Validity of the age-adjusted charlson comorbidity index on clinical outcomes for patients with nasopharyngeal cancer post radiation treatment: a 5-year nationwide cohort study

Neoadjuvant chemotherapy plus concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in elderly patients with stage III-IVa nasopharyngeal carcinoma: A real-world study based on medical comorbidities

PURPOSE

To evaluate the outcomes and toxicities of adding neoadjuvant chemotherapy (NAC) to concurrent chemoradiotherapy (CCRT) in elderly (≥65 years) patients with locoregionally advanced nasopharyngeal carcinoma (LANPC, stage III-IVa).

METHODS AND MATERIALS

Using an NPC-specific database, 245 elderly patients with stage III-IVa NPC, receiving CCRT +/- NAC, and an Adult Co-morbidity Evaluation 27 (ACE-27) score <2 were included. Recursive partitioning analysis (RPA) based on TNM stage and Epstein-Barr virus (EBV) DNA were applied for risk stratification. The primary end point was disease-free survival (DFS).

RESULTS

Two risk groups were generated by the RPA model. In the high-risk group (EBV DNA < 4000 copy/ml with stage IVa & EBV DNA ≥4000 copy/ml with stage III-IVa), patients treated with NAC plus CCRT achieved improved 5-year DFS rates compared to those who received CCRT alone (56.9% vs. 29.4%; p = 0.003). But we failed to observe the survival benefit of additional NAC in the low-risk group (EBV DNA <4000 copy/ml with stage III). The most common severe acute toxic effects were leucopenia (46.8% vs. 24.4%) and neutropenia (43.7% vs. 20.2%) in the NAC plus CCRT group versus CCRT group with statistically significant differences.

CONCLUSIONS

The addition of NAC to CCRT was associated with better DFS for the high-risk group of elderly LANPC patients with ACE-27 score <2. However, the survival benefit of additional NAC was not observed in low-risk patients.

Comorbidity in limited disease small-cell lung cancer: Age-adjusted Charlson comorbidity index and its association with overall survival following chemoradiotherapy

Background

Combined, platinum-based thoracic chemoradiotherapy (TCR) is the current state-of-the-art treatment for patients with limited disease (LD) small-cell lung cancer (SCLC). There is only limited data available regarding the effect of comorbidities on survival following TRC. The purpose of this study is to assess the age-adjusted Charlson comorbidity index (ACCI) as a predictor of overall survival in LD-SCLC patients undergoing TCR.

Patients and methods

We retrospectively analyzed 367 SCLC patients diagnosed with LD-SCLC who received TCR between 2003 and 2017. We evaluated the ACCI (n = 348) as a predictor of overall survival (OS). In this cohort, 322 patients (88%) received platinum-based TCR (either cisplatin or carboplatin), and 37 (10%) patients received vincristine based TCR. Median radiation dose was 60 Gy (range 24-66 Gy). Additionally, 83% of patients (n = 303) received prophylactic cranial irradiation (PCI, 30 Gy in 2 Gy fractions). Kaplan-Meier survival analysis was performed for OS. For comparison of survival curves, Log-rank (Mantel-Cox) test was used. Univariate and multivariate Cox proportional-hazards ratios (HRs) were used to assess the influence of cofactors on OS.

Results

Patients with an ACCI > 6 had a significantly shorter OS compared with patients with an ACCI ≤ 6 (median 11 vs. 20 months; p = 0.005). Univariate analysis for OS revealed a statistically significant effect for ACCI > 6 (HR 1.7; 95% CI 1.2-2.4; p = 0.003), PCI (HR 0.5; 95% CI 0.3-0.7; p < 0.001), and Karnofsky performance status ≤ 70% (KPS) (HR 1.4; 95% CI 1.1-1.90; p = 0.015). In multivariate analysis, OS was significantly associated with PCI (HR 0.6; 95% CI 0.4-0.9; p = 0.022) and ACCI > 6 (HR 1.5; 95% CI 1.0-2.1; p = 0.049).

Conclusion

Comorbidity is significantly associated with survival in patients with LD-SCLC undergoing TCR. The ACCI may be a valuable tool to identify patients with a shorter survival and thus might be used for risk stratification and oncological decision making.

Prognostic model on overall survival in elderly nasopharyngeal carcinoma patients: a recursive partitioning analysis identifying pre-treatment risk stratification

BACKGROUND

We aimed to evaluate the optimal management for elderly patients with nasopharyngeal carcinoma (NPC) with intensity-modulated radiotherapy (IMRT).

METHODS

A total of 283 elderly patients with NPC diagnosed from 2015 to 2019 were enrolled in the study. Overall survival (OS) was the primary endpoint. Univariate and multivariate Cox regression analyses were preformed to identify potential prognostic factors. The recursive partitioning analysis (RPA) was used for risk stratification. Kaplan-Meier survival curves were applied to evaluate the survival endpoints, and log-rank test was utilized to assess differences between groups. The prognostic index (PI) was constructed to further predict patients' prognosis displayed by nomogram model. The area under the receiver operating characteristic (ROC) curves (AUC) and the calibration curves were applied to assess the effectiveness of the model.

RESULTS

Based on RPA-based risk stratification, we demonstrated that elderly NPC patients who were treated with IC followed by RT had similar OS as those with induction chemotherapy (IC) combined with concurrent chemoradiotherapy (CCRT) in the middle- (stage I-III and pre-treatment EBV > 1840 copies/ml) and high-risk groups (stage IVA). IMRT alone may be the optimal treatment option for the low-risk group (stage I-III with pre-treatment EBV ≤ 1840 copies/ml). We established an integrated PI which was indicted with stronger prognostic power than each of the factors alone for elderly NPC patients (The AUC of PI was 0.75, 0.80, and 0.82 for 1-, 3-, 5-year prediction of OS, respectively).

CONCLUSION

We present a robust model for clinical stratification which could guide individual therapy for elderly NPC patients.

Prevalence of comorbidities and their impact on survival among older adults with the five most common cancers in Taiwan: a population study

Because of the cancer incidence increase and population aging in Taiwan, we aimed to assess the cancer prevalence, to summarize the comorbidities of older patients with the five most common cancers (i.e., breast, colorectal, liver, lung, and oral), and to develop a Taiwan cancer comorbidity index (TCCI) for studying their actual prognosis. The linkage of the Taiwan Cancer Registry, Cause of Death Database, and National Health Insurance Research Database was used. We followed the standard statistical learning steps to obtain a survival model with good discriminatory accuracy in predicting death due to noncancer causes, from which we obtained the TCCI and defined comorbidity levels. We reported the actual prognosis by age, stage, and comorbidity level. In Taiwan, cancer prevalence nearly doubled in 2004-2014, and comorbidities were common among older patients. Stage was the major predictor of patients' actual prognoses. For localized and regional breast, colorectal, and oral cancers, comorbidities correlated with noncancer-related deaths. Compared with the US, the chances of dying from comorbidities in Taiwan were lower and the chances of dying from cancer were higher for breast, colorectal, and male lung cancers. These actual prognoses could help clinicians and patients in treatment decision-making and help policymakers in resource planning.

Cytokine Levels and Severity of Illness Scoring Systems to Predict Mortality in COVID-19 Infection

Various scoring systems and cytokines have been cited as predicting disease severity in COVID-19 infection. This study analyzed the link between mortality rate, levels of cytokines, and scoring systems such as the Glasgow Coma Scale (GCS), Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Charlson Comorbidity Index in patients infected with COVID-19. Adult patients infected with COVID-19 were followed up in the intensive care unit (ICU) and analyzed prospectively. We measured serum cytokine levels (Interleukin-10 (IL-10), Interleukin-8 (IL-8), Interleukin-6 (IL-6), Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α) and High mobility group box 1 (HMGB-1)) and recorded GCS, APACHE II, SOFA, and Charlson comorbidity index scores on admission to the ICU. Receiver operating curve (ROC) analysis was performed to predict mortality from IL-1β, IL-6 IL-10, IL-8, TNF-α, and HMGB-1 values. Study participants were grouped as follows: Group A, survivors, and Group B, deceased, during the 28-day follow-up. The mean age was 65.69 (±13.56) in Group A (n = 36) and 70.85 (±10.06) in Group B (n = 27). The female/male ratio was 23/40. Age, sex, body mass index (BMI), comorbid illnesses, GCS, APACHE II, SOFA, and Charlson scores, duration of hospitalization or ICU admission, therapeutic choices, and lymphocyte, PMNL, NLR, platelet, D-dimer, fibrinogen, GGT, CRP, procalcitonin, and lactate levels were similar between the groups. The frequency of acute kidney injury (AKI) was higher in Group B (p = 0.005). Serum IL-10, IL-8, IL-6, IL-1β, TNF-α, HMGB-1, ferritin, and LDH values were higher, and PaO₂/FiO₂ was lower in Group B than in Group A. ROC analysis showed that there was an association between serum IL-1β (>1015.7), serum IL-6 (>116.7), serum IL-8 (>258.4), serum IL-10 (>247.5), serum TNF-α (>280.7), and serum HMGB-1 (>23.5) and mortality. AKI gave rise to a greater risk of mortality (odds ratio: 7.081, p = 0.014). Mortality was associated with serum IL-10, IL-8, IL-6, IL-1β, TNF-α, and HMGB-1 but not with GCS, APACHE II, SOFA, or Charlson comorbidity index scores. AKI increased the risk of mortality by seven times. Our findings suggest that cytokine levels (serum IL-10, IL-8, IL-6, IL-1β, TNF-α, and HMGB-1) were predictors of mortality in COVID-19 infection. In addition, our results might give an opinion about the course of COVID-19 infection.

Survival effect of pretreatment FDG-PET-CT on nasopharyngeal cancer

BACKGROUND/PURPOSE

Accurate staging is the first step for optimal treatment selection in patients with nasopharyngeal carcinoma (NPC). In this propensity-score-matched, population-based cohort study, we investigated the survival effects of pretreatment 8-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG-PET-CT) on patients with NPC.

METHODS

We included patients with stage I-IVA NPC receiving radiotherapy or concurrent chemoradiotherapy and categorized them into two 1:1 propensity score-matched groups according to whether or not they underwent pretreatment ¹⁸FDG-PET-CT and compared their outcomes.

RESULTS

Of the 10,756 patients, propensity score matching yielded 4366 patients in each group. According to multivariable Cox regression analyses, the most prominent correlation between pretreatment ¹⁸FDG-PET-CT and all-cause death was observed in patients with stage II NPC (adjusted hazard ratio [aHR], 0.77; 95% confidence interval [CI], 0.60-0.90; P = .0433), followed by patients with stage III NPC (aHR, 0.81; 95% CI, 0.69-0.94; P = .0071) and patients with stage IVA NPC (aHR, 0.88; 95% CI, 0.79-0.97; P = .0091). This association was not significant in patients with stage I NPC (aHR, 1.20; 95% CI, 0.75-1.93; P = .4426).

CONCLUSION

Pretreatment ¹⁸FDG-PET-CT is associated with longer survival in patients with clinical stage II-IVA NPC but not in stage I NPC.

Clinical Characteristics of Hyperandrogenism Include Hirsutism, Polycystic Ovary Syndrome, and Acne: Association with Psychiatric Disease in Women -A Nationwide Population-Based Cohort Study in Taiwan

Objective

Previous studies have shown an increased in psychiatric disorders in women with disorders associated with hyperandrogenism, but few nationwide cohorts have studied this phenomenon. Therefore, this study is aimed to examine the association between the clinical manifestations of hyperandrogenism and subsequent psychiatric disorders.

Methods

Based on the National Health Insurance Research Database, 49,770 enrolled participants were matched for age and index date between January 1, 2000, and December 31, 2015. Hirsutism, polycystic ovary syndrome, and acne are characterized by hyperandrogenism. After adjusting for confounding factors, we used Cox proportional analysis to compare the risk of psychiatric disorders during the 16 years of follow-up.

Results

Of all the participants, 1319 (13.25%) had psychiatric disorders in the study group, whereas only 3900(9.80%) had psychiatric disorders in the control group. After adjusting for age, and monthly income, the Cox regression analysis showed that the study patients were more likely to develop psychiatric disorders (hazard ratio [HR]: 2.004, 95% confidence interval [CI] = 1.327–2.724, P < 0.001). The results demonstrated that women aged 20–29 years had a more significant risk.

Conclusion

Women with clinical characteristics of hyperandrogenism have a higher risk of developing psychiatric disorders, especially those aged 20–29 years.

Management of Nasopharyngeal Carcinoma in Elderly Patients

Nasopharyngeal cancer (NPC) is one of the most difficult cancers in the head and neck region due to the complex geometry of the tumour and the surrounding critical organs. High-dose radical radiotherapy with or without concurrent platinum-based chemotherapy is the primary treatment modality. Around 10%–15% of NPC patients have their diagnosis at age after 70. The management of NPC in elderly patients is particularly challenging as they encompass a broad range of patient phenotypes and are often prone to treatment-related toxicities. Chronologic age alone is insufficient to decide on the management plan. Comprehensive geriatric assessment with evaluation on patients’ functional status, mental condition, estimated life expectancy, comorbidities, risks and benefits of the treatment, patients’ preference, and family support is essential. In addition, little data from randomized controlled trials are available to guide treatment decisions in elderly patients with NPC. In deciding which treatment strategy would be suitable for an individual elderly patient, we reviewed the literature and reviewed the analysis of primary studies, reviews, and guidelines on management of NPC. This review also summarises the current evidence for NPC management in elderly adults from early to late stage of disease.

Comparison of Long-Term Pneumonia Risk between Spleen Injury and Non-Spleen Injury after Total Splenectomy—A Population-Based Study

Patients who undergo splenectomy are at a high risk of infection. We aimed to investigate the rate of pneumonia in patients who underwent splenectomy, specifically comparing those who had splenectomy due to spleen injury and those who had it for other reasons. A population-based cohort study was conducted. Overall, 17,498 patients who underwent splenectomy between 2000 and 2015 were enrolled, including 11,817 patients with a history of spleen injury and 5681 controls without spleen injury. The incidence of pneumonia was calculated at the end of 2016. A multivariable Cox proportional hazards regression model was used to compare the hazard ratio with 95% CI for pneumonia associated with the spleen injury-caused splenectomy and splenectomy due to other causes. The crude HR for patients with splenectomy due to spleen injury to develop pneumonia was 1.649. After adjusting for covariates, the adjusted hazard ratio was 1.567. There were statistically significant differences in all subgroups, except for the group with a tracking duration >10 years. We found an increase in pneumonia risk in the ‘spleen injury’ group when comparing it to that of the ‘other causes’ group, regardless of age, sex, and area of residence.

Age-adjusted Charlson comorbidity index in recurrent glioblastoma: a new prognostic factor?

Background

For recurrent glioblastoma (GB) patients, several therapy options have been established over the last years such as more aggressive surgery, re-irradiation or chemotherapy. Age and the Karnofsky Performance Status Scale (KPSS) are used to make decisions for these patients as these are established as prognostic factors in the initial diagnosis of GB. This study’s aim was to evaluate preoperative patient comorbidities by using the age-adjusted Charlson Comorbidity Index (ACCI) as a prognostic factor for recurrent GB patients.

Methods

In this retrospective analysis we could include 123 patients with surgery for primary recurrence of GB from January 2007 until December 2016 (43 females, 80 males, mean age 57 years (range 21–80 years)). Preoperative age, sex, ACCI, KPSS and adjuvant treatment regimes were recorded for each patient. Extent of resection (EOR) was recorded as a complete/incomplete resection of the contrast-enhancing tumor part.

Results

Median overall survival (OS) was 9.0 months (95% CI 7.1–10.9 months) after first re-resection. Preoperative KPSS > 80% (P < 0.001) and EOR (P = 0.013) were associated with significantly improved survival in univariate analysis. Including these factors in multivariate analysis, preoperative KPSS < 80 (HR 2.002 [95% CI: 1.246–3.216], P = 0.004) and EOR are the only significant prognostic factor (HR 1.611 [95% CI: 1.036–2.505], P = 0.034). ACCI was not shown as a prognostic factor in univariate and multivariate analyses.

Conclusion

For patients with surgery for recurrent glioblastoma, the ACCI does not add further information about patient’s prognosis besides the well-established KPSS and extent of resection.

High Risk of Peritonsillar Abscess in End-Stage Renal Disease Patients: A Nationwide Real-World Cohort Study

Background: Peritonsillar abscess (PTA) is an infectious emergency in the head and neck, and patients with end-stage renal disease (ESRD) have an immunocompromised status. However, no relevant research has focused on the ESRD–PTA relationship. This study explored PTA in ESRD patients and their prognosis. Methods: We identified 157,026 patients diagnosed as having ESRD over January 1997 to December 2013 from Taiwan’s National Health Insurance Research Database (NHIRD). Each patient with ESRD (hereafter, patients) was matched with one control without chronic kidney disease (CKD; hereafter, controls) by sex, age, urbanization level, and income. Next, PTA incidence until death or the end of 2013 was compared between the two groups, and the relative risk of PTA was analyzed using a multiple logistic regression model. Results: The patients had a significantly higher PTA incidence than did the controls (incidence rate ratio: 2.02, 95% confidence interval [CI]: 1.40–2.91, p < 0.001). The Kaplan–Meier analysis revealed that the patients had a higher cumulative incidence of PTA than did the controls (p < 0.001). In Cox regression analysis, the patients had nearly twofold higher PTA risk (adjusted hazard ratio [HR]: 1.98, 95% CI: 1.37–2.86, p < 0.001). The between-group differences in the PTA-related hospital stay length (8.1 ± 10.3 days in patients and 5.7 ± 4.6 days in controls, p = 0.09), consequent deep-neck infection complication (4.2% in patients and 6.3% in controls, p = 0.682), and mortality (0.0% in both groups) were nonsignificant. Conclusions: Although ESRD does not predict a poor prognosis of PTA, it is an independent PTA risk factor.

Eating disorders and the risk of esophageal and stomach cancers-A nationwide, population-based cohort study in Taiwan

BACKGROUND

Previous studies have shown elevated cancer risk in anorexia nervosa but the literature on other eating disorders (EDs) is scarce. This study aimed to investigate the association between all EDs and esophageal, stomach, and other cancers.

METHODS

We used a retrospective cohort design, based on a two-million randomized longitudinal health insurance dataset, a sub-dataset of Taiwan's National Health Insurance Research Database. From all the potential participants aged 20 years or more, a total of 6,628 participants were enrolled, including 1,657 patients with EDs, with sex-, age-, and indexed date-matched (1:3) 4,971 controls. Each participant was individually tracked from 2000 to 2015 to identify incident cases of cancers, including esophageal cancer (EC), stomach cancer (SC), and all other cancers (AOC). The multivariate Cox proportional hazards model was employed to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between EDs and cancer.

RESULTS

Of the total 6,628 enrollees, 222 in 1,657 individuals with EDs and 810 in the 4,971 non-ED control individuals developed cancer (1,262.40 vs. 1,472.15 per 100,000 person-years), and the Kaplan-Meier survival analysis was not statistically significant (log-rank, p = .324). However, after adjusting for covariates, the risk of EC and SC among the individuals with an ED was significantly higher, with adjusted HRs of 5.32 (95% CI: 1.07-26.49, p < .001) and 4.61 (95% CI: 1.91-11.14, p < .001), respectively. EDs were not associated with other cancers.

CONCLUSIONS

This study provides evidence for the association between EDs and the risk for EC and SC. Further research on mechanisms and prevention is therefore needed.

Deep Neck Infection Risk in Patients with Sleep Apnea: Real-World Evidence

(1) Background: Sleep apnea may be a risk factor for deep neck infection (DNI). The objective of this study was to investigate the effects of sleep apnea on DNI. (2) Methods: In this first nationwide retrospective cohort study on the sleep apnea–DNI correlation, we obtained data from the Longitudinal Health Insurance Database 2005, a subset of the Taiwan National Health Insurance Research Database. Patients who were newly diagnosed with sleep apnea between 1997 and 2012 were identified, and patients without sleep apnea were matched at a 1:4 ratio in age, sex, socioeconomic status, and urbanization level. The primary outcome of this study was DNI occurrence. The treatment modalities for sleep apnea and the comorbidities that occurred during the study period were also analyzed. (3) Results: Our sleep apnea and comparison (non-sleep apnea) cohorts comprised 6114 and 24,456 patients, respectively. We compared the cumulative incidence of DNI between these cohorts and found a greater incidence of DNI in the sleep apnea cohort (p < 0.001). A strong sleep apnea–DNI association was found following analysis via the adjusted Cox proportional-hazards model (full model hazard ratio, 1.71; 95% confidence interval, 1.28–2.28; p < 0.001). In the subgroup analysis, sleep apnea increased DNI risk in men, in those aged < 50 years, and in those without diabetes mellitus, end-stage renal disease, liver cirrhosis, autoimmune disease, obesity, tonsillectomy, or adenotonsillectomy. (4) Conclusions: Our results confirmed sleep apnea to be an independent risk factor for DNI. Physicians should be aware of the potential occurrence of DNI in patients with sleep apnea.

A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study

BACKGROUND

Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record.

OBJECTIVE

The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research.

METHODS

The study was a hybrid type II mixed methods design to simultaneously evaluate Loop's clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system.

RESULTS

We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop's potential value for engaging the patient and caregiver, and for improving communication within the patient's circle of care, Loop's relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care.

CONCLUSIONS

Fundamental structural and implementation challenges persist toward realizing Loop's potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

The impact of comorbidities on survival in oral cancer patients: a population-based, case-control study

BACKGROUND

Comorbidities have shown to highly influence the outcome and risk of death of head and neck cancer patients. The purpose of this study was to examine the comorbidities among oral cavity squamous cell carcinoma (OSCC) patients, and to investigate the impact of comorbidities on overall survival (OS) and recurrence free survival (RFS).

METHODS

Patients diagnosed with OSCC in Eastern Denmark in the period 2000-2014 and treated with curative intend were included. Patients data were linked to the Danish National Patients Register to identify comorbidities based on the Charlson Comorbidity Index (CCI) at the time of diagnosis and five years after diagnosis. Each patient was age-and sex-matched in a 1:10 ratio with an age and sex matched reference group.

RESULTS

A total of 1,183 patients and 11,830 controls were included. Overall this study found comorbidities to be more common among OSCC compared to the reference group both at the time of diagnosis and five years after. The 5-year OS among patients with a CCI score of zero, one, two, and three or above was 60%, 44%, 41%, and 40%, respectively. Similarly, the multivariate cox-regression analysis showed that patients with increasing CCI score also had an increasing risk of death compared to patients with no comorbidities.

CONCLUSION

OSCC patients had significantly higher comorbidity burden at diagnosis and risk of developing additional comorbidities after diagnosis compared to the reference population. Survival outcomes decreased significantly with higher CCI.

Effects of continuing use of aspirin on blood loss in patients who underwent unilateral total knee arthroplasty

PURPOSE

Concerning the ongoing debate on the effects of continuing aspirin therapy on blood loss in knee arthroplasty, we conducted a retrospective investigation to test the hypothesis that continuation of aspirin prior total knee arthroplasty (TKA) will not cause more blood loss.

METHODS

From a database of patients who underwent unilateral TKA between 2011 and 2016, we identified two groups: the aspirin group (patients continued aspirin during perioperative period) and the nonaspirin group (patients had no current or recent history of aspirin usage). We extracted and compared patient demographic information, comorbidity index, baseline serum hemoglobin (Hb), and creatinine level between the two groups. We also compared our primary outcomes, including the total blood loss, transfusion requirement, and length of hospitalization between the two groups. A multivariate logistic regression for analyzing the risk factors of requiring transfusion was performed.

RESULTS

We found that apart from preoperative serum creatinine level, there was no difference in the baseline Hb level, perioperative change in Hb, total blood loss, or length of hospitalization between the two groups. The percentage of transfusion utilization was also comparable between the two groups. Our regression analysis shows that the risk of requiring transfusion after TKA is not significantly associated with patients taking aspirin therapy before operation.

CONCLUSION

Patients who underwent TKA with continuation of low-dose aspirin did not result in more blood loss. Current blood loss management has provided sufficient reduction of blood loss to accommodate aspirin therapy perioperatively. We suggest that it is safe to continue aspirin prior to TKA.

Variation of the Inpatient Cost of Care in the Treatment of Isolated Geriatric Intertrochanteric Hip Fractures

Introduction

Geriatric hip fractures are a major, costly public health issue, expected to increase in incidence and expense with the aging population. As healthcare transitions towards value-based care, understanding cost drivers of hip fracture treatment will be necessary to perform adequate risk adjustment. Historically, cost has been variable and difficult to determine. This study was purposed to identify variables that can predict the overall cost of care for geriatric intertrochanteric (IT) hip fractures and provide a better cost prediction to ensure the success of future bundled payment models.

Methods

A retrospective review of operatively-managed geriatric hip fractures was performed at single urban level I academic trauma center between 2013 and 2017. Patient variables were collected via the electronic medical record (EMR) including CCI, ACCI, ASA, overall length of stay (LOS), AO/OTA fracture classification and demographics. Direct and indirect costs were calculated by activity-based costing by the hospital's accounting software. Multivariable linear regression models evaluated which parameters predicted total inpatient cost of care.

Results

The mean cost of care was $19,822, ranging from $9,128 to $64,211. Critical care comprised 16.9% of total costs, followed by implant costs (13.6%), and nursing costs (12.6%). Regression analysis identified both ASA (p < 0.01) and ACCI (p = 0.01) as statistically significant associative parameters, but only LOS (r ² = 0.77) as a strong correlative measure for inpatient care cost.

Conclusion

This study found no correlation between ACCI or ASA and the total inpatient cost of care in isolated intertrochanteric geriatric hip fractures, suggesting that the inpatient episode-of-care costs cannot be accurately predicted by the patient demographics/comorbidities alone. Future bundled care payment models would have to be adjusted to account for variables beyond just patient characteristics.

Level of Evidence

Diagnostic Level IV.

Stereotactic body radiation therapy for empirically treated hypermetabolic lung lesions: a single-institutional experience identifying the Charlson score as a key prognostic factor

Background

Though pathologic evidence for non-small cell lung cancer (NSCLC) is preferred, many patients do not receive a biopsy prior to treatment with stereotactic body radiation therapy (SBRT). This study seeks to analyze the overall survival (OS), local control, and toxicity rates for such patients.

Methods

This retrospective review included patients empirically treated with SBRT for presumed non-metastatic NSCLC at a single institution. Inclusion criteria included a hypermetabolic pulmonary lesion noted on positron emission tomography (PET) imaging but no pathological evidence of NSCLC. Patients with another known metastatic tumor were excluded. Statistical analysis was conducted with Cox proportional hazards analysis, univariate analysis, and the Kaplan-Meier method.

Results

Ninety-one treatments in 90 unique patients met inclusion criteria. Patients were a median 77.9 years at the start of treatment and had a median Charlson score of 7. Pre-treatment standardized uptake value (SUV) was a median 4.5 and 1.5 after treatment. At a median follow-up of 12.9 months, 36-month local control of 91.3% was achieved. Twenty-four-month OS and progression-free survival were 65.4% and 44.8%, respectively. On univariate analysis, biologically effective dose (BED) ≥120 Gy was predictive of improved OS (P=0.001), with 36-month OS of 50.5% for patients with BED ≥120 Gy and only 31.6% for patients with BED <120 Gy. On Kaplan-Meier analysis, Charlson score ≥9 was predictive of decreased OS (P=0.04), and BED ≥120 Gy trended towards improved OS (P=0.08). Thirty-two cases of grade <3 toxicity were reported, and only two cases of grade 3 morbidity (fatigue) were noted.

Conclusions

Local control rates for empiric SBRT treatment for hypermetabolic, non-metastatic NSCLC are similar to those for biopsied NSCLC. OS is primarily dependent on a patient’s overall health status, which can be accurately assessed with the Charlson score. BED ≥120 Gy may also contribute to improved OS.

Clinical characteristics and prognosis of elderly nasopharyngeal carcinoma patients receiving intensity-modulated radiotherapy

Purpose

To evaluate the clinical characteristics and prognosis of elderly nasopharyngeal carcinoma (NPC) patients receiving intensity-modulated radiotherapy (IMRT).

Methods

From June 2008 to October 2014, 148 newly diagnosed non-metastatic elderly NPC patients (aged ≥ 70 years) receiving IMRT were recruited. Comorbid condition was evaluated using the age-adjusted Charlson Comorbidity Index (ACCI). Kaplan–Meier method was used to estimate survival rates and the differences were compared using log-rank test. Hazard ratio (HR) and the associated 95% confidence interval (CI) were calculated using Cox proportional hazard model by means of multivariate analysis.

Results

The median follow-up time was 66.35 months. Estimated OS rate at 5 years for the entire group was 61.8% (95% confidence interval [CI] 0.542–0.703). The 5-year OS rate of RT alone group was 58.4% (95% [CI] 0.490–0.696) compared with 65.2% (95% [CI] 0.534–0.796) in CRT group (p = 0.45).

In patients receiving IMRT only, ACCI score equal to 3 was correlated with superior 5-year OS rate in comparison with higher ACCI score 62.1% (95% [CI] 0.510–0.766) to 48.5% (95% [CI] 0.341–0.689), respectively; p = 0.024). A 5-year OS rate of 63.1% (95% [CI] 0.537–0.741) was observed in patients younger than 75 years old compared with 57.5% (95% [CI] 0.457–0.723) in patients older (p = 0.026). Patients with early-stage disease (I–II) showed better prognosis than patients with advanced-stage (III–IV) disease (5-year OS, 72.3–55.4%, respectively; p = 0.0073). The Cox proportional hazards model suggested that age independently predicted poorer OS (HR, 1.07; 95%CI 1.00–1.15, p = 0.04).

Conclusion

The survival outcome of patients aged ≥ 70 years receiving IMRT only was similar to chemoradiotherapy with significantly less acute toxicities. Among the population, age is significantly prognostic for survival outcomes.

Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care - a nationwide matched-pair retrospective cohort study in Taiwan

BACKGROUND

The association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan.

METHODS

A matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan-Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation.

RESULTS

The mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group.

CONCLUSION

Among patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.

Sex and gender differences in caregiving burden experienced by family caregivers of persons with dementia: A systematic review

Objectives

Much is known about the demands of caregiving for persons with dementia (PWD) and its effects on family caregivers, however sex and gender aspects have received less attention. We synthesized the evidence on sex and gender distinctions in: (1) the caregiving burden and (2) the impact of caregiving on the physical and mental health of family caregivers of PWD.

Design

Systematic review.

Data sources

Medline, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature between January 2007 and October 2019 were searched.

Eligibility criteria for selecting studies

Included studies met the following criteria: (1) examine experiences and/or impacts of caregiving among family caregivers of individuals with any form of dementia; (2) report sex and/or gender distribution of study population and/or report results stratified by sex and/or gender, and (3) include both male and female family caregivers.

Data extraction and synthesis

Two independent reviewers extracted the data and assessed risk of bias using the Critical Appraisal Skills Program checklist and National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-sectional Studies. Data were synthesized using a narrative synthesis approach.

Results

A total of 22 studies were included. Caregiving burden was measured using various methods. A majority of studies reported higher burden among females. All studies that did not report a sex and gender difference in caregiving burden accounted for confounders. Findings on sex and gender differences on physical and mental health conditions were inconsistent with most studies failing to account for confounders in their analyses.

Conclusions

Current evidence on sex and gender differences in caregiving burden, mental and physical health is limited. Findings suggest presence of sex and gender differences in caregiving burden. Given the variety of mental and physical health constructs that were examined, further research is required to substantiate the evidence.

PROPSERO Registration Number: CRD 42018070032.

Association of Statin Therapy With Prevention of Vision-Threatening Diabetic Retinopathy

Importance

Diabetic retinopathy is the leading cause of blindness in working-age adults. Studies have suggested that statins may reduce the risk of developing diabetic retinopathy.

Objective

To investigate the association between statin therapy and the development of diabetic retinopathy in patients with diabetes and dyslipidemia.

Design, Setting, and Participants

This population-based cohort study, conducted among 37 894 Taiwanese patients between January 1, 1998, and December 31, 2013, used the National Health Insurance Research Database to identify patients with type 2 diabetes and dyslipidemia. Outcomes were compared between those taking statins and those not taking statins. Statistical analysis was performed from May 1 to 31, 2018.

Exposure

Statin therapy with a medication possession rate of 80% or more with no other lipid-lowering medications.

Main Outcomes and Measures

Any stage of diabetic retinopathy and treatments for vision-threatening diabetic retinopathy.

Results

Of 1 648 305 patients with type 2 diabetes, 219 359 were eligible for analysis over the study period, including 199 760 patients taking statins and 19 599 patients not taking statins. After propensity score matching, there were 18 947 patients in the statin group (10 436 women and 8511 men; mean [SD] age, 61.5 [10.8] years) and 18 947 patients in the nonstatin group (10 430 women and 8517 men; mean [SD] age, 61.0 [11.0] years), with a mean follow-up of 7.6 years for the statin group and 7.3 years for the nonstatin group. During the study period, 2004 patients in the statin group (10.6%) and 2269 patients in the nonstatin group (12.0%) developed diabetic retinopathy. Patients in the statin group had a significantly lower rate of diabetic retinopathy (hazard ratio [HR], 0.86; 95% CI, 0.81-0.91), nonproliferative diabetic retinopathy (HR, 0.92; 95% CI, 0.86-0.99), proliferative diabetic retinopathy (HR, 0.64; 95% CI, 0.58-0.70), vitreous hemorrhage (HR, 0.62; 95% CI, 0.54-0.71), tractional retinal detachment (HR, 0.61; 95% CI, 0.47-0.79), and macular edema (HR, 0.60; 95% CI, 0.46-0.79) than the nonstatin group, as well as lower rates of interventions such as retinal laser treatment (HR, 0.71; 95% CI, 0.65-0.77), intravitreal injection (HR, 0.74; 95% CI, 0.61-0.89), and vitrectomy (HR, 0.58; 95% CI, 0.48-0.69), along with a smaller number of the interventions (retinal lasers: rate ratio, 0.61; 95% CI, 0.59-0.64; intravitreal injections: rate ratio, 0.68; 95% CI, 0.61-0.76; and vitrectomies: rate ratio, 0.54; 95% CI, 0.46-0.63). Statin therapy was also associated with lower risks of major adverse cardiovascular events (HR, 0.81; 95% CI, 0.77-0.85), new-onset diabetic neuropathy (HR, 0.85; 95% CI, 0.82-0.89), and new-onset diabetic foot ulcers (HR, 0.73; 95% CI, 0.68-0.78).

Conclusions and Relevance

Statin therapy was associated with a decreased risk of diabetic retinopathy and need for treatments for vision-threatening diabetic retinopathy in Taiwanese patients with type 2 diabetes and dyslipidemia.

Comorbidity in head and neck cancer: Is it associated with therapeutic delay, post-treatment mortality and survival in a population-based study?

OBJECTIVES

This study aims to investigate the relationship between comorbidities and therapeutic delay, post-treatment mortality, overall and relative survival in patients diagnosed with squamous cell carcinoma of the head and neck (HNSCC).

PATIENTS AND METHODS

9245 patients with a single HNSCC diagnosed between 2009 and 2014 were identified in the Belgian Cancer Registry. The Charlson Comorbidity Index (CCI) was calculated for 8812 patients (95.3%), distinguishing patients having none (0), mild (1-2), moderate (3-4) or severe comorbidity (>4). The relationship between CCI and therapeutic delay was evaluated using the Spearman correlation. Post-treatment mortality was modelled with logistic regression, using death within 30 days as the event. The association between comorbidity and survival was assessed using Cox proportional hazard models.

RESULTS

Among 8812 patients with a known CCI, 39.2% had at least one comorbidity. Therapeutic delay increased from 31 to 36 days when the CCI worsened from 0 to 4 (rho = 0.087). After case-mix adjustment, higher baseline comorbidity was associated with increased post-surgery mortality (mild, OR 3.52 [95% CI 1.91-6.49]; severe, OR 18.71 [95% CI 6.85-51.12]) and post-radiotherapy mortality (mild, OR 2.23 [95% CI 1.56-3.19]; severe, OR 9.33 [95% CI 4.83-18.01]) and with reduced overall survival (mild, HR 1.39, [95% CI 1.31-1.48]; severe, HR 2.41 [95% CI 2.00-2.90]). That was also the case for relative survival in unadjusted analyses (mild, EHR 1.77 [95% CI 1.64-1.92]; severe, EHR = 4.15 [95% CI 3.43-5.02]).

CONCLUSION

Comorbidity is significantly related to therapeutic delay, post-treatment mortality, 5-year overall and relative survival in HNSCC patients. Therapeutic decision support tools should optimally integrate comorbidity.

Different androgen deprivation therapies might have a differential impact on cognition - An analysis from a population-based study using time-dependent exposure model

BACKGROUND

Androgen deprivation therapy (ADT) remains the mainstay treatment for locally advanced or metastatic prostate cancer (PC). However, potential effects of ADT treatment on neurocognitive dysfunction remain unclear. The present study was conducted to assess the relation between ADT treatment and risk of cognitive decline in Asian men with PC.

METHODS

A population-based cohort of 24,464 men with PC, each newly diagnosed between 2000 and 2008, was selected from the Taiwan National Health Insurance Database. Subjects were further grouped by treatment as non-ADT (n = 4685) or ADT (n = 12,740), members of the latter subjected to bilateral orchiectomy or medical treatment (ie, luteinizing hormone-releasing hormone agonists, antiandrogens, or combination therapy). A multivariable Cox proportional hazard model with ADT as time-dependent covariate was used to generate adjusted hazard ratios (HRs) of subsequent cognitive decline, including dementia, Alzheimer's disease (AD), and Parkinson's disease (PD).

RESULTS

ADT showed a significant association with overall risk of cognitive decline (HR = 1.51, 95 % CI: 1.31-1.74), especially for PD, dementia, and non-Alzheimer dementia (non-AZD). When stratified by various ADT regimens, antiandrogen-only recipients displayed significantly heightened risks of subsequent AD, non-AZD, and PD. However, combined androgen blockade also imposed an increased risk of PD. There was no apparent correlation between duration of ADT exposure and cognitive dysfunction.

CONCLUSIONS

Various ADT therapies may have disparate impacts on cognitive function. Prospective studies exploring pertinent clinical characteristics more fully are needed to confirm these findings.

Establishing risk-adjusted quality indicators in surgery using administrative data-an example from neurosurgery

BACKGROUND

The current draft of the German Hospital Structure Law requires remuneration to incorporate quality indicators. For neurosurgery, several quality indicators have been discussed, such as 30-day readmission, reoperation, or mortality rates; the rates of infections; or the length of stay. When comparing neurosurgical departments regarding these indicators, very heterogeneous patient spectrums complicate benchmarking due to the lack of risk adjustment.

OBJECTIVE

In this study, we performed an analysis of quality indicators and possible risk adjustment, based only on administrative data.

METHODS

All adult patients that were treated as inpatients for a brain or spinal tumour at our neurosurgical department between 2013 and 2017 were assessed for the abovementioned quality indicators. DRG-related data such as relative weight, PCCL (patient clinical complexity level), ICD-10 major diagnosis category, secondary diagnoses, age and sex were obtained. The age-adjusted Charlson Comorbidity Index (CCI) was calculated. Logistic regression analyses were performed in order to correlate quality indicators with administrative data.

RESULTS

Overall, 2623 cases were enrolled into the study. Most patients were treated for glioma (n = 1055, 40.2%). The CCI did not correlate with the quality indicators, whereas PCCL showed a positive correlation with 30-day readmission and reoperation, SSI and nosocomial infection rates.

CONCLUSION

All previously discussed quality indicators are easily derived from administrative data. Administrative data alone might not be sufficient for adequate risk adjustment as they do not reflect the endogenous risk of the patient and are influenced by certain complications during inpatient stay. Appropriate concepts for risk adjustment should be compiled on the basis of prospectively designed registry studies.

Similarities and differences in the correlates of comorbidities in US male and female adult cancer survivors

OBJECTIVES

To determine both the common and the sex-specific correlates of comorbidities in adult male and female cancer survivors.

DESIGN

Cross-sectional study using the 2009-2014 National Health and Nutrition Examination Survey (NHANES).

SAMPLE

Male (n = 667) and female (n = 772) cancer survivors 20 years of age and older.

MEASUREMENTS

Questionnaire responses from NHANES provided data for this study. Comorbidities were assessed using a modified Charlson Comorbidity Index (CCI). Bivariate and multivariate linear regression analyses were conducted to identify correlates of comorbidities in male and female cancer survivors separately.

RESULTS

The mean modified CCI score was 3.88 in males and 3.68 in females. Having a greater number of cancers diagnosed, being currently or formerly married, being physically inactive, having lower socioeconomic status, and being a former smoker were significant correlates of comorbidities in both males and females. Having a prostate cancer diagnosis was also a significant correlate of comorbidities in males. White race, more years since first cancer diagnosis, being overweight or obese, and having no more than a high school education were also significant correlates of comorbidities in females.

CONCLUSIONS

There are differences between correlates of comorbidities in male and female cancer survivors.

Impact of Age-Adjusted Charlson Comorbidity on Hospital Survival and Short-Term Outcome of Patients with Extracorporeal Cardiopulmonary Resuscitation

Extracorporeal cardiopulmonary resuscitation (ECPR) has gradually come to be regarded as an effective therapy, but the hospital mortality rate after ECPR is still high and unpredictable. The present study tested whether age-adjusted Charlson comorbidity index (ACCI) can be used as an objective selection criterion to ensure the most efficient utilization of medical resources. Adult patients (age ≥ 18 years) receiving ECPR at our institution between 2006 and 2015 were included. Data regarding ECPR events and ACCI characteristics were collected immediately after the extracorporeal membrane oxygenation (ECMO) setup. Adverse events during hospitalization were also prospectively collected. The primary endpoint was survival to hospital discharge. The second endpoint was the short-term (2-year) follow-up outcome. A total of 461 patients included in the study were grouped into low ACCI (ACCI 0–3) (240, 52.1%) and high ACCI (ACCI 4–13) (221, 47.9%) groups. The median ACCI was 2 (interquartile range (IQR): 1–3) and 5 (IQR: 4–7) for the low and high ACCI groups, respectively. Cardiopulmonary resuscitation (CPR)-to-ECMO duration was comparable between the groups (42.1 ± 25.6 and 41.3 ± 20.7 min in the low and high ACCI groups, respectively; p = 0.754). Regarding the hospital survival rate, 256 patients (55.5%) died on ECMO support. A total of 205 patients (44.5%) were successfully weaned off ECMO, but only 138 patients (29.9%) survived to hospital discharge (32.1% and 27.6% in low and high ACCI group, p = 0.291). Multivariate logistic regression analysis revealed CPR duration before ECMO run (CPR-to-ECMO duration) and a CPR cause of septic shock to be significant risk factors for hospital survival after ECPR (p = 0.043 and 0.014, respectively), whereas age and ACCI were not (p = 0.334 and 0.164, respectively). The 2-year survival rate after hospital discharge for the 138 hospital survivors was 96% and 74% in the low and high ACCI groups, respectively (p = 0.002). High ACCI before ECPR does not predict a poor outcome of hospital survival. Therefore, ECPR should not be rejected solely due to high ACCI. However, high ACCI in hospital survivors is associated with a higher 2-year mortality rate than low ACCI, and patients with high ACCI should be closely followed up.

Risk of psychiatric disorders in irritable bowel syndrome-A nationwide, population-based, cohort study

AIMS

This cohort study aimed to investigate the association between irritable bowel syndrome (IBS) and the risk of developing psychiatric disorders.

METHODS

Utilizing the National Health Insurance Research Database (NHIRD) of Taiwan, IBS patients were identified and compared with age, sex, and index year-matched controls (1:3).

RESULTS

Of the IBS subjects, 3934 in 22 356 (17.60%, or 1533.68 per 100 000 person-years) developed psychiatric disorders when compared with 6127 in 67 068 (9.14%, or 802 per 100 000 person-years) in the non-IBS control group. Fine and Gray's survival analysis revealed that the study subjects were more likely to develop psychiatric disorders. The crude hazard ratio (HR) is 3.767 (95% CI: 3.614-3.925, P < .001), and the adjusted HR is 3.598 (95% CI: 3.452-3.752, P < .001) in the risk of developing psychiatric disorders after being adjusted for age, sex, comorbidities, geographical area of residence, urbanisation level of residence, and monthly insurance premiums. The cohort study revealed that IBS subjects were associated with an increased risk of anxiety, depression, bipolar, and sleep disorders.

CONCLUSIONS

This cohort study, using NHIRD, shows evidence support that patients with IBS have a 3.6-fold risk of developing psychiatric disorders. Other large or national datasets should be done to explore to underlying mechanisms.

Risk of dementia after charcoal-burning suicide attempts: a nationwide cohort study in Taiwan

This study aimed to investigate the association between charcoal-burning suicide attempts and the risk of developing dementia. A nationwide, matched cohort, population-based study enrolled a total of 4103 patients with newly diagnosed charcoal-burning suicide attempts, between 2000 and 2010, which were selected from the National Health Insurance Research Database of Taiwan, along with 12,309 controls matched for sex and age. After adjusting for confounding factors, Fine and Gray's competing risk analysis was used to compare the risk of developing dementia during the 10-year follow-up period. Of the enrolled patients (n=16,412), dementia developed in 303 (1.85%), including 2.56% in the study group (105 in 4103) and 1.61% (198 in 12,309) in the control group. The Fine and Gray's survival analysis revealed that the patients with charcoal-burning suicide attempts were likely to develop dementia, with a crude HR of 5.170 (95% CI 4.022 to 6.644, p<0.001). After adjusting for age, sex, comorbidity, geographic area and urbanization level of residence, and monthly insured premium, the adjusted HR was 4.220 (95% CI 3.188 to 5.586, p<0.001). Suicide attempts were associated with an increased risk of degenerative dementia in this study. Patients with charcoal-burning suicide attempts had a fourfold risk of dementia than the control group.

Age-adjusted comorbidity and survival in locally advanced laryngeal cancer

BACKGROUND

The purpose of this study was to quantify the relationship among age, pretreatment comorbidity, and survival outcomes in patients with locally advanced laryngeal cancer.

METHODS

Baseline comorbidity data were collected and age-adjusted Charlson Comorbidity Index (CCI) was calculated for each case. Kaplan-Meier and Cox proportional hazards modeling were used to determine associations with survival.

RESULTS

For 548 patients, with a median age of 59 years (range 31-91 years), 58% were treated with larynx preservation and the rest with total laryngectomy and adjuvant radiotherapy (RT). Two hundred thirty-eight patients (43%) had at least 1 comorbidity each. Cardiovascular diseases were the most common comorbidities (19%). The 5-year overall survival (OS) for patients with CCI ≤3 (n = 442) were superior to CCI >3 (n = 106; 60% vs 41%; P < .0001), although the 5-year disease-specific survival (DSS) rates were not significantly different. The 5-year noncancer CSS was better for age-adjusted CCI ≤3 (88% vs 67%; P < .0001).

CONCLUSION

The age-adjusted CCI is a significant predictor of noncancer CSS and OS for patients with locally advanced laryngeal cancer but is not associated with DSS.

The impact of comorbidity on overall survival in elderly nasopharyngeal carcinoma patients: a National Cancer Data Base analysis

The number of elderly patients with cancer is increasing. Medical comorbidities are more common in this population. Little is known regarding the prognostic relevance of comorbidities in elderly patients with nasopharyngeal carcinoma (NPC). Using the National Cancer Data Base (NCDB), we queried patients age >65 years diagnosed with NPC and treated with definitive radiation between 2004 and 2012 to examine the association between comorbidity and survival outcomes. Comorbidity was assessed with the Charlson Comorbidity Index (CCI). The influence of comorbidity on overall survival (OS) was evaluated. Cox proportional hazards model was used to study the impact of comorbidity on OS. A total of 1137 patients met the specified criteria. Median follow-up was 61.2 months. Five-year OS was 50.4%. Comorbidities were present in 22.4% of patients, with 17.6% of patients having a CCI score of 1% and 4.8% having a CCI score of ≥2. Patients with a CCI score of 0 had significantly higher 5-year OS than patients with a CCI score of 1 or ≥2 (53.1% vs. 42.2% vs. 32.9%, P < 0.001). In multivariate analysis, CCI was a statistically significant independent prognostic factor for the risk of death of all causes for patients with a CCI score of 1 (hazard ratio [HR]: 1.242; 95% confidence interval [CI]: 1.002-1.539) or CCI score of ≥2 (HR: 1.625; 95% CI: 1.157-2.283) when compared to patients with a CCI score of 0. Comorbidity as measured by CCI is a strong independent prognostic factor for OS in elderly patients with NPC and lends support to the inclusion of comorbidity assessment due to its prognostic value when treating elderly patients with NPC.

Perceived acceptability and preferences for low-intensity early activity interventions of older hospitalized medical patients exposed to bed rest: a cross sectional study

Background

Hospitalized older patients spend most of their time in bed, putting them at risk of experiencing orthostatic intolerance. Returning persons to their usual upright activity level is the most effective way to prevent orthostatic intolerance but some older patients have limited activity tolerance, supporting the need for low-intensity activity interventions. Consistent with current emphasis on patient engagement in intervention design and evaluation, this study explored older hospitalized patients’ perceived acceptability of, and preference for, two low-intensity early activity interventions (bed-to-sitting and sitting-to-walking), and characteristics (gender, illness severity, comorbidity, illnesses and medications with orthostatic effects, and baseline functional capacity) associated with perceived acceptability and preference.

Methods

A convenience sample was recruited from in-patient medical units of two hospitals in Ontario, Canada and included 60 cognitively intact adults aged 65+ who were admitted for a medical condition within the past 72 h, spent ≥ 24 consecutive hours on a stretcher or in bed, presented with ≥ 2 chronic diseases, understood English, and were able to ambulate before admission. A cross-sectional observational design was used. Participants were presented written and oral descriptions and a 2-min video of each intervention. The sequence of the interventions’ presention was randomized. Following the presentation, a research nurse administered measures of perceived acceptability and preference, and collected health and demographic data. Perceived acceptability and preference for the interventions were measured using the Treatment Acceptability and Preferences Scale. Illness severity was measured using the Modified Early Warning Score. Comorbidity was assessed with the Age Adjusted Charlson Comorbidity Scale and the Cumulative Illness Rating Scale – for Geriatrics. Baseline functional capacity was measured using the Duke Activity Status Index.

Results

Participants’ perceived acceptability of both interventions clustered above the scale midpoint. Most preferred the sitting-to-walking intervention (n = 26; 43.3%). While none of the patient characteristics were associated with intervention acceptability, illness severity (odds ratio = 1.9, p = 0.04) and medications with orthostatic effects (odds ratio = 9.9, p = 0.03) were significantly associated with intervention preference.

Conclusions

The interventions examined in this study were found to be acceptable to older adults, supporting future research examining their feasibility and effectiveness.

Increased Risk of Psychiatric Disorders in Allergic Diseases: A Nationwide, Population-Based, Cohort Study

BACKGROUND/OBJECTIVE

Allergic diseases, such as bronchial asthma, allergic rhinitis, atopic dermatitis, and psychiatric disorders, are major health issues. There have been reports that allergic diseases were associated with depression or anxiety disorders. This study aimed to investigate the association between these allergic diseases and the risk of developing overall psychiatric disorders in patients from Taiwan.

METHODS

This cohort study used the database of the Taiwan National Health Insurance Program. A total of 186,588 enrolled patients, with 46,647 study subjects who had suffered from allergic diseases, and 139,941 controls matched for sex and age, from the Longitudinal Health Insurance Dataset of 2000-2015, were selected from a sub-dataset of the National Health Insurance Research Database. Fine and Gray's competing risk model analysis was used to explore the hazard ratio (HR), and 95% confidence interval, for the risk of allergic diseases being associated with the risk of developing psychiatric disorders during the 15 years of follow-up.

RESULTS

Of the study subjects, 5,038 (10.8%) developed psychiatric disorders when compared to 9,376 (6.7%) in the control group, with significant difference (p < 0.001). Fine and Gray's competing risk model analysis revealed that the adjusted HR was 1.659 (95% CI = 1.602-1.717, p < 0.001). In this study, we found that the groups of atopic dermatitis alone and the allergic rhinitis + atopic dermatitis were associated with a lower risk of psychiatric disorders, but all the other four groups, such as bronchial asthma alone, allergic rhinitis alone, bronchial asthma + allergic rhinitis, bronchial asthma + atopic dermatitis, and the combination of all these three allergic diseases, were associated with a higher risk of psychiatric disorders.

CONCLUSION

Allergic diseases are therefore associated with a 1.66-fold increased hazard of psychiatric disorders in Taiwan.

Accuracy of a Staging System for Prognosis of 5-Year Survival of Patients With Nasopharyngeal Carcinoma Who Underwent Chemoradiotherapy

Importance

Concurrent chemoradiotherapy delivers a high level of tumor control and survival benefits for patients with nasopharyngeal carcinoma (NPC). However, many uncertainties still exist regarding the outcomes of chemoradiotherapy, making a more precise survival prognostic system necessary.

Objective

To introduce a new staging system that combines tumor and clinical characteristics to improve the accuracy of prognosis for patients with NPC.

Design, Setting, and Participants

This cohort study enrolled 207 patients with newly diagnosed NPC who underwent concurrent chemoradiotherapy between January 1, 2007, and December 31, 2014, at Chi-Mei Medical Center in Tainan, Taiwan. Data on these patients were collected from the cancer registry database of the Chi-Mei Medical Center. Patients who had a history of cancer or were unable to complete a full course of radiotherapy were excluded. Follow-up was completed on September 30, 2016, and the data analysis was performed from January 1, 2017, to February 28, 2017.

Main Outcomes and Measures

The risk factors associated with 5-year disease-specific survival were incorporated into the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer TNM staging system to construct a new prognostic staging system. The χ2 test for linear trend, the Akaike information criterion, and the C statistic were used to evaluate the monotonicity and discriminatory ability of the new prognostic staging system and the AJCC TNM staging system.

Results

Of the 207 patients enrolled in the study, 157 (75.8%) were men, and the mean (SD) age was 48 (11) years. Multivariate analysis identified advanced clinical T stage (adjusted hazard ratio [aHR], 3.20; 95% CI, 1.58-6.48), poor performance status (aHR, 2.62; 95% CI, 1.30-5.28), and cumulative cisplatin dose lower than 100 mg/m2 (aHR, 2.28; 95% CI, 1.10-4.74) as independent prognostic factors. The β coefficients from the Cox proportional hazards regression model were used to develop an integer-based, weighted point system; advanced clinical T stage, poor performance, and cumulative cisplatin dose lower than 100 mg/m2 were each assigned a score of 1. The sum of these risk scores was stratified into new stage I (score of 0), new stage II (score of 1), new stage III (score of 2), and new stage IV (score of 3). Compared with the AJCC TNM staging system, the new prognostic staging category had better monotonicity with a higher χ2 value (17.8 vs 25.6) for linear trend, better discriminatory ability with a smaller Akaike information criterion (367 vs 360), and a greater C statistic (0.702 vs 0.740) for 5-year disease-specific survival.

Conclusions and Relevance

The new prognostic staging system has a better accuracy of prognosis of survival than the routinely used AJCC TNM staging system and thus is more useful in identifying high-risk patients for more intense treatment and care.

Cognitive enhancers associated with decreased risk of injury in patients with dementia: a nationwide cohort study in Taiwan

This study aimed to investigate the associations among dementia, psychotropic medications and the risk of overall injuries. In this nationwide matched cohort study, a total of 144 008 enrolled patients ≥age of 50, with 36 002 study subjects who suffered from dementia and 108 006 controls matched for sex and age, from the Inpatient Dataset, for the period 2000-2010 in Taiwan were selected from the National Health Insurance Research Database, according to International Classification of Diseases, 9th Revision, Clinical Modification. When adjusting for the confounding factors, a Cox proportional hazards analysis was used to compare the risk of developing psychiatric disorders during the 10 years of follow-up. Of the study subjects, 6701 (18.61%) suffered injury when compared with 20 919 (19.37%) in the control group. The Cox regression analysis revealed that the study subjects were more likely to develop an injury (HR: 2.294, 95% CI=2.229 to 2.361, P<0.001) after adjusting for sex, age, monthly income, urbanization level, geographic region, and comorbidities. Psychotropic medications in the subjects with dementia were associated with the risk of injury (adjusted HR=0.217, 95% CI: 0.206 to 0.228, P<0.001). Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, were associated with the risk of injury in the study subjects after being adjusted for all comorbidities and medications (adjusted HR=0.712(95% CI=0.512 to 0.925, P<0.01)). In conclusion, patients who suffered dementia had a higher risk of developing injury, and the cognitive enhancers were associated with the decreased risk of injury.

Age-adjusted Charlson comorbidity index score as predictor of survival of patients with digestive system cancer who have undergone surgical resection

Comorbidities have considerable effects on survival outcomes. The primary objective of this retrospective study was to examine the association between age-adjusted Charlson comorbidity index (ACCI) score and postoperative in-hospital mortality in patients with digestive system cancer who have undergone surgical resection of their cancers. Using electronic hospitalization summary reports, we identified 315,464 patients who had undergone surgery for digestive system cancer in top-rank (Grade 3A) hospitals in China between 2013 and 2015. The Cox proportional hazard regression model was applied to evaluate the effect of ACCI score on postoperative mortality, with adjustments for sex, type of resection, anesthesia methods, and caseload of each healthcare institution. The postoperative in-hospital mortality rate in the study cohort was 1.2% (3,631/315,464). ACCI score had a positive graded association with the risk of postoperative in-hospital mortality for all cancer subtypes. The adjusted HRs for postoperative in-hospital mortality scores ≥ 6 for esophagus, stomach, colorectum, pancreas, and liver and gallbladder cancer were 2.05 (95% CI: 1.45–2.92), 2.00 (95% CI: 1.60–2.49), 2.54 (95% CI: 2.02–3.21), 2.58 (95% CI: 1.68–3.97), and 4.57 (95% CI: 3.37–6.20), respectively, compared to scores of 0–1. These findings suggested that a high ACCI score is an independent predictor of postoperative in-hospital mortality in Chinese patients with digestive system cancer who have undergone surgical resection.

Age-adjusted Charlson comorbidity index as a prognostic factor of hypopharyngeal cancer treated with chemoradiation therapy

CONCLUSION

The age-adjusted Charlson comorbidity index (ACCI) was associated with overall survival, disease-specific survival, and non-cancer death in patients treated with chemoradiation therapy (CRT) for hypopharyngeal cancer (HPC). Further studies using other CRT regimens are required.

OBJECTIVE

To investigate the impact of the ACCI on survival in patients with HPC.

METHODS

This study reviewed 128 patients with HPC who received CRT between 2004-2012. The survival rates and the cumulative incidence of non-cancer death according to the ACCI were estimated. A Cox proportional hazard model was used to assess the hazard ratio (HR) of the ACCI.

RESULTS

The disease-specific survival rates at 3 years for the low ACCI group, moderate group, and high group were 80.1%, 45.8%, and 54.8%, respectively (p = 0.007). The laryngectomy-free survival rates at 3 years were 61%, 39.7%, and 37.1%, respectively (p = 0.137). The cumulative incidences of non-HPC death were 5% for the low/moderate ACCI group and 15.5% for the high ACCI group (p = 0.031). The HRs compared to the low ACCI group for overall survival, disease-specific survival, and laryngectomy-free survival were 2.61 and 2.74, 2.55 and 2.27, and 1.75 and 1.97 in the moderate and high ACCI groups, respectively.

Role of comorbidity on outcome of head and neck cancer: a population-based study in Thuringia, Germany

To examine the impact of comorbidity on overall survival (OS) in a population-based study of patients with head and neck cancer who were treated between 2009 and 2011. Data of 1094 patients with primary head and neck carcinomas without distant metastasis from the Thuringian cancer registries were evaluated concerning the influence of patient's characteristics and comorbidity on OS. Data on comorbidity prior to head and neck cancer diagnosis was adapted to the Charlson Comorbidity (CCI), age-adjusted CCI (ACCI), head and neck CCI (HNCCI), simplified comorbidity score (SCS), and to the Adult Comorbidity Evaluation-27 (ACE-27). Most patients were male (80%; median age: 60 years; 50% stage IV tumors). Smoking, alcohol abuse, and anemia were registered for 38%, 33%, and 23% of the patients, respectively. Predominant therapy was surgery + radiochemotherapy (30%), surgery (29%), and surgery + radiotherapy (21%). Mean CCI, ACCI, HNCCI, SCS and ACE-27 were 1.0 ± 1.5, 2.6 ± 2.1, 0.6 ± 0.8, 4.4 ± 4.2, and 0.9 ± 0.9, respectively. Median follow-up was 25.7 months. Multivariable analyses showed that higher age, higher UICC stage, no therapy, including surgery or radiotherapy, alcohol abuse, and anemia, higher comorbidity were independent risk factors for worse OS (all P < 0.05). According to the discriminatory power analysis none of the five comorbidity scores was superior to the other scores to prognosticate OS. This population-based study showed that comorbidity is frequent in German patients with head and neck cancer and is an important risk factor for poor OS. Comorbidity should be routinely assessed and taken into account in prospective clinical trials.

Hospital and patient influencing factors of treatment schemes given to type 2 diabetes mellitus inpatients in Inner Mongolia, China

Background:

In clinical practice, the physician’s treatment decision making is influenced by many factors besides the patient’s clinical conditions and is the fundamental cause of healthcare inequity and discrimination in healthcare settings. Type 2 diabetes mellitus (T2DM) is a chronic disease with high prevalence, long average length of stay and high hospitalization rate. Although the treatment of T2DM is well guideline driven, there is a large body of evidence showing the existence of treatment disparities. More empirical studies from the provider side are needed to determine if non-clinical factors influence physician’s treatment choices.

Objective:

To determine the hospital and patient influencing factors of treatment schemes given to T2DM inpatients in Inner Mongolia, China.

Methods:

A cross-sectional, hospital-based survey using a cluster sampling technique was conducted in three tertiary hospitals and three county hospitals in Inner Mongolia, China. Treatment schemes were categorized as lifestyle management, oral therapy or insulin therapy according to the national guideline. Socio-demographic characteristics and variables related to severity of disease at the individual level and hospital level were collected. Weighted multinomial logistic regression models were used to determine influencing factors of treatment schemes.

Results:

Regardless of patients’ clinical conditions and health insurance types, both hospital and patient level variables were associated with treatment schemes. Males were more likely to be given oral therapy (RRR=1.72, 95% CI=1.06-2.81) and insulin therapy (RRR=1.94, 95% CI=1.29-2.91) compared to females who were given lifestyle management more frequently. Compared to the western region, hospitals in the central regions of Inner Mongolia were less likely to prescribe T2DM patients oral therapy (RRR = 0.18, 95% CI=0.05-0.61) and insulin therapy (RRR = 0.20, 95% CI=0.06-0.67) than lifestyle management. Compared with non-reformed tertiary hospitals, reformed tertiary hospitals and county hospitals were less likely to give T2DM patients oral therapy (RRR = 0.07 and 0.1 respectively) and insulin therapy (RRR = 0.11 and 0.17 respectively).

Conclusion:

Gender was the only socio-demographic factors associated with treatment scheme for T2DM patients. Hospitals from different regions have different T2DM treatment patterns. Implementation of reform was shown to be associated with controlling medication use for T2DM inpatients. Further studies are needed to investigate the causes of unreasonable treatment disparities so that policies can be generated accordingly.