patients: a propensity analysis of multicenter clinical databases.

Rehydration volume may be underestimated in obese critically ill patients, which can lead to acute kidney injury (AKI). This study aimed to investigate the association between input/weight ratio (IWR) and AKI risk in obese critical patients. This retrospective observational study analyzed data from three large open databases. Patients were divided into lean and obese groups and matched 1:1 based on age, sex, APACHE II score, SOFA score, sepsis status, mechanical ventilation status, renal replacement therapy status, and hospital type. The exposure of interest was the mean IWR during the first three ICU admission days. The primary outcome was the incidence of AKI within 28days after ICU admission. Cox regression analysis was used to evaluate the association between IWR and AKI risk. A total of 82,031 eligible patients were included in the study, with 25,427 obese patients matched with 25,427 lean patients. The IWRs were significantly lower in the obese groups in both the unmatched cohort (35.85 ± 19.05 vs. 46.01 ± 30.43ml/kg, p < 0.01) and the matched cohort (36.13 ± 19.16 vs. 47.34 ± 31.13ml/kg, p < 0.01). An increase in IWR was significantly associated with decreased creatinine levels, increased urine output and a lower AKI risk. The interaction terms of IWR and obesity were significantly associated with decreased AKI incidence in both the unmatched cohort (hazard ratio [HR] = 0.97, 95% CI 0.96-0.97, p < 0.01) and the matched cohort (HR = 0.97, 95% CI 0.96-0.97, p < 0.01). Inadequate rehydration of patients with obesity may contribute to an increased risk of AKI in patients with obesity. These results highlight the need for better rehydration management in patients with obesity.

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

Optimal hemostatic resuscitation in pediatric trauma is not well defined. To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.

Case-Matched Outcomes of Proton Beam and Intensity-Modulated Radiation Therapy for Localized Prostate Cancer.

Although both intensity-modulated radiation therapy (IMRT) and proton beam therapy (PBT) offer effective long-term disease control for localized prostate cancer (PCa), there are limited data directly comparing the 2 modalities. The data from 334 patients treated with conventionally fractionated (79.2 GyRBE in 44 fractions) PBT or IMRT were retrospectively analyzed. Propensity score matching was used to balance factors associated with biochemical failure-free survival (BFFS). Age, race, and comorbidities (not BFFS associates) remained imbalanced after matching. Univariable and covariate-adjusted multivariable (MVA) Cox regression models were used to determine if modality affected BFFS. Of 334 patients, 176 (52.7%) were included in the matched cohort with exact matching to National Comprehensive Cancer Network (NCCN) risk group. With a median follow-up time of 9.0 years (interquartile range [IQR]: 7.8-10.2 years), long-term BFFS was similar between the IMRT and PBT matched arms with 8-year estimates of 85% (95% CI: 76%-91%) and 91% (95% CI: 82%-96%, P = .39), respectively. On MVA, modality was not significantly associated with BFFS in both the unmatched (hazard ratio [HR] = 0.75, 95% CI: 0.35-1.63, P = .47) and matched (HR = 0.87, 95% CI: 0.33-2.33, P = .78) cohorts. Prostate cancer-specific survival (PCSS) and overall survival (OS) were also similar (P > .05). However, in an unmatched analysis, the PBT arm had significantly fewer incidences of secondary cancers within the irradiated field (0.6%, 95% CI: 0.0%-3.1% versus 4.5%, 95% CI: 1.8%-9.0%, P = .028). Both PBT and IMRT offer excellent long-term disease control for PCa, with no significant differences between the 2 modalities in BFFS, PCSS, and OS in matched patients. In the unmatched cohort, fewer incidences of secondary malignancy were noted in the PBT group; however, owing to overall low incidence of secondary cancer and imbalanced patient characteristics between the 2 groups, these data are strictly hypothesis generating and require further investigation.

Nalbuphine May Be Superior to Sufentanil in Relieving Postcesarean Uterine Contraction Pain in Multiparas: A Retrospective Cohort Study.

Postcesarean pain remains a major complaint from puerperium women who have undergone cesarean section, especially uterine contraction induced visceral pain. The optimal opioid for pain relief after cesarean section (CS) is still unclear. The goal of this study was to compare the analgesic effect of Nalbuphine to Sufentanil in patients who underwent CS. In this single-center retrospective cohort study, we included patients who received Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia (PCIA) after CS between 1 January 2018 and 30 November 2020. Data on a Visual Analog Scale (VAS) at uterine contraction, at rest, and at movement, analgesic consumption, and side effects were collected. We performed logistic regression to identify predictors of severe uterine contraction pain. A total of 674 patients were identified in the unmatched cohort, and 612 patients in the matched one. Compared to the Sufentanil group, lower VAS-contraction was recorded in the Nalbuphine group in both the unmatched and matched cohorts, the mean difference (MD) on POD1 was 0.35 (95% CI: 0.17 to 0.54, p<0.001) and 0.28 (95% CI: 0.08 to 0.47, p<0.001), respectively, and the MD of POD2 was 0.12 (95% CI: 0.03 to 0.40, P=0.019) and 0.12 (95% CI: 0.03 to 0.41, P=0.026), respectively. On POD1 but not POD2, VAS-movement was lower in the Nalbuphine group as compared to the Sufentanil group. No difference was found between VAS-rest on POD1 and POD2 in both unmatched and matched cohorts. Less analgesic consumption, and side effects were recorded in the Nalbuphine group. Logistic regression indicated that multipara and analgesic consumption were risk factors for severe uterine contraction pain. In subgroup analysis, VAS-contraction was meaningfully reduced in the Nalbuphine group compared with the Sufentanil group in multipara patients, but not primiparas. Compared to Sufentanil, Nalbuphine may provide better analgesia on uterine contraction pain. The superior analgesia may only exhibit in multiparas.

Closed Incision Negative Pressure Therapy in Oncoplastic Surgery Prevents Delays to Adjuvant Therapy.

Patient demographics, ciNPT use, postoperative complication rates, and time to adjuvant therapy were analyzed from the records of 150 patients (ciNPT = 29, SOC = 121). Propensity score matching was used to match patients based on age, body mass index, diabetes, tobacco use, and prior breast surgery. In the matched cohort, the overall complication rate of ciNPT-treated cancerous breasts was 10.3% (3/29) compared with 31% (9/29) in SOC-treated cancerous breasts (P = 0.096). Compared with the SOC-treated cancerous breasts, the ciNPT breasts had lower skin necrosis rates [1/29 (3.4%) versus 6/29 (20.7%); P = 0.091] and dehiscence rates [0/29 (0%) versus 8/29 (27.6%); P = 0.004]. In the unmatched cohort, the total number of ciNPT patients who had a delay in adjuvant therapy was lower compared to the SOC group (0% versus 22.5%, respectively; P = 0.007). Use of ciNPT following oncoplastic breast reduction effectively lowered postoperative wound healing complication rates and, most importantly, decreased delays to adjuvant therapy.

Association of survival with adjuvant radiotherapy for pN0 esophageal cancer

Introduction: This study was conducted to elucidate the link between adjuvant radiotherapy and survival in pathologic node-negative (pN0) esophageal cancer patients with upfront esophagectomy. Methods: From 2000 to 2016, patients with pN0 esophageal cancer who underwent upfront esophagectomy were selected from the Surveillance, Epidemiology, and End Results (SEER) database. The association of high-risk covariates with survival after adjuvant radiotherapy was evaluated using propensity score matching and multivariate analysis. Results: We identified 3197 patients, 321 (10.0%) underwent postoperative radiotherapy and 2876 (90.0%) underwent esophagectomy alone. In the unmatched cohort, postoperative radiotherapy was associated with a statistically significant but modest absolute decrease in survival outcomes (P < 0.001). In the matched cohort, the survival differences disappeared. Additionally, adjuvant radiotherapy was linked to a 5-year overall survival (OS) benefit for patients with the pT3-4N0 disease (34.8% vs. 27.7%; P = 0.008). Adjuvant radiotherapy for pT3-4N0 disease with tumor length ≥3 cm, adenocarcinoma, and evaluated lymph node count <12 was shown to independently function as a risk factor for improved OS, as per a multivariate analysis (P < 0.01). Conclusions: This population-based trial showed that high-risk patients with pT3-4N0 esophageal cancer had better OS following upfront esophagectomy followed by radiotherapy therapy. This discovery may have major significance in the use of adjuvant radiotherapy following upfront esophagectomy in patients with pN0 esophageal cancer.

MP77-19 IS ANDROGEN DEPRIVATION THERAPY ASSOCIATED WITH CEREBRAL INFARCTION IN PATIENTS WITH PROSTATE CANCER? A KOREAN NATIONWIDE POPULATION-BASED PROPENSITY SCORE MATCHING STUDY

You have accessJournal of UrologyCME1 Apr 2023MP77-19 IS ANDROGEN DEPRIVATION THERAPY ASSOCIATED WITH CEREBRAL INFARCTION IN PATIENTS WITH PROSTATE CANCER? A KOREAN NATIONWIDE POPULATION-BASED PROPENSITY SCORE MATCHING STUDY Bum Sik Tae, Jung Wan Yoo, Hoon Choi, Jae Hyun Bae, and Jae Young Park Bum Sik TaeBum Sik Tae More articles by this author , Jung Wan YooJung Wan Yoo More articles by this author , Hoon ChoiHoon Choi More articles by this author , Jae Hyun BaeJae Hyun Bae More articles by this author , and Jae Young ParkJae Young Park More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003351.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Previous studies have suggested that androgen deprivation therapy (ADT) is associated with cerebral infarction. However, conflicting results have been reported by other researchers. The aim of the present study was to evaluate the association between ADT and cerebral infarction in patients with prostate cancer (PC) using big data. METHODS: Using information from the National Health Insurance Service database representative of the entire Korean adult PC population (n=206,735), data regarding ADT and cerebral infarction between 2009 and 2016 were analyzed. Adjusted hazard ratios for cerebral infarction associated with ADT were estimated using propensity score-matched Cox proportional hazards models and Kaplan-Meier survival analyses. RESULTS: The final cohort comprised 36,146 individuals with PC, including 24,069 men (66.6%) who underwent ADT. During the mean follow-up of 4.1 years, 2792 patients were newly diagnosed with cerebral infarction. In the unmatched cohort, there was a significant difference in the annual incidence of cerebral infarction between the ADT and non-ADT groups (22.8 versus [vs] 14.6 per 1000 person-years, respectively). However, there was no significant difference between the ADT and non-ADT groups in the matched cohort (14.9 vs 14.6 per 1000 person-years). The adjusted hazard ratio for cerebral infarction for PC patients who underwent ADT was 1.045 (95% CI 0.943–1.159; p=0.401) compared with those who did not undergo ADT. In addition, the cumulative duration of ADT was also not associated with an increased risk for cerebral infarction. However, older age, hypertension, diabetes, myocardial infarction, congestive heart failure, peripheral vascular disease, renal disease, dementia, and atrial fibrillation were revealed to be factors contributing to cerebral infarction. CONCLUSIONS: This nationwide population-based study revealed that ADT was not associated with cerebral infarction after adjusting for potential confounders. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1109 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bum Sik Tae More articles by this author Jung Wan Yoo More articles by this author Hoon Choi More articles by this author Jae Hyun Bae More articles by this author Jae Young Park More articles by this author Expand All Advertisement PDF downloadLoading ...

Effect of Coronary Artery Dominance In-terms of Presentation and In-hospital Outcomes of patients undergoing Primary PCI for Culprit Proximal Left Anterior Descending Artery

Objectives: Objective of this study was to assess the difference in terms of presentation and in-hospital course between patients with right vs. left dominant arterial circulation undergoing “primary percutaneous coronary intervention (PCI)” for culprit proximal left anterior descending artery (LAD). Methodology: We included consecutive adult (≥18 years) patients diagnosed with STE-ACS undergoing primary PCI for culprit proximal LAD. Patients were categorized into right vs. left dominant circulation on left heart catheterization. Demographic, clinical characteristics, presentation, and hospital course were compared between the matched (propensity matched) and unmatched cohort of patients with right vs. left dominance. Results: We included 775 patients, out of which 81.3% (630) were males and mean age was 54.59 ± 11.3 years. On coronary angiogram left dominance was observed in 14.3% (111). Single vessel disease was higher with left compared to right dominant system, 53.2% vs. 43.5%, respectively. The rate of slow flow/no-reflow (15.4% vs. 7.2%; p=0.0.230), heart failure (9.3% vs. 6.3%; p=0.299), and in-hospital mortality (5.1% vs. 3.6%, p=0.493) were not different between right vs. left dominance, respectively. In the matched cohorts, the frequency of slow flow/no-reflow (15.3% vs. 7.2%; p=0.056), heart failure (6.3% vs. 6.3%; p&gt;0.999), and mortality (5.4% vs. 3.6%, p=0.493) were not different between right vs. left dominance, respectively. Conclusion: No significant increase in complications and outcomes is witnessed among patients with left dominant arterial circulation undergoing primary PCI for culprit proximal LAD. However, careful handling of left main during intervention is warranted due lack of support from right system.

MP32-09 A PREDICTOR OF COMPLICATIONS AFTER RADICAL CYSTECTOMY: THE MODIFIED GLIM STATUS IN A PROPENSITY MATCHED ANALYSIS OF THE AMERICAN COLLEGE OF SURGEONS - NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM DATA

You have accessJournal of UrologyCME1 Apr 2023MP32-09 A PREDICTOR OF COMPLICATIONS AFTER RADICAL CYSTECTOMY: THE MODIFIED GLIM STATUS IN A PROPENSITY MATCHED ANALYSIS OF THE AMERICAN COLLEGE OF SURGEONS - NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM DATA Elia Abou Chawareb, Christian Habib Ayoub, Christelle Lattouf, Albert El Hajj, and Jose M. El asmar Elia Abou ChawarebElia Abou Chawareb More articles by this author , Christian Habib AyoubChristian Habib Ayoub More articles by this author , Christelle LattoufChristelle Lattouf More articles by this author , Albert El HajjAlbert El Hajj More articles by this author , and Jose M. El asmarJose M. El asmar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003265.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nutritional status and malnutrition are important predictors of morbidity and mortality after surgery. For this reason, we aim to assess the modified Global Leadership Initiative on Malnutrition (mGLIM) status as a predictor of post-operative mortality and morbidity in patients undergoing Radical Cystectomy (RC). METHODS: Using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset, we selected patients who underwent RC between the years 2011-2020. A positive mGLIM status includes patients with preoperative albumin levels <3.5 g/L, or patients with ≥ 10% weight loss over 6 months or BMI ≤ 21 kg/m2. We compared prolonged length of stay, mortality, major morbidity and Clavien-Dindo complications between mGLIM positive and negative patients. We also performed multivariable logistic regression models and propensity score matching to control for possible confounders. RESULTS: The unmatched cohort consisted of 13,585 patients whereas the matched cohort yielded 5,610 matched patients who underwent RC. Patients with a positive mGLIM status were more likely to be older, with a higher ASA class, and with comorbidities (p<0.001). After multivariable analysis and propensity score matching, patients with a positive mGLIM status had higher odds of prolonged length of stay (OR=2.29), mortality (OR 1.97), major morbidity (OR=1.82), Clavien-Dindo class I and II (OR=1.90), and Clavien-Dindo class ≥ IV (OR=1.14) as compared to those with a negative mGLIM status (p<0.04). CONCLUSIONS: A positive mGLIM status is associated with prolonged hospital stay, morbidity, and mortality following RC. This highlights the importance of optimizing patient pre-operative nutritional counseling. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e443 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elia Abou Chawareb More articles by this author Christian Habib Ayoub More articles by this author Christelle Lattouf More articles by this author Albert El Hajj More articles by this author Jose M. El asmar More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparing the risk of serious infections in patients with and without MS: A German claims data analysis

Research suggests that serious infections (SIs), comorbidities, and advanced disability represent key drivers of early death in people with Multiple Sclerosis (pwMS). Nevertheless, further research is warranted to better characterize and quantify the risk of SI among pwMS compared to the general population. Our study consisted of a retrospective analysis of claims data provided by a German statutory health insurance fund, AOK PLUS, covering 3.4 million individuals in Saxony and Thuringia from 01/01/2015-31/12/2019. A propensity score (PS) matching method was used to compare the incidence of SIs among people with and without MS. PwMS were required to have ≥1 inpatient or ≥2 confirmed outpatient diagnoses of MS (ICD-10 G35) from a neurologist from 01/01/2016-31/12/2018, while people from the general population could not have any inpatient/outpatient codes for MS during the entire study period. The index date was defined as the first observed MS diagnosis or, in the case of the non-MS cohort, a randomly assigned date within the inclusion period. For both cohorts a PS was assigned, corresponding with their probabilistic likelihood of having MS based on observable factors including patient characteristics, comorbidities, medication use and other variables. People with and without MS were matched using a 1:1 nearest neighbor strategy. An exhaustive list of ICD-10 codes was created in association with 11 main SI categories. SIs were those recorded as the main diagnosis during an inpatient stay. ICD-10 codes from the 11 main categories were sorted into smaller classification units, used to distinguish between infections. A 60-day threshold for measuring new cases was defined to account for the potential risk of re-infection. Patients were observed until the end of the study period (31/12/2019) or death. Cumulative incidence, incidence rates (IRs) and IR ratios (IRRs) were reported during follow-up and at 1-, 2- and 3-years post-index. A total of 4250 and 2,098,626 patients were included in the unmatched cohorts of people with and without MS. Ultimately, one match was identified for all 4,250 pwMS, corresponding with a final population of 8,500 patients. On average, patients were 52.0/52.2 years in the matched MS/non-MS cohorts; the gender breakdown was 72% female. Overall, IRs of SIs per 100 patient years (PY) were higher in pwMS than in those without MS (1 year: 7.6vs. 4.3; 2 years: 7.1vs. 3.8; 3 years: 6.9vs. 3.9). During follow-up, the most common infection types in pwMS were of a bacterial/parasitic origin (2.3 per 100 PY), followed by respiratory (2.0) and genitourinary (1.9) infections. Respiratory infections were most common in patients without MS (1.5 per 100 PY). Differences in the IRs of SIs were statistically significant (p<0.01) at each measurement window, with IRRs ranging from 1.7-1.9. PwMS had a higher risk of hospitalized genitourinary infections (IRR: 3.3-3.8) and bacterial/parasitic infections (2.0-2.3). The incidence of SIs is much higher in pwMS, than comparators from the general population in Germany. Differences in hospitalized infection rates were largely driven by higher levels of bacterial/parasitic and genitourinary infections in the MS population.