Acute Treatment Outcomes Research Articles

The long-term effect of trauma history on adolescent depression treatment.

Childhood trauma is associated with the development of depression during adolescence. Prior research suggests that traumatic experiences may result in differential acute treatment outcomes for depressed adolescents. However, the long-term effects of trauma on treatment response remain unclear. Participants (N = 318) with a primary diagnosis of major depressive disorder were randomly assigned to 1 of 3 treatment groups: cognitive-behavioral therapy (CBT), fluoxetine (FLX), or their combination (COMB). All participants received 36 weeks of active treatment followed by 1 year of open follow-up. We hypothesized that (a) adolescents without a trauma history would have greater symptom reduction over the course of treatment compared to those with a trauma history and (b) there would be an interaction between trauma history, treatment arm, and time such that adolescents without trauma histories in combination treatment would improve the most rapidly. Linear mixed effects modeling, factorial ANOVAs, and log-linear analyses were used to test these hypotheses. The linear mixed effect model revealed a significant 3-way interaction of time, trauma, and treatment type. In the CBT and COMB groups, adolescents without trauma histories improved more rapidly than traumatized adolescents. In the single-time-point analyses, there were no significant differences between adolescents with trauma histories and those without trauma histories. Whereas all treatment groups experienced significant reductions in depression regardless of trauma history, adolescents without trauma histories receiving psychotherapy demonstrated more rapid improvements in depression symptom severity. Treatment response did not differ between traumatized and nontraumatized youth at long-term follow-up. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evidence that Tenecteplase Is Noninferior to Alteplase for Acute Ischemic Stroke: Meta-Analysis of 5 Randomized Trials.

Background and Purpose- TNK (tenecteplase), a newer fibrinolytic agent, has practical delivery advantages over ALT (alteplase) that would make it a useful agent if noninferior in acute ischemic stroke treatment outcome. Accordingly, the most recent US American Heart Association/American Stroke Association acute ischemic stroke guideline recognized TNK as an alternative to ALT, but only based on informal consideration, rather than formal meta-analysis, of completed randomized control trials. Methods- Systematic literature search and formal meta-analysis were conducted per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses), adapted to noninferiority analysis. The primary outcome of freedom from disability (modified Rankin Scale score, 0-1) outcome at 3 m, and additional efficacy and safety outcomes, were analyzed. Results- Systematic search identified 5 trials enrolling 1585 patients (828 TNK, 757 ALT). Across all trials, mean age was 70.8, 58.5% male, baseline National Institutes of Health Stroke Scale mean 7.0, and time from last known well to treatment start mean 148 minutes. All ALT patients received standard 0.9 mg/kg dosing, while TNK dosing was 0.1 mg/kg in 6.8%, 0.25 mg/kg in 24.6%, and 0.4 mg/kg in 68.6%. For the primary end point, crude cumulative rates of disability-free (modified Rankin Scale score, 0-1) 3 m outcome were TNK 57.9% versus ALT 55.4%. Informal, random-effects meta-analysis, the risk difference was 4% (95% CI, -1% to 8%). The lower 95% CI bound fell well within the prespecified noninferiority margin. Similar results were seen for the additional efficacy end points: functional independence (modified Rankin Scale score, 0-2): crude TNK 71.9% versus ALT 70.5%, risk difference 2% (95% CI, -3% to 6%); and modified Rankin Scale shift analysis, common odds ratio 1.21 (95% CI, 0.93-1.57). For safety end points, lower event rates reduced power, but point estimates were also consistent with noninferiority Conclusions- Accumulated clinical trial data provides strong evidence that TNK is noninferior to ALT in the treatment of acute ischemic stroke. These findings provide formal support for the recent guideline recommendation to consider TNK an alternative to ALT.

Markers of Coagulation and Fibrinolysis Predicting the Outcome of Acute Ischemic Stroke Thrombolysis Treatment: A Review of the Literature.

Intravenous administration of recombinant tissue plasminogen activator (rt-PA) has been proven to be safe and effective in the treatment of acute ischemic stroke. Little is known, however, why this treatment is less effective in some patients while in others life-threatening side-effects, e.g., symptomatic intracerebral hemorrhage might occur. Clinical failure of thrombolysis related to absent or partial recanalization or reocclusion as well as hemorrhagic complications of thrombolysis are possibly related to hemostatic events. Data on markers of coagulation and/or fibrinolysis in acute stroke patients are numerous and may provide indications regarding therapy outcomes. Better understanding of the hemostatic and fibrinolytic system during rt-PA therapy might be clinically useful and ultimately might lead to an improvement in the efficacy or safety of this treatment. Studies on thrombus composition retrieved from cerebral arteries may also advance our knowledge and provide a key to improve acute stroke therapy. Here we provide a comprehensive review on a wide range of factors and markers of coagulation and fibrinolysis that have been studied in the context of thrombolysis outcome in ischemic stroke patients. Moreover, a brief summary is given on the most recent research on thrombus composition having a potential influence on outcomes.

Associated Factors and Clinical Implication of Cutaneous Allodynia in Patients with Cluster Headache: A Prospective Multicentre Study

Cutaneous allodynia (CA) is an abnormal pain in response to non-painful stimuli. In the present study, we sought to investigate the presence of CA, its associated factors, and its clinical implications in patients with cluster headache (CH). In this cross-sectional study, we analysed data from a prospective multicentre registry enrolling consecutive patients with CH. We identified CA during and between headache attacks using the 12-item Allodynia Symptom Checklist (ASC) administered during the CH bout period. Comorbid depression and anxiety were ascertained using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) scales. Headache impact was evaluated using the Headache Impact Test-6 (HIT-6). Of 119 eligible patients, 48 and two (40.3% and 1.7%) had CA during and between headache attacks, respectively. In univariable analyses, total CH duration, major depressive disorder (MDD), and generalized anxiety disorder (GAD) were associated with CA during headache attack. They remained significantly associated with CA during headache attack in multivariable analyses. Patients with CA during headache attack had higher headache impact (P = 0.002). A “50% responder” analysis showed no difference in outcome of acute and preventive treatment between patients with and without CA during headache attack. Patients with CH commonly experienced CA during headache attack, but not between headache attacks. CA during headache attack was associated with disease duration, depression, and anxiety.

In-Hospital Bleeding Outcomes of Myocardial Infarction in the Era of Warfarin and Direct Oral Anticoagulants for Atrial Fibrillation in the United States: A Report From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry.

BackgroundWe sought to examine patient characteristics, peri‐infarction invasive and pharmacologic management, and in‐hospital major bleeding in myocardial infarction patients with atrial fibrillation or flutter, based on home anticoagulant use.Methods and ResultsWe stratified patients by home anticoagulant: (1) no anticoagulant, (2) warfarin, and (3) direct oral anticoagulants (DOACs) among ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) patients with atrial fibrillation or flutter treated at 761 US hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. The primary outcome of our study was in‐hospital major bleeding. Multivariable logistic regression was used to examine the independent association between home anticoagulant and in‐hospital major bleeding. Among 6471 STEMI patients with atrial fibrillation or flutter, 15.7% were on warfarin and 13.0% on DOACs; among 19 954 NSTEMI patients, 22.8% were on warfarin and 15.4% on DOACs. In STEMI, door‐to‐balloon times were slightly higher in those on anticoagulant, with similar rates of angiography within 24 hours in the 3 groups. NSTEMI patients on anticoagulant were less likely to undergo angiography (49.3% no anticoagulant, 33.4% on warfarin, 36.4% on DOACs; P<0.01) or percutaneous coronary intervention within 24 hours (21.1% no anticoagulant, 14.3% on warfarin, 15.9% on DOACs; P<0.01). After multivariate adjustment, use of home warfarin (odds ratio: 1.00 [95% CI, 0.79–1.27] in STEMI and 1.13 [95% CI, 0.97–1.30] in NSTEMI) or DOAC (odds ratio: 0.93 [95% CI, 0.73–1.20] in STEMI and 0.97 [95% CI, 0.81–1.16] in NSTEMI) was not associated with increased in‐hospital major bleeding compared with no anticoagulant.ConclusionsIn routine clinical practice, home warfarin or DOAC therapy is not associated with an increased risk of in‐hospital bleeding compared with no anticoagulant.

Trends in Performance and Opportunities for Improvement on a Composite Measure of Acute Myocardial Infarction Care.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P<0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P<0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P<0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P<0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P<0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

Development and Validation of a Novel Risk Score for In-Hospital Major Bleeding in Acute Myocardial Infarction:-The SWEDEHEART Score.

BackgroundBleeding risk stratification in acute coronary syndrome is of highest clinical interest but current risk scores have limitations. We sought to develop and validate a new in‐hospital bleeding risk score for patients with acute myocardial infarction.Methods and ResultsFrom the nationwide SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register, 97,597 patients with acute myocardial infarction enrolled from 2009 until 2014 were selected. A full model with 23 predictor variables and 8 interaction terms was fitted using logistic regression. The full model was approximated by a model with 5 predictors and 1 interaction term. Calibration, discrimination, and clinical utility was evaluated and compared with the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) scores. Internal and temporal validity was assessed. In‐hospital major bleeding, defined as fatal, intracranial, or requiring surgery or blood transfusion, occurred in 1356 patients (1.4%). The 5 predictors in the approximate model that constituted the SWEDEHEART score were hemoglobin, age, sex, creatinine, and C‐reactive protein. The ACTION and CRUSADE scores were poorly calibrated in the derivation cohort and therefore were recalibrated. The SWEDEHEART score showed higher discriminative ability than both recalibrated scores, overall (C‐index 0.80 versus 0.73/0.72) and in all predefined subgroups. Decision curve analysis demonstrated consistently positive and higher net benefit for the SWEDEHEART score compared with both recalibrated scores across all clinically relevant decision thresholds. The original ACTION and CRUSADE scores showed negative net benefit.ConclusionsThe 5‐item SWEDEHEART score discriminates in‐hospital major bleeding in patients with acute myocardial infarction and has superior model performance compared with the recalibrated ACTION and CRUSADE scores.

Association of acute myocardial infarction cardiac arrest patient volume and in‐hospital mortality in the United States: Insights from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network Registry

BackgroundLittle is known about how differences in out of hospital cardiac arrest patient volume affect in‐hospital myocardial infarction (MI) mortality.HypothesisHospitals accepting cardiac arrest transfers will have increased hospital MI mortality.MethodsMI patients (ST elevation MI [STEMI] and non‐ST elevation MI [NSTEMI]) in the Acute Coronary Treatment Intervention Outcomes Network Registry were included. Hospital variation of cardiac arrest and temporal trend of the proportion of cardiac arrest MI patients were explored. Hospitals were divided into tertiles based on the proportion of cardiac arrest MI patients, and association between in‐hospital mortality and hospital tertiles of cardiac arrest was compared using logistic regression adjusting for case mix.ResultsA total of 252 882 patients from 224 hospitals were included, of whom 9682 (3.8%) had cardiac arrest (1.6% of NSTEMI and 7.5% of STEMI patients). The proportion of MI patients who had cardiac arrest admitted to each hospital was relatively low (median 3.7% [25th, 75th percentiles: 3.0%, 4.5%]).with a range of 4.2% to 12.4% in the high‐volume tertiles. Unadjusted in‐hospital mortality increased with tertile: low 3.8%, intermediate 4.6%, and high 4.7% (P < 0.001); this was no longer significantly different after adjustment (intermediate vs high tertile odds ratio (OR) = 1.02; 95% confidence interval [0.90‐1.16], low vs high tertile OR = 0.93 [0.83, 1.05]).ConclusionsThe proportion of MI patients who have cardiac arrest is low. In‐hospital mortality among all MI patients did not differ significantly between hospitals that had increased proportions of cardiac arrest MI patients. For most hospitals, overall MI mortality is unlikely to be adversely affected by treating cardiac arrest patients with MI.

Bilateral Repetitive Transcranial Magnetic Stimulation in Older Adults with Depression

Depression is the most common, treatable, mental disorder in late life, making it a major public health concern: 2 to 4 % of persons over the age of 65 suffer from major depression. Current pharmacological treatments for LLD, however, provide modest efficacy. Rates of treatment resistance in randomized controlled trials (RCT) in LLD range from 55-81% using first line antidepressants. The failure of first line treatment to induce remission in patients leads to impaired psychosocial function and diminished quality of life. Depression in older adults, and non-response to antidepressants, is associated with low connectivity in the cognitive control network. Cognition, in particular executive function and processing speed, are often impaired in LLD. It is an important predictor of acute antidepressant treatment outcome. In a 2010 report from the National Institutes of Health (NIH), depression was identified as one of six potentially modifiable risks for cognitive decline, AD, or both. Successful interventions targeting depression could reduce the prevalence of AD by up to 15% in North America, making depression the second most promising target for prevention studies after physical inactivity. Data from three randomized sham controlled trials that have included older adults show converging evidence for the efficacy of bilateral repetitive transcranial magnetic stimulation in this population. Emerging data suggests that intermittent theta burst stimulation (TBS) is similar in effectiveness to high frequency rTMS. An ongoing study is exploring the effectiveness of bilateral (low frequency right then high frequency left) dorsolateral prefontal rTMS compared to continuous TBS right and intermittent TBS left in older adults with depression while also examining the effects on cognition. The design and interim results of this trial will be presented.

Association of State Medicaid Expansion With Quality of Care and Outcomes for Low-Income Patients Hospitalized With Acute Myocardial Infarction

Lack of insurance is associated with worse care and outcomes among adults hospitalized for acute myocardial infarction (AMI). It is unclear whether states' decision to expand Medicaid eligibility under the Patient Protection and Affordable Care Act in 2014 were associated with improved quality of care and outcomes among low-income patients hospitalized with AMI. To investigate whether rates of uninsurance, quality of care, and outcomes changed among patients hospitalized for AMI 3 years after states elected to expand Medicaid compared with nonexpansion states. Retrospective cohort study completed at hospitals participating in National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. Participants were patients younger than 65 years hospitalized for AMI from January 1, 2012, to December 31, 2016. State Medicaid expansion in 2014. Rates of uninsured and Medicaid-insured hospitalizations for AMI in states that expanded Medicaid vs those that did not. Comparison of in-hospital care quality, procedure use, and mortality between expansion and nonexpansion states for the years prior to and after Medicaid expansion. Hierarchical logistic regressions models were used to assess the association between Medicaid expansion and outcomes. The initial cohort included 325 343 patients. Uninsured AMI hospitalizations declined in expansion states (18.0% [4395 of 24 358 hospitalizations] to 8.4% [2638 of 31 382 hospitalizations]) and more modestly in nonexpansion states (25.6% [7963 of 31 137 hospitalizations] to 21.1% [8668 of 41 120 hospitalizations]) from 2012 to 2016 (P < .001 difference in trend expansion vs nonexpansion). Medicaid coverage increased from 7.5% (1818 of 24 358 hospitalizations) to 14.4% (4502 of 31 382 hospitalizations) in expansion states and 6.2% (1924 of 31 137 hospitalizations) to 6.6% (2717 of 41 120 hospitalizations) in nonexpansion states (P < .001). The low-income cohort included 55 737 patients across 765 sites. In expansion states, low-income adults' odds of receipt of defect-free care increased (76.3% to 75.9%, adjusted odds ratio 1.11; 95% CI, 1.02-1.21) but to a lesser degree than in nonexpansion states (72.8% to 74.5%, adjusted odds ratio, 1.38; 95% CI, 1.30-1.47; P for interaction < .001). There was no change in use of most procedures (ie, percutaneous coronary intervention for non-ST-segment elevation myocardial infarction) in expansion compared with nonexpansion states. Improvement in in-hospital mortality was similar between expansion and nonexpansion states (3.2% to 2.8%, adjusted odds ratio, 0.93; 95% CI, 0.77-1.12 vs 3.3% to 3.0%, adjusted odds ratio, 0.85; 95% CI, 0.73-0.99; P for interaction = .48). Medicaid expansion was associated with a significant reduction in rates of uninsurance among patients hospitalized with AMI. Quality of care and outcomes did not improve among low-income adults in expansion compared with nonexpansion states. Hospital care for AMI may be less sensitive to insurance than has been recognized in the past.

Functional connectivity predictors of acute depression treatment outcome.

Few studies have examined functional connectivity (FC) patterns using functional magnetic resonance imaging (fMRI) to predict outcomes in late-life depression. We hypothesized that FC within and between frontal and limbic regions would be associated with 12-week depression outcome in older depressed adults. Seventy-one subjects with major depression were enrolled in the study. A study geriatric psychiatrist performed a clinical interview and completed a Montgomery-Åsberg Depression Rating Scale (MADRS). All study participants were free of medication at baseline and had a brain fMRI scan. Using a regions of interest (ROI) atlas (including 164 ROIs), we conducted ROI-to-ROI resting-state FC analyses for each participant. In terms of treatment participants were offered sertraline initially, although in this naturalistic study, other medications were also prescribed. Subjects were evaluated every 2 weeks up to 12 weeks by the study psychiatrist, who followed a flexible, clinically based medication dosing schedule. Multivariate regression analysis was used to examine correlation between change of MADRS score over 12 weeks and baseline FC between brain regions, controlling for age, gender, mean head motion, and baseline MADRS. We found greater FC between the left inferior frontal gyrus pars triangularis and the left frontal eye field and FC of these two regions with a number of brain regions related to reward, salience, and sensorimortor function were correlated with change in MADRS score over 12 weeks. Our results highlight the important role of between inner speech-reward, attention-salience, and attention-sensorimotor network synchronization in predicting acute treatment response in late-life depression.

Irrigation and Debridement, Modular Exchange, and Implant Retention for Acute Periprosthetic Infection After Total Knee Arthroplasty.

The role of irrigation and debridement, modular exchange, and implant retention for the treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) remains controversial. The proposed benefits of debridement, antibiotics, and implant retention, often referred to as DAIR, include reduced economic cost and morbidity of 2-stage reimplantation1. The primary disadvantage of this approach is a higher rate of failure and infection recurrence2,3. Furthermore, several authors have demonstrated inferior outcomes of 2-stage exchange revision arthroplasty after a failed attempt at limited debridement with implant retention4-6. Because of study heterogeneity, the outcomes of acute PJI treatment with irrigation and debridement and implant retention have been variable in the literature, with reported success rates ranging from 16% to 100%; overall, the success rate is around 50%3,7,8. Recently, studies evaluating outcomes of DAIR have indicated that host factors, organism type, the timing of intervention, and the duration of symptoms can influence the likelihood of success with this approach7,9-12. DAIR may be considered for all patients with early postoperative PJI or an acute hematogenous infection in the context of well-fixed implants and a healthy soft-tissue envelope. Chronic PJI should be considered an absolute contraindication to DAIR13. The patient's health status, comorbidities, and immune status also should be considered. Caution should be exercised when considering DAIR for a patient in whom preoperative cultures demonstrate a drug-resistant or highly virulent organism, because of a higher risk of failure1,9,14,15. With careful patient selection and meticulous surgical technique, it is possible to achieve success with this treatment strategy. The surgical procedure begins with a medial parapatellar approach and arthrotomy. A complete synovectomy is then performed, and remaining synovial tissue is aggressively debrided. Multiple culture samples should be obtained, and aseptic technique should be utilized to decrease contamination. The implant is interrogated to ensure stable fixation. Following adequate debridement, high-volume irrigation is performed; in cases involving irrigation and debridement with implant retention, we recommend incorporation of an antiseptic solution such as povidone-iodine. We recommend switching to a clean setup to facilitate sterile, uncontaminated closure of the wound, which is performed in a standard fashion. Meticulous attention should be paid to layered closure, and, if there is concern about delayed skin-healing, incisional negative-pressure wound therapy may be utilized.

Improving Care of STEMI in the United States 2008 to 2012.

BackgroundWe aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program.Methods and ResultsWe assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001).ConclusionsQuality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.

Acute Phase Treatment Outcomes of Electroconvulsive Therapy in Adolescents and Young Adults.

Electroconvulsive therapy (ECT) is a highly efficacious, well-tolerated treatment in adults. Little is known, however, about its effectiveness in adolescents and young adults. Our objectives were to assess clinical outcomes after acute phase ECT in adolescents and young adults and determine whether screening positive or negative for a substance use disorder (SUD) is associated with differences in treatment outcomes. Study sample consisted of all patients 16 to 25 years old who received ECT from May 2011 to August 2016 and who completed self-reported SUD screens and the Behavior and Symptom Identification Scale-24 (BASIS-24) initially and completed the BASIS-24 again after the fifth ECT treatment. For 5 BASIS-24 domains, longitudinal changes in mean domain scores were assessed; mean changes by SUD screening status were also examined using linear mixed models. One hundred ninety adolescents and young adults, with mean age 21.0 ± 2.6 years, met inclusion criteria. Electroconvulsive therapy was associated with significant clinical improvement (score decreases) in all 5 BASIS-24 domains during the acute phase treatment (P < 0.001). Sixty-four percent (122/190) screened positive for SUD. Compared with adolescents and young adults screening negative for SUD, those screening positive for co-occurring SUD had greater improvement in depression/functioning (-0.37 ± 0.14, P = 0.009), interpersonal relationships (-0.27 ± 0.13, P = 0.045), and emotional lability (-0.27 ± 0.14, P = 0.044) domains after the fifth ECT treatment. Electroconvulsive therapy in adolescents and young adults was associated with significantly improved clinical outcomes during acute phase treatment. Adolescents and young adults screening positive for SUD had better acute phase ECT outcomes in self-reported depression/functioning, interpersonal relationships, and emotional lability than those screening negative. More research is needed to clarify adolescents and young adult patient characteristics that may be associated with differential ECT outcomes.

Acute cellular rejection treatment outcomes stratified by Banff grade in pediatric kidney transplant.

There are limited data to guide optimal treatment strategies for acute cellular rejection (ACR) based on Banff grade for pediatric kidney transplant recipients. This report reviews a large pediatric transplant center's experience with ACR. A retrospective analysis of pediatric kidney transplant recipients at our center from 2007 to 2014 was performed. Primary outcomes were incidence of graft failure and graft function one year following ACR based on Banff grade and treatment received. A total of 204 patients were reviewed, of which 65 received rejection treatment with either an oral steroid cycle (n=16), intravenous steroid pulse (n=28), or anti-thymocyte globulin (rATG, n=21). Overall, patients received rATG for treatment of more severe rejection associated with impaired graft function and as a group experienced statistically significant improvements in eGFR over the year following treatment, though most did not regain baseline graft function. Our data suggest that rATG is partially effective in treating ACR, but our study was underpowered to determine the effect of different treatments based on Banff grade. Since there is limited literature to guide clinical treatment of ACR in children, large transplant centers should collaborate to evaluate outcomes and establish evidence-based practice.

Early Clinical and Economic Outcomes of Prophylactic and Acute Pathologic Fracture Treatment.

Pathologic fractures often contribute to adverse events in metastatic bone disease, and prophylactic fixation offers to mitigate their effects. This study aims to analyze patient selection, complications, and in-hospital costs that are associated with prophylactic fixation compared with traditional acute fixation after completed fracture. The Nationwide Inpatient Sample database was queried from 2002 to 2014 for patients with major extremity pathologic fractures. Patients were divided by fixation technique (prophylactic or acute) and fracture location (upper or lower extremity). Patient demographics, comorbidities, complications, hospitalization length, and hospital charges were compared between cohorts. Preoperative variables were analyzed for potential confounding, and χ2 tests and Student's t tests were used to compare fixation techniques. Cumulatively, 43,920 patients were identified, with 14,318 and 28,602 undergoing prophylactic and acute fixation, respectively. Lower extremity fractures occurred in 33,582 patients, and 10,333 patients had upper extremity fractures. A higher proportion of prophylactic fixation patients were white ( P = .043), male ( P = .046), age 74 years or younger ( P < .001), and privately insured ( P < .001), with decreased prevalence of obesity ( P = .003) and/or preoperative renal disease ( P = .008). Prophylactic fixation was also associated with decreased peri- and postoperative blood transfusions ( P < .001), anemia ( P < .001), acute renal failure ( P = .010), and in-hospital mortality ( P = .031). Finally, prophylactic fixation had decreased total charges (-$3,405; P = .001), hospitalization length ( P = .004), and extended length of stay (greater than 75th percentile; P = .012). Prophylactic fixation of impending pathologic fractures is associated with decreased complications, hospitalization length, and total charges, and should be considered in appropriate patients.

Abstract 16902: The Effect of Kidney Function on Antithrombotic Regimen Among Patients With Atrial Fibrillation and Acute Myocardial Infarction: Insights From the National Cardiovascular Disease Registry’s Acute Coronary Treatment and Intervention Outcomes Network Registry

Introduction: The impact of kidney function in selecting antithrombotic therapy at hospital discharge for patients with atrial fibrillation (AF) who survive an acute myocardial infarction (AMI) is uncertain. Hypothesis: We hypothesized that kidney dysfunction is associated with decreased oral anticoagulant (OAC) use in AF patients who survive AMI. Methods: We studied 30,308 AF patients at 791 hospitals who survived AMI and were hospitalized between January 2015 and December 2017 (Acute Coronary Treatment and Intervention Outcomes Network Registry). We separated patients into 4 mutually exclusive groups: triple antithrombotic therapy (TAT), dual-antiplatelet therapy (DAPT), dual antithrombotic therapy excluding DAPT (DAT), and single therapy. Logistic regression was used to explore the trend for each antithrombotic strategy across CKD stage. Results: Of the 30,308 patients included in this analysis, 6,618 were on TAT (22%), 12,920 on DAPT (43%), 6,148 on DAT (20%), and 4,622 were on single therapy (15%). Overall, 46% of patients were discharged on an OAC (warfarin 22%; apixaban 14%; rivaroxaban 8%; dabigatran 2%). Patients with higher CHA 2 DS 2 -VASC scores (≥4) were more likely to be discharged on oral anticoagulation, except patients with GFR &lt; 15 ml/min/1.73m 2 . Compared to patients with normal kidney function, patients with GFR &lt; 30 ml/min/1.73m 2 had lower rates of TAT use (23% vs. 18%) despite higher warfarin use (20% vs. 27%). Within each antithrombotic discharge strategy, there was no significant trend across GFR strata among patients with in-hospital PCI ( Figure ). Conclusion: Significant heterogeneity in antithrombotic discharge strategy was seen among AF patients who survived AMI, however, the trend of each strategy across CKD stage was not significant among patients with in-hospital PCI. More research is needed to understand whether a particular antithrombotic strategy has improved outcomes in this population.

Aberrant ARID5B expression and its association with Ikaros dysfunction in acute lymphoblastic leukemia

Mutations and single nucleotide polymorphisms of AT-rich interactive domain-containing protein 5B (ARID5B) are involved in the oncogenesis of acute lymphoblastic leukemia (ALL) and treatment outcomes. However, ARID5B expression and clinical significance in ALL remain unclear. We found ARID5B is significantly down-regulated in ALL compared to healthy bone marrow controls. ARID5B also interacts with PHD finger protein 2 (PHF2). Low expression of ARID5B (ARID5Blow) or ARID5B and PHF2 (ARID5BlowPHF2low) is correlated with the markers of cell proliferation and poor prognosis in ALL patients. Ikaros directly regulates ARID5B expression in ALL. Restoring Ikaros function by Casein Kinase II inhibition also promotes ARID5B expression through recruitment of trimethylation of lysine 4 on histone H3 (H3K4me3) at its promoter region. In summary, our data show that aberrant expression of ARID5B and PHF2 is related to leukemic cell proliferation and several poor prognostic markers. Our data indicate ARID5Blow expression, particularly ARID5BlowPHF2low expression, is linked to Ikaros dysfunction and involved in the oncogenic effect of high-risk ALL, which may represent a high-risk subgroup of ALL.

The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry

ObjectivesThe aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI). BackgroundFrailty is a common syndrome in older adults. MethodsFrailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding. ResultsAmong 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14). ConclusionsFrail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

Outcomes of Acute Pancreatitis Treatment in the Cannabis Users: A Nationwide Propensity Matched Analysis

Introduction: Cannabis is most commonly used illicit drug in the world and is also one of the most commonly abused drugs among alcohol drinkers. Experimental studies have shown conflicting results on the effects of cannabis on the severity and outcomes of acute pancreatitis (AP). The purpose of this study is to ascertain the clinical effects and outcomes in AP in cannabis users by using the largest nationwide propensity-matched cluster. Methods: We assessed the Nationwide Inpatient Sample (NIS) from Jan. 2010-Dec. 2014 and identified adult AP patients and relevant comorbidities with and without cannabis use using ICD-9 CM codes (Table 1). Propensity-score matching was performed using multivariate analysis while adjusting for potential confounders, and categorical & continuous variables were compared in matched cohorts using Chi-square and Student’s T-test, respectively. Primary outcomes were all-cause mortality and other complications, whereas secondary outcomes were the length of stay (LOS) (days) and total hospital charges. Results: The propensity-matched clusters comprised of 5576 patients in both the groups(Table 2). Results were non-significant for all-cause mortality (11%vs. 15% p=0.432) but they were significant for lesser need for total parenteral nutrition (TPN) (1.6% vs. 2.5% p=0.001) in the cannabis-AP group. There were no significant differences in complication rates of SIRS (1.7% vs. 2.0%, p=0.265), acute respiratory distress syndrome (ARDS) (1.4%vs.1.7% p=0.164), disseminated intravascular coagulation (DIC) (0.00%vs.0.1% p=0.095), peritonitis (0.3%vs. 0.3% p=0.857), pancreatic pseudocysts/necrosis (8.3%vs.9.3% p=0.057) between both the groups. The hospital stay was shorter (mean 4.0 vs 4.4 days) and total hospital charges were lower (mean $26,107.40 vs $29,756.74) in cannabis-AP group (p<0.001) Conclusion: This study is our attempt to compare outcomes in AP patients in relation to cannabis use using the largest US inpatient database where we found a lesser need for TPN, shorter LOS and lower hospital charges, which appear to be inter-related. Complication rates tended to be lower but non-significant for the presence of SIRS, lower all-cause in-hospital mortality, development of pancreatic pseudocyst/necrosis, ARDS, and DIC. The results should be interpreted with caution because of inability to adjust multiple other confounding factors and lack of information about type, timing, route, amount, and duration of the cannabis consumption.93_A Figure 1. No Caption available.93_B Figure 2. No Caption available.