Liver cirrhosis is a major yet largely preventable and underappreciated cause of global health loss. Variations in cirrhosis mortality at the country level reflect differences in prevalence of risk ...factors such as alcohol use and hepatitis B and C infection. We estimated annual age-specific mortality from liver cirrhosis in 187 countries between 1980 and 2010.
We systematically collected vital registration and verbal autopsy data on liver cirrhosis mortality for the period 1980 to 2010. We corrected for misclassification of deaths, which included deaths attributed to improbable or nonfatal causes. We used ensemble models to estimate liver cirrhosis mortality with uncertainty by age, sex, country and year. We used out-of-sample predictive validity to select the optimal model.
Global liver cirrhosis deaths increased from around 676,000 (95% uncertainty interval: 452,863 to 1,004,530) in 1980 to over 1 million (1,029,042; 670,216 to 1,554,530) in 2010 (about 2% of the global total). Over the same period, the age-standardized cirrhosis mortality rate decreased by 22%. This was largely driven by decreasing cirrhosis mortality rates in China, the US and countries in Western Europe. In 2010, Egypt, followed by Moldova, had the highest age-standardized cirrhosis mortality rates, 72.7 and 71.2 deaths per 100,000, respectively, while Iceland had the lowest. In Egypt, almost one-fifth (18.1%) of all deaths in males 45- to 54-years old were due to liver cirrhosis. Liver cirrhosis mortality in Mexico is the highest in Latin America. In France and Italy, liver cirrhosis mortality fell by 50% to 60%; conversely, in the United Kingdom, mortality increased by about one-third. Mortality from liver cirrhosis was also comparatively high in Central Asia countries, particularly Mongolia, Uzbekistan and Kyrgyzstan, and in parts of sub-Saharan Africa, notably Gabon.
Liver cirrhosis is a significant cause of global health burden, with more than one million deaths in 2010. Our study identifies areas with high and/or rapidly increasing mortality where preventive measures to control and reduce liver cirrhosis risk factors should be urgently strengthened.
Purpose To compare overall survival between patients who received neoadjuvant therapy (NAT) followed by resection and those who received upfront resection (UR)-as well as a subgroup of UR patients ...who also received adjuvant therapy-for early-stage resectable pancreatic adenocarcinoma. Patients and Methods Adult patients with resected, clinical stage I or II adenocarcinoma of the head of the pancreas were identified in the National Cancer Database from 2006 to 2012. Patients who underwent NAT followed by curative-intent resection were matched by propensity score with patients whose tumors were resected upfront. Overall survival was compared by using a Cox proportional hazards regression model. Early postoperative and oncologic outcomes were evaluated. Results We identified 15,237 patients with clinical stage I or II resected pancreatic head adenocarcinoma. From the NAT group, 2,005 patients (95%) were matched with 6,015 patients who underwent UR. The NAT group was associated with improved survival compared with UR (median survival, 26 months v 21 months, respectively; stratified log-rank P < .01; hazard ratio, 0.72; 95% CI, 0.68 to 0.78). Patients in the UR group had higher pathologic T stage (pT3 and T4: 86% v 73%; P < .01), higher positive lymph nodes (73% v 48%; P < .01), and higher positive resection margin (24% v 17%; P < .01). Compared with a subset of UR patients who received adjuvant therapy, NAT patients had a better survival (adjusted hazard ratio, 0.83; 95% CI, 0.73 to 0.89). Conclusion NAT followed by resection has a significant survival benefit compared with UR in early-stage, resected pancreatic head adenocarcinoma. These findings support the use of NAT, particularly as a patient selection tool, in the management of resectable pancreatic adenocarcinoma.
Pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME), in patients with locally advanced rectal cancer, occurs in 15-27% of patients. ...Because blood cell counts and albumin are a direct indicator of the host environment, a response to nCRT might be predicted by these markers. This study was carried out to determine whether the neutrophil to albumin ratio (NAR) was predictive of pCR in veteran patients. Ninety-eight patients with rectal cancer who underwent standard nCRT, followed by TME were analyzed. Pre-nCRT and post-nCRT hematologic data were collected. Univariate and multivariate analyses were carried out. Kaplan-Meier curves were constructed with our primary endpoint of pCR. Male patients (99%), age 62.4±9.1 years, BMI=27.4±5.9 kg/m, rectal cancer distance from anal verge=7.1±4.5 cm (SD), interval between nCRT and TME=8 weeks, 55% patients=low anterior resection, 95% received 5-fluorouracil, and all patients received radiation, with 15% achieving a pCR. Univariate analysis showed that pre-nCRT carcinoembryonic antigen (15.8±45.1 vs. 3.5±5.3 ng/dl; P=0.002) and the pre-nCRT NAR (16.4±4.8 vs. 14.2±1.6; P=0.002) were associated with pCR. On multivariate analysis, pre-nCRT carcinoembryonic antigen (odds ratio=0.41, 95% confidence interval 0.22-0.77) and pre-nCRT NAR (odds ratio=0.76, 95% confidence interval 0.60-0.97) remained independent predictors of pCR. Overall survival between nonresponders and pCR patients at 1, 5, and 10 years was 96, 62, and 44% versus 93, 85, and 61%, P=0.13, and disease-free survival was 95, 60, and 47% versus 93, 85, and 61%, P=0.17; respectively. Our study shows that the pre-nCRT NAR is an independent predictor of pCR. These findings should be applied to other cohorts to determine its validity and reliability for use as a potential predictor of pCR.
The purpose of this study was to quantify disparities in the utilization of outpatient pediatric surgical care and to examine the extent to which neighborhood-level socioeconomic disadvantage is ...associated with access to care among children.
Clinic “no-shows” were examined among children scheduled from 2017 to 2019 at seven pediatric surgery clinics associated with a tertiary care children’s hospital. The association between Area Deprivation Index, a neighborhood-level measure of socioeconomic disadvantage, and other patient factors with clinic no-shows was examined using multivariable logistic regression models. Difficulties in accessing postoperative care in particular were explored in a subgroup analysis of postoperative (within 90 days) clinic visits after appendectomy or inguinal/umbilical hernia repairs.
Among 10,162 patients, 16% had at least 1 no-show for a clinic appointment. Area Deprivation Index (most deprived decile adjusted odds ratio 3.17, 95% confidence interval 2.20–4.58, P < .001), Black race (adjusted odds ratio 3.30, 95% confidence interval 2.70–4.00, P < .001), and public insurance (adjusted odds ratio 2.75, 95% confidence interval 2.38–3.31, P < .001) were associated with having at least 1 no-show. Similar associations were identified among 2,399 children scheduled for postoperative clinic visits after undergoing appendectomy or inguinal/umbilical hernia repair, among whom 20% were a no-show.
Race, insurance type, and neighborhood-level socioeconomic disadvantage are associated with disparities in utilization of outpatient pediatric surgical care. Challenges accessing routine outpatient care among disadvantaged children may be one mechanism through which disparate outcomes result among children requiring surgical care.
Patients with Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC) have variable long-term outcomes. Better delineation of prognosis is important for clinical trial enrollment ...and clinical practice in an era of precision medicine. We hypothesized that stratification of patients with BCLC stage C HCC by presence of vascular invasion and/or metastasis improves prognostic discrimination.
Using a prospectively maintained database, we identified 234 patients diagnosed with BCLC stage C HCC between 2005 and 2015. Patients were stratified into 3 groups based on tumor characteristics: (1) vascular invasion alone, (2) metastasis alone, and (3) vascular invasion and metastasis. Overall survival (OS) was compared using a Cox model. A subgroup analysis was performed based on extent of vascular invasion and site of metastasis.
The cohort comprised 123 patients (53%) with vascular invasion alone, 34 (15%) with metastasis alone, and 77 (33%) with both vascular invasion and metastasis. Median survival was 5.7, 3.9, and 3.0 months, respectively (
<.01). Patients with vascular invasion or metastasis alone had significantly better survival compared with those with vascular invasion and metastasis (adjusted hazard ratio HR,0.68; 95% CI, 0.49-0.94, and HR, 0.61; 95% CI, 0.39-0.96, respectively). Compared with tumoral invasion of branch portal veins, involvement of the main portal vein was associated with worse survival (HR, 2.13; 95% CI, 1.29-3.49). OS did not differ by site of metastasis.
Stratification of patients within the BCLC stage C staging subgroup by vascular invasion and presence of metastasis further discriminates patient prognosis. This substratification may have implications for therapy and more accurate prognostic features.
Abstract Background The present single-institution, single-surgeon experience interrogated morbidity as well as predictors of inguinodynia, recurrence, and metachronous hernias in 953 consecutive ...inguinal herniorrhaphies between 2005 and 2015. Methods Data were prospectively collected and retrospectively analyzed from patient medical records at the VA North Texas Health Care System. Results Ninety-nine percent of our patients were male, 73% Caucasian, 60.4 ± 1.4 years old, body mass index = 26.7 ± 4.2 kg/m2 . Overall morbidity was 11.9%. The most common complication was urinary retention (2.3%). Inguinodynia and recurrence occurred at a rate of 1.5% and .8%, respectively. If a patient had a hernia repair, he had a 12% chance of needing a contralateral repair within 7.6 years. Younger age (odds ratio OR, .96; 95% confidence interval CI, .91 to 1.0), current history of smoking (OR, 5.3; 95% CI, 1.3 to 22.3), and a previous contralateral hernia repair (OR, 5.5; 95% CI, 1.2 to 25.0) were independent predictors of inguinodynia. A direct hernia was associated with recurrence (45% vs 100%; P = .02). Current smoking was an independent predictor of recurrence (OR, 5.4; 95% CI 1.0 to 29.3). Age (55- to 75-year old; OR, 2.0; 95% CI, 1.1 to 3.9), age (>75-year old; OR, 2.6; 95% CI, 1.1 to 6.1), an indirect hernia repair (OR, 1.9; 95% CI, 1.2 to 3.1), a pantaloon hernia repair (OR, 2.0; 95% CI, 1.0 to 3.8), and current consumption of alcohol (OR, 1.6; 95% CI, 1.0 to 2.5) were independent predictors of a metachronous hernia. Conclusions The following study presents several factors predictive of outcomes in patients with inguinal hernias that might be useful in preventing complications and providing informed consent to this patient population.
The association between hospital volume and outcome following high-risk low volume cancer surgery is well documented. However, this association is not well understood in cancer patients undergoing ...non-surgical therapies. We explored this association in a cohort of newly diagnosed patients with hepatocellular carcinoma (HCC).
Data from the 2000 through 2011 in Texas Cancer Registry were used to study adults with newly diagnosed HCC (17,231 patients from 322 hospitals). Hospital volume was stratified into low and high volume using Contal's outcome-based method. A multivariable Cox regression with shared frailty was used to evaluate the association between hospital volume and overall survival. The relationship between treatment modality and hospital volume was explored using mixed effects logistic regression.
The majority (61%) of HCC patients were seen in 21 high-volume hospitals. An annual hospital volume cutoff point of 24 patients was determined to stratify between high- and low-volume hospitals. Patients at high-volume hospitals presented more commonly with localized disease (56 vs. 50%, P<0.01) and were more likely to receive curative therapies including surgical resection, liver transplantation, or ablation (22 vs. 12%, P<0.01). High-volume hospitals were significantly associated with improved survival (HR=0.96, 95% CI=0.94-0.98). In multivariable analysis, hospital volume was associated with increased overall treatment utilization (OR=1.3, 95% CI=1.2-1.4).
Hospital volume is associated with improved overall survival, particularly in localized HCC. Improved survival may be mediated by increased utilization of treatments in high HCC volume hospitals.
PDF
