CCI Score Research Articles

Utilization of Telemedicine among Medicare beneficiaries undergoing Hepatopancreatic Surgery during the COVID-19 Pandemic

IntroductionTelemedicine may serve as an important avenue to address disparities in access to cancer care. We sought to define factors associated with telemedicine use among Medicare beneficiaries who underwent hepatopancreatic (HP) surgery, as well as characterize trends in telemedicine usage relative to community vulnerability based on the enactment of the Medicare telemedicine coverage waiver. MethodsPatients who underwent HP surgery between 2013–2020 were identified from the Medicare Standard Analytic Files (SAF). Telemedicine utilization was assessed pre- versus post- implementation of the Medicare telemedicine coverage waiver; the county-level social vulnerability index (SVI) was obtained from the Center for Disease Control. Interrupted time series analysis with negative binomial and multivariable logistic regression methods were used to assess changes in telemedicine utilization after the implementation of the Medicare telemedicine coverage waiver relative to SVI. ResultsPre-waiver telemedicine visits were scarce among 16,690 patients (0.2%, n = 28), while post-waiver telemedicine adoption was substantial among 3,301 patients (45.8%, n = 1,388). Post-waiver, the median patient age was 70 years (IQR, 66–74) with the majority of patients being age 65–69 (n = 994, 32.8%); 1,599 (52.8%) were female. Most patients self-identified as White (n = 2641, 87.1%), while a minority of patients self-identified as Black (n = 190, 6.3%), Asian (n = 18, 0.6%), Hispanic (n = 35, 1.2%), or Other/unknown (n = 147, 4.9%). On multivariable regression analysis, patients who lived in highly vulnerable counties (referent Low SVI; moderate SVI: OR 1.09, 95% CI 0.86–1.39, p = 0.449; high SVI: OR 0.72, 95% CI 0.55–0.94, p = 0.001) and individuals with advancing age (referent 18–64; 65–69, OR 0.68, 95%CI 0.54–0.86; 70–74, OR 0.56, 95%CI 0.44–0.71; 75–79, OR 0.57, 95%CI 0.44–0.75; 80–84, OR 0.43, 95%CI 0.30–0.61; 85 + , OR 0.25, 95%CI 0.13–0.49) had lower odds of utilizing telemedicine. In contrast, Black patients (referent White; OR 2.26, 95% CI 1.65–3.10) and patients with a higher CCI score > 2 (referent ≤ 2; OR 1.49, 95% CI 1.28–1.71) were more likely to use telemedicine (all p < 0.001). ConclusionsMedicare beneficiaries residing in counties with extreme vulnerability, as well as elderly individuals, were markedly less likely to use telemedicine services related to HP surgical episodes of care. The lower utilization of telemedicine in areas of high social vulnerability was attributable to concomitant lower rates of internet access in these areas.

High risk of osteoporosis and fracture following solid organ transplantation: a population-based study.

Osteoporosis and fractures increase morbidity and mortality rates after solid organ transplantation (SOT), but few studies have analyzed the risk of osteoporosis and related fractures after SOT. In this retrospective cohort study, we investigated the risk of osteoporosis and fractures in different SOT recipients. This study was a retrospective cohort study using a nationally representative database in Taiwan. We collected the data of SOT recipients and used the propensity score matching method to obtain a comparison cohort. To reduce bias, we excluded patients who had been diagnosed with osteoporosis or fracture before inclusion. All participants were followed up until the date of diagnosis as having a pathological fracture, death, or the end of 2018, whichever occurred first. The Cox proportional hazards model was used to investigate the risk of osteoporosis and pathological fracture in SOT recipients. After adjustment for the aforementioned variables, SOT recipients were observed to have a higher risk of osteoporosis (hazard ratio (HR) = 1.46, 95% confidence interval (CI): 1.29-1.65) and fracture (HR: 1.19, 95% CI: 1.01-1.39) than the general individuals. Among the different SOT recipients, the highest risk of fractures was noted in heart or lung transplant recipients, with a HR of 4.62 (95% CI: 2.05-10.44). Among the age groups, patients aged >61 years had the highest HRs for osteoporosis (HR: 11.51; 95% CI, 9.10-14.56) and fracture (HR: 11.75, 95% CI: 8.97-15.40). SOT recipients had a higher risk of osteoporosis and related fractures than the general population, with the highest risks observed in patients receiving heart or lung transplants, older patients, and patients with CCI scores of >3.

First Comparison of Retroperitoneal Versus Transperitoneal Robot-Assisted Nephroureterectomy with Bladder Cuff: A Single Center Study.

After recent presentation of the first complete robot-assisted retroperitoneal nephroureterectomy with bladder cuff (RRNU) for patients with upper tract urothelial cancer (UTUC), we aimed to compare this new surgical technique with robot-assisted transperitoneal nephroureterectomy (TRNU) representing the current standard of care. Robot-assisted nephroureterectomies (NUs) were retrospectively analyzed and compared based on two groups: transperitoneal versus retroperitoneal approach. Baseline data were collected for patient demographics, tumor characteristics, intra- (EAUiaiC) and postoperative (Clavien-Dindo) complications, and perioperative variables. Tumor characteristics included grade of malignancy, clinical stage, and surgical margin status.Short-term follow-up data including 30-day readmission rates were collected. Statistical analyses were performed assuming a significant p-valueof < 0.05. The analysis includes perioperative patient data after proven UTUC of 24 TRNU versus 12 RRNU (mean age: 70 versus 71 years; BMI: 25.9 versus 26.1 kg/m2; CCI score ≥ 4: 83% versus 75%;ASA score ≥ 3: 37% vs 33%).Intraoperative (16.4% vs 0%, p = 0.35) and postoperative (25% vs 12.5%, p = 0.64) complications demonstrated no significant discrepancy. Notably, RRNU demonstrated significantly shorter surgery time (p < 0.05) and length of stay (p < 0.05). There was no significant difference in histopathological tumor characteristics, whereas significantly more lymph nodes were removed through RRNU (11.0±3.3vs. 6.4±5.1, p < 0.05). Finally, no statistical difference was shown in short-term follow-up. We report the first head-to-head comparison between RRNU and TRNU. RRNU proves to be a safe and feasible approach which appears to be non-inferior to TRNU. RRNU expands the spectrum of minimally invasive treatment options, particularly for patients with major previous abdominal surgery.

Understanding the Role of Ureteral Access Sheath in Preventing Post-Operative Infectious Complications in Stone Patients Treated with Ureteroscopy and Ho:YAG Laser Lithotripsy: Results from a Tertiary Care Referral Center.

The use of ureteral access sheaths (UAS) limits the irrigation-induced increase in intrarenal pressure during ureteroscopy (URS). We investigated the relationship between UAS and rates of postoperative infectious complications in stone patients treated with URS. Data from 369 stone patients treated with URS from September 2016 to December 2021 at a single institution were analyzed. UAS (10/12 Fr) placement was attempted in case of intrarenal surgery. The chi-square test was used to assess the relationship between the use of UAS and fever, sepsis, and septic shock. Univariable and multivariable logistic regression analyses tested the association of patients' characteristics and operative data and the rate of postoperative infectious complications. Full data collection of 451 URS procedures was available. Overall, UAS was used in 220 (48.8%) procedures. As for postoperative infectious sequalae, we recorded fever (n = 52; 11.5%), sepsis (n = 10; 2.2%), and septic shock (n = 6; 1.3%). Of those, UAS was not used in 29 (55.8%), 7 (70%), and 5 (83.3%) cases, respectively (all p > 0.05). At multivariable logistic regression analysis, performing URS without UAS was not associated with the risk of having fever and sepsis, but it increased the risk of septic shock (OR = 14.6; 95% CI = 1.08-197.1). Moreover, age-adjusted CCI score (for fever-OR = 1.23; 95% CI = 1.07-1.42, sepsis-OR = 1.47; 95% CI = 1.09-1.99, and septic shock-OR = 1.61; 95% CI = 1.08-2.42, respectively), history of fever secondary to stones (for fever-OR = 2.23; 95% CI = 1.02-4.90) and preoperative positive urine culture (for sepsis-OR = 4.87; 95% CI = 1.12-21.25) did emerge as further associated risk factors. The use of UAS emerged to prevent the onset of septic shock in patients treated with URS, with no clear benefit in terms of fever and sepsis. Further studies may help clarify whether the reduction in fluid reabsorption load mediated by UAS is protective against life-threatening conditions in case of infectious complications. The patients' baseline characteristics remain the main predictors of infectious sequelae in a clinical setting.

Association of medical comorbidities and cardiovascular disease with toxicity and survival among patients receiving checkpoint inhibitor immunotherapy.

Medical comorbidities (MC) are highly prevalent among patients with cancer and predict worse outcomes for traditional therapies. This association is poorly understood for checkpoint inhibitor immunotherapy (IO). We aimed to explore the relationship between common MC including cardiovascular disease (CVD), immune-related adverse events (irAEs), and overall survival (OS) among patients receiving IO for advanced cancer. This is a retrospective cohort study of 671 patients with any cancer who received IO at our institution from 2011 to 2018. Clinical data were abstracted via chart review and query of ICD-10 codes and used to calculate modified Charlson comorbidity index (mCCI) scores. The primary outcomes were the association of individual MC with irAEs and OS using bivariate and multivariable analyses. Secondary outcomes included association of mCCI score with irAEs and OS. Among 671 patients, 62.1% had a mCCI score ≥ 1. No individual MC were associated with irAEs or OS. Increased CCI score was associated with decreased OS (p < 0.01) but not with irAEs. Grade ≥ 3 irAEs were associated with increased OS among patients without CVD (HR 0.37 [95% CI: 0.25, 0.55], p < 0.01), but not among patients with CVD. No specific MC predicted risk of irAEs or OS for patients receiving IO. Increased CCI score did not predict risk of irAEs but was associated with shorter OS. This suggests IO is safe for patients with MC, but MC may limit survival benefits of IO. CVD may predict shorter OS in patients with irAEs and should be evaluated among patients receiving IO.

Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs.

Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p=0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p =0.05), cardiac arrhythmia (12% vs. 3%; p=0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p=0.09) and those ≥80 years old (-2.3 days; p=0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p=0.01), with $17,832 less per patient with CCI ≥3 (p=0.01), than the control group. A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

Effectiveness of gelatin matrix with human thrombin for reducing blood loss in palliative decompressive surgery with posterior spinal fusion for metastatic spinal tumors

BackgroundThis study aimed to investigate the effect of gelatin matrix with human thrombin (GMHT) on blood loss and survival time in patients with metastatic spinal tumors treated with palliative decompression surgery with posterior spinal fusion. MethodsWe retrospectively reviewed 67 consecutive patients with metastatic spinal tumors who underwent palliative decompression surgery with posterior spinal fusion. We compared patients in whom GMHT was not used during surgery with those in whom GMHT was used. The following baseline characteristics were evaluated: age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, Karnofsky Performance Status score, Charlson comorbidities index score, the percentage of patients who received perioperative chemotherapy, main tumor level, Frankel category, revised Tokuhashi score, spinal instability neoplastic score (SINS), number of fusion segments, operation time, intraoperative blood loss, drainage blood loss, red blood cell transfusion, hemoglobin level, total protein (TP), albumin values, total blood loss (TBL), hidden blood loss, postoperative bed rest and postoperative survival time. Perioperative complications were assessed. ResultsAge, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, CCI score, main level of tumors, SINS score, preoperative Tokuhashi score and number of fusion segments did not differ significantly between the two groups. Operation time, intraoperative blood loss, postoperative drainage blood loss, and TBL were significantly decreased in the group with GMHT than in the group without GMHT. The total number of perioperative complications was significantly lesser in the group with GMHT than in the group without GMHT. The median postoperative survival time was significantly longer in the GMHT group than in the group without GMHT. ConclusionGMHT should be considered a valid option for the treatment of patients with metastatic spinal tumors with a short life expectancy.

In-hospital malnutrition among adult patients in a national referral hospital in Indonesia.

Malnutrition during hospitalization is linked to increased morbidity and mortality, but there are insufficient studies observing clinical factors contributing to weight loss during hospitalization in Indonesia. This study was therefore undertaken to determine the rate of weight loss during hospitalization and the contributing factors. This was a prospective study involving hospitalized adult patients aged 18-59 yrs, conducted between July and September 2019. Body weight measurement was taken at the time of admission and on the last day of hospitalization. The factors studied were malnutrition at admission (body mass index < 18.5 kg/m2), immobilization, depression (Beck Depression Inventory-II Indonesia), polypharmacy, inflammatory status (neutrophil-lymphocytes ratio; NLR), comorbidity status (Charlson Comorbidity Index; CCI), and length of stay. Totally, 55 patients were included in the final analysis, with a median age of 39 (18-59 yrs) yrs. Of these, 27% had malnutrition at admission, 31% had a CCI score > 2, and 26% had an NLR value of ≥ 9. In all, 62% presented with gastrointestinal symptoms, and depression was documented in one-third of the subjects at admission. Overall, we recorded a mean weight loss of 0.41 kg (P = 0.038) during hospitalization, with significant weight loss observed among patients hospitalized for 7 days or more (P = 0.009). The bivariate analysis revealed that inflammatory status (P = 0.016) was associated with in-hospital weight loss, while the multivariate analysis determined that the contributing factors were length of stay (P < 0.001) and depression (P = 0.019). We found that inflammatory status of the patient might influence the incidence of weight loss during hospitalization, while depression and length of stay were independent predictors of weight loss during hospitalization.

Determine the Frequency of Factors Leading to Hepatic Encephalopathy in Patients with Liver Cirrhosis

Aim: To determine the frequency of factors leading to hepatic encephalopathy in patients with liver cirrhosis. Study design: Retrospective study Place and duration of study: Department of Internal Medicine, Rawalpindi Medical Universityfrom 01-07-2021 to 30-06-2022 Methodology: One hundred patients were included and divided into two groups. One group was those which developed hepatic encephalopathy while the other group was of those which did not develop any hepatic encephalopathy. Various risk factors and their frequencies were measured through a modelled hepatic encephalopathy pharmacological, clinical as well as demographic data. Comparison on the frequency of the variable seen in hepatic encephalopathy patients with non-hepatic encephalopathy was conducted for better assessment of the frequency of risk factors. Results: Seventy patients did not develop hepatic encephalopathy while 30 patients did develop hepatic encephalopathy. Fifteen patients had developed alcoholic liver cirrhosis followed by hepatitis C and non-alcoholic cirrhosis. Age greater than 60 years had a percentage of 60% within cases of hepatic encephalopathy only. Prevalence of hepatitis C cirrhosis in 36.6%, diabetes in 49%, cardiovascular disease in 51%, hepatocellular carcinoma in 6.6%, use of proton pump inhibitor in 63.3% were presented and were higher than who did not develop hepatic encephalopathy. Benzodiazepines, gamma aminobutyric acid [GABA]ergics, opioids and proton pump inhibitors each of them was associated with increased chances of hepatic encephalopathy. Conclusion: Hepatic encephalopathy was more commonly observed in older patients (60%) and more specifically in male population. Higher frequency of comorbidities (hypertension, diabetes, cardiovascular disease, ascites, alcoholic cirrhosis), CCI score and pharmacological drugs were identifiable risk factors for hepatic encephalopathy. Key words: Neurotoxicity; Cirrhosis, Complications, Hepatitis C, Deteriorate

The oral cavity as a site for developing a heterogeneous bacterial population in patients with cystic fibrosis

Cystic fibrosis is an important medical and social problem. Despite significant advances in modern science and practice, bacterial complications are still among the main causes of patient mortality. One of the crucial bacterial pathogens in cystic fibrosis is Pseudomonas aeruginosa, which can lead to rapidly decreased pulmonary function. At the same time, the lungs are not the only site for microbial colonization. The oral cavity can also serve as a reservoir for initial entry and adaptation of microbial strains, which, however, were only sparsely investigated. A clinical case of isolated heterogeneous microbial population of P. aeruginosa from various loci of the oral cavity and sputum of a patient with cystic fibrosis is described. A proteomic mass-spectrum analysis obtained from eleven isolates as well as their mutual comparison with the control strain of P. aeruginosa ATCC 27853 visualized with CCI matrix was performed. As a result, a high level of heterogeneity of the studied population was revealed, while high CCI Score values were obtained only for individual pairs of isolates. It was shown that the bacterial strains isolated from the patient sputum turned out to be more homogeneous in protein profiles than cultures detected from various oral sites. At the same time, in case of isolated several morphotypes of P. aeruginosa from single oral site, no closely related strains were found. Thus, it is shown that the oral cavity is more important viewed from microbial dissociation in cystic fibrosis, which may be due to more diverse microecological conditions. Representatives of the microbiological community can recolonize the tracheobronchial tree through microaspiration, thereby contributing to the maintenance of infectious inflammation in the lower respiratory tract and partially accounting for ineffectiveness of nebulized antibacterial therapy. At the same time, clones adapted to the lung tissue upon coughing up sputum are able to colonize oral sites. The data obtained actualize the question of the need for a comprehensive microbiological approach while examining patients to increase effectiveness of eradication measures in cystic fibrosis.

1818. Characteristics Associated with Mortality in Patients with Gram-negative Bacteremia in Intensive Care Units

Abstract Background Gram negative rod (GNR) bloodstream infections in patients requiring ICU level of care are associated with high risk of mortality. Very limited data is available on specific risk factors that are associated with this high mortality. The purpose of this study was to identify characteristics associated with mortality in ICU patients who were diagnosed with GNR bacteremia. Methods This was an IRB approved retrospective chart review that was conducted during November 2019 to November 2021 at a three hospital health system in NJ. Patients were included if they required ICU level of care, age ≥ 18 years old and had documented gram negative bacteremia. Patients were excluded if they had metastatic cancer, left against medical advice, or the blood culture was determined to be a contaminant. The primary endpoint of the study was to evaluate the association of characteristics and risk factors with all-cause inpatient mortality (ACIM) in patients with GNR bacteremia requiring ICU level of care. Secondary endpoints included impact of time to appropriate therapy and time to microbiologic cure on ACIM. Results There was a total of 79 patients who met inclusion criteria. The median age of patients was 69 years, 44% of the patients were female, and 81% of patients were in septic shock upon presentation to the ICU. The most common source of GNR bacteremia was urinary tract, followed by lower respiratory tract. The most common causative organism of bacteremia was E.coli, causing 25% of the cases. When evaluating primary endpoint, higher CCI (OR = 1.79, 95% CI [1.09-2.94]), and Pitt Bacteremia (OR = 2.1, 95% CI [1.32-3.35]) scores were independently associated with an increased risk of mortality in patients with gram-negative bacteremia in the ICU setting. Microbiologic cure was associated with a lower risk of mortality (OR=0.02, 95% CI [0.002-0.2]). Longer time to appropriate therapy and microbiologic cure were not associated with increased ACIM. Results Enterobacterales Breakdown Conclusion Patients admitted with GNR bacteremia requiring ICU level of care with higher CCI and Pitt Bacteremia scores have higher likelihood of suffering from ACIM. Microbiologic cure was independently associated with lower risk of ACIM. In a subset of patients, longer time to appropriate therapy and microbiologic cure was not associated with increased ACIM. Disclosures All Authors: No reported disclosures.

The Role of Intraoperative Indocyanine Green (ICG) and Preoperative 3-Dimensional (3D) Reconstruction in Laparoscopic Adrenalectomy: A Propensity Score-matched Analysis.

Laparoscopic adrenalectomy (LA) is considered the "gold standard" treatment of adrenal lesions that are often coincidentally diagnosed during the radiologic workup of other diseases. This study aims to evaluate the intraoperative role of indocyanine green (ICG) fluorescence associated with preoperative 3-dimensional reconstruction (3DR) in laparoscopic adrenalectomy in terms of perioperative outcomes. To our knowledge, this is the first prospective case-controlled report comparing these techniques. All consecutive patients aged≥18 and undergoing laparoscopic transperitoneal adrenalectomy for all adrenal masses from January 1, 2019 to January 31, 2022 were prospectively enrolled. Patients undertaking standard LA and those undergoing preoperative 3D reconstruction and intraoperative ICG fluorescence were matched through a one-on-one propensity score matching analysis (PSM) for age, gender, BMI, CCI score, ASA score, lesion histology, tumor side, and lesion diameter. Differences in operative time, blood loss, intraoperative and postoperative complications, conversion rate, and length of stay were analyzed. After propensity score matching analysis, we obtained a cohort of 36 patients divided into 2 groups of 18 patients each. The operative time and intraoperative blood loss were shorter in patients of the 3DR group ( P =0,004 and P =0,004, respectively). There was no difference in terms of length of stay, conversion rate, and intraoperative and postoperative complications between the 2 groups. The use of intraoperative ICG in LA and preoperative planning with 3DR images is a safe and useful addition to surgery. Furthermore, we observed a reduction in terms of operating time and intraoperative blood loss.

Neutrophil-to-Lymphocyte Ratio As a Predictor of All-Cause Mortality in the General Population and Patients with Myeloproliferative Neoplasms

Background: Across the human lifespan, an age-related decline in immunocompetence and a concurrent increase in chronic inflammation are evident. The Philadelphia-negative myeloproliferative neoplasms (MPNs) represent a heterogeneous group of acquired hematopoietic stem cell diseases where chronic inflammation is essential for both the clonal evolution and development of comorbidities prior to and after diagnosis. Neutrophilic heterogeneity is well described where neutrophils have the capability to inhibit T-lymphocytes and natural killer cells, potentially implying reduced immune competence, which may enhance the clonal progression and evolution of the malignant clone. Thus, the neutrophil-to-lymphocyte ratio (NLR) is a simple biomarker index that both encapsulates chronic inflammation and reduced immune competence. Increased NLR is associated with several inflammatory-mediated diseases, including MPNs. Aims: We investigated if increased NLR is associated with higher all-cause mortality in both the general population and in patients with myeloproliferative neoplasms in a Danish Cohort with 18 years of follow-up. Methods: Blood cell count measurements were used from The Copenhagen Primary Care Laboratory Database (CopLab), and three hospital-derived Laboratory Information Management Systems from Roskilde, Copenhagen, and the Northern part of Jutland. First, occurring neutrophil and lymphocyte counts were used. Inclusion criteria were an age ≥20 years, hsCRP or CRP <10mg/L. Individuals with inpatient stay or emergency room admissions ±15 days from the sample date were excluded using the Danish National Patient Registry (DNPR), thus allowing only outpatient hospital and general practitioner visits. On included individuals (N=272,933), comorbidities were retrospectively assessed across 19 major disease categories to calculate the Charlson Comorbidity Index score (CCI) using ICD8 and ICD10 codes from DNPR. The sample date for blood count measurements was used as the index date for CCI calculation. MPNs were defined by ICD8 (ET: 28729, PV: 20899, MF: 20900) and ICD10 (ET: DD474 / DD752, PV: DD459, MF: DD474 ). MPN diagnosis after sample date and during follow-up was termed pre-MPN. The CCI score was defined as having 0, 1-2, or >2 comorbidities. NLR was calculated and categorized as NLR <1.5, NLR ≥1.5 - 2, NLR ≥2 - 3, NLR ≥3 - 4, and NLR ≥4. All-cause mortality was ascertained from the National Danish Causes of Death Registry. We used proportional hazard Cox-regression analysis to estimate the hazard ratio (HR) with a 95% confidence interval (95%CI) to investigate all-cause mortality in the general population, MPN patients, and the impact of CCI-score. The analyses were adjusted for age, gender, population, CCI, or NLR. Results: Among 272,933 individuals, 85 had MPN prior to the sample date, whereas 469 developed MPNs during the observation time. Compared to non-MPNs, preMPNs and MPNs had more accumulated comorbidities in both the 1-2 CCI score (17.4% vs. 26.4% vs. 37.7%) and >2 CCI score (4.1% vs. 8.5% vs. 23.5%),P < 2.2x10-16, see figure 1A. For the NLR strata, a stepwise increase in CCI scores was also evident in the 1-2 and >2 CCI scores, P < 2.2x10-16, see figure 1A. During follow-up with 42,831 events, a stepwise increase in all-cause mortality was observed across the population (see figure 1B). Compared to NLR <1.5 (reference group), NLR 1.5-2 had a HR(95%CI) of 1.05 (1.02 - 1.09), P=0.003, NLR 2-3 had a HR(95%CI) of 1.23 (1.20 - 1.27), P <2x10-16, NLR 3-4 had a HR(95%CI) of 1.48 (1.43- 1.53), P<2x10-16 whereas the highest HR(95%CI) was observed among individuals with NLR ≥4 of 1.83 (1.77-1.89),P <2x10-16. We also investigated the impact of CCI and MPNs on all-cause mortality. Compared to No MPNs & No CCI (reference group), No MPN with 1-2 or >2 CCI had an HR(95%CI) of 1.90 (1.85 - 1.93), P <2x10-16 and 3.25 (3.16 - 3.35), P<2x10-16, respectively. In contrast, individuals with MPNs & 0 CCI, 1-2 CCI or >2 CCI had a HR(95%CI) of 2.20 (1.39 - 3.50), P=0.0008, 3.62 (2.25 - 2.58), P=1.17x10-7, and 8.15 (4.90 - 13.52), P=4.78x10-16, respectively. We observed similar results of NLR and MPNs on all-cause mortality. Conclusion: In a general population study, we observed a stepwise increase in mortality among individuals with higher NLR compared to NLR<1.5. Individuals with higher NLR, preMPN, and MPNs had more comorbidities than those with lower NLR and No MPNs measured by the CCI score. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Zanubrutinib Plus Rituximab for the Treatment of Elderly Unfit Patients with Previously Untreated Diffuse Large-B Cell Lymphoma

Background: Diffuse Large B-cell lymphoma (DLBCL) is common in the elderly patients, Some elderly patients can not tolerate the standard dose of R-CHOP due to age, poor physical condition, and severe complications. The overall response rate of elderly unfit DLBCL patients who received a reduced dose R-CHOP regimen was only 60%. It is extremely important to explore new therapeutic options. Zanubrutinib is a Bruton tyrosine kinase (BTK) inhibitor which was still in an exploratory phase in patients with DLBCL. The efficacy of Zanubrutinib plus Rituximab in elderly unfit Patients with DLBCL is still unknown. Methods: In the present study, a prospective, single-arm, single-center study was conducted (CHiCTR-2000039342).patients who fulfil the inclusion and exclusion criteria were enrolled. Inclusion criteria: patients aged ≥65 years, and treatment-naive pathologically confirmed with DLBCL, and assessed unfit by Comprehensive Geriatric Assessment(IACA). Unfit patients were defined as follows: i.e. IADL score ≤7, or age >75 years, or CCI score ≥3, or serum albumin <3.4 g/ml. Exclusion criteria: history of malignancy with chemotherapy or radiotherapy before, or serious infectious disease, or bleeding tendency, or hemophilia. Patients enrolled were planned to treat with Zanubrutinib combined with rituximab (Zanubrutinib 160 mg orally twice daily and rituximab 375 mg/m2 day1 iv, every 28 days, ZR regimen), for a total of eight courses. After induction therapy, maintenance treatment with Zanubrutinib 160mg orally twice daily was given until disease progression or unacceptable toxicity. Efficacy was evaluated by PET/CT or enhanced Computed Tomography scan every two to four months, treatment-related adverse effects were evaluated every month. This study was approved by the Ethics Committee of Beijing Hospital, National Center of Gerontology, Beijing, China. Results: From July 2020 to June 2022, A total of ten elderly unfit DLBCL patients who fulfil the inclusion and exclusion criteria were enrolled(CHiCTR-2000039342).The median age was 86.5 years (80-93 years). The most common comorbidities were cardiovascular disease, hypertension, diabetes mellitus. The female to male ratio was 6:4. Two patients were classified as GCB pathological subtype, Seven patients were diagnosed with stage III-IV. At a median follow up of 9.5 months(2-24months). Eight patients could be evaluated for efficacy. Overall response rate(ORR) was 87.5% (7/8) , five patients (62.5%) achieved complete response(CR). In two patients with GCB pathological subtype, one patient achieved CR, the other one had partial response (PR). In six patients with non-GCB pathological subtype, four patients achieved CR, one had PR, one achieved progression disease(PD) . Median progression-free survival (PFS) was not achieved, one patient had progressing at 8 months, and died due to disease progression, with overall survival (OS) of 11 months. ZR regimen was well-tolerated, three patients had grade 2 urinary tract infections, one had grade 2 respiratory infections, one had grade 1 Petechial hemorrhages, two had grade 2 skin rash, two had acute kidney injury. No grade 3 or higher adverse events were observed. Ten patients had a dose reduction due to toxicity. Two patients had discontinued Zanubrutinib due to adverse events for one to three weeks. In addition, two patients who met exclusion criteria were also off-label use of ZR regimen therapy. They were classified as GCB pathological subtype, and diagnosed with stage III or IV. One patient was 72 years old with IADL score of 6, CCI score of 4, previously diagnosis of lung cancer and renal cancer, treated with radiotherapy and surgery. This patient achieved PR after 2 cycles and had disease progression after 4cycles, with PFS of 4 months. He had grade 2 Petechial hemorrhages or skin rash. The other patient was 81 years old, previously diagnosis of decompensated liver cirrhosis ，with bleeding tendency, IADL score of 2, CCI score of 4.She achieved SD after 2 cycles and had disease progression after 4 cycles, with a PFS of 4 months, and died due to disease progression, with OS of 5 months. Conclusion: Zanubrutinib in combination with Rituximab may be a well-tolerated and effective regimen in elderly unfit DLBCL patients. Dose reduction may be required for some patients to improve tolerability. A large sample size clinical trial is needed to further validate this conclusion in the future. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Patients with Essential Thrombocythemia Have a Gut Microbiota That Differs from Healthy Controls

Background:Essential thrombocythemia (ET), along with polycythemia vera (PV) and primary myelofibrosis (PMF), belongs to the Philadelphia chromosome negative myeloproliferative neoplasms (MPNs). Chronic inflammation is considered a hallmark in the pathogenesis and progression of the MPNs. The human gut microbiota helps regulate and mature the immune system, digest food, protect against pathogens and induce hematopoiesis. As our immune system constantly interacts with our gut microbiota any change to the microbiota could have significant impact on the overall health of the patient. This influence of the gut microbiota on the patient has been described as being involved in the pathogenesis of several diseases, such as obesity and diabetes mellitus. We recently added to this list by showing that the gut microbiota in patients with PV differs significantly from that of healthy controls (HCs), however the composition of the gut microbiota in patients with ET remains unknown. Thus, we hypothesized that patients with ET have a distinct gut microbiota signature compared with that of HCs. This study is the first to explore the gut microbiota in patients with ET specifically and compared with that of HCs. Methods: We included patients with ET, diagnosed according to the 2016 WHO classification. Included patients had not received antibiotics within the last 2 months and no change in cytoreductive treatment had occurred within the last 3 months. Comorbidities were assessed using the Charlson Comorbidity Index score (CCI). The gut microbiota was characterized using amplicon-based next generation sequencing of the V3-V4 region of the 16S ribosomal unit while dada2 was used for taxonomic classification. Alpha diversity, beta diversity and linear discriminant analysis effect size (LEfSe), were used to assess the microbiota between and within the patient groups. Alpha diversity describes the richness and evenness within a sample and beta diversity the difference in composition between the samples, while LEfSe is used for differential abundance analysis. Results: In total, 54 patients with ET (median age 68, range 38-83) and 42 HCs (median age 71, range 66-74), fulfilled the inclusion criteria. Patients with ET had a higher CCI score (p=0.038) compared with the HCs. Thirty-six patients had the JAK2V617F mutation. Seven were positive for calreticulin (CALR), three for myeloproliferative leukemia virus gene (MPL), two for CALR+JAK2V617F mutations, and 6 were triple negative. The treatments were: no cytoreductive treatment (n=15), PEG-interferon-α2 (n=11), anagrelide (ANG)(n=3), hydroxyurea (HU)(n=23) and HU+ANG(n=2). Patients with ET had a significantly higher observed richness (number of different bacteria present) compared with HCs (median, 283.5 vs 191.5; p<0.001), however, no significant difference was found in alpha diversity. The bacterial composition differed significantly between ET and HCs (p=0.004 and R=0.063). Eight taxa, with a relative abundance >1%, differed between ET and HCs. Patients with ET had a lower relative abundance of the phylum Firmicutes (p=0.03), class Clostridia (p=0.001), order Oscillospirales (p<0.01), and family Ruminococcaceae (p<0.001) compared with HCs. On genus level, patients with ET had a lower relative abundance of Faecalibacterium (p <0.001). While all mutations were associated with a significantly different microbiota in ET compared with HCs, ET patients who only had the JAK2V617F differed to a larger degree. Conclusion: The gut microbiota in patients with ET differed significantly from that of HCs, both in regard to richness and bacterial composition. The relative abundance of several taxa within the phylum Firmicutes differed significantly, with ET patients having a lower relative abundance in general. These differences appear to be more pronounced in patients who have the JAK2V617F mutation. Thus, it needs to be elucidated if the change of the microbiota is the cause or the consequence of the disease. Is it the increased inflammatory response which changes the microbiota or is it the change in microbiota which aggravates the inflammatory effects of the JAK2V617F mutation?

Abstract 12823: Racial Disparities and Geographic Variation in Anticoagulant Treatment Among Medicare Beneficiaries With Non-Valvular Atrial Fibrillation in the United States

Introduction: Little is known about racial disparities and the geographic variation in oral anticoagulant (OAC) use throughout the United States (US) since the approval of direct oral anticoagulants (DOACs) as a safe alternative treatment compared to warfarin for non-valvular atrial fibrillation (NVAF). Methods: Patients with NVAF were selected from the US Centers for Medicare &amp; Medicaid Services claims database (01JAN2013 to 31DEC2016). The final population consisted of patients with 12 months of health plan enrollment before and after the NVAF diagnosis and with a baseline CHAD 2 S 2 -VASc ≥ 2. Each patient was assigned a 3-digit zip code based on their primary residence. Results were stratified by race. Geographic variations within each race and differences between races were visualized using ArcGIS Pro software. Results: Of the 2,756,097 patients with NVAF and CHAD 2 S 2 -VASc ≥ 2, majority (88.9%) were White, and 6.3% were Black. Age and HASBLED scores ranged from 79 (Black) to 81 (White) and 3.4 (White) to 3.9 (Black), respectively. The CHAD 2 S 2 -VASc and CCI scores ranged from 5.1 (White) to 5.5 (Black) and 3.0 (White) to 4.3 (Black), respectively. In general, Black patients had a higher untreated rate with an OAC than Whites (Figures 1 and 2). There were also geographic variations in treatment rates mostly noted among Whites with lower rates in the mid-west compared to the south and west (Figure 2). Conclusion: OAC use by race varies considerably by 3-digit zip code in the US. Higher untreated rates and use of warfarin over DOACs in the Black population indicate a potential target for further research into disparities between races in availability of anticoagulant treatment.

309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Abstract Background Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty. Methods All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons. Results Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age &amp;gt;75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465). Conclusion There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

Haemospermia in the Real- Life Setting: A New High-Risk Stratification

To (i) identify a novel risk stratification for patients complaining of haemospermia; and, (ii) compare its predictive ability to select high-risk patients by retrospectively validating the EAU guidelines classification. Data from 283 consecutive patients complaining of a single episode/recurrent haemospermia were retrospectively analyzed. Patients were stratified into low vs high-risk according to EAU guidelines, whose diagnostic performance was then validated. We identified a new risk stratification model based on clinical factors associated with (i) positive semen culture and (ii) prostate cancer (PCa) and bladder cancer (BC). Diagnostic accuracy of the two predictive models (EAU vs New) was assessed and decision curve analyses (DCA) tested their clinical benefit. Overall, 259 (91.5%) were high-risk and 24 (8.5%) low risk according to the EAU guidelines. Recurrent haemospermia was reported by 134 (47.4%) patients. 126 (44.5%) had baseline CCI score ≥ 1. At MVA logistic regression analysis, history of recurrent genito - urinary tract infections was identified as a predictor for positive semen culture (OR: 3.39, 95% CI: 1.77 - 6.57, P =.002). Likewise, baseline CCI ≥ 1 was identified as a predictor for PCa and BC (OR: 1.55, 95% CI: 1.17 - 2.04, P =.009). Sensitivity, specificity, and AUC of the EAU guidelines were 13.3%, 89.2% and 51% respectively, whereas the new model performed substantially better: 98.9%, 58% and 78% respectively. The application of the EAU guidelines risk stratification does not ensure proper identification of high-risk patients complaining of haemospermia. We propose a novel, better performing and easily implementable risk stratification tool.

Clinical Analysis of Elderly Patients with AML/High-Risk MDS

To analyze the clinical features of acute myeloid leukemia (AML)/high-risk myelodysplastic syndrome (MDS) patients aged over 60 years old. The clinical data of 61 elderly newly diagnosed patients with AML and high-risk MDS who submitted to the Department of Hematology/Oncology of the First Affiliated Hospital of Tsinghua University from January 2009 to April 16, 2021 were retrospectively analyzed. These patients were divided into chemotherapy group (45 cases) and supportive treatment group (16 cases). The overall survival (OS) was analyzed by Kaplan-Meier method, and the prognostic factors of survival were analyzed by multivariate Cox regression. After 2 cycles of induction chemotherapy, the complete remission (CR) rate was 37.8% (17/45), and overall response rate was 62.2% (28/45) in the chemotherapy group. The median OS in the chemotherapy group and supportive treatment group was 11.3 (0.07-43) and 1.6 (0.33-7.72) months, respectively (P<0.001). The median OS in patients who reached CR or did not reach after 1 cycle of induction chemotherapy was 19.8 (10-30.63) and 8.17 (0.07-43) months, respectively (P<0.05), while after 2 cycles was 22.7 (4.2-43) and 7.26 (0.07-26) months, respectively (P<0.001). Univariate analysis showed that age > 80 years old, CCI score > 2, PS score > 2 and supportive treatment were the adverse prognostic factors for OS. Further multivariate analysis suggested that chemotherapy was the only independent prognostic factor for OS (HR=0.140, 95%CI: 0.048-0.409, P<0.001). In the chemotherapy group, univariate analysis showed that CCI score > 2 and failure to reach CR after induction chemotherapy were poor prognostic factors. Multivariate analysis showed that CCI score > 2 (HR=0.139, 95%CI: 0.050-0.384, P<0.001) and failure to achieve CR after induction chemotherapy (HR=0.103, 95%CI: 0.041-0.259, P<0.001) were the adverse prognostic factors for OS. The patients were tolerant to side-effect of chemotherapy. Appropriate chemotherapy can prolong the survival of elderly patients with AML and high-risk MDS.

Development and internal validation of predictive models to assess risk of post-acute care facility discharge in adults undergoing multi-level instrumented fusions for lumbar degenerative pathology and spinal deformity

PurposeTo develop a model for factors predictive of Post-Acute Care Facility (PACF) discharge in adult patients undergoing elective multi-level (≥ 3 segments) lumbar/thoracolumbar spinal instrumented fusions.MethodsThe State Inpatient Databases acquired from the Healthcare Cost and Utilization Project from 2005 to 2013 were queried for adult patients who underwent elective multi-level thoracolumbar fusions for spinal deformity. Outcome variables were classified as discharge to home or PACF. Predictive variables included demographic, pre-operative, and operative factors. Univariate and multivariate logistic regression analyses informed development of a logistic regression-based predictive model using seven selected variables. Performance metrics included area under the curve (AUC), sensitivity, and specificity.ResultsIncluded for analysis were 8866 patients. The logistic model including significant variables from multivariate analysis yielded an AUC of 0.75. Stepwise logistic regression was used to simplify the model and assess number of variables needed to reach peak AUC, which included seven selected predictors (insurance, interspaces fused, gender, age, surgical region, CCI, and revision surgery) and had an AUC of 0.74. Model cut-off for predictive PACF discharge was 0.41, yielding a sensitivity of 75% and specificity of 59%.ConclusionsThe seven variables associated significantly with PACF discharge (age > 60, female gender, non-private insurance, primary operations, instrumented fusion involving 8+ interspaces, thoracolumbar region, and higher CCI scores) may aid in identification of adults at risk for discharge to a PACF following elective multi-level lumbar/thoracolumbar spinal fusions for spinal deformity. This may in turn inform discharge planning and expectation management.