Balance diagnostics in propensity score analysis following multiple imputation: A new method

The combination of propensity score analysis and multiple imputation has been prominent in epidemiological research in recent years. However, studies on the evaluation of balance in this combination are limited. In this paper, we propose a new method for assessing balance in propensity score analysis following multiple imputation. A simulation study was conducted to evaluate the performance of balance assessment methods (Leyrat's, Leite's, and new method). Simulated scenarios varied regarding the presence of missing data in the control or treatment and control group, and the imputation model with/without outcome. Leyrat's method was more biased in all the studied scenarios. Leite's method and the combine method yielded balanced results with lower mean absolute difference, regardless of whether the outcome was included in the imputation model or not. Leyrat's method had a higher false positive ratio and Leite's and combine method had higher specificity and accuracy, especially when the outcome was not included in the imputation model. According to simulation results, most of time, Leyrat's method and Leite's method contradict with each other on appraising the balance. This discrepancy can be solved using new combine method.

Postoperative Complications of Surgery for Cervical Spondylotic Myelopathy with and Without Athetoid Cerebral Palsy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

With the aging of the Japanese population, patients with athetoid cerebral palsy (ACP) are getting older, and the rate of surgery for CSM is increasing in ACP patients. However, postoperative complications of such surgery among adult patients with ACP have not been reported yet. We investigated postoperative complications of surgery for CSM with ACP and compared them with those of surgery for CSM without ACP using a national inpatient database of Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified 61382 patients who underwent surgery for CSM from July 2010 to March 2018. We examined patient backgrounds, surgical procedures, and type of hospital, and a 4:1 propensity score matching was performed to compare the outcomes between the non-ACP and ACP groups.

RESULTS

There were 60 847 patients without ACP and 535 patients with ACP. The mean age was 68.5 years in the non-ACP group and 55 years in the ACP group. The percentages of patients who underwent fusion surgery were 21.6% and 68.8% in the non-ACP and ACP groups, respectively. The 4:1 propensity score matching selected 1858 in the non-ACP group and 465 in the ACP group. The ACP group was more likely to have postoperative urinary tract infection (.4% vs 2.8%, P < .001), postoperative pneumonia (.4% vs 2.4%, P < .001), and 90-day readmission for reoperation (1.9% vs 4.3%, P = .003).

CONCLUSIONS

We found that ACP patients were more vulnerable to postoperative complications and reoperation after CSM than non-ACP patients.

An outcome-wide analysis of the effects of diagnostic labeling of Alzheimer's disease and related dementias on social relationships

INTRODUCTION

This study examines how receiving a dementia diagnosis influences social relationships by race and ethnicity.

METHODS

Using data from the Health and Retirement Study (10 waves; 7,159 observations) of adults 70 years and older predicted to have dementia using Gianattasio-Power scores (91% accuracy), this study assessed changes in social support, engagement, and networks after a dementia diagnosis. We utilized quasi-experimental methods to estimate treatment effects and subgroup analyses by race/ethnicity.

RESULTS

A diagnostic label significantly increased the likelihood of gaining social support but reduced social engagement and one measure of social networks. With some exceptions, the results were similar by race and ethnicity.

DISCUSSION

Results suggest that among older adults with assumed dementia, being diagnosed by a doctor may influence social relationships in both support-seeking and socially withdrawn ways. This suggests that discussing services and supports at the time of diagnosis is important for healthcare professionals.

Long-Term Outcomes of Endoscopic Resection versus Open Surgery for Locally Advanced Sinonasal Malignancies in Combination with Radiotherapy

Objective  Our objective was to compare the long-term outcomes of endoscopic resection versus open surgery in combination with radiotherapy for locally advanced sinonasal malignancies (SNMs). Methods  Data for continuous patients with sinonasal squamous cell carcinoma and adenocarcinoma who received surgery (endoscopic or open surgery) combined with radiotherapy in our center between January 1999 and December 2016 were retrospectively reviewed. A 1:1 matching with propensity scores was performed. Overall survival (OS), progression-free survival (PFS), and local recurrence rate (LRR) were evaluated. Results  We identified 267 eligible patients, 90 of whom were included after matching: 45 patients in the endoscopy group and 45 in the open group. The median follow-up time was 87 months. In the endoscopic group, 84.4% of patients received intensity-modulated radiotherapy (IMRT), with a mean gross tumor volume (GTV) dose of 68.28 Gy; in the open surgery group, 64.4% of patients received IMRT, with a mean GTV dose of 64 Gy. The 5-year OS, PFS, and LRR were 69.9, 58.6, and 24.5% in the endoscopic group and 64.6, 54.4, and 31.8% in the open surgery group, respectively. Multivariable regression analysis revealed that the surgical approach was not associated with lower OS, PFS, or LRR. The overall postoperative complications were 13% in the endoscopic group, while 21.7% in the open group. Conclusion  For patients with locally advanced SNMs, minimally invasive endoscopic resection, in combination with a higher radiation dose and new radiation techniques such as IMRT, yields survival outcomes similar to those of open surgery in combination with radiotherapy.

Low-Volume Acute Normovolemic Hemodilution Does Not Reduce Allogeneic Red Blood Cell Transfusion in Cardiac Surgery in the Modern Era of Patient Blood Management: A Propensity Score-Matched Cohort Study

OBJECTIVES

Patients undergoing cardiac surgery often require blood transfusions, which are associated with increased morbidity and mortality. Patient blood management (PBM) strategies, including acute normovolemic hemodilution (ANH), have been implemented to minimize allogeneic transfusion requirements. Older studies suggested that ANH is associated with reduced transfusions; however, its effectiveness in the modern era of PBM remains unclear.

DESIGN

This was a retrospective cohort study.

SETTING

The study was held at a single university hospital.

PARTICIPANTS

542 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB) using low-priming-volume circuits between January 2017 and March 2022.

INTERVENTIONS

Patients who received ANH were matched with those who did not receive ANH, using propensity scores.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the proportion of patients who received perioperative red blood cell (RBC) transfusion. Of the 542 eligible patients, 49 ANH cases were propensity-score matched to 97 controls. The median ANH volume was 450 mL (IQR, 400-800 mL). There was no significant difference in perioperative RBC transfusion rates between the 2 groups (24.5% in the ANH group vs 30.9% in the control group, p = 0.42). The odds ratio for perioperative RBC transfusion in the ANH group versus the control group was 0.72 (95% CI, 0.32-1.55, p = 0.42).

CONCLUSIONS

Low-volume ANH was not associated with a significant reduction in perioperative allogeneic RBC transfusion during cardiac surgery with CPB using low-priming-volume circuits. The benefits of low-volume ANH in reducing the requirement for RBC transfusion in the modern era of PBM may be smaller than reported previously.

Propensity score analysis of low-dose aspirin and bleeding complications in pregnancy

OBJECTIVE

Low-dose aspirin (LDA) has been shown to reduce the risk of preterm pre-eclampsia and it has been suggested that it should be recommended for all pregnancies. However, some studies have reported an association between LDA and an increased risk of bleeding complications in pregnancy. Our aim was to evaluate the risk of placental abruption and postpartum hemorrhage (PPH) in patients for whom their healthcare provider had recommended prophylactic aspirin.

METHODS

This multicenter cohort study included 72 598 singleton births at 19 hospitals in the USA, between January 2019 and December 2021. Pregnancies complicated by placenta previa/accreta, birth occurring at less than 24 weeks' gestation, multiple pregnancy or those with data missing for aspirin recommendation were excluded. Propensity scores were calculated using 20 features spanning sociodemographic factors, medical history, year and hospital providing care. The association between LDA recommendation and placental abruption or PPH was estimated by inverse-probability treatment weighting using the propensity scores.

RESULTS

We included 71 627 pregnancies in the final analysis. Aspirin was recommended to 6677 (9.3%) and was more likely to be recommended for pregnant individuals who were 35 years or older (P < 0.001), had a body mass index of 30 kg/m2 or higher (P < 0.001), had prepregnancy hypertension (P < 0.001) and who had a Cesarean delivery (P < 0.001). Overall, 1.7% of the study cohort (1205 pregnancies) developed preterm pre-eclampsia: 1.3% in the no-aspirin and 5.8% in the aspirin group. After inverse-probability weighting with propensity scores, aspirin was associated with increased risk of placental abruption (adjusted odds ratio (aOR), 1.44 (95% CI, 1.04-2.00)) and PPH (aOR, 1.21 (95% CI, 1.05-1.39)). The aOR translated to a number needed to harm with LDA of 79 (95% CI, 43-330) for PPH and 287 (95% CI, 127-3151) for placental abruption.

CONCLUSIONS

LDA recommendation in pregnancy was associated with increased risk for placental abruption and for PPH. Our results support the need for more research into aspirin use and bleeding complications in pregnancy before recommending it beyond the highest-risk pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Favorable effect of CD26/DPP-4 inhibitors on postoperative outcomes after lung transplantation: A propensity-weighted analysis

BACKGROUND

We have shown the efficacy of CD26/dipeptidyl peptidase 4 (CD26/DPP-4) inhibitors, antidiabetic agents, in allograft protection after experimental lung transplantation (LTx). We aimed to elucidate whether CD26/DPP-4 inhibitors effectively improve postoperative outcomes after clinical LTx.

METHODS

We retrospectively reviewed the records of patients undergoing LTx at our institution between 2010 and 2021 and extracted records of patients with diabetes mellitus (DM) at 6 months post-LTx. The patient characteristics and postoperative outcomes were analyzed. We established 6 months post-LTx as the landmark point for predicting overall survival (OS) and chronic lung allograft dysfunction (CLAD)-free survival. Hazard ratios were estimated by Cox regression after propensity score weighting, using CD26/DPP-4 inhibitor treatment up to 6 months post-LTx as the exposure variable. We evaluated CLAD samples pathologically, including for CD26/DPP-4 immunohistochemistry.

RESULTS

Of 102 LTx patients with DM, 29 and 73 were treated with and without CD26/DPP-4 inhibitors, respectively. Based on propensity score adjustment using standardized mortality ratio weighting, the 5-year OS rates were 77.0% and 44.3%, and the 5-year CLAD-free survival rates 77.8% and 49.1%, in patients treated with and without CD26/DPP-4 inhibitors, respectively. The hazard ratio for CD26/DPP-4 inhibitor use was 0.34 (95% confidence interval (CI) 0.14-0.82, p = 0.017) for OS and 0.47 (95% CI 0.22-1.01, p = 0.054) for CLAD-free survival. We detected CD26/DPP-4 expression in the CLAD grafts of patients without CD26/DPP-4 inhibitors.

CONCLUSIONS

Analysis using propensity score weighting showed that CD26/DPP-4 inhibitors positively affected the postoperative prognosis of LTx patients with DM.

Propensity score analysis of red cell distribution width to serum calcium ratio in acute myocardial infarction as a predictor of in-hospital mortality

Objective

Red cell distribution width (RDW) and serum calcium (Ca) levels are predictors of in-hospital mortality in acute myocardial infarction (AMI) patients. However, their sensitivity and specificity are limited. Therefore, this study aimed to determine whether the RDW to Ca ratio (RCR) acquired on admission can be used to predict the in-hospital mortality of AMI patients.

Methods

This retrospective cohort study extracted clinical information from the Medical Information Market for Intensive IV (MIMIC-IV) database on 2,910 AMI patients enrolled via propensity score matching (PSM). Prognostic values were assessed using a multivariate logistic model and three PSM approaches. Analysis was performed based on stratified variables and interactions among sex, age, ethnicity, anemia, renal disease, percutaneous transluminal coronary intervention (PCI), coronary artery bypass grafting (CABG), atrial fibrillation, congestive heart failure, dementia, diabetes, paraplegia, hypertension, cerebrovascular disease, and Sequential Organ Failure Assessment (SOFA) score.

Results

A total of 4,105 ICU-admitted AMI patients were analyzed. The optimal cut-off value of the RCR for in-hospital mortality was 1.685. The PSM was performed to identify 1,455 pairs (2,910) of score-matched patients, with balanced differences exhibited for nearly all variables.The patients' median age was 72 years (range, 63-82 years) and 60.9% were male. The risk of in-hospital mortality incidence increased with increasing RCR levels. After adjusting for confounders, the risk ratio for the incidence of in-hospital mortality for high RCR was 1.75 [95% confidence interval (CI): 1.60-1.94, P = 0.0113] compared to that associated with low RCR in the PSM cohort. High RCR was also substantially implicated in in-hospital mortality incidence in the weighted cohorts [odds ratio (OR) = 1.76, 95% CI: 1.62-1.94, P = 0.0129]. Assessment of RCR in three groups showed that patients with high RCR also had a higher risk of in-hospital mortality (OR = 3.04; 95% CI, 2.22-4.16; P < 0.0001) than in patients with RCR in the adjusted model. In the sensitivity analysis, both the original and weighted groups showed similar results.

Conclusion

The RCR at admission may be useful for predicting in-hospital mortality in ICU-admitted AMI patients.

Early and late urinary continence outcomes after unilateral and bilateral nerve-sparing robot-assisted radical prostatectomy: A retrospective multicentre cohort study in Japan (the MSUG94 group)

BACKGROUND

The impact of unilateral and bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (NS-RARP) procedures on continence and the time to continence recovery have not been established.

MATERIAL AND METHODS

We retrospectively reviewed a total of 2801 patients who underwent RARP in 9 institutions. Procedures were classified as NS or non-NS; NS procedures were further classified as unilateral or bilateral. The recovery of continence was analysed using propensity score matching method.

RESULTS

The pad-free rates at 12 months after surgery were higher in the NS group (95% confidence interval of odds ratio, 1.06-1.51). Pad-free rates at all time points within 12 months of surgery did not significantly differ between the unilateral and bilateral NS groups.

CONCLUSIONS

NS-RARP resulted in better urinary continence outcomes than non-NS-RARP in the first 12 months after surgery. Urinary recovery rates did not significantly differ between unilateral and bilateral NS-RARP.

Confounding adjustment in the analysis of augmented randomized controlled trial with hybrid control arm

The augmented randomized controlled trial (RCT) with hybrid control arm includes a randomized treatment group (RT), a smaller randomized control group (RC), and a large synthetic control (SC) group from real-world data. This kind of trial is useful when there is logistics and ethics hurdle to conduct a fully powered RCT with equal allocation, or when it is necessary to increase the power of the RCT by incorporating real-world data. A difficulty in the analysis of augmented RCT is that the SC and RC may be systematically different in the distribution of observed and unmeasured confounding factors, causing bias when the two control groups are analyzed together as hybrid controls. We propose to use propensity score (PS) analysis to balance the observed confounders between SC and RC. The possible bias caused by unmeasured confounders can be estimated and tested by analyzing propensity score adjusted outcomes from SC and RC. We also propose a partial bias correction (PBC) procedure to reduce bias from unmeasured confounding. Extensive simulation studies show that the proposed PS + PBC procedures can improve the efficiency and statistical power by effectively incorporating the SC into the RCT data analysis, while still control the estimation bias and Type I error inflation that might arise from unmeasured confounding. We illustrate the proposed statistical procedures with data from an augmented RCT in oncology.

Assessment of Fast-Track Pathway in Hip and Knee Replacement Surgery by Propensity Score Matching on Patient-Reported Outcomes

Total hip (THA) and total knee (TKA) arthroplasty procedures have steadily increased over the past few decades, and their use is expected to grow further, mainly due to an increasing number of elderly patients. Cost-containment strategies, supporting a rapid recovery with a positive functional outcomes, high patient satisfaction, and enhanced patient reported outcomes, are needed. A Fast Track surgical procedure (FT) is a coordinated perioperative approach aimed at expediting early mobilization and recovery following surgery and, accordingly, shortening the length of hospital stay (LOS), convalescence and costs. In this view, rapid rehabilitation surgery optimizes traditional rehabilitation methods by integrating evidence-based practices into the procedure. The aim of the present study was to compare the effectiveness of Fast Track versus Care-as-Usual surgical procedures and pathways (including rehabilitation) on a mid-term patient-reported outcome (PROs), the SF12 (with regard both to Physical and Mental Scores), 3 months after hip or knee replacement surgery, with the use of Propensity score-matching (PSM) analysis to address the issue of the comparability of the groups in a non-randomized study. We were interested in the evaluation of the entire pathways, including the postoperative rehabilitation stage, therefore, we only used early home discharge as a surrogate to differentiate between the Fast Track and Care-as-Usual rehabilitation pathways. Our study shows that the entire Fast Track pathway, which includes the post-operative rehabilitation stage, has a significantly positive impact on physical health-related status (SF12 Physical Scores), as perceived by patients 3 months after hip or knee replacement surgery, as opposed to the standardized program, both in terms of the PROs score and the relative improvements observed, as compared with the minimum clinically important difference. This result encourages additional research into the effects of Fast Track rehabilitation on the entire process of care for patients undergoing hip or knee arthroplasty, focusing only on patient-reported outcomes.

Effectiveness of episiotomy to prevent OASIS in nulliparous women at term

OBJECTIVE

To assess the association between episiotomy and severe obstetric anal sphincter injury (OASIS) in nulliparous women at term according to the use of an instrument for delivery with control confounding by indication.

METHODS

This was an observational retrospective cohort study including 12 346 women from 2004 to 2020. All nulliparous women with a cephalic singleton pregnancy were included. The primary outcome was the occurrence of OASIS. Association between episiotomy and OASIS was assessed by multivariate logistic regression with adjustment for confounding factors and stratification on the use of an instrument at delivery. Propensity score matching was used to account for indication bias.

RESULTS

Among 12 346 women included, 7803 (63.2%) had an episiotomy and 4543 (36.8%) did not have an episiotomy; the rate of OASIS was similar in both groups (0.7%). After stratification on use of instrument, an association between episiotomy and OASIS was shown in the case of instrumental delivery (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.80) but not if the delivery was spontaneous (OR 0.76, 95% CI 0.29-1.98). The result was similar after matching on propensity score (in the case of operative vaginal delivery: OR 0.20, 95% CI 0.10-0.75).

CONCLUSION

Episiotomy seems to be a protective factor for OASIS in nulliparous woman at term only in the case of operative vaginal delivery.

A 24-month updated analysis of the comparative effectiveness of ZUMA-5 (axi-cel) vs. SCHOLAR-5 external control in relapsed/refractory follicular lymphoma

BACKGROUND

In the ZUMA-5 trial (Clinical trials identification: NCT03105336), axicabtagene ciloleucel (axi-cel; a chimeric antigen receptor T-cell therapy) demonstrated high rates of durable response in relapsed/refractory (r/r) follicular lymphoma (FL) patients and clear superiority relative to the SCHOLAR-5 external control cohort. We update this comparison using the ZUMA-5 24-month data.

RESEARCH DESIGN AND METHODS

The SCHOLAR-5 cohort is comprised of r/r FL patients who initiated ≥3^rd line of therapy after July 2014 and meeting ZUMA-5 eligibility criteria. Groups were balanced for patient characteristics through propensity scoring on prespecified prognostic factors using standardized mortality ratio (SMR) weighting. The overall response rate was compared using a weighted logistic regression. Time-to-event outcomes were evaluated using a Cox regression.

RESULTS

For SCHOLAR-5, the sum of weights for the 143 patients was 85 after SMR weighting, versus 86 patients in ZUMA-5. The median follow-up was 29.4 months and 25.4 months for ZUMA-5 and SCHOLAR-5, respectively. The hazard ratios for overall survival and progression-free survival were 0.52 (95% confidence interval (CI): 0.28-0.95) and 0.28 (95% CI: 0.17-0.45), favoring axi-cel.

CONCLUSION

This updated analysis, using a longer minimum follow-up than a previously published analysis, shows that the improved efficacy of axi-cel, relative to available therapies, in r/r FL is durable. .

Lower subcutaneous fat index predicts bone metastasis in breast cancer

BACKGROUND

Bone metastases affect 50% to 70% of breast cancer (BC) patients and have a high mortality rate. Adipose tissue loss plays a pivotal role in the progression of cancer.

OBJECTIVE

This study aims to evaluate the prognostic value of adipose tissue for bone metastasis in BC patients.

METHODS

517 BC patients were studied retrospectively. Patients' characteristics before the surgery were collected. Quantitative measurements of the subcutaneous fat index (SFI) were performed at the level of the eleventh thoracic vertebra. In order to adjust for the heterogeneity between the low SFI and high SFI groups, propensity score matching (PSM) was used. The Kaplan-Meier method was used to estimate the 5-year bone metastatic incidence. The prognostic analysis was performed with the Cox regression models.

RESULTS

Compared with the patients without bone metastasis, the patients with bone metastasis had reduced SFI levels. In addition, Kaplan-Meier analysis revealed that patients with low SFI were more likely to develop bone metastases. The independent predictive value of SFI for bone metastases was confirmed by Cox regression analysis. The survival analysis was repeated after PSM with a 1:1 ratio, yielding similar results (P< 0.05).

CONCLUSIONS

SFI is an independent predictor of bone metastasis in BC patients.

Insulin-like growth factor 2 hypermethylation in peripheral blood leukocytes and colorectal cancer risk and prognosis: a propensity score analysis

Background

To comprehensively assess and validate the associations between insulin-like growth factor 2 (IGF2) gene methylation in peripheral blood leukocytes (PBLs) and colorectal cancer (CRC) risk and prognosis.

Methods

The association between IGF2 methylation in PBLs and CRC risk was initially evaluated in a case-control study and then validated in a nested case-control study and a twins' case-control study, respectively. Meanwhile, an initial CRC patient cohort was used to assess the effect of IGF2 methylation on CRC prognosis and then the finding was validated in the EPIC-Italy CRC cohort and TCGA datasets. A propensity score (PS) analysis was performed to control for confounders, and extensive sensitivity analyses were performed to assess the robustness of our findings.

Results

PBL IGF2 hypermethylation was associated with an increased risk of CRC in the initial study (OR_PS-adjusted, 2.57, 95% CI: 1.65 to 4.03, P<0.0001), and this association was validated using two independent external datasets (OR_PS-adjusted, 2.21, 95% CI: 1.28 to 3.81, P=0.0042 and OR_PS-adjusted, 10.65, 95% CI: 1.26 to 89.71, P=0.0295, respectively). CRC patients with IGF2 hypermethylation in PBLs had significantly improved overall survival compared to those patients with IGF2 hypomethylation (HR_PS-adjusted, 0.47, 95% CI: 0.29 to 0.76, P=0.0019). The prognostic signature was also observed in the EPIC-Italy CRC cohort, although the HR did not reach statistical significance (HR_PS-adjusted, 0.69, 95% CI: 0.37 to 1.27, P=0.2359).

Conclusions

IGF2 hypermethylation may serve as a potential blood-based predictive biomarker for the identification of individuals at high risk of developing CRC and for CRC prognosis.

Conventional vs. Drug-Eluting Beads Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma-A Propensity Score Weighted Comparison of Efficacy and Safety

This study compared the efficacy and safety of conventional transarterial chemoembolization (cTACE) with drug-eluting beads (DEB)-TACE in patients with unresectable hepatocellular carcinoma (HCC). This retrospective analysis included 370 patients with HCC treated with cTACE (n = 248) or DEB-TACE (n = 122) (January 2000-July 2014). Overall survival (OS) was assessed using uni- and multivariate Cox proportional hazards models and Kaplan-Meier analysis. Additionally, baseline imaging was assessed, and clinical and laboratory toxicities were recorded. Propensity score weighting via a generalized boosted model was applied to account for group heterogeneity. There was no significant difference in OS between cTACE (20 months) and DEB-TACE patients (24.3 months, ratio 1.271, 95% confidence interval 0.876-1.69; p = 0.392). However, in patients with infiltrative disease, cTACE achieved longer OS (25.1 months) compared to DEB-TACE (9.2 months, ratio 0.366, 0.191-0.702; p = 0.003), whereas DEB-TACE proved more effective in nodular disease (39.4 months) than cTACE (18 months, ratio 0.458, 0.308-0681; p = 0.007). Adverse events occurred with similar frequency, except for abdominal pain, which was observed more frequently after DEB-TACE (101/116; 87.1%) than cTACE (119/157; 75.8%; p = 0.02). In conclusion, these findings suggest that tumor morphology and distribution should be used as parameters to inform decisions on the selection of embolic materials for TACE for a more personalized treatment planning in patients with unresectable HCC.

Association of Maternal Body Mass Index and Maternal Morbidity And Mortality

OBJECTIVE

 This study aimed to assess the association of maternal body mass index (BMI) with a composite of severe maternal outcomes.

STUDY DESIGN

 Secondary analysis of a cohort of deliveries on randomly selected days at 25 hospitals from 2008 to 2011. Data on comorbid conditions, intrapartum events, and postpartum course were collected. The reference group (REF, BMI: 18.5-29.9kg/m2), obese (OB; BMI: 30-39.9kg/m2), morbidly obese (MO; BMI: 40-49.9kg/m2), and super morbidly obese (SMO; BMI ≥ 50kg/m2) women were compared. The composite of severe maternal outcomes was defined as death, intensive care unit (ICU) admission, ventilator use, deep venous thrombosis/pulmonary embolus (DVT/PE), sepsis, hemorrhage, disseminated intravascular coagulation (DIC), unplanned operative procedure, or stroke. Patients in the REF group were matched 1:1 with those in all other obesity groups based on propensity score using the baseline characteristics of age, race/ethnicity, previous cesarean, preexisting diabetes, chronic hypertension, parity, cigarette use, and insurance status. Multivariable Poisson's regression was used to estimate adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for the association between BMI and the composite outcome. Because cesarean delivery may be in the causal pathway between obesity and adverse maternal outcomes, models were then adjusted for mode of delivery to evaluate potential mediation.

RESULTS

 A total of 52,162 pregnant patients are included in the analysis. Risk of composite maternal outcomes was increased for SMO compared with REF but not for OB and MO [OB: aRR=1.06, 95% CI: 0.99-1.14; MO: aRR=1.10, 95% CI: 0.97-1.25; SMO: aRR=1.32, 95% CI: 1.02-1.70]. However, in the mediation analysis, cesarean appears to mediate 46% (95% CI: 31-50%) of the risk of severe morbidity for SMO compared with REF.

CONCLUSION

 Super morbid obesity is significantly associated with increased serious maternal morbidity and mortality; however, cesarean appears to mediate this association. Obesity and morbid obesity are not associated with maternal morbidity and mortality.

KEY POINTS

· Super morbid obesity is associated with increased morbidity.. · Cesarean appears to mediate the association between super morbid obesity and morbidity.. · Obesity and morbid maternal obesity are not associated with morbidity..

Effectiveness of a new triple-row circular stapler in reducing the risk of colorectal anastomotic leakage: A historical control and propensity score-matched study

Anastomotic leakage (AL) after colorectal surgery is a serious complication. This study aimed to evaluate the effectiveness of the EEA™ circular stapler, a new triple-row circular stapler (TCS), relative to a conventional, double-row circular stapler (DCS). A total of 285 patients who underwent anastomosis with the double stapling technique at the Tokyo Medical University Hospital between 2017 and 2021 were included in this nonrandomized clinical trial with historical controls using a propensity score (PS) analysis. The primary endpoint was the risk of AL. We performed a 1:2 PS matching analysis. Before case matching, AL occurred in 15 (7.4%) and 2 (2.4%) patients in the DCS and TCS groups, respectively, with no significant difference (P = .17). After case matching, AL occurred in 13 patients (11.6%) and 1 patient (1.8%) in the DCS and TCS groups, respectively, revealing a significant difference (P = .04). Cox models were created by applying PS to adjust for group differences via regression adjustment. Odds ratios for AL in the DCS group versus the TCS group were 0.31 (95% confidence interval [CI]: 0.07-1.38) in the entire cohort, 0.15 (95% CI: 0.02-0.64) in the regression adjustment cohort, and 0.14 (95% CI: 0.02-1.09) in the 1:2 PS-matched cohort. PS analysis of clinical data suggested that the use of TCS contributes to a reduced risk of AL after colorectal anastomosis CTwith the double stapling technique.

Long-term labour market and economic consequences of school exclusions in England: Evidence from two counterfactual approaches

Background

Previous research suggests that school exclusion during childhood is a precursor to social exclusion in adulthood. Past literature on the consequences of school exclusion is, however, scarce and mainly focused on short‐term outcomes such as educational attainment, delinquency, and mental health in early adolescence. Moreover, this evidence is based primarily on descriptive and correlational analysis, whereas robust causal evidence is required to best inform policy.

Aims

We aimed to estimate the mid‐to‐long‐term impact of school exclusion on labour market and economic outcomes.

Sample

The sample included 6,632 young people who at the age of 25/26 in the year 2015 participated in the Next Steps survey of whom 86 were expelled from school and 711 were suspended between the ages of 13/14 and 16/17.

Method

Using high quality existing longitudinal data, we utilized four approaches to evaluate the impact of school exclusion: logistic regression‐adjustment models, propensity score matching, school fixed‐effects analysis, and inverse propensity weighting. The latter two counterfactual approaches were used to estimate causal effects.

Results

We found that school exclusion increased the risk of becoming NEET at the age of 19/20, and then remaining economically inactive at the age of 25/26, as well as experiencing higher unemployment risk and earning lower wages also at the age of 25/26.

Conclusion

School exclusion has pervasive negative effects into adulthood. Policy interventions should focus on both prevention and mitigating its negative effects. Interventions aimed at re‐integrating excluded individuals into education or vocational training could be key in reducing the risk of poor socio‐economic outcomes and social exclusion.

Comparing the Survival Outcomes of Radical Prostatectomy Versus Radiotherapy for Patients With De Novo Metastasis Prostate Cancer: A Population-Based Study

Purpose

The efficacy of local treatments (LTs) in selected patients with metastatic prostate cancer (mPCa) had been demonstrated. However, the comparative effectiveness between LTs is unclear. Here, we compared the impact of radical prostatectomy (RP) and brachytherapy (RT) on the survival outcomes of mPCa patients.

Materials and Methods

mPCa patients who received RT or RP between 2004 and 2016 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariable Cox proportional hazards analysis was used to evaluate the comparative risk of prostate cancer-specific mortality (CSM) and all-cause mortality (ACM) between LTs. A 1:1 propensity score matching (PSM) and adjusted standardized mortality ratio weighting (SMRW) were performed to balance the clinicopathological characteristics of the groups.

Results

Of 684 mPCa patients, 481 underwent RP and 203 received RT. After PSM, both groups included 148 cases, and RT resulted in comparable CSM versus RP [CSM: hazard ratio (HR) = 0.77, p = 0.325; ACM: HR = 0.73, p = 0.138], which was consistent with the SMRW model [CSM: HR = 0.83, p = 0.138; overall survival (OS): HR = 0.75, p = 0.132]. However, RP was associated with a lower CSM in the T_1–2 subgroup (HR = 0.42, p = 0.048) and a lower ACM in the T_1–2 (HR = 0.55, p = 0.031) and prostate-specific antigen (PSA) ≤20ng/ml (HR = 0.48, p = 0.022) subgroups. Besides, the results showed that the mortality risk was similar between the two groups in the T_3–4, Gleason score (GS) >7, PSA >20 ng/ml, and all metastatic subgroups (all p > 0.100).

Conclusions

RP could confer better survival outcomes than could RT in mPCa patients with favorable primary tumor features, but not in those with advanced primary tumor features. Moreover, the metastatic substage has limited impact on the comparative effectiveness between RP and RT. Further clinical trials are necessary to confirm the present results.

A comparison of clinical outcomes between additional excision after unplanned and planned excisions in patients with soft-tissue sarcoma of the limb : a propensity matching cohort study

AIMS

Patients with soft-tissue sarcoma (STS) who undergo unplanned excision (UE) are reported to have worse outcomes than those who undergo planned excision (PE). However, others have reported that patients who undergo UE may have similar or improved outcomes. These discrepancies are likely to be due to differences in characteristics between the two groups of patients. The aim of the study is to compare patients who underwent UE and PE using propensity score matching, by analyzing data from the Japanese Bone and Soft Tissue Tumor (BSTT) registry.

METHODS

Data from 2006 to 2016 was obtained from the BSTT registry. Only patients with STS of the limb were included in the study. Patients with distant metastasis at the initial presentation and patients with dermatofibrosarcoma protuberans and well-differentiated liposarcoma were excluded from the study.

RESULTS

A total of 4,483 patients with STS of the limb were identified before propensity score matching. There were 355 patients who underwent UE and 4,128 patients who underwent PE. The five-year disease-specific survival (DSS) rate was significantly better in the patients who received additional excision after UE than in those who underwent PE. There was no significant difference in local recurrence-free survival (LRFS) between the two groups. After propensity score matching, a new cohort of 355 patients was created for both PE and UE groups, in which baseline covariates were appropriately balanced. Reconstruction after tumour excision was frequently performed in patients who underwent additional excision after UE. There were no significant differences in DSS and LRFS between the patients who underwent PE and those who had an additional excision after UE.

CONCLUSION

Using propensity score matching, patients with STS of the limb who underwent additional excision after UE did not experience higher mortality and local failure than those who underwent PE. Reconstruction may be necessary when additional excision is performed. Cite this article: Bone Joint J 2021;103-B(12):1809-1814.

Efficacy of Postoperative Unilateral Neck Irradiation in Patients with Buccal Mucosa Squamous Carcinoma with Extranodal Extension: A Propensity Score Analysis

Unilateral radiotherapy (RT) as a postoperative treatment for multiple ipsilateral lymph node (LN) metastases remains controversial. We investigated the efficacy of postoperative unilateral RT for buccal mucosa squamous cell carcinoma (BMSCC) with extranodal extensions (ENEs). We retrospectively reviewed the clinical records of 186 patients with ENE+ BMSCC who received postoperative RT during 1997-2016. Propensity score matching was used to establish comparable cohorts. The endpoints were contralateral nodal control (CLNC), overall survival (OS), disease-free survival (DFS), distant metastasis-free survival (DMFS), local control (LC), and regional control (RC). After matching, 123 patients were selected for analysis; 45 (36.6%) and 78 (63.4%) patients underwent unilateral and bilateral RT, respectively. The median follow-up was 36.27 months. The survival outcomes in the unilateral and bilateral RT groups were similar: 3-year CLNC (85.6% vs. 89.1%, p = 0.748), OS (53.2% vs. 57.4%, p = 0.229), DFS (46.5% vs. 48.6%, p = 0.515), DMFS (70.7% vs. 72.0%, p = 0.499), LC (78.0% vs. 75.6%, p = 0.692), and RC (79.9% vs. 76.2%, p = 0.465). On multivariable Cox regression analysis, unilateral and bilateral RT showed comparable outcomes; the number of ENEs ≥ 4 was the only significant prognostic factor for all clinical outcomes. Using decision tree analysis, we classified our patients to have a low, intermediate, or high risk of contralateral failure based on three factors: number of ENEs, margin status, and tumor stage. In conclusion, postoperative unilateral RT did not worsen outcomes in patients with ENE+ BMSCC in this cohort. The decision tree model may assist physicians in optimizing and tailoring radiation fields.

Effectiveness and Tolerance of Renin-Angiotensin System Inhibitors With Aging in Chronic Kidney Disease

OBJECTIVES

Renin-angiotensin system inhibitors (RASi) are recommended for slowing chronic kidney disease (CKD) progression to kidney failure. Their effectiveness and tolerance as patients age remain uncertain because older patients have often been excluded from clinical trials.

DESIGN

CKD-REIN cohort study.

SETTING AND PARTICIPANTS

We studied 2762 patients with CKD stages 3 and 4 and a clinical indication for RASi enrolled between 2013 and 2016 in 40 nephrology clinics nationally representative in France.

METHODS

The primary outcome was the occurrence of kidney failure or death. The secondary outcomes were the occurrence of cardiovascular events and hospitalizations with acute kidney injury (AKI) or hyperkalemia. A propensity score analysis was performed. We used Cox models to estimate hazard ratios (HRs) for each outcome associated with RASi prescription and tested interactions with age.

RESULTS

Patients' mean age was 67 years, including 841 (30%) aged 75 years and older; 2178 (79%) were prescribed RASi's. During a median follow-up of 4.6 years, 33% of patients reached kidney failure or died. RASi prescription was associated with a lower risk of kidney failure or death (HR 0.79, 95% CI 0.66, 0.95), an association not modified by age (P for interaction = .72). It was not significantly associated with cardiovascular events. During the first 3 years of follow-up, 14% of patients were hospitalized with AKI or hyperkalemia, but risk was not higher among those prescribed RASi's (HR 0.75, 95% CI 0.55-1.02) and age did not modify its effect (P for interaction = .28).

CONCLUSIONS AND IMPLICATIONS

This study shows that aging does not appear to modify either RASi's beneficial effects on major CKD outcomes or their potential adverse effects.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Thromboembolic and bleeding complications following primary total knee arthroplasty : a Danish nationwide cohort study

AIMS

The aim of this study is to compare the effectiveness and safety of thromboprophylactic treatments in patients undergoing primary total knee arthroplasty (TKA).

METHODS

Using nationwide medical registries, we identified patients with a primary TKA performed in Denmark between 1 January 2013 and 31 December 2018 who received thromboprophylactic treatment. We examined the 90-day risk of venous thromboembolism (VTE), major bleeding, and all-cause mortality following surgery. We used a Cox regression model to compute hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome, pairwise comparing treatment with dalteparin or dabigatran with rivaroxaban as the reference. The HRs were both computed using a multivariable and a propensity score matched analysis.

RESULTS

We identified 27,736 primary TKA patients who received thromboprophylactic treatment (rivaroxaban (n = 18,846); dalteparin (n = 5,767); dabigatran (n = 1,443); tinzaparin (n = 1,372); and enoxaparin (n = 308)). In the adjusted multivariable analysis and compared with rivaroxaban, treatment with dalteparin (HR 0.68 (95% CI 0.49 to 0.92)) or dabigatran (HR 0.31 (95% CI 0.13 to 0.70)) was associated with a decreased risk of VTE. No statistically significant differences were observed for major bleeding or all-cause mortality. The propensity score matched analysis yielded similar results.

CONCLUSION

Treatment with dalteparin or dabigatran was associated with a decreased 90-day risk of VTE following primary TKA surgery compared with treatment with rivaroxaban. Cite this article: Bone Joint J 2021;103-B(10):1571-1577.

The Value of Sentinel Lymph Node Mapping for the Staging of Node-Negative Colon Cancer: Propensity Score and Mediation Analyses

Objectives

Mediation analysis to assess the protective impact of sentinel lymph node (SLN) mapping on prognosis and survival of patients with colon cancer through a more precise evaluation of the lymph node (LN) status.

Background

Up to 20% of patients with node-negative colon cancer develop disease recurrence. Conventional histopathological LN examination may be limited in describing the real metastatic burden of LN.

Methods

Data of 312 patients with stage I & II colon cancer was collected prospectively. Patients were either staged using intraoperative SLN mapping with multilevel sectioning and immunohistochemical staining of the SLN or conventional techniques. The value of the SLN mapping for the detection of truly node-negative patients was assessed using Cox regression and mediation analysis.

Results

SLN mapping was performed in 143 patients. Disease recurrence was observed in 13 (9.1%) patients staged with SLN mapping and in 27 (16%) staged conventionally. Five-year overall survival (OS) rate was 82.7% (95% confidence interval [CI], 76.5-89.4%) with SLN mapping compared with 65.8% (95% CI, 58.8-73.7%). Five-year cancer-specific survival (CSS) was 95.1% (95% CI, 91.3-99.0%) with SLN mapping compared with 92.5% (95% CI, 88.0-97.2%). Node-negative staging with SLN mapping was associated with significantly better OS (hazard ratio [HR], 0.64; 95% CI, 0.56-0.72; P < 0.001) and CSS (HR, 0.49; 95% CI, 0.39-0.61; P < 0.001) in multivariate analysis. Mediation analysis confirmed a direct protective effect of SLN mapping on OS (HR, 0.78; 95% CI, 0.52-0.96; P < 0.01) and disease-free survival (DFS) (HR, 0.75; 95% CI, 0.48-0.89; P < 0.01).

Conclusions

Staging performed by SLN mapping with multilevel sectioning provides more accurate results than conventional staging. The observed clinically relevant and statistically significant benefit in OS and DFS is explained by a more accurate detection of positive LN by SLN mapping.

Correlation Analysis of Breast and Thyroid Nodules: A Cross-Sectional Study

Objective

Based on physical examination, to explore the relationship between breast mass (BM) and thyroid nodule (TN) prevalence, and to further explore other related factors that affect the occurrence of BM and TN.

Methods

From January 1, 2018, to January 1, 2021, 12,538 female subjects received breast and thyroid ultrasound examinations at the same time in the health examination center of the Affiliated Hospital of North Sichuan Medical College. Univariate analysis and multivariate logistic analysis were used to screen the relevant factors affecting TN and BM, and propensity score matching was used to further verify the results of the relationship between breast and thyroid.

Results

A total of 4975 (39.7%) of the included subjects have BM and a total of 6315 (50.4%) have TN,2557 (20.4%) had both BM and TN. The logistic regression results show that patients with TN are more likely to suffer from BM [OR = 1.185, 95% CI (1.099-1.278), p<0.0001]. In addition, age, free T4, HDL, height, BMI, systolic blood pressure, diastolic blood pressure, and albumin are independent factors affecting the occurrence of BM; patients with BM are more likely to have TN [OR = 1.180, 95% CI (1.094-1.272), p<0.0001], and age, free T3, free T4, AST, ALT, albumin, height, and BMI are independent influencing factors on the occurrence of TN. The result of propensity score matching confirmed the relationship between BM and TN.

Conclusion

There is a bidirectional pathogenic relationship between BM and TN, women with BM are at increased risk of TN, and women with TN are more likely to have BM. Thyroid hormone is not only related to the occurrence of TN but also affects the occurrence of BM.

Relationship between Masticatory Function and Bone Mineral Density in Community-Dwelling Elderly: A Cross-Sectional Study

The relationship between masticatory function and bone mineral density (BMD) is unclear. This cross-sectional study examined this relationship after adjusting for confounding factors. The subjects were 702 community-dwelling elderly adults (306 men, 396 women) who had been recruited for the Community-Based Healthcare Research and Education study in 2019. Objective masticatory function was assessed using the gummy jelly method. The median for each descriptive statistic was 69.0 years for age, 86.2% for the young adult mean, and 18.0 for masticatory function. Comparisons of the groups with good and poor masticatory function by sex revealed a significant difference in muscle mass and the tooth number for both sexes (p < 0.05). Men showed significant differences in age (p < 0.05) and salivary occult blood findings (p < 0.05). Multivariate analysis using propensity scores showed a significant association between masticatory function and BMD in both sexes (men: odds ratio 163.0, 95% confidence interval 1.36–19,610.55, p = 0.04; women: odds ratio 48.65, 95% confidence interval 1.52–1561.15, p = 0.03 in women). Masticatory function and BMD in the community-dwelling elderly may be related. However, other factors, including frailty and sarcopenia, may also be involved. Regular oral health care by dentists and dental hygienists may benefit this population.

Imputing missing patient-level data and propensity score matching in cost-effectiveness analysis in Crohn's disease

Objectives: The effect of imputing missing data followed by propensity score analysis on the incremental cost-effectiveness ratio (ICER) in a cost-effectiveness analysis is unknown. The objective was to compare alternative approaches in grouping data following imputation and prior to calculating propensity scores for use in economic evaluation.Methods: Patient-level data from an observational study of 573 children with Crohn's disease were used in a microsimulation model to determine the incremental cost of early anti-tumor necrosis factor-α treatment compared to standard care per remission week gained. Multiple imputation of a missing covariate followed by propensity score matching to create comparator groups was approached in two ways. The Within approach calculated propensity scores on each imputed dataset separately, while the Across method averaged propensity scores to create one matched population resulting in multiple sets of health state transition probabilities.Results: The incremental cost per remission week gained ranged from CAD$2,236 to CAD$12,464 (mean CAD$4,266) with Within datasets and was CAD$4,679 per remission week gained with the Across dataset.Conclusion: Imputation of missing patient-level data and propensity score analysis increases methodological uncertainty in cost-effectiveness analysis. The present study indicated that the Across approach may be less cumbersome, and slightly reduce bias and variance.

Comparison of porcine versus bovine pericardial bioprosthesis in the mitral position

BACKGROUND

There are no reports of midterm outcomes after mitral valve replacement with a 25-mm bioprosthesis in a large series of patients. This study aimed to examine perioperative and midterm outcomes of bioprosthetic valve choice, porcine or bovine pericardial, in the mitral position, focusing on 25-mm valves.

METHODS

From 2007 to 2018, 467 patients received a mitral bioprosthesis, with or without concomitant procedures. Of these, 111 (23.8%) were porcine, and 356 (76.2%) were bovine pericardial, and 219 patients (46.9%) received a 25-mm valve. A propensity-matched cohort of 192 patients was used for outcome analyses. The influence of the valve type on midterm survival and incidence of cardiac death was assessed. Similarly, subanalysis stratified by valve size was conducted.

RESULTS

In matched patients, there were no differences in midterm survival and incidence of cardiac death between the two groups (log-rank test; p = .268 and p = .097, respectively). There were no differences in midterm survival and incidence of cardiac death between the 25-mm valve and larger valve (log-rank test; p = .563 and p = .597, respectively). The Cox proportional-hazards model revealed that the valve type and 25-mm valve did not affect midterm survival (p = .487 and p = .375, respectively) and incidence of cardiac death (p = .678 and p = .562, respectively).

CONCLUSIONS

The choice of a porcine or bovine pericardial bioprosthesis does not affect midterm survival and cardiac death. The 25-mm valves, whether bovine or porcine, could be an appropriate alternative when the patient's body size is small.

Head-to-head comparison of biological drugs for inflammatory bowel disease: from randomized controlled trials to real-world experience

During past years, the increasing knowledge of molecular mechanisms of inflammatory bowel disease (IBD) have led to the development of several targeted biological therapies. This great expansion of available medical options has prompted the need for comparative data between drugs. For years, given that most randomized controlled trials (RCTs) were performed only versus placebo, this demand has clashed with the absence of head-to-head trials comparing two or more treatments. The quality of evidence coming from real-world experience was low overall, so it was extremely difficult to clarify the correct positioning of the biologicals inside the therapeutic algorithms for IBD. Fortunately, times are changing: head-to-head comparative RCTs have been conducted or are ongoing, and the methodological quality of real-world studies is gradually increasing, mainly thanks to a higher rate of application of statistical methods capable of reducing the selection bias, such as the propensity score. In this evolving scenario, the increasing number of comparative RCTs is providing high-quality data for a correct drug positioning in IBD. In parallel, real-world observational studies are supporting the data coming from RCTs, and covering those comparisons not performed in the RCT setting. We believe that there is moderate evidence already available to support clinicians in the correct choice between different biologicals, and data will certainly be more robust in the near future.

E-cigarette use is associated with subsequent cigarette use among young adult non-smokers, over and above a range of antecedent risk factors: a propensity score analysis

BACKGROUND AND AIMS

There is a public health concern that the use of e-cigarettes among non-smoking young adults could be associated with transition to combustible cigarette use. The current study is a quasi-experimental test of the relationship between e-cigarette use and subsequent combustible cigarette use among young adult non-smokers, accounting for a wide range of common risk factors.

DESIGN

Logistic regression was used to predict combustible cigarette use on three or more occasions at age 23 years based on age 21 e-cigarette use. Inverse probability weighting (IPW) was used to account for confounding variables.

SETTING

Data were drawn from the Community Youth Development Study (CYDS), a cohort study of youth recruited in 2003 in 24 rural communities in seven US. states PARTICIPANTS: Youth in the CYDS study (n = 4407) were surveyed annually from ages 11 to 16, and at ages 18, 19, 21 and 23 years (in 2016). The sample was gender balanced (50% female) and ethnically diverse (20% Hispanic, 64% white, 3% black and 12% other race or ethnicity). The current study was limited to participants who had never used combustible cigarettes by age 21 (n = 1825).

MEASUREMENTS

Age 21 use of e-cigarettes and age 23 use of combustible cigarettes (three or more occasions) were included in the regression analysis. Age 11-19 measures of 22 common predictors of both e-cigarette and combustible cigarette use (e.g. pro-cigarette attitudes, peer smoking, family monitoring) were used to create IPWs.

FINDINGS

After applying IPW, e-cigarette use at age 21 was associated with a twofold increase in odds of combustible cigarette use on three or more occasions 2 years later (odds ratio = 2.16, confidence interval 1.23, 3.79).

CONCLUSIONS

Among previously never-smoking US young adults, e-cigarette use appears to be strongly associated with subsequent combustible cigarette smoking, over and above measured preexisting risk factors.

Short-Course Versus Long-Course Colistin for Treatment of Carbapenem-Resistant A.baumannii in Cancer Patient

Carbapenem-resistant Acinetobacter baumannii (CRAB) is one of the most commonly reported nosocomial infections in cancer patients and could be fatal because of suboptimal immune defenses in these patients. We aimed to compare clinical response, microbiological response, nephrotoxicity, and 30-day mortality between cancer patients who received short (<14 days) and long (≥14 days) courses of colistin for treatment of CRAB infection. A retrospective cohort study was conducted in cancer patients with CRAB infection who received short or long courses of colistin between 2015 to 2017 at Chiang Mai University Hospital (CMUH). A total of 128 patients met the inclusion criteria. The results of this study show that patients who received long course of colistin therapy had a higher rate of clinical response; adjusted odds ratio (OR) was 3.16 times in patients receiving long-course colistin therapy (95%CI, 1.37–7.28; p value = 0.007). Microbiological response in patients with long course was 4.65 times (adjusted OR) higher than short course therapy (95%CI, 1.72–12.54; p value = 0.002). Moreover, there was no significant difference in nephrotoxicity (adjusted OR, 0.91, 95%CI, 0.39–2.11; p value = 0.826) between the two durations of therapy. Thirty-day mortality in the long-course therapy group was 0.11 times (adjusted OR) compared to the short-course therapy group (95%CI, 0.03–0.38; p value = 0.001). Propensity score analyses also demonstrated similar results. In conclusion, cancer patients who received a long course of colistin therapy presented greater clinical and microbiological responses and lower 30-day mortality but similar nephrotoxicity as compared with those who a received short course. Therefore, a long course of colistin therapy should be considered for management of CRAB infection in cancer patients.

Generalizability of Eccentric Exercise for Patients with Subacromial Pain Syndrome to Real-world Clinical Practice: A Propensity Score-based Analysis

Objectives:

Subacromial pain syndrome is a common problem in primary care. Although several randomized controlled trials have shown that eccentric exercise is effective in patients with subacromial pain syndrome, its generalizability to real-world clinical practice is unknown. This study aimed to investigate, using propensity score analysis, the generalizability of eccentric exercise for patients with subacromial pain syndrome to real-world daily clinical practice.

Methods:

In this study, 78 patients underwent eccentric exercise in addition to traditional exercise, and 77 patients underwent only traditional exercise for 4 weeks. Outcomes measured using a visual analog scale (VAS) and American Shoulder and Elbow Surgeons Society Standardized Shoulder Assessment Form (ASES) scores were assessed at baseline and at 4 weeks.

Results:

In the propensity score-matched analysis, 65 patients in each group were successfully matched (130 of 155 patients, 84% overall). After 4 weeks of exercise, pain intensity was lower in the eccentric exercise group than in the traditional exercise group (VAS −14.5, 95% CI −21.2 to −7.9, P<0.001). No significant difference in the improvement in function was found between the two groups (ASES 4.1, 95% CI −2.0 to 10.2, P=0.18).

Conclusions:

Eccentric and traditional exercise in combination could reduce pain in patients with subacromial pain syndrome to a greater extent than traditional exercise alone. These findings have clinical relevance to primary care practitioners who provide conservative treatment for patients with subacromial pain syndrome.

Relationship between Oral Health Status and Bone Mineral Density in Community-Dwelling Elderly Individuals: A Cross-Sectional Study

The relationship between oral health status and bone mineral density has been poorly elucidated. We conducted a cross-sectional study to examine the relationship between oral health status and bone mineral density with data from healthy community-dwelling elderly individuals in Ohnan-cho, Shimane Japan who were recruited in 2019 for the Shimane Center for Community-Based Health Research and Education (CoHRE) study. The study included 702 participants (306 men and 396 women). The median age, bone mineral density, and number of remaining teeth were 69.0 years, 86.2%, and 26.0, respectively. The two groups (Low teeth group and High teeth group) showed significant differences in age, hemoglobin A1c (HbA1c) level, and masticatory function in men (p < 0.05). In women, age, number of untreated teeth, and masticatory function were significantly different (p < 0.05). The odds ratio of propensity score analysis for the association between the number of remaining teeth and bone mineral density was 27.7 (95% confidence interval: 1.86–414.9, p < 0.05). The number of remaining teeth could be associated with bone mineral density in the healthy elderly women, and no significant association was observed in men. Number of remaining teeth and bone mineral density may be interrelated, and oral care by dentists/dental hygienists may play an important role in maintaining bone mineral density in elderly women.

Parkinson's Disease Cognitive Phenotypes Show Unique Clock Drawing Features when Measured with Digital Technology

BACKGROUND

A companion paper (Crowley et al., 2020) reports on the neuroimaging and neuropsychological profiles of statistically determined idiopathic non-dementia Parkinson's disease (PD).

OBJECTIVE

The current investigation sought to further examine subtle behavioral clock drawing differences within the same PD cohort by comparing 1) PD to non-PD peers on digitally acquired clock drawing latency and graphomotor metrics, and 2) PD memory, executive, and cognitively well phenotypes on the same variables.

METHODS

230 matched participants (115 PD, 115 non-PD) completed neuropsychological tests and dCDT. Statistically-derived PD cognitive phenotypes characterized PD participants as PD low executive (PDExe; n = 25), PD low memory (PDMem; n = 34), PD cognitively well (PDWell; n = 56). Using a Bayesian framework and based on apriori hypotheses, we compared groups on: total completion time (TCT), pre-first hand latency (PFHL), post-clock face latency (PCFL), total clock face area (TCFA), and total number of pen strokes.

RESULTS

Fewer strokes and slower performance to command were associated with higher odds of PD diagnosis, while a larger clock face in the copy condition was associated with lower odds of PD diagnosis. Within PD cognitive phenotypes, slower performance (TCT, PCFL) and smaller clock face to command were associated with higher odds of being PDExe than PDWell, whereas larger clock faces associated with higher odds of being PDMem than PDWell. Longer disease duration, more pen strokes (command) and smaller clocks (command) associated with higher odds of being PDExe than PDWell.

CONCLUSION

Digitally-acquired clock drawing profiles differ between PD and non-PD peers, and distinguish PD cognitive phenotypes.

Survival after pulmonary metastasectomy for relapsed osteosarcoma

OBJECTIVES

The purpose of this study was to evaluate the postrelapse survival of relapsed osteosarcoma with pulmonary metastases in patients who received pulmonary metastasectomy using intent to treat and propensity score analysis.

METHODS

Patients with osteosarcoma who relapsed with pulmonary metastases between 2004 and 2018 who were treated in a hospital affiliated with a medical school were included. All the enrolled patients were evaluated as operable with assessment algorithm at the time of diagnosis of pulmonary relapse and intent to treat analysis was done. Multiple propensity score methods (eg, matching, stratification, covariate adjustment, and inverse probability of treatment weighting) were performed to balance confounding bias. Cox proportional hazards regression and the Kaplan-Meier method were used to evaluate patient survival.

RESULTS

A total of 125 patients met the study criteria. Of these, 59 (47.2%) patients received pulmonary metastasectomy combined with chemotherapy and 66 (52.8%) received chemotherapy alone. The 2-year and 5-year postrelapse survival rate of metastasectomy group and nonmetastasectomy group were 68.4% versus 25.0% and 41.0% versus 0%, respectively. The median postrelapse survival was 24.9 versus 13.5 months, respectively. Pulmonary metastasectomy was independently associated with improved survival (hazard ratio, 0.185; 95% confidence interval, 0.103-0.330; P < .001). These results were confirmed by multiple propensity score analyses. Further stratified analysis revealed that the survival advantage associated with metastasectomy was not significant in patients with metastases involving ≥3 lung lobes and patients with very high pretreatment serum alkaline phosphatase (more than twice the upper limit).

CONCLUSIONS

Pulmonary metastasectomy is associated with improved survival in patients with recurrent osteosarcoma.

Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta

OBJECTIVE

To compare conservative management and cesarean hysterectomy in patients with placenta increta or percreta.

MATERIALS AND METHODS

In this multicenter retrospective study, we recorded data on 2219 patients with placenta increta or percreta from 20 tertiary care centers in China from 1 January 2011 to 31 December 2015. Propensity score analysis was used to control for baseline characteristics. We divided patients into conservative management (C) and hysterectomy (H) groups. The primary outcome was operative/postoperative maternal morbidity; secondary outcomes were maternal-neonatal outcomes.

RESULTS

In total, 17.9% (398/2219) of patients had placenta increta and percreta; 82.1% (1821/2219) of the patients were in group C. After propensity score matching, 140 pairs of patients from the two groups underwent one-to-one matching. Group C showed less average blood loss within 24 h of surgery (1518 ± 1275 vs. 4309 ± 2550 ml in group H, p<.001). There were more patients with blood loss >1000 ml in group H than in group C (93.6% [131/140] vs. 61.4% [86/140], p<.001). More patients received blood transfusions in group H than in group C (p=.014). There was no significant difference between the groups in terms of bladder injury, postoperative anemia, fever, and disseminated intravascular coagulation. Neonatal outcomes in the two groups were similar.

CONCLUSION

Either conservative management or hysterectomy should be considered after thorough evaluation and detailed discussion of risks and benefits. A balance between bleeding control and fertility can be achieved.

Propensity scores using missingness pattern information: a practical guide

Electronic health records are a valuable data source for investigating health-related questions, and propensity score analysis has become an increasingly popular approach to address confounding bias in such investigations. However, because electronic health records are typically routinely recorded as part of standard clinical care, there are often missing values, particularly for potential confounders. In our motivating study-using electronic health records to investigate the effect of renin-angiotensin system blockers on the risk of acute kidney injury-two key confounders, ethnicity and chronic kidney disease stage, have 59% and 53% missing data, respectively. The missingness pattern approach (MPA), a variant of the missing indicator approach, has been proposed as a method for handling partially observed confounders in propensity score analysis. In the MPA, propensity scores are estimated separately for each missingness pattern present in the data. Although the assumptions underlying the validity of the MPA are stated in the literature, it can be difficult in practice to assess their plausibility. In this article, we explore the MPA's underlying assumptions by using causal diagrams to assess their plausibility in a range of simple scenarios, drawing general conclusions about situations in which they are likely to be violated. We present a framework providing practical guidance for assessing whether the MPA's assumptions are plausible in a particular setting and thus deciding when the MPA is appropriate. We apply our framework to our motivating study, showing that the MPA's underlying assumptions appear reasonable, and we demonstrate the application of MPA to this study.

Using Meta-Analysis and Propensity Score Methods to Assess Treatment Effects Toward Evidence-Based Practice in Extensive Reading

This study aimed to depict the assessment process of treatment effects of extensive reading in a second language (L2) toward the establishment of an evidence-based practice. Although standardized mean differences between treatment and control groups have been applied to interpret the magnitude of treatment effects in observational studies on L2 teaching, individual effect sizes vary according to differences in learners, measures, teaching approaches, and research quality. Prior research on extensive reading has suffered from methodological restrictions, especially due to a lack of appropriate comparison between treatment and control groups. For these reasons, a retrospective meta-analysis including only studies that ensured between-group equivalence was conducted in Study 1 to estimate the effect sizes of extensive reading expected in specific teaching environments. When the focused skill of the one-semester program was reading comprehension, its effect size was predicted as d = 0.55. However, the moderator analysis showed that this treatment effect was overestimated due to selection bias in the analyzed studies and adjusted the effect size from 0.55 to 0.37. In Study 2, propensity score analysis was applied to minimize selection bias attributed to observed confounding variables in the comparison between non-randomized treatment and control groups. Data were collected from 109 Japanese university students of English who received in-class extensive reading for one semester and 115 students who attended another English class as the control group. Various types of matching were attempted, and in consideration of balancing the five covariates that might affect treatment effect estimation, the best solutions were nearest neighborhood matching without replacement, nearest neighborhood matching with replacement, and full matching. The results showed that the average treatment effects of extensive reading on all the participants (d = 0.24–0.44) and on the treated individuals (d = 0.32–0.40) were both consistent with the benchmark established in Study 1. Pedagogical implications and methodological limitations are discussed for decision-making regarding the implementation of L2 teaching practices based on research evidence.

Do In-Prison Correctional Programs Affect Postrelease Employment and Earnings?

The objective of this research is to examine the effects of general educational development (GED) attainment in prison and therapeutic community participation on postrelease employment and earnings. The participants are all males released from prisons in Idaho during 2004. The dependent variables are employment and mean quarterly earnings up to 57 months after release. Propensity score matching analysis was used to enhance the equivalence of the comparison groups, with a small percentage of overly influential observations trimmed. Logistic regression was used to examine the effects of programming on employment. GED had no effect on employment. The effect of therapeutic community approached significance. The statistical analyses on earnings used generalized linear models based on the gamma distribution due to the highly skewed distribution of this variable. These analyses found that GED had no effect on earnings and that participation in a therapeutic community had a highly significant effect on mean quarterly earnings.

Effects of Surgery on Survival of Early-Stage Patients With SCLC: Propensity Score Analysis and Nomogram Construction in SEER Database

Purpose: We aimed to assess the survival benefit of surgery for patients with stage IA–IIB small cell lung cancer (SCLC) and construct a nomogram for predicting overall survival (OS).

Methods: Patients who had been diagnosed with stage IA–IIB SCLC between 2004 and 2014 and who had received active treatment were selected from the Surveillance, Epidemiology, and End Results database. The primary endpoint was OS. Cox proportional hazards models and propensity score (PS) analyses were used to compare the associations between surgery and OS. The probability of 1- and 3-year OS was predicted using a nomogram.

Results: We reviewed 2,246 patients. The median OS of the surgery and non-surgery groups was 35 months and 19 months, respectively. Multivariable Cox proportional hazards models showed a survival benefit in the surgery group (hazards ratio [HR], 0.642; 95% confidence interval [CI], 0.557–0.740; P < 0.001). To balance the between-group measurable confounders, the impact of surgery on OS was assessed using PS matching. After PS matching, OS analysis still favored surgical resection. The PS-stratification, PS-weighting, and PS-adjustment models showed similar results to demonstrate a statistically significant benefit for surgery. Further, the nomogram was well calibrated and had good discriminative ability (Harrell's C-index = 0.645).

Conclusion: Our analysis suggests that surgery is a viable option for patients with early-stage SCLC. Our nomogram is a viable tool for quantifying treatment trade-off assumptions and may assist clinicians in decision-making. Future work is needed to validate our results and improve our tools.

Association between adjuvant posterior repair and success of native tissue apical suspension

BACKGROUND

Posterior repairs and perineorrhaphies are often performed in prolapse surgery to reduce the size of the genital hiatus. The benefit of an adjuvant posterior repair at the time of sacrospinous ligament fixation or uterosacral ligament suspension is unknown.

OBJECTIVE

We aimed to determine whether an adjuvant posterior repair at transvaginal apical suspension is associated with improved surgical success.

MATERIALS AND METHODS

This secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial compared 24-month outcomes in 190 participants who had a posterior repair (posterior repair group) and 184 who did not (no posterior repair group) at the time of sacrospinous ligament fixation or uterosacral ligament suspension. Concomitant posterior repair was performed at the surgeon's discretion. Primary composite outcome of "surgical success" was defined as no prolapse beyond the hymen, point C ≤ -2/3 total vaginal length, no bothersome bulge symptoms, and no retreatment at 24 months. The individual components were secondary outcomes. Propensity score methods were used to build models that balanced posterior repair group and the no posterior repair group for ethnographic factors and preoperative Pelvic Organ Prolapse Quantification values. Adjusted odds ratios were calculated to predict surgical success based on the performance of a posterior repair. Groups were also compared with unadjusted χ² analyses. An unadjusted probability curve was created for surgical success as predicted by preoperative genital hiatus.

RESULTS

Women in the posterior repair group were less likely to be Hispanic or Latina, and were more likely to have had a prior hysterectomy and to be on estrogen therapy. The groups did not differ with respect to preoperative Pelvic Organ Prolapse Quantification stage; however, subjects in the posterior repair group had significantly greater preoperative posterior wall prolapse. There were no group differences in surgical success using propensity score methods (66.7% posterior repair vs 62.0% no posterior repair; adjusted odds ratio, 1.07; 95% confidence interval, 0.56-2.07; P = 0.83) or unadjusted test (66.2% posterior repair vs 61.7% no posterior repair; P = 0.47). Individual outcome measures of prolapse recurrence (bothersome bulge symptoms, prolapse beyond the hymen, or retreatment for prolapse) also did not differ by group. Similarly, there were no differences between groups in anatomic outcomes of any individual compartment (anterior, apical, or posterior) at 24 months. There was high variation in performance of posterior repair by surgeon (interquartile range, 15-79%). The unadjusted probability of overall success at 24 months, regardless of posterior repair, decreased with increasing genital hiatus, such that a genital hiatus of 4.5 cm was associated with 65.8% success (95% confidence interval, 60.1-71.1%).

CONCLUSION

Concomitant posterior repair at sacrospinous ligament fixation or uterosacral ligament suspension was not associated with surgical success after adjusting for baseline covariates using propensity scores or unadjusted comparison. Posterior repair may not compensate for the pathophysiology that leads to enlarged preoperative genital hiatus, which remains prognostic of prolapse recurrence.

Venoarterial Extracorporeal Membrane Oxygenation for Severe Neonatal Acute Respiratory Distress Syndrome in a Developing Country

Objective: Extracorporeal membrane oxygenation (ECMO) has supported oxygen delivery and carbon dioxide removal in neonatal severe respiratory failure for more than 4 decades. The definition and diagnosis of neonatal acute respiratory distress syndrome (ARDS) was made according to the criteria first established by a Montreux Conference in 2017. By far, there has been no ECMO efficiency studies in neonatal ARDS. We aimed to compare the outcomes of neonates with severe ARDS supported with and without ECMO. Design: Retrospective pair-matched study. Setting: In the present retrospective pair-matched study, the outcomes of severe ARDS with ECMO support and without ECMO support were analyzed and compared. Propensity score matching was conducted. The study subjects were selected from a China Neonatal ECMO (CNECMO) study. In total, five hospitals were included in the CNECMO study. The patients were matched with demographic and clinical data. The primary endpoint was in-hospital mortality. Secondary outcomes included ventilator-time, ICU stay, hospitalization costs and cranial MRI results. Patients: 145 neonates with severe ARDS (Oxygenation Index, OI ≥16) from 5 hospitals. Interventions: No interventions. Measurements and Main Results: We collected the data of 145 neonates with severe ARDS (Oxygenation Index, OI≥16) from 5 hospitals. Among them, 42 neonates received venoarterial (VA) ECMO support, and the remaining 103 neonates were treated with conventional mechanical ventilation. The mortality of ECMO-supported neonates was not significantly different compared with the ESLO neonatal respiratory-supported from 2012 to 2018 (23.8 vs. 32.5%, p = 0.230). After matching with the propensity score we got 31 pairs. The ECMO-supported neonates had a lower in-hospital mortality (6 of 31, 19.4%) vs. non ECMO-supported patients (18 of 31, 58.1%) (p = 0.002). Hospitalization costs of survivors in ECMO-supported neonates were significantly higher than that of non-ECMO-supported neonates (p < 0.001). There was no difference of ventilator-times (p = 0.206), ICU stay (p = 0.879) and cranial MRI (p = 0.899) between the survivors of ECMO-supported and non-ECMO-supported neonates with ARDS. Conclusions: By far, there has been no ECMO efficiency studies in neonatal ARDS. This study found that ECMO-support have superior outcomes compared with non-ECMO-support in neonates with severe ARDS.

Savings ownership and the use of maternal health services in Indonesia

In low- and middle-income countries (LMICs), many women of reproductive age experience morbidity and mortality attributable to inadequate access to and use of health services. Access to personal savings has been identified as a potential instrument for empowering women and improving access to and use of health services. Few studies, however, have examined the relation between savings ownership and use of maternal health services. In this study, we used data from the Indonesian Family Life Survey to examine the relation between women's savings ownership and use of maternal health services. To estimate the effect of obtaining savings ownership on our primary outcomes, specifically receipt of antenatal care, delivery in a health facility and delivery assisted by a skilled attendant, we used a propensity score weighted difference-in-differences approach. Our findings showed that acquiring savings ownership increased the proportion of women who reported delivering in a health facility by 22 percentage points [risk difference (RD) = 0.22, 95%CI = 0.08-0.37)] and skilled birth attendance by 14 percentage points (RD = 0.14, 95%CI = 0.03-0.25). Conclusions were qualitatively similar across a range of model specifications used to assess the robustness of our main findings. Results, however, did not suggest that savings ownership increased the receipt of antenatal care, which was nearly universal in the sample. Our findings suggest that under certain conditions, savings ownership may facilitate the use of maternal health services, although further quasi-experimental and experimental research is needed to address threats to internal validity and strengthen causal inference, and to examine the impact of savings ownership across different contexts.

Blinatumomab compared with standard of care for the treatment of adult patients with relapsed/refractory Philadelphia chromosome-positive B-precursor acute lymphoblastic leukemia

Background

A single‐arm, phase 2 trial demonstrated the efficacy and safety of blinatumomab, a bispecific T‐cell–engaging antibody construct, in patients with relapsed/refractory (r/r) Philadelphia chromosome–positive (Ph+) acute lymphoblastic leukemia (ALL), a rare hematologic malignancy with limited treatment options. This study compared outcomes with blinatumomab with those of a historical control treated with the standard of care (SOC).

Methods

The blinatumomab trial enrolled adult patients with Ph+ ALL who were r/r to at least 1 second‐generation tyrosine kinase inhibitor (n = 45). Propensity score analysis (PSA) was used to compare outcomes with blinatumomab with those of an external cohort of similar patients receiving SOC chemotherapy (n = 55). The PSA mitigated confounding variables between studies by adjusting for imbalances in the age at diagnosis and start of treatment, sex, duration from diagnosis to most recent treatment, prior allogeneic hematopoietic stem cell transplantation, prior salvage therapy, and number of salvage therapies. Bayesian data augmentation was applied to improve power to 80% with data from a phase 3 blinatumomab study in r/r Philadelphia chromosome–negative ALL.

Results

In the PSA, the rate of complete remission or complete remission with partial hematologic recovery was 36% for blinatumomab and 25% for SOC, and this resulted in an odds ratio of 1.54 (95% confidence interval [CI], 0.61‐3.89) or 1.70 (95% credible interval [CrI], 0.94‐2.94) with Bayesian data augmentation. Overall survival favored blinatumomab over SOC, with a hazard ratio of 0.81 (95% CI, 0.57‐1.14) or 0.77 (95% CrI, 0.61‐0.96) with Bayesian data augmentation.

Conclusions

These results further support blinatumomab as a treatment option for patients with r/r Ph+ ALL.

A single‐arm, phase 2 trial has demonstrated the efficacy and safety of blinatumomab, a bispecific T‐cell–engaging antibody construct, in patients with relapsed/refractory (r/r) Philadelphia chromosome–positive (Ph+) acute lymphoblastic leukemia (ALL), a rare hematologic malignancy with limited treatment options. Using propensity score analysis, this study demonstrates that efficacy outcomes (complete remission and overall survival) from the phase 2 trial with blinatumomab compare favorably with those for a cohort of similar patients with r/r Ph+ ALL treated with standard‐of‐care chemotherapy.

Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy

BACKGROUND

Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high-risk conditions related to the first cesarean delivery and are known to recur.

OBJECTIVE

The objective of the study was to determine whether there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery.

STUDY DESIGN

This was a retrospective cohort study of women with the first 2 consecutive singleton deliveries (2007-2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared with women whose first pregnancy resulted in a vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women who underwent a cesarean delivery with those who underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous vs indicated), late preterm delivery (34-36 6/7 weeks), early preterm delivery (<34 weeks), and small-for-gestational-age birth.

RESULTS

Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%). The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8) and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery. The risks of preterm delivery in the second pregnancy among women with a previous cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio, 1.46, 95% confidence interval, [CI] 0.77-2.76). In an analysis stratified by the type of preterm delivery in the second pregnancy, no associations were seen between cesarean delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted odds ratio, 1.40, 95% confidence interval, 0.59-3.32) or indicated preterm delivery (1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60-2.46). Similarly, no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted odds ratio, 1.13, 95% confidence interval, 0.55-2.29), early preterm delivery (1.6% vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59-2.67), or neonates with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%; adjusted odds ratio, 1.26, 95% confidence interval, 0.52-3.06).

CONCLUSION

After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.

Outcomes of gastrectomy following upfront chemotherapy in advanced gastric cancer patients with a single noncurable factor: a cohort study

Purpose

Chemotherapy is the standard care for patients with incurable advanced gastric cancer. Whether or when the addition of gastrectomy to chemotherapy improves survival of advanced gastric cancer patients with a single noncurable factor remains controversial. We aimed to evaluate the superiority of gastrectomy following chemotherapy vs chemotherapy alone regarding overall survival (OS) in these patients.

Patients and methods

Patients with advanced gastric cancer from January 2008 to December 2014 were retrieved from our prospectively acquired database and retrospectively analyzed. The patients with a single noncurable factor were grouped in terms of cancer treatment: chemotherapy alone or gastrectomy following chemotherapy.

Results

Four hundred and fourteen patients (333 chemotherapy alone and 81 gastrectomy following chemotherapy) were included in this study. Kaplan–Meier survival curve showed a significant difference on median OS between chemotherapy-alone group and the gastrectomy plus chemotherapy group (10.9 vs 15.9 months, P<0.01). After propensity score analysis (n=126), chemotherapy plus surgery (81 patients) also showed survival benefit over chemotherapy alone (35 patients) (15.9 vs 10.0 months, P<0.01). Furthermore, stratified analyses indicated that patients with liver metastasis, <65 years of age, male, having normal level of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA199) upon diagnosis, or having nongastro-esophageal junction tumor benefited from surgery.

Conclusion

This study suggests that gastrectomy after chemotherapy could lead to survival benefit over chemotherapy alone in advanced gastric cancer patients with a single nonresectable factor if the disease was controllable by chemotherapy.

A Propensity Score Analysis of Homework Adherence-Outcome Relations in Cognitive Behavioral Therapy for Depression

Little is known about whether or not a consistently high level of homework adherence over the course of therapy benefits patients. This question was examined in two samples of patients who were receiving individual Cognitive Behavioral Therapy (CBT) for depression (Ns = 128 [Sequenced Treatment Alternatives to Relieve Depression: STAR-D] and 183 [Continuation Phase Cognitive Therapy Relapse Prevention: C-CT-RP]). Logistic and linear regression and propensity score models were used to identify whether or not clinician assessments of homework adherence differentiated symptom reduction and remission, as assessed by the Hamilton Depression Rating Scale-17 (HDRS-17), the Quick Inventory of Depressive Symptomatology-Self-Reported Scale (QIDS-SR), and the QIDS-Clinician Scale (QIDS-C). CBT-related response and remission were equally likely between both high and low homework adherers in both studies and in all models. But in propensity adjusted models that adjusted for session attendance, for both the STAR-D and C-CT-RP samples, greater homework adherence was significantly associated with greater response and remission from depression in the first and last 8 sessions of CBT. Our results suggest that homework adherence can account for response and remission early and late in treatment, with adequate session attendence.