Comparative analysis among therapeutic modalities in ruptured hepatocellular carcinoma and identification of imaging predictors for survival.

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (rHCC) poses a life-threatening complication with a mortality rate of 25-75%. Treatment aims at achieving hemostasis and includes options such as trans-arterial embolization, perihepatic packing, and hepatic resection. The optimal treatment remains a subject of debate. Our retrospective review evaluates these treatments and investigates imaging's role in prognosis for rHCC patients. PURPOSE: We aimed to compare survival outcomes among rHCC patients who received transarterial embolization (TAE), surgery (perihepatic packing, hepatectomy), or best supportive care (BSC), while also identifying predictive imaging factors in these patients. MATERIALS AND METHODS: All patients diagnosed with rHCC and admitted to Maharaj Nakorn Chiangmai Hospital between January 2012 and December 2021 were included. We reviewed clinical features, imaging results, treatment modalities, and outcomes. In order to balance pretreatment confounders, inverse probability treatment weighting (IPTW) was employed. Flexible parametric survival regression was utilized to compare survival outcomes and identify imaging factors predicting the survival of rHCC patients. Hazard ratios (HR) and the difference in restricted mean survival time (RMST) were reported. RESULT: Among the 186 rHCC patients included, we observed 90-day and 1-year mortality rates of 64% and 84%, respectively. Both the TAE and surgery groups exhibited significantly lower 1-year mortality rates compared to BSC. The HR were 0.56 (95% CI 0.33-0.96) for TAE and 0.52 (95% CI 0.28-0.95) for surgery compared to BSC. Both the TAE and surgery also significantly extended the 1-yeaar life expectancy post-initial treatment when compared to BSC, with an RMST difference of + 55.40 days (95% CI 30.18-80.63) for TAE vs. BSC and + 68.43 days (95% CI 38.77-98.09) for surgery vs. BSC. The presence of active contrast extravasation and bleeding in both lobes were independent prognostic factors for 1-year survival. CONCLUSIONS: TAE and surgical treatments provide comparable survival benefits for rHCC patients, extending survival time by approximately 2 months compared to best supportive care. We strongly recommend active management for all rHCC patients whenever possible.

Incidence of venous thromboembolism and predictive ability of age-adjusted international prognostic index for prediction of venous thromboembolism in Asian patients with diffuse large B-cell lymphoma.

Diffuse large B-cell lymphoma (DLBCL) is one of the malignancies at high risk for the development of venous thromboembolism (VTE). We aimed to evaluate the incidence of VTE and the predictive ability of the age-adjusted international prognostic index (aaIPI) for the prediction of VTE among DLBCL patients. This was a retrospective cohort study including adult patients with newly diagnosed DLBCL. Differences in VTE occurrence within one year after diagnosis of DLBCL were estimated across aaIPI groups using the Kaplan-Meier model, Cox's model, and Gray's model with deaths regarded as competing events. Five hundred and ninety-one newly diagnosed DLBCL patients with a median age of 58 (range 16-93) years were included in this study. At a median follow-up time of 365 (range 2-365) days, VTE events were objectively diagnosed in 32 patients, giving a one-year cumulative incidence of VTE of 5.4% (95% confidence interval [CI], 3.7-7.6). Patients with aaIPI ≥ 2 had a significantly higher risk of VTE than patients with aaIPI < 2 (hazard ratio, 3.5; 95% CI, 1.6-7.8; p = 0.001 based on Cox's model and sub-distribution hazard ratio, 3.0; 95% CI, 1.3-6.7; p = 0.007 using Gray's model). The C-statistic of aaIPI was 0.65 (95% CI, 0.58-0.72). We demonstrated that the incidence of VTE in Asian DLBCL patients was not uncommon. The aaIPI was effective in determining the risk of VTE in DLBCL patients, even when including death as a competing event. aaIPI may be helpful in identifying patients at higher risk of VTE in DLBCL patients.

PREVALENCE AND PERSISTENCE OF HYPERTRANSMISSION DEFECTS OF VARIOUS SIZES IN EYES WITH INTERMEDIATE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To determine the prevalence and rate of persistence over 2 years of various-sized hypertransmission defects (hyperTDs) in eyes with intermediate age-related macular degeneration. METHODS: Retrospective analysis of optical coherence tomography data from consecutive intermediate age-related macular degeneration patients. Choroidal en face optical coherence tomography images were evaluated for the presence and number of hyperTDs of three different sizes based on greatest linear dimension (small, 63-124 µ m; medium, 125-249 µ m; large, ≥250 µ m) at baseline and at the 2-year follow-up. Interreader agreement was determined by Gwet's agreement coefficient. Disagreements between graders were resolved by the senior investigator to yield a single consensus for all cases. RESULTS: From 273 intermediate age-related macular degeneration eyes (247 patients), 72 and 76 hyperTD lesions were independently identified by two graders at baseline and overall agreement coefficient was 0.89 (95% CI, 0.86-0.93). After adjudication by the senior grader, the final consensus yielded 78 hyperTD lesions from 46 eyes (16.8%) of 42 patients (17.0%) in this study cohort. Among eyes with follow-up optical coherence tomography, 32 of 45 hyperTD lesions (71.1%) persisted. The rates of persistence were 100.0%, 72.7%, and 53.3% in large, medium, and small hyperTD sizes, respectively. CONCLUSION: HyperTDs were present in a significant proportion of intermediate age-related macular degeneration eyes. Acceptable interreader agreement was demonstrated in identifying hyperTD. Larger hyperTD lesions were more likely to persist over 2 years.

Survival analysis of older adults with dementia: predicting factors after unplanned hospitalization in Maharaj Nakorn Chiang Mai Hospital.

BACKGROUND: Hospitalization in individuals with dementia can be associated with negative and unintended outcomes. Research indicates that people with dementia experience more hospital admissions in comparison to individuals without dementia. This study aims to assess the survival time of individuals with dementia who experience unplanned hospitalization and examine the factors that are associated with mortality in this population. METHODS: This retrospective cohort study was conducted using data from older adults with dementia who survived unplanned hospitalizations at Maharaj Nakorn Chiang Mai Hospital between January 1, 2009, and December 31, 2016. The association between factors and mortality were analyzed using a multivariable Cox proportional hazards model. RESULTS: One hundred and eighty-one cases were included. The mean age of the study population was 80.07 (SD 7.49) years, and the majority were female (56.91%). The median survival time of the studied cohort was 3.06 years (95% CI 3.14-3.60). The multivariable analysis revealed that older age (aHR = 1.02, 95% CI 1.00-1.05), a diagnosis of mixed-type dementia (aHR = 3.45, 95% CI 1.17-10.14), higher Charlson comorbidity index score (aHR = 1.19, 95% CI 1.04-1.36), higher serum creatinine level (aHR = 1.35, 95% CI 1.10-1.66), insertion of endotracheal tube (aHR = 1.95, 95% CI 1.07-3.54), and readmission within 30 days (aHR = 1.88, 95% CI 1.18-2.98) were associated with an increased risk of mortality. CONCLUSIONS: We identified several notable predictors of mortality. Healthcare providers can use the findings of this study to identify patients who may be at higher risk of mortality and develop targeted interventions which may improve patient outcomes.

External Validation of the Charlson Comorbidity Index-based Model for Survival Prediction in Thai Patients Diagnosed with Dementia.

BACKGROUND: The Charlson Comorbidity Index (CCI) is commonly employed for predicting mortality. Nonetheless, its performance has rarely been evaluated in patients with dementia. This study aimed to examine the predictive capability of the CCI-based model for survival prediction in Thai patients diagnosed with dementia. METHODS: An external validation study was conducted using retrospective data from adults with dementia who had visited the outpatient departments at Maharaj Nakorn Chiang Mai Hospital between 2006 and 2012. The data obtained from electronic medical records included age, gender, date of dementia diagnosis and death, types of dementia, and comorbidities at the time of dementia diagnosis. The discriminative ability and calibration of the CCI-based model were estimated using Harrell's C Discrimination Index and visualized with calibration plot. As the initial performance did not meet satisfaction, model updating and recalibration were performed. RESULTS: Of 702 patients, 56.9% were female. The mean age at dementia diagnosis was 75.22 (SD 9.75) year-old. During external validation, Harrell's C-statistic of the CCI-based model was 0.58 (95% CI, 0.54-0.61). The model showed poor external calibration. Model updating was subsequently performed. All updated models demonstrated a modest increase in Harrell's C-statistic. Temporal recalibration did not significantly improve the calibration of any of the updated models. CONCLUSION: The CCI-based model exhibited fair discriminative ability and poor calibration for predicting survival in Thai patients diagnosed with dementia. Despite attempts at model updating, significant improvements were not achieved. Therefore, it is important to consider the incorporation of other influential prognostic factors.

Predictive Model of Recovery to Prefracture Activities-of-Daily-Living Status One Year after Fragility Hip Fracture.

Background and Objectives: Achieving prefracture functional status is a critical objective following a hip fracture, yet fewer than half of patients reach this milestone. The adoption of tools for assessing functional outcomes is increasingly recognized as essential for evaluating recovery following treatment for fragility hip fractures. We developed multivariable clinical prediction criteria to estimate the likelihood of patients regaining their prefracture activities-of-daily-living (ADL) status one year after sustaining a fragility hip fracture. Materials and Methods: A retrospective cohort of patients treated for fragility hip fractures at a university-affiliated tertiary care center between February 2017 and April 2019 served as the basis for developing and internally validating the clinical prediction criteria. We applied a multivariable fractional polynomial method to integrate several continuous predictors into a binary logistic regression model. Results: The study included 421 patients, 324 (77%) of whom reported regaining their prefracture activities-of-daily-living level one year after experiencing fragility hip fractures. Significant predictors, such as the prefracture Barthel index, EQ-VAS score, and treatment modality, were incorporated into the predictive model. The model demonstrated excellent discriminative power (AuROC of 0.86 [95% CI 0.82-0.91]) and satisfactory calibration. Conclusions: The predictive model has significant discriminative ability with good calibration and provides clinicians with a means to forecast the recovery trajectories of individual patients one year after a fragility hip fracture, which could be useful because prompt clinical decision-making is aided by this information. Patients and caregivers can also be counseled and encouraged to follow up with the medical activities and interventions deemed essential by doctors who used the prediction tool. Access to the model is provided through a web application. External validation is warranted in order to prove its applicability and generalizability.

The efficacy of induction treatment in Thai patients with lupus nephritis: Observational cohort analysis.

BACKGROUND: For active proliferative lupus nephritis (LN), intravenous cyclophosphamide (IVCYC) is a standard therapy whereby mycophenolate mofetil (MMF) is less effective than IVCYC, according to the clinical trials in non-Asians. In this observational study, the clinical outcomes will be compared among Thai patients. METHODS: We had analyzed 93 adult patients who underwent a renal biopsy for active proliferative LN confirmation between January 2013 and June 2021. The assessment of the response outcomes compared the induction treatment of IVCYC versus MMF. The primary endpoint had achieved complete remission (CR) at 24 weeks, while the secondary endpoint is overall remission (OR) and urine protein creatinine ratio (UPCR) changed over time. RESULTS: 93 LN patients were separated into two groups; 40 in IVCYC and 53 in MMF. In the 24th week, based on unadjusted analysis, patient had achieved CR 20.0% of IVCYC, whereas 28.3% of MMF had achieved CR. Unadjusted CR Risk difference was -0.08 (95% CI -0.26, -0.09, p-value = 0.351) and the adjusted CR risk difference was -0.19 (95% CI -0.42, 0.04, p-value = 0.098). The unadjusted OR risk difference was -0.06 (95% CI -0.26, 0.14, p-value = 0.553) while adjusted OR risk difference was -0.24 (95% CI -0.50, 0.02, p-value = 0.067). Unadjusted UPCR mean was -0.29 (95% CI -0.77, 0.17, p-value = 0.210) and adjusted UPCR mean was -0.27 (95% CI -0.88, 0.32, p-value = 0.366). CONCLUSIONS: The induction treatment with either IVCYC or MMF had similar efficacy in Thai LN patients. The decision of treatment should be taken by applying an individualized therapeutic strategy and balancing risks, costs, and benefits.

Reactive Neutrophilic Dermatoses in Adult-Onset Immunodeficiency due to Interferon-Gamma Autoantibody and Their Associated Factors.

BACKGROUND: Adult-onset immunodeficiency (AOID) due to interferon-gamma autoantibody is a rare, acquired immunodeficiency disease. Reactive neutrophilic dermatoses (RND), predominantly Sweet syndrome (SS), and generalized pustular eruption have been reported repeatedly. OBJECTIVES: The aims of this study were to describe the cutaneous manifestations in AOID patients and determine the incidence of RND and associated factors using a larger population size than have been previously reported. METHODS: A retrospective chart review of all confirmed AOID cases in Chiang Mai University Hospital from January 2006 to June 2020 was conducted. The demographics and characteristics of RND including type, onset, and laboratory information in every episode of cutaneous manifestations were collected. Generalized estimating equations of binary logistic regression were used to determine the indicators of RND. RESULTS: A total of 146 patients with confirmed AOID were identified. Of these, 57 cases (39%) developed at least one episode of RND. Thirteen cases (23%) of the patients experienced RND twice during the follow-up period. All recurrence of RND displayed the same cutaneous phenotype, with the exception of 2 cases who had both SS and generalized pustular eruption. Finally, 49 episodes of SS and 22 episodes of generalized pustular eruption were included in the analysis. All patients with RND had concomitant active opportunistic infections, of which most were non-tuberculous mycobacterium (NTM) infection. NTM infection (prevalence odds ratio [POR] 2.87), lymphadenopathy (POR 3.30) as well as lower serum alkaline phosphatase (ALP) level (POR 0.71 for every 100-unit increment in ALP) were found to be significantly associated with RND occurrence. CONCLUSIONS: 39% of our AOID patients experienced RND once during the course of the disease. Notable factors associated with RND occurrence were concomitant NTM infection, lymphadenopathy, and lower level of ALP.

Molecular-based classification of endometrial carcinoma in Northern Thailand: impact on prognosis and potential for implementation in resource-limited settings.

BACKGROUND: Endometrial carcinoma is molecularly categorized into four subgroups: polymerase-E exonuclease domain-mutant (POLE-mut), mismatch repair-deficient (MMR-d), p53-abnormal (p53-abn), and no specific molecular profile (NSMP). This classification scheme has been included into clinical recommendation for post-operative risk-based management, although there have been few Asian studies on this topic. The present study aimed to evaluate the prevalence and clinical outcomes of endometrial carcinoma using this classification in Northern Thailand and the feasibility of implementation in resource-limited settings. METHODS: Endometrial carcinomas from hysterectomy specimens were classified using immunohistochemistry for MMR proteins and p53, as well as POLE mutation testing. Clinicopathological variables and outcomes were analyzed. The costs of the molecular information-based approach were compared to those incurred by the conventional approach (without molecular classification). RESULTS: Of 138 patients, 52.9% in the NSMP subgroup, 28.2% were in the MMR-d, 13.8% in the p53-abn, and 5.1% in the POLE-mut. After adjusting for other variables, patients with POLE-mut showed the most favorable outcomes, while those with p53-abn had the poorest survival. When estimating the costs for post-operative management, the use of molecular classification resulted in a 10% increase over the conventional approach. However, the cost increased only by 1% if only POLE testing was used to identify patients for treatment omission. CONCLUSION: In Northern Thailand, endometrial carcinoma had comparable subgroup distribution and prognostic implications to previous reports, supporting the implementation of management guidelines that incorporate molecular information. In resource-limited settings, at least POLE mutation testing in early-stage patients should be considered.

Performance of the Matsumiya scoring system in cervical cancer patients with bone metastasis: an external validation study.

BACKGROUND: Accurate prognostic prediction of survival in cervical cancer patients with bone metastasis is important for treatment planning. We aimed to externally validate the Matsumiya scoring system using external patient data. METHODS: We collected a retrospective cohort of patients with cervical cancer diagnosed with bone metastasis at Chiang Mai University Hospital from 1st January 2007 to 31st December 2016. The Matsumiya score was composed of 5 predictors, including the presence of extraskeletal metastasis, ECOG performance status, history of previous chemo- or radiotherapy, the presence of multiple bone metastasis, and bone metastasis-free interval < 12 months. Harrell's C-statistics and score calibration plots were used to evaluate the score performance. We also reconstructed the development study to estimate apparent performance values for comparison during external validation. RESULTS: A total of 124 cervical cancer patients with bone metastasis were included in this study. The 13-, 26-, and 52-week survival probabilities in the validation study were 70.1%, 50.5%, and 25.7%, respectively. Several differences were identified between development and validation studies regarding clinical characteristics, case-mix, and predictor-outcome associations. Harrell's C-statistics in the development and validation study were 0.714 and 0.567. The score showed poor agreement between the observed and the predicted survival probabilities in the validation study. Score reweighting and refitting showed only modest improvement in performance. CONCLUSION: A prognostic scoring system by Matsumiya et al. performed poorly in our cohort of Thai cervical cancer patients with bone metastasis. We suggested that the score should be sufficiently updated before being used.