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Tejera-Vaquerizo A, Gómez-Tomás Á, Jaka A, Toll A, Del Río M, Ferrándiz-Pulido C, Fuente MJ, Carrasco C, Almazán-Fernández FM, Toledo-Pastrana T, Ferrer-Fuertes A, Ribero S, Avallone G, Cañueto J, Santos-Juanes J, Sanmartín O. Sentinel lymph node biopsy versus observation in high-risk cutaneous squamous cell carcinoma in immunosuppressed and immunocompetent patients: An inverse probability of treatment weighting study. J Eur Acad Dermatol Venereol 2024; 38:1588-1598. [PMID: 38738666 DOI: 10.1111/jdv.20051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/28/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND The survival benefit of sentinel lymph node biopsy (SLNB) in immunocompetent and immunosuppressed patients with high-risk cutaneous squamous cell carcinoma (cSCC) has not been established. OBJECTIVE To determine whether SLNB improves disease-specific survival (DSS) in high-risk cSCC. Secondary objectives were to analyse disease-free survival, nodal recurrence-free survival and overall survival (OS). METHODS Multicentre, retrospective, observational cohort study comparing survival outcomes in immunosuppressed and immunocompetent patients treated with SLNB or watchful waiting. Inverse probability of treatment weighting was used to adjust for possible confounding effects. RESULTS We studied 638 tumours in immunocompetent patients (SLNB n = 42, observation n = 596) and 173 tumours in immunosuppressed patients (SLNB n = 28, observation n = 145). Overall, SLNB was positive in 15.7% of tumours. SLNB was associated with a reduced risk of nodal recurrence (NR) (hazard ratio [HR], 0.05 [95% CI, 0.01-0.43]; p = 0.006), disease specific mortality (HR, 0.17 [95% CI, 0.04-0.72]; p = 0.016) and all-cause mortality (HR, 0.33 [95% CI, 0.15-0.71]; p = 0.004) only in immunocompetent patients. CONCLUSIONS SLNB was associated with improvements in NR, DSS and OS in immunocompetent but not in immunosuppressed patients with high-risk cSCC.
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Affiliation(s)
- Antonio Tejera-Vaquerizo
- Cutaneous Oncology Unit, Hospital San Juan de Dios, Córdoba, Spain
- Dermatology Department, Instituto Dermatológico GlobalDerm, Palma del Río, Córdoba, Spain
| | - Álvaro Gómez-Tomás
- Dermatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ane Jaka
- Dermatology Department, Hospital Universitari Germans Trials i Pujol, Institut d'Investigació GermansTrias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Agustín Toll
- Dermatology Department, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - María Del Río
- Plastic Surgery Department, Hospital Universitari Germans Trials i Pujol, Institut d'Investigació GermansTrias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Carla Ferrándiz-Pulido
- Dermatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María J Fuente
- Dermatology Department, Hospital Universitari Germans Trials i Pujol, Institut d'Investigació GermansTrias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Cristian Carrasco
- Plastic Surgery Department, Hospital Universitari Germans Trials i Pujol, Institut d'Investigació GermansTrias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Tomás Toledo-Pastrana
- Dermatology Department, Hospital Quirón Salud Infanta Luisa, Hospital Quirón Salud Sagrado Corazón, Sevilla, Spain
| | | | - Simone Ribero
- Section of Dermatology, Medical Sciences Department, University of Turin, Turin, Italy
| | - Gianluca Avallone
- Section of Dermatology, Medical Sciences Department, University of Turin, Turin, Italy
| | - Javier Cañueto
- Dermatology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Jorge Santos-Juanes
- Dermatology Department, Central Universitary Hospital of Asturias and Instituto de Investigación Sanitaria of Principado de Asturias, IUOPA, Oviedo University, Oviedo, Spain
| | - Onofre Sanmartín
- Dermatology Department, Instituto Valenciano de Oncología, Valencia, Spain
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2
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Bellavia A, Murphy SA. Summarizing Primary Results in Clinical Trials With a Time-to-Event End Point: Complementing Different Measures for a Comprehensive Assessment of Treatment Effect. Circulation 2024; 149:1154-1156. [PMID: 38588333 DOI: 10.1161/circulationaha.123.068037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Andrea Bellavia
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Sanchis J, Bueno H, García-Blas S, Alegre O, Martí D, Martínez-Sellés M, Domínguez-Pérez L, Díez-Villanueva P, Barrabés JA, Marín F, Villa A, Sanmartín M, Llibre C, Sionís A, Carol A, Fernández-Cisnal A, Calvo E, Morales MJ, Elízaga J, Gómez I, Alfonso F, García del Blanco B, Formiga F, Núñez E, Núñez J, Ariza-Solé A. Invasive Treatment Strategy in Adults With Frailty and Non-ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e240809. [PMID: 38446482 PMCID: PMC10918507 DOI: 10.1001/jamanetworkopen.2024.0809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/10/2024] [Indexed: 03/07/2024] Open
Abstract
Importance The MOSCA-FRAIL randomized clinical trial compared invasive and conservative treatment strategies in patients with frailty with non-ST-segment elevation myocardial infarction (NSTEMI). It showed no differences in the number of days alive and out of the hospital at 1 year. Objective To assess the outcomes of the MOSCA-FRAIL trial during extended follow-up. Design, Setting, and Participants The MOSCA-FRAIL randomized clinical trial was conducted at 13 hospitals in Spain between July 7, 2017, and January 9, 2021, and included 167 adults (aged ≥70 years) with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. In this preplanned secondary analysis, follow-up was extended to January 31, 2023. Data analysis was performed from April 5 to 29, 2023, using the intention-to-treat principle. Interventions Patients were randomized to a routine invasive (coronary angiography and revascularization if feasible [n = 84]) or a conservative (medical treatment with coronary angiography only if recurrent ischemia [n = 83]) strategy. Main outcomes and measures The primary end point was the difference in restricted mean survival time (RMST). Secondary end points included readmissions for any cause, considering recurrent readmissions. Results Among the 167 patients included in the analysis, the mean (SD) age was 86 (5) years; 79 (47.3%) were men and 88 (52.7%) were women. A total of 93 deaths and 367 readmissions accrued. The RMST for all-cause death over the entire follow-up was 3.13 (95% CI, 2.72-3.60) years in the invasive and 3.06 (95% CI, 2.84-3.32) years in the conservative treatment groups. The RMST analysis showed inconclusive differences in survival time (invasive minus conservative difference, 28 [95% CI, -188 to 230] days). Patients under invasive treatment tended to have shorter survival in the first year (-28 [95% CI, -63 to 7] days), which improved after the first year (192 [95% CI, 90-230] days). Kaplan-Meier mortality curves intersected, displaying higher mortality to 1 year in the invasive group that shifted to a late benefit (landmark analysis hazard ratio, 0.58 [95% CI, 0.33-0.99]; P = .045). Early harm was more evident in the subgroup with a Clinical Frailty Scale score greater than 4. No differences were found for the secondary end points. Conclusions and Relevance In this extended follow-up of a randomized clinical trial of patients with frailty and NSTEMI, an invasive treatment strategy did not improve outcomes at a median follow-up of 1113 (IQR, 443-1441) days. However, a differential distribution of deaths was observed, with early harm followed by later benefit. The phenomenon of depletion of susceptible patients may be responsible for this behavior. Trial registration ClinicalTrials.gov Identifier: NCT03208153.
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Affiliation(s)
- Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
- Complutense University, Madrid, Spain
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Oriol Alegre
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - David Martí
- Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, Complutense University, European University, Madrid, Spain
| | - Laura Domínguez-Pérez
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
- Complutense University, Madrid, Spain
| | - Pablo Díez-Villanueva
- University Hospital La Princesa, Autonomous University of Madrid, Instituto de Investigación Sanitaria Princesa, CIBERCV, Madrid, Spain
| | | | - Francisco Marín
- University Hospital Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria–Arrixaca, CIBERCV, El Palmar, Murcia, Spain
| | - Adolfo Villa
- Southeast University Hospital, Arganda del Rey, Madrid, Spain
| | | | - Cinta Llibre
- University Hospital Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | | | - Antoni Carol
- Moisés Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Agustín Fernández-Cisnal
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Elena Calvo
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jaime Elízaga
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, Complutense University, European University, Madrid, Spain
| | - Iván Gómez
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
- Complutense University, Madrid, Spain
| | - Fernando Alfonso
- University Hospital La Princesa, Autonomous University of Madrid, Instituto de Investigación Sanitaria Princesa, CIBERCV, Madrid, Spain
| | | | - Francesc Formiga
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Eduardo Núñez
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Albert Ariza-Solé
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
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Setti M, Merlo M, Gigli M, Munaretto L, Paldino A, Stolfo D, Pio Loco C, Medo K, Gregorio C, De Luca A, Graw S, Castrichini M, Cannatà A, Ribichini FL, Dal Ferro M, Taylor M, Sinagra G, Mestroni L. Role of arrhythmic phenotype in prognostic stratification and management of dilated cardiomyopathy. Eur J Heart Fail 2024; 26:581-589. [PMID: 38404225 DOI: 10.1002/ejhf.3168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/22/2023] [Accepted: 02/05/2024] [Indexed: 02/27/2024] Open
Abstract
AIMS Dilated cardiomyopathy (DCM) with arrhythmic phenotype combines phenotypical aspects of DCM and predisposition to ventricular arrhythmias, typical of arrhythmogenic cardiomyopathy. The definition of DCM with arrhythmic phenotype is not universally accepted, leading to uncertainty in the identification of high-risk patients. This study aimed to assess the prognostic impact of arrhythmic phenotype in risk stratification and the correlation of arrhythmic markers with high-risk arrhythmogenic gene variants in DCM patients. METHODS AND RESULTS In this multicentre study, DCM patients with available genetic testing were analysed. The following arrhythmic markers, present at baseline or within 1 year of enrolment, were tested: unexplained syncope, rapid non-sustained ventricular tachycardia (NSVT), ≥1000 premature ventricular contractions/24 h or ≥50 ventricular couplets/24 h. LMNA, FLNC, RBM20, and desmosomal pathogenic or likely pathogenic gene variants were considered high-risk arrhythmogenic genes. The study endpoint was a composite of sudden cardiac death and major ventricular arrhythmias (SCD/MVA). We studied 742 DCM patients (45 ± 14 years, 34% female, 410 [55%] with left ventricular ejection fraction [LVEF] <35%). During a median follow-up of 6 years (interquartile range 1.6-12.1), unexplained syncope and NSVT were the only arrhythmic markers associated with SCD/MVA, and the combination of the two markers carried a significant additive risk of SCD/MVA, incremental to LVEF and New York Heart Association class. The probability of identifying an arrhythmogenic genotype rose from 8% to 30% if both early syncope and NSVT were present. CONCLUSION In DCM patients, the combination of early detected NSVT and unexplained syncope increases the risk of life-threatening arrhythmic outcomes and can aid the identification of carriers of malignant arrhythmogenic genotypes.
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MESH Headings
- Humans
- Female
- Cardiomyopathy, Dilated/genetics
- Cardiomyopathy, Dilated/physiopathology
- Cardiomyopathy, Dilated/diagnosis
- Cardiomyopathy, Dilated/complications
- Male
- Middle Aged
- Phenotype
- Prognosis
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Adult
- Risk Assessment/methods
- Syncope/genetics
- Syncope/etiology
- Syncope/physiopathology
- Arrhythmias, Cardiac/genetics
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/diagnosis
- Stroke Volume/physiology
- Tachycardia, Ventricular/genetics
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/diagnosis
- Genetic Testing/methods
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Affiliation(s)
- Martina Setti
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Marta Gigli
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Laura Munaretto
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Alessia Paldino
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carola Pio Loco
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Kristen Medo
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Caterina Gregorio
- Biostatistics Unit, University of Trieste, Trieste, Italy
- MOX-Modeling and Scientific Computing Laboratory, Department of Mathematics, Politecnico di Milano, Milan, Italy
| | - Antonio De Luca
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Sharon Graw
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matteo Castrichini
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antonio Cannatà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
- Department of Cardiovascular Sciences, King's College London, London, UK
| | | | - Matteo Dal Ferro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Matthew Taylor
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luisa Mestroni
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Zhu E, Wang J, Shi W, Jing Q, Ai P, Shan D, Ai Z. Optimizing adjuvant treatment options for patients with glioblastoma. Front Neurol 2024; 15:1326591. [PMID: 38456152 PMCID: PMC10919147 DOI: 10.3389/fneur.2024.1326591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
Background This study focused on minimizing the costs and toxic effects associated with unnecessary chemotherapy. We sought to optimize the adjuvant therapy strategy, choosing between radiotherapy (RT) and chemoradiotherapy (CRT), for patients based on their specific characteristics. This selection process utilized an innovative deep learning method. Methods We trained six machine learning (ML) models to advise on the most suitable treatment for glioblastoma (GBM) patients. To assess the protective efficacy of these ML models, we employed various metrics: hazards ratio (HR), inverse probability treatment weighting (IPTW)-adjusted HR (HRa), the difference in restricted mean survival time (dRMST), and the number needed to treat (NNT). Results The Balanced Individual Treatment Effect for Survival data (BITES) model emerged as the most effective, demonstrating significant protective benefits (HR: 0.53, 95% CI, 0.48-0.60; IPTW-adjusted HR: 0.65, 95% CI, 0.55-0.78; dRMST: 7.92, 95% CI, 7.81-8.15; NNT: 1.67, 95% CI, 1.24-2.41). Patients whose treatment aligned with BITES recommendations exhibited notably better survival rates compared to those who received different treatments, both before and after IPTW adjustment. In the CRT-recommended group, a significant survival advantage was observed when choosing CRT over RT (p < 0.001). However, this was not the case in the RT-recommended group (p = 0.06). Males, older patients, and those whose tumor invasion is confined to the ventricular system were more frequently advised to undergo RT. Conclusion Our study suggests that BITES can effectively identify GBM patients likely to benefit from CRT. These ML models show promise in transforming the complex heterogeneity of real-world clinical practice into precise, personalized treatment recommendations.
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Affiliation(s)
- Enzhao Zhu
- School of Medicine, Tongji University, Shanghai, China
| | - Jiayi Wang
- School of Medicine, Tongji University, Shanghai, China
| | - Weizhong Shi
- Shanghai Hospital Development Center, Shanghai, China
| | - Qi Jing
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Pu Ai
- School of Medicine, Tongji University, Shanghai, China
| | - Dan Shan
- Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Zisheng Ai
- Department of Medical Statistics, School of Medicine, Tongji University, Shanghai, China
- Clinical Research Center for Mental Disorders, Chinese-German Institute of Mental Health, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
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6
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Nickel NC, Phillips-Beck W, Enns JE, Ekuma O, Taylor C, Fileatreault S, Eze N, Star L, Lavoie J, Katz A, Brownell M, Mahar A, Urquia M, Chateau D, Lix L, Chartier M, Brownell E, Tso Deh M, Durksen A, Romanescu R. COVID-19 diagnostic testing and vaccinations among First Nations in Manitoba: A nations-based retrospective cohort study using linked administrative data, 2020-2021. PLoS Med 2024; 21:e1004348. [PMID: 38363739 PMCID: PMC10871479 DOI: 10.1371/journal.pmed.1004348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/15/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Differential access to healthcare has contributed to a higher burden of illness and mortality among First Nations compared to other people in Canada. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, First Nations organizations in Manitoba partnered with public health and Manitoba government officials to ensure First Nations had early, equitable and culturally safe access to COVID-19 diagnostic testing and vaccination. In this study, we examined whether prioritizing First Nations for vaccination was associated with faster uptake of COVID-19 vaccines among First Nations versus All Other Manitobans (AOM). METHODS AND FINDINGS In this retrospective cohort study, we used linked, whole-population administrative data from the Manitoba healthcare system (February 2020 to December 2021) to determine rates of COVID-19 diagnostic testing, infection, and vaccination, and used adjusted restricted mean survival time (RMST) models to test whether First Nations received their first and second vaccine doses more quickly than other Manitobans. The cohort comprised 114,816 First Nations (50.6% female) and 1,262,760 AOM (50.1% female). First Nations were younger (72.3% were age 0 to 39 years) compared to AOM (51% were age 0 to 39 years) and were overrepresented in the lowest 2 income quintiles (81.6% versus 35.6% for AOM). The 2 groups had a similar burden of comorbidities (65.8% of First Nations had none and 6.3% had 3 or more; 65.9% of AOM had none and 6.0% had 3 or more) and existing mental disorders (36.9% of First Nations were diagnosed with a mood/anxiety disorder, psychosis, personality disorder, or substance use disorder versus 35.2% of AOM). First Nations had crude infection rates of up to 17.20 (95% CI 17.15 to 17.24) COVID-19 infections/1,000 person-months compared with up to 6.24 (95% CI 6.16 to 6.32) infections/1,000 person-months among AOM. First Nations had crude diagnostic testing rates of up to 103.19 (95% CI 103.06 to 103.32) diagnostic COVID-19 tests/1,000 person-months compared with up to 61.52 (95% CI 61.47 to 61.57) tests/1,000 person-months among AOM. Prioritizing First Nations to receive vaccines was associated with faster vaccine uptake among First Nations versus other Manitobans. After adjusting for age, sex, income, region of residence, mental health conditions, and comorbidities, we found that First Nations residents received their first vaccine dose an average of 15.5 (95% CI 14.9 to 16.0) days sooner and their second dose 13.9 (95% CI 13.3 to 14.5) days sooner than other Manitobans in the same age group. The study was limited by the discontinuation of population-based COVID-19 testing and data collection in December 2021. As well, it would have been valuable to have contextual data on potential barriers to COVID-19 testing or vaccination, including, for example, information on social and structural barriers faced by Indigenous and other racialized people, or the distrust Indigenous people may have in governments due to historical harms. CONCLUSION In this study, we observed that the partnered COVID-19 response between First Nations and the Manitoba government, which oversaw creation and enactment of policies prioritizing First Nations for vaccines, was associated with vaccine acceptance and quick uptake among First Nations. This approach may serve as a useful framework for future public health efforts in Manitoba and other jurisdictions across Canada.
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Affiliation(s)
- Nathan C. Nickel
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | | | - Jennifer E. Enns
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Okechukwu Ekuma
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Carole Taylor
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Sarah Fileatreault
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Nkiru Eze
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Leona Star
- First Nations Health and Social Secretariat of Manitoba, Winnipeg, Canada
| | - Josée Lavoie
- Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Alan Katz
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Dept of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Marni Brownell
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Alyson Mahar
- School of Nursing, Faculty of Health Sciences, Queen’s University, Kingston, Canada
| | - Marcelo Urquia
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Dan Chateau
- National Centre for Epidemiology and Population Health, College of Health and Medicine, Australia National University, Canberra, Australia
| | - Lisa Lix
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Mariette Chartier
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Emily Brownell
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Miyosha Tso Deh
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Anita Durksen
- Manitoba Centre for Health Policy, Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Razvan Romanescu
- Dept of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
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7
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Alkalbani M, Psotka MA. Rethinking heart failure clinical trials: the heart failure collaboratory. Front Cardiovasc Med 2024; 11:1350569. [PMID: 38327488 PMCID: PMC10847294 DOI: 10.3389/fcvm.2024.1350569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
The Heart Failure Collaboratory (HFC) is a consortium of stakeholders in the heart failure (HF) community that aims to improve the infrastructure of clinical research to promote development of novel therapies for patients. Since its launch in 2018, HFC has implemented several solutions to tackle obstacles in HF clinical research including training programs to increase the number of clinicians skilled in conducting clinical trials, novel study designs, and advocacy for a diverse and inclusive HF research ecosystem. We highlight some of the HFC successes since its establishment.
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Affiliation(s)
- Mutaz Alkalbani
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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8
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Chen HT, Tung CH, Yu BH, Chang CM, Chen YC. Renal and survival benefits of seventeen prescribed Chinese herbal medicines against oxidative-inflammatory stress in systemic lupus erythematosus patients with chronic kidney disease: a real-world longitudinal study. Front Pharmacol 2024; 14:1309582. [PMID: 38235107 PMCID: PMC10791791 DOI: 10.3389/fphar.2023.1309582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/05/2023] [Indexed: 01/19/2024] Open
Abstract
Background: Systemic lupus erythematosus (SLE) significantly links to LN, a type of CKD with high mortality despite modern Western treatments. About 70% of SLE patients develop LN, and 30% advance to end-stage renal disease (ESRD). Concerns about glucocorticoid side effects and LN worsening due to oxidative stress prompt alternative treatment searches. In Taiwan, over 85% of SLE patients opt for complementary methods, especially Chinese herbal medicine (CHM). We pinpointed seventeen CHMs for SLE (PRCHMSLE) with antioxidative and anti-inflammatory properties from national health insurance data (2000-2017). Our primary aim was to assess their impact on renal and survival outcomes in SLE patients progressing to CKD (SLE-CKD), with a secondary focus on the risks of hospitalization and hyperkalemia. Methods: We established a propensity-matched cohort of 1,188 patients with SLE-CKD, comprising 594 PRCHMSLE users and 594 nonusers. We employed Cox proportional hazards models and restricted mean survival time (RMST) analyses to assess the renal and survival outcomes of PRCHMSLE users. Moreover, we performed pooling and network analyses, specifically focusing on the renal effects linked to PRCHMSLE. Results: PRCHMSLE use was associated with decreased adjusted hazard ratios for ESRD (0.45; 95% confidence interval, 0.25-0.79, p = 0.006), all-cause mortality (0.56; 0.43-0.75, p < 0.0001), non-cardiovascular mortality (0.56; 0.42-0.75, p < 0.0001), and hospitalization (0.72; 0.52-0.96, p = 0.009). Hyperkalemia risk did not increase. Significant differences in RMST were observed: 0.57 years (95% confidence interval, 0.19-0.95, p = 0.004) for ESRD, 1.22 years (0.63-1.82, p < 0.0001) for all-cause mortality, and 1.21 years (0.62-1.80, p < 0.0001) for non-cardiovascular mortality, favoring PRCHMSLE use. Notably renoprotective PRCHMSLE included Gan-Lu-Ying, Anemarrhena asphodeloides Bunge [Asparagaceae; Rhizoma Anemarrhenae] (Zhi-Mu), Rehmannia glutinosa (Gaertn.) DC. [Orobanchaceae; Radix Rehmanniae] (Sheng-Di-Huang), Jia-Wei-Xiao-Yao-San, and Paeonia suffruticosa Andr. [Paeoniaceae; Cortex Moutan] (Mu-Dan-Pi). Network analysis highlighted primary treatment strategies with central components like Liu-Wei-Di-Huang-Wan, Paeonia suffruticosa Andr. [Paeoniaceae; Cortex Moutan] (Mu-Dan-Pi), Anemarrhena asphodeloides Bunge [Asparagaceae; Rhizoma Anemarrhenae] (Zhi-Mu), Rehmannia glutinosa (Gaertn.) DC. [Orobanchaceae; Radix Rehmanniae] (Sheng-Di-Huang), and Zhi-Bai-Di-Huang-Wan. Conclusion: This work underscores the pronounced renal and survival benefits associated with the seventeen PRCHMSLE in the treatment of SLE-CKD, concurrently mitigating the risks of hospitalization and hyperkalemia. This highlights their potential as alternative treatment options for individuals with this condition.
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Affiliation(s)
- Hsiao-Tien Chen
- Department of Chinese Medicine, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chien-Hsueh Tung
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ben-Hui Yu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chun Chen
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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9
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Wu H, Zhang C, Hou Y, Chen Z. Communicating and understanding statistical measures when quantifying the between-group difference in competing risks. Int J Epidemiol 2023; 52:1975-1983. [PMID: 37738672 DOI: 10.1093/ije/dyad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/06/2023] [Indexed: 09/24/2023] Open
Abstract
Competing risks issues are common in clinical trials and epidemiological studies for patients in follow-up who may experience a variety of possible outcomes. Under such competing risks, two hazard-based statistical methods, cause-specific hazard (CSH) and subdistribution hazard (SDH), are frequently used to assess treatment effects among groups. However, the outcomes of the CSH-based and SDH-based methods have a close connection with the proportional hazards (CSH or SDH) assumption and may have an non-intuitive interpretation. Recently, restricted mean time lost (RMTL) has been used as an alternative summary measure for analysing competing risks, due to its clinical interpretability and robustness to the proportional hazards assumption. Considering the above approaches, we summarize the differences between hazard-based and RMTL-based methods from the aspects of practical interpretation, proportional hazards model assumption and the selection of restricted time points, and propose corresponding suggestions for the analysis of between-group differences under competing risks. Moreover, an R package 'cRMTL' and corresponding step-by-step guidance are available to help users for applying these approaches.
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Affiliation(s)
- Hongji Wu
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, P.R. China
| | - Chengfeng Zhang
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, P.R. China
| | - Yawen Hou
- Department of Statistics and Data Science, School of Economics, Jinan University, Guangzhou, P.R. China
| | - Zheng Chen
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, P.R. China
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Yang KJ, Fu HY, Chang CJ, Wang TC, Wang CH, Chou NK, Wu IH, Hsu RB, Huang SC, Yu HY, Chen YS, Chi NH. Long-term outcomes of mitral valve replacement in dialysis patients: evidence from a nationwide database. Int J Surg 2023; 109:3778-3787. [PMID: 37678297 PMCID: PMC10720870 DOI: 10.1097/js9.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND To compare the late outcomes between mechanical and bioprostheses after isolated mitral valve replacement (MVR) in dialysis-dependent patients. METHODS A nationwide propensity-matched retrospective cohort study was conducted involving dialysis patients who underwent primary mitral replacement between 2001 and 2018. Ten-year postoperative outcomes were compared between mitral bioprosthesis and mechanical prosthesis using the Cox proportional hazard model and restricted mean survival time (RMST). RESULTS The all-cause mortality was 20.8 and 13.0 events per 100 person-years, with a 10-year RMST of 7.40 and 7.31 years for bioprosthesis and mechanical prosthesis, respectively. Major bleeding was the most common adverse event for both bioprosthesis and mechanical prosthesis, with an incidence rate of 19.5 and 19.1 events per 100 person-years, respectively. The incidence of valve reoperation was higher among those who received bioprosthesis (0.55 events per 100 person-years). After 1:1 matching, the all-cause mortality was 15.45 and 14.54 events per 100 person-years for bioprosthesis and mechanical prosthesis, respectively. The RMST at 10 years was comparable between the two groups after matching (5.10 years for bioprosthesis vs. 4.59 years for mechanical prosthesis), with an RMST difference of -0.03. Further, no difference was observed in the incidence of major adverse valve-related events between bioprosthesis and mechanical valves. However, bioprosthesis was associated with a higher incidence of mitral valve reoperation among all major adverse events (RMST difference -0.24 years, 95% CI -0.48 to -0.01, P =0.047). CONCLUSIONS This study found no association between valve selection and long-term survival outcomes in dialysis patients after MVR. However, bioprosthetic valves may be associated with a slightly higher incidence of reoperation, while other valve-related adverse events, including major bleeding and stroke, were comparable between the two types of prostheses.
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Affiliation(s)
- Kelvin J. Yang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Hsun-Yi Fu
- Department of Cardiovascular Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu
| | - Chia-Jui Chang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University
- Department of Pharmacy, National Taiwan University Cancer Center
| | - Ting-Chuan Wang
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Nai-Kuan Chou
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - I-Hui Wu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Ron-Bin Hsu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shu-Chien Huang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Hsi-Yu Yu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Yih-Sharng Chen
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Nai-Hsin Chi
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
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11
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Curry J, Bakhtiyar SS, Kim S, Sakowitz S, Verma A, Ali K, Chervu NL, Benharash P. Association of postoperative length of stay with outcomes following orthotopic heart transplantation-A national analysis. Clin Transplant 2023; 37:e15096. [PMID: 37552712 DOI: 10.1111/ctr.15096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/15/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND In the absence of standardized recovery protocols, there is little evidence to guide postoperative care to ensure optimal in-hospital and long-term outcomes following heart transplantation (HT). Using two national databases, we examined the association between postoperative length of stay (LOS) with patient/graft survival, index hospitalization costs, and non-elective readmissions. METHODS Adult HT recipients from 2010 to 2019 were identified and analyzed within the Organ Procurement and Transplantation Network (OPTN) Database and Nationwide Readmissions Database (NRD). The risk-adjusted relationship between 1-year mortality and LOS was assessed with restricted cubic splines and subsequently used to stratify patients into Expedited (7-11 days), Routine (12-16 days), and Delayed (>16) discharge groups. Survival outcomes were analyzed using Restricted Means Survival Time analysis (RMST) and multivariable Cox models. RESULTS Of 9995 HT recipients within the OPTN, 3777 (38%) were categorized as Expedited, and 3040 (30%) as Routine. After adjustment, expedited discharge was not associated with inferior 90-day (ΔRMST -.01, p = .91) and 1-year patient survival (ΔRMST -.02, p = .53). Additionally, expedited was not associated with increased odds of non-elective readmission at 90-days (HR 1.04, CI .77-1.43) relative to Routine discharge. Counterfactual analysis revealed an estimated cost saving of $50 million if all Routine patients received an expedited discharge. CONCLUSION Expedited discharge after HT seems to be cost-effective and is not associated with inferior outcomes. Institutional-level outcome analyses should be performed to identify patients that would benefit from expedited discharge, and future studies should analyze the feasibility of implementing standardized discharge protocols following HT.
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Affiliation(s)
- Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
- Department of Surgery, University of Colorado Anschutz Medical Center, Denver, Colorado, USA
| | - Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California, USA
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Esmail A, Randall P, Oelofse S, Tomasicchio M, Pooran A, Meldau R, Makambwa E, Mottay L, Jaumdally S, Calligaro G, Meier S, de Kock M, Gumbo T, Warren RM, Dheda K. Comparison of two diagnostic intervention packages for community-based active case finding for tuberculosis: an open-label randomized controlled trial. Nat Med 2023; 29:1009-1016. [PMID: 36894651 DOI: 10.1038/s41591-023-02247-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/01/2023] [Indexed: 03/11/2023]
Abstract
Two in every five patients with active tuberculosis (TB) remain undiagnosed or unreported. Therefore community-based, active case-finding strategies require urgent implementation. However, whether point-of-care (POC), portable battery-operated, molecular diagnostic tools deployed at a community level, compared with conventionally used POC smear microscopy, can shorten time-to-treatment initiation, thus potentially curtailing transmission, remains unclear. To clarify this issue, we performed an open-label, randomized controlled trial in periurban informal settlements of Cape Town, South Africa, where we TB symptom screened 5,274 individuals using a community-based scalable mobile clinic. Some 584 individuals with HIV infection or symptoms of TB underwent targeted diagnostic screening and were randomized (1:1) to same-day smear microscopy (n = 296) or on-site DNA-based molecular diagnosis (n = 288; GeneXpert). The primary aim was to compare time to TB treatment initiation between the arms. Secondary aims included feasibility and detection of probably infectious people. Of participants who underwent targeted screening, 9.9% (58 of 584) had culture-confirmed TB. Time-to-treatment initiation occurred significantly earlier in the Xpert versus the smear-microscopy arm (8 versus 41 d, P = 0.002). However, overall, Xpert detected only 52% of individuals with culture-positive TB. Notably, Xpert detected almost all of the probably infectious patients compared with smear microscopy (94.1% versus 23.5%, P = <0.001). Xpert was associated with a shorter median time to treatment of probably infectious patients (7 versus 24 d, P = 0.02) and a greater proportion of infectious patients were on treatment at 60 d compared with the probably noninfectious patients (76.5% versus 38.2%, P < 0.01). Overall, a greater proportion of POC Xpert-positive participants were on treatment at 60 d compared with all culture-positive participants (100% versus 46.5%, P < 0.01). These findings challenge the traditional paradigm of a passive case-finding, public health strategy and argues for the implementation of portable DNA-based diagnosis with linkage to care as a community-oriented, transmission-interruption strategy. The study was registered with the South African National Clinical Trials Registry (application ID 4367; DOH-27-0317-5367) and ClinicalTrials.gov (NCT03168945).
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Affiliation(s)
- Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Philippa Randall
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Suzette Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Michele Tomasicchio
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Richard Meldau
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Edson Makambwa
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Lynelle Mottay
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Shameem Jaumdally
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Gregory Calligaro
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Stuart Meier
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Marianna de Kock
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Robin Mark Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.
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Bakhtiyar SS, Sakowitz S, Ali K, Verma A, Cho NY, Chervu NL, Benharash P. Expanding the heart donor pool: Can left ventricular assist devices substitute for marginal donor heart allografts? Surgery 2023; 173:1329-1334. [PMID: 36959074 DOI: 10.1016/j.surg.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/03/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Generally, heart transplantation with marginal donor allografts is reserved for a subset of high-risk patients. However, given the improved survival rates for patients on left ventricular assist devices, it is worth analyzing if they could potentially substitute for marginal donor allografts. This study aimed to compare survival outcomes of waitlisted patients with left ventricular assist devices who did not undergo heart transplantation to those who underwent heart transplantation with marginal allografts. METHODS This was a retrospective cohort study of adults (≥18 years) listed for heart transplantation between 2010 and 2022 in the Organ Procurement and Transplantation Network database. A previously validated risk score was used to define marginal donor organs. The primary outcome was death after transplantation or on the waitlist, as appropriate. RESULTS Of 5,713 patients with left ventricular assist devices, 4,683 (82%) comprised the left ventricular assist devices group and 1,030 (18%) the marginal group. The marginal cohort was older (57 [49-64] vs 55 [45-62] years, P < .001), similarly female (26 vs 24%, P = .16), and less often White (51 vs 60%, P < .001). Relative to the left ventricular assist devices group, the marginal group demonstrated higher 5-year survival from 2010 to 2014 (81 vs 43%, P < .001) and from 2015 to 2019 (77 vs 66%, P < .001). After adjustment, marginal patients demonstrated a significantly reduced hazard of 5-year mortality for those listed from 2010 to 2014 (hazard ratio 0.25, confidence interval 0.20-0.31; P < .001) and from 2015 to 2019 (hazard ratio 0.46, confidence interval 0.37-0.57; P < .001). CONCLUSION Our study validates the superiority of transplantation relative to left ventricular assist devices but also underscores the survival benefit of heart transplantation with marginal donor allografts, even in high-risk patients.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA. https://twitter.com/SaraSakowitz
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA. https://twitter.com/arjun_ver
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, University of California-Los Angeles, CA. https://twitter.com/CoreLabUCLA
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Patel BH, Melamed KH, Wilhalme H, Day GL, Wang T, DiNorcia J, Farmer D, Agopian V, Kaldas F, Barjaktarevic I. Implications of Pleural Fluid Composition in Persistent Pleural Effusion following Orthotopic Liver Transplant. Med Sci (Basel) 2023; 11:medsci11010024. [PMID: 36976532 PMCID: PMC10058754 DOI: 10.3390/medsci11010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Persistent pleural effusions (PPEf) represent a known complication of orthotopic liver transplant (OLT). However, their clinical relevance is not well described. We evaluated the clinical, biochemical, and cellular characteristics of post-OLT PPEf and assessed their relationship with longitudinal outcomes. We performed a retrospective cohort study of OLT recipients between 2006 and 2015. Included patients had post-OLT PPEf, defined by effusion persisting >30 days after OLT and available pleural fluid analysis. PPEf were classified as transudates or exudates (ExudLight) by Light's criteria. Exudates were subclassified as those with elevated lactate dehydrogenase (ExudLDH) or elevated protein (ExudProt). Cellular composition was classified as neutrophil- or lymphocyte-predominant. Of 1602 OLT patients, 124 (7.7%) had PPEf, of which 90.2% were ExudLight. Compared to all OLT recipients, PPEf patients had lower two-year survival (HR 1.63; p = 0.002). Among PPEf patients, one-year mortality was associated with pleural fluid RBC count (p = 0.03). While ExudLight and ExudProt showed no association with outcomes, ExudLDH were associated with increased ventilator dependence (p = 0.03) and postoperative length of stay (p = 0.03). Neutrophil-predominant effusions were associated with increased postoperative ventilator dependence (p = 0.03), vasopressor dependence (p = 0.02), and surgical pleural intervention (p = 0.02). In summary, post-OLT PPEf were associated with increased mortality. Ninety percent of these effusions were exudates by Light's criteria. Defining exudates using LDH only and incorporating cellular analysis, including neutrophils and RBCs, was useful in predicting morbidity.
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Affiliation(s)
- Bhavesh H Patel
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Kathryn H Melamed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Holly Wilhalme
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Gwenyth L Day
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Joseph DiNorcia
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Douglas Farmer
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Vatche Agopian
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Fady Kaldas
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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15
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Peng ZY, Yang CT, Kuo S, Wu CH, Lin WH, Ou HT. Restricted Mean Survival Time Analysis to Estimate SGLT2i-Associated Heterogeneous Treatment Effects on Primary and Secondary Prevention of Cardiorenal Outcomes in Patients With Type 2 Diabetes in Taiwan. JAMA Netw Open 2022; 5:e2246928. [PMID: 36520437 PMCID: PMC9856417 DOI: 10.1001/jamanetworkopen.2022.46928] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Increasing numbers of post hoc analyses have applied restricted mean survival time (RMST) analysis on the aggregated-level data from clinical trials to report treatment effects, but studies that use individual-level claims data are needed to determine the feasibility of RMST analysis for quantifying treatment effects among patients with type 2 diabetes in routine clinical settings. OBJECTIVES To apply RMST analysis for assessing sodium-glucose cotransporter-2 inhibitor (SGLT2i)-associated cardiovascular (CV) events and estimating heterogenous treatment effects (HTEs) on CV and kidney outcomes in routine clinical settings. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness study of Taiwan's National Health Insurance Research Database examined 21 144 propensity score (PS)-matched pairs of patients with type 2 diabetes with SGLT2i and dipeptidyl peptidase-4 inhibitor (DPP4i) treatment for assessing CV outcomes, and 19 951 PS-matched pairs of patients with type 2 diabetes with SGLT2i and DPP4i treatment for assessing kidney outcomes. Patients were followed until December 31, 2018. Statistical analysis was performed from August 2021 to April 2022. EXPOSURES Newly stable SGLT2i or DPP4i use in 2017. MAIN OUTCOMES AND MEASURES Study outcomes were CV events including hospitalization for heart failure (HHF), 3-point major adverse CV events (3P-MACE: nonfatal myocardial infarction [MI], nonfatal stroke, and CV death), 4-point MACE (4P-MACE: HHF and 3P-MACE), and all-cause death, and chronic kidney disease (CKD). RMST and Cox modeling analyses were applied to estimate treatment effects on study outcomes. RESULTS After PS matching, the baseline patient characteristics were comparable between 21 144 patients with stable SGLT2i use (eg, mean [SD] age: 58.3 [10.7] years; 11 990 [56.7%] male) and 21 144 patients with stable DPP4i use (eg, mean [SD] age: 58.1 [11.6] years; 12 163 [57.5%] male) for assessing CV outcomes, and those were also comparable between 19 951 patients with stable SGLT2i use (eg, mean [SD] age: 58.1 [10.7] years; 11 231 [56.2%] male) and 19 951 patients with stable DPP4i use (eg, mean [SD] age: 57.9 [11.5] years; 11 340 [56.8%] male) for assessing kidney outcome. The 2-year difference in RMST between patients with SGLT2i use and patients with DPP4i use was 4.99 (95% CI, 3.56-6.42) days for HHF, 4.12 (95% CI, 2.72-5.52) days for 3P-MACE, 7.72 (95% CI, 5.83-9.61) days for 4P-MACE, 1.26 (95% CI, 0.47-2.04) days for MI, 2.70 (95% CI, 1.57-3.82) days for stroke, 0.69 (95% CI, 0.28-1.11) days for CV death, 6.05 (95% CI, 4.89-7.20) days for all-cause death, and 14.75 (95% CI, 12.99-16.52) days for CKD. Directions of hazard ratios from Cox modeling analyses were consistent with RMST estimates. No association was found between study treatment and the negative control outcome (dental visits for tooth care). Consistent results across sensitivity analyses using high-dimensional PS-matched and PS-weighting approaches supported the validity of primary analysis results. Largest difference in RMST of SGLT2i vs DPP4i use for HHF and CKD was found among patients with established heart failure (30.80 [95% CI, 5.08-56.51] days) and retinopathy (40.43 [95% CI, 31.74-49.13] days), respectively. CONCLUSIONS AND RELEVANCE In this comparative effectiveness study, RMST analysis was feasible for translating treatment effects into more clinical intuitive estimates and valuable for quantifying HTEs among diverse patients in routine clinical settings.
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Affiliation(s)
- Zi-Yang Peng
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shihchen Kuo
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Chih-Hsing Wu
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Hung Lin
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Tamakawa T, Endoh H, Kamimura N, Deuchi K, Nishiyama K. Impact on outcomes of measuring lactates prior to ICU in unselected heterogeneous critically ill patients: A propensity score analysis. PLoS One 2022; 17:e0277948. [PMID: 36441770 PMCID: PMC9704607 DOI: 10.1371/journal.pone.0277948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Elevated blood lactate levels were reported as effective predictors of clinical outcome and mortality in ICU. However, there have been no studies simply comparing the timing of measuring lactates before vs. after ICU admission. METHODS A total of 19,226 patients with transfer time ≤ 24 hr were extracted from the Medical Information Mart for Intensive Care IV database (MIMIC-IV). After 1:1 propensity score matching, the patients were divided into two groups: measuring lactates within 3 hr before (BICU group, n = 4,755) and measuring lactate within 3 hr after ICU admission(AICU group, n = 4,755). The primary and secondary outcomes were hospital mortality, hospital 28-day mortality, ICU mortality, ICU length of stay (LOS), hospital LOS, and restricted mean survival time (RMST). RESULTS Hospital, hospital 28-day, and ICU mortality were significantly higher in AICU group (7.0% vs.9.8%, 6.7% vs. 9.4%, and 4.6% vs.6.7%, respectively, p<0.001 for all) Hospital LOS and ICU LOS were significantly longer in AICU group (8.4 days vs. 9.0 days and 3.0 days vs. 3.5 days, respectively, p<0.001 for both). After adjustment for predefined covariates, a significant association between the timing of measuring lactate and hospital mortality was observed in inverse probability treatment weight (IPTW) multivariate regression, doubly robust multivariate regression, and multivariate regression models (OR, 0.96 [95%CI, 0.95-0.97], OR 0.52 [95%CI, 0.46-0.60], OR 0.66 [95%CI, 0.56-0.78], respectively, p<0.001 for all), indicating the timing as a significant risk-adjusted factor for lower hospital mortality. The difference (BICU-AICU) of RMST at 28- days after ICU admission was 0.531 days (95%CI, 0.002-1.059, p<0.05). Placement of A-line and PA-catheter, administration of intravenous antibiotics, and bolus fluid infusion during the first 24-hr in ICU were significantly more frequent and faster in the BICU vs AICU group (67.6% vs. 51.3% and 126min vs.197min for A-line, 19.6% vs.13.2% and 182min vs. 274min for PA-catheter, 77.5% vs.67.6% and 109min vs.168min for antibiotics, and 57.6% vs.51.6% and 224min vs.278min for bolus fluid infusion, respectively, p<0.001 for all). Additionally, a significant indirect effect was observed in frequency (0.19879 [95% CI, 0.14061-0.25697] p<0.001) and time (0.07714 [95% CI, 0.22600-0.13168], p<0.01) of A-line replacement, frequency of placement of PA-catheter (0.05614 [95% CI, 0.04088-0.07140], p<0.001) and frequency of bolus fluid infusion (0.02193 [95%CI, 0.00303-0.04083], p<0.05). CONCLUSIONS Measuring lactates within 3 hr prior to ICU might be associated with lower hospital mortality in unselected heterogeneous critically ill patients with transfer time to ICU ≤ 24hr, presumably due to more frequent and faster therapeutic interventions.
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Affiliation(s)
- Taro Tamakawa
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
| | - Hiroshi Endoh
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- * E-mail:
| | - Natuo Kamimura
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
| | - Kazuki Deuchi
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
| | - Kei Nishiyama
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
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Kim DH, Tatsuoka C, Chen Z, Wright JT, Odden MC, Beddhu S, Bellows BK, Bress A, Carson T, Cushman WC, Johnson KC, Morisky DE, Punzi H, Tamariz L, Yang S, Wei LJ. Intensive Versus Standard Blood Pressure Lowering and Days Free of Cardiovascular Events and Serious Adverse Events: a Post Hoc Analysis of Systolic Blood Pressure Intervention Trial. J Gen Intern Med 2022; 37:3797-3804. [PMID: 35945470 PMCID: PMC9640478 DOI: 10.1007/s11606-022-07753-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 07/27/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Communication of the benefits and harms of blood pressure lowering strategy is crucial for shared decision-making. OBJECTIVES To quantify the effect of intensive versus standard systolic blood pressure lowering in terms of the number of event-free days DESIGN: Post hoc analysis of the Systolic Blood Pressure Intervention Trial PARTICIPANTS: A total of 9361 adults 50 years or older without diabetes or stroke who had a systolic blood pressure of 130-180 mmHg and elevated cardiovascular risk INTERVENTIONS: Intensive (systolic blood pressure goal <120 mmHg) versus standard blood pressure lowering (<140 mmHg) MAIN MEASURES: Days free of major adverse cardiovascular events (MACE), serious adverse events (SAE), and monitored adverse events (hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls, or acute kidney injury) over a median follow-up of 3.33 years KEY RESULTS: The intensive treatment group gained 14.7 more MACE-free days over 4 years (difference, 14.7 [95% confidence interval: 5.1, 24.4] days) than the standard treatment group. The benefit of the intensive treatment varied by cognitive function (normal: difference, 40.7 [13.0, 68.4] days; moderate-to-severe impairment: difference, -15.0 [-56.5, 26.4] days; p-for-interaction=0.009) and self-rated health (excellent: difference, -22.7 [-51.5, 6.1] days; poor: difference, 156.1 [31.1, 281.2] days; p-for-interaction=0.001). The mean overall SAE-free days were not significantly different between the treatments (difference, -14.8 [-35.3, 5.7] days). However, the intensive treatment group had 28.5 fewer monitored adverse event-free days than the standard treatment group (difference, -28.5 [-40.3, -16.7] days), with significant variations by frailty status (non-frail: difference, 38.8 [8.4, 69.2] days; frail: difference, -15.5 [-46.6, 15.7] days) and self-rated health (excellent: difference, -12.9 [-45.5, 19.7] days; poor: difference, 180.6 [72.9, 288.4] days; p-for-interaction <0.001). CONCLUSIONS Over 4 years, intensive systolic blood pressure lowering provides, on average, 14.7 more MACE-free days than standard treatment, without any difference in SAE-free days. Whether this time-based effect summary improves shared decision-making remains to be elucidated. TRIAL REGISTRATION ClinicalTrials.gov Registration: NCT01206062.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
| | - Curtis Tatsuoka
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Jackson T Wright
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Srinivasan Beddhu
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Adam Bress
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thaddeus Carson
- Department of Medicine, Medical College of Georgia, Augusta, GA, USA
| | - William C Cushman
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karen C Johnson
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Donald E Morisky
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Leonardo Tamariz
- Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Song Yang
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Lee-Jen Wei
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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18
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Claggett BL, McCaw ZR, Tian L, McMurray JJV, Jhund PS, Uno H, Pfeffer MA, Solomon SD, Wei LJ. Quantifying Treatment Effects in Trials with Multiple Event-Time Outcomes. NEJM EVIDENCE 2022; 1:10.1056/evidoa2200047. [PMID: 37645407 PMCID: PMC10465123 DOI: 10.1056/evidoa2200047] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Data on the occurrence times of multiple outcomes, reflecting the temporal profile of disease burden/progression, have been used to estimate treatment effects in various recent randomized trials. Most procedures for analyzing these data require specific model assumptions. When the assumptions are not met, the results may be misleading. Robust, model-free procedures for study design and analysis that enable clinically meaningful interpretations are warranted. METHODS For each treatment group, we constructed and summarized the estimated mean cumulative count of events over time by the area under the curve (AUC), which can be interpreted as the mean total event-free time lost from multiple undesirable outcomes. A higher curve, and resulting larger AUC, implies a worse treatment. The treatment effect is quantified by the ratio and/or difference of AUCs. The timing and occurrence of recurrent heart failure hospitalizations (HFHs) and cardiovascular (CV) death from Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction (PARAGON-HF), comparing sacubitril/valsartan with valsartan, are presented for illustration. We also discuss the design of future studies on the basis of the proposed method. RESULTS With 48 months of follow-up, estimated AUCs, representing the total event-free time lost to HFHs and CV death, were 11.3 and 13.1 event-months for sacubitril/valsartan and valsartan, respectively. The ratio of these AUCs was 0.86 (95% confidence interval, 0.75 to 1.00; P=0.049), a 14% reduction of disease burden favoring combination therapy. A future study, similar to PARAGON-HF, designed using the new proposal would require fewer patients would than a conventional time-to-first-event analysis. CONCLUSIONS The proposed method is robust and model-free and provides a clinically interpretable, time-scale summary of the treatment effect. (Funded by National Institutes of Health.).
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Affiliation(s)
- Brian Lee Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | - Lu Tian
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Center, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Center, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Lee-Jen Wei
- Harvard T.H. Chan School of Public Health, Boston
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Wujanto C, Chan TY, Soon YY, Vellayappan B. Should adjuvant radiotherapy be used in atypical meningioma (WHO grade 2) following gross total resection? A systematic review and Meta-analysis. Acta Oncol 2022; 61:1075-1083. [PMID: 36052871 DOI: 10.1080/0284186x.2022.2116994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The role of adjuvant radiotherapy (RT) following gross total resection (GTR) in atypical meningioma (AM) is not well established and its benefit remains unclear. We aim to evaluate the survival benefit of adjuvant RT in AM following GTR. METHODS We searched biomedical databases for studies published between January 1964-February 2021 and included studies reporting primary outcomes of 5-year PFS, 5-year OS and had survival curves for restricted mean survival time (RMST) calculations. Data extracted from survival curves were pooled and analyzed using a random-effects model. Hazard ratio (HR) was calculated for sensitivity analysis. RESULTS We included 12 non-randomized studies comprising 1,078 patients. 803 (74.5%) patients were treated with GTR alone and 275 (25.5%) patients received adjuvant RT. In 9 studies, RT included 3 D conformal RT, intensity modulated RT, or fractionated stereotactic radiotherapy); in 3 studies, stereotactic radiosurgery was also used. Median dose of RT was 59.4 Gy. Adjuvant RT resulted in an increase of 3.9 months for restricted mean PFS truncated at 5 years (95% CI 0.23-7.72; p = 0.037) and a 22% reduction in the hazard of disease progression or death (hazards ratio 0.78; 95% CI 0.46-1.33; p = 0.370). Restricted mean OS, truncated at 5 years, was improved with adjuvant RT by 1.1 months (95% CI 0.37-1.81; p = 0.003) and a 21% reduction in the hazard of death from any cause (HR 0.79; 95% CI 0.51-1.24; p = 0.310). Meta-regression analysis of the RMST of EBRT dose did not reveal any significant difference in PFS or OS between studies reporting median dose of <59.4 Gy vs. ≥ 59.4 Gy. CONCLUSION Adjuvant RT following GTR in patients with AM improved restricted mean PFS and OS. While we await the results from ongoing randomized controlled trials, adjuvant RT should be recommended.
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Affiliation(s)
- Caryn Wujanto
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Tabitha Y Chan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore, Singapore
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Mentias A, Saad M, Michael M, Nakhla S, Menon V, Harb S, Chaudhury P, Johnston D, Saliba W, Wazni O, Svensson L, Desai MY, Kapadia S. Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Valve Replacement or Repair. J Am Heart Assoc 2022; 11:e026666. [PMID: 36000413 PMCID: PMC9496414 DOI: 10.1161/jaha.122.026666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background We sought to examine outcomes of direct oral anticoagulants (DOACs) versus warfarin in atrial fibrillation with valve repair/replacement. Methods and Results Two atrial fibrillation cohorts from Medicare were identified from 2015 to 2019. They comprised patients who underwent surgical or transcatheter mitral valve repair (MV repair cohort) and surgical aortic or mitral bioprosthetic or transcatheter aortic valve replacement (bioprosthetic cohort). Each cohort was divided into warfarin and DOACs (apixaban, rivaroxaban, and dabigatran) groups. Study outcomes included mortality, stroke, and major bleeding. Inverse probability weighting was used for adjustment between the 2 groups in each cohort. The MV repair cohort included 1178 patients. After a median of 468 days, DOACs were associated with lower risk of mortality (hazard ratio [HR], 0.67 [95% CI, 0.55–0.82], P<0.001), ischemic stroke (HR, 0.72 [95% CI, 0.52–1.00], P=0.05) and bleeding (HR, 0.79 [95% CI, 0.63–0.99], P=0.04) compared with warfarin. The bioprosthetic cohort included 8089 patients. After a median follow‐up of 413 days, DOACs were associated with similar risk of mortality (adjusted HR, 0.93 [95% CI, 0.86–1.01], P=0.08), higher risk of ischemic stroke (adjusted HR, 1.27 [95% CI, 1.13–1.43], P<0.001), and lower risk of bleeding (adjusted HR, 0.86 [95% CI, 0.80–0.93], P<0.001) compared with warfarin. Conclusions In patients with atrial fibrillation, DOACs are associated with similar mortality, lower bleeding, but higher stroke with bioprosthetic valve replacement and lower risk of all 3 outcomes with MV repair compared with warfarin.
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Affiliation(s)
- Amgad Mentias
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Marwan Saad
- Department of Cardiology Warren Alpert School of Medicine at Brown University Providence RI
| | - Madonna Michael
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Shady Nakhla
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Venu Menon
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Serge Harb
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Pulkit Chaudhury
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Douglas Johnston
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Walid Saliba
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Oussama Wazni
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Lars Svensson
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Milind Y Desai
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Samir Kapadia
- Heart, Thoracic and Vascular Institute Cleveland Clinic Foundation Cleveland OH
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Deo SV, Marsia S, McAllister DA, Elgudin Y, Sattar N, Pell JP. The time-varying cardiovascular benefits of glucagon-like peptide-1 receptor agonist therapy in patients with type 2 diabetes mellitus: Evidence from large multinational trials. Diabetes Obes Metab 2022; 24:1607-1616. [PMID: 35491516 PMCID: PMC9540124 DOI: 10.1111/dom.14738] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate the time-varying cardio-protective effect of glucagon-like peptide-1 receptor agonists (GLP-1RAs) using pooled data from eight contemporary cardiovascular outcome trials using the difference in the restricted mean survival time (ΔRMST) as the effect estimate. MATERIAL AND METHODS Data from eight multinational cardiovascular outcome randomized controlled trials of GLP-1RAs for type 2 diabetes mellitus were pooled. Flexible parametric survival models were fit from published Kaplan-Meier plots. The differences between arms in RMST (ΔRMST) were calculated at 12, 24, 36 and 48 months. ΔRMST values were pooled using an inverse variance-weighted random-effects model; heterogeneity was tested with Cochran's Q statistic. The endpoints studied were: three-point major adverse cardiovascular events (MACE), all-cause mortality, stroke, cardiovascular mortality and myocardial infarction. RESULTS We included eight large (3183-14 752 participants, total = 60 080; median follow-up range: 1.5 to 5.4 years) GLP-1RA trials. Among GLP-1RA recipients, we observed an average delay in three-point MACE of 0.03, 0.15, 0.37 and 0.63 months at 12, 24, 36 and 48 months, respectively. At 48 months, while cardiovascular mortality was comparable in both arms (pooled ΔRMST 0.163 [-0.112, 0.437]; P = 0.24), overall survival was higher (ΔRMST = 0.261 [0.08-0.43] months) and stroke was delayed (ΔRMST 0.22 [0.15-0.33]) in patients receiving GLP-1RAs. CONCLUSIONS Glucagon-like peptide-1 receptor agonists may delay the occurrence of MACE by an average of 0.6 months at 48 months, with meaningfully larger gains in patients with cardiovascular disease. This metric may be easier for clinicians and patients to interpret than hazard ratios, which assume a knowledge of absolute risk in the absence of treatment.
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Affiliation(s)
- Salil V. Deo
- Institute of Health and WellbeingUniversity of GlasgowGlasgowUK
- Surgical ServicesLouis Stokes Cleveland VA Medical CenterClevelandOhioUSA
- Case School of MedicineCase Western Reserve UniversityClevelandOhioUSA
| | - Shayan Marsia
- Department of Internal MedicineDow Medical CollegeKarachiPakistan
| | | | - Yakov Elgudin
- Surgical ServicesLouis Stokes Cleveland VA Medical CenterClevelandOhioUSA
- Case School of MedicineCase Western Reserve UniversityClevelandOhioUSA
| | - Naveed Sattar
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Jill P. Pell
- Institute of Health and WellbeingUniversity of GlasgowGlasgowUK
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Chen T, Shao F, Chen K, Wang Y, Wu Z, Wang Y, Gao Y, Cornelius V, Li C, Jiang Z. Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years and Older With Hypertension: A Secondary Analysis of Randomized Clinical Trials. JAMA Intern Med 2022; 182:660-667. [PMID: 35532917 PMCID: PMC9086939 DOI: 10.1001/jamainternmed.2022.1657] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/26/2022] [Indexed: 11/14/2022]
Abstract
Importance Recent guidelines recommend a systolic blood pressure (BP) goal of less than 150 mm Hg or even 130 mm Hg for adults aged 60 years or older. However, harms from intensive BP treatments occur immediately (eg, syncope, fall), and benefits for cardiovascular event reduction emerge over time. Therefore, harms with low chance of benefit need to be clearer, particularly for those with limited life expectancy. Objective To estimate the time needed to potentially derive clinical benefit from intensive BP treatment in patients 60 years and older. Design, Setting, and Participants This secondary analysis included individual patient data from published randomized clinical trials with 27 414 patients 60 years or older with hypertension. Patient-level survival data were reconstructed when the original data were not available. Published trials were identified by searching PubMed until October 15, 2021. Exposures Intensive BP lowering vs standard BP lowering with the treat-to-target design. Main Outcomes and Measures Major adverse cardiovascular event (MACE) defined by each trial, which was broadly similar with all trials including myocardial infarction, stroke, and cardiovascular mortality. Results Six trials (original data from 2 trials and reconstructed data from 4 trials) with 27 414 participants (mean age, 70 years; 56.3% were women) were included in the analysis. Intensive BP treatment with a systolic BP target below 140 mm Hg was significantly associated with a 21% reduction in MACE (hazard ratio, 0.79; 95% CI, 0.71-0.88; P < .001). On average, 9.1 (95% CI, 4.0-20.6) months were needed to prevent 1 MACE per 500 patients with the intensive BP treatment (absolute risk reduction [ARR], 0.002). Likewise, 19.1 (95% CI, 10.9-34.2) and 34.4 (95% CI, 22.7-59.8) months were estimated to avoid 1 MACE per 200 (ARR, 0.005) and 100 (ARR, 0.01) patients, respectively. Conclusions and Relevance In this analysis, findings suggest that for patients 60 years and older with hypertension, intensive BP treatment may be appropriate for some adults with a life expectancy of greater than 3 years but may not be suitable for those with less than 1 year.
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Affiliation(s)
- Tao Chen
- Department of Public Health, Policy and Systems, Institute of Population Health, The University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Fang Shao
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Jiangsu, Nanjing, China
| | - Kangyu Chen
- Department of Cardiology, The First Affiliated Hospital of USTC, Hefei, China
- Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Mentougou District, Beijing, China
| | - Zhenqiang Wu
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand
| | - Yongjuan Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yanpei Gao
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom
| | - Chao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Zhixin Jiang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, China
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23
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Gini's mean difference and the long-term prognostic value of nodal quanta classes after pre-operative chemotherapy in advanced breast cancer. Sci Rep 2022; 12:2983. [PMID: 35194143 PMCID: PMC8863879 DOI: 10.1038/s41598-022-07078-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/27/2022] [Indexed: 12/04/2022] Open
Abstract
Gini's mean difference (GMD, mean absolute difference between any two distinct quantities) of the restricted mean survival times (RMSTs, expectation of life at a given time limit) has been proposed as a new metric where higher GMD indicates better prognostic value. GMD is applied to the RMSTs at 25 years time-horizon to evaluate the long-term overall survival of women with breast cancer who received neoadjuvant chemotherapy, comparing a classification based on the number (pN) versus a classification based on the ratio (LNRc) of positive nodes found at axillary surgery. A total of 233 patients treated in 1980–2009 with documented number of positive nodes (npos) and number of nodes examined (ntot) were identified. The numbers were categorized into pN0, npos = 0; pN1, npos = [1,3]; pN2, npos = [4,9]; pN3, npos ≥ 10. The ratios npnx = npos/ntot were categorized into Lnr0, npnx = 0; Lnr1, npnx = (0,0.20]; Lnr2, npnx = (0.20,0.65]; Lnr3, npnx > 0.65. The GMD for pN-classification was 5.5 (standard error: ± 0.9) years, not much improved over a simple node-negative vs. node-positive that showed a GMD of 5.0 (± 1.4) years. The GMD for LNRc-classification was larger, 6.7 (± 0.8) years. Among other conventional metrics, Cox-model LNRc's c-index was 0.668 vs. pN's c = 0.641, indicating commensurate superiority of LNRc-classification. The usability of GMD-RMSTs warrants further investigation.
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24
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Han K, Jung I. Restricted Mean Survival Time for Survival Analysis: A Quick Guide for Clinical Researchers. Korean J Radiol 2022; 23:495-499. [PMID: 35506526 PMCID: PMC9081686 DOI: 10.3348/kjr.2022.0061] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/12/2022] [Accepted: 03/20/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Inkyung Jung
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
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25
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Rossello X, González-Del-Hoyo M. Análisis de supervivencia en investigación cardiovascular (II): metodología estadística en situaciones complejas. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.06.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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26
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Thomas LE, Navar AM, Pencina MJ. Extrapolating Survival From Randomized Clinical Trial Data-Possibilities and Caution. JAMA Cardiol 2021; 6:1305-1307. [PMID: 34319362 DOI: 10.1001/jamacardio.2021.2629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laine Elliott Thomas
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina.,Associate Editor for Statistics, JAMA Cardiology
| | - Ann Marie Navar
- Department of Cardiology, University of Texas Southwestern Medical School, Dallas.,Associate Editor, JAMA Cardiology
| | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina.,Associate Editor for Statistics, JAMA Cardiology
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27
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Survival analyses in cardiovascular research, part II: statistical methods in challenging situations. ACTA ACUST UNITED AC 2021; 75:77-85. [PMID: 34326022 DOI: 10.1016/j.rec.2021.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022]
Abstract
This article is the second of a series of 2 educational articles. In the first article, we described the basic concepts of survival analysis, summarizing the common statistical methods and providing a set of recommendations to guide the strategy of survival analyses in randomized clinical trials and observational studies. Here, we introduce stratified Cox models and frailty models, as well as the immortal time bias arising from a poor assessment of time-dependent variables. To address the issue of multiplicity of outcomes, we provide several modelling strategies to deal with other types of time-to-event data analyses, such as competing risks, multistate models, and recurrent-event methods. This review is illustrated with examples from previous cardiovascular research publications, and each statistical method is discussed alongside its main strengths and limitations. Finally, we provide some general observations about alternative statistical methods with less restrictive assumptions, such as the win ratio method, the restrictive mean survival time, and accelerated failure time model.
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28
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Kim DH, Shi SM, Carroll D, Najafzadeh M, Wei LJ. Restricted mean survival time versus conventional measures for treatment decision-making. J Am Geriatr Soc 2021; 69:2282-2289. [PMID: 33901300 DOI: 10.1111/jgs.17195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/17/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Restricted mean survival time (RMST) summarizes treatment effect in terms of a gain or loss in the event-free days. It remains uncertain whether communicating treatment benefit and harm using RMST-based summary is more effective than conventional summary based on absolute and relative risk reduction. We compared the effect of RMST-based approach and conventional approach on decisional conflict using an example of intensive versus standard blood pressure-lowering strategies. DESIGN On-line survey. SETTING A convenience sample of patients in the United States. PARTICIPANTS Two hundred adults aged 65 and older with hypertension requiring anti-hypertensive treatment (response rate 85.5%). INTERVENTIONS Participants were randomly assigned to either RMST-based summary or conventional summary about the benefit and harm of blood pressure-lowering strategies. MEASUREMENTS Decisional Conflict Scale (DCS), ranging from 0 (no conflict) to 100 (high conflict), and preference for intensive blood pressure-lowering strategy. RESULTS Participants assigned to RMST-based approach (n = 100) and conventional approach (n = 100) had similar age (mean [standard deviation, SD]: 72.3 [5.6] vs 72.8 [5.5] years) and proportions of female (50 [50.0%] vs 61 [61.0%]) and white race (92 [92.0%] vs 92 [92.0%]). The mean (SD) DCS score was 25.2 (15.0) for RMST-based approach and 25.6 (14.1) for conventional approach (p = 0.84). The number (%) of participants who preferred intensive strategy was 10 (10.0%) for RMST-based approach and 14 (14.0%) for conventional approach (p = 0.52). The results were consistent in subgroups defined by age, sex, education level, cardiovascular disease status, and predicted mortality risk categories. CONCLUSION In a sample of relatively healthy older adults with hypertension, RMST-based approach was as effective as conventional approach on decisional conflict about choosing a blood pressure-lowering strategy. This study provides proof-of-concept evidence that RMST-based approach can be used in conjunction with absolute and relative risk reduction for communicating treatment benefit and harm in a decision aid.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sandra M Shi
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Danette Carroll
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lee-Jen Wei
- Department of Biostatistics, Harvard University, Boston, Massachusetts, USA
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