Performance of existing risk scores around heart transplantation: validation study in a 4‐year cohort

Several risk scores exist to help identify best candidate recipients for heart transplantation (HTx). This study describes the performance of five heart failure risk scores and two post‐HTx mortality risk scores in a French single‐centre cohort. All patients listed for HTx through a 4‐year period were included. Waiting‐list risk scores [Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC), Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE‐HF) and Get With The Guidelines‐Heart Failure (GWTG‐HF)] and post‐HTx scores Index for Mortality Prediction After Cardiac Transplantation (IMPACT and CARRS) were computed. Main outcomes were 1‐year mortality on waiting list and after HTx. Performance was assessed using receiver operator characteristic (ROC), calibration and goodness‐of‐fit analyses. The cohort included 414 patients. Waiting‐list mortality was 14.0%, and post‐HTx mortality was 16.3% at 1‐year follow‐up. Heart failure risk scores had adequate discrimination regarding waiting‐list mortality (ROC AUC for HFSS = 0.68, SHFM = 0.74, OPTIMIZE‐HF = 0.72, MAGGIC = 0.70 and GWTG = 0.77; all P‐values <0.05). On the contrary, post‐HTx risk scores did not discriminate post‐HTx mortality (AUC for IMPACT = 0.58, and CARRS = 0.48, both P‐values >0.50). Subgroup analysis on patients undergoing HTx after ventricular assistance device (VAD) implantation (i.e. bridge‐to‐transplantation) (n = 36) showed an IMPACT AUC = 0.72 (P < 0.001). In this single‐centre cohort, existing heart failure risk scores were adequate to predict waiting‐list mortality. Post‐HTx mortality risk scores were not, except in the VAD subgroup.     

Regional Variation in Survival Before and After Pediatric Heart Transplantation—An Analysis of The UNOS Database

Geographic variation occurs in a variety of health outcomes. Regional influences on outcomes before and after listing for pediatric heart transplantation have not been assessed. Review of the UNOS dataset identified 5398 pediatric (≤18 years) patients listed for heart transplantation 2000–2011. Patients were stratified based on the region of listing. Regional‐level variables were correlated with individual risk‐adjusted outcomes. Mean time spent on the waitlist varied from 91.0 ± 163 days (Region 6 [R6]) to 248.1 ± 493 days (R4, p < 0.0001). Regions with more transplant centers (p < 0.0001) and fewer transplants (p = 0.0015) had higher waitlist mortality. Risk‐adjusted individual waitlist mortality varied from 6.9% (R1, CI 6.2–7.8) to 19.2% (R5, CI 18.0–20.6). Waitlist mortality was higher for individuals awaiting transplant in regions with more listings per center (OR 1.04, CI 1.01–1.08) and lower in regions with more donors per center (OR 0.95, CI 0.90–0.99 per donor). Posttransplant risk‐adjusted survival varied across regions (R4: 5.4%, CI 4.2–7.4; R7: 18.0%, CI 12.4–32.5), but regional variables were not correlated with outcomes. Outcomes among children undergoing heart transplantation vary by region. Factors leading to increased competition for donor allografts are associated with poorer waitlist survival. Equitable allocation of cardiac allografts requires further investigation of these findings.     

Interaction between socioeconomic deprivation and likelihood of pre‐emptive transplantation: influence of competing risks and referral characteristics – a retrospective study

Socioeconomic deprivation (SED) influences likelihood of pre‐emptive kidney transplantation (PET), but the mechanisms behind this are unclear. We explored the relationships between SED and patient characteristics at referral, which might explain this discrepancy. A retrospective cohort study was performed. SED was measured by Scottish Index of Multiple Deprivation (SIMD). Logistic regression evaluated predictors of PET. A competing risks survival analysis evaluated the interaction between SED and progression to end‐stage kidney disease (ESKD) and death. Of 7765 patients with follow‐up of 5.69 ± 6.52 years, 1298 developed ESKD requiring RRT; 113 received PET, 64 of which were from live donors. Patients receiving PET were “less deprived” with higher SIMD (5 ± 7 vs. 4 ± 5; P = 0.003). This appeared independent of overall comorbidity burden. SED was associated with a higher risk of death but not ESKD. Higher SIMD decile was associated with a higher likelihood of PET (OR 1.14, 95% CI 1.06, 1.23); the presence of diabetes and malignancy also reduced PET. SED was associated with reduced likelihood of PET after adjustment for baseline comorbidity, and this was not explained by risk of death or faster progression to ESKD. Education and outreach into transplantation should be augmented in areas with higher deprivation.     

Recently accepted for the waiting list for heart or lung transplantation - patients' experiences of information and support

The aim of the study was to describe the patients' experiences of the information and support they received after being placed on the waiting list for a heart or lung transplant. The design was qualitative, and the critical incident technique was used. Incidents were collected via interviews with 21 patients. A total of 357 important events, both positive and negative, were identified and divided into two main groups: Body and mind and Information and support. The following subgroups emerged: chronic illness affects the patients, attitudes towards the future, impact of information, support from public organizations, and support from the private sphere. The patients showed knowledge of and involvement in the upcoming transplantation, which indicates that healthcare professionals managed to convey information and support effectively. By identifying the importance of factors such as body and mind and information and support for patients recently accepted for heart or lung transplantation, healthcare professionals are able to make specific improvements in the information and support that they provide. An important implication is to enhance the knowledge regarding transplant patients in other institutions and improve cooperation. Specific support programs to assist patients who have dependent children should be developed. Society needs to become more enlightened about organ donation and transplantation patients.     

Comparison of mortality outcomes after radical prostatectomy versus radiotherapy in patients with localized prostate cancer: A population‐based analysis

Objectives: To compare the mortality outcomes of radical prostatectomy and radiotherapy as treatment modalities for patients with localized prostate cancer. Methods: Our cohort consisted of 68 665 patients with localized prostate cancer, treated with radical prostatectomy or radiotherapy, between 1992 and 2005. Propensity‐score matching was used to minimize potential bias related to treatment assignment. Competing‐risks analyses tested the effect of treatment type on cancer‐specific mortality, after accounting for other‐cause mortality. All analyses were stratified according to prostate cancer risk groups, baseline Charlson Comorbidity Index and age. Results: For patients treated with radical prostatectomy versus radiotherapy, the 10‐year cancer‐specific mortality rates were 1.4 versus 3.9% in low‐intermediate risk prostate cancer and 6.8 versus 11.5% in high‐risk prostate cancer, respectively. Rates were 2.4 versus 5.9% in patients with Charlson Comorbidity Index of 0, 2.4 versus 5.1% in patients with Charlson Comorbidity Index of 1, and 2.9 versus 5.2% in patients with Charlson Comorbidity Index of ≥2. Rates were 2.1 versus 5.0% in patients aged 65–69 years, 2.8 versus 5.5% in patients aged 70–74 years, and 2.9 versus 7.6% in patients aged 75–80 years (all P < 0.001). At multivariable analyses, radiotherapy was associated with less favorable cancer‐specific mortality in all categories (all P < 0.001). Conclusions: Patients treated with radical prostatectomy fare substantially better than those treated with radiotherapy. Patients with high‐risk prostate cancer benefit the most from radical prostatectomy. Conversely, the lowest benefit was observed in patients with low‐intermediate risk prostate cancer and/or multiple comorbidities. An intermediate benefit was observed in the other examined categories.     

In‐Series Versus In‐Parallel Mechanical Circulatory Support for the Right Heart: A Simulation Study

Right heart failure (RHF) is a serious health issue with increasing incidence and high mortality. Right ventricular assist devices (RVADs) have been used to support the end‐stage failing right ventricle (RV). Current RVADs operate in parallel with native RV, which alter blood flow pattern and increase RV afterload, associated with high tension in cardiac muscles and long‐term valve complications. We are developing an in‐series RVAD for better RV unloading. This article presents a mathematical model to compare the effects of RV unloading and hemodynamic restoration on an overloaded or failing RV. The model was used to simulate both in‐series (sRVAD) and in‐parallel (pRVAD) (right atrium‐pulmonary artery cannulation) support for severe RHF. The results demonstrated that sRVAD more effectively unloads the RV and restores the balance between RV oxygen supply and demand in RHF patients. In comparison to simulated pRVAD and published clinical and in silico studies, the sRVAD was able to provide comparable restoration of key hemodynamic parameters and demonstrated superior afterload and volume reduction. This study concluded that in‐series support was able to produce effective afterload reduction and preserve the valve functionality and native blood flow pattern, eliminating complications associated with in‐parallel support.     

Beyond rose colored glasses: the adaptive role of depressive and anxious symptoms among individuals with heart failure who were evaluated for transplantation

The prospect of and the evaluative period for transplantation can be stressful for individuals with heart failure (HF). Little is known about the impact of psychosocial factors on service utilization and health outcomes. The current study examined the impact of depression, dysthymia, and anxiety on two-yr hospitalization and mortality among 96 individuals with HF who were evaluated for transplantation. Results revealed that only a small percentage of individuals endorsed sufficient symptomatology to meet criteria for a psychiatric, Axis I disorder (3.1% = anxiety; 2.1% = depression; 1.0% = dysthymia) although a significant proportion of the sample was prescribed an antidepressant or an anxiolytic (37%). Multivariable regression analysis was conducted to examine the association between significant independent demographic, medical, and psychiatric predictors and total duration of hospitalizations; logistic regression analysis was used to examine the relation between predictors and mortality. An increase in anxious symptoms was associated with a decrease in total number of days hospitalized during the two-yr period following the initial evaluation. Similarly, as depressive symptoms increased, risk of two-yr mortality decreased. Future research should assess communication between the patient and providers to further elucidate the potential relationship between psychiatric symptoms, service utilization/hospitalization, and mortality in this patient population.     

Comparison of two equivalent model for end‐stage liver disease scores for hepatocellular carcinoma patients using data from the United Network for Organ Sharing liver transplant waiting list registry

Patients with hepatocellular carcinoma (HCC) have been advantaged on the liver transplant waiting list within the United States, and a 6‐month delay and exception point cap have recently been implemented to address this disparity. An alternative approach to prioritization is an HCC‐specific scoring model such as the MELD Equivalent (MELD_EQ) and the mixed new deMELD. Using data on adult patients added to the UNOS waitlist between 30 September 2009 and 30 June 2014, we compared projected dropout and transplant probabilities for patients with HCC under these two models. Both scores matched actual non‐HCC dropout in groups with scores <22 and improved equity with non‐HCC transplant probabilities overall. However, neither score matched non‐HCC dropout accurately for scores of 25–40 and projected dropout increased beyond non‐HCC probabilities for scores <16. The main differences between the two scores were as follows: (i) the MELD_EQ assigns 6.85 more points after 6 months on the waitlist and (ii) the deMELD gives greater weight to tumor size and laboratory MELD. Post‐transplant survival was lower for patients with scores in the 22–30 range compared with those with scores <16 (P = 0.007, MELD_EQ; P = 0.015, deMELD). While both scores result in better equity of waitlist outcomes compared with scheduled progression, continued development and calibration is recommended.     

MELD scores with incorporation of serum sodium and death prediction in cirrhotic patients on the waiting list for liver transplantation: a single center experience in southern Brazil

To compare the accuracy of standard model for end‐stage liver disease (MELD) score with that of four MELD‐based scores incorporating serum sodium (SNa) to predict three‐ and six‐month mortality in cirrhotic patients after their placement on the waiting list for liver transplantation (LT). A cohort study was performed. Receiver operating characteristic (ROC) curves were generated for MELD, MELD incorporating SNa (MELD‐Na, MELD‐Na2), integrated MELD (iMELD), and MELD to SNa ratio (MESO) index to assess the predictive accuracy of these scores to determine three‐ and six‐month mortality. The c‐statistic (area under the ROC curve [AUC]) was used to determine predictive power and the Cox proportional‐hazard ratio to estimate death risk. We studied 558 patients. There was a statistically significant difference in the predictive accuracy of scores at three months (AUCs: MELD = 0.79 [95% CI = 0.72–0.87]; MELD‐Na = 0.84 [95% CI = 0.78–0.90]; MELD‐Na2 = 0.85 [95% CI = 0.80–0.91]; iMELD = 0.85 [95% CI = 0.80–0.90]; MESO = 0.81 [95% CI = 0.80–0.91]) and at six months (MELD = 0.73 [95% CI = 0.67–0.80]; MELD‐Na = 0.79 [95% CI = 0.73–0.84]; MELD‐Na2 = 0.80 [95% CI = 0.74–0.85]; iMELD = 0.80 [95% CI = 0.75–0.85]; MESO = 0.75 [95% CI = 0.69–0.81]) (p < 0.001). Death risk was independent of age and sex. Sodium‐modified MELD scores are able to more accurately predict three‐ and six‐month mortality among cirrhotic patients awaiting LT.     

Hypertension might be a risk factor for erectile dysfunction: a meta‐analysis

The study aimed to evaluate whether hypertension was a risk factor for erectile dysfunction (ED). Databases including PubMed and Embase were retrieved to identify studies related to hypertension in ED patients. Odds ratio (OR) and 95% confidence interval (CI) were used as the effect size. Subgroup analyses stratified by total number of enrolled subjects and research regions were performed. Sensitivity analysis was performed by removing a single study at one time. Egger's test was used to evaluate the publication bias. Totally, 40 studies including 121,641 subjects were included in the meta‐analysis. As a result, hypertension was closely related to ED (OR = 1.74, 95% CI, 0.63–0.80, p < .01). Subgroup analysis indicated hypertension was the risk factor for ED whatever the participants numbers. When stratified by different regions, hypertension was a risk factor for ED in Africa (OR = 3.35, 95% CI, 1.45–7.77, p < .01), Americas (OR = 1.97, 95% CI, 1.68–2.31, p < 0.01), Asia (OR = 1.46, 95% CI, 1.16–1.84, p < .01) and Europe (OR = 1.83, 95% CI, 1.34–2.49, p < .01), but not in Australia. Hypertension may be a potential risk factor for ED.