Charlson Age Comorbidity Index Research Articles

The survival in octogenarians undergoing surgery for pancreatic cancer and its association with the nutritional status.

This study explored the association between the nutritional status and survival outcomes after pancreatic cancer surgery and reconsidered surgical indications in octogenarians. Three hundred and ninety-three consecutive pancreatic cancer patients who underwent resection were analyzed and grouped according to age (< 70years old; septuagenarians [70-79years old], and octogenarians [80-89years old]). The Charlson age comorbidity index and nutritional parameters were recorded. Survival outcomes and their association with nutritional parameters and prognostic factors were examined. The overall survival was worse in the octogenarians than in other patients. The median overall survivals in the < 70years old group, septuagenarians, and octogenarians were 27.2, 26.4, and 15.3months, respectively (P = 0.0828). DUPAN-2 ≥ 150 U/mL, borderline resectable/unresectable tumors, blood loss volume ≥ 500mL, and blood transfusion were predictors of the overall survival among octogenarians. Nutritional parameter values were worse in the octogenarians than in other patients. The octogenarian age group was not an independent predictor of postoperative complications in a univariate analysis. Survival outcomes were poor in octogenarians. However, an age ≥ 80years old alone should not be considered a contraindication for pancreatic cancer surgery. The maintenance of perioperative nutritional status is an important factor associated with the survival.

Association of frailty with chemotherapy toxicity in chemotherapy-naive older patients with cancer.

The purpose of this study is to assess the relationship between chemotherapy toxicity and frailty as determined using the Edmonton Frail Scale (EFS). Older adults (≥ 65years old) newly diagnosed with cancer were evaluated for frailty with EFS prior to chemotherapy. Participants evaluated on 17 points were grouped as "No Frailty" (0-4), "Apparently Vulnerable" (5-6), "Mild Frailty" (7-8), "Moderate Frailty" (9-10), and "Severe Frailty" (11 or more). Before the second and third chemotherapy cycles, patients were reassessed for toxicity. Of the 44 participants, 12 (27.4%) were rated as "frail" (EFS score ≥ 7). The median Charlson Age-Comorbidity Index score was 3 (IQR: 1), and the median EFS score was 5 (IQR: 3). There was no significant difference between the "frail" and "robust" groups in terms of the toxicity. There was no correlation between age, gender, chemotherapy intent, chemotherapy dosing, ECOG performance score, or other parameters with grade 3 or higher toxicity development. The Edmonton Frail Scale is not successful in predicting the toxicity risk of chemotherapy. However, it may be used as a tool to determine the need for comprehensive geriatric assessment and it may lead to increased alertness to adverse events during treatment of frail patients.

Preoperative predictors for early and very early disease recurrence in patients undergoing resection of pancreatic ductal adenocarcinoma.

This study aimed to identify predictors for early and very early disease recurrence in patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) resection with and without neoadjuvant therapy. Included were patients who underwent PDAC resection (2014-2016). Multivariable multinomial regression was performed to identify preoperative predictors for manifestation of recurrence within 3, 6 and 12 months after PDAC resection. 836 patients with a median follow-up of 37 (interquartile range [IQR] 30-48) months and overall survival of 18 (IQR 10-32) months were analyzed. 670 patients (80%) developed recurrence: 82 patients (10%) <3 months, 96 patients (11%) within 3-6 months and 226 patients (27%) within 6-12 months. LogCA 19-9 (OR 1.25 [95% CI 1.10-1.41]; P<0.001) and neoadjuvant treatment (OR 0.09 [95% CI 0.01-0.68]; P=0.02) were associated with recurrence <3 months. LogCA 19-9 (OR 1.23 [95% CI 1.10-1.38]; P<0.001) and 0-90° venous involvement on CT imaging (OR 2.93 [95% CI 1.60-5.37]; P<0.001) were associated with recurrence within 3-6 months. A Charlson Age Comorbidity Index ≥4 (OR 1.53 [95% CI 1.09-2.16]; P=0.02) and logCA 19-9 (OR 1.24 [95% CI 1.14-1.35]; P<0.001) were related to recurrence within 6-12 months. This study demonstrates preoperative predictors that are associated with the manifestation of early and very early recurrence after PDAC resection. Knowledge of these predictors can be used to guide individualized surveillance and treatment strategies.

Nonalcoholic Fatty Liver Disease-A Novel Risk Factor for Recurrent Clostridioides difficile Infection.

Recurrent Clostridioides difficile infections (rCDI) have a substantial impact on healthcare systems, with limited and often expensive therapeutic options. Nonalcoholic fatty liver disease (NAFLD) affects about 25% of the adult population and is associated with metabolic syndrome, changes in gut microbiome and bile acids biosynthesis, all possibly related with rCDI. The aim of this study was to determine whether NAFLD is a risk factor associated with rCDI. A retrospective cohort study included patients ≥ 60 years hospitalized with CDI. The cohort was divided into two groups: those who were and were not readmitted with CDI within 3 months of discharge. Of the 329 patients included, 107 patients (32.5%) experienced rCDI. Patients with rCDI were older, had higher Charlson Age–Comorbidity Index (CACI) and were more frequently hospitalized within 3 months. Except for chronic kidney disease and NAFLD, which were more frequent in the rCDI group, there were no differences in other comorbidities, antibiotic classes used and duration of antimicrobial therapy. Multivariable Cox regression analysis showed that age >75 years, NAFLD, CACI >6, chronic kidney disease, statins and immobility were associated with rCDI. In conclusion, our study identified NAFLD as a possible new host-related risk factor associated with rCDI.

Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage

BackgroundIt is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC). MethodsThis single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019. ResultsOne hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R. ConclusionELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.

Hypoalbuminemia on admission in COVID-19 infection: An early predictor of mortality and adverse events. A retrospective observational study

ObjectivesHypoalbuminemia is a negative acute phase reactant which has been associated with inflammatory response and poor outcome in infectious diseases. The aim of this study was to analyze the value of hypoalbuminemia on admission as a predictor of mortality and adverse events in COVID-19 patients. MethodsWe analyzed retrospective data from a cohort of 609 consecutive patients, with confirmed diagnosis of COVID-19, discharged from hospital (deceased or alive). Demographic characteristics, previous comorbidities, symptoms and laboratory findings on admission were collected. Comorbidities were assessed by Charlson-Age Comorbidity Index. ResultsHypoalbuminemia on admission (<34g/L) was more frequent in nonsurvivors than survivors (65.6% vs. 38%, p<0.001) and was significantly associated with the development of sepsis, macrophage activation syndrome, acute heart failure, acute respiratory distress syndrome and acute kidney injury, regardless of Charlson-Age Comorbidity Index. Hypoalbuminemia was a predictor of mortality in multivariable Cox regression analysis (HR 1.537, 95% CI 1.050–2.250, p=0.027), independently of Charlson-Age Index, gender, lymphocyte count <800/μL, creatinine, high-sensitivity C- reactive protein >8mg/L, lactate dehydrogenase >250U/L, bilateral infiltration on chest X-ray and q-SOFA ≥2. ConclusionsHypoalbuminemia was an early predictor of in-hospital mortality in COVID-19, regardless of age, comorbidity and inflammatory markers. It also had significant association with severe adverse events, independently of Charlson-Age Comorbidity Index. Our results suggest that serum albumin determination on admission may help to identify patients with SARS-CoV-2 infection at high risk of developing potential life-threatening conditions and death.

Hypoalbuminemia on admission in COVID-19 infection: An early predictor of mortality and adverse events. A retrospective observational study

ObjectivesHypoalbuminemia is a negative acute phase reactant which has been associated with inflammatory response and poor outcome in infectious diseases. The aim of this study was to analyze the value of hypoalbuminemia on admission as a predictor of mortality and adverse events in COVID-19 patients. MethodsWe analyzed retrospective data from a cohort of 609 consecutive patients, with confirmed diagnosis of COVID-19, discharged from hospital (deceased or alive). Demographic characteristics, previous comorbidities, symptoms and laboratory findings on admission were collected. Comorbidities were assessed by Charlson-Age Comorbidity Index. ResultsHypoalbuminemia on admission (<34g/L) was more frequent in nonsurvivors than survivors (65.6% vs. 38%, p<0.001) and was significantly associated with the development of sepsis, macrophage activation syndrome, acute heart failure, acute respiratory distress syndrome and acute kidney injury, regardless of Charlson-Age Comorbidity Index. Hypoalbuminemia was a predictor of mortality in multivariable Cox regression analysis (HR 1.537, 95% CI 1.050–2.250, p=0.027), independently of Charlson-Age Index, gender, lymphocyte count <800/μL, creatinine, high-sensitivity C- reactive protein >8mg/L, lactate dehydrogenase >250U/L, bilateral infiltration on chest X-ray and q-SOFA ≥2. ConclusionsHypoalbuminemia was an early predictor of in-hospital mortality in COVID-19, regardless of age, comorbidity and inflammatory markers. It also had significant association with severe adverse events, independently of Charlson-Age Comorbidity Index. Our results suggest that serum albumin determination on admission may help to identify patients with SARS-CoV-2 infection at high risk of developing potential life-threatening conditions and death.

Tolerability and efficacy of vortioxetine versus SSRIs in elderly with major depression. Study protocol of the VESPA study: a pragmatic, multicentre, open-label, parallel-group, superiority, randomized trial

IntroductionDepression is a highly prevalent condition in the elderly, with a vast impact on quality of life, life expectancy, and medical outcomes. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed agents in this condition and, although generally safe, tolerability issues cannot be overlooked. Vortioxetine is an antidepressant with a novel mechanism of action. Based on studies to date, it may have a promising tolerability profile in the elderly, as it does not adversely affect psychomotor or cognitive performance and does not alter cardiovascular and endocrine parameters. The present study aims to assess the tolerability profile of vortioxetine in comparison with the SSRIs considered as a single group in elderly participants with depression. The rate of participants withdrawing from treatment due to adverse events after 6 months of follow up will be the primary outcome.Methods and analysisThis is a pragmatic, multicentre, open-label, parallel-group, superiority, randomized trial funded by the Italian Medicines Agency (AIFA - Agenzia Italiana del Farmaco). Thirteen Italian Community Psychiatric Services will consecutively enrol elderly participants suffering from an episode of major depression over a period of 12 months. Participants will be assessed at baseline and after 1, 3 and 6 months of follow up. At each time point, the following validated rating scales will be administered: Montgomery–Åsberg Depression Rating Scale (MADRS), Antidepressant Side-Effect Checklist (ASEC), EuroQual 5 Dimensions (EQ-5D), Short Blessed Test (SBT), and Charlson Age-Comorbidity Index (CACI). Outcome assessors and the statistician will be masked to treatment allocation. A total of 358 participants (179 in each group) will be enrolled.Ethics and disseminationThis study will fully adhere to the ICH E6 Guideline for Good Clinical Practice. Participants’ data will be managed and safeguarded according to the European Data Protection Regulation 2016/679. An external Ethical Advisory Board will help guarantee high ethical standards.Trial registrationClinicaltrials.gov: NCT03779789, Registered on 19 December 2018. Submitted on 19 December. EudraCT number: 2018–001444-66.Trial statusProtocol version 1.5; 09/06/2018. Recruitment started In February 2019 and it is ongoing. It is expected to end approximately on 30 September 2021.

Outcomes of patients with Severe Acute Respiratory Infections (SARI) admitted to the intensive care unit: results from the Egyptian Surveillance Study 2010-2014.

BackgroundFew data exist about respiratory viral infections in Egyptian patients. Hereby we describe the outcomes of hospitalized Egyptian patients with severe acute respiratory infections (SARI) admitted to the ICU.MethodsA prospective study in which all hospitalized patients meeting the WHO case definition for SARI and admitted to the ICU, during the period 2010–2014, were enrolled. Samples were tested using RT-PCR for influenza A, B, respiratory syncytial virus (RSV), human metapneumovirus (hMPV), parainfluenza virus, adenovirus, bocavirus, enterovirus, and rhinovirus. Data were analyzed to study the clinical features of SARI-ICU patients and which pathogens are related to severe outcomes. Associated comorbidities were evaluated using Charlson Age-Comorbidity Index (CACI).ResultsOut of 1,075 patients with SARI, 219 (20.3%) were admitted to the ICU. The highest rates were reported for RSV (37%). SARI-ICU patients had higher rates of hospital stay, pneumonia, respiratory failure, ARDS, and mortality. Multivariate logistic regression analysis identified associated respiratory disorders (p=0.001), radiological abnormalities (p=0.023), and longer hospital stay (p=0.005) as risk factors for severe outcomes.ConclusionsThis surveillance study showed that 20% of hospitalized Egyptian patients with viral SARI needed ICU admission. SARI-ICU patients had higher rates of hospital stay, pneumonia, respiratory failure, ARDS, and mortality. Higher comorbidity index scores, radiological abnormalities, and longer hospital stay are risk factors for severe outcomes in SARI-ICU patients in our locality.

SUN-283 MACROCYTOSIS: CAN IT PREDICT MORTALITY ON HEMODIALYSIS PATIENTS?

Anemia is a commun consequence of end stage renal disease. It’s typically normocytic and normochromic. But macrocytosis is not rare in hemodialysis patients. However, it’s significance and association to mortality is still unknown. We conducted a single –centre prospective cohort study of 70 stable chronic hemodialysis patients followed for 24 months. Macrocytosis was defined as a mean corposcular volume(MCV)>97 fl. Patients was divided into 2 groups:with macrocytosis(G1) and without macrocytosis(G2). Three measurements of MCV were repeated monthly for three months to avoid laboratory error associated with single measurements. Follow up began from the date of last blood work and patients were prospectively followed for 2 years. We collected 70 patients undergoing chronic hemodialysis since 3 months at least with anemia. Among them,29 (40%) have macrocytic anemia. We divided our population into 2 groups:group1 (G1 :29 patients) included patients with macrocytic anemia and group2 (G2 :41 patients ) without macrocytosis. It was noted that the G1 was older than the G2 with a mean age respectively of 54 and 48 years with a significant difference (p < 0.05). Similarly, the association with neoplasia was more frequent in G1 with a significant difference (p = 0.01). The mean Hb was 9.8 g / dl and 9.6 g/dl respectively in G1 and G2 with a significant difference. Hypoalbuminemia(<40g / l) was more common in G1 with a significant difference(p = 0.016). Moreover, no significant difference was found between the two groups concerning the dose of erythropoetin, the incidence of diabetes, hypertension and hypothyroidism. In terms of prognosis, the charlson comorbidity index was significantly higher in G1(p = 0.01) with higher mortality(28%). In G1, the average rate of the MCV was 100.9fl[97.66-107], that for the three measurements of the MCV was on average 101.38%, 100.64% and 100.73% respectively.25% [8] patients had a MCV greater than 102fl.MCV> 102 fl was associated with a higher Charlson-Age comorbidity index(CACI) (p = 0.01) and higher mortality(p = 0.025). Among G1 patients,9% (3) have B12 vitamin deficiency and 11% (4) have folate deficiency, both have a combined deficiency in B12 and B9 vitamin. However, the cause of macrocytosis remains unexplained in the others. Macrocytosis may be associated with mortality in stable chronic hemodialysis patients. Future studies will need to be conducted to confirm this findings.

Prognostic impact of Charlson's Age-Comorbidity Index and other risk factors in patients with pancreatic cancer.

Few studies have evaluated the impact of risk factors and comorbidity on overall survival (OS) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim was to investigate the prognostic importance of Charlson's age-comorbidity index (CACI) and other risk factors on prognosis in a clinical real-world cohort of PDAC patients. A total of 1,159 patients with PDAC who had received at least one cycle of adjuvant or palliative chemotherapy were included from the Danish BIOPAC study. We analysed OS according to CACI, tobacco smoking, alcohol intake, performance status (PS), BMI and diabetes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for OS using Cox proportional hazards regression. At the end of follow-up, 994 (86%) patients had died. The median OS was 298days for all patients (range 3-3010) and shortest in patients with stage IV. No association with short OS was seen for CACI>2, diabetes, alcohol abuse, tobacco smoking, hypertension, and high BMI. Multivariate analysis showed that stage (IV vs. I: HR=9.05, 95% CI 5.17-15.84), PS (2 vs. 0: HR=3.67, 2.92-4.61) and treatment with angiotensin-converting enzyme inhibitors (yes vs. no: HR=1.31, 1.06-1.61) were independent negative prognostic factors. We found that CACI, diabetes, tobacco smoking, alcohol abuse, hypertension, and high BMI were not associated with OS in a real-world cohort of patients with PDAC treated with chemotherapy. Only stage and PS were prognostic parameters.

Nonalcoholic fatty liver disease as a risk factor for Clostridioides difficile infection.

Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea while nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. The aim of this study was to determine whether NAFLD increases susceptibility to CDI. A retrospective cohort study included patients ≥ 65 years, treated with antimicrobial therapy ≥ 24 h, and hospitalized ≥ 72 h in a 36-month period. Three-hundred fourteen patients were included; 83 with NAFLD and 231 controls. Except for diabetes mellitus (37.35% vs. 25.11%, p = 0.0462) and obesity (18.07% vs. 8.23%, p = 0.0218) that were more frequent in NAFLD group, there were no differences in other comorbidities, hospital admissions, antibiotic therapy within 3 months, prescription, and duration of antibiotic therapy. Fourteen (16.9%) patients with NAFLD and 17 (7.4%) in control group developed in-hospital CDI (p = 0.0156). The Charlson Age-Comorbidity Index > 6 (OR 4.34, 95%CI 1.39-13.57), hospital admission within 3 months (OR 7.14, 95%CI 2.33-21.83), serum albumins < 28 g/L (OR 3.15, 95%CI 1.04-9.53), NAFLD (OR 3.27, 95%CI 1.04-10.35), eGFR < 40 (OR 4.89, 95%CI 1.61-14.88), treatment with piperacillin/tazobactam (OR 4.86, 95%CI 1.59-14.83), and carbapenems (OR 3.99, 95%CI 1.28-12.40) were independently associated with CDI. Our study identified NAFLD as an independent predictor of CDI.

Feasibility of a tailored ERAS programme in octogenarian patients undergoing minimally invasive surgery for colorectal cancer.

The enhanced recovery after surgery (ERAS) is nowadays a widely accepted multimodal programme of care in colorectal surgery, but still there is some reluctance in its application to very elderly patients. The aim of this study is to investigate short-term outcomes of laparoscopic resection for colorectal cancer in octogenarian patients within the ERAS programme. Data on 162 consecutive patients aged ≥ 80years receiving elective minimally invasive colorectal resections within ERAS programme were collected in a multicentre, retrospective database in the period 2008-2017 in Italy. Univariate and multivariate analyses were performed to assess possible risk factors for poor clinical outcomes. The postoperative minor morbidity rate (Clavien-Dindo 1 and 2) was 25.9%. The incidence of postoperative major morbidity rate (severe medical and surgical complications defined as Clavien-Dindo 3 and 4) accounted 6.1% and only 1.8% had an anastomotic leakage. Reoperation rate was 5.5%, perioperative 30-day mortality was 1.8%, and 30-day readmission rate was 6.8%. On average, patients were released after 6days. A univariate analysis showed that possible risk factors for severe medical complications were: low preoperative albumin level, high Charlson Age Comorbidity Index Score and number of days in the intensive care unit (ICU); risk factors for severe surgical complications were: low preoperative albumin level; risk factors for late hospital discharge were: multivisceral resections, number of days in ICU and body mass index (BMI) > 25kg/m2. The multivariate analysis confirmed a low level of preoperative albumin and a longer ICU stay as independent risk factors for both postoperative severe surgical complications and late hospital discharge. The minimal invasive nature of the laparoscopic approach together with a multimodal analgesia therapy, the early resumption to oral diet and mobilisation could minimize the surgical stress and play an essential role in order to reduce medical morbidity in high-risk patients. Colorectal surgery within ERAS programme in octogenarians is a safe and flexible treatment in high-volume centres.

Perioperative adverse events associated with pelvic organ prolapse repair by nerve-preserving sacropexy: an analysis of 768 cases over a 10-year period.

To report the perioperative adverse events associated with nerve-preserving sacropexy for pelvic organ prolapse (POP) repair and to identify risk factors that could predict possible adverse events. A total of 768 women who underwent sacropexy for POP repair performed by one surgeon using the same technique, beyond the learning curve, over a 10-year period, between January 1st 2007 and December 31st 2016. The medical records of 768 women were reviewed for age, body mass index (BMI), tobacco use, previous surgeries (for POP and incontinence, abdominal surgeries in general), operating time, duration of hospitalization and perioperative events at time of surgery and 6weeks postoperatively. Additionally, the complications were classified according to the Clavien-Dindo grading system and the Charlson Age Comorbidity Index (CACI) was evaluated for the patients. Between January 1st 2007 and December 31st 2016, 768 patients underwent sacropexy for POP. 27 (3.5%) adverse events occurred intra- and post-operative within 6weeks after surgery. In univariate and multivariate analyses, only comorbidity and concomitant posterior colporrhaphy are significantly associated with complications. Surgeon's experience and a standardized technique minimize the risk of perioperative adverse events. The data on complications we found can be used to guide effective consent.

Defining and Predicting Early Recurrence in 957 Patients With Resected Pancreatic Ductal Adenocarcinoma.

To establish an evidence-based cut-off to differentiate between early and late recurrence and to compare clinicopathologic risk factors between the two groups. A clear definition of "early recurrence" after pancreatic ductal adenocarcinoma resection is currently lacking. Patients undergoing pancreatectomy for pancreatic ductal adenocarcinoma between 2000 and 2013 were included. Exclusion criteria were neoadjuvant therapy and incomplete follow-up. A minimum P-value approach was used to evaluate the optimal cut-off value of recurrence-free survival to divide the patients into early and late recurrence cohorts based on subsequent prognosis. Potential risk factors for early recurrence were assessed with logistic regression models. Of 957 included patients, 204 (21.3%) were recurrence-free at last follow-up. The optimal length of recurrence-free survival to distinguish between early (n = 388, 51.5%) and late recurrence (n = 365, 48.5%) was 12 months (P < 0.001). Patients with early recurrence had 1-, and 2-year post-recurrence survival rates of 20 and 6% compared with 45 and 22% for the late recurrence group (both P < 0.001). Preoperative risk factors for early recurrence included a Charlson age-comorbidity index ≥4 (OR 1.65), tumor size > 3.0 cm on computed tomography (OR 1.53) and CA 19-9 > 210 U/mL (OR 2.30). Postoperative risk factors consisted of poor tumor differentiation grade (OR 1.66), microscopic lymphovascular invasion (OR 1.70), a lymph node ratio > 0.2 (OR 2.49), and CA 19-9 > 37 U/mL (OR 3.38). Adjuvant chemotherapy (OR 0.28) and chemoradiotherapy (OR 0.29) were associated with a reduced likelihood of early recurrence. A recurrence-free interval of 12 months is the optimal threshold for differentiating between early and late recurrence, based on subsequent prognosis.

293 Goals of Care Determination Prior to Transfer: A Missed Opportunity

To determine the prevalence of goals of care discussion documentation by sending institutions among adults transferred to our tertiary care medical center who died within the first 48 hours of their transfer. We performed a retrospective chart review of patients 18 years and older transferred from outlying hospital emergency departments and inpatient units to our rural tertiary medical center as either floor level or critical care level patients from October 2011 through April 2016 who died within 48 hours of arriving. Data was abstracted from both the referring hospital’s documentation provided upon transfer and our electronic medical record. Physiologic and laboratory data was abstracted from the referring facilities chart or our electronic medical record reflecting the patient’s condition at the time of transfer; this was used to calculate the Charlson Age-Comorbidity Index. The presence of documented goals of care was specifically determined through review transfer documentation accompanying the patient. Data was analyzed using STATA 10 statistical software. A total of 181 patients met the inclusion criteria. The average age was 69.3 years and 47.5% were female. 76% of the referring hospitals were critical access hospitals. 45 % came from emergency departments, 55% from inpatient units. The mean Charlson Age-Comorbidity Index score was 5.5±2.7. Mode of transfer to our facility was local EMS 52.5% of the time, critical care helicopter 32%, and critical care ground transport 15.5%. The cause of death was septic shock for 24.9%, cerebrovascular accident for 14.4%, and acute myocardial infarction or cardiogenic shock for 12.7%. Documented goals of care discussion was available in 18 of 181 (10%) of transfer records. Our chart review revealed 22 (12%) instances of initial goals of care discussion taking place on admission to the hospital which resulted in the decision to transition to a comfort-based end-of-life care upon arrival. Care was transitioned to a comfort-based care within the first 24 hours for 88 (49%) of the patients. While transfer to a higher level of care is often necessary, the sought after care should be in line with the patient’s goals. In this single center review of critically ill patients, it was striking that only 1 in 10 patients who were critically ill had a discussion about their goals of care addressed and documented prior to transfer. Although the decision to transfer a critically ill patient must often be made with in information, these results suggest an opportunity to improve on the current state. The 12% of patients transitioned to comfort-based care upon arrival to our hospital suggests an opportunity to improve patient care while also decreasing unnecessary transfer. Addressing goals of care along with aggressive medical interventions is important to providing a therapy consistent with our patients’ goals and avoiding costly and invasive treatments that do not align with their goals of care.

Impact of an Age-Adjusted Co-morbidity Index on Survival of Patients With Heart Failure Implanted With Cardiac Resynchronization Therapy Devices

Age is an adverse prognostic factor in patients with heart failure. We aimed to assess the impact of age and noncardiac co-morbidities in the outcome of patients undergoing cardiac resynchronization therapy (CRT), and determine which of these two factors is the most important predictor of survival. The study involved a single-center retrospective assessment of 697 consecutive CRT implants during a 12-year period. Patient co-morbidity profile was assessed using the Charlson Co-morbidity Index (CCI) and the Charlson Age-Co-morbidity Index (CACI). Predictors of survival free from heart transplantation were assessed. CRT-related complications and cause of death analysis were assessed within tertiles of the CACI. During a mean follow-up of 1,813 ± 1,177 days, 347 patients (49.9%) died and 37 (5.3%) underwent heart transplantation. On multivariate Cox regression, female gender (HR = 0.78, 95% confidence interval [CI] 0.62 to 0.99, p = 0.041), estimated glomerular filtration rate (HR per ml/min = 0.99, 95% CI 0.98 to 0.99, p < 0.001), left ventricular ejection fraction (HR per % = 0.99, 95% CI 0.98 to 1.00, p = 0.022), New York Heart Association class (HR = 1.83, 95% CI 1.53 to 2.20, p < 0.001), presence of left bundle branch block (HR = 0.70, 95% CI 0.56 to 0.87, p = 0.001), and CACI tertile (HR = 1.37, 95% CI 1.18 to 1.59, p < 0.001) were independent predictors of all-cause mortality or heart transplantation. Compared with age and the CCI, the CACI was the best discriminator of all-cause mortality. Inappropriate therapies occurred less frequently in higher co-morbidity tertiles. In conclusion, patient co-morbidity profile adjusted to age impacts on mortality after CRT implantation. Use of the CACI may help refine guideline criteria to identify patients more likely to benefit from CRT.

Verification of Survival Predictors in Elderly Patients with Myelodysplastic Syndrome from Outpatient Clinical Practice

Summary Background Myelodysplastic syndrome (MDS) is a clonal disorder affecting older persons. We aimed to analyze the effectiveness of the scoring systems and of the number of received red blood cell (RBC) units in predicting survival. Methods The study included an unselected group of 73 patients with MDS who were diagnosed and treated in a single hospital over a period of 12 years. International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), WHO-Prognostic Scoring System (WPSS), Charlson Age-Comorbidity Index (CACI), and impact of performance status (PS) on overall survival (OS) and event free survival (EFS) were tested. The follow-up of received RBC units was conducted. Results The median age at diagnosis was 69.5 years, the median CACI was 3.0. The median survival times of the group were 7.04 and 2.78 years for OS and EFS, respectively. The concordance values of the IPSS, IPSS-R and WPSS are 0.812, 0.892 and 0.889 for OS; 0.785, 0.847 and 0.827 for EFS. The comorbidity index and PS were the only auxiliary criteria when determining the risk and selecting the therapeutic approach in MDS patients. In transfusion-dependent unchelated patients, both OS and EFS were negatively influenced by both higher ferritin levels and the numbers of RBC units; however, the risk does not continue to increase after more than 20 RBC units are administered. Conclusions IPSS-R is best suited as a predictor of survival. CACI and PS present auxiliary criteria for determining the risk. Number of received RBC units was detected as a significant predictor of survival.

The Charlson age comorbidity index predicts prognosis in patients with resected pancreatic cancer

BackgroundThe Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers. MethodA total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI<4 was considered the low-CACI group, whereas CACI≥4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed. ResultsThe patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P < 0.0001). The overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group (P = 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival (P = 0.024). In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better relapse-free survival (RFS) and OS than those with low RDI (both P < 0.0001). ConclusionsThe CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy in the resected pancreatic cancer.

The Charlson age comorbidity index to predict prognosis in patients with resected pancreatic cancer.

495 Background: The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers. Methods: A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI &lt; 4 was considered the low-CACI group, whereas CACI ≥ 4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed. Results: The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P&lt; 0.0001). There was no difference in relapse-free survival (RFS) between the low- and high-CACI groups; however, the overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group ( P= 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival. In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better RFS and OS than those with low RDI (both P&lt; 0.0001). Conclusions: The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy and could be clinically useful for decision-making in the treatment strategy for pancreatic cancer.