Impact of different doses of remifentanil on chronic postsurgical pain after video-assisted thoracic surgery: A propensity score analysis

A remifentanil infusion dose of >0.2 μg/kg/min is associated with hyperalgesia, leading to acute postsurgical pain; however, its contribution to the development of chronic postsurgical pain after video-assisted thoracic surgery remains unclear. This study aimed to evaluate the impact of different remifentanil doses on chronic postsurgical pain after video-assisted thoracic surgery. This study included inpatients aged ≥ 55 years who underwent video-assisted thoracic surgery under general anesthesia between April 2016 and December 2018. An inverse probability of treatment weighted using stabilized inverse propensity scores was adopted to minimize bias. After adjustments based on patient data, the outcomes of interest were compared with intraoperative covariates using a generalized estimating equation. The primary study outcome was chronic postsurgical pain 1 year after surgery, defined as a pain score ≥1 on a numerical rating scale. Of the 262 eligible patients, 258 with a mean age of 71.2 years were included in this analysis. Chronic postsurgical pain occurred in 23.6% of patients. The generalized estimating equation revealed that a remifentanil infusion dose >0.2 μg/kg/min was associated with chronic postsurgical pain at 1 year after surgery (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.03-2.27), while remifentanil infusion doses >0.15 μg/kg/min (OR 1.12; 95% CI 0.79-1.59) and >0.175 μg/kg/min (OR 1.17; 95% CI 0.83-1.64) were not associated with our primary outcome. Remifentanil infusions >0.2 μg/kg/min were associated with chronic postsurgical pain 1 year after video-assisted thoracic surgery.

Inverse Probability Weights for Quasicontinuous Ordinal Exposures With a Binary Outcome: Method Comparison and Case Study

Inverse probability weighting (IPW), a well-established method of controlling for confounding in observational studies with binary exposures, has been extended to analyses with continuous exposures. Methods developed for continuous exposures may not apply when the exposure is quasicontinuous because of irregular exposure distributions that violate key assumptions. We used simulations and cluster-randomized clinical trial data to assess 4 approaches developed for continuous exposures-ordinary least squares (OLS), covariate balancing generalized propensity scores (CBGPS), nonparametric covariate balancing generalized propensity scores (npCBGPS), and quantile binning (QB)-and a novel method, a cumulative probability model (CPM), in quasicontinuous exposure settings. We compared IPW stability, covariate balance, bias, mean squared error, and standard error estimation across 3,000 simulations with 6 different quasicontinuous exposures, varying in skewness and granularity. In general, CBGPS and npCBGPS resulted in excellent covariate balance, and npCBGPS was the least biased but the most variable. The QB and CPM approaches had the lowest mean squared error, particularly with marginally skewed exposures. We then successfully applied the IPW approaches, together with missing-data techniques, to assess how session attendance (out of a possible 15) in a partners-based clustered intervention among pregnant couples living with human immunodeficiency virus in Mozambique (2017-2022) influenced postpartum contraceptive uptake.

The prognosis of fibrolamellar carcinoma versus conventional hepatocellular carcinoma: a study based on propensity score matching

BACKGROUND

The prognosis of fibrolamellar carcinoma (FLC) versus conventional hepatocellular carcinoma (HCC) remains controversial. Thus, this study aimed to compare the prognosis of FLC and HCC.

METHODS

Patients with FLC and HCC in the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2015 were included. Propensity score matching (PSM) was performed to balance the clinical characteristics between FLC and HCC. Cox regression and Kaplan-Meier analysis were applied to identify the effect of pathology in prognosis before and after match in the whole cohort, as well as in subgroups of fibrosis score, AJCC stage and therapy.

RESULTS

A total of 213 patients with FLC and 33365 patients with HCC between 2000 and 2015 were identified. Before matching, the overall survival (OS) and cancer-specific survival (CSS) were significantly better in FLC than HCC. After matching, FLC patients had better OS than HCC patients, but the CSS was similar between groups. Further analyses found that in patients at early stage (AJCC I-III) and/or accepted curative therapy, the prognosis was comparable between HCC and FLC. In patients without cirrhosis (F0), the HCC patients had similar prognosis with FLC patients. Prognosis benefit of FLC was observed in subgroups of AJCC stage IV and non-curative therapy, however, the concomitant diseases may affect the results.

CONCLUSIONS

The prognosis of FLC was significantly better than HCC before matching. However, after matching for clinical characteristics, the CSS was comparable between FLC and HCC.

Overall and patient-specific comparative effectiveness of dimethyl fumarate versus teriflunomide: A novel approach to precision medicine applied to the German NeuroTrans Data Multiple Sclerosis Registry

Background

Multiple sclerosis (MS) comparative effectiveness research needs to go beyond average treatment effects (ATEs) and post-host subgroup analyses.

Objective

This retrospective study assessed overall and patient-specific effects of dimethyl fumarate (DMF) versus teriflunomide (TERI) in patients with relapsing-remitting MS.

Methods

A novel precision medicine (PM) scoring approach leverages advanced machine learning methods and adjusts for imbalances in baseline characteristics between patients receiving different treatments. Using the German NeuroTransData registry, we implemented and internally validated different scoring systems to distinguish patient-specific effects of DMF relative to TERI based on annualized relapse rates, time to first relapse, and time to confirmed disease progression.

Results

Among 2791 patients, there was superior ATE of DMF versus TERI for the two relapse-related endpoints (p = 0.037 and 0.018). Low to moderate signals of treatment effect heterogeneity were detected according to individualized scores. A MS patient subgroup was identified for whom DMF was more effective than TERI (p = 0.013): older (45 versus 38 years), longer MS duration (110 versus 50 months), not newly diagnosed (74% versus 40%), and no prior glatiramer acetate usage (35% versus 5%).

Conclusion

The implemented approach can disentangle prognostic differences from treatment effect heterogeneity and provide unbiased patient-specific profiling of comparative effectiveness based on real-world data.

Propensity score analysis the clinical characteristics of active distal and extensive ulcerative colitis: a retrospective study

Background and Objectives: Ulcerative Colitis (UC) subtypes defined by disease extent and shared pathophysiology are important. Analyzing the clinical characteristics of UC with different disease extent and optimizing clinical typing are conducive to the pathogenesis research, disease monitoring and precise treatment. Methods: 188 patients with active UC were divided into distal and extensive colitis. The clinical characteristics of the two groups were analyzed by propensity score. Spearman is used for correlation analysis, and receiver operating characteristic (ROC) curve was used to evaluate the ability of clinical indicators to predict Mayo endoscopic subscore (MES). Results: Compared with distal colitis, extensive colitis had more severe disease activity, younger age, higher utilization rate of corticosteroids and incidence of extra intestinal manifestations (EIMs), and clinical indicators were differentially expressed in the two groups. After using propensity score, the incidence of EIMs in the extensive colitis was still higher than that in distal colitis. Inflammation, coagulation and immune indicators like CRP, FC, IL-10, D-D and α1-MG are higher in extensive colitis, and metabolic indicators like LDL-C, HDL-C, TC, GSP and albumin are higher in distal colitis. The correlation between clinical indicators and MES is affected by disease extent. The area under curve (AUC) of CRP + D-D + α2-MG for predicting distal colitis MES3 was 0.85, and the AUC of IL-6+ GSP+ α1-MG predicted extensive colitis MES3 can reach 0.82. Conclusion: Differential clinical indicators can become potential markers for predicting disease progression and prognosis, and have significance for UC mechanism research and drug development. We can select biomarkers according to lesion site.

Changes in employment status and income before and after newly diagnosed depressive disorders in Taiwan: a matched cohort study using controlled interrupted time series analysis

AIMS

We explored long-term employment status and income before and after depression diagnosis among men and women and at different working ages in Taiwan.

METHODS

Data from 2006 to 2019 were obtained from the National Health Insurance Research Database (NHIRD). Individuals with newly diagnosed depressive disorder aged 15 to 64 years during the study period were identified. An equal number of individuals without depression were matched for their demographic and clinical characteristics. Employment outcomes included employment status, which was categorized into employed or unemployed, and annual income. Based on the occupation categories and monthly insurance salary recorded in the Registry for Beneficiaries of the NHIRD, a subject was defined as unemployed if he or she differed from the income earner or the occupation category was unemployed. Monthly income was defined as zero for unemployed subjects and proxied as monthly insurance salary for others. Annual income was the sum of monthly income in each observation year.

RESULTS

A total of 420,935 individuals with depressive disorder were included in the study, and an equal number of individuals with not diagnosed depression served as controls. Employment rate and income were lower in the depression group than in the control group before the year of diagnosis, with a difference of 5.7% in employment rate and USD 1,173 in annual income. This gap increased considerably after the year of diagnosis (7.3% in employment rate and USD 1,573 in annual incomes) and further widened in the subsequent years (8.1% in employment rate and USD 2,006 in annual incomes in the 5th following year). The drops in the employment rate and income caused by depression were more evident in men and older age groups than in women and younger age groups, respectively. However, the reduction in employment rate and income in the following years after the diagnosis was more considerable among younger age groups.

CONCLUSIONS

The effect of depression on employment status and income was significant during the year of diagnosis and continued afterwards. The effect on employment outcomes varied between genders and across all age groups.

Survey of Dietary Habits and Physical Activity in Japanese Patients with Non-Obese Non-Alcoholic Fatty Liver Disease

The incidence of non-obese non-alcoholic fatty liver disease (NAFLD), characterized by the presence of a fatty liver in individuals with a normal body mass index, is on the rise globally. Effective management strategies, including lifestyle interventions such as diet and exercise therapy, are urgently needed to address this growing public health concern. The aim of this study was to investigate the association between non-obese NAFLD, dietary habits, and physical activity levels. By elucidating these relationships, this research may contribute to the development of evidence-based recommendations for the management of non-obese NAFLD. The study had a single-center retrospective cross-sectional design and compared clinical data and dietary and physical activity habits between patients with and without non-obese NAFLD. Logistic regression analysis was utilized to investigate the relationship between food intake frequency and the development of NAFLD. Among the 455 patients who visited the clinic during the study period, 169 were selected for analysis, including 74 with non-obese NAFLD and 95 without NAFLD. The non-obese NAFLD group showed a less-frequent consumption of fish and fish products as well as olive oil and canola/rapeseed oil, while they showed more frequent consumption of pastries and cake, snack foods and fried sweets, candy and caramels, salty foods, and pickles compared to the non-NAFLD group. Logistic regression analysis revealed that NAFLD was significantly associated with the consumption of fish, fish products, and pickles at least four times a week. The physical activity level was lower and the exercise frequency was lower in patients with non-obese NAFLD compared to those without NAFLD. The results of this study suggest that a low consumption of fish and fish products and high consumption of pickles may be associated with a higher risk of non-obese NAFLD. Moreover, dietary habits and physical activity status should be taken into consideration for the management of patients with non-obese NAFLD. It is important to develop effective management strategies, such as dietary and exercise interventions, to prevent and treat NAFLD in this patient population.

Comparison of Oral and Intravenous Definitive Antibiotic Therapy for Beta-Hemolytic Streptococcus Species Bloodstream Infections from Soft Tissue Sources: a Propensity Score-Matched Analysis

Beta-hemolytic streptococci are common causes of bloodstream infection (BSI). There is emerging data regarding oral antibiotics for BSI but limited for beta-hemolytic streptococcal BSI. We conducted a retrospective study of adults with beta-hemolytic streptococcal BSI from a primary skin/soft tissue source from 2015 to 2020. Patients transitioned to oral antibiotics within 7 days of treatment initiation were compared to those who continued intravenous therapy, after propensity score matching. The primary outcome was 30-day treatment failure (composite of mortality, infection relapse, and hospital readmission). A prespecified 10% noninferiority margin was used for the primary outcome. We identified 66 matched pairs of patients treated with oral and intravenous antibiotics as definitive therapy. Based on an absolute difference in 30-day treatment failure of 13.6% (95% confidence interval 2.4 to 24.8%), the noninferiority of oral therapy was not confirmed (P = 0.741); on the contrary, the superiority of intravenous antibiotics is suggested by this difference. Acute kidney injury occurred in two patients who received intravenous treatment and zero who received oral therapy. No patients experienced deep vein thrombosis or other vascular complications related to treatment. In patients treated for beta-hemolytic streptococcal BSI, those who transitioned to oral antibiotics by day 7 showed higher rates of 30-day treatment failure than propensity-matched patients. This difference may have been driven by underdosing of oral therapy. Further investigation into optimal antibiotic choice, route, and dosing for definitive therapy of BSI is needed.

Uterine atony prophylaxis with carbetocin versus oxytocin and the risk of major haemorrhage during caesarean section: A retrospective cohort study

Carbetocin and oxytocin are commonly recommended agents for active management of the third stage of labour. Evidence is inconclusive whether either one more effectively reduces the occurrence of important postpartum haemorrhage outcomes at caesarean section. We examined whether carbetocin is associated with a lower risk of severe postpartum haemorrhage (blood loss ≥ 1000 ml) in comparison with oxytocin for the third stage of labour in women undergoing caesarean section. This was a retrospective cohort study among women undergoing scheduled or intrapartum caesarean section between 1 January 2010 and 2 July 2015 who received carbetocin or oxytocin for the third stage of labour. The primary outcome was severe postpartum haemorrhage. Secondary outcomes included blood transfusion, interventions, third stage complications and estimated blood loss. Outcomes were examined overall and by timing of birth, scheduled versus intrapartum, using propensity score-matched analysis. Among 21,027 eligible participants, 10,564 women who received carbetocin and 3836 women who received oxytocin at caesarean section were included in the analysis. Carbetocin was associated with a lower risk of severe postpartum haemorrhage overall (2.1% versus 3.3%; odds ratio, 0.62; 95% confidence interval 0.48 to 0.79; P < 0.001). This reduction was apparent irrespective of timing of birth. Secondary outcomes also favoured carbetocin over oxytocin. In this retrospective cohort study, the risk of severe postpartum haemorrhage associated with carbetocin was lower than that associated with oxytocin in women undergoing caesarean section. Randomised clinical trials are needed to further investigate these findings.

The association between vitamin D supplementation and the long-term prognosis of differentiated thyroid cancer patients: a retrospective observational cohort study with propensity score matching

Objective

Benefits of vitamin D in various cancers have been reported, but its effects on differentiated thyroid cancer (DTC) have not been established. We aimed to analyze the effect of vitamin D supplementation on the prognosis of DTC.

Methods

A retrospective observational cohort study was conducted on 9,739 DTC patients who underwent thyroidectomy from January 1997 to December 2016. Mortality was classified as all-cause, cancer-related, or thyroid cancer-related. Patients were divided into the "VD group" (supplemented with vitamin D) and the "control group" (without vitamin D supplementation). Propensity score matching was performed in a 1:1 ratio according to age, sex, tumor size, extrathyroidal extension (ETE), and lymph node metastasis (LNM) status, and 3,238 patients were assigned to each group. Kaplan-Meier curves, log-rank test and Cox proportional hazards regression analysis were performed.

Results

The follow-up period was 10.7 ± 4.2 years. Clinicopathological variables between two groups were similar except for all-cause (p<0.001) and total cancer death (p=0.001). From the Kaplan-Meier curve and log-rank test, "VD group" had significantly favorable all-cause (p<0.001) and total cancer mortality (p=0.003), but similar thyroid cancer mortality (p=0.23). In Cox regression, vitamin D intake reduced the risk of all-cause (hazard ratio [HR], 0.617, p=0.001) and total cancer mortality (HR, 0.668, p=0.016) but had no effect on thyroid cancer mortality.

Discussion/conclusion

Vitamin D supplementation was positively associated with all-cause and total cancer mortality in DTC and might be a modifiable prognostic factor for improved survival. Further research will be needed to clarify the effect of vitamin D supplementation on DTC.

Low-molecular-weight heparin therapy reduces 28-day mortality in patients with sepsis-3 by improving inflammation and coagulopathy

Background and aim

Sepsis is a syndromic response to infection and is associated with high mortality, thus imposing a significant global burden of disease. Although low-molecular-weight heparin (LMWH) has been recommended to prevent venous thromboembolism, its anticoagulant and anti-inflammatory effects in sepsis remain controversial. Owing to the modification of the Sepsis-3 definition and diagnostic criteria, further evaluation of the efficacy and benefit population of LMWH is required.

Methods

We performed a retrospective cohort study to assess whether LMWH improved the inflammation, coagulopathy, and clinical outcomes against Sepsis-3 and to identify the target patients. All patients diagnosed with sepsis at the First Affiliated Hospital of Xi'an Jiaotong University (the largest general hospital in northwest China) from January 2016 to December 2020 were recruited and re-evaluated using Sepsis-3 criteria.

Results

After 1:1 propensity score matching, 88 pairs of patients were categorized into the treatment and control groups based on subcutaneous LMWH administration. Compared with the control group, a significantly lower 28-day mortality was observed in the LMWH group (26.1 vs. 42.0%, p = 0.026) with a comparable incidence of major bleeding events (6.8 vs. 8.0%, p = 0.773). Cox regression analysis showed that LMWH administration was the independent protective factor for septic patients (aHR, 0.48; 95% CI, 0.29-0.81; p = 0.006). Correspondingly, the LMWH treatment group showed a significant improvement in inflammation and coagulopathy. Further subgroup analysis showed that LMWH therapy was associated with favorable outcomes in patients younger than 60 years and diagnosed with sepsis-induced coagulopathy (SIC), ISTH overt DIC, non-septic shock, or non-diabetics and in patients included in the moderate-risk group (APACHE II score 20-35 or SOFA score 8-12).

Conclusion

Our study results showed that LMWH improves 28-day mortality by improving inflammatory response and coagulopathy in patients meeting Sepsis-3 criteria. The SIC and ISTH overt DIC scoring systems can better identify septic patients who are likely to benefit more from LMWH administration.

General versus Neuraxial Anesthesia on Clinical Outcomes in Patients Receiving Hip Fracture Surgery: An Analysis of the ACS NSQIP Database

Whether the use of neuraxial anesthesia or general anesthesia leads to more favorable postoperative outcomes in patients receiving hip fracture surgery remains unclear. We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Data Files between 2016 and 2020 to investigate the association of neuraxial anesthesia and general anesthesia with morbidity and mortality after hip fracture surgery. Inverse probability of treatment weighting (IPTW) was used to balance the baseline characteristics, and multivariable Cox regression models were used to estimate the hazard ratio (HR) with a 95% confidence interval (CI) for postoperative morbidity and mortality among the different anesthesia groups. A total of 45,874 patients were included in this study. Postoperative adverse events occurred in 1087 of 9864 patients (11.0%) who received neuraxial anesthesia and in 4635 of 36,010 patients (12.9%) who received general anesthesia. After adjustment for IPTW, the multivariable Cox regressions revealed that general anesthesia was associated with increased risks of postoperative morbidity (adjusted HR, 1.19; 95% CI, 1.14-1.24) and mortality (adjusted HR, 1.09; 95% CI, 1.03-1.16). The results of the present study suggest that, compared with general anesthesia, neuraxial anesthesia is associated with lower risks of postoperative adverse events in patients undergoing hip fracture surgery.

An Assessment of Program Eligibility Among Participants in Day Reporting Centers

Day reporting centers (DRCs) vary considerably in how participant eligibility is determined and to date, there is little to no knowledge whether criteria for DRC eligibly are appropriately applied in program entrance. This study examines a statewide sample of individuals in community supervision settings and compares DRC eligibility criteria between DRC and non-DRC participants to examine differences between DRC participants and non-participants. Using a propensity score matched sample of 1,554 participants, study findings suggest that DRC participants show higher risk, need, and responsivity factors, consistent with the DRC programing model. These results suggest many individuals appear to be appropriately matched to DRCs, which may in turn, may influence their likelihood of program success, among other factors.

Impact of corticosteroids use on midterm sequelae in survivors of COVID-19 admitted to hospital: A prospective cohort study

An understanding of the midterm sequelae in COVID-19 and their association with corticosteroids use are needed. Between March and July 2020, we evaluated 1227 survivors of COVID-19, 3 months posthospitalization, of whom 213 had received corticosteroids within 7 days of admission. Main outcome was any midterm sequelae (oxygen therapy, shortness of breath, one major clinical sign, two minor clinical signs or three minor symptoms). Association between corticosteroids use and midterm sequelae was assessed using inverse propensity-score weighting models. Our sample included 753 (61%) male patients, and 512 (42%) were older than 65 years. We found a higher rate of sequelae among users than nonusers of corticosteroids (42% vs. 35%, odds ratio [OR] 1.40 [1.16-1.69]). Midterm sequelae were more frequent in users of low-dose corticosteroids than nonusers (64% vs. 51%, OR 1.60 [1.10-2.32]), whereas no association between higher doses (≥20 mg/day equivalent of dexamethasone) and sequelae was evidenced (OR 0.95 [0.56-1.61]). Higher risk of sequelae with corticosteroids use was observed among subjects with propensity score below the 90th percentile. Our study suggest that corticosteroids use during hospitalization for COVID-19 is associated with higher risk of midterm sequelae.

Adaptability of High Dimensional Propensity Score Procedure in the Transition from ICD-9 to ICD-10 in the US Healthcare System

Background

High-Dimensional Propensity Score procedure (HDPS) is a data-driven approach to assist control for confounding in pharmacoepidemiologic research. The transition to the International Classification of Disease (ICD-9/10) in the US health system may pose uncertainty in applying the HDPS procedure.

Methods

We assembled a base cohort of patients in MarketScan^® Commercial Claims Database who had newly initiated celecoxib or traditional NSAIDs to compare gastrointestinal bleeding risk. We then created bootstrapped hypothetical cohorts from the base cohort with predefined patient selection patterns from the ICD eras. Three strategies for HDPS deployment were tested: 1) split the cohort by ICD era, deploy HDPS twice, and pool the relative risks (pooled RR), 2) consider codes from each ICD era as a separate data dimension and deploy HDPS in the entire cohort (data dimensions) and 3) map ICD codes from both eras to Clinical Classifications Software (CCS) concepts before deploying HDPS in the entire cohort (CCS mapping). We calculated percent bias and root-mean-squared error to compare the strategies.

Results

A similar bias reduction was observed in cohorts where patient selection pattern from each ICD era was comparable between the exposure groups. In the presence of considerable disparity in patient selection, we observed a bimodal distribution of propensity scores in the data dimensions strategy, indicating instrument-like covariates. Moreover, the CCS mapping strategy resulted in at least 30% less bias than pooled RR and data dimensions strategies (RMSE: 0.14, 0.19, 0.21, respectively) in this scenario.

Conclusion

Mapping ICD codes to a stable terminology like CCS serves as a helpful strategy to reduce residual bias when deploying HDPS in pharmacoepidemiologic studies spanning both ICD eras.

Bayesian causal inference: a critical review

This paper provides a critical review of the Bayesian perspective of causal inference based on the potential outcomes framework. We review the causal estimands, assignment mechanism, the general structure of Bayesian inference of causal effects and sensitivity analysis. We highlight issues that are unique to Bayesian causal inference, including the role of the propensity score, the definition of identifiability, the choice of priors in both low- and high-dimensional regimes. We point out the central role of covariate overlap and more generally the design stage in Bayesian causal inference. We extend the discussion to two complex assignment mechanisms: instrumental variable and time-varying treatments. We identify the strengths and weaknesses of the Bayesian approach to causal inference. Throughout, we illustrate the key concepts via examples. This article is part of the theme issue 'Bayesian inference: challenges, perspectives, and prospects'.

Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy

BACKGROUND

Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques.

METHODS

This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used.

RESULTS

Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015).

CONCLUSION

Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.

Comparison of the survival outcomes between primary and secondary muscle-invasive bladder cancer: a propensity score-matched study

BACKGROUND

Studies have classified muscle-invasive bladder cancer (MIBC) into primary (initially muscle-invasive, PMIBC) and secondary subtypes (initially non-muscle-invasive but progresses, SMIBC), for which controversial survival outcomes were demonstrated. This study aimed to compare the survival outcomes between PMIBC and SMIBC patients in China.

METHODS

Patients diagnosed with PMIBC or SMIBC at West China Hospital from January 2009 to June 2019 were retrospectively included. Kruskal-Wallis and Fisher tests were employed to compare clinicopathological characteristics. Kaplan-Meier curves and Cox competing proportional risk model were used to compare survival outcomes. Propensity score matching (PSM) was employed to reduce the bias and subgroup analysis was used to confirm the outcomes.

RESULTS

A total of 405 MIBC patients were enrolled, including 286 PMIBC and 119 SMIBC, with a mean follow-up of 27.54 and 53.30 months, respectively. The SMIBC group had a higher proportion of older patients (17.65% [21/119] vs. 9.09% [26/286]), chronic disease (32.77% [39/119] vs . 22.38% [64/286]), and neoadjuvant chemotherapy (19.33% [23/119] vs . 8.04% [23/286]). Before matching, SMIBC had a lower risk of overall mortality (OM) (hazard ratios [HR] 0.60, 95% confidence interval [CI] 0.41-0.85, P  = 0.005) and cancer-specific mortality (CSM) (HR 0.64, 95% CI 0.44-0.94, P  = 0.022) after the initial diagnosis. However, higher risks of OM (HR 1.47, 95% CI 1.02-2.10, P  = 0.038) and CSM (HR 1.58, 95% CI 1.09-2.29, P  = 0.016) were observed for SMIBC once it became muscle-invasive. After PSM, the baseline characteristics of 146 patients (73 for each group) were well matched, and SMIBC was confirmed to have an increased CSM risk (HR 1.83, 95% CI 1.09-3.06, P  = 0.021) than PMIBC after muscle invasion.

CONCLUSIONS

Compared with PMIBC, SMIBC had worse survival outcomes once it became muscle-invasive. Specific attention should be paid to non-muscle-invasive bladder cancer with a high progression risk.

The likelihood of a healthy live birth after frozen embryo transfer with endometrium prepared by natural ovulation regimen vs programmed regimen: a propensity-score matching study

BACKGROUND

The number of frozen embryo transfer cycles is increasing, but the optimal method of endometrial preparation for frozen embryo transfer remains controversial. Few studies have investigated the healthy live birth outcome after the natural ovulation regimen vs the programmed regimen.

OBJECTIVE

This study aimed to explore whether the likelihood of a healthy live birth after frozen embryo transfer differs between the natural ovulation regimen and the programmed regimen.

STUDY DESIGN

We conducted a retrospective cohort study including 7824 ovulatory women who underwent the first frozen embryo transfer cycle of single-blastocyst transfer with endometrial preparation by natural ovulation regimen vs programmed regimen, between June 2017 and June 2021. Propensity score matching was used to control for confounding variables in a 1:1 ratio. The primary outcome was healthy live birth, defined as birth of a live, singleton infant born at term, with an appropriate birthweight for gestational age.

RESULTS

The natural ovulation regimen resulted in a higher probability of achieving healthy live birth compared with the programmed regimen (35.8% vs 30.6%; P<.0001). In addition, a higher rate of singleton live birth was observed after the natural ovulation regimen relative to the programmed regimen (49.6% vs 45.7%; P=.003). Women with the natural ovulation regimen were also less likely to experience clinical pregnancy loss (16.0% vs 19.7%; P=.005) and hypertensive disorders of pregnancy (3.9% vs 6.0%; P=.004) compared with women with the programmed regimen. Singletons born after the programmed regimen had greater mean birthweight (3441.50±539.97 vs 3394.96±503.87; P=.020) and higher risk of being large for gestational age (23.3% vs 18.7%; P=.003) than those conceived after the natural ovulation regimen.

CONCLUSION

The natural ovulation regimen may be superior to the programmed regimen with regard to higher likelihood of healthy live birth and lower risk of pregnancy loss and maternal hypertensive disorders of pregnancy.

Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction and Nonsevere Aortic Stenosis

BACKGROUND

The potential benefit of transcatheter aortic valve replacement (TAVR) in patients with nonsevere aortic stenosis (AS) and heart failure is controversial. This study aimed to assess outcomes of patients with nonsevere low-gradient AS (LGAS) and reduced left ventricular ejection fraction undergoing TAVR or medical management.

METHODS

Patients undergoing TAVR for LGAS and reduced left ventricular ejection fraction (<50%) were included in a multinational registry. True-severe low-gradient AS (TS-LGAS) and pseudo-severe low-gradient AS (PS-LGAS) were classified according to computed tomography-derived aortic valve calcification thresholds. A medical control group with reduced left ventricular ejection fraction and moderate AS or PS-LGAS was used (Medical-Mod). Adjusted outcomes between all groups were compared. Among patients with nonsevere AS (moderate or PS-LGAS), outcomes after TAVR and medical therapy were compared using propensity score-matching.

RESULTS

A total of 706 LGAS patients undergoing TAVR (TS-LGAS, N=527; PS-LGAS, N=179) and 470 Medical-Mod patients were included. After adjustment, both TAVR groups showed superior survival compared with Medical-Mod patients (all P<0.001), while no difference was found between TS-LGAS and PS-LGAS TAVR patients (P=0.96). After propensity score-matching among patients with nonsevere AS, PS-LGAS TAVR patients showed superior 2-year overall (65.4%) and cardiovascular survival (80.4%) compared with Medical-Mod patients (48.8% and 58.5%, both P≤0.004). In a multivariable analysis including all patients with nonsevere AS, TAVR was an independent predictor of survival (hazard ratio, 0.39 [95% CI, 0.27-0.55]; P<0.0001).

CONCLUSIONS

Among patients with nonsevere AS and reduced left ventricular ejection fraction, TAVR represents a major predictor of superior survival. These results reinforce the need for randomized-controlled trials comparing TAVR versus medical management in heart failure patients with nonsevere AS.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04914481.

In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms

OBJECTIVE

To compare costs and effectiveness of elective open (OR) versus fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAA) in a high-volume center.

METHODS

This single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger Health Technology Assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. Endpoints were clinical success, major adverse events (MAE), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value (CEV) and Incremental Cost-Effectiveness Ratio (ICER) were calculated, considering the absence of MAEs as a measure of effectiveness.

RESULTS

Propensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). Access complication rate (6% vs 27%; p<.001) was higher in the ER group. Intensive Care Unit stay was longer (p<.001) for OR and ER patients were discharged home more frequently (3% vs 94%; p<.001). No differences in mid-term endpoints were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. CEV for ER was favorable to OR (56 365 vs 64 903 €/patient) with an ICER of 48 409 € per MAE saved.

CONCLUSIONS

ER of TAAA reduces perioperative mortality and morbidity compared to OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing MAEs.

Significance of surgical first assistant expertise for surgical site infection prevention: Propensity score matching analysis

Surgical site infection (SSI) is one of the most common postoperative complications in patients undergoing major operations, such as spinal fusion surgery, and a major contributor to patient morbidity and mortality. SSI is considered the most preventable type of infection; however, the risk of SSI is multifactorial. This study aimed to determine the extent to which the expertise of the surgical first assistant (SFA) affected SSI rates. We retrospectively reviewed 528 patients at a single institution who underwent lumbar spine fusion surgery via the posterior approach performed by a single surgeon between January 2012 and May 2020. The SFAs participating in the surgeries were classified into 2 groups: a certified neurosurgery specialist and relatively less experienced neurosurgery resident trainees. To reduce potential selection bias and confounding factors, propensity score matching was performed between the 2 groups. In 170 of the 528 lumbar spine fusion surgeries, the SFA was a certified neurosurgery specialist. In the other 358 surgeries, the SFA was a resident trainee. Seventeen patients met the SSI criteria. The SSI rate was significantly different between the 2 groups (0.6% (1 patient) and 4.5% (16 patients) in the certified specialist and resident trainee groups, respectively; P = .02). After propensity score matching, 170 paired patients were selected. After adjusting for confounding factors, SFAs that were certified neurosurgery specialists were associated with a lower likelihood of SSI (adjusted OR 0.09; 95% CI, 0.01 to 0.79; P = .029) than SFAs that were neurosurgery residents. A higher level of SFA expertise was significantly associated with a lower overall SSI rate in lumbar spine fusion surgeries. It is difficult to predict the incidence of SSI; however, this finding suggests the importance of SFA expertise in preventing SSI.

Association between Chronic Kidney Disease and Sudden Sensorineural Hearing Loss: A Longitudinal Follow-Up Studies Using ICD-10 Codes in a National Health Screening Cohort

This study aims to investigate the association between chronic kidney disease (CKD) and sudden sensorineural hearing loss (SSNHL) using a population-based cohort study. We used data from the Korean National Health Insurance Service-Health Screening Cohort. Participants were selected based on diagnosis and treatment codes, and CKD participants were 1:4 matched with control participants. Covariates, including demographic and lifestyle factors, and comorbidities were considered in the analysis. We calculated the incidence rate and hazards ratio of SSNHL. A total of 16,713 CKD participants and 66,852 matched controls were enrolled. The CKD group had a higher incidence rate of SSNHL compared to the control group at 2.16 and 1.74 per 1000 person-years, respectively. The CKD group exhibited a higher risk for SSNHL compared to the control group with adjusted HR 1.21. In the subgroup analysis, the presence of cardiovascular risk factors was associated with a diminished effect of CKD on the risk of developing SSNHL. This study provides strong evidence of an association between CKD per se and an increased risk of SSNHL even after adjusting for various demographic and comorbidity factors. The findings suggest that CKD patients may require more comprehensive monitoring for hearing loss.

Similar short-term KOOS between open-wedge high tibial osteotomy and total knee arthroplasty in patients over age 60: A propensity score-matched cohort study

OBJECTIVES

The purpose of the present study was to evaluate improvement in the Knee Injury and Osteoarthritis Outcome Score (KOOS) after open-wedge high tibial osteotomy (HTO) in comparison with total knee arthroplasty (TKA) in cohorts over age 60 matched by pre-operative age, gender, body mass index (BMI), hip-knee-ankle angle (HKAA), KOOS sub-scores, and osteoarthritis (OA) grade.

METHODS

Propensity score matching was performed between 162 HTO patients and 134 TKA patients. When calculating the propensity score by multivariate logistic regression analysis, the following pre-operative confounders were included: age, gender, BMI, HKAA, KOOS sub-scores, and OA grade. Consequently, a total of 55 patients were included in each group. The Student's t-test was used to analyse differences in the post-operative KOOS sub-scores between groups.

RESULTS

After propensity score matching, all matched pre-operative valuables were identical, with no significant differences between the HTO and TKA groups. None of the post-operative KOOS sub-scores at 1 year after surgery showed a significant difference between the HTO and TKA groups. Both groups demonstrated significant and comparable post-operative improvement in every KOOS sub-score.

CONCLUSIONS

In patients over age 60, there was no significant difference in short-term pain relief and improvements in activity and quality of life between HTO and TKA after propensity score matching including pre-operative age, KOOS sub-scores, and OA grade. HTO is a joint preservation procedure that is valid for knee OA even in individuals over age 60.

Propensity Scores: Confounder Adjustment When Comparing Nonrandomized Groups in Orthopaedic Surgery

Many studies in arthroplasty research are based on nonrandomized, retrospective, registry-based cohorts. In these types of studies, patients belonging to different treatment or exposure groups often differ with respect to patient characteristics, medical histories, surgical indications, or other factors. Consequently, comparisons of nonrandomized groups are often subject to treatment selection bias and confounding. Propensity scores can be used to balance cohort characteristics, thus helping to minimize potential bias and confounding. This article explains how propensity scores are created and describes multiple ways in which they can be applied in the analysis of nonrandomized studies. Please visit the following (https://www.youtube.com/watch?v=sqgxl_nZWS4&t=3s) for a video that explains the highlights of the paper in practical terms.