Baseline Functional Status Research Articles

Anemia at Presentation Predicts Acute Mortality and Need for Readmission Following Geriatric Hip Fracture.

Background:There is a paucity of research regarding the relationship between anemia and postoperative morbidity and mortality among geriatric patients presenting with hip fracture. The objective of this study was to determine the effect of anemia at presentation on 30-day morbidity and mortality among geriatric patients with hip fracture.Methods:The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all hip fracture patients ≥60 years old from 2011 to 2016. Included were all emergency unilateral, nonpathological hip fractures (femoral neck, intertrochanteric, or subtrochanteric) treated with arthroplasty, intramedullary nailing, or open reduction and internal fixation. Anemia was classified as a hematocrit (HCT) level of <0.41 and <0.36 for male and female patients, respectively. Age, body mass index (BMI), race, comorbidities, smoking status, American Society of Anesthesiologists (ASA) class, baseline functional status, time to surgery, operative time, anesthesia type, need for transfusion, fixation method, length of stay (LOS), and discharge destination were collected. Our primary outcome of interest was 30-day postoperative mortality, with all-cause readmission and any postoperative ischemic events (cerebrovascular accident [CVA] and myocardial infarction [MI]) analyzed as secondary outcomes. A multivariable regression analysis was performed and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated while controlling for confounding variables.Results:Of 34,805 patients identified, 22,469 (65%) were anemic at presentation (63% female; mean age, 80 ± 8 years), while 12,336 (35%) were non-anemic (85% female; mean age, 79 ± 8 years). Anemia at presentation was independently associated with higher odds of mortality (OR,1.3 [95% CI, 1.1 to 1.5]) and readmission (OR, 1.2 [95% CI, 1.1 to 1.3]), while no relationship was observed for MI (OR, 1.1 [95% CI, 0.9 to 1.4]) or CVA (OR, 0.8 [95% CI, 0.6 to 1.1]).Conclusions:Our findings suggest that anemia at presentation is associated with greater 30-day postoperative morbidity and mortality in geriatric hip fracture patients. Additional research should focus on elucidating this modifiable risk factor and advancing the preoperative optimization of hip fracture patients.Level of Evidence:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Longitudinal Study of the Association of Opioid Use with Change in Pain Interference and Functional Limitations in a Nationally Representative Cohort of Adults with Osteoarthritis in the United States.

IntroductionReal-world data are sparse on longitudinal associations of opioid use with pain interference with activities (PIA) and daily function with osteoarthritis (OA) in the USA.MethodsData from the 2010–2015 Medical Expenditure Panel Surveys were analyzed for community-dwelling adults with OA. Opioid use patterns were defined as persistent, intermittent, and no use. Evaluated outcomes were a change in PIA and functional limitations (activities of daily living [ADL], instrumental ADL [IADL], social and work activities, and cognitive function). Multivariable regression analyses explored the association of persistent/intermittent versus no opioid use with PIA and functional limitations. Results were weighted for the US population.ResultsAmong 4172 patients (66.2% female, 80.8% white, mean age 61.7 years), 62.1% reported no PIA change at follow-up, 17.9% worsened, and 20.0% improved. Although 51.0–93.1% of patients reported no functional limitations, 3.8–13.1% worsened (1.1–11.3% improved). Relative to no opioid use, persistent users had higher odds of severe/extreme PIA (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.95–4.32; P < 0.001) and moderate PIA (AOR, 2.04; 95% CI, 1.31–3.20; P < 0.01) at follow-up. For patients with baseline functional limitations, persistent opioid users were more likely to report physical and work limitations at follow-up (both P < 0.05). For patients without baseline functional limitations, persistent opioid users had higher odds than those without use of reporting IADL, physical, social, and cognitive limitations at follow-up (all P < 0.05); intermittent users were more likely to report physical and social limitations (both P < 0.05).ConclusionsPersistent opioid use for pain in patients with OA appeared to be associated with poorer PIA and functional outcomes, regardless of baseline functional status. These findings highlight the importance of patient-reported outcomes for opioid benefit–risk assessment and suggest the need for alternative analgesic approaches.

How Should We Define Clinically Significant Improvement on Patient-Reported Outcomes Measurement Information System Test for Patients Undergoing Knee Meniscal Surgery?

The purpose of the study was to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds for the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) computerized adaptive test (CAT) instrument in patients undergoing arthroscopic meniscal surgery. The PROMIS PF CAT was administered preoperatively and postoperatively to patients undergoing arthroscopic meniscal surgery. At 6months postoperatively, patients graded their knee function based on a domain-specific anchor question. A satisfaction anchor question was used to indicate achievement of the PASS. Receiver operating characteristic analysis determined the relevant psychometric values. Cutoff analysis was performed to find preoperative patient-reported outcome scores predicting achievement of clinically significant outcomes (CSOs). A total of 73 patients (41.1% female patients) were included, with a mean age of 44.9 ± 12.8.0years and average follow-up period of 24.0 ± 1.2weeks. The MCID on the PROMIS PF CAT was calculated to be 2.09 (area under the curve [AUC], 0.75; 95% CI, 0.57-0.94). Net score improvement equivalent to achievement of SCB was found to be 6.50 (AUC, 0.77; 95% CI, 0.55-0.99). The PASS was found to be 46.1 (AUC, 0.86; 95% CI, 0.76-0.96). A preoperative score below 37.6 on the PROMIS PF CAT predicted achievement of the MCID (AUC, 0.76; 95% CI, 0.62-0.87), whereas scores above 41.9 predicted achievement of the PASS (AUC, 0.77; 95% CI, 0.65-0.90). Higher baseline functional status and the absence of pre-existing arthritis were also found to be statistically significant predictors of achieving CSOs. Our study defined the MCID, SCB, and PASS for the PROMIS PF CAT. We found that a preoperative score below 37.6 was predictive of achieving a meaningful clinical change with surgery whereas a preoperative score above 41.9 was predictive of patients who would attain an acceptable postoperative health state. In addition, exercising more days per week and the absence of arthritis increased the likelihood of achieving postoperative CSOs. Level III, retrospective cohort.

Methotrexate and Area Under the Curve Exposure in Patients Receiving MT-R for Primary CNS Lymphoma: A Single Institution Retrospective Study

Background: The combination of methotrexate, temozolomide, and rituximab (MT-R) as per CALGB 50202 is a commonly used induction regimen for patients with primary central nervous system lymphoma (PCNSL). Achieving a high level of serum exposure to methotrexate (MTX) is important for therapeutic penetration of the central nervous system (CNS). However, in practice, the dose of MTX is often reduced from 8g/m2 due to age, renal dysfunction and co-morbidities. Thus, we performed a retrospective analysis of patients with PCNSL treated with MT-R at the University of Iowa to assess usual clinical practice in this disease, as well as outcomes associated with dose intensity of MTX and area-under-the-curve (AUC) exposure to MTX. Methods: All patients with PCNSL treated at University of Iowa from July 2013 to March 2019 were identified from a prospectively collected institutional cohort and via retrospective review of pathology records. Newly diagnosed, immunocompetent PCNSL patients with diffuse large B cell lymphoma (DLBCL) histology receiving at least one dose of methotrexate were included. Baseline patient data were obtained via retrospective review of the medical record. Population pharmacokinetic modelling was performed using a nonlinear-mixed effect modeling approach to estimate the pharmacokinetic parameters of MTX in each patient and each cycle of therapy. Further model simulation was performed to estimate areas under the curve (AUC) of MTX for each dose of therapy. For each patient, the average dose of MTX (avgMTX) and estimated AUC (avgAUC) received across all treatments was calculated. Toxicities were retrospectively assessed and graded according to CTCAE v5.0. Imaging data was reviewed and response to treatment reported using the criteria described by Abrey et al. (JCO 2005 23:22 5034-43). Survival probabilities were estimated and plotted using the Kaplan-Meier method. Survival differences were evaluated with the log-rank test. Statistical analysis was performed using SAS v9.4. Results: Thirty-two patients were identified for inclusion. Baseline demographics and disease characteristics are shown in table 1. Age was ≥ 60 in 53%. Median baseline creatinine clearance was 97.1 ml/min. Eastern Cooperative Oncology Group (ECOG) performance status was ≤ 1 in 69% of patients. Median time from biopsy to treatment initiation was 8 days (range 2-39 days). Overall, 16% of patients received the maximum 8 g/m2. The mean dose of average MTX was &lt; 4 g/m2 in 12 patients (37.5%) and was ≥ 4 g/m2 in 20 patients (63.5%) (Table 1). The correlation between avgMTX and avgAUC is shown in figure 1 (Pearson co-efficient 0.85, p-value &lt;0.01). Median follow up for the cohort was 22 months. Three total patients were unevaluable for response to induction: two patients with poor baseline functional status died shortly after beginning MT-R therapy and one patient completed therapy but had not yet undergone response assessment MRI imaging. At the end of induction therapy, the rate of complete remission (CR + uCR) was 75.9%, partial response (PR) was 13.8%, and progressive disease was 10.3% (table 2). The progression free survival at 24 months (PFS24) was 73% (figure 2). PFS24 for patients receiving ≥6 doses of methotrexate was 84% (figure 3). Among patients receiving an average dose of MTX &lt; 4g/m2, the rate of CR/uCR/PR was 90.8%, and PFS24 was 71%. Among patients receiving an average dose of MTX ≥ 4g/m2, the rate of CR/uCR/PR was 88.8%, and PFS24 was 75% (figure 4). The incidence of acute kidney injury (grade 2+) was 35% and 67% in the ≥ 4g/m2 and &lt; 4g/m2 avgMTX dose groups, respectively. In total, 7 of 32 (21.9%) of patients died over a median follow-up time of 22 months. The cause of death was PCNSL in 6 patients, and bowel perforation in 1 patient (table 2). Conclusions: Although few patients received the maximum dose of methotrexate (8g/m2), the progression free survival at 24 months was comparable to prior clinical trial experience (CALGB 50202). Despite a range of ages and creatinine clearances, the average dose of methotrexate and average AUC correlated well. Though subset analyses are limited by sample size, patients receiving MT-R with average MTX doses &lt; 4g/m2 and ≥ 4g/m2 each had excellent outcomes in terms of response rate and progression free survival. Disclosures Farooq: Kite Pharma: Research Funding; Celgene: Honoraria.

DELIRIUM SEVERITY AND COGNITIVE OUTCOMES

Delirium is heterogeneous and can vary by severity. The impact of its severity is unclear. This prospective cohort study enrolled emergency department (ED) patients who were > 65 years old and admitted to the hospital. Delirium severity was determined by the Confusion Assessment Method for the Intensive Care Unit Severity (CAM-ICU-S) Scale measured at enrollment. This scale ranges from 0 (no symptoms) to 7 (most severe). Premorbid and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine if delirium severity was associated with 6-month function and cognition adjusted for pre-illness IQCODE, baseline functional status, comorbidity burden, severity of illness, and central nervous system diagnosis. Two-factor interactions were incorporated to determine if pre-illness cognition modified the relationship between delirium severity as measured by the CAM-ICU-S and 6-month cognition. A total of 228 older patients were enrolled in the ED and of these, 105 were delirious. Median (interquartile range) CAM-ICU-S scores was 2 (0, 5). In patients with intact pre-illness cognition, a point increase in the CAM-ICU-S significantly increased the 6-month IQCODE by 0.06 (95%CI: 0.01 to 0.12) points. In patients with impaired pre-illness cognition, there was no significant association between the CAM-ICU-S and 6-month IQCODE. Thus delirium severity is associated with poorer 6-month cognition, but this association is more prominent in those with intact pre-illness cognition.

Adolescent and Caregiver-derived Utilities for Traumatic Patella Dislocation Health States.

The treatment of a first-time traumatic patella dislocation in children and adolescents remains controversial. Preference-based health utility assessments can provide health-related quality of life information for orthopaedic conditions and their subsequent treatment. The purpose of this study was to determine utilities for pediatric acute traumatic patella dislocation and subsequent treatment health states from both children with patellar dislocation, and their parents. Adolescents with acute first-time patella dislocations and their parents were identified. Six patella dislocation health states were defined: (1) Immediate post injury (Injury), (2) Postdislocation and nonoperative treatment with physical therapy (Rehabilitation), (3) Immediately poststabilization surgery (Postsurgical), (4) Recurrent dislocation after treatment (Recurrent dislocator), (5) Stable knee after initial treatment but unable to participate in sport at previous level (Stable return to lower function), and (6) Stable knee after initial treatment and fully able to participate in sport at previous level (Stable return to same function). Classic feeling thermometer utilities acquisition was performed, with self-report (patient) and proxy-report (parent) interviews performed separately. Patients' physical activity levels were collected using the UCLA Activity Score and the HSS Pedi-FABS. Comparisons between groups were made using Mann-Whitney U test and Wilcoxon signed-rank test. Ninety-five adolescents and 95 parents were included. Median (interquartile range) patient utilities for Injury, Rehabilitation, Postsurgical, Recurrent dislocator, Stable return to lower function, and Stable return to same function health states were: 25 (10 to 45), 50 (35 to 62.5), 30 (15 to 48.5), 20 (10 to 40), 70 (50 to 80), and 100 (100 to 100), respectively. Caregiver-derived utilities for children going through these health states were: 25 (10 to 49.5), 50 (25 to 60), 40 (15 to 60), 20 (5 to 40), 60 (50 to 77.5), and 100 (100 to 100). Stable return to a lower function was assigned a significantly higher utility by adolescents than their caregivers (P=0.03); highly active adolescents assigned a significantly higher utility to achieving a stable return to same function (P=0.02) while assigning significantly lower utility to health states in which they were not fully participating in sport. Adolescents and their parents felt that successful treatment of an acute patella dislocation was equivalent to perfect health (utility=1); however, adolescents assigned a significantly higher utility to a stable but lower functioning health state compared with their parents. Baseline functional status is an important modifier of health state preference-highly active adolescents assign a significantly greater disutility to health states in which they are not participating in sports at their regular level of play. These findings provide insight into the health-related quality of life impact for acute patella dislocations and their management, and potentially support minimizing time out of play and more aggressive treatment of first time acute patellar dislocations in athletic adolescents. Level III.

2315. The Relationship of Pre-Hospital Functional Status and Clinical Outcomes in Patients with Laboratory-Confirmed RSV Infection: Active Population-Based Surveillance, 2017–2019

BackgroundRespiratory syncytial virus (RSV) infection is a common cause of acute respiratory infection (ARI) in adults. Prospective surveillance enables collection of representative data on demographic and clinical characteristics. Few data of this kind are available for adults hospitalized with RSV infection. We used active population-based surveillance to identify patients with laboratory-confirmed RSV infection and evaluated demographic characteristics and clinical outcomes.MethodsHospitalized adults ≥ 18 years old residing in a predefined catchment area with ≥ 2 ARI symptoms or exacerbation of underlying cardiopulmonary disease were screened for eligibility during October 2017–April 2018 and October 2018–April 2019 in 3 hospitals in Rochester, NY and New York City. Respiratory specimens were tested for RSV using PCR assays. Clinical and demographic data were abstracted from the medical record. Multivariate analysis was used to evaluate the relationship of patient characteristics with clinical outcomes.Results8,217 hospitalized adults were screened and 9.4% positive for RSV infection. Preliminary clinical and demographic data were available for 348 patients including 14% 18–49 years, 28% 50–64 years and 58% > 65 years. Mean age was 68 years and 60% were female (Figure 1). Patients had a mean of 3 co-morbidities, with diabetes (40%), chronic obstructive pulmonary disease (30%), chronic kidney disease (28%), congestive heart failure (28%), coronary artery disease (25%) and asthma (24%) the most common co-morbidities (Figure 2). Median hospital length of stay was 6 days (IQR 4–10), 13% of patients were admitted to the ICU, 5% were mechanically ventilated and 5% died during admission and 12% within 6 months. In multivariate analysis having > 3 comorbidities, cardiac disease or a lower baseline functional status measured by activities of daily living scores was significantly associated with 6-month mortality.ConclusionThe majority of hospitalized patients with RSV infection were older adults with ≥ 3 chronic comorbid conditions. Baseline functional status may be predictive of worse clinical outcomes in patients with RSV infection. These insights into patient characteristics and clinical outcomes will provide information for prevention programs. Disclosures All authors: No reported disclosures.

Measuring patient-centred long-term outcome following a bloodstream infection: a pilot study

ObjectivesTo evaluate the sequential organ failure assessment (SOFA) and modified SOFA (mSOFA) scoring and a novel performance score based on the Karnofsky score for measuring outcome following a bloodstream infection (BSI). MethodThis prospective observational cohort study assessed patients with BSI for mortality and functional outcomes with a novel performance score: the functional bloodstream infection score (FBIS). We also tested the SOFA and, given the difficulties with measuring SOFA on ward-based patients, the mSOFA over the first 7 days following a BSI for their association with outcomes. ResultsOne hundred participants were prospectively recruited. Mortality at 52 weeks following BSI was 21% (21/100). Only 57% of survivors (39/69) were at their baseline functional status at 52 weeks. Stable or improved SOFA/mSOFA over the first 7 days was associated with survival and return to premorbid performance score (risk ratio 3.2, 95%CI 1.3–9.4, p < 0.01). ConclusionsThe acute change in SOFA/mSOFA was associated with 52-week survival and return to premorbid functional performance. The FBIS measurement represents a simple and easy-to-apply measure of functional performance for patients with BSI and was associated with a high response rate (89%) from participants.

Differential characteristics of acute heart failure in very elderly patients: the prospective RICA study.

Acute heart failure (AHF) is a frequent epidemic in geriatrics. The main aim of this study was to evaluate the clinical and prognostic differences of very elderly patients with AHF compared to the rest, and evaluate the factors associated with 90-day mortality. We analyzed 3828 patients hospitalized for AHF with an age of ≥ 70years. The population was divided into three groups: 70-79, 80-89 and ≥ 90years old (nonagenarians). The baseline characteristics of patients nonagenarians were compared with the rest. In the group of nonagenarians, their clinical characteristics were analyzed according to the left ventricular ejection fraction (LVEF) and the factors associated with mortality at 90days of follow-up. Nonagenarians showed higher comorbidity and cognitive deterioration, worse basal functional status, and preserved LVEF. Alternatively, they presented a lower rate of diabetes mellitus, lower incidence of de novo AHF, and lower prescription of angiotensin-converting-enzyme inhibitors, aldosterone blockers, anticoagulants, and statins at hospital discharge. Of the total, 334 patients (9.3%) had died by 90days. The 90-day mortality rate was highest in nonagenarians (7.1% vs 9.8% vs 17%; p = 0.001). Multivariate analysis showed that renal failure, New York Heart Association (NYHA) functional classifications of III-IV, and a more advanced functional deterioration at baseline are predictors of mortality within 90days. The AHF in patients nonagenarians has a different clinical profile compared to younger patients and a higher mortality. In this subgroup of patients having a worse baseline functional status, higher NYHA classification (III-IV), and renal failure are predictors of 90-day mortality.

Novel Definition of Stroke “Good Responders” Predicts 90-Day Outcome after Thrombolysis

IntroductionIdentifying predictors of good response in thrombolytic-treated stroke is important to clinical care, resource allocation, and research design. We developed a simple, novel measure of “Good Responders” to assess if 2 short-term variables could predict 90-day outcomes after thrombolysis in stroke. MethodsIntravenous thrombolysis-treated stroke cases from June 2004 to June 2018 were analyzed from a stroke registry. Intraarterial treatment cases were excluded. Good responders (GR++) were defined as those with length of stay less than or equal to 3 days and discharge to home. Poor responders (GR- -) had length of stay more than 3 days and discharge other than home. Mixed responders (GR+/-) composed the remainder. Baseline characteristics and predictors of 90-day outcome were assessed. ResultsOf 261 patients, there were 101(38.7%) GR++, 67(25.7%) GR- -, and 93(35.6%) GR+/-. For GR++ versus GR- - versus GR+/-, there were differences in mean age (62.7, 71.2, 69.2; P = .0016), and baseline modified Rankin score (mRS) 0-2 (%: 94.9, 74.6, 84.8; P = .008). Younger age, male sex, lower values for systolic BP, glucose, and baseline mRS were associated with good responders. Older age, atrial fibrillation, symptomatic intracerebral hemorrhage, and baseline mRS greater than 2 were associated with poor responders. At 90 days, mortality was reduced in GR++ versus GR- - versus GR+/- (%alive: 92.6, 72, 86; P = .04), and mRS(0-2) (%: 36.8, 0, 11.8; P < .001). ConclusionsGood responders to thrombolysis are younger and have better baseline functional status. Our novel definition of “Good Responders”, using 2 early variables of home disposition and short length of stay, may help predict 90-day post-thrombolytic outcome. Future work should focus on validating this definition.

171 Predictors of Repeat Emergency Department Visits in Older Adults

For older adults, an emergency department (ED) encounter has been associated with adverse outcomes including functional decline, increased health care utilization, nursing home admission, and mortality. ED utilization is increasing rapidly in this population, and previous studies have identified self-reported data, including sex, living status, and functionality, as risk factors for short-term repeat ED visits. Our objective was to assess the association of baseline functional and health status and social engagement with repeat ED visits among older adults.

Does the Duration of Cervical Radicular Symptoms Impact Outcomes After Anterior Cervical Discectomy and Fusion?

Retrospective cohort study. To compare clinical outcomes after anterior cervical discectomy and fusion (ACDF) based on preoperative duration of radiculopathy symptoms. There is no clear indication of when outcomes after ACDF become less effective in the setting of acute versus chronic symptoms from cervical nerve root compression. A retrospective cohort study of consecutive patients who underwent an ACDF between 2008 and 2015 for radiculopathy was performed. Patients were divided into 3 groups: radicular symptoms lasting for <6 months, symptoms lasting for 6-12 months, and those with symptoms for ≥12 months. Neck Disability Index (NDI) and Visual Analog Scale (VAS) scores for both the neck and arms were obtained at preoperative and final postoperative visits. Radiographs were assessed for adjacent segment degeneration, fusion, and subsidence. Bivariate and multivariate regressions were subsequently used to compare outcomes between groups. A total of 379 patients were included. Patients with symptoms lasting for 6-12 months and those with symptoms lasting for ≥12 months had worse preoperative VAS neck pain compared with patients with symptoms lasting for < 6 months (P=0.000 and P=0.004, respectively). Patients with symptoms lasting for ≥12 months had worse baseline functional status compared with patients with symptoms lasting for <6 months (P=0.009). At final follow-up, there were no significant differences in VAS neck, VAS arm, or NDI between symptom duration groups. However, differences in outcomes were noted when considering the type of preoperative symptom. Patients with pain symptoms of ≥12 months had worse preoperative VAS neck (P=0.001), VAS arm (P=0.008), and NDI (P<0.001) and had significantly worse final VAS arm (P=0.019) and NDI (P=0.016) compared with patients with preoperative pain symptoms lasting for <6 months. The overall reoperation rate was 4.5%. Fusion was achieved in 97.6% of the patients, and subsidence was observed in 5.5%. There were no significant differences in the risk of adjacent segment degeneration, reoperations, fusion rates, or subsidence rates based on preoperative symptom duration. Despite worse preoperative neck pain and functional status in patients with preoperative duration of symptoms >6 months, there were no differences in final clinical outcomes across groups.

Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

BackgroundSpinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis.Case presentationA 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine.ConclusionsPartial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Return to Baseline Functional Status in Older Women Undergoing Surgery for Pelvic Organ Prolapse.

The aim of the study was to determine the rate of return to baseline functional status 3 months after surgery for pelvic organ prolapse (POP) in women 65 years or older. This is a multicenter prospective cohort study of women older than 65 years undergoing POP surgery. Functional status was determined by the Activities Assessment Scale at the preoperative visit and 3 months after surgery. We compared a variety of clinical variables and preoperative functional status scores for women who worsened, improved, or returned to baseline functional status after surgery using univariable and multivariable analysis. A total of 192 women were enrolled in the study. Of 176 women who completed both sets of questionnaires, 59% improved, 35% returned, and 6% worsened from their baseline functional status. Variables significantly associated with postoperative functional status score were depression (P < 0.002) and preoperative functional status score (P < 0.001). The group that improved from baseline had the lowest (worst) preoperative functional status score (78.7 ± 16.4), whereas the group that worsened after surgery had the highest (best) preoperative functional status score (98.6 ± 2.2). After adjusting for age and depression, higher preoperative functional status score was predictive of failure to return to baseline functional status. Most older women undergoing surgery for POP, including those with low preoperative functional status, return to or improve from their baseline functional status within 3 months of surgery. Women with higher functional status before surgery are less likely to report improvement in physical functioning after surgery.

Categorising trajectories and individual item changes of the North Star Ambulatory Assessment in patients with Duchenne muscular dystrophy.

Functional variability among boys with Duchenne muscular dystrophy (DMD) is well recognised and complicates interpretation of clinical studies. We hypothesised that boys with DMD could be clustered into groups sharing similar trajectories of ambulatory function over time, as measured by the North Star Ambulatory Assessment (NSAA) total score. We also explored associations with other variables such as age, functional abilities, and genotype. Using the NorthStar Clinical Network database, 395 patients with >1 NSAA assessment were identified. We utilised latent class trajectory analysis of longitudinal NSAA scores, which produced evidence for at least four clusters of boys sharing similar trajectories versus age in decreasing order of clinical severity: 25% of the boys were in cluster 1 (NSAA falling to ≤ 5 at age ~10y), 35% were in cluster 2 (NSAA ≤ 5 ~12y), 21% in were cluster 3 (NSAA≤ 5 ~14y), and 19% in cluster 4 (NSAA > 5 up to 15y). Mean ages at diagnosis of DMD were similar across clusters (4.2, 3.9, 4.3, and 4.8y, respectively). However, at the first NSAA assessment, a significant (p<0.05) association was observed between earlier declining clusters and younger age, worse NSAA, slower rise from supine, slower 10 metre walk/run times, and younger age of steroid initiation. In order to assess the probability of observing complete loss of function for individual NSAA items, we examined the proportion of patients who shifted from a score of 1 or 2 at baseline to a score of 0. We also assessed the probability of gain of function using the inverse assessment and stratified the probability of deterioration, improvement–or static behavior–by age ranges and using baseline functional status. Using this tool, our study provides a comprehensive assessment of the NSAA in a large population of patients with DMD and, for the first time, describes discrete clusters of disease progression; this will be invaluable for future DMD clinical trial design and interpretation of findings.

Algorithm Assignment to Stereotactic Body Radiation Therapy Is Associated with High Risk of Post-Surgical Serious Adverse Events in Stage I Non-small Cell Lung Cancer Patients

For clinical Stage I non-small cell lung cancer (NSCLC) patients, identifying patients at increased risk for adverse events from surgical intervention, and thus more appropriate for stereotactic body radiation therapy (SBRT), remains a clinical challenge. Using a prospective treatment allocation model, we evaluated whether serious surgical events could identify high risk patients prior to treatment selection. From 2016 – 2018, clinical Stage I NSCLC patients receiving treatment in either the Department of Radiation Oncology or Division of Thoracic Surgery were invited to participate in a prospectively maintained database that included physiologic, pathologic, and functional status metrics. A multivariable logistic regression model was made to characterize the likelihood of SBRT receipt for all participating patients, and used to generate a predicted group value (allocation to surgery versus SBRT). From this, ≥ Grade 3 Common Terminology Criteria for Adverse Events (CTCAE) were compared among those surgical patients that the model allocated to surgery (concordant), versus those assigned to SBRT (discordant). In this prospective database, 104 (53%) received SBRT, 91 (47%) received surgery. Variables independently associated with allocation to SBRT included current smoking status (Odds Ratio 8.2, 95% CI 1.5 – 44.7), Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2, (OR 2.7, 95% CI 1.1 – 6.6), increasing 15-foot walk test time (per second increase OR 1.7, 95% CI 1.2 – 2.5), and ECOG ≥1 (OR 8.0, 95% CI 3.0 – 21.4). Of the 73 (80%) surgical patients with complete data for model allocation, 60 patients (82%) were predicted to receive surgery and 13 (18%) were predicted to receive SBRT. The rate of ≥Grade 3 CTCAE among discordantly assigned surgical patients was significantly higher than concordantly assigned surgical patients, 6/13 (46.2%) versus 10/60 (16.7%) respectively, p=0.03. Discordant allocation to SBRT was significantly associated with experiencing a ≥Grade 3 CTCAE following surgery (OR 4.3, 95% CI 1.2 – 15.5). Prospectively collected patient information that includes baseline functional and performance status metrics may assist in identifying surgical patients that are high-risk for ≥ Grade 3 CTCAE events. Identifying these patients at the time of consultation may assist in consideration for SBRT and shared-decision making.

Thoracic Discectomy Through a Unilateral Transpedicular or Costotransversectomy Approach With Intraoperative Ultrasound Guidance.

The disc location, extent of calcification, limited visualization of the ventral cord, and tenuous blood supply to the thoracic spinal cord pose unique technical challenges when surgically treating thoracic disc herniation. To report our initial experience with a series of cases in which intraoperative ultrasound image guidance was used for thoracic discectomy through a unilateral transpedicular or costotransversectomy approach. Five patients (n=5) underwent a transpedicular approach and five (n=5) underwent costotransversectomy for thoracic discectomy. Pre- and postoperative clinical records, operative reports, disc location/calcification, and complications were reviewed. There were 6 (n=6) males and 4 (n=4) females with an average age of 54 yr (range: 33-74). All patients had symptoms attributable to a single-level of thoracic disc herniation. Discs were classified as central (n=5) and paracentral (n=5). Preoperative CT and/or intraoperative visualization demonstrated calcified disc material in 6 (n=6) patients. Final outcomes data at last follow-up was available for 9 of 10 patients. Eight of these nine patients experienced a return to normal baseline functional status. Postoperative imaging confirmed that no wrong-level surgeries were performed. The mean length of follow-up was 20.4 wk (range 4-48). Thoracic discectomy with ultrasound visualization via a unilateral transpedicular or costotransversectomy approach is safe and effective for treatment of central and paracentral calcified disc herniations. This tool improves the safety profile of thoracic discectomy and allows for treatment of thoracic discs through less invasive approaches.

Effectiveness and analysis of factors predictive of discharge to home in a 4-year cohort in a residential transitional care unit.

ObjectiveThe aim of this study was to evaluate the effectiveness and identify factors predictive of home discharge in a cohort of patients admitted to the residential Transitional Aged Care Program (r‐TACP) after a stay in an acute hospital.MethodsA retrospective observational cohort study of patients admitted to a single r‐TACP unit between 1 January 2014 and 31 December 2017 was carried out. Baseline patient characteristics and discharge outcomes were analyzed.ResultsThree hundred sixty‐nine patients were admitted during the study period. The discharge outcomes were as follows: 68% returned home, 17% went onto residential care, 14% were readmitted to hospital, and 1% died. Factors associated with not returning home were increased age, increased comorbidities, and lower Barthel Index on admission to the r‐TACP.ConclusionOur r‐TACP is an effective program that successfully returns the majority (67.8%) of older patients home after an acute hospital admission. Older patients with greater comorbidities and poorer baseline functional status in our program were less likely to return home.

Effects of Baseline Opioid Medication Use on Patient-Reported Functional and Psychological Impairment Among Hand Clinic Patients

To test the null hypothesis that baseline opioid use is not associated with functional or psychological impairment among new hand surgery clinic patients, as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) instruments. New adult (≥ 18 years) patient visits to a tertiary academic orthopedic nonshoulder hand and upper extremity clinic between February 2014 and April 2018 were eligible. Collected outcomes include the question, "Are you currently taking narcotic pain medications?", the PROMIS Upper Extremity (UE) computerized adaptive testing (CAT), abbreviated version of the Disorders of the Arm, Shoulder, and Hand (QuickDASH), PROMIS Physical Function (PF) CAT, PROMIS Pain Interference (PI) CAT, PROMIS Depression CAT, and PROMIS Anxiety CAT. Patients responding to the opioid question, plus the UE CAT or QuickDASH, were included. Bivariate and multivariable logistic regression modelling were used to assess factors associated with baseline scores. Of 5997 included patients, 1,046 (17.4%) reported baseline opioid use. Patients in the opioid group demonstrated significantly worse scores on all patient-reported outcomes, and a significantly greater proportion of patients with PROMIS Depression CAT scores exceeding 60 (associated with a clinical diagnosis of depression; 29.5% vs 15.5%). Lower functional scores were observed in the opioid group after controlling for age, sex, other activity-limiting comorbidities, and either depression (UE CAT -7.0; QuickDASH+18.1; and PF CAT -6.6 points), anxiety (UE CAT -6.3; QuickDASH+16.4; PF CAT -6.3), or PI (UE CAT -3.7; QuickDASH+9.5; and PF CAT -4.2 points). Pain interference was greater among opiate users when controlling for age, sex, other activity-limiting comorbidities, and baseline function or psychological status: PI was 2.5, 5.0, or 4.3 points greater when controlling for the PROMIS UE CAT, Depression CAT, or Anxiety CAT. New patients presenting to a hand surgery clinic who endorse use of opioid medications at baseline report significantly decreased physical function, increased psychological burden, and greater levels of pain interference than nonusers. Diagnostic III.

Utilization of Rehabilitation Services in Stroke: A Study Utilizing the Health and Retirement Study With Linked Medicare Claims Data

ObjectivesTo describe Medicare fee-for-service beneficiaries who used poststroke rehabilitation services and identified the strongest predictors of utilization after the initial stroke care episode. DesignPooled, cross-sectional design using data from 1998 to 2010 from the Health and Retirement Study (HRS) with linked Medicare claims data. SettingNA. ParticipantsStroke survivors who were Medicare fee-for-service beneficiaries and participated in the HRS were included (N=515). Main Outcome MeasureUtilization of rehabilitation services up to 10 years poststroke was the primary outcome with logistic regression used to predict utilization. Covariates included demographic factors, baseline functional status, health conditions, personal lifestyle factors, and social support. ResultsRehabilitation service utilization was 21.6%, 6.8%, 15.8%, 16.5%, and <16% in years 2, 4, 6, 8, and 10, respectively. Age was the primary factor predicting use of rehabilitation in the first 10 years poststroke (odds ratio: 1.14; P=.001). Recurrent stroke (odds ratio: 1.64; P=.051) was also significantly associated with utilization, whereas unspecified incident stroke at incident trended toward significance (odds ratio: 2.17; P=.077). None of the other factors was a significant predictor of participation in rehabilitation services in this period. ConclusionA small number of Medicare fee-for-service beneficiaries who are stroke survivors utilize rehabilitation services in the first 10 years poststroke. Of those who do, age is the primary driver of utilization. We analyzed a multitude of factors that might influence utilization, but other factors not available in these data also need to be explored.