Propensity Score Methods for Bias Reduction in Observational Studies of Treatment Effect

Association between periodontal disease and malignant soft tissue sarcomas

OBJECTIVE

Malignant soft tissue sarcoma (MSTS) is a rare disease, but is seen in patients undergoing orthopedic surgery. Although the association of periodontal disease with various cancers occurring in the oral cavity, gastrointestinal tract, lungs, and prostate, has been reported, the association between periodontal disease and MSTS remains unclear. This study investigated the association between periodontal disease and MSTS in patients undergoing orthopedic surgery.

SUBJECTS AND METHODS

One hundred fifteen patients who underwent orthopedic surgery between 2017 and 2021 were retrospectively enrolled (mean age = 66.8 ± 10.7 years). The patient background was adjusted by the propensity score (PS). Subsequently, the association of periodontal disease with MSTS was analyzed using PS inverse probability of treatment weighting (IPTW). Periodontal status was determined by evaluating the periodontal inflamed surface area, which was calculated by measuring the periodontal probing pocket depth and detecting bleeding on probing.

RESULTS

Multivariate logistic regression analysis after adjustment by the PS showed that severe periodontitis was significantly associated with MSTS (odds ratio 2.81, p = 0.04). Furthermore, IPTW showed that severe periodontitis was significantly associated with MSTS (odds ratio 3.21, p = 0.01).

CONCLUSION

The results indicate an association between periodontal inflammation and MSTS.

Associations of infections and vaccines with Alzheimer's disease point to a role of compromised immunity rather than specific pathogen in AD

INTRODUCTION

Diverse pathogens (viral, bacterial, fungal) have been associated with Alzheimer's disease (AD) and related traits in various studies. This suggests that compromised immunity, rather than specific microbes, may play a role in AD by increasing an individual's vulnerability to various infections, which could contribute to neurodegeneration. If true, then vaccines that have heterologous effects on immunity, extending beyond protection against the targeted disease, may hold a potential for AD prevention.

METHODS

We evaluated the associations of common adult infections (herpes simplex, zoster (shingles), pneumonia, and recurrent mycoses), and vaccinations against shingles and pneumonia, with the risks of AD and other dementias in a pseudorandomized sample of the Health and Retirement Study (HRS).

RESULTS

Shingles, pneumonia and mycoses, diagnosed between ages 65 and 75, were all associated with significantly increased risk of AD later in life, by 16 %-42 %. Pneumococcal and shingles vaccines administered between ages 65-75 were both associated with a significantly lower risk of AD, by 15 %-21 %. These effects became less pronounced when AD was combined with other dementias.

DISCUSSION

Our findings suggest that both the pneumococcal polysaccharide vaccine and the live attenuated zoster vaccine can offer significant protection against AD. It remains to be determined if non-live shingles vaccine has a similar beneficial effect on AD. This study also found significant associations of various infections with the risk of AD, but not with the risks of other dementias. This indicates that vulnerability to infections may play a more significant role in AD than in other types of dementia, which warrants further investigation.

Carbonylation of Runx2 at K176 by 4-Hydroxynonenal Accelerates Vascular Calcification

BACKGROUND

Vascular calcification, which is characterized by calcium deposition in arterial walls and the osteochondrogenic differentiation of vascular smooth muscle cells, is an actively regulated process that involves complex mechanisms. Vascular calcification is associated with increased cardiovascular adverse events. The role of 4-hydroxynonenal (4-HNE), which is the most abundant stable product of lipid peroxidation, in vascular calcification has been poorly investigated.

METHODS

Serum was collected from patients with chronic kidney disease and controls, and the levels of 4-HNE and 8-iso-prostaglandin F2α were measured. Sections of coronary atherosclerotic plaques from donors were immunostained to analyze calcium deposition and 4-HNE. A total of 658 patients with coronary artery disease who received coronary computed tomography angiography were recruited to analyze the relationship between coronary calcification and the rs671 mutation in aldehyde dehydrogenase 2 (ALDH2). ALDH2 knockout (ALDH2-/-) mice, smooth muscle cell-specific ALDH2 knockout mice, ALDH2 transgenic mice, and their controls were used to establish vascular calcification models. Primary mouse aortic smooth muscle cells and human aortic smooth muscle cells were exposed to medium containing β-glycerophosphate and CaCl2 to investigate cell calcification and the underlying molecular mechanisms.

RESULTS

Elevated 4-HNE levels were observed in the serum of patients with chronic kidney disease and model mice and were detected in calcified artery sections by immunostaining. ALDH2 knockout or smooth muscle cell-specific ALDH2 knockout accelerated the development of vascular calcification in model mice, whereas overexpression or activation prevented mouse vascular calcification and the osteochondrogenic differentiation of vascular smooth muscle cells. In patients with coronary artery disease, patients with ALDH2 rs671 gene mutation developed more severe coronary calcification. 4-HNE promoted calcification of both mouse aortic smooth muscle cells and human aortic smooth muscle cells and their osteochondrogenic differentiation in vitro. 4-HNE increased the level of Runx2 (runt-related transcription factor-2), and the effect of 4-HNE on promoting vascular smooth muscle cell calcification was ablated when Runx2 was knocked down. Mutation of Runx2 at lysine 176 reduced its carbonylation and eliminated the 4-HNE-induced upregulation of Runx2.

CONCLUSIONS

Our results suggest that 4-HNE increases Runx2 stabilization by directly carbonylating its K176 site and promotes vascular calcification. ALDH2 might be a potential target for the treatment of vascular calcification.

COVID-19 outcomes in persons with hemophilia: results from a US-based national COVID-19 surveillance registry

BACKGROUND

Hypercoagulable state contributing to thrombotic complications worsens COVID-19 severity and outcomes, whereas anticoagulation improves outcomes by alleviating hypercoagulability.

OBJECTIVES

To examine whether hemophilia, an inherent hypocoagulable condition, offers protection against COVID-19 severity and reduces venous thromboembolism (VTE) risk in persons with hemophilia (PwH).

METHODS

A 1:3 propensity score-matched retrospective cohort study used national COVID-19 registry data (January 2020 through January 2022) to compare outcomes between 300 male PwH and 900 matched controls without hemophilia.

RESULTS

Analyses of PwH demonstrated that known risk factors (older age, heart failure, hypertension, cancer/malignancy, dementia, and renal and liver disease) contributed to severe COVID-19 and/or 30-day all-cause mortality. Non-central nervous system bleeding was an additional risk factor for poor outcomes in PwH. Odds of developing VTE with COVID-19 in PwH were associated with pre-COVID VTE diagnosis (odds ratio [OR], 51.9; 95% CI, 12.8-266; p < .001), anticoagulation therapy (OR, 12.7; 95% CI, 3.01-48.6; p < .001), and pulmonary disease (OR, 16.1; 95% CI, 10.4-25.4; p < .001). Thirty-day all-cause mortality (OR, 1.27; 95% CI, 0.75-2.11; p = .3) and VTE events (OR, 1.32; 95% CI, 0.64-2.73; p = .4) were not significantly different between the matched cohorts; however, hospitalizations (OR, 1.58; 95% CI, 1.20-2.10; p = .001) and non-central nervous system bleeding events (OR, 4.78; 95% CI, 2.98-7.48; p < .001) were increased in PwH. In multivariate analyses, hemophilia did not reduce adverse outcomes (OR, 1.32; 95% CI, 0.74-2.31; p = .2) or VTE (OR, 1.14; 95% CI, 0.44-2.67; p = .8) but increased bleeding risk (OR, 4.70; 95% CI, 2.98-7.48; p < .001).

CONCLUSION

After adjusting for patient characteristics/comorbidities, hemophilia increased bleeding risk with COVID-19 but did not protect against severe disease and VTE.

Associations of infections and vaccines with Alzheimer's disease point to a major role of compromised immunity rather than specific pathogen in AD

INTRODUCTION

Diverse pathogens (viral, bacterial, fungal) have been linked to Alzheimer's disease (AD) indicating a possibility that the culprit may be compromised immunity rather than particular microbe. If true, then vaccines with broad beneficial effects on immunity might be protective against AD.

METHODS

We estimated associations of common adult infections, including herpes simplex, zoster (shingles), pneumonia, and recurrent mycoses, as well as vaccinations against shingles and pneumonia, with the risk of AD in a pseudorandomized sample of the Health and Retirement Study.

RESULTS

Shingles, pneumonia, and mycoses diagnosed between ages 65-75, were all associated with higher risk of AD later in life, by 16%-42%. Pneumococcal and shingles vaccines received between ages 65-75 both lowered the risk of AD, by 15%-21%.

DISCUSSION

Our results support the idea that the connection between AD and infections involves compromised immunity rather than specific pathogen. We discuss mechanisms by which the declining immune surveillance may promote AD, and the role of biological aging in it. Repurposing of vaccines with broad beneficial effects on immunity could be a reasonable approach to AD prevention. Pneumococcal and zoster vaccines are promising candidates for such repurposing.

Repeat hepatectomy versus percutaneous ablation for recurrent hepatocellular carcinoma: emphasis on the impact of early or late recurrence

PURPOSE

Recurrent hepatocellular carcinoma (rHCC) patients with early recurrence usually suffer a poorer prognosis than those with late recurrence. We aimed to compare the treatment efficacy of repeat hepatectomy (RH) and percutaneous ablation (PA) in early-stage rHCC patients with early or late recurrence.

METHODS

This retrospective study enrolled 268 patients diagnosed with early-stage rHCC who received RH and PA. Overall survival (OS) and repeat recurrence-free survival (rRFS) were compared using log-rank analysis. Propensity score matching (PSM) was used to reduce the confounding bias.

RESULTS

Among the 268 patients with early-stage rHCC, 79 underwent RH and 189 underwent PA. Early (n = 174) and late (n = 94) recurrence was defined as recurrence within and after 2 years following initial hepatectomy, respectively. For patients with early recurrence, RH and PA provided similar 5-year OS (71.5% versus 74.4%, P = 0.87) and rRFS rates (24.7% versus 24.9%, P = 0.73). For patients with late recurrence, RH resulted in comparable 5-year OS (73.1% versus 86.1%, P = 0.62) and rRFS rates (36.6% versus 27.8%, P = 0.34) as PA. After PSM, RH continued to share similar 5-year OS and rRFS rates with PA in patients with early recurrence, and comparable efficacy of RH and PA was also observed in patients with late recurrence.

CONCLUSION

RH can offer comparable OS and rRFS rates as PA for early-stage rHCC patients, regardless of whether they experience early or late recurrence. Therefore, both RH and PA are feasible treatment options for early-stage rHCC patients.

Differences in Risk of Alzheimer's Disease Following Later-Life Traumatic Brain Injury in Veteran and Civilian Populations

OBJECTIVE

To directly compare the effect of incident age 68+ traumatic brain injury (TBI) on the risk of diagnosis of clinical Alzheimer's disease (AD) in the general population of older adults, and between male veterans and nonveterans; to assess how this effect changes with time since TBI.

SETTING AND PARTICIPANTS

Community-dwelling traditional Medicare beneficiaries 68 years or older from the Health and Retirement Study (HRS).

DESIGN

Fine-Gray models combined with inverse-probability weighting were used to identify associations between incident TBI, post-TBI duration, and TBI treatment intensity, with a diagnosis of clinical AD dementia. The study included 16 829 older adults followed over the 1991-2015 period. For analyses of veteran-specific risks, 4281 veteran males and 3093 nonveteran males were identified. Analysis of veteran females was unfeasible due to the age structure of the population. Information on occurrence(s) of TBI, and onset of AD and risk-related comorbidities was constructed from individual-level HRS-linked Medicare claim records while demographic and socioeconomic risk factors were based on the survey data.

RESULTS

Later-life TBI was strongly associated with increased clinical AD risk in the full sample (pseudo-hazard ratio [HR]: 3.22; 95% confidence interval [CI]: 2.57-4.05) and in veteran/nonveteran males (HR: 5.31; CI: 3.42-7.94), especially those requiring high-intensity/duration care (HR: 1.58; CI: 1.29-1.91). Effect magnitude decreased with time following TBI (HR: 0.72: CI: 0.68-0.80).

CONCLUSION

Later-life TBI was strongly associated with increased AD risk, especially in those requiring high-intensity/duration care. Effect magnitude decreased with time following TBI. Univariate analysis showed no differences in AD risk between veterans and nonveterans, while the protective effect associated with veteran status in Fine-Gray models was largely due to differences in demographics, socioeconomics, and morbidity. Future longitudinal studies incorporating diagnostic procedures and documentation quantifying lifetime TBI events are necessary to uncover pathophysiological mediating and/or moderating mechanisms between TBI and AD.

The effects and process of the intervention "Individual Shantala Infant Massage" in preventive child healthcare to improve parent-child interaction: study protocol for a quasi-experimental study

BACKGROUND

Individual Shantala Infant Massage is an intervention that is offered by several Dutch Preventive Child Healthcare (PCH) organizations as optional preventive support, in addition to basic care as offered to all children. It targets vulnerable families and aims to enhance sensitive parenting and to reduce (effects of) parental stress. The intervention is carried out by a certified nurse. It consists of three structured home visits. Parents learn to massage their infant and receive parenting support. This study aims to investigate the effectiveness and the process of the intervention. The main hypothesis is that Individual Shantala Infant Massage leads to increased parental sensitive responsiveness, lower perceived and physiological parental stress, and improved child growth and development in the intervention group, compared to a control group where this intervention is not offered by PCH. Secondary research questions address effects on parenting confidence and parental concerns regarding the infant, the influence of background characteristics and the intervention process.

METHODS

The study is a quasi-experimental non-randomized trial. The aim is to include 150 infant-parent dyads in both the intervention and the control group. This takes into account possible attrition and missing data as 105 dyads with complete data per group are sufficient for analysis. All participants complete questionnaires at T0 (pre-test, child age between six-sixteen weeks), T1 (post-intervention, or ± four weeks after T0), and T2 (follow-up at five months). At T2, a hair tuft is cut from the parents' head to measure hair cortisol levels. Data on infant growth and development is obtained from PCH files. In the intervention group, additional data is collected to evaluate the intervention process: parents complete an evaluation questionnaire at T1, nurses keep semi-structured logbooks of intervention sessions and interviews are conducted with parents and professionals.

DISCUSSION

Study results can contribute to the evidence base of infant massage as applied in Dutch PCH, and can inform parents, PCH practitioners, policy makers and researchers both inside and outside the Netherlands on feasibility and effectiveness of the infant massage intervention as applied in this format and setting.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN16929184. Date (retrospectively) registered: 29/03/2022.

What is the impact of national public expenditure and its allocation on neonatal and child mortality? A machine learning analysis

BACKGROUND

Understanding the impact of national public expenditure and its allocation on child mortality may help governments move towards target 3.2 proposed in the 2030 Agenda. The objective of this study was to estimate the impacts of governmental expenditures, total, on health, and on other sectors, on neonatal mortality and mortality of children aged between 28 days and five years.

METHODS

This study has an ecological design with a population of 147 countries, with data between 2012 and 2019. Two steps were used: first, the Generalized Propensity Score of public spending was calculated; afterward, the Generalized Propensity Score was used to estimate the expenditures' association with mortality rates. The primary outcomes were neonatal mortality rates (NeoRt) and mortality rates in children between 28 days and 5 years (NeoU5Rt).

RESULTS

The 1% variation in Int$ Purchasing Power Parity (Int$ PPP) per capita in total public expenditures, expenditure in health, and in other sectors were associated with a variation of -0.635 (95% CI -1.176, -0.095), -2.17 (95% CI -3.051, -1.289) -0.632 (95% CI -1.169, -0.095) in NeoRt, respectively The same variation in public expenditures in sectors other than health, was associates with a variation of -1.772 (95% CI -6.219, -1.459) on NeoU5Rt. The results regarding the impact of total and health public spending on NeoU5Rt were not consistent.

CONCLUSION

Public investments impact mortality in children under 5 years of age. Likely, the allocation of expenditures between the health sector and the other social sectors will have different impacts on mortality between the NeoRt and the NeoU5Rt.

Impact of treatment-duration-ratio of traditional Chinese medicine on survival period of primary liver cancer -A real-world study

Introduction

In China, traditional Chinese medicine (TCM) is regarded as an effective treatment for primary liver cancer (PLC). The present study analyzed the effect of TCM on the survival period of patients with PLC by analyzing the relationship between the treatment-duration-ratio of traditional Chinese medicine (C-TDR, (traditional Chinese medicine treatment duration)/(Overall treatment duration) × 100%) and the survival time of 1002 patients with PLC.

Methods

In this study, 1002 patients with PLC admitted to TCM Oncology Department of Changhai Hospital from January, 2015 to December, 2019 were enrolled. The univariate and multivariate Cox regression equation, propensity score matching (PSM) were performed to identify independent prognostic factors for survival outcomes of PLC patients at different stages and estimate the influence of C-TDR on survival time.

Results

Cox regression analysis indicated that C-TDR was an independent prognostic factor for survival outcome (P＜0.05) and a corresponding reduction of relative risk of death of 75.67% (relative risk (RR) = 0.2433; 95%Confedential Interval (CI) = 0.1747-0.3388). Similarly, it is also an independent prognostic factor for patients outcome of each stage (P＜0.05). The 251 patients of BCLC-A reduced 96.09% risk of mortality (RR = 0.0391; 95%CI = 0.0151-0.1012). The 396 BCLC-B patients decreased risk of death of 81.24% (RR = 0.1876, 95%CI = 0.1112-0.3163). Moreover, 355 patients of stage C demonstrated a 51.36% lower risk of death (RR = 1.0016, 95%CI = 0.9885-1.0149). Significant differences were found in the median overall survival (OS) both higher and lower C-TDR of all patients. Even after PSM, the overall survival of two groups were significantly improved following each stage.

Conclusion

Earlier administration of traditional Chinese medicine can reduce the risk of mortality and prolong survival in patients with liver cancer.

Impact of a digitized workflow for knee endoprothesis implantations on hospital-specific ratios

BACKGROUND: The continuous decrease of healthcare resources requires hospitals to improve efficiency while striving to improve quality standards that deliver better patient outcomes. OBJECTIVE: The objective of this study was to analyze whether the implementation of digital support systems during orthopedic surgery positively affected clinical processes and quality ratios. METHODS: A retrospective case-control study of 297 knee joint replacement procedures was conducted between 2015 and 2020. Thirty-five patients were allocated to the treatment and control groups after they were identified with exact matching and estimation of the propensity score. Both groups were balanced regarding the selected covariates. The effect of the surgical procedure manager (SPM) on the incidence of acute haemorrhagic anaemia between the two groups was evaluated with a t-test, and the odds ratio was calculated. RESULTS: SPM-supported surgery has no significant influence on the incidence of acute haemorrhagic anaemia but leads to significantly shorter hospital stay (1.93 days), changeover (4.14 minutes) and recovery room time (20.20 minutes). In addition, it reduces the standard deviation of operation room times. CONCLUSIONS: The study concludes that SPM enhances surgical efficiency and maintains quality outcomes. To overcome their increasing financial pressure hospital management should commercially evaluate the implementation of digital support systems.

The Impact of Long-Term Care Insurance on Medical Utilization and Expenditures: Evidence from Jingmen, China

The purpose of this study was to evaluate the impact of long-term care insurance (LTCI) on medical utilization and expenditures in Jingmen, a pilot city of China. The propensity score matching-difference in difference (PSM-DID) approach was employed to examine the expenses and frequency of inpatient and outpatient services before and after the implementation of the LTCI based on the 2015-2018 panel data from the China Health and Retirement Longitudinal Study (CHARLS). The results showed that the annual expenditure and frequency of the inpatient services of Jingmen residents were reduced by 1923 Yuan (287.0 USD) and 0.24 times, respectively. The impact of the LTCI varied between urban and rural areas. The annual expenditure and frequency of inpatient services in rural areas were reduced by 1600 Yuan (238.8 USD) and 0.30 times, which were lower than those (3400 Yuan (507.5 USD) and 0.20 times) in urban areas. The monthly outpatient expenses and frequency in rural areas were reduced by 300 Yuan (44.8 USD) and 0.14 times, but increased by 555 Yuan (82.8 USD) and 0.07 times in urban area. The findings indicated that the implementation of the LTCI can reduce the medical utilization and expenses, and it had a greater effect in rural areas than in urban areas. It is suggested to promote the LTCI nationwide, and more policy preference should be given to the development of the LTCI in rural areas.

Prior influenza vaccine is not a risk factor for bacterial coinfection in patients admitted to the ICU due to severe influenza

OBJECTIVE

To determine whether the prior usage of the flu vaccine is a risk factor for bacterial co-infection in patients with severe influenza.

DESIGN

This was a retrospective observational cohort study of subjects admitted to the ICU. A propensity score matching, and logistic regression adjusted for potential confounders were carried out to evaluate the association between prior influenza vaccination and bacterial co-infection.

SETTINGS

184 ICUs in Spain due to severe influenza.

PATIENTS

Patients included in the Spanish prospective flu registry.

INTERVENTIONS

Flu vaccine prior to the hospital admission.

RESULTS

A total of 4175 subjects were included in the study. 489 (11.7%) received the flu vaccine prior to develop influenza infection. Prior vaccinated patients were older 71 [61-78], and predominantly male 65.4%, with at least one comorbid condition 88.5%. Prior vaccination was not associated with bacterial co-infection in the logistic regression model (OR: 1.017; 95%CI 0.803-1.288; p=0.885). After matching, the average treatment effect of prior influenza vaccine on bacterial co-infection was not statistically significant when assessed by propensity score matching (p=0.87), nearest neighbor matching (p=0.59) and inverse probability weighting (p=0.99).

CONCLUSIONS

No association was identified between prior influenza vaccine and bacterial coinfection in patients admitted to the ICU due to severe influenza. Post influenza vaccination studies are necessary to continue evaluating the possible benefits.

Nimotuzumab Increases the Recovery Rate of Severe and Critical COVID-19 Patients: Evaluation in the Real-World Scenario

EGFR signaling is an important regulator of SARS-CoV induced lung damage, inflammation and fibrosis. Nimotuzumab is a humanized anti-EGFR antibody registered for several cancer indications. An expanded access study was conducted to evaluate the safety and recovery rate of severe and critical patients with confirmed SARS-CoV-2 infection, treated with nimotuzumab in combination with the standard of care in the real-world scenario. The antibody was administered as an intravenous infusions every 72 h, up to 5 doses. In order to assess the impact of nimotuzumab, the recovery rate was compared with a paired retrospective cohort. Control patients received standard treatment according the national protocol but not nimotuzumab. Overall, 1,151 severe or critical patients received nimotuzumab in 21 hospitals of Cuba. Median age was 65 and 773 patients had at least one comorbidity. Nimotuzumab was very well-tolerated and mild or moderate adverse events were detected in 19 patients. 1,009 controls matching with the nimotuzumab patients, were selected using a "propensity score" method. The 14-day recovery rate of the nimotuzumab cohort was 72 vs. 42% in the control group. Controls had a higher mortality risk (RR 2.08, 95% CI: 1.79, 2.38) than the nimotuzumab treated patients. The attributable fraction was 0.52 (95% CI: 0.44%; 0.58), and indicates the proportion of deaths that were prevented with nimotuzumab. Our preliminary results suggest that nimotuzumab is a safe antibody that can reduce the mortality of severe and critical COVID-19 patients.

An observational, retrospective, comprehensive pharmacovigilance analysis of hydroxychloroquine-associated cardiovascular adverse events in patients with and without COVID-19

Background

Coronavirus disease 2019 (COVID-19) is a global pandemic. Hydroxychloroquine (HCQ)-associated cardiovascular adverse events (CVAEs) have been increasingly reported.

Aim

This study aimed to present an observational, retrospective, and comprehensive pharmacovigilance analysis of CVAE associated with HCQ in patients with and without COVID-19 using the US Food and Drug Administration Adverse Events Reporting System (FAERS) data from January 2020 to December 2020.

Method

We identified 3302 adverse event reports from the FAERS database in the year 2020 and divided them into COVID-19 and non-COVID-19 groups, respectively. Then we analyzed whether there were differences in CVAEs between the two groups.

Results

We found that CVAE was higher in cases with COVID-19 compared to those without COVID-19, odds ratio (OR) of 1.26 and a 95% confidence interval (95% CI) of 1.02–1.54. Cases with COVID-19 treated with HCQ exhibited relatively higher proportions of torsade de points (TdP) and QT prolongation (OR 3.10, 95% CI 2.24–4.30), shock-associated TdP (OR 2.93, 95% CI 2.13–4.04), cardiac arrhythmias (OR 2.07, 95% CI 1.60–2.69), cardiac arrhythmia terms (including bradyarrhythmias and tachyarrhythmias) (OR 2.15, 95% CI 1.65–2.80), bradyarrhythmias (including conduction defects and disorders of sinus node function) (OR 2.56, 95% CI 1.86–3.54), and conduction defects (OR 2.56, 95% CI 1.86–3.54).

Conclusion

Our retrospective observational analysis suggested that the proportion of CVAE associated with HCQ, especially TdP and QT prolongation, was higher in patients with COVID-19. Understanding the effects of COVID-19 on the cardiovascular system is essential to providing comprehensive medical care to patients receiving HCQ treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01457-w.

No Benefit with Preservation of Midline Structures in Decompression for Lumbar Spinal Stenosis: Results From the National Swedish Spine Registry 2-Year Post-Op

STUDY DESIGN

Observational cohort study.

OBJECTIVE

The aim of this study was to investigate whether preservation of the midline structures is associated with a better clinical outcome compared to classic central decompression for lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

The classic surgical procedure for LSS is a central, facet joint sparing decompressive laminectomy (LE). Alternative approaches have been developed to preserve the midline structures. The effect of the alternative techniques compared to LE remains unclear.

METHODS

All patients >50 years of age who underwent decompression surgery for LSS without concomitant fusion in the National Swedish Spine Registry (Swespine) from December 31, 2015 until October 6, 2017 were included in this study based on surgeon-reported data and patient questionnaires before and 2 years postoperatively. Propensity score matching was used to compare decompression with preservation of midline structures with patients who underwent LE. The primary outcome was the Oswestry Disability Index (ODI) and secondary outcomes were the Numeric Rating Scale (NRS) for leg and back pain, EuroQol-5 Dimensions (EQ-5D), Global Assessment (GA), patient satisfaction and rate of subsequent surgery.

RESULTS

Some 3339 patients completed a 2-year follow-up. Of these, 2974 (89%) had decompression with LE and 365 underwent midline preserving surgery. Baseline scores were comparable between the groups. Mean ODI improvement at follow-up was 16.6 (SD = 20.0) in the LE group and 16.9 (SD = 20.2) in the midline preserving surgery group. In the propensity score-matched analysis the difference in improved ODI was 0.53 (95% confidence interval, CI -1.71 to 2.76; P = 0.64). The proportion of patients who showed a decreased ODI score of at least our defined minimal clinically important difference (=8) was 68.3% after LE and 67.0% after preserving the midline structures (P = 0.73). No significant differences were found in the improvement of NRS for leg and back pain, EQ-5D, GA or patient satisfaction. The rate of subsequent surgery was 5.5% after LE and 4.9% after midline preserving surgery without a significant difference in the propensity score-matched analysis (hazard ratio, HR 0.87; 95% CI 0.49-1.54; P = 0.64).

CONCLUSION

In this study on decompression techniques for LSS, there was no benefit in preserving the midline structures compared to LE 2 years after decompression. The conclusion is that the surgeon is free to choose the surgical method that is thought most suitable for the patient and the condition with which the patient presents.Level of Evidence: 3.

Acute Kidney Injury Associated With Remdesivir: A Comprehensive Pharmacovigilance Analysis of COVID-19 Reports in FAERS

Acute kidney injury (AKI) is a common complication among patients with the novel coronavirus (COVID-19). COVID-19 along with AKI usually resulted in a poor prognosis for those affected. Remdesivir is a novel antiviral drug that was urgently approved for the treatment of COVID-19. In the current study, safety data of remdesivir were limited. We gathered information on COVID-19 cases in patients with adverse events that were reported to the U.S. Food and Drug Administration (US FDA) Adverse Event Reporting System (FAERS) database. We employed the reporting odds ratio (ROR) method to perform disproportionality analysis. Finally, we identified 12,869 COVID-19 cases. A total of 3,991 of these cases reported remdesivir as a primary suspected drug, while 8,878 cases were treated with other drugs. More AKI events occurred in cases of male patients and those above the age of 65 years. We detected a significant association between remdesivir and AKI: ROR = 2.81, 95% CI (2.48, 3.18). The association was stronger after the propensity score matching ROR = 3.85, 95% CI (3.11, 4.78). The mean time to AKI event onset was 4.91 ± 7.25 days in COVID-19 cases with remdesivir therapy. The fatality proportion was 36.45% in AKI cases with remdesivir treatment. This pharmacovigilance study identified a significant association between AKI events and remdesivir treatment in COVID-19 patients by mining FAERS real-world big data. Although causality was not confirmed, the association between remdesivir and AKI should not be ignored, especially in the older, male COVID-19 inpatients.

Percutaneous Radiofrequency Ablation with or without Chemolipiodolization for Hepatocellular Carcinoma: A Propensity-Score-Matched Analysis

Chemolipiodolization (CL) is less invasive than transarterial chemoembolization (TACE) for managing hepatocellular carcinoma (HCC) because it helps avoid embolization. However, the treatment outcomes of percutaneous radiofrequency ablation (PRFA) with or without CL for HCC remain unclear. Herein, we compared the prognostic factors for overall survival (OS) following PRFA with or without CL for HCC using propensity-score-matched analysis. A total of 221 patients with HCC treated with PRFA at Saga Central Hospital between April 2004 and October 2020, with or without CL, were enrolled. No significant difference was observed in OS between PRFA with and without CL cohorts (median survival time (MST): 4.5 vs. 5.4 years; p = 0.0806). To reduce the confounding effects of 12 variables, we performed propensity-score-matched analysis to match patients treated with PRFA with or without CL. No significant difference was observed in OS between PRFA with and without CL cohorts (MST: 4.0 vs. 3.6 years; p = 0.5474). After stratification according to tumor size, no significant difference was observed in OS for patients with tumor size ≥20 mm between PRFA with and without CL cohorts (MST: 3.5 vs. 3.4 years; p = 0.8236). PRFA with CL was not a significant prognostic factor in both univariate and multivariate analyses (p = 0.5477 and 0.9600, respectively). Our findings suggest that PRFA with CL does not demonstrate more favorable prognosis than PRFA without CL for HCC, regardless of tumor size.

Hepatic Arterial Infusion Chemotherapy with Cisplatin versus Sorafenib for Intrahepatic Advanced Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

Simple Summary

Thus far, clinical studies have shown that immunotherapy (atezolizumab-bevacizumab) has shown better and favorable overall survival than sorafenib for advanced hepatocellular carcinoma (HCC). However, the treatment outcomes of hepatic arterial infusion chemotherapy (HAIC) with cisplatin compared with sorafenib for intrahepatic advanced HCC remain unclear. We therefore aimed to determine the prognostic factors for HAIC with cisplatin. Our results showed that HAIC with cisplatin could significantly prolong the overall survival for intrahepatic advanced HCC and had a longer prognostic effect than sorafenib. Therefore, our results suggest that HAIC should be used in intrahepatic advanced HCC.

Abstract

Given that the outcome of hepatic arterial infusion chemotherapy (HAIC) with cisplatin for intrahepatic advanced hepatocellular carcinoma (HCC) is unclear, we aimed to compare prognostic factors for overall survival (OS) following HAIC with cisplatin versus sorafenib for intrahepatic advanced HCC using propensity score-matched analysis. We enrolled 331 patients with intrahepatic advanced HCC who received HAIC with cisplatin (n = 88) or sorafenib (n = 243) between June 2006 and March 2020. No significant difference was observed in OS between HAIC with cisplatin and sorafenib cohorts (median survival time [MST]: 14.0 vs. 12.3 months; p = 0.0721). To reduce confounding effects, 166 patients were selected using propensity score-matched analysis (n = 83 for each treatment). HAIC with cisplatin significantly prolonged OS compared with sorafenib (MST: 15.6 vs. 11.0 months; p = 0.0157). Following stratification according to the Child-Pugh classification, for patients with class A (MST: 24.0 vs. 15.0 months; p = 0.0145), HAIC with cisplatin rather than sorafenib significantly prolonged OS. Our findings suggest that HAIC with cisplatin demonstrates longer prognostic effects than sorafenib in intrahepatic advanced HCC.

Food Insecurity and micronutrient status biomarkers in school-age Colombian children

Introduction: Half of the Colombian households experience some degree of food insecurity. Food insecurity has been associated with malnutrition, which could result in micronutrient deficiencies in children; however, the evidence is not conclusive. Objective: To examine the associations between food insecurity and blood concentrations of hemoglobin, ferritin, vitamin A, vitamin B12, folate, and zinc in school-age children from Bogotá, Colombia. Materials and methods: We conducted a cross-sectional study among 2,660 children aged 5-12 from Bogotá’s public schools. We assessed their household food insecurity level with the Spanish version of the Household Food Security Survey Module (HFSSM), a validated scale, and quantified blood biomarkers of iron, vitamin A, folate, vitamin B12, and zinc status. We examined the associations between food insecurity, severe hunger, and micronutrient status biomarkers using propensity scores. Results: Three-quarters of households had some degree of food insecurity and 12 % had food insecurity and severe hunger. Prevalence of marginal vitamin B12 status and vitamin A and zinc deficiencies were, respectively, 17%, 14%, and 1.4%. Compared with children from households without severe hunger, those exposed to it had lower adjusted mean concentrations of vitamin A, vitamin B12, and folate, but these differences were not statistically significant. Conclusion: Food insecurity with severe hunger was not associated with micronutrient status biomarkers in Colombian school-age children. The HFSSM may adequately measure hardship in food acquisition due to lack of resources, but it does not yield an index that is associated with micronutrient status biomarkers.

The Efficacy of Long-Term Chinese Herbal Medicine Use on Lung Cancer Survival Time: A Retrospective Two-Center Cohort Study with Propensity Score Matching

Objective

To explore the efficacy of long-term use of Chinese herbal medicine (CHM) on survival time of lung cancer.

Methods

We conducted a retrospective cohort study on lung cancer patients. A propensity score matching (PSM) was performed to balance the covariates. Progression-free survival (PFS) was the primary endpoint and overall survival (OS) was the secondary endpoint. Patients who received CHM therapy from the initial date of diagnosis of lung cancer were included in the CHM group. Patients who were not treated with CHM during the same interval were categorized in the control group. A Cox regression model was used to explore the prognostic factors related to lung cancer. Hazard ratios of different subgroups were also analyzed.

Results

A total of 1134 patients were included in our study: 761 patients were in the CHM group and 373 patients were in the control group. After PSM, the mPFS and mOS in the CHM group were 70.4 months and 129.1 months, respectively, while the mPFS and mOS in the control group were 23.8 months and 99.7 months, respectively. The results of survival analysis on each stage demonstrated that patients may benefit from the long-term CHM treatment especially for patients with early stage. One-year to ten-year progression-free survival rates in the CHM group were higher than those in the control group (p < 0.001). COX multivariate regression analysis indicated that CHM treatment, female, low age at diagnosis, early tumor stage, and surgery were independent protective factors against recurrence and metastasis of lung cancer. Subgroup analysis showed that CHM treatment could reduce the risk of recurrence and metastasis in each subgroup (p < 0.01).

Conclusion

Long-term CHM treatment with the Fuzheng Quxie Formula, which can be flexibly applied in the course of lung cancer treatment, not only has a positive influence on the progression-free survival time of lung cancer patients, but also reduces the risk of recurrence and metastasis of lung cancer.

Acquired low immunoglobulin levels and risk of clinically relevant infection in adult patients with systemic lupus erythematosus: a cohort study

OBJECTIVE

Infection is a leading cause of death in the SLE population. Low immunoglobulin levels might be a potential risk for infection. We aimed to assess whether acquired low levels of any type of immunoglobulin increase the risk of clinically relevant infection in adult patients with SLE.

METHODS

We compared adult SLE patients who had acquired any low immunoglobulin levels (IgA, IgM or IgG) for 2 years with patients with normal or high levels with respect to clinically relevant infection (defined as infections requiring intravenous or oral antibiotics) in a prospective cohort study. Group balance was achieved using propensity score adjustment, matching and inverse probability weighting. Primary analysis was time to event using Cox-regression modelling adjusting for potential confounders. Sensitivity analyses were conducted to examine several exposure and outcome definitions.

RESULTS

Patients with hypogammaglobulinaemia had longer disease duration, more lupus nephritis history, higher proteinuria and more accumulated damage. Low IgA level was associated with increased risk of clinically relevant infection [hazard ratio (HR): 2.24, 95% CI: 1.61, 3.12] while low IgG (HR: 1.15, 95% CI: 0.84, 1.59) or low IgM (HR: 0.95, 95% CI: 0.73, 1.23) was not. Low immunoglobulin recovery in the first year was 2.5% (11), second year 8.2% (36), third year 10.1% (44) and fourth year 18.4% (80), and 60% (263) of acquired hypogammaglobulinaemia recovered over 4 years.

CONCLUSION

The majority of acquired hypogammaglobulinaemia in adult patients with SLE is transient. Only low acquired IgA was associated with increased risk of infection among adult patients with SLE. Whether immunoglobulin replacement provides additional protective effect requires further investigation.

Cigarette smoking may accelerate the progression of IgA nephropathy

Background

Whether cigarette smoking is associated with the progression of immunoglobulin A nephropathy (IgAN) remains uncertain; therefore, we aimed to evaluate the effect of cigarette smoking on the prognosis of IgAN.

Methods

We divided 1239 IgAN patients from West China Hospital of Sichuan University who met the inclusion criteria into smoker (current or former) and non-smoker groups. The endpoint was end-stage renal disease (ESRD: eGFR < 15 mL/min/1.73 m² or undergoing renal replacement treatment) and/or eGFR decreased by > 50%. Kaplan–Meier, correlation, logistic regression and Cox proportional hazards analyses were performed. The association between cigarette smoking and IgAN was further verified by propensity-score-matched cohort analysis.

Results

During the mean follow-up period of 61 months, 19% (40/209) of the smoker group and 11% (110/1030) of the non-smoker group reached the study endpoint (p < 0.001). Multivariate Cox regression analysis revealed that cigarette smoking (hazard ratio (HR) = 1.58; p = 0.043) was an independent risk factor predicting poor renal progression in IgAN, and that IgAN patients with chronic kidney disease (CKD) stage 3–4 were more susceptible to cigarette smoking (p < 0.001). After propensity score matching (PSM), a significant correlation between cigarette smoking and renal outcomes in IgAN patients was seen. Furthermore, Spearman’s correlation test revealed that smoking dose was negatively correlated with eGFR (r = 0.141; p < 0.001) and positively related with proteinuria (r = 0.096; p = 0.001).

Conclusions

Cigarette smoking is an independent risk factor for IgAN progression, especially for advanced patients.

Prior influenza vaccine is not a risk factor for bacterial coinfection in patients admitted to the ICU due to severe influenza

OBJECTIVE

To determine whether the prior usage of the flu vaccine is a risk factor for bacterial co-infection in patients with severe influenza.

DESIGN

This was a retrospective observational cohort study of subjects admitted to the ICU. A propensity score matching, and logistic regression adjusted for potential confounders were carried out to evaluate the association between prior influenza vaccination and bacterial co-infection.

SETTINGS

184 ICUs in Spain due to severe influenza.

PATIENTS

Patients included in the Spanish prospective flu registry.

INTERVENTIONS

Flu vaccine prior to the hospital admission.

RESULTS

A total of 4175 subjects were included in the study. 489 (11.7%) received the flu vaccine prior to develop influenza infection. Prior vaccinated patients were older 71 [61-78], and predominantly male 65.4%, with at least one comorbid condition 88.5%. Prior vaccination was not associated with bacterial co-infection in the logistic regression model (OR: 1.017; 95%CI 0.803-1.288; p=0.885). After matching, the average treatment effect of prior influenza vaccine on bacterial co-infection was not statistically significant when assessed by propensity score matching (p=0.87), nearest neighbor matching (p=0.59) and inverse probability weighting (p=0.99).

CONCLUSIONS

No association was identified between prior influenza vaccine and bacterial coinfection in patients admitted to the ICU due to severe influenza. Post influenza vaccination studies are necessary to continue evaluating the possible benefits.

Investigating changes in disease activity as a mediator of cardiovascular risk reduction with methotrexate use in rheumatoid arthritis

OBJECTIVE

Examine the association of methotrexate (MTX) use with cardiovascular disease (CVD) in rheumatoid arthritis (RA) using marginal structural models (MSM) and determine if CVD risk is mediated through modification of disease activity.

METHODS

We identified incident CVD events (coronary artery disease (CAD), stroke, heart failure (HF) hospitalisation, CVD death) within a multicentre, prospective cohort of US Veterans with RA. A 28-joint Disease Activity Score with C-reactive protein (DAS28-CRP) was collected at regular visits and medication exposures were determined by linking to pharmacy dispensing data. MSMs were used to estimate the treatment effect of MTX on risk of incident CVD, accounting for time-varying confounders between receiving MTX and CVD events. A mediation analysis was performed to estimate the indirect effects of methotrexate on CVD risk through modification of RA disease activity.

RESULTS

Among 2044 RA patients (90% male, mean age 63.9 years, baseline DAS28-CRP 3.6), there were 378 incident CVD events. Using MSM, MTX use was associated with a 24% reduced risk of composite CVD events (HR 0.76, 95% CI 0.58 to 0.99) including a 57% reduction in HF hospitalisations (HR 0.43, 95% CI 0.24 to 0.77). Individual associations with CAD, stroke and CVD death were not statistically significant. In mediation analyses, there was no evidence of indirect effects of MTX on CVD risk through disease activity modification (HR 1.03, 95% CI 0.80 to 1.32).

CONCLUSIONS

MTX use in RA was associated with a reduced risk of CVD events, particularly HF-related hospitalisations. These associations were not mediated through reductions in RA disease activity, suggesting alternative MTX-related mechanisms may modify CVD risk in this population.

Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation

Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.

Chemotherapy and the Risk of Alzheimer's Disease in Colorectal Cancer Survivors: Evidence From the Medicare System

PURPOSE

Evidence on the nature of the relationship between patients receiving chemotherapy as an essential part of guideline-concordant cancer care and the onset of Alzheimer's Disease (AD) and other adverse cognitive outcomes has been mixed. Biological mechanisms were proposed to support both a potentially beneficial and an adverse role. To explore the relationship between chemotherapy and onset of AD and other neurocognitive disorders (ND) in colorectal cancer survivors.

METHODS

We conducted a retrospective cohort study of 135,834 individuals older than 65 years diagnosed with colorectal cancer between 1998 and 2007, using SEER-Medicare data. A proportional hazards model was used before and after the use of inverse probability weighting to account for populational differences between the chemotherapy and nonchemotherapy groups. Weights were normalized to the total sample size.

RESULTS

After inverse probability weighting, chemotherapy was associated with decreased AD risk (hazard ratio [HR]: 0.791; 95% CI: 0.758 to 0.824) and lower risk for the majority of other ND including AD-related diseases (HR: 0.823; CI: 0.802 to 0.844), dementia (permanent mental disorder) (HR: 0.807; CI: 0.782 to 0.832), and dementia (senile) (HR: 0.772; CI: 0.745 to 0.801). The only adverse effect to remain significant was cerebral degeneration (excluding AD) (HR: 1.067; CI: 1.033 to 1.102). The effects for AD remained after treatment was stratified by chemotherapy agent type and remained significant for up to 6 years past diagnosis.

CONCLUSION

Chemotherapy use in colorectal cancer survivors demonstrated an association with reduced risk for AD and other ND.

Oral Frailty Index-8 in the risk assessment of new-onset oral frailty and functional disability among community-dwelling older adults

BACKGROUND

Oral frailty is associated with the loss of oral function and increased care needs. We have previously developed an Oral Frailty Index (OFI-8) to identify older adults at risk of oral frailty. Herein, we aimed to examine whether OFI-8 scores are indicative of oral frailty or functional disability risk in community-dwelling older adults.

METHODS

A total of 2,011 individuals (51% women; mean age, 73.0 ± 5.5 years) participated in the 2012 baseline survey (last follow-up wave 2018). Oral frailty was assessed at each time point, based on tooth status, oral function, and other subjective measures. Functional disability was defined as long-term care certification granted during 2012-2019. The OFI-8 items were assessed at baseline.

RESULTS

The prevalence and incidence rates of oral frailty at baseline and 6 years were 16% and 24%, respectively. The area under the receiver operating characteristic curve of OFI-8 was 0.88 with 95% confidence interval of 0.86-0.90 for oral frailty. The OFI-8 score of ≥4 points maximized the sum of sensitivity and specificity values. The corresponding positive rate, sensitivity, specificity, positive, and negative predictive values were 30%, 80%, 80%, 43%, and 95%, respectively, for baseline oral frailty. A 1-point increase in the OFI-8 score corresponded to a 1.3-fold increase in the risk of new-onset oral frailty and 1.1-fold increase in the risk of disability.

CONCLUSIONS

OFI-8 may help identify individuals at risk of oral frailty and functional disability. It may also increase the awareness of oral care and facilitate its uptake.

Use of matching methods in observational studies with critical patients and renal outcomes. Scoping review

Introduction: The use of matching techniques in observational studies has been increasing and is not always used appropriately. Clinical experiments are not always feasible in critical patients with renal outcomes, and observational studies are an important alternative. Objective: Through a scoping review, determine the available evidence on the use of matching methods in studies involving critically ill patients and assessing renal outcomes. Methods: Medline, Embase, and Cochrane databases were used to identify articles published between 1992 and 2020 up to week 10, which studied different exposures in the critically ill patient with renal outcomes and used propensity matching methods. Results: Most publications are cohort studies 94 (94. 9 %), five studies (5. 1 %) were cross-sectional. The main pharmacological intervention was the use of antibiotics in seven studies (7. 1%) and the main risk factor studied was renal injury prior to ICU admission in 10 studies (10. 1%). The balance between the baseline characteristics assessed by standardized means, in only 28 studies (28. 2%). Most studies 95 (96 %) used logistic regression to calculate the propensity index. Conclusion: Major inconsistencies were observed in the use of methods and in the reporting of findings. A summary is made of the aspects to be considered in the use of the methods and reporting of the findings with the matching by propensity index.

Propensity Score Methods in Rare Disease: A Demonstration Using Observational Data in Systemic Lupus Erythematosus

Observational studies allow researchers to understand the natural history of rheumatic conditions, risk factors for disease development, and factors affecting important disease-related outcomes, and to estimate treatment effect from real-world data. However, this design carries a risk of confounding bias. A propensity score (PS) is a balancing score that aims to minimize the difference between study groups and consequently potential confounding effects. The score can be applied in 1 of 4 methods in observational research: matching, stratification, adjustment, and inverse probability weighting. Systemic lupus erythematosus (SLE) is a rare disease characterized by a relatively small sample size and/or low event rates. In this article, we review the PS methods. We demonstrate application of the PS methods to achieve study group balance in a rare disease using an example of risk of infection in SLE patients with hypogammaglobulinemia.

Primary Treatment with Molecular-Targeted Agents for Hepatocellular Carcinoma: A Propensity Score-matching Analysis

Sorafenib and lenvatinib, as molecular-targeted agents, constitute effective primary treatment options for advanced hepatocellular carcinoma (HCC). However, the choice of optimal primary treatment agent remains controversial. Here, we aimed to assess the respective outcomes between these agents as primary treatment in patients with advanced HCC through use of propensity score-matching analysis (PSMA). We enrolled 670 consecutive patients who were diagnosed with advanced HCC and received sorafenib (n = 524) or lenvatinib (n = 146) as the primary treatment among 18 participating institutions between May 2009 and October 2019. To reduce confounding, we used PSMA regarding seven variables related to advanced HCC prognosis, resulting in the selection of 292 patients (n = 146 for each agent). Following PSMA, no significant difference was observed in the outcome of overall survival time between patients treated with sorafenib or lenvatinib (median survival time 15.3 or 14.9 months, respectively; P = 0.2358). Patients treated with lenvatinib exhibited significantly greater therapeutic effects (response rate: 5% and 31%; disease control rate: 46% and 69% for sorafenib and lenvatinib, respectively; P < 0.0001), but showed significantly lower probability of transition to secondary treatment (sorafenib, 60%; lenvatinib, 45%; P < 0.0269) and higher any adverse events rate (sorafenib, 86%; lenvatinib, 95%; P = 0.0207). Conclusion: As a primary molecular-targeted agent-based treatment for advanced HCC, our findings suggested that sorafenib is generally appropriate as it offers significantly lower frequency of adverse events and higher probability of transition to secondary treatment, in consideration of the enhanced postprogression survival mediated by sequential treatment. Alternatively, lenvatinib affords a significantly higher therapeutic effect and should be used when immediate tumor reduction is required.

Immunosuppressive treatment in diffuse cutaneous systemic sclerosis is associated with an improved composite response index (CRISS)

Background

Outcomes of therapeutic studies in diffuse cutaneous systemic sclerosis (dcSSc) have mainly been measured for specific organs, particularly the skin and lungs. A new composite response index in dcSSc (CRISS) has been developed for clinical trials. The goal of this study was to determine whether, in an observational dcSSc cohort, immunosuppression was associated with global disease improvement measured with the CRISS.

Methods

We conducted a retrospective cohort study in a multi-centered SSc registry comparing 47 patients newly exposed to immunosuppression for ≥ 1 year to 254 unexposed patients. Inverse probability of treatment weighting (IPTW) was performed to create comparable exposed and unexposed groups by balancing for age, sex, disease duration, modified Rodnan skin score (mRSS), forced vital capacity, patient and physician global assessments, and Health Assessment Questionnaire score. A CRISS score ≥ 0.6 at 1 year was defined as improvement.

Results

Exposed patients had shorter disease duration (5.5 versus 11.7 years, p < 0.01), more interstitial lung disease (67.4% versus 40.3%, p < 0.01), and worse physician global severity scores (4.2 versus 2.5 points, p < 0.01) compared to unexposed patients. Improvement in CRISS scores was more common in exposed patients after IPTW (odds ratio 1.85, 95% confidence interval 1.11, 3.09). Of the individual CRISS variables, only mean patient global assessment scores were significantly better among exposed than unexposed patients (− 0.4 versus 0 points, p = 0.03) while other variables including mRSS were similar.

Conclusion

Using a composite response measure, immunosuppression was associated with better outcomes at 1 year in a dcSSc cohort. These results provide real-world data that align with clinical trials to support our current use of immunosuppression.

Effectiveness of press needle treatment and electroacupuncture in patients with postherpetic neuralgia: A matched propensity score analysis

BACKGROUND AND PURPOSE

Postherpetic neuralgia (PHN) is a well-known painful syndrome. Acupuncture is a treatment for PHN. We aimed to compare the effectiveness of pain control between press needle and electroacupuncture (EA) in PHN patients.

MATERIALS AND METHODS

We conducted a retrospective cohort study by a review of PHN patients treated with the press needle and the EA and compared the Pain visual analogue scale (VAS) before and after treatment. Propensity score matching was applied to adjust the confounding.

RESULTS

48 patients in each group had a matched propensity score. The absolute reduction of VAS in the press needle and the EA groups were not different (5.4±2.8 vs. 5.4±2.9, p=0.971). The VAS score improvement was not statistically different between groups.

CONCLUSION

The Press needle and the EA are equally effective in the treatment of PHN.

Transcatheter arterial chemoembolization alone or combined with ablation for recurrent intermediate-stage hepatocellular carcinoma: a propensity score matching study

PURPOSE

The recurrence after curative hepatectomy is common. Limited data have investigated the effect of transcatheter arterial chemoembolization (TACE) combined with ablation in treating recurrent intermediate-stage hepatocellular carcinoma (HCC) after hepatectomy. We aim to compare the efficacy of TACE combined with ablation versus TACE alone in treating recurrent intermediate-stage HCC after hepatectomy.

METHODS

A total of 183 patients with recurrent intermediate-stage HCC after hepatectomy were enrolled at Sun Yat-sen University Cancer Centre, including 111 patients who underwent TACE alone and 72 patients who underwent TACE combined with ablation (TACE-Ablation). Overall survival (OS) and progression-free survival (PFS) were compared by the log-rank test. Propensity score matching (PSM) was used to reduce the confounding bias.

RESULTS

Before PSM, the 5-year OS rates were 43.3% vs. 27.9% (P = 0.001), and the 5-year PFS rates were 21.7% vs. 13.0% (P < 0.001) for TACE-Ablation and TACE-alone groups, respectively. After PSM, TACE-Ablation still resulted in better 5-year OS (41.6% vs. 30.2%, P = 0.028) and 5-year PFS rate (21.3% vs. 15.8%, P = 0.024) than that of TACE alone. Patients in TACE-Ablation group exhibited similar major complication rates to TACE-alone group but higher minor complication rates both before and after PSM. Cox regression analysis identified TACE-alone modality as an independently unfavourable predictor for OS and PFS (both P < 0.05).

CONCLUSION

TACE combined with ablation is safe and superior to TACE alone in tumour control and prolonging overall survival in recurrent intermediate-stage HCC after hepatectomy.

Association Between Anemia and Dementia: A Nationwide, Populationbased Cohort Study in Taiwan

Background:

In addition to the traditional risk predictors, whether anemia is an early biomarker of dementia, needs to be confirmed.

Objective:

This population-based cohort study aimed to investigate the dementia risk in patients with newly diagnosed anemia using data from the Taiwan National Health Insurance Research Database.

Methods:

All newly diagnosed anemia patients (n = 26,343) with no history of stroke hospitalization, central nervous disease other than dementia, psychiatric disorders, traumatic brain injury, major operations, or blood loss diseases, were enrolled. A group of non-anemic controls, 1:4 matched with anemic patients on the basis of demographics and comorbidities, was also included. A competing risk analysis was used to evaluate the dementia risk in anemic patients compared to that of their matched controls.

Results:

The adjusted subdistribution hazard ratio (SHR) of dementia risk in anemic patients was 1.14 (95% confidence interval [CI]: 1.08~1.21, p<0.001). Patients with iron supplements tended to exhibit a lower dementia risk (adjusted SHR: 0.84; 95% CI: 0.75~0.94, p=0.002) compared to patients without iron supplement. A subgroup analysis showed that a positive association between dementia and anemia existed in females, those aged 70 years and older, and patients without hypertension, diabetes, or hyperlipidemia.

Conclusion:

The present population-based cohort study identified that newly diagnosed anemia is a risk factor for dementia and also that iron supplementation was able to reduce the risk of dementia in people with iron deficiency anemia.

Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps

OBJECTIVE

Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP.

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed.

RESULTS

The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855.

CONCLUSIONS

The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner.

LEVEL OF EVIDENCE

2C Laryngoscope, 131:E26-E33, 2021.

Propensity score-matched analysis of clinical outcome after enucleation versus regular pancreatectomy in patients with small non-functional pancreatic neuroendocrine tumors

OBJECTIVES

The effectiveness of enucleation in treatment for low-grade (G1, G2) small (≤2 cm) non-functional pancreatic neuroendocrine tumors (sNF-pNETs) remains controversial. This study investigated short- and long-term outcome of enucleation comparing with regular pancreatectomy in patients with sNF-pNETs.

METHODS

The clinical data of patients with sNF-pNETs who underwent surgery in our hospital from January 2000 to December 2017 were retrospectively collected. Short- and long-term outcomes of two operations were analyzed. The propensity score matching (PSM) was performed to reduce potential selection bias.

RESULTS

A total of 123 patients with sNF-pNETs were enrolled with 62 males, 69 G1, and median age was 56.91 ± 10.04 years old. During the follow-up period (mean 87 ± 58.1 months), 9(7.32%) disease progressed (recurrence or metastasis) and 2 died (1.62%), 5-years OS was 100%, 5-years DFS was 91.4%. Both lymph node metastasis (p = 0.117) and pathological grade (p = 0.050) were not prognostic factors for sNF-pNETs. The propensity score-matched cohort comprised 27 patients with enucleation and 44 patients with regular pancreatectomy. Enucleation was noninferior to regular pancreatectomy in terms of DFS, before or after PSM. The surgical duration (P < 0.01) and blood loss (P < 0.01) significantly decreased in enucleation compared with regular pancreatectomy. The other postoperative complications tended to occur in regular pancreatectomy than in enucleation, but no statistically significant difference (all p > 0.05).

CONCLUSION

Enucleation seems to be an effective option for the treatment of sNF-pNETs with a lower total rate of postoperative complications and similar long-term prognosis, compared with regular pancreatectomy.

Real-World Evidence to Assess Medication Safety or Effectiveness in Children: Systematic Review

Background

The promise of real-world evidence (RWE) is especially relevant to pediatrics, where medicines prescribed for children are often used without evidence derived from randomized clinical trials.

Objectives

The aim of this systematic review was to describe the state of RWE in pediatrics by identifying observational studies published during 2016 that used RWE to assess medication safety or effectiveness in children.

Methods

An electronic search of PubMed was combined with an extended search of references within systematic reviews and expert suggestions. Studies were included if they reported on an infant or child under 18 years with exposure to medications; assessed safety or effectiveness; specified a comparison or control group, and were published in English in 2016. Data extraction was conducted by one team member using a standardized form and reviewed by a second team member. Study quality was assessed using the GRACE checklist for rating the quality of observational studies.

Results

After removing duplicates, 915 citations were screened and 29 studies met the eligibility criteria. Most of the eligible studies relied on primary data collection or chart review at a single institution and did not use the growing number of administrative or electronic health record databases available. One-quarter of the studies did not use well-established statistical methods to control for confounders. No single disease group or medication predominated, and age groups ranged from infants to adolescents.

Conclusions

A small body of observational studies published in 2016 were categorized by the study team as using real-world data to assess medication safety or effectiveness in children. Studies varied in age groups, diseases or conditions, and methods, and may not have fully met the FDA definition of RWE. Our review indicates that the use of RWE is not fully developed in pediatrics, and suggests an opportunity to further develop capabilities and more fully leverage administrative and electronic health record databases to study medication safety and effectiveness in children. Our systematic review appears generalizable to pediatrics broadly, and documents that the high level of activity in RWE in general has had less of an impact on pediatrics.

Electronic supplementary material

The online version of this article (10.1007/s40801-020-00182-y) contains supplementary material, which is available to authorized users.

Statin therapy and recurrent venous thromboembolism in the elderly: a prospective cohort study

Previous studies reported lower rates of recurrent venous thromboembolism (rVTE) among statin users, but this association could be influenced by concurrent anticoagulation and confounding by statin indication. This study aimed to confirm the beneficial association between statins and rVTE, stratified according to periods with and without anticoagulation, and additionally employ propensity score weighted approach to reduce risk of confounding by indication. The setting was a prospective multicentre cohort study and the outcome was time to first rVTE in statin vs. non-statin users. 980 participants with acute VTE were enrolled (mean age 75.0 years, 47% women), with median follow-up of 2.5 years. Of 241 (24.3%) statin users, 21 (8.7%) suffered rVTE vs. 99 (13.4%) among 739 non-users. The overall adjusted sub-hazard ratio (aSHR) for rVTE comparing statin users to non-users was 0.72 (95%CI 0.44 to 1.19, p = 0.20). This association was only apparent during periods without anticoagulation (aSHR 0.50, 95%CI 0.27 to 0.92, p = 0.03; vs. with anticoagulation: aSHR 1.34, 95%CI 0.54 to 3.35, p = 0.53). Using propensity scores, the rVTE risk during periods without anticoagulation fell further (aSHR 0.20, 95%CI 0.08 to 0.49, p < 0.001). In conclusion, statin use is associated with a more pronounced risk reduction for rVTE than previously estimated, but only during periods without anticoagulation.

Propensity Score Methods in Health Technology Assessment: Principles, Extended Applications, and Recent Advances

Randomized clinical trials (RCT) are accepted as the gold-standard approaches to measure effects of intervention or treatment on outcomes. They are also the designs of choice for health technology assessment (HTA). Randomization ensures comparability, in both measured and unmeasured pretreatment characteristics, of individuals assigned to treatment and control or comparator. However, even adequately powered RCTs are not always feasible for several reasons such as cost, time, practical and ethical constraints, and limited generalizability. RCTs rely on data collected on selected, homogeneous population under highly controlled conditions; hence, they provide evidence on efficacy of interventions rather than on effectiveness. Alternatively, observational studies can provide evidence on the relative effectiveness or safety of a health technology compared to one or more alternatives when provided under the setting of routine health care practice. In observational studies, however, treatment assignment is a non-random process based on an individual’s baseline characteristics; hence, treatment groups may not be comparable in their pretreatment characteristics. As a result, direct comparison of outcomes between treatment groups might lead to biased estimate of the treatment effect. Propensity score approaches have been used to achieve balance or comparability of treatment groups in terms of their measured pretreatment covariates thereby controlling for confounding bias in estimating treatment effects. Despite the popularity of propensity scores methods and recent important methodological advances, misunderstandings on their applications and limitations are all too common. In this article, we present a review of the propensity scores methods, extended applications, recent advances, and their strengths and limitations.

Alcohol consumption is associated with the risk of developing colorectal neoplasia: Propensity score matching analysis

Although alcohol intake is known to be associated with the development of colorectal cancer, the effect of alcohol consumption on the development of colorectal neoplasm (CRN) is unclear. We performed a retrospective cohort analysis with 1 to 1 propensity score matching in a single center of Korea. Among 1,448 patients who underwent index and surveillance colonoscopy, 210 matched pairs were analyzed. The 5-year cumulative occurrence of overall CRN after index colonoscopy was higher in the significant alcohol consumption group (defined as alcohol consumption more than 30 g/day in men and 20 g/day in women) (vs. without significant alcohol consumption group) (40% vs. 27.6%, p = 0.004). Significant alcohol consumption increased the development of overall CRN (adjusted hazard ratio [aHR]: 1.86, 95% confidence interval [CI]: 1.28–2.70, p = 0.001) at surveillance colonoscopy. However, this effect was not valid on the development of advanced CRN. In subgroup analysis considering the risk classification of index colonoscopy, significant alcohol consumption increased the overall CRN development at surveillance colonoscopy in the normal group (patients with no detected adenoma in the index colonoscopy) (aHR: 1.90, 95% CI: 1.16–3.13, p = 0.01). Alcohol consumption habits should be considered in optimizing time intervals of surveillance colonoscopy.

Influence of Hospital Volume of Procedures by Year on the Risk of Revision of Total Hip and Knee Arthroplasties: A Propensity Score-Matched Cohort Study

The volume of total hip (THA) and knee arthroplasties (TKA) performed in a hospital per year could be an influential factor on the revision of these procedures. The aims of this study were: To obtain comparable cohorts in higher- and lower-volume hospitals; and to assess the association between the hospital volume and the incidence of revision. Data from patients undergoing THA and TKA caused by osteoarthritis and recorded in the Catalan Arthroplasty Register (RACat) between January 2005 and December 2016 were used. The main explanatory variable was hospital volume by year (higher/lower). The cut-off point was fixed, based on previous research, at 50 THA and 125 TKA procedures/year. To obtain comparable populations, a propensity-score matching method (1:1) was used. Patient characteristics prior to and after matching were compared. To assess differences by volume, subhazard ratios (SHRs) from competing risks models were obtained. After matching, 13,772 THA and 36,316 TKA patients remained in the study. Prior to matching, in both joints, significant differences in all confounders were observed between volume groups. After matching, none of them remained significant. Both in THA and TKA, a higher risk of revision in higher-volume hospitals was observed (THA SHR: 1.25, 95%CI: 1.02–1.53; and TKA SHR: 1.29, 95%CI: 1.16–1.44). Unlike other contexts, currently in Catalonia, higher-volume hospitals have a greater risk of revision than lower-volume hospitals. Further research could be valuable to define context-dependent measures to reduce the incidence of revision.

Differences in Risk of Revision and Mortality Between Total and Unicompartmental Knee Arthroplasty. The Influence of Hospital Volume

BACKGROUND

The volume of arthroplasties performed in a hospital by year has an influence on the outcomes of total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). The aims of this study are (1) to evaluate and compare the risk of revision and mortality of TKA and UKA and (2) to assess whether hospital volume is related to differences in revision risk and mortality.

METHODS

All individuals recorded in the Catalan Arthroplasty Register between 1/1/2005 and 31/12/2016, diagnosed with osteoarthritis, undergoing cemented TKA and UKA were included. A propensity score matching method was used to obtain comparable cohorts, including 2374 matched prostheses overall. Hospital volume was considered as a dichotomous variable (lower/higher). Descriptive analyses were done before and after matching. Risks of revision and mortality at 30 days, 90 days, 1, 3, and 5 years were calculated and competing risks models and Cox models were fitted.

RESULTS

For the population as a whole, higher risk of revision (sub-hazard ratio, 1.98; 95% confidence interval, 1.25-3.17) was found in UKA than in TKA but higher mortality was not. Considering the volume groups, significantly higher risk of revision in UKA than TKA was found in the lower-volume group only (sub-hazard ratio, 1.95; 95% confidence interval, 1.11-3.44). No differences in mortality between TKA and UKA were found in either group.

CONCLUSION

Mortality and revision rates after TKA and UKA at higher-volume hospitals are similar. UKAs performed at lower-volume hospitals have higher revision rates. Volume-dependent specialization thus might help to reduce revision and mortality after surgery.

Long Term Outcomes and Effects of Surgery on Degenerative Spinal Deformity: A 14-Year National Cohort Study

Degenerative spinal deformity (DSD) has become a prevalent cause of disability and pain among the aging population worldwide. Though surgery has emerged as a promising option for DSD, the natural course, outcomes, and effects of surgery on DSD have remained elusive. This cohort study used a national database to comprehensively follow up patients of DSD for all-cause mortality, respiratory problems, and hip fracture-related hospitalizations. All patients were grouped into an operation or a non-operation group for comparison. An adjustment of demographics, comorbidities, and propensity-score matching was conducted to ameliorate confounders. A Cox regression hazard ratio (HR) model and Kaplan-Meier analysis were also applied. The study comprised 21,810 DSD patients, including 12,544 of the operation group and 9266 of the non-operation group. During the 14 years (total 109,591.2 person-years) of follow-up, the operation group had lower mortality (crude hazard ratio = 0.40), lower respiratory problems (cHR = 0.45), and lower hip fractures (cHR = 0.63) than the non-operation group (all p < 0.001). After adjustment, the risks for mortality and respiratory problems remained lower (adjusted HR = 0.60 and 0.65, both p < 0.001) in the operation than the non-operation group, while hip fractures were indifferent (aHR = 1.08, p > 0.05). Therefore, surgery for DSD is invaluable since it could reduce the risks of mortality and of hospitalization for respiratory problems.

Comparable Outcomes of First-Line Hematopoietic Stem Cell Transplantation from Unrelated and Matched Sibling Donors in Adult Patients with Aplastic Anemia: A Retrospective Single-Center Study

To explore the feasibility of upfront unrelated donor (URD) hematopoietic stem cell transplantation (HSCT) in the treatment of adult aplastic anemia (AA), we conducted a retrospective, single-center study and compared the outcomes of adult patients who underwent first-line URD HSCT or matched sibling donor (MSD) HSCT between August 2012 and June 2018. In all, 23 URD HSCT recipients had an increased cumulative incidence of grade II acute graft-versus-host disease (aGVHD) (21.7% versus 3.4%; P =.007), but similar rates of secondary graft failure (8.7 ± 6.0% versus 6.9 ± 3.4%; P = .764), chronic GVHD (cGVHD) (18.2% versus 8.8%; P = .285), extensive cGVHD (9.1% versus 3.5%; P = .328), 5-year estimated overall survival (87.0% versus 94.2%; P = .501), and 5-year estimated failure-free survival (82.0% versus 89.3%; P = .404) compared with 58 MSD HSCT recipients treated during the same period. After using propensity score matching to reduce the influence of potential confounders, the 2 groups were well balanced in terms of pretransplantation clinical factors. The median survival time was similar, and no significant differences in the aforementioned outcomes were observed between the 2 groups. Our results suggest that URD HSCT may be an effective and feasible option for first-line therapy in adult AA patients who lack an MSD.