SEARCH · PubMed Health

Results for “Propensity Score”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 469 records · Page 26Linked to original sources

PubMed2005

Does wide primary perirectal dissection during radical retropubic prostatectomy alter pathologic and biochemical outcomes?

The aim of this article is to evaluate wide primary perirectal dissection (WR) during the course of radical prostatectomy as a technique to decrease positive surgical margin rates and improve subsequent biochemical outcomes. A retrospective review of a single surgeon's series of 320 patients, including 61 who underwent WR, from 1998 to the present was performed. Patients were stratified into risk groups based on preoperative data known to predict time to prostate cancer mortality. Pathologic outcomes were tabulated and biochemical outcomes were analyzed at follow-up. Comparisons were made between WR and radical retropubic prostatectomy (RRP) with or without nerve sparing based on these parameters within each risk group. Kaplan-Meier, multivariate, and propensity score analyses were used to evaluate the impact of surgical technique on biochemical recurrence. Urinary morbidity was compared using a retrospective review of University of California-Los Angeles Prostate Cancer Symptom Index self-questionnaires. No increase in urinary or rectal morbidity was noted using the WR technique. A statistically significant decrease in positive surgical margins was noted in the high-risk population (55% vs 16%, P = 0.010) in favor of WR. Biochemical failure was similar between groups (WR vs RRP), and no biochemical survival advantage could be documented. Thus, the WR technique may successfully decrease the rate of positive surgical margins in a high-risk group without any increased urinary morbidity. This technique may affect only local control because biochemical recurrence rates were not statistically different. This finding implies the presence of occult metastatic disease at the time of surgery. A larger population with better-matched subjects is needed to clarify the potential role of WR in an intermediate-risk population.

Follow-Up Studies↗

PubMedDate not supplied

Long-term costs of intimate partner violence in a sample of female HMO enrollees.

OBJECTIVES: To compare costs associated with intimate partner violence (IPV) overall and for selected physical health problems in a non-poor, privately insured sample. METHODS: We compared 185 women aged 21-55 who were physically and/or sexually abused between 1989 and 1997 and enrolled in a multisite metropolitan health maintenance organization (HMO) to 198 never abused women enrolled in the same plan who had been matched using propensity score stratification. Costs associated with HMO visits, hospital stays, referrals, and emergency room (ER) visits, prescriptions, and radiology are based on the Medicare Resource-Based Relative Value System, expressed in 2005 dollars. RESULTS: Average health care costs for women who reported physical, sexual, and/or emotional abuse exceeded those of never abused women by $1,700 over the 3-year study period. Women who reported abuse within 12 months of interview had higher average costs, as did women who reported physical abuse; however, sexual or emotional abuse and previous abuse also elevated costs. Costs associated with neurologic symptoms, injuries, mental health care, and unclassified symptoms account for most of these differences. CONCLUSIONS: IPV elevates health care costs, not only among women currently experiencing abuse, but also among women for whom the abuse has ceased. Efforts to control health care costs should focus on early detection and prevention of IPV.

Adult↗

PubMed1999

Long-term nitrate use may be deleterious in ischemic heart disease: A study using the databases from two large-scale postinfarction studies. Multicenter Myocardial Ischemia Research Group.

BACKGROUND: Secondary coronary prevention studies have generally focused on specific medications, often to the exclusion of commonly used therapies. To date, long-term nitrate use has not been investigated in large-scale clinical trials. METHODS AND RESULTS: We examined the relation between long-acting nitrates given during the chronic phase of the disease and the outcome. We analyzed data prospectively acquired in a large, observational study involving 1042 patients enrolled for the Multicenter Study of Myocardial Ischemia (MSMI) in North America, Israel, and Japan as well as 1779 patients enrolled for the Multicenter Diltiazem Post Infarction Trial (MDPIT). The Cox analyses with all the variables retained revealed that nitrates were associated with a significantly increased mortality risk (MSMI: hazard ratio 3.78, P =.011; MDPIT: hazard ratio 1.61, P =.019) in patients who had recovered from an acute coronary event. The analyses with the propensity score method on the MSMI and the MSMI databases also showed that the risk for cardiac death with use of nitrates was increased in most of the 5 subclasses according to the score. CONCLUSION: These analyses raise concern about the potential adverse effects of long-acting nitrate therapy in chronic coronary disease.

Databases, Factual↗

PubMed2002

Beta-blockers are associated with lower C-reactive protein concentrations in patients with coronary artery disease.

PURPOSE: C-reactive protein is an important risk factor for coronary artery disease, and plasma concentrations are lowered by treatment with pravastatin and aspirin. We examined whether other cardiovascular drugs that are used in the treatment of ischemic heart disease affect C-reactive protein concentrations. SUBJECTS AND METHODS: Plasma C-reactive protein concentration was measured by high sensitivity immunonephelometric assay in 333 consecutive patients with stable angina and confirmed coronary artery disease who underwent diagnostic angiography. RESULTS: Patients prescribed beta-blockers had significantly lower mean C-reactive protein concentrations than did patients in whom these were not prescribed (by 1.2 mg/L, or 40% difference in geometric mean concentration; P <0.001). This association remained significant (P = 0.03) after excluding patients with contraindications to the use of beta-blockers, and adjusting for the probability of beta-blocker therapy (propensity score) and other clinical predictors of C-reactive protein concentration, including body mass index, high-density lipoprotein cholesterol level, family history of coronary artery disease, and angiographic severity. No differences among types or dosages of beta-blockers were evident. CONCLUSION: Beta-blockers may affect C-reactive protein concentrations. Randomized studies are required to confirm these findings.

Adrenergic beta-Antagonists↗

PubMed2002

Effectiveness and cost-effectiveness of implantable cardioverter defibrillators in the treatment of ventricular arrhythmias among medicare beneficiaries.

PURPOSE: The implantable cardioverter defibrillator has been assessed in randomized trials, but the generalizability of trial results to broader clinical settings is unclear. Our purpose was to evaluate the outcomes and costs of defibrillator use in an unselected population. SUBJECTS AND METHODS: We identified 125,892 Medicare patients who were discharged between 1987 and 1995 after hospitalization with a primary diagnosis of ventricular tachycardia or ventricular fibrillation, 7789 of whom (6.2%) received a defibrillator. We used a multivariable propensity score that included patient and hospital characteristics to match pairs of patients, in which one patient received a defibrillator and the other did not. We compared mortality and costs in these 7612 matched pairs during 8 years of follow-up. RESULTS: Patients who received a defibrillator were more likely to be younger, white, male, and urban dwelling, and to have ischemic heart disease, heart failure, or a history of ventricular fibrillation. In the matched-pairs analysis, those who received a defibrillator had significantly lower mortality: 11% versus 19% at 1 year (odds ratio [OR] = 0.57; 95% confidence interval [CI]: 0.51 to 0.63), 20% versus 30% at 2 years (OR = 0.66; 95% CI: 0.60 to 0.72), and 28% versus 39% at 3 years (OR = 0.70; 95% CI: 0.63 to 0.77). These patients also had lower mortality at 8 years (P = 0.0001), although this advantage over patients who received medical treatment only decreased over time. Expenditures among defibrillator recipients were consistently higher, with a cost-effectiveness ratio of $78,400 per life-year gained. CONCLUSION: The use of implantable defibrillators was associated with significantly lower mortality and higher costs, whereas the cost-effectiveness was higher than many, but not all, generally accepted therapies.

Aged↗

PubMed2002

The effects of beta-blockers on morbidity and mortality in a population-based cohort of 11,942 elderly patients with heart failure.

PURPOSE: Randomized trials have shown that beta-blockers prevent morbidity and mortality in heart failure. However, whether beta-blockers are effective in older patients or those with conditions that would have led to their exclusion from these trials remains unclear. SUBJECTS AND METHODS: The associations between beta-blocker use and outcomes were examined in a population-based cohort of 11,942 older (age >/=65 years) patients with incident heart failure between 1994 and 1999. Cox proportional hazards models were used to adjust for propensity scores, age, sex, comorbid conditions, and other medications. RESULTS: The mean (+/- SD) age of the patients was 79 +/- 8 years, 5819 (49%) were men, and 2569 (22%) had Charlson comorbidity scores of at least 2. During follow-up (median, 21 months), 3539 patients were hospitalized for heart failure and 6757 died. Overall, 1162 patients received beta-blockers. After adjustment, beta-blocker use was associated with substantial reductions in all-cause mortality (hazard ratio [HR] = 0.72; 95% confidence interval [CI]: 0.65 to 0.80), mortality due to heart failure (HR = 0.65; 95% CI: 0.47 to 0.90), and hospitalizations for heart failure (HR = 0.82; 95% CI: 0.74 to 0.92). These endpoints were less frequent in patients treated with beta-blockers than in untreated patients in all examined subgroups. All doses of beta-blockers were associated with benefit, but there was a trend towards greater benefit in patients prescribed higher doses. CONCLUSIONS: The benefits of beta-blockers seen in randomized trials extend to older patients and to those with conditions that would have led to their exclusion from the trials. There is a need for a randomized trial comparing different doses of beta-blockers in heart failure.

Adrenergic beta-Antagonists↗

PubMed2003

An invasive strategy is associated with decreased mortality in patients with unstable angina and non-ST-elevation myocardial infarction: GUSTO IIb trial.

There has been much debate concerning an invasive versus a conservative strategy for patients with acute coronary syndromes. The purpose of this study was to determine whether early in-hospital catheterization reduced mortality in patients with unstable angina and non-ST-elevation myocardial infarction. We performed a retrospective analysis of data collected in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb trial, which compared hirudin and heparin in patients with acute coronary syndromes. We identified 8011 patients with non-ST-segment elevation myocardial infarction and unstable angina who were enrolled in the trial. The primary endpoints were all-cause mortality at 30 days and 1 year. Data were analyzed with multivariate hazards models and propensity scores.After accounting for inception time bias, there were 7897 patients identified, of whom 4536 patients (57%) underwent invasive therapy and 3361 (43%) underwent conservative therapy. Adjusting for propensity scores, the adjusted 30-day mortality for the invasive group was 2.5% compared with 2.7% in the conservative group (P = 0.92); at 1 year, the invasive group had a 6.2% mortality, versus 8.6% in the conservative group (P = 0.005). In a multivariate analysis that adjusted for other clinical factors, an invasive strategy was associated with lower 1-year mortality (hazard ratio = 0.46; 95% confidence interval: 0.10 to 0.84). In patients presenting with acute coronary syndromes, an invasive strategy is associated with improved survival at 1 year even after adjusting for baseline differences.

Aged↗

PubMed2002

What is the best treatment for patients with acute type B aortic dissections--medical, surgical, or endovascular stent-grafting?

BACKGROUND: Controversy continues regarding treatment for patients with acute type B aortic dissection. METHODS: One hundred eighty-nine patients with acute type B aortic dissection managed over a 36-year period were analyzed retrospectively for three outcome endpoints: survival; freedom from reoperation, and freedom from late aortic-related complications or late death. Risk factors for death were identified using a multivariable Cox proportional hazards model. Then to account for patient selection bias, heterogeneity of the population, and continuous evolution in techniques, propensity score analysis was used to identify risk-matched cohorts (quintiles I and II) in which the results of medical (n = 111) or surgical (n = 31) therapy were compared more comprehensively. RESULTS: The two main determinants of death were shock (hazard ratio [HR] = 14.5, 95% confidence level [CL] 4.7, 44.5; p < 0.001) and visceral ischemia (HR = 10.9, 95% CL 3.9, 30.3; p < 0.001). Arch involvement, rupture, stroke, previous sternotomy, and coronary or lung disease roughly doubled the hazard. Female sex was also a significant but weaker independent predictor of death. Actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients. The Marfan syndrome predicted reoperation and late aortic complications or late death. In a separate analysis of the 142 patients in quintiles I and II, survival, freedom from reoperation, as well as freedom from late aortic complications or death were almost identical in the medical and surgical subsets. CONCLUSIONS: The poor long-term prognosis of patients with acute type B aortic dissection is determined primarily by dissection-related and patient-specific risk factors, which are not readily modifiable. Whether the outlook in the future will be improved using stent-grafts remains to be determined.

Acute Disease↗

PubMed2003

Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement.

BACKGROUND: The purpose of this study was to evaluate morbidity and mortality after double valve replacement (DVR) and aortic valve replacement with mitral valve repair (AVR + MVP). METHODS: From 1977 to 2000, 379 patients underwent DVR (n = 299) or AVR + MVP (n = 80). Actuarial survival and freedom from reoperation were determined by the Kaplan-Meier method. Potential predictors of mortality and reoperation were entered into a Cox multiple regression model. Propensity score was introduced for the multivariable regression modeling for adjustment of a selection bias. RESULTS: Survival 15 years after surgery was similar between the groups (DVR, 81% +/- 3%; AVR + MVP, 79% +/- 7%; p = 0.44). Freedom from thromboembolic event at 15 years was similar between the groups (p = 0.25). Freedom from mitral valve reoperation at 15 years was significantly better for the DVR group (54% +/- 5%) as compared with the AVR + MVP group (15% +/- 6%; p = 0.0006), primarily due to progression of mitral valve pathology and early structural deterioration of bioprosthetic aortic valve used for patients with AVR + MVP. After AVR + MVP, freedom from mitral reoperation at 15 years was 63% +/- 16% for nonrheumatic heart diseases, and 5% +/- 5% for rheumatic disease (p = 0.04). CONCLUSIONS: Although both DVR and AVR + MVP provided excellent survival, DVR with mechanical valves should be the procedure of choice for the majority of patients because of lower incidence of valve failure and similar rate of thromboembolic complications compared with AVR + MVP. MVP should not be performed in patients with rheumatic disease because of higher incidence of late failure.

Actuarial Analysis↗

PubMed2003

Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians.

BACKGROUND: Despite well-established benefits of arterial (ART) grafting, surgeons have been reluctant to use this conduit in octogenarians. This study explores the influence of arterial revascularization on operative and long-term outcomes of coronary artery bypass grafting surgery. METHODS: A retrospective analysis was conducted of 987 consecutive patients 80 years of age or older who underwent isolated coronary artery bypass grafting between January 1989 and November 2000. Patients with saphenous vein graft only (SVG; n = 574) were compared with those receiving arterial and saphenous vein grafts (ART+SVG; n = 413). Mean follow-up for SVG patients was 3.8 years (range, 4 months to 12.6 years) and 98.6% complete, and mean follow-up was 3.1 years for ART+SVG patients (range, 2 months to 11.2 years) and 97.3% complete. RESULTS: Patients with SVG had a significantly higher (p = 0.009) operative mortality (11.1% versus 6.3%) and significantly longer postoperative length of stay (12.9 versus 10.7 days; p = 0.002) than ART+SVG recipients. More ART+SVG than SVG patients were free of all postoperative complications (290 of 413; 70.2% versus 372 of 574; 64.8%; p = 0.086). Multivariable analysis identified SVG as an independent predictor of operative mortality (p = 0.014) and late mortality (p = 0.040). When patients were matched by equivalent propensity scores to receive SVG only, operative mortality was higher for SVG patients in four of the five quintiles. At 10 years, 97.0% +/- 1.2% of SVG and 92.9% +/- 3.7% of ART+SVG current survivors were free of all late major adverse cardiac events (p = 0.565), and 95.5% of SVG patients and 97.5% of ART+SVG patients were in Canadian class 1 or 2 (p = 0.162). On the SF-36 quality-of-life assessment, ART+SVG patients scored significantly higher than both SVG patients and age-adjusted normal subjects. Physical health summary component scores were 36.8 +/- 11.0 for SVG and 41.0 +/- 10.3 for ART+SVG (p = 0.001). Mental health summary scores were comparable for the two groups. CONCLUSIONS: Arterial grafting confers an operative survival benefit, and an enhanced long-term quality of life in elderly patients.

Age Factors↗

PubMed2003

Allogeneic blood transfusion requirements after minimally invasive versus conventional aortic valve replacement: a risk-adjusted analysis.

BACKGROUND: Aortic valve replacement (AVR) through a partial sternotomy (mini-AVR) has been suggested to significantly reduce postoperative morbidity compared with conventional AVR. This study sought to investigate whether mini-AVR patients require fewer transfusions than patients who had conventional AVR. METHODS: Of 511 patients who had AVR, 56 had mini-AVR and 455 had conventional AVR. A matched-case logistic regression analysis was used to adjust for these imbalances between groups. RESULTS: No patient in the mini-AVR cohort required conversion to a conventional AVR. Cardiopulmonary bypass time was longer in the mini-AVR group compared with the conventional AVR group, with a median of 102 minutes (range, 78 to 119 minutes) versus 75 minutes (range, 61 to 96 minutes; p < 0.01) in the conventional AVR group. A total of 31 patients (55%) in the mini-AVR group and 336 patients (74%) in the conventional sternotomy group required transfusions during their hospital stay (p < 0.01). After adjusting for differences in preoperative risk factors, year of operation, and surgeon, by matching on propensity score, the differences were not statistically significant (odds ratio = 0.84, 95% confidence interval = 0.40 to 1.75, p = 0.63). CONCLUSIONS: Mini-AVR produces better wound cosmesis and less surgical trauma but requires more time to perform. Matched-case analysis failed to show a significant difference in blood transfusion requirements after mini-AVR compared with the conventional AVR approach.

Aged↗

PubMed1998

Benefits of home health care after inpatient rehabilitation for hip fracture: health service use by Medicare beneficiaries, 1987-1992.

OBJECTIVE: To examine the added benefit of home health services for elderly patients with hip fracture discharged home after inpatient rehabilitation. DATA: Medicare claims from 1% of 1986 beneficiaries followed until 1992. STUDY POPULATION: Persons hospitalized with hip fracture at 70 years or older who had no major Medicare claims during the year before hospitalization and who were discharged home after inpatient rehabilitation. OUTCOMES: Rehospitalization and any nonskilled nursing facility (non-SNF) nursing home admission during the 12 months after hospital discharge. RESULTS: Patients who received additional home health services (27.2%) were less likely to be hospitalized than those who received rehabilitation only (31.1%); they were also less likely to have a non-SNF nursing home admission (11.3% vs 23.3%), and more likely to survive the year with no subsequent Medicare claims (65.6% vs 55%). Propensity scores were used to adjust for nonrandom treatment selection in a Cox proportional hazards analysis showing that home health was associated with a significantly lower risk of nursing home admission (adjusted odds ratio = .42, 95% confidence interval .21-.84), and hospitalization (adjusted odds ratio = .65, 95% confidence interval .26-1.00). CONCLUSIONS: Studies of the relative effectiveness of post-acute services and postdischarge evaluations of inpatient rehabilitation should consider additional home care as a postacute service and examine optimal postacute treatment to minimize additional service use.

Aged↗

PubMed2000

Aortic valve replacement: is valve size important?

OBJECTIVE: We sought to determine whether aortic prosthesis size adversely influences survival after aortic valve replacement. METHODS: A total of 892 adults receiving a mechanical (n = 346), pericardial (n = 463), or allograft (n = 83) valve for aortic stenosis were observed for up to 20 years (mean, 5.0 +/- 3.9 years) after primary isolated aortic valve replacement. We used multivariable propensity scores to adjust for valve selection factors, multivariable hazard function analyses to identify risk factors for all-cause mortality, and bootstrap resampling to quantify the reliability of the results. RESULTS: Twenty-five percent of patients had indexed internal orifice areas of less than 1.5 cm(2)/m(2) and more than 2 SDs (Z-value) below predicted normal aortic valve size. Mechanical valve orifices were smaller (1.3 +/- 0. 29 cm(2)/m(2), Z = -2.2 +/- 1.16) than pericardial (1.9 +/- 0.36 cm(2)/m(2), Z = -0.40 +/- 1.01) or allograft valves (2.1 +/- 0.50, Z = 0.24 +/- 1.17). The overall survival was 98%, 96%, 86%, 69%, and 49% at 30 days and 1, 5, 10, and 15 years postoperatively. Univariably, survival was weakly and inversely related to manufacturer valve size (P =.16) and internal orifice diameter (P =. 2) but completely unrelated to indexed valve area (P =.6) or Z-value (P =.8). These, and univariable differences among valve types (P =. 004), were accounted for by different prevalences in patient risk factors and not by valve size or type per se. Bootstrap resampling indicated that these findings had a less than 15% chance of being incorrect. CONCLUSIONS: Survival after aortic valve replacement is strongly related to patient risk factors but appears not to be adversely affected by moderate patient-prosthesis mismatch (down to about 4 SDs below normal). Aortic root enlargement to accommodate a large prosthesis may be required in few situations.

Adolescent↗

PubMed2000

Mitral valve repair and replacement for rheumatic disease.

OBJECTIVES: Mitral valve repair may be technically feasible in patients with suitable anatomy, but the appropriateness of repair for rheumatic disease remains controversial. We evaluated our late outcomes after mitral repair and replacement for rheumatic disease. METHODS: Five hundred seventy-three patients underwent mitral valve surgery for rheumatic disease at our institution from 1978-1995. Follow-up was 98% complete (mean, 68 +/- 46 months). Survival and morbidity were evaluated by Kaplan-Meier analysis and Cox regression, including propensity score analysis. RESULTS: Mean age was 54 +/- 14 years, 55% of patients had congestive heart failure, 22% were undergoing redo mitral valve surgery, and 9% also underwent coronary bypass. Mitral stenosis was present in 53%, regurgitation in 15%, and both in 32%. Valve repair was performed in 25%, bioprosthetic replacement was performed in 28%, and a mechanical valve was placed in 47%. Patients undergoing repair were younger and less likely to be undergoing reoperation or to have atrial fibrillation than those undergoing replacement (P =.001). The operative mortality rate was 4. 2%. Better late cardiac survival was independently predicted by valve repair rather than replacement (P =.04) after adjustment for baseline differences between patients. Freedom from reoperation was greatest (P =.005) but that from thromboembolic complications was worst (P <.0001) after mechanical valve replacement. Twenty-three patients underwent reoperation after initial repair, with no operative deaths. CONCLUSIONS: Mechanical valves minimize reoperation but limit survival and increase thromboembolic complications. Patients undergoing valve repair had improved late cardiac survival independent of their preoperative characteristics. Rheumatic mitral valves should be repaired when technically feasible, accepting a risk of reoperation, to maximize survival and reduce morbidity.

Adult↗

PubMed2003

Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease.

OBJECTIVE: We sought to compare mitral valve repair and replacement as treatments for degenerative mitral valve disease with coexisting ischemic heart disease. Specifically, we sought to (1) identify differences between patients undergoing repair and replacement, (2) determine whether the choice of mitral valve procedure affected survival after adjusting for those differences, and (3) discover which patients were predicted to benefit from mitral valve repair and which from replacement. METHODS: From 1973 to 1999, 679 patients (mean age, 67 +/- 9.1 years; 73% men) with degenerative mitral valve and ischemic heart diseases underwent combined coronary artery bypass grafting and either mitral valve repair (66%) or replacement (34%). Factors associated with repair and replacement were used for multivariable propensity matching. Risk factors for death were identified by means of multivariable, multiphase hazard-function analysis. RESULTS: Patients more likely to undergo repair had isolated posterior chordal rupture (P <.0001) or more recent date of operation (P <.0001); those more likely to undergo replacement were older (P =.0003) or had bileaflet prolapse (P <.0001). Unadjusted survival at 30 days and 1, 5, and 10 years was 97%, 92%, 79%, and 59% after repair and 94%, 88%, 70%, and 37% after replacement. After adjusting for comorbid factors, the extent and effect of ischemic heart disease, and propensity score, the survival benefit of repair became evident after 2 years (P =.01). Eighty-nine percent of patients were predicted to benefit from repair. CONCLUSIONS: In patients with degenerative mitral valve and ischemic heart diseases, mitral valve repair confers a survival advantage over replacement that becomes evident about 2 years after the operation.

Aged↗

PubMed2003

Atrial fibrillation after esophagectomy is a marker for postoperative morbidity and mortality.

OBJECTIVE: Postoperative atrial fibrillation complicates recovery in 20% to 25% of patients after esophagectomy for cancer. The purpose of this study is to understand this phenomenon. METHODS: Between 1982 and 2000, 198 (22% of 921) patients had postoperative atrial fibrillation after esophagectomy. Propensity scoring and the Greedy Match algorithm were used to develop a cohort of control patients for statistical comparisons. One hundred forty-four patients who had postoperative atrial fibrillation were matched. RESULTS: Pulmonary complications affected 42% of patients in the atrial fibrillation group compared with 17% in the control group (P <.001). Anastomotic leakage was more common in the atrial fibrillation group (6.9% vs 1.4%, P =.035). Surgical sepsis migrated with atrial fibrillation 4 times more frequently (P =.001). Multivariate analysis demonstrated that postoperative pulmonary complications (odds ratio, 2.5; 95% confidence interval, 1.42-4.3) and surgical sepsis (odds ratio, 3.4; 95% confidence interval, 1.2-9.6) were associated with postoperative atrial fibrillation. The mortality rates of the atrial fibrillation and control groups were 23% and 6.3%, respectively (P <.001). Median survival, excluding hospital deaths, was not different at 14.5 months (atrial fibrillation group) and 16.9 months (control group; P =.4). CONCLUSION: Atrial fibrillation is a surrogate for surgical morbidity and mortality after esophagectomy. The occurrence of atrial fibrillation after esophageal resection should prompt not only the appropriate management of the arrhythmia but also a search for a more ominous underlying cause.

Aged↗

PubMed1999

Impact of small prosthetic valve size on operative mortality in elderly patients after aortic valve replacement for aortic stenosis: does gender matter?

OBJECTIVE: Ideal management of the elderly patient with a small aortic root remains controversial. This retrospective analysis was performed to determine whether small prosthetic valve size is related to outcome in patients 70 years of age or older undergoing aortic valve replacement for aortic stenosis. METHODS: Between December 1991 and July 1998, 366 patients 70 years of age or older (median age 77 years, range 73-81 years, 49% male) underwent isolated aortic valve replacement or aortic valve replacement with coronary bypass grafting with standard Carpentier-Edwards bovine pericardial valves (Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif) (n = 277; 76%) or St Jude Medical mechanical valves (St Jude Medical, Inc, St Paul, Minn) (n = 89; 24%). Propensity scoring and multivariable regression models were used to evaluate the risks associated with implantation of 19-mm valves. RESULTS: Operative mortality was 16.7% (17/102) in patients who received 19-mm valves and 3% (8/264) among those receiving >/=21-mm valves (P </=.0005). The univariable odds ratio for operative death for 19-mm versus >/=21-mm valves was 6.4 (95% CI 2.7, 15.4; P </=.0005). In the final multivariable model, receipt of a 19-mm valve alone was not a statistically significant predictor of operative death (odds ratio 2. 1; 95% CI 0.7, 6.4; P =.21). However, the combination of male sex and 19-mm valve resulted in a significant risk of operative death (4/9 patients; odds ratio 17.5; 95% CI 2.2, 139; P =.007). Use of a 19-mm valve was not related to late death in either the univariable (hazard ratio 1.0; 95% CI 0.5, 2.0; P =.95) or the multivariable analysis (hazard ratio 0.7; 95% CI 0.3, 1.8; P =.51). CONCLUSIONS: Implantation of a standard 19-mm aortic valve in elderly men with aortic stenosis may be associated with an increased risk of operative mortality. A higher performance valve and/or a root enlargement procedure should be considered in men with a measured 19-mm anulus.

Aged↗

PubMed1999

Pulmonary function after segmentectomy for small peripheral carcinoma of the lung.

OBJECTIVE: The aim of this study is to compare the pulmonary function after a segmentectomy with that after a lobectomy for small peripheral carcinoma of the lung. PATIENTS AND METHODS: Between 1993 and 1996, segmentectomy and lobectomy were performed on 48 and 133 good-risk patients, respectively. Lymph node metastases were detected after the operation in 6 and 24 patients of the segmentectomy and lobectomy groups, respectively. For bias reduction in comparison with a nonrandomized control group, we paired 40 segmentectomy patients with 40 lobectomy patients using nearest available matching method on the estimated propensity score. RESULTS: Twelve months after the operation, the segmentectomy and lobectomy groups had forced vital capacities of 2.67 +/- 0.73 L (mean +/- standard deviation) and 2.57 +/- 0.59 L, which were calculated to be 94.9% +/- 10.6% and 91.0% +/- 13.2% of the preoperative values (P =.14), respectively. The segmentectomy and lobectomy groups had postoperative 1-second forced expiratory volumes of 1.99 +/- 0.63 L and 1.95 +/- 0.49 L, which were calculated to be 93.3% +/- 10.3% and 87.3% +/- 14.0% of the preoperative values, respectively (P =.03). The multiple linear regression analysis showed that the alternative of segmentectomy or lobectomy was not a determinant for postoperative forced vital capacity but did affect postoperative 1-second forced expiratory volume. CONCLUSION: Pulmonary function after a segmentectomy for a good-risk patient is slightly better than that after a lobectomy. However, segmentectomy should be still the surgical procedure for only poor-risk patients because of the difficulty in excluding patients with metastatic lymph nodes from the candidates for the procedure.

Aged↗