Hip bone geometry in HIV/HCV-co-infected men and healthy controls

Summary

People with both HIV and hepatitis C are more likely than those with HIV alone to have wrist, hip, and spine fractures. We compared hip strength between HIV/HCV-co-infected men and healthy men and found that HIV/HCV-co-infected men had decreased hip strength due to lower lean body mass.

Introduction

Hepatitis C co-infection is a risk factor for fragility fracture among HIV-infected populations. Whether bone strength is compromised in HIV/HCV-co-infected patients is unknown.

Methods

We compared dual-energy x-ray absorptiometry (DXA)-derived hip geometry, a measure of bone strength, in 88 HIV/HCV-co-infected men from the Johns Hopkins HIV Clinic to 289 men of similar age and race and without HIV or HCV from the Boston Area Community Health Survey/Bone Survey. Hip geometry was assessed at the narrow neck, intertrochanter, and shaft using hip structural analysis. Lean body mass (LBM), total fat mass (FM), and fat mass ratio (FMR) were measured by whole-body DXA. Linear regression was used to identify body composition parameters that accounted for differences in bone strength between cohorts.

Results

HIV/HCV-co-infected men had lower BMI, LBM, and FM and higher FMR compared to controls (all p?p?Conclusion HIV/HCV-co-infected men have compromised hip strength at the narrow neck compared to uninfected controls, which is attributable in large part to lower lean body mass.     

Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments

Background

Missed appointments (MA) are frequent, but there are no studies on the effects of the first MA at supportive care outpatient clinics on clinical outcomes.

Methods

We determined the frequency of MA among all patients referred to our clinic from January–December 2011 and recorded the clinical and demographic data and outcomes of 218 MA patients and 217 consecutive patients who kept their first appointments (KA).

Results

Of 1,352 advanced-cancer patients referred to our clinic, 218 (16 %) had an MA. The MA patients’ median age was 57 years (interquartile range, 49–67). The mean time between referral and appointment was 7.4 days (range, 0–71) for KA patients vs. 9.1 days (range, 0–89) for MA patients (P?=?0.006). Reasons for missing included admission to the hospital (17/218 [8 %]), death (4/218 [2 %]), appointments with primary oncologists (37/218 [18 %]), other appointments (19/218 [9 %]), visits to the emergency room (ER) (9/218 [9 %]), and unknown (111/218 [54 %]). MA patients visited the ER more at 2 weeks (16/214 [7 %] vs. 5/217 [2 %], P?=?0.010) and 4 weeks (17/205 [8 %] vs. 8/217 [4 %], P?=?0.060). Median-survival duration for MA patients was 177 days (range, 127–215) vs. 253 days (range, 192–347) for KA patients (P?=?0.013). Multivariate analysis showed that MAs were associated with longer time between referral and scheduled appointment (odds ratio [OR], 1.026/day, P?=?0.030), referral from targeted therapy services (OR, 2.177, P?=?0.004), living in Texas/Louisiana regions (OR, 2.345, P?=?0.002), having an advanced directive (OR, 0.154, P?P?=?0.0003).

Conclusion

MA patients with advanced cancer have worse survival and increased ER utilization than KA patients. Patients at higher risk for MA should undergo more aggressive follow-up. More research is needed.     

Comparison of three different tools for prediction of seminal vesicle invasion at radical prostatectomy

Background

Statistical prediction tools are increasingly common, but there is considerable disagreement about how they should be evaluated. Three tools—Partin tables, the European Society for Urological Oncology (ESUO) criteria, and the Gallina nomogram—have been proposed for the prediction of seminal vesicle invasion (SVI) in patients with clinically localized prostate cancer who are candidates for a radical prostatectomy.

Objectives

Using different statistical methods, we aimed to determine which of these tools should be used to predict SVI.

Design, settings, and participants

The independent validation cohort consisted of 2584 patients treated surgically for clinically localized prostate cancer at four North American tertiary care centers between 2002 and 2007.

Interventions

Robot-assisted laparoscopic radical prostatectomy.

Outcome measurements and statistical analysis

Primary outcome was the presence of SVI. Traditional (area under the receiver operating characteristic [ROC] curve, calibration plots, the Brier score, sensitivity and specificity, positive and negative predictive value) and novel (decision curve analysis and predictiveness curves) statistical methods quantified the predictive abilities of the three models.

Results and limitations

Traditional statistical methods (ie, ROC plots and Brier scores) could not clearly determine which one of the three SVI prediction tools should be preferred. For example, ROC plots and Brier scores seemed biased against the binary decision tool (ESUO criteria) and gave discordant results for the continuous predictions of the Partin tables and the Gallina nomogram. The results of the calibration plots were discordant with those of the ROC plots. Conversely, the decision curve indicated that the Partin tables represent the best strategy for stratifying the risk of SVI, resulting in the highest net benefit within the whole range of threshold probabilities.

Conclusions

When predicting SVI, surgeons should prefer the Partin tables over the ESUO criteria and the Gallina nomogram because this tool provided the highest net benefit. In contrast to traditional statistical methods, decision curve analysis gave an unambiguous result applicable to both continuous and binary models, providing an insight into clinical utility.     

The effect of insurance status on outcomes after partial nephrectomy

Background

Privately insured patients may have favorable health outcomes when compared to those covered by federally funded initiatives. This study explored the effect of insurance status on five short-term outcomes after partial nephrectomy (PN).

Methods

Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on PNs performed between 1998 and 2007. We tested the rates of in-hospital mortality, blood transfusions, prolonged length of stay, as well as intraoperative and postoperative complications, stratified according to insurance status. Multivariable logistic regression analyses fitted with general estimation equations for clustering among hospitals further adjusted for confounding factors.

Results

Overall, 8,513 PNs were identified. Of those, most patients were privately insured (53.5%), followed by Medicare (37.5%), uninsured (4.6%) and Medicaid (4.4%). Medicare and Medicaid patients had higher rates of transfusions (P?P?P?P?P?=?0.015) and length of stay beyond the median (OR?=?1.4, P?Conclusion Patients with private insurance undergoing PN have better short-term outcomes, when compared to their publicly insured counterparts.     

The effect of annual surgical caseload on the rates of in-hospital pneumonia and other in-hospital outcomes after radical prostatectomy

Purpose

To examine the effect of annual surgical caseload (ASC) on contemporary in-hospital pneumonia (IHP) rates and three other in-hospital outcomes after radical prostatectomy (RP).

Methods

Between 1999 and 2008, 34,490 open RPs were performed in the state of Florida. First, logistic regression models predicting the rate of IHP were fitted. Second, other logistic regression models examined the association between IHP and three other outcomes: in-hospital mortality, hospital charges within the highest quartile, and length of stay (LOS) within the highest quartile. Covariates included ASC, age, race, baseline Charlson Comorbidity Index (CCI), interval between admission and surgery, as well as blood transfusion.

Results

The overall IHP rate was 0.5%. It was higher in patients operated within the low (0.7%) and intermediate (0.5%) ASC tertile versus high ASC tertile (0.2%, P?P?P?P?$37,333, and were 20-fold more likely to have a LOS >3?days (all P?Conclusions RP by high ASC surgeons exerts a protective effect on IHP rates. Additionally, IHP is associated with higher in-hospital mortality, prolonged LOS, and higher hospital charges.     

Propensity-score-matched comparison of perioperative outcomes between open and laparoscopic nephroureterectomy: a national series

Background

Nephroureterectomy (NU) represents the primary management for patients with nonmetastatic upper tract urothelial carcinoma (UTUC). Either an open NU (ONU) or a laparoscopic NU (LNU) may be considered. Despite the presence of several reports comparing perioperative and cancer-control outcomes between the two approaches, no reports relied on a population-based cohort.

Objectives

Examine intraoperative and postoperative morbidity of ONU and LNU in a population-based cohort.

Design, setting, and participants

We relied on the US Nationwide Inpatient Sample (NIS) to identify patients with nonmetastatic UTUC treated with ONU or LNU between 1998 and 2009. Overall, 7401 (90.8%) and 754 (9.2%) patients underwent ONU and LNU, respectively. To adjust for potential baseline differences between the two groups, propensity-score-based matching was performed. This resulted in 3016 (80%) ONU patients matched to 754 (20%) LNU patients.

Intervention

All patients underwent NU.

Measurements

The rates of intra- and postoperative complications, blood transfusions, prolonged length of stay (pLOS), and in-hospital mortality were assessed for both procedures. Multivariable logistic regression analyses were performed within the cohort after propensity-score matching.

Results and limitations

For ONU versus LNU respectively, the following rates were recorded: blood transfusions, 15% versus 10% (p < 0.001); intraoperative complications, 4.7% versus 2.1% (p = 0.002); postoperative complications, 17% versus 15% (p = 0.24); pLOS (≥5 d), 47% versus 28% (p < 0.001); in-hospital mortality, 1.3% versus 0.7% (p = 0.12). In multivariable logistic regression analyses, LNU patients were less likely to receive a blood transfusion (odds ratio [OR]: 0.6; p < 0.001), to experience any intraoperative complications (OR: 0.4; p = 0.002), and to have a pLOS (OR: 0.4; p < 0.001). Overall, postoperative complications were equivalent. However, LNU patients had fewer respiratory complications (OR: 0.4; p = 0.007). This study is limited by its retrospective nature.

Conclusions

After adjustment for potential selection biases, LNU is associated with fewer adverse intra- and perioperative outcomes than ONU.     

Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores

Background

Few predictive models aimed at predicting the presence of lymph node invasion (LNI) in patients with prostate cancer (PCa) treated with extended pelvic lymph node dissection (ePLND) are available to date.

Objective

Update a nomogram predicting the presence of LNI in patients treated with ePLND at the time of radical prostatectomy (RP).

Design, setting, and participants

The study included 588 patients with clinically localised PCa treated between September 2006 and October 2010 at a single tertiary referral centre.

Intervention

All patients underwent RP and ePLND invariably including removal of obturator, external iliac, and hypogastric nodes.

Measurements

Prostate-specific antigen, clinical stage, and primary and secondary biopsy Gleason grade as well as percentage of positive cores were included in univariable (UVA) and multivariable (MVA) logistic regression models predicting LNI and formed the basis for the regression coefficient-based nomogram. The area under the curve (AUC) method was used to quantify the predictive accuracy (PA) of the model.

Results and limitations

The mean number of lymph nodes removed and examined was 20.8 (median: 19; range: 10-52). LNI was found in 49 of 588 patients (8.3%). All preoperative PCa characteristics differed significantly between LNI-positive and LNI-negative patients (all p < 0.001). In UVA predictive accuracy analyses, percentage of positive cores was the most accurate predictor of LNI (AUC: 79.5%). At MVA, clinical stage, primary biopsy Gleason grade, and percentage of positive cores were independent predictors of LNI (all p ≤ 0.006). The updated nomogram demonstrated a bootstrap-corrected PA of 87.6%. Using a 5% nomogram cut-off, 385 of 588 patients (65.5%) would be spared ePLND. and LNI would be missed in only 6 patients (1.5%). The sensitivity, specificity, and negative predictive value associated with the 5% cut-off were 87.8%, 70.3%, and 98.4%, respectively. The relatively low number of patients included as well as the lack of an external validation represent the main limitations of our study.

Conclusions

We report the first update of a nomogram predicting the presence of LNI in patients treated with ePLND. The nomogram maintained high accuracy, even in more contemporary patients (87.6%). Because percentage of positive cores represents the foremost predictor of LNI, its inclusion should be mandatory in any LNI prediction model. Based on our model, those patients with a LNI risk < 5% might be safely spared ePLND.