Significant drop in serum C-reactive protein in patients with solid neoplasia and bacterial infection is associated with a better prognosis and identifies candidates for short-course antibiotic therapy.

INTRODUCTION: The greater predisposition to infections, as well as the possibility of a worse response to treatment, can lead to the excessive use of antimicrobials among cancer patients. C-reactive protein (CRP) has gained prominence as a tool for monitoring therapeutic responses and reducing the duration of antibiotic therapy; however, few studies have analyzed this protein in cancer patient populations. We hypothesize that cancer patients with a good response to antibiotic therapy show a faster decline in serum CRP levels, which would allow us to identify candidates for short-course treatments. OBJECTIVE: To evaluate the behavior of serum CRP levels among adult cancer patients using antibiotic therapy, and its association with the duration of this treatment, therapeutic response, and clinical recurrence. METHODS: This work consisted of a retrospective study with cancer patients admitted to a university hospital between September 2018 and December 2019. Adults (age ≥ 18 years) who underwent at least one course of antibiotic therapy were included. CRP behavior over the first 7 days of treatment was classified as: i) good response: when the CRP value on the fifth day of therapy reached 50% or less of the peak value detected in the first 48 h of treatment, and ii) poor response: Maintenance, within the same interval, of a CRP value > 50% of the peak value in the first 48 h. The duration of antibiotic therapy was categorized as up to seven full days or more. Outcomes were assessed by events that occurred during the 30 days of hospitalization or until hospital discharge. PRIMARY OUTCOME: Clinical recurrence of the index infection. SECONDARY OUTCOMES: i) Death from any cause; ii) microbiological recurrence; iii) therapeutic response; iv) colitis associated with Clostridioides difficile; and v) isolation of multi-resistant bacteria, whether in clinical or surveillance samples. RESULTS: The final analysis consisted of 212 patients, with a median age (IQ) of 59.2 (48 - 67) years old and a predominance of females (65%), who were hypertensive (35%), smokers (21%), and diabetics (17.8%). There was no difference in clinical recurrence between the two groups (8.1% vs. 12.2%; p = 0.364), with a lower 30-day mortality in the good CRP response group (32.2% vs. 14.5%; p = 0.002). Despite the tendency towards a lower occurrence of other secondary outcomes in the good response group, these differences were not statistically significant. In the poor CRP response group, outcomes like clinical recurrence, mortality, and therapeutic response were significantly worse, regardless of the duration of antibiotic treatment. CONCLUSION: In this study, cancer patients with a good CRP response during antibiotic therapy presented lower mortality and a higher proportion of satisfactory therapeutic responses. CRP can be a useful tool when combined with other clinical information in optimizing the duration of antimicrobial treatment in a hospitalized cancer population.

Impact of duration of dual anti-platelet therapy on risk of complications after stent-assisted coiling of unruptured aneurysms.

BACKGROUND: The optimal duration for dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC) of intracranial aneurysms is unclear. Longer-term therapy may reduce thrombotic complications but increase the risk of bleeding complications. METHODS: A retrospective review of prospectively maintained data at 12 institutions was conducted on patients with unruptured intracranial aneurysms who underwent SAC between January 1, 2016 and December 31, 2020, and were followed ≥6 months postprocedure. The type and duration of DAPT, stent(s) used, outcome, length of follow-up, complication rates, and incidence of significant in-stent stenosis (ISS) were collected. RESULTS: Of 556 patients reviewed, 450 met all inclusion criteria. Nine patients treated with DAPT <29 days after SAC and 11 treated for 43-89 days were excluded from the final analysis as none completed their prescribed duration of treatment. Eighty patients received short-term DAPT. There were no significant differences in the rate of thrombotic complications during predefined periods of risk in the short, medium, or long-term treatment groups (1/80, 1.3%; 2/188, 1.1%; and 0/162, 0%, respectively). Similarly, no differences were found in the rate of hemorrhagic complications during period of risk in any group (0/80, 0%; 3/188, 1.6%; and 1/162, 0.6%, respectively). Longer duration DAPT did not reduce ISS risk in any group. CONCLUSIONS: Continuing DAPT >42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis, although the risk of additional hemorrhagic complications remained low. It may be reasonable to discontinue DAPT after 42 days following non-flow diverting SAC of unruptured intracranial aneurysms.

Endothelial Cell Transcription Modulation in Cerebral Aneurysms After Endovascular Flow Diversion.

PURPOSE: Flow diverting stents (FDS) are used to treat cerebral aneurysms, by promoting thrombosis and occlusion of the aneurysm sac. However, retreatment is required in some cases, and the biologic basis behind treatment outcome is not known. The goal of this study was to understand how changes in hemodynamic flow after FDS placement affect aneurysmal endothelial cell (EC) activity. METHODS: Three-dimensional models of patient-specific aneurysms were created to quantify the EC response to FDS placement. Computational fluid dynamic simulations were used to determine the hemodynamic impact of FDS. Two identical models were created for each patient; into one a FDS was inserted. Each model was then populated with human carotid ECs and subjected to patient-specific pulsatile flow for 24 h. ECs were isolated from aneurysm dome from each model and bulk RNA sequencing was performed. RESULTS: Paired untreated and treated models were created for four patients. Aneurysm dome EC analysis revealed 366 (2.6%) significant gene changes between the untreated and FDS conditions, out of 13909 total expressed genes. Gene set enrichment analysis of the untreated models demonstrated enriched gene ontology terms related to cell adhesion, growth/tensile activity, cytoskeletal organization, and calcium ion binding. In the FDS models, enriched terms were related to cellular proliferation, ribosomal activity, RNA splicing, and protein folding. CONCLUSION: Treatment of cerebral aneurysms with FDS induces significant EC gene transcription changes related to aneurysm hemodynamics in patient-specific in vitro 3D-printed models subjected to pulsatile flow. Further investigation is needed into the relationship between transcriptional change and treatment outcome.

Pulsed-field ablation versus thermal ablation for atrial fibrillation: A meta-analysis.

Background: Pulsed-field ablation (PFA) is an alternative to thermal ablation (TA) in patients with atrial fibrillation (AF) receiving catheter-based therapy for pulmonary vein isolation (PVI). However, its efficacy and safety have yet to be fully elucidated. Objective: The purpose of this study was to compare the acute and long-term efficacies and safety of PFA and TA. Methods: We performed a systematic review and meta-analysis of randomized and nonrandomized controlled trials comparing PFA and TA in patients with AF undergoing their first PVI ablation. The TA group was divided into cryoballoon (CB) and radiofrequency subgroups. AF patients were divided into paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PersAF) subgroups for further analysis. Results: Eighteen studies involving 4998 patients (35.2% PFA) were included. Overall, PFA was associated with a shorter procedure time (mean difference [MD] -21.68; 95% confidence interval [CI] -32.81 to -10.54) but longer fluoroscopy time (MD 4.53; 95% CI 2.18-6.88) than TA. Regarding safety, lower (peri-)esophageal injury rates (odds ratio [OR] 0.17; 95% CI 0.06-0.46) and higher tamponade rates (OR 2.98; 95% CI 1.27-7.00) were observed after PFA. In efficacy assessment, PFA was associated with a better first-pass isolation rate (OR 6.82; 95% CI 1.37-34.01) and a lower treatment failure rate (OR 0.83; 95% CI 0.70-0.98). Subgroup analysis showed no differences in PersAF and PAF. CB was related to higher (peri)esophageal injury, and lower PVI acute success and procedural time. Conclusion: Compared to TA, PFA showed better results with regard to acute and long-term efficacy but significant differences in safety, with lower (peri)esophageal injury rates but higher tamponade rates in procedural data.

Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial.

PURPOSE: Limited high-quality studies have compared robot-assisted laparoscopic prostatectomy (RALP) vs open retropubic radical prostatectomy. We sought to compare their postoperative outcomes in a randomized setting. MATERIALS AND METHODS: In a single center, 354 men with newly diagnosed prostate cancer were assessed for eligibility; 342 were randomized (1:1). The primary outcome was 90-day complication rates. Functional outcomes and quality of life were assessed over 18 months, and oncological outcomes, biochemical recurrence-free survival, and additional treatment over 36 months. RESULTS: From 2014 to 18, 327 patients underwent surgery (retropubic radical prostatectomy = 156, RALP = 171). Complications occurred in 27 (17.3%) vs 19 (11.1%; P = .107). Patients undergoing RALP experienced lower median bleeding (250.0 vs 719.5 mL; P < .001) and shorter hospitalization time. Urinary EPIC (Expanded Prostate Cancer Index Composite) median scores were better for RALP over 18 months, with higher continence rate at 3 months (80.5% vs 64.7%; P = .002), 6 months (90.1% vs 81.6%; P = .036) and 18 months (95.4% vs 78.8%; P < .001). Sexual EPIC and Sexual Health Inventory for Men median scores were higher with RALP up to 12 months, while the potency rate was superior at 3 months (23.9% vs 5.3%; P = .001) and 6 months (30.6% vs 6.9%; P < .001). Quality of life over the 18 months and oncological outcomes over 36 months were not significantly different between arms. CONCLUSIONS: Complications at 90 days were similar. RALP showed superior sexual outcomes at 1 year, improved urinary outcomes at 18 months, and comparable oncological outcomes at 36 months. TRIAL REGISTRATION: Prospective Analysis of Robot-Assisted Surgery; NCT02292914. https://clinicaltrials.gov/ct2/show/NCT02292914?cond=NCT02292914&draw=2&rank=1.

Numerical Modeling of Flow in the Cerebral Vasculature: Understanding Changes in Collateral Flow Directions in the Circle of Willis for a Cohort of Vasospasm Patients Through Image-Based Computational Fluid Dynamics.

The Circle of Willis (CoW) is a ring-like network of blood vessels that perfuses the brain. Flow in the collateral pathways that connect major arterial inputs in the CoW change dynamically in response to vessel narrowing or occlusion. Vasospasm is an involuntary constriction of blood vessels following subarachnoid hemorrhage (SAH), which can lead to stroke. This study investigated interactions between localization of vasospasm in the CoW, vasospasm severity, anatomical variations, and changes in collateral flow directions. Patient-specific computational fluid dynamics (CFD) simulations were created for 25 vasospasm patients. Computed tomographic angiography scans were segmented capturing the anatomical variation and stenosis due to vasospasm. Transcranial Doppler ultrasound measurements of velocity were used to define boundary conditions. Digital subtraction angiography was analyzed to determine the directions and magnitudes of collateral flows as well as vasospasm severity in each vessel. Percent changes in resistance and viscous dissipation were analyzed to quantify vasospasm severity and localization of vasospasm in a specific region of the CoW. Angiographic severity correlated well with percent changes in resistance and viscous dissipation across all cerebral vessels. Changes in flow direction were observed in collateral pathways of some patients with localized vasospasm, while no significant changes in flow direction were observed in others. CFD simulations can be leveraged to quantify the localization and severity of vasospasm in SAH patients. These factors as well as anatomical variation may lead to changes in collateral flow directions. Future work could relate localization and vasospasm severity to clinical outcomes like the development of infarct.

Cannabinoid products for pain management: recommendations from the São Paulo State Society of Anesthesiology.

There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions.

Endoscopic decompression of a C1 osteophyte causing bow hunter's syndrome in a 22-year-old male.

The patient is a 22-year-old male with a history of C1 avulsion fracture causing vertebral artery compression with pseudoaneurysm and symptomatic stroke. Cerebral angiography demonstrated dynamic compression of the V3 segment of the vertebral artery due to a chronic C1 avulsion fracture. The authors utilized a full endoscopic approach with intraoperative angiography for proximal control and Doppler ultrasound to confirm adequate decompression. The surgery duration was 3 hours with blood loss < 5 ml. The patient was discharged on postoperative day 1 with no complication and has been asymptomatic since surgery. This is the first documented use of endoscopic decompression to treat this condition. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23234.

Children's preoperative stress according to the parental presence evaluated by salivary cortisol and mYPAS: quasi-randomized trial.

OBJECTIVE: The main objective of this study was to compare stress and anxiety levels in children undergoing surgical procedures with or without parental presence at induction of anesthesia by measuring salivary cortisol levels and applying the mYPAS. METHOD: Quasi-randomized trial with children aged 5-12 year, with ASA physical status I, II, or III, undergoing elective surgery. According to parents' willingness, the pair were defined as accompanied or unaccompanied group. Chi-square, Fisher's exact tests, Student's t test, Mann-Whitney, Hodges-Lehman and Spearman's tests were used for statistical analyzes. RESULTS: We included 46 children; 63% were preschool children mostly accompanied by their mothers (80%). The median mYPAS score was 37.5 (quartile range, 23.4-51.6) in unaccompanied children, and 55.0 (quartile range, 27.9-65.0) in accompanied children, with an estimated median difference of +11.8 (95% CI of 0 to 23.4; p = 0.044). There were no significant differences in the mean salivary cortisol levels. CONCLUSION: The level of anxiety was higher in accompanied children. There were no differences in salivary cortisol levels between both groups. Brazilian Registry of Clinical Trials (ReBEC): RBR-9wj4qvy.

Dry needling, trigger point electroacupuncture and motor point electroacupuncture for the treatment of myofascial pain syndrome involving the trapezius: a randomised clinical trial.

OBJECTIVE: The objective of this study was to compare trigger point (TrP) dry needling, TrP electroacupuncture and motor point electroacupuncture of the trapezius muscle for the treatment of myofascial pain syndrome (MPS). METHODS: This randomised clinical trial included 90 patients divided into three groups. Group 1 was treated with dry needling of TrPs, group 2 with intramuscular electrical stimulation of TrPs, and group 3 with electroacupuncture of motor points and/or the spinal accessory nerve. Each group received seven treatment sessions. The outcomes were the pain score measured by visual analogue scale (VAS) and quality of life evaluated by the 12-item short form (SF-12) health questionnaire. We compared the pain outcome over serial time points using growth curve analysis methods. RESULTS: Participants in the three groups experienced significant improvements in pain scores over time. The average pain level of participants in group 3 across the repeated assessments was 0.98 units lower than in group 1 (mean difference (95% confidence interval (CI) = 1.74-0.23)), p = 0.012). There were no significant differences in pain scores between participants in groups 1 and 2, and there were no significant differences in quality of life across the three groups at the end of the treatment period. CONCLUSION: Our results provide evidence that electrical stimulation of motor points and/or of the spinal accessory nerve may be superior in terms of pain relief (but not quality of life) to dry needling and possibly electrical stimulation of trigger points for the management of MPS involving the trapezius. TRIAL REGISTRATION NUMBER: TRIAL-RBR-43R7RF (Brazilian Clinical Trials Registry).

Evaluating the Interaction Between Pain Intensity and Resilience on the Impact of Pain in the Lives of People With Fibromyalgia.

OBJECTIVE: Recent theoretical models posit that resilience acts as a resource/mechanism opposing pain catastrophizing and other vulnerability sources against pain adaptation. The aim of this study was to investigate the relationship between resilience, pain, and functionality in people living with fibromyalgia (FM). MATERIALS AND METHODS: We conducted a cross-sectional online survey of people participating in Brazilian fibromyalgia virtual support groups on Facebook in May 2018. Resilience was evaluated by the Connor-Davidson Resilience Scale. Average pain and the degree of interference of pain in the lives of participants (DIPLP) were assessed using the Brief Pain Inventory. The association between these 3 variables was evaluated through multivariable robust linear regression with adjustment for 21 potential confounders. RESULTS: We included 2176 participants with FM. Resilience was associated with a decreased DIPLP (ß: -0.38, 95% CI: -0.54 to -0.22, P <0.001) but not with average pain scores (ß: -0.01, 95% CI: -0.18 to 0.16, P =0.93). A significant interaction between resilience and average levels of pain on the DIPLP was observed so that resilience showed a much stronger protective association among participants with average null-to-mild pain than among those with moderate and severe pain levels. DISCUSSION: Our results provide evidence against beliefs that the pain of people with FM is related to low psychological resilience and shed light on the complex interrelationships between resilience, pain, and functionality. This research signals both the relevance and limits of resilience in the management of FM. Future studies evaluating behavioral interventions for FM should consider how those interventions interact with baseline pain levels and resilience.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care.

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Abstract Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Children's preoperative stress according to the parental presence evaluated by salivary cortisol and mYPAS: quasi-randomized trial / Estresse pré-operatório em crianças de acordo com a presença dos pais avaliada por cortisol salivar e mYPAS: ensaio quase-randomizado / Estrés preoperatorio en niños según la presencia de los padres evaluado mediante cortisol salival y mYPAS: ensayo cuasi-aleatorio

ABSTRACT Objective: The main objective of this study was to compare stress and anxiety levels in children undergoing surgical procedures with or without parental presence at induction of anesthesia by measuring salivary cortisol levels and applying the mYPAS. Method: Quasi-randomized trial with children aged 5-12 year, with ASA physical status I, II, or III, undergoing elective surgery. According to parents' willingness, the pair were defined as accompanied or unaccompanied group. Chi-square, Fisher's exact tests, Student's t test, Mann-Whitney, Hodges-Lehman and Spearman's tests were used for statistical analyzes. Results: We included 46 children; 63% were preschool children mostly accompanied by their mothers (80%). The median mYPAS score was 37.5 (quartile range, 23.4-51.6) in unaccompanied children, and 55.0 (quartile range, 27.9-65.0) in accompanied children, with an estimated median difference of +11.8 (95% CI of 0 to 23.4; p = 0.044). There were no significant differences in the mean salivary cortisol levels. Conclusion: The level of anxiety was higher in accompanied children. There were no differences in salivary cortisol levels between both groups. Brazilian Registry of Clinical Trials (ReBEC):RBR-9wj4qvy.

RESUMO Objetivo: O principal objetivo deste estudo foi comparar os níveis de estresse e ansiedade em crianças submetidas a procedimentos cirúrgicos com ou sem presença dos pais na indução da anestesia, medindo os níveis de cortisol salivar e aplicando o mYPAS. Método: Ensaio quaserandomizado com crianças de 5 a 12 anos, com estado físico ASA I, II ou III, submetidas a cirurgia eletiva. De acordo com a disposição dos pais, o par foi definido como grupo acompanhado ou não acompanhado. Foram utilizados testes de qui-quadrado, exato de Fisher, t de Student, Mann-Whitney, Hodges-Lehman e Spearman para as análises estatísticas. Resultados: Foram incluídas 46 crianças; 63% delas em idade préescolar, principalmente acompanhadas por suas mães (80%). A pontuação mYPAS mediana foi de 37,5 (intervalo interquartil, 23,4-51,6) em crianças não acompanhadas e de 55,0 (intervalo interquartil, 27,9-65,0) em crianças acompanhadas, com uma diferença mediana estimada de +11,8 (IC de 95% de 0 a 23,4; p = 0,044). Não houve diferenças significativas nos níveis médios de cortisol salivar. Conclusão: O nível de ansiedade foi maior em crianças acompanhadas. Não houve diferenças nos níveis de cortisol salivar entre os dois grupos. Registro Brasileiro de Ensaios Clínicos (ReBEC):RBR-9wj4qvy.

RESUMEN Objetivo: El objetivo principal de este estudio fue comparar los niveles de estrés y ansiedad en niños sometidos a procedimientos quirúrgicos con o sin presencia de los padres en la inducción de la anestesia mediante la medición de los niveles de cortisol salival y la aplicación del mYPAS. Método: Ensayo cuasi-aleatorio con niños de 5 a 12 años, con estado físico ASA I, II o III, sometidos a cirugía electiva. Según la disposición de los padres, se definieron como grupo acompañado o no acompañado. Se utilizaron pruebas de chi-cuadrado, exacta de Fisher, t de Student, Mann-Whitney, Hodges-Lehman y Spearman para los análisis estadísticos. Resultados: Se incluyeron 46 niños; el 63% eran niños en edad preescolar, en su mayoría acompañados por sus madres (80%). La puntuación mYPAS mediana fue de 37,5 (rango intercuartílico, 23,4-51,6) en niños no acompañados y de 55,0 (rango intercuartílico, 27,9-65,0) en niños acompañados, con una diferencia mediana estimada de +11,8 (IC del 95% de 0 a 23,4; p = 0,044). No hubo diferencias significativas en los niveles medios de cortisol salival. Conclusión: El nivel de ansiedad fue mayor en los niños acompañados. No hubo diferencias en los niveles de cortisol salival entre ambos grupos. Registro Brasileño de Ensayos Clínicos (ReBEC):RBR-9wj4qvy.

Performance of modeling and balancing approach methods when using weights to estimate treatment effects in observational time-to-event settings.

In observational studies weighting techniques are often used to overcome bias due to confounding. Modeling approaches, such as inverse propensity score weighting, are popular, but often rely on the correct specification of a parametric model wherein neither balance nor stability are targeted. More recently, balancing approach methods that directly target covariate imbalances have been proposed, and these allow the researcher to explicitly set the desired balance constraints. In this study, we evaluate the finite sample properties of different modeling and balancing approach methods, when estimating the marginal hazard ratio, through Monte Carlo simulations. The use of the different methods is also illustrated by analyzing data from the Swedish stroke register to estimate the effect of prescribing oral anticoagulants on time to recurrent stroke or death in stroke patients with atrial fibrillation. In simulated scenarios with good overlap and low or no model misspecification the balancing approach methods performed similarly to the modeling approach methods. In scenarios with bad overlap and model misspecification, the modeling approach method incorporating variable selection performed better than the other methods. The results indicate that it is valuable to use methods that target covariate balance when estimating marginal hazard ratios, but this does not in itself guarantee good performance in situations with, e.g., poor overlap, high censoring, or misspecified models/balance constraints.