scholarly journals Between-centre differences for COVID-19 ICU mortality from early data in England

2020 ◽  
Author(s):  
Zhaozhi Qian ◽  
Ahmed M. Alaa ◽  
Mihaela van der Schaar ◽  
Ari Ercole
Keyword(s):  
Lead Time ◽  
Proportional Hazards ◽  
Mixed Effects ◽  
Early Data ◽  
Shared Decision ◽  
Icu Mortality ◽  
Time Effects ◽  
Factors Associated ◽  
Early Results ◽  
Icu Outcome

The high numbers of COVID-19 patients developing severe respiratory failure has placed exceptional demands on ICU capacity around the world. Understanding the determinants of ICU mortality is important for surge planning and shared decision making. We used early data from the COVID-19 Hospitalisation in England Surveillance System (from the start of data collection 8th February -22nd May 2020) to look for factors associated with ICU outcome in the hope that information from such timely analysis may be actionable before the outbreak peak. Immunosuppressive disease, chronic cardiorespiratory/renal disease and age were key determinants of ICU mortality in a proportional hazards mixed effects model. However variation in site-stratified random effects were comparable in magnitude suggesting substantial between-centre variability in mortality. Notwithstanding possible ascertainment and lead-time effects, these early results motivate comparative effectiveness research to understand the origin of such differences and optimise surge ICU provision.

scholarly journals A foci cohort analysis to monitor successful and persistent foci under Thailand’s Malaria Elimination Strategy

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Prayuth Sudathip ◽  
Suravadee Kitchakarn ◽  
Jui A. Shah ◽  
Donal Bisanzio ◽  
Felicity Young ◽  
...  
Keyword(s):  
Malaria Elimination ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Forest Disturbance ◽  
Cohort Analysis ◽  
Information Criteria ◽  
Factors Associated ◽  
Malaria Burden ◽  
Hazards Model ◽  
Autochthonous Transmission

Abstract Background Thailand’s success in reducing malaria burden is built on the efficient “1-3-7” strategy applied to the surveillance system. The strategy is based on rapid case notification within 1 day, case investigation within 3 days, and targeted foci response to reduce the spread of Plasmodium spp. within 7 days. Autochthonous transmission is still occurring in the country, threatening the goal of reaching malaria-free status by 2024. This study aimed to assess the effectiveness of the 1-3-7 strategy and identify factors associated with presence of active foci. Methods Data from the national malaria information system were extracted from fiscal years 2013 to 2019; after data cleaning, the final dataset included 81,012 foci. A Cox’s proportional hazards model was built to investigate factors linked with the probability of becoming an active focus from 2015 to 2019 among foci that changed status from non-active to active focus during the study period. We performed a model selection technique based on the Akaike Information Criteria (AIC). Results The number of yearly active foci decreased from 2227 to 2013 to 700 in 2019 (68.5 %), and the number of autochthonous cases declined from 17,553 to 3,787 (78.4 %). The best Cox’s hazard model showed that foci in which vector control interventions were required were 18 % more likely to become an active focus. Increasing compliance with the 1-3-7 strategy had a protective effect, with a 22 % risk reduction among foci with over 80 % adherence to 1-3-7 timeliness protocols. Other factors associated with likelihood to become or remain an active focus include previous classification as an active focus, presence of Plasmodium falciparum infections, level of forest disturbance, and location in border provinces. Conclusions These results identified factors that favored regression of non-active foci to active foci during the study period. The model and relative risk map align with the national malaria program’s district stratification and shows strong spatial heterogeneity, with high probability to record active foci in border provinces. The results of the study may be useful for honing Thailand’s program to eliminate malaria and for other countries aiming to accelerate malaria elimination.

scholarly journals Trends and factors associated with modification or discontinuation of the initial antiretroviral regimen during the first year of treatment in the Turkish HIV-TR Cohort, 2011–2017

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Volkan Korten ◽  
◽  
Deniz Gökengin ◽  
Gülhan Eren ◽  
Taner Yıldırmak ◽  
...  
Keyword(s):  
Proportional Hazards ◽  
Virologic Failure ◽  
Risk Function ◽  
Transcriptase Inhibitor ◽  
Cox Proportional Hazards ◽  
Antiretroviral Drugs ◽  
Competing Risk ◽  
First Year ◽  
Strand Transfer ◽  
Factors Associated

Abstract Background There is limited evidence on the modification or stopping of antiretroviral therapy (ART) regimens, including novel antiretroviral drugs. The aim of this study was to evaluate the discontinuation of first ART before and after the availability of better tolerated and less complex regimens by comparing the frequency, reasons and associations with patient characteristics. Methods A total of 3019 ART-naive patients registered in the HIV-TR cohort who started ART between Jan 2011 and Feb 2017 were studied. Only the first modification within the first year of treatment for each patient was included in the analyses. Reasons were classified as listed in the coded form in the web-based database. Cumulative incidences were analysed using competing risk function and factors associated with discontinuation of the ART regimen were examined using Cox proportional hazards models and Fine-Gray competing risk regression models. Results The initial ART regimen was discontinued in 351 out of 3019 eligible patients (11.6%) within the first year. The main reason for discontinuation was intolerance/toxicity (45.0%), followed by treatment simplification (9.7%), patient willingness (7.4%), poor compliance (7.1%), prevention of future toxicities (6.0%), virologic failure (5.4%), and provider preference (5.4%). Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based (aHR = 4.4, [95% CI 3.0–6.4]; p < 0.0001) or protease inhibitor (PI)-based regimens (aHR = 4.3, [95% CI 3.1–6.0]; p < 0.0001) relative to integrase strand transfer inhibitor (InSTI)-based regimens were significantly associated with ART discontinuation. ART initiated at a later period (2015-Feb 2017) (aHR = 0.6, [95% CI 0.4–0.9]; p < 0.0001) was less likely to be discontinued. A lower rate of treatment discontinuation for intolerance/toxicity was observed with InSTI-based regimens (2.0%) than with NNRTI- (6.6%) and PI-based regimens (7.5%) (p < 0.001). The percentage of patients who achieved HIV RNA < 200 copies/mL within 12 months of ART initiation was 91% in the ART discontinued group vs. 94% in the continued group (p > 0.05). Conclusion ART discontinuation due to intolerance/toxicity and virologic failure decreased over time. InSTI-based regimens were less likely to be discontinued than PI- and NNRTI-based ART.

scholarly journals Implementation of Shared Decision Making for Lung Cancer Screening Among the Privately Insured Nonelderly

2021 ◽  
Vol 6 (1) ◽  
pp. 238146832098477
Author(s):  
Ya-Chen Tina Shih ◽  
Ying Xu ◽  
Lisa M. Lowenstein ◽  
Robert J. Volk
Keyword(s):  
Lung Cancer ◽  
Decision Making ◽  
Cancer Screening ◽  
Shared Decision Making ◽  
Private Insurance ◽  
Lung Cancer Screening ◽  
Shared Decision ◽  
Factors Associated ◽  
Coverage Policy ◽  
Privately Insured

Introduction. The Centers for Medicare & Medicaid Services requires a written order of shared decision making (SDM) visit in its coverage policy for low-dose computed tomography (LDCT) for lung cancer screening (LCS). With screening eligibility starting at age 55, private insurance plans will likely adopt this coverage policy. This study examined the implementation of SDM in the context of LCS among the privately insured. Methods. We constructed two study cohorts from MarketScan Commercial Claims and Encounters database 2016-2017: a LDCT cohort who received LDCT for LCS and an SDM cohort who had an LCS-related SDM visit. For the LDCT cohort, we examined the trend and factors associated with the receipt of SDM within 3 months prior to LDCT. For the SDM cohort, we studied the trend and factors associated with LDCT within 3 months after an SDM visit. Results. For privately insured adults aged <64, 93% (19,681/21,084) of the LDCT cohort did not have a billing claim indicating SDM, although the uptake of SDM increased from 3.1% in 1Q2016 to 8.2% in 4Q2017 ( P < 0.0001). For the SDM cohort, 46% (948/2048) did not have a claim for an LDCT for lung cancer screening in the 3 months after the SDM visit; this percentage increased from 29.5% in 1Q2016 to 61.8% in 3Q2017 ( P < 0.0001). Limitations. Findings cannot be generalized to other nonelderly adults without private insurance. Additionally, the rate of SDM identified from claims may be underreported. Conclusions. We found a growing but low uptake of SDM among privately insured individuals who underwent LDCT. The higher rate of LDCT in the SDM cohort than the rate reported in national studies emphasized the importance of patient awareness.

scholarly journals Nephrectomy Delay of More than 10 Weeks from Diagnosis Is Associated with Decreased Overall Survival in pT3 RCC

2021 ◽  
Vol 8 (2) ◽  
pp. 27-33
Author(s):  
Jiping Zeng ◽  
Ken Batai ◽  
Benjamin Lee
Keyword(s):  
Risk Factors ◽  
Overall Survival ◽  
Logistic Regression ◽  
Proportional Hazards ◽  
Surgical Margin ◽  
Cox Proportional Hazards ◽  
Cancer Center ◽  
Integrated Network ◽  
Factors Associated ◽  
The Impact

In this study, we aimed to evaluate the impact of surgical wait time (SWT) on outcomes of patients with renal cell carcinoma (RCC), and to investigate risk factors associated with prolonged SWT. Using the National Cancer Database, we retrospectively reviewed the records of patients with pT3 RCC treated with radical or partial nephrectomy between 2004 and 2014. The cohort was divided based on SWT. The primary out-come was 5-year overall survival (OS). Logistic regression analysis was used to investigate the risk factors associated with delayed surgery. Cox proportional hazards models were fitted to assess relations between SWT and 5-year OS after adjusting for confounding factors. A total of 22,653 patients were included in the analysis. Patients with SWT > 10 weeks had higher occurrence of upstaging. Using logistic regression, we found that female patients, African-American or Spanish origin patients, treatment in academic or integrated network cancer center, lack of insurance, median household income of <$38,000, and the Charlson–Deyo score of ≥1 were more likely to have prolonged SWT. SWT > 10 weeks was associated with decreased 5-year OS (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.15–1.33). This risk was not markedly attenuated after adjusting for confounding variables, including age, gender, race, insurance status, Charlson–Deyo score, tumor size, and surgical margin status (adjusted HR, 1.13; 95% CI, 1.04–1.24). In conclusion, the vast majority of patients underwent surgery within 10 weeks. There is a statistically significant trend of increasing SWT over the study period. SWT > 10 weeks is associated with decreased 5-year OS.

Lymph node yield is an independent predictor of survival in rectal cancer regardless of receipt of neoadjuvant therapy

2016 ◽  
Vol 70 (7) ◽  
pp. 584-592 ◽  
Author(s):  
Zhaomin Xu ◽  
Mariana E Berho ◽  
Adan Z Becerra ◽  
Christopher T Aquina ◽  
Bradley J Hensley ◽  
...  
Keyword(s):  
Rectal Cancer ◽  
Lymph Node ◽  
Neoadjuvant Therapy ◽  
Neoadjuvant Treatment ◽  
Neoadjuvant Chemoradiation ◽  
Mixed Effects ◽  
Patient Factors ◽  
Lymph Node Yield ◽  
Factors Associated ◽  
Node Yield

AimsLymph node yield (LNY) is used as a marker of adequate oncological resection. The American Joint Committee on Cancer (AJCC) currently recommends that at least 12 nodes are necessary to confirm node-negative disease for rectal cancer. A LNY of 12 is not always achieved, particularly in patients who have undergone neoadjuvant treatment. This study attempts to examine factors associated with LNY and its prognostic impact following neoadjuvant chemoradiation in rectal cancer.MethodsThe 2006–2011 National Cancer Data Base was queried for patients with clinical stage I–III rectal cancer who underwent a proctectomy. Suboptimal LNY was defined as <12 lymph nodes examined. A mixed-effects multinomial logistic regression model was used to identify independent factors associated with LNY. Mixed-effects Cox proportional hazards models were used to estimate the adjusted effect of LNY on 5-year overall survival.Results25 447 patients met inclusion criteria. Overall, 62% of the cohort received neoadjuvant chemoradiation and 32% had suboptimal LNY. The median LNY for patients who received neoadjuvant therapy was 13 (IQR: 9–18) and for patients who did not receive neoadjuvant therapy was 15 (IQR: 12–21). After risk adjustment, there was a 3.5-fold difference in the rate of suboptimal LNY among individual hospitals (27%–95%). Suboptimal LNY was independently associated with an 18% increased hazard of death among patients who did not receive neoadjuvant treatment and a 20% increased hazard of death among those who did receive neoadjuvant treatment when controlled for adjuvant treatment, staging, proximal/distal margins and other patient factors.ConclusionsSuboptimal LNY is independently associated with worse overall survival regardless of neoadjuvant therapy, pathological staging and patient factors in rectal cancer. This finding underlies the importance and challenge of an optimal lymph node evaluation for prognostication, especially for patients receiving neoadjuvant therapy.

scholarly journals Longterm Outcomes of 188 Japanese Patients with Eosinophilic Granulomatosis with Polyangiitis

2018 ◽  
Vol 45 (8) ◽  
pp. 1159-1166 ◽  
Author(s):  
Aiko Saku ◽  
Shunsuke Furuta ◽  
Masaki Hiraguri ◽  
Kei Ikeda ◽  
Yoshihisa Kobayashi ◽  
...  
Keyword(s):  
Granulomatosis With Polyangiitis ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Disease Onset ◽  
Japanese Patients ◽  
Eosinophilic Granulomatosis With Polyangiitis ◽  
Factors Associated ◽  
Hazards Model ◽  
Eosinophilic Granulomatosis ◽  
Eosinophil Counts

Objective.Patients with eosinophilic granulomatosis with polyangiitis (EGPA) frequently experience relapses, which lead to cumulative organ damage. In this retrospective observational study, we aimed to reveal the risk factors for relapse in EGPA.Methods.A total of 188 Japanese patients with EGPA diagnosed between 1996 and 2015 were identified from medical records in 10 hospitals. The diagnosis was based on the American College of Rheumatology 1990 criteria or Lanham’s criteria. Baseline characteristics, treatments, asthma exacerbation, and relapses were evaluated by retrospective chart review.Results.The median followup period was 56 months. The median age at disease onset was 59.7 years. At the disease onset, 95.2% of the patients had a history of bronchial asthma and 44.7% were positive for antineutrophil cytoplasmic antibodies. The cumulative survival and relapse-free survival rates at 5 years were 89.6% and 64.0%, respectively. Multivariate analysis with 2 models, proportional hazards, and competing risk models, was performed to identify the factors associated with relapse. The proportional hazards model identified azathioprine (AZA) maintenance therapy and high eosinophil counts at onset as independent factors with lower relapse risks, and high immunoglobulin E (IgE) levels at onset as a risk factor for relapse. The competing risk model identified no statistically significant factors.Conclusion.Although potential benefit of AZA maintenance therapy in preventing relapse of EGPA was suggested by the proportional hazards model, there was a discrepancy in the results between the models. Eosinophil counts and IgE levels at onset were also identified as candidates of factors associated with relapse in EGPA.

scholarly journals Factors associated with non-invasive mechanical ventilation failure in patients with hematological neoplasia and their association with outcomes

2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Lídia Miranda Barreto ◽  
◽  
Cecilia Gómez Ravetti ◽  
Thiago Bragança Athaíde ◽  
Renan Detoffol Bragança ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Clinical Judgment ◽  
Oxygen Therapy ◽  
Invasive Mechanical Ventilation ◽  
Ventilatory Support ◽  
Orotracheal Intubation ◽  
Icu Mortality ◽  
Factors Associated ◽  
Non Invasive ◽  
Ventilation Failure

Abstract Background The usefulness of non-invasive mechanical ventilation (NIMV) in oncohematological patients is still a matter of debate. Aim To analyze the rate of noninvasive ventilation failure and the main characteristics associated with this endpoint in oncohematological patients with acute respiratory failure (ARF). Methods A ventilatory support protocol was developed and implemented before the onset of the study. According to the PaO2/FiO2 (P/F) ratio and clinical judgment, patients received supplementary oxygen therapy, NIMV, or invasive mechanical ventilation (IMV). Results Eighty-two patients were included, average age between 52.1 ± 16 years old; 44 (53.6%) were male. The tested protocol was followed in 95.1% of cases. Six patients (7.3%) received IMV, 59 (89.7%) received NIMV, and 17 (20.7%) received oxygen therapy. ICU mortality rates were significantly higher in the IMV (83.3%) than in the NIMV (49.2%) and oxygen therapy (5.9%) groups (P < 0.001). Among the 59 patients who initially received NIMV, 30 (50.8%) had to eventually be intubated. Higher SOFA score at baseline (1.35 [95% CI = 1.12–2.10], P = 0.007), higher respiratory rate (RR) (1.10 [95% CI = 1.00–1.22], P = 0.048), and sepsis on admission (16.9 [95% CI = 1.93–149.26], P = 0.011) were independently associated with the need of orotracheal intubation among patients initially treated with NIMV. Moreover, NIMV failure was independently associated with ICU (P < 0.001) and hospital mortality (P = 0.049), and mortality between 6 months and 1 year (P < 0.001). Conclusion The implementation of a NIMV protocol is feasible in patients with hematological neoplasia admitted to the ICU, even though its benefits still remain to be demonstrated. NIMV failure was associated with higher SOFA and RR and more frequent sepsis, and it was also related to poor prognosis.

scholarly journals Variation in Surgeons’ Requests for General Anesthesia When Scheduling Carpal Tunnel Release

Hand ◽  
2019 ◽  
Vol 15 (5) ◽  
pp. 608-614
Author(s):  
Alex H. S. Harris ◽  
Esther L. Meerwijk ◽  
Robin N. Kamal ◽  
Erika D. Sears ◽  
Mary Hawn ◽  
...  
Keyword(s):  
General Anesthesia ◽  
Carpal Tunnel ◽  
Carpal Tunnel Release ◽  
Veterans Health Administration ◽  
Mixed Effects ◽  
Veterans Health ◽  
Health Administration ◽  
Patient Factors ◽  
Factors Associated ◽  
Future Clinical Practice

Background: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons’ requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities. Methods: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques. Results: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients. Conclusions: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.

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