BACKGROUND
Assessing trends in breast cancer survival among young women who are largely unaffected by breast cancer screening will provide important information regarding improvements in the ...effectiveness of cancer care for breast cancer in the last few decades.
METHODS
The cohort for this study consisted of women who were diagnosed with breast cancer between ages 20 and 39 years from the Surveillance, Epidemiology, and End Results program's 9‐registry areas from 1975 to 2015. Trends in the breast cancer incidence rate and survival were assessed among young women.
RESULTS
Among women aged 20 to 39 years, breast cancer incidence increased from 24.6 per 100,000 in 1975 to 31.7 per 100,000 in 2015 (annual percent change, 0.5; 95% confidence interval CI, 0.4‐0.6). Among women with breast cancer, 5‐year breast‐cancer‐specific survival increased significantly from 74.0% during 1975 to 1979 to 88.5% during 2010 to 2015 (hazard ratio for dying from breast cancer for 2010‐2015 vs 1975‐1979, 0.37; 95% CI, 0.32‐0.41). The increase in cancer‐specific survival reached a plateau in 2005; however, among young women with metastatic breast cancer, it continued to increase after 2005, from 45.6% during 2005 to 2009 to 56.5% during 2010 to 2015 (hazard ratio for dying from breast cancer for 2010‐2015 vs 2005‐2009, 0.74; 95% CI, 0.60‐0.92). Similar patterns also were observed for 5‐year overall survival and among women aged 20 to 29 years and those aged 30 to 39 years.
CONCLUSIONS
There were substantial improvements in the effectiveness of breast cancer treatment on overall and cancer‐specific survival from 1975 to 2015. However, improvements appeared to have reached a plateau after 2005, except among young women with metastatic breast cancer, in whom survival continued to improve throughout the period.
Data for the period from 1975 to 2015 in the Surveillance, Epidemiology, and End Results registry indicate that survival has improved significantly for young women (aged 20 to 39 years) with breast cancer in the last 4 decades, although the improvement recently has plateaued, except among young women with metastatic cancer, whose survival continued to improve throughout the period. This improved survival is most likely attributed to advances in cancer care, because these populations typically are not screened.
Summary
Background
Data comparing waitlist and post‐transplant outcomes of liver transplantation (LT) alone (LTA) versus simultaneous liver kidney (SLK) listings are limited.
Aim
To examine 90‐days ...waitlist and 1‐year post‐transplant outcomes of LT listings since Organ Procurement Transplant Network (OPTN) policy for SLK, who had cirrhosis with eGFR <30 mL/min or on dialysis at listing.
Methods
Adults (08/2017–03/2021) with first LT listing (2628 SLK) were stratified on renal function from listing: acute kidney injury (AKI): rise of serum creatinine by ≥0.3 mg/dL or <42 days hemodialysis; chronic kidney disease (CKD): eGFR <60 mL/min for ≥90 days or ≥42 days hemodialysis.
Results
Among 7094 adults analyzed, 90‐days competing cumulative waitlist mortality was 18.2% in LTA + CKD (
n
= 37), 15.3% in LTA + AKI (
n
= 3337), 15% in SLK + AKI (
n
= 2070), and 11% in SLK + CKD (
n
= 403),
p
< 0.001. On fine and gray model, compared to SLK + CKD, LTA + AKI had 1.4–fold waitlist mortality. On a median post‐transplant follow up of 1 year, patient survival was similar comparing LTA versus SLK for AKI (89% each,
p
= 0.83), for CKD (93 vs. 86%,
p
= 0.55), but lower in recipients listed for SLK with no AKI or CKD (93 vs. 88%,
p
= 0.02), adjusted hazard ratio (95% CI) of 0.7 (0.4–1.2). Among 1024 LTA recipients without AKI or CKD from listing, 117 were listed for SLK, and their 1‐year survival was poorer compared to LT alone listings (79 vs. 95%,
p
< 0.002, adjusted HR 3.6 (1.3–10.3);
p
= 0.015).
Conclusions
Among candidates with renal dysfunction at listing for LT, those listed for LT alone should receive transplant promptly to optimise waitlist outcomes. Those listed for SLK should wait to receive both organs to optimise post‐transplant outcomes.
Summary
Background
Hepatorenal syndrome (HRS) contributes to significant morbidity and mortality in hospitalised patients with cirrhosis.
Aims
To examine recent trends, magnitude and outcomes of HRS ...in the National Inpatient Sample (NIS) database
Methods
Among the NIS database on cirrhosis hospitalisations (2016–2019) due to alcohol (ALD), chronic viral hepatitis (CVH), or NASH and complicated by acute kidney injury (AKI) were analyzed.
Results
Of 113,454 hospitalisations, 18,735 (16.5%) had HRS (mean age 56 years, 36% females, 68% whites, 80% ALD, 7% NASH) with a stable trend over time. Among 1:1 propensity‐matched 36,090 hospitalisations, the odds of HRS were 12% higher in NASH versus CVH. Based on weighted national estimates, there were 27,180 (8.3 per 100,000 US population) HRS hospitalisations in 2019, with economic burden of $4.2 billion USD. Mean hospitalisation and total charges (ALD vs. CVH vs. NASH) were 11 versus 10.8 versus 9.2 days and 151,000 versus 157,000 versus 120,000 USD, respectively; p < 0.001. In‐hospital mortality was 18.9%, higher in HRS (25.8 vs. 12%, p < 0.001), and decreased by 15% annually. Survivors were more likely to be discharged to short‐ or long‐term care facilities (HRS vs. non‐HRS 42 vs. 27%, p < 0.001); only 28.7% received palliative care.
Conclusion
HRS was the cause of AKI in 16.5% of patients hospitalised with cirrhosis and conferred significant healthcare burden with 27,180 HRS hospitalisations in 2019 and requiring an estimated 4.2 billion USD for hospital care. While there has been a decrease in in‐hospital mortality over time, it remained high at 23.7% in 2019 in those with HRS.
Healthcare and economic burden of hepatorenal syndrome among hospitalised patients with cirrhosis.
The goal of this study was to examine the impact of substance use disorder on the risk of hospitalization, complications, and mortality among adult patients diagnosed as having COVID-19.
The authors ...conducted a propensity score (PS)-matched double-cohort study (N=5,562 in each cohort) with data from the TriNetX Research Network database to identify 54,529 adult patients (≥18 years) diagnosed as having COVID-19 between February 20 and June 30, 2020.
Primary analysis (PS matched on demographic characteristics and presence of diabetes and obesity) showed that substance use disorder was associated with an increased risk of hospitalization (odds ratio OR=1.84, 95% confidence interval CI=1.69-2.01), ventilator use (OR=1.45, 95% CI=1.22-1.72), and mortality (OR=1.30, 95% CI=1.08-1.56).
The findings suggest that COVID-19 patients with substance use disorders are at increased risk for adverse outcomes. The attenuation of ORs in the model that matched for chronic respiratory and cardiovascular diseases associated with substance abuse suggests that the observed risks may be partially mediated by these conditions.
Acute‐on‐chronic liver failure (ACLF) is characterized by multiple organ failure (OF) with high short‐term mortality. There is lack of population‐based data on trends on etiology specific ACLF ...related burden. National Inpatient Sample (2006‐2014) was queried using ICD‐09 codes for admissions with cirrhosis and ACLF (≥2 extrahepatic OF). Of 1,928,764 admissions for cirrhosis between 2006 and 2014, 112,174 (5.9%) had ACLF (4.5%, 1.2%, and 0.2% with ACLF 1, 2, and 3, respectively). The brain was the most common OF in 11.9%, followed by respiratory failure in 7.7%, cardiac failure in 6.3%, and renal failure in 5.6%. ACLF increased by 24% between 2006 and 2014 with a 63% increase in 179,104 patients with nonalcoholic steatohepatitis (NASH) cirrhosis (3.5% to 5.7%); a 28% increase in patients with 429,306 alcoholic cirrhosis (5.6% to 7.2%); a 25% increase in patients with 1,091,053 with other etiologies (5.2% to 6.5%); and no significant change in 229,301 patients with viral hepatitis (VH) (4.0% to 4.1%). In‐hospital mortality was higher among ACLF patients compared with patients without ACLF (44% versus 4.7%; P < 0.0001). Each NASH‐related ACLF patient compared with other etiologies had a longer mean length of stay (14 versus 12 days), was associated with higher median total charges (US $151,196 versus US $134,597), and had more frequent use of dialysis (45% versus 36%) and longterm care (32% versus 26%; P < 0.0001 for all). Results remained similar in a subgroup analysis after including half of admissions with cryptogenic cirrhosis as NASH. In conclusion, NASH cirrhosis is the most rapidly growing indication for ACLF‐related hospitalization and use of hospital resources. In the setting of improved treatment options for chronic hepatitis, the health care burden of chronic viral‐related liver disease remains stable. Population‐based strategies are needed to reduce the health care burden of cirrhosis, particularly related to NASH.
Introduction
Gabapentinoids (GABA) prescribing as a potential and conceivably safer substitute for opioids has substantially increased. Understanding all potential adverse drug events (ADEs) ...associated with GABA will guide clinical decision‐making for pain management.
Methods
A 20% sample of Medicare enrollees with new chronic pain diagnoses in 2017–2018 was selected. GABA users were those with >=30 consecutive days prescription in a year without opioid prescription. Opioid users were similarly defined. The control group used neither of these drugs. Propensity score match across three groups based on demographics and comorbidity was performed. We used proportional reporting ratio (PRR), Gamma Poisson Shrinker, and tree‐based scan statistic (TBSS) to detect ADEs within 3, 6, and 12 months of follow‐up.
Results
Immunity disorder was detected within 3 months of follow‐up by PRR compared to opioid use (PRR:2.33), and by all three methods compared to controls. Complications of transplanted organs/tissues and schizophrenia spectrum/other psychotic disorders were consistently detected by PRR and TBSS within 3 months. Skin disorders were detected by TBSS; and stroke was detected by PRR within 3 months compared to opioid use (PRR:4.74). Some malignancies were detected by PRR within 12 months. Other signals detected in GABA users were neuropathy and nerve disorders.
Conclusions
Our study identified expected and unexpected ADE signals in GABA users. Neurological signals likely related to indications for GABA use. Signals for immunity, mental/behavior, and skin disorders were found in the FDA adverse event reporting system database. Unexpected signals of stroke and cancer require further confirmatory analyses to verify.
Background & Aim
We aimed to develop a risk score for LT recipients and donor selection among patients with ACLF‐3.
Methods and Results
A total of 7166 adult LT recipients (mean age 53 years, 63% ...males, 56% Caucasians, 42% obese, median MELD score 36.5) using deceased donor grafts in the UNOS database (01/2002–06/2018) who were in ACLF‐3 at LT as per EASL‐CLIF criteria were analysed. Cox regression model on the derivation dataset (N = 3583) showed recipient age, non‐alcohol aetiology, pulmonary failure, brain failure and cardiovascular failure to be associated with 1‐year patient survival. Observed and expected post‐transplant 1‐year survival showed excellent correlation (R = .920). Risk score from cox model on derivation dataset stratified 3583 recipients in validation cohort using cut‐off scores 7.55 and 11.57 to low (N = 1211), medium (N = 1168) and high risk (N = 1199), with 1‐year patient survival of 89%, 82% and 80% respectively. Based on poor versus good quality graft (donor risk index cut‐off at 1.50), 1‐year patient survival for low, medium and high‐risk categories were 90 versus 89% (p = .490), 83 versus 82% (p = .390) and 83 versus 78% (p = .038) respectively. Among recipients with a high‐risk score, donor factors of age ≥60 years, grafts obtained from national sharing and macro‐steatosis >15% were associated with 1‐year patient survival below 66%.
Conclusion
Among ACLF‐3 liver transplant recipients, those with high risk at the time of transplant receiving better quality graft will improve post‐transplant outcomes. Prospective studies using additional characteristics are needed to derive an accurate risk score model in predicting post‐transplant outcomes among recipients with ACLF‐3.
Summary
Background
Alcohol use and alcohol‐associated liver disease (ALD) burden are increasing in young individuals.
Aim
To assess host factors associated with this burden.
Methods
National Health ...and Nutrition Examination Survey (NHANES), National Inpatient Sample (NIS), and United Network for Organ Sharing (UNOS) databases (2006‐2016) were used to identify individuals with harmful alcohol use, ALD‐related admissions, and ALD‐related LT listings respectively.
Results
Of 15 981 subjects in NHANES database, weighted prevalence of harmful alcohol use was 17.7%, 29.3% in <35 years (G1) versus 16.9% in 35‐64 years (G2) versus 5.1% in ≥65 years (G3). Alcohol use was about 11 and 4.7 folds higher in G1 and G2 versus G3, respectively. Male gender and Hispanic race associated with harmful alcohol use. Of 593 600 ALD admissions (5%, 77%, and 18% in G1‐G3 respectively), acute on chronic liver failure (ACLF) occurred in 7.2%, (7.2 in G2 vs 6.7% in G1 and G3, P < 0.001). After controlling for other variables, ACLF development among ALD hospitalizations was higher by 14% and 10% in G1 and G2 versus G3, respectively. Female gender and Hispanic race were associated with increased ACLF risk by 8% and 17% respectively. Of 20,245 ALD LT listings (3.4%, 84.4%, and 12.2% in G1‐G3 respectively), ACLF occurred in 28% candidates. Risk of severe (grade 2 or 3) ACLF was higher by about 1.7 fold in G1, 1.5 fold in females and 20% in Hispanics.
Conclusion
Young age, female gender, and Hispanic race are independently associated with ALD‐related burden and ACLF in the United States. If these findings are validated in prospective studies, strategies will be needed to reduce alcohol use in high risk individuals to reduce burden from ALD.
Objectives
To examine how an October 2014 Drug Enforcement Administration policy reclassified hydrocodone product from schedule III to II has affected older adults, who are among the largest ...consumers of prescription opioids in the United States.
Design
Retrospective cohort study.
Setting
United States.
Participants
A 20% sample of Medicare Part D beneficiaries aged 65 and older from 2013 through 2015 (> 2,500,000 beneficiaries each year)
Measurements
From January 2013 to December 2015, we calculated the monthly prevalence of opioid prescriptions and the prevalence of individuals who received prescriptions for a 90‐day supply or longer (prolonged), as well as hospitalizations related to opioid toxicity in 2013 and 2015.
Results
From 2013 to 2015, the proportion of Medicare Part D enrollees who received a hydrocodone prescription in a year decreased from 21.9% to 18.3%. Monthly rates for hydrocodone prescriptions declined significantly in 2014. The risk of receiving prolonged opioid prescriptions decreased by approximately 7% in the multivariable analyses comparing 2015 to 2013 (prevalence ratio=0.93, 95% confidence interval (CI)=0.93–0.94). Medicare enrollees with an original entitlement because of disability or with Medicaid eligibility had smaller decreases in prolonged prescriptions and, unexpectedly, small increases in high‐dose prescriptions. Opioid‐related hospitalizations did not change significantly, but opioid‐related hospitalizations without a documented opioid prescription increased (odds ratio=1.24, 95% CI=1.03–1.50).
Conclusion
The 2014 change in hydrocodone from schedule III to schedule II was associated with modest decreases in rates of opioid use in the elderly. The unexpected increase in opioid‐related hospitalizations without documented opioid prescriptions may represent an increase in illegal use.
Studies have investigated the association between pain and cognitive impairment among older adults, but the findings are mixed. We assessed the relationship of activity-limiting pain (pain ...interference) with incident cognitive impairment and the mediating effect of depressive symptoms among Mexican American adults aged ≥80.
Data were taken from the Hispanic Established Population for the Epidemiological Study of the Elderly (2010-2016). Pain interference, or pain that limited daily activities in the last 12 months, was categorized into none, untreated pain interference, and treated pain interference. Cognitive impairment was defined as scoring <21 on the Mini-Mental State Examination and difficulty with at least one instrumental activity of daily living. We used general estimation equations to assess this relationship between pain and incident cognitive impairment over the 6-year period (n = 313).
Participants reporting both untreated and treated pain interference had higher odds of incident cognitive impairment than those reporting no pain or pain interference (untreated adjusted odds ratio aOR: 2.18; 95% confidence interval CI: 1.09-4.36; treated aOR: 1.99; 95% CI: 1.15-3.44). Depressive symptoms explained 15.0% of the total effect of untreated pain and 25.3% of treated pain.
Among very old Mexican American adults, both treated and untreated pain interference was associated with incident cognitive impairment. This association was partially mediated by depressive symptoms, underscoring a need for depression screening in patients with chronic pain. Future work is needed to examine mechanistic/causal pathways between pain and subsequent cognitive impairment and the role of pharmacological and non-pharmacological treatments in these pathways.
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