Jemma Mytton

Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage

Objective To conduct a nationwide study of associations between removal of all ovarian tissue versus conservation of at least one ovary at the time of hysterectomy and important health outcomes (ischaemic heart disease, cancer, and all cause mortality). Study design and setting Retrospective analysis of the English Hospital Episode Statistics database linked to national registers of deprivation indices and of deaths. Participants 113 679 patients aged 35-45 who had had a hysterectomy for benign conditions between April 2004 and March 2014. Exposures Bilateral ovarian removal versus no removal or unilateral ovarian removal (ovarian conservation). Main outcome measures Hospital admissions for ischaemic heart disease, cancer, or attempted suicide; deaths, overall and from heart disease, cancer, or suicide. Statistical adjustments were made using Cox regression and propensity score matching for potential confounders. Results A third of patients had bilateral ovarian removal. Patients in the ovarian conservation group were less likely to be admitted for ischaemic heart disease after hysterectomy than were those in the bilateral removal group (adjusted hazard ratio 0.85, 95% confidence interval 0.77 to 0.93; P=0.001). They were also less likely to have a cancer related post-hysterectomy admission (adjusted hazard ratio 0.83, 0.78 to 0.89; P<0.001). A significant difference in all cause mortality was also seen: 0.60% (456/76 581) of patients with ovarian conservation compared with 1.01% (376/37 098) of patients with bilateral removal. Again, this difference in favour of ovarian conservation was significant (adjusted hazard ratio 0.64, 0.55 to 0.73; P<0.001). Fewer deaths related specifically to heart disease (adjusted hazard ratio 0.50, 0.28 to 0.90; P=0.02) and to cancer (0.54, 0.45 to 0.65; P<0.001) occurred in the ovarian conservation group than in the bilateral removal group. No significant difference between groups was found relating to suicide (attempted or completed). The results after propensity score matching were essentially unchanged. Conclusion Patients who had ovarian conservation had a significantly lower hazard of all cause mortality compared with those who had bilateral ovarian removal and also had lower death rates from ischaemic heart disease and cancer. Consistent with this observation, admissions to hospital for both ischaemic heart disease and cancer were also lower in the ovarian conservation group than in the bilateral removal group. Although removal of both ovaries protects against subsequent development of ovarian cancer, premenopausal women should be advised that this benefit comes at the cost of an increased risk of cardiovascular disease and of other (more prevalent) cancers and higher overall mortality.

Outcomes After Weekend Admission for Deceased Donor Kidney Transplantation: A Population Cohort Study

Background Outcomes for weekend hospital admissions or emergency procedures have become a topical and controversial issue for the UK National Health Service. Deceased-donor kidney transplantation is frequently performed at weekends and evidence for its relative safety are lacking. Methods We undertook a population-based cohort analysis, obtaining data from every deceased-donor kidney-alone transplant procedure performed in England between January 2003 and December 2014. Data were extracted from Hospital Episode Statistics, with linkage to the Office for National Statistics to create a comprehensive dataset for mortality, rehospitalization and kidney allograft failure/rejection for weekend (defined as Friday to Sunday) versus weekday transplantation. Results Data were extracted for 12 902 deceased-donor kidney alone transplants performed in all 19 English transplant centres between 2003 and 2014. Based on initial &khgr;2 tests, no significant difference was observed when comparing weekend versus weekday transplantation in 30-day (0.9% vs 1.2%; P = 0.126) or 1-year mortality (3.7% vs 3.8%; P = 0.788), 1-year kidney allograft failure/rejection (16.7% vs 16.8%; P = 0.897), delayed graft function (29.97% vs 29.36%; P = 0.457) or 1-year risk for readmission (63.5% vs 63.3%; P = 0.774). In a Cox regression model, transplantation at the weekend was not associated with any increased risk for 1-year mortality, rehospitalization, or allograft failure/rejection. Conclusions Deceased-donor kidney transplants performed at the weekend do not have inferior short-term outcomes on the basis of 1-year risk for rehospitalization, mortality, or allograft failure/rejection. Our data are reassuring for patients and professionals alike, but may also provide speculative insight into models of care that attenuate the weekend effect.

A Comparison of Mortality Following Emergency Laparotomy Between Populations From New York State and England

OBJECTIVE The aim of this study was to compare mortality following emergency laparotomy between populations from New York State and England. SUMMARY OF BACKGROUND DATA Mortality following emergency surgery is a key quality improvement metric in both the United States and UK. Comparison of the all-cause 30-day mortality following emergency laparotomy between populations from New York State and England might identify factors that could improve care. METHODS Patient demographics, in-hospital, and 30-day outcomes data were extracted from Hospital Episode Statistics (HES) in England and the New York Statewide Planning and Research Cooperative System (SPARCS) administrative databases for all patients older than 18 years undergoing laparotomy for emergency open bowel surgery between April 2009 and March 2014. The primary outcome measure was all-cause mortality within 30 days of the index laparotomy. Mixed-effects logistic regression was performed to model independent demographic variables against mortality. A one-to-one propensity score matched dataset was created to compare the odd ratios of mortality between the 2 populations. RESULTS Overall, 137,869 patient records, 85,286 (61.9%) from England and 52,583 (38.1%) from New York State, were extracted. Crude 30-day mortality for patients was significantly higher in the England compared with New York State [11,604 (13.6%) vs 3633 (6.9%) patients, P < 0.001]. Patients undergoing emergency laparotomy in England had significantly higher risk of mortality compared with those in New York State (odds ratio 2.35, confidence interval 2.24-2.46, P < 0.001). CONCLUSION The risk of mortality at 30 days is higher following emergency laparotomy in England as compared with New York State despite similar patient groups.

Increased fracture risk in plasma cell dyscrasias is associated with poorer overall survival

Pathological fractures are a common complication of plasma cell dyscrasias (PCD) and are associated with significant morbidity. Routine use of bisphosphonates over the past decade has aimed to reduce the risk of fractures in patients with multiple myeloma, but despite this, fractures continue to represent a significant burden of disease. In this study we report the fracture rate of hospital in‐patients with PCD in England. Data from the national registry Hospital Episode Statistics between 2001 and 2015 were used to determine fracture rate and its effect on overall survival. Fracture rates were 17·8 times higher than the general population in the first year after admission with PCD, and remained elevated for up to 10 years after first admission. The increased fracture risk preceded the first admission with PCD and, conversely, the incidence of PCD increased after admission with one or more fractures. Overall survival is improving with PCD, however poorer survival is found in patients with a preceding fracture (Hazard ratio 1·20). Despite widespread bisphosphonate use, fractures remain common in PCD, and are associated with poorer outcomes.

PWE-122 The results of endoscopic and surgical treatment for achalasia in england between 2005 and 2016

Introduction Achalasia is an uncommon condition characterised by failed relaxation of the lower oesophageal sphincter. Achalasia can be treated by botulinum toxin injection, pneumatic dilatation, Heller’s myotomy or per-oral endoscopic myotomy. The aim of this study is to examine long term outcomes of the major treatment modalities. Method The Hospital Episode Statistics (HES) database includes diagnostic and procedural data for all hospital attendances in England. All subjects with an ICD10 code for achalasia and initial treatment between January 2006- September 2016 were grouped by coded initial treatment; injection, endoscopic dilatation or surgery. Procedural success was defined by time to further treatment, in the case of dilatations up to 3 procedures over 10 years were considered to not be a failure. Adverse events were recorded per procedure and predictors sought by logistic regression. Results 7373 subjects were included of whom 3828 (51.9%) were male, mean age at diagnosis 59.6 years (SD 19.75). 435 initially received (5.90%) endoscopic injection, 4748 (64.4%) dilatation and 2190 (29.7%) underwent surgery. Perforation rate following dilatation was 1.62%. Charlson score was 1–4 in 8.74%, 10.00%, 10.87% and >4 in 13.33%, 12.64%, 3.01% of the injection, dilatation and surgical groups respectively. Mortality at 30 days was; 2.99%, 1.87%, 0%, for the Injection, dilatation and surgical groups respectively. Factors predicting mortality after dilation included; age quintiles 66–77 (OR 3.94, 95% CI 1.83–8.46, p<0.001),>77 (7.93, 3.74–16.81, p<0.001), Charlson co-morbidity score >4 (2.99, 2.21–4.04 p<0.001), and previous surgical treatment (2.03, 1.09–3.78, p=0.025). Only Charlson score >4 (2.55 (1.11–5.85 p<0.028) predicted mortality in those receiving endoscopic injection. Durability for each group of single initial treatment at 9 years follow-up was 19.23%, 43.97%, 85.78% for injection, dilatation and surgical treatment respectively. The durability of up to 3 dilatations compared to single surgical treatment is reported in the table below. Endoscopic Dilatations Surgical treatment 2 years 94.83% 91.01% 5 years 88.35% 87.04% 7 years 86.93% 86.56% 9 years 86.09% 85.78% Conclusion The durability of surgical and pnuematic dilatation therapy for achalasia appears to be similar over up to 9 years. There was no mortality associated with surgery but 1.87% of subjects died within 30 days of dilatation. Older age and increased co-morbidity predicted mortality in subjects. Disclosure of Interest None Declared

Cancer-related outcomes in kidney allograft recipients in England versus New York State: a comparative population-cohort analysis between 2003 and 2013

It is unclear whether cancer‐related epidemiology after kidney transplantation is translatable between countries. In this population‐cohort study, we compared cancer incidence and all‐cause mortality after extracting data for every kidney‐alone transplant procedure performed in England and New York State (NYS) between 2003 and 2013. Data were analyzed for 18,493 and 11,602 adult recipients from England and NYS respectively, with median follow up 6.3 years and 5.5 years respectively (up to December 2014). English patients were more likely to have previous cancer at time of transplantation compared to NYS patients (5.6% vs. 3.5%, P < 0.001). Kidney allograft recipients in England versus NYS had increased cancer incidence (12.3% vs. 5.9%, P < 0.001) but lower all‐cause mortality during the immediate postoperative stay (0.7% vs. 1.0%, P = 0.011), after 30‐days (0.9% vs. 1.8%, P < 0.001) and after 1‐year post‐transplantation (3.0% vs. 5.1%, P < 0.001). However, mortality rates among patients developing post‐transplant cancer were equivalent between the two countries. During the first year of follow up, if patients had an admission with a cancer diagnosis, they were more likely to die in both England (Odds Ratio 4.28 [95% CI: 3.09–5.93], P < 0.001) and NYS (Odds Ratio 2.88 [95% CI: 1.70–4.89], P < 0.001). Kidney allograft recipients in NYS demonstrated higher hazard ratios for developing kidney transplant rejection/failure compared to England on Cox regression analysis. Our analysis demonstrates significant differences in cancer‐related epidemiology between kidney allograft recipients in England versus NYS, suggesting caution in translating post‐transplant cancer epidemiology between countries.

Cardiovascular, cancer and mortality events after bariatric surgery in people with and without pre‐existing diabetes: A nationwide study

Bariatric surgery reduces cardiovascular events and mortality risk in obese individuals. However, it is unclear whether diabetes modifies this effect. This study examined mortality, cardiovascular, and cancer risk following bariatric surgery in adults with and without pre‐existing diabetes.

Incidence, morbidity and mortality of patients with achalasia in England: findings from a study of nationwide hospital and primary care data

Background Achalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited. Methods Hospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality. Results There were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p<0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p<0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years. Conclusion The incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality.

Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study

Previous studies have raised concerns that the use of anti‐tumour necrosis factor (anti‐TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population‐based approach to investigate whether there is an association between anti‐TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy.

Fractures in kidney transplant recipients : a comparative study between England and New York State

OBJECTIVES Fractures are associated with high morbidity and are a major concern for kidney transplant recipients. No comparative analysis has yet been conducted between countries in the contemporary era to inform future international prevention trials. MATERIALS AND METHODS Data were obtained from the Hospital Episode Statistics and the Statewide Planning and Research Cooperative databases on all adult kidney transplants performed in England and New York State from 2003 to 2013, respectively, and on posttransplant fracture-related hospitalization from 2003 to 2014. RESULTS Our analysis included 18 493 English and 11 602 New York State kidney transplant recipients. Overall, 637 English recipients (3.4%) and 398 New York State recipients (3.4%) sustained a fracture, giving an unadjusted event rate of 7.0 and 5.9 per 1000 years, respectively (P = .948). Of these, 147 English (0.8%) and 101 New York State recipients (0.9%) sustained a hip fracture, giving an unadjusted event rate of 1.6 and 1.5 per 1000 years, respectively (P = .480). There were no differences in the cumulative incidence of all fractures or hip fractures. One-year mortality rates after any fracture (9% and 11%) or after a hip fracture (15% and 17%) were not different between cohorts. CONCLUSIONS Contemporaneous English and New York State kidney transplant recipients have similar fracture rates and mortality rates postfracture.