Ambulatory Patients Research Articles

The use of pedometers to assess patient ambulation following gynecologic oncology surgery: A prospective observational study

The use of pedometers to assess patient ambulation following gynecologic oncology surgery: A prospective observational study

Venous Thromboembolism Risk Assessment in Inpatient and Ambulatory Otolaryngology Surgical Patients.

Venous thromboembolic events (VTEs) are a leading cause of postoperative morbidity, prolonged hospital stay, and increased cost. Recommendations for mechano- and chemoprophylaxis are currently based on the 2005 Caprini score, a screening tool developed to identify patients at risk for VTE. The Caprini risk assessment model (RAM) was designed for surgical impatients and has been tested in a number of surgical fields, including otolaryngology. However, the vast majority of otolaryngology cases are performed as ambulatory surgery. Simpler RAMs include the COBRA scoring system and Pannucci-NSQIP. Here, we evaluate risk stratification of otolaryngology surgical patients and correlate the findings of these three RAMs. Retrospective chart review. A retrospective chart review of 869 patients undergoing surgery by Weill Cornell faculty otolaryngologists between June and December 2022 was performed. Patient demographics, VTE risk factors, admission status, surgical subservice, and postoperative events were collected, and RAM scores were calculated for each patient. Wilcoxon and Kruskal-Wallis rank-sum tests were utilized to assess differences in VTE risk scores based on type of procedure and admission status, and Spearman's correlation was utilized to assess agreement between the three different scoring systems. Multivariate linear regressions were utilized to assess variables that impacted the Caprini, COBRA, and NSQIP RAMs. In total, two patients developed postoperative venous thromboembolism. Furthermore, there is a strong positive correlation between Caprini and COBRA RAMs (even when broken down by admission status, although it weakens in the inpatient population). There is a moderate positive correlation between Caprini and Pannucci-NSQIP in the full cohort, but that correlation is lost in the inpatient population. Otolaryngology surgical patients are at low risk of postoperative VTE. Caprini, Pannucci-NSQIP, and COBRA RAMs correlate well in determining ambulatory patients at risk for postoperative VTE and shorter, simpler RAMS such as COBRA and Pannucci-NSQIP can be used instead of Caprini RAM. 3 Laryngoscope, 2024.

Circulating secretoneurin concentrations predict cardiovascular death in ambulatory patients with heart failure

Abstract Background Secretoneurin (SN) is a novel biomarker, which predicts cardiovascular (CV)-related mortality in patients with acute dyspnea and sepsis. Higher SN concentrations have also been found associated with all-cause death in outpatients with heart failure (HF), but whether SN primarily reflects cardiovascular (CV)-related mortality in HF outpatients is not known. Objectives To evaluate the relation between SN concentrations and CV- & non-CV death in ambulatory patients with HF. Methods We studied 184 consecutive patients who attended our HF clinic for routine follow up and had stored blood samples available for SN analysis. SN concentrations were measured with a CE-marked SN ELISA assay. We assessed the associations between SN concentrations and CV & non-CV death. Mortality was ascertained using medical records, autopsy reports and death certificates, and CV deaths included sudden cardiac deaths or mortality due to myocardial infarction, HF or stroke. We assessed association with CV & non-CV death by Kaplan-Meier curves and by Cox proportional hazard regression analysis. Results Median age was 76 years (range: 38-94 years) and two thirds were male. Sixty-three percent had HF with reduced ejection fraction, 22% had NYHA III/IV symptoms and median NT-proBNP was 1079 (interquartile range: 462-2347) ng/L. Median SN level was 60 (range: 21-134) pmol/L. In multivariable linear regression analysis, impaired renal function and lower body-mass index were significantly associated with increasing (log)SN concentration. During median follow up of 540 days, there were 18 CV deaths, including 15 HF deaths, and 7 non-CV deaths. A higher SN concentration was associated with higher risk of CV death, while we did not find statistically significant association between SN concentrations and non-CV deaths (Figure). Patients with SN concentration in the top tertile had 15-fold increased risk of CV death compared to patients with SN concentration in the lowest tertile. In multivariable Cox regression analysis that adjusted for age, NYHA functional class, frailty status, increasing SN concentrations were independently associated with CV death: hazard ratio per logSN (95% CI): 3.01 (1.02-8.90), p=0.04. Conclusion In ambulatory patients with HF, circulating SN concentrations were predictive of CV death. Higher SN concentrations in ambulatory HF patients seemed to be linked to impaired renal function and lower body-mass index. Figure: Kaplan Meier curves illustrating the relation between SN tertiles and (A) CV mortality (B) Non-CV mortality.

Hemodynamic profiles and survival in chronic advanced heart failure patients evaluated for heart replacement therapy

Abstract Background Advanced heart failure (HF) is associated with dismal prognosis despite optimal medical therapy. Invasive assessment with right heart catheterization (RHC) is a valuable tool to assess transplant candidates and hemodynamic profiling is crucial to stratify prognosis and select patients for advanced therapies. Purpose This study aims to examine the relationship between hemodynamic profiles based on cardiac index (CI) and filling pressures and survival in ambulatory patients with advanced HF evaluated for heart replacement therapy (HRT) such as heart transplantation (HT) and left ventricular assist device (LVAD) implant. Methods We analyzed adult ambulatory advanced HF patients evaluated for HRT with an available baseline RHC from 2003 to 2022. Hemodynamic data were classified using a CI < 2.2 l/min/m2 as marker of reduced cardiac output ("cold" profile opposed to the "warm" profile) and increased filling pressure, defined as right atrial pressure ≥ 10 mmHg and/or pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg as a marker for congestion ("wet" profile opposed to the "dry" profile). Study endpoint was death or urgent HT or LVAD implant at 5 years. Results Study population included 610 patients (mean age 53±10 years, 79% males). According to hemodynamic criteria, 332 patients (55%) exhibited a "wet cold" hemodynamic profile, 117 (19%) a "cold dry", 91 (15%) a "warm wet" and 66 (11%) a "warm dry" phenotype. The "wet" patients showed a significantly higher prevalence of pulmonary hypertension (96% wet cold, 94% wet warm vs 21% dry warm, 19% dry cold; p<0,001), a lower pulmonary artery pulsatility index (4,0 wet cold, 4,1 wet warm vs 7,4 dry warm, 6,9 dry cold; p<0,001). No differences were found in etiology of HF. Both reduced CI [OR 1,6 (1-2,4), p=0.003] and increased filling pressures [OR 1,9, (1,2-2,8) p=0.007] were associated with worse outcomes. Survival differed significantly among hemodynamic profiles, with a survival rate of 48% in the "cold wet" profile compared to 68% in the "cold dry" [OR 1,9 (1,2-3,1) p=0,007] and 65% in the "warm dry" [OR 2,2 (1,1-4,2), p=0.01]. The difference between "cold wet" and "warm wet" was borderline significant (p=0.07). Further stratification between right and left ventricular filling pressures showed that isolated right ventricular congestion was rare and associated with low event rate, while in patients with preserved CI, biventricular congestion was associated with borderline worse survival as compared to isolated left ventricular increased filling pressures (p=0.06). Conclusions Hemodynamic profiles assessed with RHC stratify prognosis in ambulatory patients with advanced HF referred for HRT. Evaluation of hemodynamic phenotype may help identify subgroups of patients at high risk and guide therapeutic decisions. Further studies are needed to confirm these findings and develop personalized management strategies to improve clinical outcomes in this population.Survival-hemodynamic phenotypeSurvival-filling pressures

Efficacy and safety of ambulatory, weekly, high-intensity intravenous diuretic strategy for congestion-refractory heart failure patients: insights from the DEA-HF prospective randomized clinical trial

Abstract Background Congestion and volume overload are strongly associated with low quality of life and pose a significant risk for both rehospitalization and mortality in heart failure (HF) patients. Despite the widespread use of diuretics in HF, the use of weekly, intravenous (IV), high-intensity diuretic treatment has not been prospectively studied in the setting of ambulatory congestion-refractory patients. Purpose To assess the efficacy and safety of weekly high-intensity diuresis regimens in a practical setting of ambulatory day care for chronically congested HF patients. Methods We performed a sub-analysis on data from a prospective, randomized, cross-over controlled study (DEA-HF) originally designed to compare diuresis regimens in the setting of an HF ambulatory daycare unit who had signs of congestion or volume overload despite adherence to guideline-directed medical therapy. Each patient received three different IV diuretic regimens, in one of six randomized sequences: IV furosemide 250mg; IV furosemide 250mg + oral metolazone 5mg; and IV furosemide 250mg + IV acetazolamide 500mg. All regimens given on the same chronological week were pooled, and diuresis efficacy was assessed by measuring excreted urine volume and sodium weight 6 hours post treatment initiation. Additional assessment at one week post each treatment included serum levels of NT-ProBNP, body weight and creatinine as well as congestion score based on the presence of ascites, pleural effusion and pedal edema. Statistical analysis was based on linear mixed models while accounting for the random effect of patient identity. Results A total of 42 patients were recruited. The mean age was 72±9 years, twenty-one subjects (50%) had LVEF ≥ 50%. 74% of patients were NYHA III class. All patients were on contemporary guidelines-directed HF therapy. Analysis of excreted sodium weight and urine volume revealed values of 4202.1±180.1 mg (Mean±SEM) and 1.77±0.07 liter per visit, respectively. No significant differences in efficacy were detected among treatments given in consecutive weeks (P= 0.80 and 0.69 for differences in sodium weight and urine volume, respectively). After 4 weeks, log(NT-ProBNP) was significantly decreased (P=0.044), accompanied by a significant decrease of 2.4±0.62 kg in body weight (P=0.0004) and of 0.92±0.44 points in congestion score (P=0.037). Serum creatinine level was only slightly increased by 0.19±0.04 mg/dl (P=0.0001), demonstrating the overall safety of the high-intensity diuresis strategy. Conclusions In ambulatory, congestion refractory HF patients a strategy based on high-intensity, weekly diuresis therapy was safe and effective for three consecutive weeks. The natriuresis response to the treatments was maintained, NT-ProBNP levels and congestion score were decreased. The strategy may be instrumental for ambulatory HF patients that require diuretic therapy intensification and may allow to prevent hospitalization.

Cardiopulmonary exercise testing predicts risk of progressive heart failure and long term mortality in ambulatory patients awaiting isolated heart transplant

Abstract Introduction Cardiopulmonary exercise testing (CPET) parameters such as peak VO2 ≤ 14ml/kg/min, percentage predicted peak VO2 (ppVO2) ≤ 50% and ventilation equivalent of carbon dioxide (Ve/VCO2) >35 l/min/l/min are recommended thresholds to list for isolated heart transplant. There is minimal data on clinical events after listing to guide clinical management or priority in organ allocation. Purpose To assess the effect of peak VO2, ppVO2, Ve/VCO2 on clinical events after listing for isolated heart transplant. Methods In a single centre retrospective study, we identified patients who were status 6 or status 2 prior to 2018 at time of listing for isolated heart transplant between 2007 and 2021. Clinical data were collected by chart review. Primary outcome of progressive heart failure was defined as death or upgrade in transplant priority status (new inotropes or mechanical circulatory support). Comparison was made between peak VO2 strata (> 14 vs ≤ 14 ml/kg/min), ppVO2 strata (> 50% vs 40-50% vs <40%) and Ve/VCO2 strata (<35 vs >35 l/min/l/min). Secondary outcome was time dependent survival after listing for heart transplant. Results We identified 141 patients of which 133 underwent CPET and follow up was available for 130 who were included in the analysis. Median age was 53 years (interquartile range 41-59 years), 29.1% of patients were female. Median peak VO2 was 14.0 ml/kg/min (11.2-15.7), ppVO2 was 44% (36-52), Ve/VCO2 slope was 34.0 (31.0-37.0) and RER was 1.1 (1.1-1.2). 87 patients had progressive heart failure consisting of 34 deaths and 83 patients having upgrade in priority status. There was a significant difference in risk of progressive heart failure comparing peak VO2 strata (Figure 1) (freedom from event at one year 71.4% with peak VO2 > 14 vs 46.5% with peak VO2 ≤ 14, p=0.00061) and ppVO2 strata (Figure 2) (freedom from event at one year 75.0% with ppVO2 >50% vs 61.2% with ppVO2 40-50% vs 42.6% with ppVO2 <40%, p=0.0015). There was no significant difference with Ve/VCO2 strata (freedom from event at one year 59.8% with Ve/VCO2 <34 vs 54.9% with Ve/VCO2 >34, p=0.52). There were 34 deaths before transplant and 23 deaths after transplant. 87 patients underwent transplant. In a time dependent survival analysis, age, gender and ppVO2<50% (HR 1.65 (0.87-3.12)) were not significant predictors of mortality. Both early transplant (defined as < 1 year after listing, HR 0.14 (0.06-0.34) and late transplant (defined as > 1 year after listing, HR 0.16 (0.08-0.32)) were significant predictors of lower mortality whilst Ve/VCO2>35 (HR 2.09 (1.19-3.68)) was a significant predictor of higher mortality. Conclusions Peak VO2 and ppVO2 stratify risk of progressive heart failure in ambulatory patients awaiting isolated heart transplant. However, Ve/VCO2 is a predictor of significantly higher mortality. These findings should affect clinical management and transplant priority status; and influence revision of future guidelines.Freedom from event by peak VO2 strataFreedom from event by ppVO2 strata

Population Pharmacokinetic Quantification of CYP2D6 Activity in Codeine Metabolism in Ambulatory Surgical Patients for Model-Informed Precision Dosing.

Codeine metabolism in humans is complex due to the involvement of multiple cytochrome P450 (CYP) enzymes, and has a strong genetic underpinning, which determines the levels of relevant CYP450 enzyme expression in vivo. Polymorphic CYP2D6 metabolises codeine to morphine via O-demethylation, while a strong correlation between CYP2D6 phenotype and opioidergic adverse effects of codeine is well documented. The aim of this study was to quantify the effect of CYP2D6 genotype on the biotransformation of codeine. We conducted a prospective clinical trial with 1000 patients, during which ambulatory patients were administered 60 mg of codeine preoperatively and the association between CYP2D6 activity and morphine exposure across various CYP2D6 genotypes was quantified using a population pharmacokinetic model. Plasma concentration data for codeine and its primary metabolites were obtained from 997 patients and CYP2D6 genotype was screened for study subjects, and respective sums of activity scores assigned for each CYP2D6 allele were used as covariates in model development. Our final model predicts the disposition of codeine and the formation of morphine, codeine-6-glucuronide and morphine-3-glucuronide adequately while accounting for variability in morphine exposure on the basis of CYP2D6 genotype. In agreement with previous results, patients with decreased function alleles (CYP2D6*10 and *41) showed varying levels of decrease in CYP2D6 activity that were inconsistent with increasing activity scores. Model simulations demonstrate that morphine concentrations in ultrarapid CYP2D6 metabolisers reach systemic concentrations that can potentially cause respiratory depression (over 9.1 ng/mL), and have 218% higher exposure (19 versus 8.7 µg · h/L, p < 0.001) to morphine than normal metabolisers. Similarly, poor and intermediate metabolisers had significantly reduced morphine exposure (1.0 and 3.7 versus 8.7 µg · h/L, p < 0.001) as compared with normal metabolisers. Our final model leads the way in implementing model-informed precision dosing in codeine therapy and identifies the use of genetic testing as an integral component in the effort to implement rational pharmacotherapy with codeine.

Effects of sarcopenia and nutritional status on surgical outcomes for metastatic spinal tumors: In the perspective of peri-operative complications and performance improvement.

With the advancement of cancer treatment, appropriate treatment for musculoskeletal problems is becoming more important as it extends the patient's lifespan and improves the quality of life. In surgical treatment for metastatic spine tumors (MST), various efforts are being considered to obtain a good prognosis. The purposes of this study are to analyze prognostic factors for postoperative ambulation and perioperative complications in patients surgically treated for MST with neurologic symptoms. Seventy five cases of patients who underwent surgery for MST with neurologic symptoms were enrolled between December 2016 and January 2023. Postoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. We defined the improvement of ambulatory function as improvement in Eastern Cooperative Oncology Group (ECOG) scale. For complications, we applied complication classification system for orthopaedic surgery. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient's admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax. Prognostic factors were collected and analyzed for relationship by logistic regression. Of the 75 cases, postoperatively 42 (56%) cases of patients were improved in Nurick grade, 36 (48%) cases of patients in ECOG performance. And 21 (28%) cases of patients were treated in intensive care unit (ICU) and 15 (20%) cases of patients suffered from major perioperative complications. Regression analysis showed that clinical factors such as ECOG, psoas muscle index (PMI) and prognostic nutritional index (PNI) were related to the improvement of ambulatory function and incidence of perioperative complications. On multivariate analysis, improvement of ambulatory function was associated with PMI (p = 0.014) and incidence of perioperative complications was associated with PNI (p = 0.045). Preoperative nutritional status and sarcopenia are related factors in the outcome of surgical treatment for MST, and preoperative efforts to improve these may be a way to obtain better clinical results.

Direct-Acting Oral Anticoagulants and Potential Inconsistencies with FDA-Approved Dosing for Non-Valvular Atrial Fibrillation: A Retrospective Real-World Analysis Across Nine US Healthcare Systems.

Direct-acting oral anticoagulants (DOACs) are recommended to reduce risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). However, DOAC dosing inconsistent with FDA-approved product labels is common and associated with poor clinical outcomes. Identify DOAC dosing inconsistent with FDA-approved product labels in ambulatory care patients with NVAF; identify variables associated with dosing lower and higher than label. Retrospective analysis using electronic health records from nine US healthcare systems. Adults with NVAF receiving DOAC therapy in 2022. Rates of label-inconsistent dosing; multivariable regression analysis to identify demographic and clinical variables associated with dosing lower and higher than label. Among 51,128 NVAF patients (56.1% male, 94.3% White, mean [SD] age 73.5 [10.5] years), 5008 (9.8%) were prescribed label-inconsistent doses of DOACs (6.8% lower and 3.0% higher than label). Age ≥ 75years, renal impairment, and hypertension were significantly associated with inconsistent dosing both higher and lower than label. Female sex and higher weight were significantly associated with dosing lower than label, as were heart failure, vascular or liver disease, and bleeding history. Dosing higher than label was significantly associated with male sex, race (African American/Black), weight < 60kg, and use of drugs with potential drug-drug interactions. When prescribed by primary care physicians, DOAC doses were 37% (95% CI, 27-49%) more likely to be lower than label and 30% (95% CI, 16-46%) more likely to be higher than label than when prescribed by cardiologists or electrophysiologists. Label-inconsistent dosing varied (6.7 to 15.8%) across participating systems. DOAC dosing inconsistent with label varied by demographics, clinical characteristics, prescriber specialty, and healthcare system, suggesting a need to monitor and assess dosing decisions in NVAF. Identification of variables associated with dosing inconsistencies may enable targeted interventions to ensure label-consistent dosing in vulnerable populations.

Increasing the Knee Arc of Motion in Patients With Arthrogryposis: Minimum 2-year Follow-up.

Surgery for knee flexion contractures in patients with arthrogryposis multiplex congenital (AMC) have achieved extension to redirect the arc of motion and improve ambulation but has not demonstrated maintained increases in total range of motion (ROM). This study aimed to review the clinical outcomes of combined posterior knee release, proximal femoral shortening, and nerve decompression in patients with arthrogryposis. A retrospective chart and radiographic review were performed on patients with AMC who underwent treatment for knee flexion deformities ≥30 degrees. ROM, ambulation status, and orthotic use were reviewed and analyzed. Complications were recorded. Twenty-nine patients with 51 knees and a mean age of 5.7 years were included. The mean follow-up was 36.9 months. The mean ROM increased from 49 to 80 degrees between pre-op and latest follow-up (P<0.0001). The mean final follow-up flexion deformity was 10 degrees (P<0.0001). Preoperative ROM was moderately correlated with final ROM (rs=0.51). The percentage of ambulatory patients improved from 39% to 93%. Five limbs experienced a fracture either intraoperatively or postoperatively, and 5 limbs required a return trip to the operating room. Improved ambulation and knee ROM can be maintained in patients with AMC at a minimum 2-year follow-up. Prospective investigation and longer follow-up are required to validate these findings. Level IV-therapeutic.

Primary Prevention of Cancer-Associated Thrombosis: Current Perspectives.

Over the past two decades, the incidence of cancer-associated thrombosis (CAT) has increased. It is nowadays a common and often serious complication among patients with cancer. Although medical thromboprophylaxis is recommended for most surgical and nonsurgical cancer patients, it has been infrequently used in ambulatory patients with cancer because of the burden of treatment and concerns about bleeding. However, various risk assessment scores are now available and randomized placebo-controlled trials have established the efficacy of low-molecular-weight heparin or the direct oral Xa inhibitors rivaroxaban and apixaban in ambulatory patients with cancer at high risk of venous thromboembolism (VTE). This review provides an overview of (1) primary thromboprophylaxis in the setting of hospitalized surgical and medical patients, (2) extended thromboprophylaxis after hospital discharge, (3) performance of risk assessment tools for CAT, and (4) primary thromboprophylaxis in ambulatory patients with cancer. The aim is to provide support to physicians in identifying ambulatory patients with cancer at high VTE risk who benefit most from medical thromboprophylaxis according to current recommendations from international guidelines.

The endocrine manifestations of adults with spinal muscular atrophy.

Changes in body composition in patients with spinal muscular atrophy (SMA) can cause endocrine abnormalities that are insufficiently studied in adults. We aimed to assess the endocrine profile in a cohort of adults with SMA. Second, we compared body composition and endocrine profiles between nonambulatory and ambulatory patients and between different types of SMA. The cross-sectional study included 29 SMA patients (18 [62.1%] males and 11 [37.9%] females) of median age 44 (IQR 30-51.5) years with type 2, 3, or 4. Body composition was measured by bioimpedance. Morning blood samples were drawn for glycated hemoglobin (HbA1c), lipid profile, testosterone, cortisol, and insulin-like growth factor-1 (IGF-1). Blood glucose, insulin, and beta-hydroxybutyrate (BHB) were measured during a 75 g oral glucose tolerance test. The homeostatic model assessment for insulin resistance index was calculated. In total, 75.9% of patients had increased fat mass (FM), with 51.7% having an increase despite normal body mass index. Ambulation was the most important discriminating factor of body composition. 93.1% of patients had metabolic abnormalities, including hyperglycemia, insulin resistance, and dyslipidemia. Increased BHB, a marker of ketosis, was present in more than a third of patients. Functional hypogonadism was present in half of male patients. Testosterone and IGF-1 negatively correlated with FM. Adult patients with SMA had abnormal body composition and highly prevalent metabolic disturbances that might increase cardiometabolic risk. Because treatments have modified the course of SMA, it is important to investigate whether these observations translate into clinically relevant outcomes.

Ambulation in patients with peripheral veno-arterial extracorporeal membrane oxygenation and concomitant femoral intra-aortic balloon pump support.

The mobilization and ambulation of patients with severe cardiogenic shock supported with peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) and concomitant femoral intra-aortic balloon pump (IABP) support is not well-described. This technical paper describes an ambulation protocol to prevent deconditioning in this critically ill patient population. A protocol for the ambulation of patients with pVA-ECMO and concomitant IABP support was created in December 2022 and implemented at a single center. To initiate ambulation, patients were initially placed in a vertical position utilizing the VitalGo Total Lift Bed (VitalGo Systems, Miramar, FL) with mechanical circulatory support device monitoring performed by a critical care multidisciplinary team. Retrospective analysis of successfully ambulated patients was performed from December 2022 to January 2024. A total of 35 patients out of 112 patients with ECMO support were ambulated in the study period. Four of these patients had pVA-ECMO with concomitant IABP support with this cohort completing a total of 11 sessions during the study period. Patients ambulated an average of 200 feet per session without any adverse events, including cannula and balloon pump migration or displacement. Three of the four patients studied were either bridged to an advanced therapy including orthotopic heart transplant or durable left ventricular assist device or were discharged. A protocol for ambulation of CS patients with pVA-ECMO support and concomitant femoral IABP support is feasible and can safely be implemented in this critically ill patient population. Further multicenter studies are necessary to determine the overall impact of ambulation on patient outcomes.

Psychological burden and depressive symptoms in caregivers of hemato-oncological patients: the role of medical visits

AbstractInformal caregivers of patients with cancer are known to experience extensive burdens, whereas this issue remains unresolved in the setting of hematological malignancies. Yet, these diseases are characterized by a prolonged course, numerous relapses, and implementation of multiline therapy, administered in outpatient facilities. This study aimed to assess the factors contributing to burden and depressive symptoms in informal caregivers of patients with hematological malignancies, while concentrating on the role of medical visits. The study population comprised patients and their caregivers, recruited at the Rambam Hematology Ambulatory Unit. Participants completed validated questionnaires, including the Center for Epidemiologic Studies Depression Scale and the Zarit Caregiver Burden Interview. The cohort (n = 185) included 115 patients (average age, 62.8 ± 14.5 years; 54 males) and 70 caregivers. Among caregivers, 80% reported high psychological burden, and 50% reported significant depressive symptoms. The burden was higher if caregivers were females and if patients were less educated, less healthy, and more depressed. The caregiver burden and depressive symptoms were significantly linked, and the medical visit frequency predicted the level of both. The caregiver burden fully mediated the link between the independent variables of self-rated health and medical visits and the dependent variable of caregiver depressive symptoms. Informal caregivers of ambulatory patients with hemato-oncological malignancies experience high levels of psychological burden and depressive symptoms. This is partly attributed to the medical visit frequency. Hence, a decrease in the number and length of such visits via the implementation of advanced technology could essentially reduce burden and depressive symptoms of caregivers, without compromising patient outcomes.

A-039 Parathyroid Hormone and Vitamin D Follow an Inversely Correlated Serum Level

Abstract Background Parathyroid hormone (PTH) is a polypeptide responsible for regulating the physiological level of serum calcium through a complex homeostatic process closely associated with bone metabolism. In response to a decreased serum concentration of calcium, PTH level is increased leading to the elevation of calcium via bone resorption. Furthermore, Vitamin D (Vit-D) is a critical component of the endocrine system that also contributes to calcium homeostasis. Vit-D increases the level of serum calcium by stimulating intestinal absorption and renal reabsorption. Vit-D impacts the serum level of PTH by two distinct mechanisms. First indirectly, an increase in serum concentration of calcium, caused by Vit-D-mediated intestinal absorption and renal reabsorption disengages the process of PTH release through interaction with calcium-sensing receptors on parathyroid cells. Secondly, Vit-D directly interacts with parathyroid cells resulting in a reduced expression of PTH. Taken together, Vit-D is assumed to negatively impact the serum level of PTH. This study examined the homeostatic correlation between the circulating concentrations of Vit-D and PTH. Methods Retrospective serum concentrations of PTH and Vit-D were retrieved from the biochemical profiles of hospitalized and ambulatory patients who presented to or admitted at the tertiary care level hospital of University of Texas Southwestern Medical Center during the period between July-to-September of 2021. Correlation analysis between Vit-D and PTH was performed using GraphPad-PRISM-version-8. Results A total of 163 corresponding serum Vit-D and PTH values were obtained. Vit-D and PTH values displayed an inverse correlation (Figure 1). Pearson r values for linear and logarithmic trendlines (-0.6745 and -0.785, respectively) demonstrated a negative correlation between Vit-D and PTH. Conclusions Measuring Vit-D and PTH levels are critically important for assessing the homeostatic status of calcium. PTH level maintains an inverse relationship with Vit-D. Therefore, therapeutic targeting of Vit-D or PTH would mutually affect their concentration eventually reflected in calcium homeostasis.

Association between malnutrition risk and healthcare utilization in a culturally diverse sample of ambulatory patients with cancer.

254 Background: Malnutrition is prevalent among cancer patients placing them at an increased risk for treatment-related complications and poor clinical outcomes. This study investigated the relationship between malnutrition risk and healthcare utilization in a diverse sample of adult ambulatory cancer patients from the Sylvester Comprehensive Cancer Center. Methods: A retrospective analysis was conducted with data collected through the My Wellness Check (MWC), an electronic health record (EHR)-based assessment. Malnutrition was assessed through the NUTRISCORE, an integrated and validated nutritional screening tool within MWC that evaluates self-reported weight loss, appetite, cancer type, and treatment modality to assess risk of malnutrition. A NUTRISCORE greater or equal to 5 is considered malnutrition risk. Time to an emergency room (ER) visit and hospitalization were calculated in days from the first MWC questionnaire assignment and the first event, respectively. All ER visits and hospitalizations in the University of Miami Health System, self-reported patient demographics, and clinical characteristics were captured from the EHR. Uni- and multi-variate logistic regression models were used to examine factors associated with malnutrition risk. For survival analyses, the Kaplan-Meier method was used to calculate the cumulative incidence function of events and the cox proportional hazards regression models adjusting for patient demographics and clinical characteristics. Results: A total of5,984 ambulatory patients completed the MWC assessment between October 2019, and August 2023, with 31.2% (n=1,868) identified at malnutrition risk (NUTRISCORE ≥5). Patients were predominately White (n=5,092, 85.2%), and Hispanic (n=2,341, 39.1%). Hematologic cancer was the most common diagnosis (n=1284, 21.5%) followed by malignancies in digestive system (n=903, 15.1%) and male genitourinary (n=892, 14.9%). After adjusting for covariates, patients at malnutrition risk were at significantly higher risk for both ER visits (HR 1.57, 95% CI; 1.29 - 1.91, p&lt;0.0001) and hospitalizations (17.4% vs. 7.4% at 100 days, p&lt;0.0001) compared to those with low malnutrition risk. Factors associated with malnutrition risk included Hispanic ethnicity (aOR 1.17, 95% CI; 1.01-1.35), fatigue (aOR 1.62, 95%CI; 1.07-2.45), declined physical function (aOR 1.75, 95% CI;1.37 - 2.24), physical inactivity (aOR 1.20, 95%CI;1.04 - 1.38) and low HRQOL (aOR 2.48, 95%CI; 1.93-3.19). Conclusions: Malnutrition was associated with higher healthcare utilization in a diverse sample of ambulatory cancer patients. Hispanic ethnicity and worse PROs are factors associated with higher risk for malnutrition. Results from this work underscore the need of early nutritional interventions to prevent malnutrition and improve clinical outcomes.

395P Age at loss of ambulation in patients with nmDMD from the STRIDE Registry: sensitivity analyses

395P Age at loss of ambulation in patients with nmDMD from the STRIDE Registry: sensitivity analyses

Effectiveness of Nusinersen in Adolescents and Adults with Spinal Muscular Atrophy: Systematic Review and Meta-analysis.

Nusinersen clinical trials have limited data on adolescents and adults with 5q-associated spinal muscular atrophy (SMA). We conducted a systematic literature review (SLR) and meta-analysis to assess effectiveness of nusinersen in adolescents and adults with SMA in clinical practice. Our search included papers published 12/23/2016 through 07/01/2022 with≥5 individuals≥13years of age and with≥6months' data on≥1 selected motor function outcomes [Hammersmith Functional Motor Scale-Expanded (HFMSE), Revised Upper Limb Module (RULM), and Six-Minute Walk Test (6MWT)]. For meta-analysis, effect sizes were pooled using random-effects models. To understand treatment effects by disease severity, subgroup meta-analysis by SMA type and ambulatory status was conducted. Fourteen publications including 539 patients followed up to 24months met inclusion criteria for the SLR. Patients were age 13-72years and most (99%) had SMA Type II or III. Modest improvement or stability in motor function was consistently observed at the group level. Significant mean increases from baseline were observed in HFMSE [2.3 points (95% CI 1.3-3.3)] with 32.1% (21.7-44.6) of patients demonstrating a clinically meaningful increase (≥3 points) at 18months. Significant increases in RULM were consistently found, with a mean increase of 1.1 points (0.7-1.4) and 38.3% (30.3-47.1) showing a clinically meaningful improvement (≥2 points) at 14months. Among ambulatory patients, there was a significant increase in mean 6MWT distance of 25.0m (8.9-41.2) with 50.9% (33.4-68.2) demonstrating a clinically meaningful improvement (≥30m) at 14months. The increases in HFMSE were greater for less severely affected patients, whereas more severely affected patients showed greater improvement in RULM. Findings provide consolidated evidence that nusinersen is effective in improving or stabilizing motor function in many adolescents and adults with a broad spectrum of SMA.

Gender differences in outcomes of ambulatory and hospitalized patient with obesity hypoventilation syndrome

Obesity hypoventilation syndrome (OHS) is associated with high morbidity and mortality. There is a paucity of data on whether there are gender differences in outcomes. Research Question Is female gender associated with worse outcomes in ambulatory and hospitalized patients with OHS? We performed post hoc analyses on two separate OHS cohorts: 1) stable ambulatory patients from the two Pickwick randomized controlled trials and 2) hospitalized patients with acute-on-chronic hypercapnic respiratory failure from a retrospective international cohort. We first conducted bivariate analyses of baseline characteristics and therapeutics between genders. Variables of interest from these analyses were then grouped into linear mixed effects models, Cox proportional hazards models or logistic regression models to assess the association of gender on various clinical outcomes. The ambulatory prospective cohort included 300 patients (64% female) and the hospitalized retrospective cohort included 1,162 patients (58% female). For both cohorts, women were significantly older and more obese than men. Compared to men, baseline PaCO2 was similar in ambulatory patients, but higher in hospitalized women. In the ambulatory cohort, in unadjusted analysis, women had increased risk of emergency room visits. However, gender was not associated with the composite outcome of emergency room visit, hospitalization, or all-cause mortality in the fully adjusted model. In the hospitalized cohort, positive airway pressure (PAP) prescription was less prevalent in women upon discharge. In unadjusted analysis, hospitalized women had a higher mortality at 3, 6, and 12 months after hospital discharge compared to men. However, after adjusting for age, gender was not associated with mortality. Although the diagnosis of OHS is established at a more advanced age in women, gender is not independently associated with worse clinical outcomes after adjusting for age. Future studies are needed to examine gender-related health disparities in diagnosis and treatment of OHS.

The Canadian Heart Failure (CAN-HF) Registry: A Canadian Multicentre, Retrospective Study of Outpatients with Heart Failure

BackgroundGuideline-directed medical therapy (GDMT) reduces events in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Despite this impact, underutilization of GDMT persists. This report sought to describe HF management in Canadian outpatients treated at specialized HF clinics (HFCs). MethodsThe Canadian Heart Failure (CAN-HF) study was retrospective and observational, and it included 1775 patients from 6 Canadian outpatient HFCs, from the period January 2017-April 2020. ResultsWe observed improvement in prescription rates in patients with HFrEF, between their first visit and their most-recent clinic visit, across all GDMT classes, in those who were followed at the HFC for ≥ 6 months. The largest prescription rate increases were observed for angiotensin receptor–neprilysin inhibitors and mineralocorticoid-receptor antagonists. However, more than half of the patients remained on angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blockers, despite being symptomatic, according to their New York Heart Association class. Most patients (50%) were on triple therapy, as of their most-recent visit, with fewer (36%) on dual therapy, monotherapy (13%), or no GDMT (2%). Our data also suggest that patients who had been managed at the HFC for > 6 months had higher prescription rates of GDMT and were on higher doses of GDMT, compared to those who were new to the clinic. For patients with HF with preserved ejection fraction, few patients were on candesartan and less than half were on a mineralocorticoid-receptor antagonist. ConclusionsOur data from HFCs that in most cases were affiliated with academic centres compare favourably with data from other analyses of ambulatory patients with HFrEF, evidence that supports the use of a specialized patient-care model.