Charlson Comorbidity Score Research Articles

EPID-23. HISTORY OF TYPE III IMMUNE HYPERSENSITIVITY IMPROVES SURVIVAL IN GLIOBLASTOMA

Abstract Preexisting atopy, particularly allergic rhinitis, is consistently associated with decreased risk of glioma, and there is evidence that preexisting autoimmune conditions may also decrease risk. Glioblastoma is both locally and systemically immunosuppressive and, unlike many other forms of cancer, its initiation is not strongly linked with chronic inflammation. Therefore, history of immune hypersensitivity could be associated with improved anti-glioma immunosurveillance. We leveraged Surveillance, Epidemiology and End Results (SEER) data combined with Medicare claims to investigate the effect of preexisting immune hypersensitivities on overall survival of glioblastoma patients receiving resection, radiation, and temozolomide (standard of care, or SOC) from 2008-2019. Patients <66 years of age, enrolled in Medicare Advantage, not continuously enrolled in Medicare Part A/B, missing follow-up, reported by autopsy/death certificate only, or who did not receive surgery were excluded. Prior history of immune hypersensitivity (≥6 months prior to primary cancer diagnosis) was identified by ICD-9/ICD-10 codes. Treatment pattern was determined using ICD-9/ICD-10 and HCPCS/CPT codes. Conditions were classified into broad immune hypersensitivity types: type I (IgE-mediated, including atopy), type II (IgG- or IgM-mediated), type III (immune complex-mediated, including lupus and rheumatoid arthritis), and type IV (cell-mediated). Survival comparisons were made using Cox proportional hazard models adjusted for demographics, extent of resection, and Charlson comorbidity score (excluding immune conditions) to estimate hazard ratios, 95% confidence intervals, and p-values. Overall, 44% of 3,426 glioblastoma patients who received SOC had an immune hypersensitivity (type I: 33%, type II: 4%, type III: 8%, and type IV: 15%). These conditions were significantly more common in females (47% vs 41%, p<0.001). After adjustment, only type III immune sensitivity was associated with improved OS (HR=0.81, 95% CI:0.71-0.92, p=0.002). These results suggest that underlying immune-complex mediated hypersensitivity may improve treatment response and prognosis in glioblastoma, and that these pathways could potentially be exploited for therapy.

Do I sound sick? Self-perceived and objectively measured voice impairment in acutely decompensated heart failure: fist insights from the AHF-Voice study

Abstract Introduction Acute heart failure (AHF) is a common reason for recurrent hospitalization. Daily smartphone-based recording of vocal biomarkers appears promising for the early detection of impeding AHF. However, the value of patient-reported outcome measures (PROMs), i.e. self-perceived voice alterations during decompensation, is unknown. Methods AHF-Voice is an ongoing monocentric prospective cohort study focusing on voice alterations in patients hospitalized for AHF. Exclusion criteria: listed for heart transplantation, high output HF, cardiogenic shock, history of vocal fold disease or surgery, or life-expectancy <6 months. During hospitalization, medical history & echocardiogram were taken and routine blood sampling was done. Daily voice recordings including sustained vowels and standardized reading were collected using a specially designed smartphone app under supervision. At admission and discharge, the self-perceived level of voice alteration was assessed by the Voice–Handicap Index-12 (VHI-12, 0-48 points) questionnaire and a global voice scale (Likert scale, 0-3 points). For both scales, higher values indicate a more severe voice impairment. Hypervolemia was quantified by body composition analysis. Preprocessing and feature extraction of voice recordings were performed using Praat software. The association of self-perceived voice impairment with surrogates of congestion and vocal biomarkers was assessed by bivariate correlation and linear regression. Results Between Apr 2023 and Feb 2024, 72 hospitalized patients with AHF were included. Four patients withdrew consent, 5 patients were excluded due to limited voice recording quality. Hence, 63 patients were considered for analysis: mean age 75±10 years, 67% men, 91% were in NYHA class III/IV, 49% de novo HF, mean LVEF was 45±16%, and median value of Charlson comorbidity score was 2 [1, 3]. Both measures of self-perceived voice impairment improved between admission and discharge (Table 1A and Figure). Concomitantly, body weight, hypervolemia, NT-proBNP, and vocal biomarkers (total reading time and shimmer) decreased. Bivariate correlation showed that both self-perceived scales of voice impairment were closely correlated, as expected (Spearman’s rho 0.36). Linear regression identified surrogates of congestion and objective voice impairments as predictors for change in both PROMs (Table 1B). However, the explained variance was low, e.g. for change in volume status and NT-proBNP 14% and 1% (VHI-12), and 4% and 7% (Global voice scale), respectively. Conclusion This preliminary analysis in patients with AHF showed that self-perceived voice impairment was sensitive to change during recompensation. Objectively generated voice measures and congestion only partially explained the observed improvement of these PROMs. This might indicate that the self-perceived voice impairment constitutes a complimentary domain of patient well-being and indicator for congestion that should be explored further.

Determinants of Outcomes for Acute Myeloid Leukemia Patients Treated in a Community-Based Specialized Versus Non-Specialized Hospital Setting.

The treatment setting influences acute myeloid leukemia (AML) outcomes. Most cancer patients receive care in the community, yet few studies have evaluated the effectiveness of clinical programs outside of academic or National Cancer Institute (NCI)-designated cancer centers. This was a multi-level, case-controlled study of real-world outcomes for initial AML treatment in a community-based network for 1,391 patients with AML between 2011 and 2018. We benchmarked survival within our network against the Surveillance, Epidemiology, and End Results (SEER) database. Coarsened exact matching was performed against 17,186 chemotherapy-treated patients in the SEER database. Cox proportional and accelerated failure time multivariable modeling were performed to identify patient, disease, therapy and center characteristics associated with the risk of AML mortality. Within the network, 799 patients were treated at six specialized blood cancer centers and 592 at 63 other hospitals. Patients receiving high-intensity induction at specialized centers had improved median survivals of 31 months versus 18 months [P<0.001] at non-specialized centers. Median survivals were 13 for non-specialized centers versus 10 months for SEER [P<0.001], and 18 for the entire network versus 10 months for SEER [P<0.001]. Multivariable modeling showed significant impacts from age (HR = 1.025), high-intensity induction therapy (HR= .695), diagnosis year (HR= .937), neighborhood income (HR = .997; P<0.01), higher acuity (HR = 1.002) and Charlson comorbidity score (HR = 1.117). AML treatment may be effectively delivered in the community hospital setting, with specialized centers producing better outcomes for higher intensity treatments.

Exploring the circulating metabolome of sepsis: metabolomic and lipidomic profiles sampled in the ambulance

BackgroundSepsis is defined as a dysfunctional host response to infection. The diverse clinical presentations of sepsis pose diagnostic challenges and there is a demand for enhanced diagnostic markers for sepsis as well as an understanding of the underlying pathological mechanisms involved in sepsis. From this perspective, metabolomics has emerged as a potentially valuable tool for aiding in the early identification of sepsis that could highlight key metabolic pathways and underlying pathological mechanisms.ObjectiveThe aim of this investigation is to explore the early metabolomic and lipidomic profiles in a prospective cohort where plasma samples (n = 138) were obtained during ambulance transport among patients with infection according to clinical judgement who subsequently developed sepsis, patients who developed non-septic infection, and symptomatic controls without an infection.MethodsMultiplatform metabolomics and lipidomics were performed using UHPLC–MS/MS and UHPLC–QTOFMS. Uni- and multivariable analysis were used to identify metabolite profiles in sepsis vs symptomatic control and sepsis vs non-septic infection.ResultsUnivariable analysis disclosed that out of the 457 annotated metabolites measured across three different platforms, 23 polar, 27 semipolar metabolites and 133 molecular lipids exhibited significant differences between patients who developed sepsis and symptomatic controls following correction for multiple testing. Furthermore, 84 metabolites remained significantly different between sepsis and symptomatic controls following adjustment for age, sex, and Charlson comorbidity score. Notably, no significant differences were identified in metabolites levels when comparing patients with sepsis and non-septic infection in univariable and multivariable analyses.ConclusionOverall, we found that the metabolome, including the lipidome, was decreased in patients experiencing infection and sepsis, with no significant differences between the two conditions. This finding indicates that the observed metabolic profiles are shared between both infection and sepsis, rather than being exclusive to sepsis alone.

Prevalence, Risk Factors, and Outcome of Carbapenem-resistant Acinetobacter Infections in a Community Hospital in Madinah, Saudi Arabia

Abstract Background: Acinetobacter is a Gram-negative bacterium that causes nosocomial infections, increasing healthcare costs, patient morbidity, and mortality. The rate of carbapenem resistance among Acinetobacter species is rising in several countries, including Saudi Arabia. Objective: To determine the risk factors and compare the predictors of mortality in patients infected with carbapenem-susceptible and carbapenem-resistant Acinetobacter strains. Materials and Methods: This retrospective study included patients with Acinetobacter infection who were admitted to a community hospital in Madinah, Saudi Arabia, between January 2017 and June 2021. A logistic regression analysis was conducted to assess the risks of acquiring carbapenem-resistant Acinetobacter infections and the mortality risk associated with these infections. Results: This study included 138 Acinetobacter-infected cases, of which 114 (82%) were carbapenem-resistant infections. Between 2017 and 2020, resistance rates increased from 75% to 87%. Patients with carbapenem-resistant Acinetobacter infections had higher 90-day mortality than those with carbapenem-susceptible infection (62% vs. 29%, P = 0.006). The risk factors for carbapenem-resistant Acinetobacter infections were prior antimicrobial therapy (aOR: 8.36 [1.69–41.29]; P = 0.009) and mechanical ventilation (aOR: 6.07 [1.82–20.20]; P = 0.003). Among all patients with Acinetobacter infections, significant predictors of 90-day mortality were carbapenem resistance (aOR: 3.26 [1.19–8.90]; P = 0.021) and Charlson comorbidity score (aOR: 1.19 [1.06–1.34]; P = 0.004). Conclusion: The increase in carbapenem-resistant Acinetobacter cases in this study was consistent with the findings of other studies from Saudi Arabia. This, together with the high associated mortality rates, indicates the urgent need for effective antimicrobials and infection prevention strategies to combat carbapenem-resistant Acinetobacter infections in hospitals.

Perioperative Antibiotic Choice and Postoperative Infectious Complications in Pelvic Organ Prolapse Surgery

ObjectiveThe objective of this study was to determine how rates of postoperative infectious complications after pelvic organ prolapse surgery differ based on perioperative antibiotic administered. In particular, we sought to determine whether anaerobic coverage is associated with reduced rates of infectious complications. DesignThis was a retrospective cohort study. SettingPremier Healthcare U.S. national database, a comprehensive all-payer dataset capturing patients from urban and rural nonprofit, community, and teaching hospitals. ParticipantsAdult patients who underwent vaginal, laparoscopic, and/or abdominal prolapse surgery with or without hysterectomy from January 2000 to March 2020. Procedures with and without mesh were included. InterventionsRates of infectious complications were compared among patients who received guideline-concordant antibiotic regimens, including those with anaerobic coverage. The primary outcome was any surgical site infection within 30 days of surgery without mesh or 90 days of surgery involving mesh. ResultsAmong 130,198 prolapse surgeries, the most common antibiotic regimens were cefazolin (n = 97,058, 74.5%), second-generation cephalosporin (n = 16,442, 12.6%), clindamycin + aminoglycoside (n = 8,397, 6.4%) and cefazolin + metronidazole (n = 4,328, 3.3%). On multivariable logistic regression, only clindamycin + aminoglycoside was associated with a higher rate of surgical site infections (OR = 1.37; 95% CI 1.09–1.72) and other infectious morbidity (OR = 1.26; 95% CI 1.12–1.42) when compared to cefazolin alone. The addition of metronidazole to cefazolin was not associated with reduced rates of surgical site infections (OR = 1.09; 95% CI 0.82–1.45). Obesity (OR = 1.22; 95% CI 1.03–1.43), diabetes without complication (OR = 1.30; 95% CI 1.08–1.57), Charlson comorbidity score >0 (OR = 1.24; 95% CI 1.06–1.45), and tobacco use (OR = 1.22, 95% CI 1.05–1.40) were also associated with increased composite surgical site infection. ConclusionCompared with cefazolin alone, the use of alternative perioperative antibiotics, including those with anaerobic coverage, was not associated with reduced infectious complications after pelvic organ prolapse surgery in this U.S. national sample.

Positive preoperative cultures but not bacterial species predict postoperative urine culture results after holmium laser enucleation of the prostate

Purpose: The purpose of this study was to evaluate risk factors associated with positive urine cultures following holmium laser enucleation of the prostate (HoLEP). Materials and Methods: The data from a prospectively maintained database were analyzed to evaluate urine culture results following HoLEP and determine the contribution of predefined variables (age, prostate size, Charlson comorbidity score, surgical time [surrogate for case difficulty], the presence of a catheter preoperatively, postoperative urinary retention, and preoperative positive culture) on urine culture positivity at 60 days postoperatively. Statistical analyses included logistic regression and ANOVA. Results: The data from 136 subjects were included in the database and were evaluated at a median of 13.37 ± 6.72 months after their HoLEP. Postoperative positive cultures were noted in 23 subjects (16.91%). Preoperative positive cultures were found to predict positive postoperative urine cultures (odds ratio: 3.78, confidence interval: 1.18–12.78, P = 0.03). However, the preoperative and postoperative results were discordant in 9 of 14 subjects with both positive preoperative and postoperative cultures. Conclusions: Positive preoperative cultures were predictive of positive postoperative cultures. However, the pre- and postoperative results were often discordant. Host factors increasing susceptibility to bacteriuria may explain these findings.

Incidence and outcomes for children with idiopathic inflammatory myopathy in Western Australia-a long-term population-based study.

To determine the incidence and health outcomes for juvenile idiopathic inflammatory myopathy (JIIM) in a long-term whole-population study. We included patients under 18 years hospitalized in Western Australia (WA) from 1985 and 2015 with incident JIIM as defined by pertinent diagnostic codes for dermatomyositis (JDM) polymyositis (JPM), other JIIM and overlap myositis (JOM). We compared clinical outcomes and modified Charlson comorbidity scores with age and gender matched (2:1 ratio) patients with new onset juvenile idiopathic arthritis (JIA). Trends over time for annual incidence rate per million child-population (AIR) were analyzed by least square regression and survival by Kaplan-Meier curves. We included 40 patients with JIIM (63% female, median age 8.5 years) for an average AIR of 2.52 per million (CI 1.09-5.57). AIR was stable over time leading to a point prevalence of 52.61 (CI 40.57-67.06) in 2015. Most patients (80%) were classified as JDM with an AIR for JDM of 2.02 (CI 1.09-5.58) and AIR for the combined other JIIM at 0.51 (CI 0.24-1.15). There was female preponderance (62.5%) in both JIIM groups, but no evidence of seasonality. Over a median follow-up of 13 years, one- and ten-year survival was 94.1%. Compared to JIA patients, readmission (80.4 vs. 63.7, p = .02) and infection rates (15.2 vs. 9.6, p < .01) per 100 person-years were higher for JIIM, with similar frequency of interstitial lung disease, fractures, and thrombotic events. At last observation, nearly all patients in both JIIM cohorts (97.5 vs. 92.5%) had accrued some form of comorbidity. The overall incidence of JIIM leading to hospitalization in WA was stable over 30 years. JIIM prognosis remains suboptimal due to early mortality and accrual of long-term comorbidity.

Abstract A114: Inequities in advanced stage at diagnosis of non-small cell lung cancer among people with and without HIV in the US

Abstract Background: Lung cancer is the leading cause of non-AIDS death among people with HIV (PWH). PWH are also more likely to die due to lung cancer compared to people with HIV. Late presentation at diagnosis due to barriers to lung cancer screening may contribute to disproportionate deaths among PWH. Our objective was to evaluate associations of HIV status with advanced stage at diagnosis and evaluate social determinants of health (SDoH) associated with advanced stage at diagnosis of lung cancer among PWH. Methods: We used data from the 2004-2020 National Cancer Database, including patients aged 18-89 years diagnosed with lung cancer (ICD-0-3 codes: C340-C349). PWH were identified using ICD9 (04200 to 04499, 07953, and V08) and ICD10 (B20 to B24, R75, Z21, B97.35).The primary outcome was advanced stage at diagnosis (stage 3/4). Our main SDoH exposures were quantified as quartiles (Q1-Q4) and included measures of area-level SDoH based on a patient’s zip code: (1) % of adults without a high school degree, or area-level education; (2) median household income of adults, or area-level income. We used hierarchical multivariable logistic regression models clustered by facility ID to estimate adjusted odds ratios(aOR) with 95% confidence intervals(95% CI), and evaluated each exposure separately adjusting for age, sex, year of diagnosis, and Charlson comorbidity score, and stratified by race/ethnicity and insurance status. Results: Overall, we identified 6,585 PWH and 1,665,030 without HIV. Seventy one percent of PWH were diagnosed with stage 3 or 4 lung cancer compared to 64.9% of people without HIV (p&amp;lt;0.001). PWH were more likely to be under the age of 60 (43.5% vs.15.1%, p&amp;lt;0.001), After adjustment for sex, age, and year of diagnosis, PWH had 15% higher odds of advanced stage at diagnosis compared to those without HIV (aOR: 1.15; 95% CI: 1.09-1.22). Residing in areas with larger proportions of the population without a HS diploma (Q4 vs. Q1: aOR:1.19; 95% CI: 1.01-1.41) and larger proportions with lower household income (Q1 vs. Q4: aOR: 1.15; 95% CI: 1.01-1.31) were positively associated with advanced stage-at-diagnosis of lung cancer. When we stratified by insurance status, only PWH who were Medicaid insured residing in the least educated areas (aOR: 1.84; 95% CI: 1.11-3.06) and in the lowest income areas (aOR: 1.86; 95% CI: 1.30-2.65) had higher odds of advanced stage at diagnosis with lung cancer. Conclusions: Living with HIV is independently associated with presenting at a later stage of lung cancer at diagnosis. Area-level measures of lower education and lower household income are significantly associated with advanced stage-at- diagnosis of lung cancer regardless, particularly among those who are Medicaid insured. Citation Format: Jessica Y Islam, Yi Guo, Kea Turner, Amir Alishahi Tabriz, Marlene Camacho-Rivera, Gita Suneja. Inequities in advanced stage at diagnosis of non-small cell lung cancer among people with and without HIV in the US [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A114.

Bacteremia and infective endocarditis following left-sided heart valve surgery.

In patients undergoing heart valve surgery, subsequent bacteremia and infective endocarditis are feared events. Data on the incidence and bacterial microbiological etiology following left-sided heart valve surgery are sparse. Between 2010-2021, all patients undergoing left-sided valve surgery were identified using Danish nationwide registries. Incidence and type bacteremia within one-year post-surgery was analyzed. Secondary outcome of interest was infective endocarditis. Cumulative incidence curves were stratified for bacterial species and for subgroups of interest: type of valve surgery, age, and sex. A total of 14 935 patients were included, of which 69% were male and the median age was 70.4 years (25th-75th percentile 62.4-76.2 years). The one-year cumulative incidence of bacteremia was 6.1% (95% CI 5.7-6.5%), and the most frequent bacteremia was coagulase-negative staphylococci (27%). More than half of the bacteremia with coagulase-negative staphylococci occurred within 30 days of follow-up. Patients developing bacteremia had a significantly higher Charlson comorbidity score at baseline, more often underwent CABG concomitant to valve surgery, and more often had surgery on both valves. The one-year cumulative incidence of infective endocarditis was 1.5% (95% CI 1.3-1.7), of which 23% were caused by Enterococci, and 22% were blood culture negative. The median time from surgery to infective endocarditis was 109 days. Bacteremia and infective endocarditis following left-sided heart valve surgery occurred in 6.1% and 1.5% of patients, respectively. The most frequent bacteremia was coagulase-negative staphylococci, and more than half of these occurred within 30 days of surgery. Optimization of prophylactic strategies are warranted.

Resistance Genes and Mortality in Carbapenem-resistant Klebsiella pneumoniae Bacteremias: Effects of the COVID-19 Pandemic

Emerging carbapenem-resistant Klebsiella pneumoniae (K. pneumoniae) (CRKP) bacteremias are presenting significant public health risks due to limited treatment options and increased mortality. K. pneumoniae isolates exhibit carbapenem resistance rates that vary from 25% to 50% throughout the European continent, including our country. To assess the characteristics of CRKP bacteremia, a condition that has recently demonstrated an increasing prevalence in our center. We sought to ascertain the resistance rates of isolated strains to antibiotics other than carbapenems, identify the responsible carbapenemase genes, evaluate the efficacy of antibiotics, determine mortality rates, explore clonality among strains, and investigate the influence of the COVID-19 pandemic on all these factors. Retrospective observational study. This study included patients aged 18 and older who had experienced meropenem-resistant K. pneumoniae bacteremia. Meropenem resistance was confirmed by employing the Kirby-Bauer disk diffusion method. Meropenem minimum inhibitory concentration (MIC) levels were determined using the gradient test, while colistin MIC levels were ascertained using the disk elution technique. Carbapenemase genes were evaluated via colony polymerase chain reaction (PCR), and clonality analysis was performed using the arbitrarily primed PCR technique. The study comprised 230 patients, with a mean age of 63.1 ± 15.9 years, of whom 58.7% were male. Oxacillinase-48 (OXA-48) was detected in 74.8% of the patients, New Delhi metallo-beta-lactamase (NDM) in 12.6%, OXA-48 + NDM in 7.8%, and KPC in 4.8%. The 14-day and 30-day mortality rates were 57% and 69.6%, respectively. Multivariate analysis of the 30-day mortality revealed several crucial factors, including bacteremia development in the intensive care unit, the occurrence of bacteremia during the COVID-19 pandemic, polymicrobial bacteremia, the use of indwelling intravenous catheters, a platelet count of ≤ 140,000/μl, procalcitonin levels of ≥ 6 μg/l, and a Charlson comorbidity score ≥ 3. Notably, the OXA-48 and KPC genes were upregulated significantly during the COVID-19 pandemic, while the NDM gene groups were downregulated. Additionally, both 14-day and 30-day mortality rates increased significantly. In this study, the most prevalent carbapenemase gene was OXA-48; however, there has been a recent increase in KPC genes. No dominant epidemic strain was identified through clonality analysis. The clustering rate was 68% before the pandemic, increasing to 85.7% during the pandemic. The significance of infection control measures is underscored by the rise in both clustering and mortality rates during the COVID-19 pandemic.

Survival among patients cured from gastric adenocarcinoma compared to the background population

BackgroundIt is unknown if gastric adenocarcinoma survivors have longer, shorter, or similar survival compared to the background population. This knowledge could contribute to evidence-based monitoring strategies, healthcare recommendations, and information for patients and families.MethodsThis population-based cohort study included all patients who underwent gastrectomy for gastric adenocarcinoma between 2006–2015 in Sweden and survived ≥ 5 years after surgery. They were followed up until death, postoperative year 10, or end of study period (31 December, 2020). Division of the observed by the expected survival yielded relative survival rates with 95% confidence intervals (CIs) using the life table method. The expected survival was derived from the entire Swedish population of the corresponding age, sex, and calendar year. Data came from medical records and nationwide registers.ResultsThe survival among all 767 gastric adenocarcinoma survivors was shorter than the expected. The reduction in relative survival increased for each follow-up year, from 97.3% (95% CI 95.4–99.1%) year 6 to 86.6% (95% CI 82.3–90.9%) year 10. The decline in relative survival was more pronounced among patients who had gastrectomy in earlier calendar years (82.9% [95% CI 77.4–88.4%] year 10 for years 2011–2015), shorter education (85.2% [95% CI 77.4–93.0%] year 10 for education ≤ 9 years), more comorbidities (78.0% [95% CI 63.9–92.0%] year 10 for Charlson comorbidity score ≥ 2), and no neoadjuvant therapy (83.2% [95% CI 77.4–89.0%] year 10).ConclusionGastric adenocarcinoma survivors seem to have poorer survival than the corresponding background population, particularly in certain subgroups.

Frequency of cefiderocol heteroresistance among patients treated with cefiderocol for carbapenem-resistant Acinetobacter baumannii infections.

Cefiderocol exhibits potent in vitro activity against carbapenem-resistant Acinetobacter baumannii (CRAb), but this activity has not consistently translated to improved outcomes among patients. Cefiderocol heteroresistance, or the presence of a resistant subpopulation, has been proposed as one possible explanation. The objective of this study was to explore associations between heteroresistance and outcomes of patients with CRAb infections. Baseline CRAb isolates were collected from 27 consecutive patients in the USA and Italy. Cefiderocol susceptibility was tested by broth microdilutions in triplicate. Heteroresistance was defined by population analysis profiling in duplicate. Resistance mechanisms and strain relatedness were evaluated through comparative genomic analysis. Overall, 59% of infecting CRAb isolates were identified as cefiderocol-heteroresistant; rates were higher among isolates from Italy (79%) than the USA (38%). The median Charlson Comorbidity and SOFA scores were 4 and 5, respectively; 44% of patients had pneumonia, which was the most common infection type. Rates of 28-day clinical success and survival were 30% and 73%, respectively. By broth microdilution, cefiderocol MICs ≥1 mg/L were associated with higher failure rates than MICs ≤0.5 mg/L (81% versus 55%). Rates of clinical failure were numerically higher among patients infected by cefiderocol-heteroresistant compared with susceptible CRAb (81% versus 55%). Whole-genome sequencing identified a premature stop codon in the TonB-dependent receptor gene piuA in six isolates, all of which were heteroresistant. This pilot study supports the hypothesis that cefiderocol treatment failure may be associated with higher MICs and/or the presence of heteroresistance. Further studies are needed to confirm these findings.

360. RECURRENCE PATTERNS AFTER PRIMARY SURGERY AND NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL ADENOCARCINOMA: ACROSS THE CROSS RECURRENCES

Abstract Background Our publication Across the CROSS in daily practice challenged the routine use of neoadjuvant chemoradiotherapy for locally advanced esophageal adenocarcinoma, showing a comparable 5-year overall and disease-free survival after primary surgery. This current study reevaluated overall and disease-free survival on long term and aimed to differentiate recurrence patterns and its final impact on overall survival. Methods This retrospective cohort study with propensity score-matched analysis included all surgically treated patients between 2000 and 2018 with locally advanced adenocarcinoma (cT1/2N+ or cT3/4N0/+). Exclusion criteria of the CROSS trial were applied. Patients were matched on age, Charlson comorbidity score, clinical tumor length, and lymph node status. The primary end point was time to recurrence. Results 149 propensity score-matched cases were defined in each group. There was still no significant difference after 10 years in median overall survival (33.6 vs 34.9 months, p=0.52) and median disease-free survival (14.1 vs 14.0 months, p=0.13) between both groups. Furthermore, nCRT resulted in a shorter time to overall recurrence (6.3 vs 11.5 months, p=0.004) and locoregional recurrence (6.3 vs 13.6 months, p=0.005). Additionally, overall survival after diagnosis of recurrence was also significantly shorter for nCRT patients than for primary surgery patients (6.9 vs 9.6 months, p=0.032). Conclusion Our propensity score-matched results indicate that primary surgery can offer a comparable long-term overall and disease-free survival as nCRT followed by surgery. Both overall and locoregional recurrences occur earlier in nCRT patients and overall survival after recurrence is significantly longer after primary surgery.

Burden of Respiratory Syncytial Virus (RSV) Infection Among Adults in Nursing and Care Homes: A Systematic Review.

Older adults in nursing and care homes (NCHs) are vulnerable to severe respiratory syncytial virus (RSV) infection, hospitalization, and death. This study aimed to gather data on RSV disease among older adults in NCHs and identify reported risk factors for RSV hospitalization and case fatality. The study protocol was registered in PROSPERO (CRD42022371908). We searched MEDLINE, EMBASE, and Global Health databases to identify articles published between 2000 and 2023. Observational and experimental studies conducted among older adults in NCHs requiring assistive care and reporting RSV illness were included and relevant data were extracted. Of 18,690 studies screened, 32 were selected for full-text review, and 20 were included. Overall, the number of NCH residents ranged from 42 to 1459 with a mean age between 67.6 and 85 years. Attack rates ranged from 6.7% to 47.6% and annual incidence ranged from 0.5% to 14%. Case fatality rates ranged from 7.7% to 23.1%. We found similar annual incidence rates of RSV-positive acute respiratory infection (ARI) of 4582 (95% CI: 3259-6264) and 4785 (95% CI: 2258-10,141) per 100,000 reported in two studies. Annual incidence rate of RSV-positive lower respiratory tract infection was 3040 (95% CI: 1986-4454) cases per 100,000 adults. Annual RSV-ARI hospital admission rates were between 600 (95% CI: 190-10,000) and 1104 (95% CI: 350-1930) per 100,000 person-years. Among all RSV disease cases, commonly reported chronic medical conditions included chronic obstructive pulmonary disease (COPD), heart failure, ischemic heart disease, coronary artery disease, hypertension, diabetes, kidney dysfunction, cerebrovascular accident, malignancies, dementia, and those with a Charlson comorbidity score > 6.5. Data on RSV infection among NCH residents are limited and largely heterogeneous but document a high risk of illness, frequent hospitalization, and high mortality. Preventive interventions, such as vaccination, should be considered for this high-risk population. Nationally representative epidemiologic studies and NCH-based viral pathogen surveillance could more precisely assess the burden on NCH residents.

324. A RETROSPECTIVE SINGLE CENTRE PROPENSITY-MATCHED ANALYSIS OF TRANSTHORACIC VERSUS TRANSABDOMINAL PROCEDURES FOR GIANT HIATAL HERNIAS

Abstract Background Transthoracic open procedure (TTO) was historically the preferred approach for treatment of giant hiatal hernias. However, the last decades transabdominal laparoscopic procedures (TAL) became the standard approach in many centres. The aim of the study was to compare short-term and midterm outcomes, as well as patient-reported outcome measures (PROMs, between TTO and TAL for giant hiatal hernias. Methods A retrospective analysis was conducted on all primary surgeries performed for giant hiatal hernias between 2008 and 2022. Patients who underwent TAL were propensity-matched (n= 36) to those who underwent TTO based on: age, gender, Charlson Comorbidity Score and hernia type. The two groups were compared in terms of surgery duration, length of stay (LOS), Clavien-Dindo score, intrahospital reoperation, hernia recurrence and need for reinterventions. PROMswere compared between total of TTO (n= 187) and TAL (n= 48): for symptom score, QoL-score, overall satisfaction and wound pain. Median clinical follow-up was 365.5 days. Median PROMsfollow-up was 55.3 months. Results Surgery duration (224 vs 177min, P&amp;lt;0.001) and LOS (11 vs 4days, P&amp;lt;0.001) were longer in TTO. Clavien-Dindo scores were alike (P= 0.260). Intrahospital reoperation was not statistically different (8.3% vs 0%, P= 0.239). Midterm recurrence rates suggested a non-significant trend towards lower recurrence in TTO (2.8% vs 16.7%, P= 0.107). Reintervention rates were alike (16.7% vs 11.1%, P= 0.735). QoL-score was inferior for TTO (0.705 vs 0.355, P= 0.036). Wound pain scores were higher in TTO (1 vs 0, P &amp;lt;0.001). Symptom score and satisfaction scores were alike, respectively 0.685 vs 0.760, P= 0.688 and 9 vs 9, P= 0.421. Conclusions TAL for giant hiatal hernias showed superior results compared to TTO for duration of surgery, length of hospital stay, QoL-score and wound pain scores. However, midterm results showed a noticeable trend towards higher recurrence rates for TAL. TAL should be considered when proceeding with surgery for giant hiatal hernias but a possible higher risk of recurrence must be taken into account. Further long-term clinical follow-up and comparison to PROMscould guide future decision-making.

Incidence and Predictors of Stroke in Australian Adults With Congenital Heart Disease (2000-2017).

Adults with congenital heart disease (CHD) are at increased risk of stroke but high-quality population level data on stroke incidence in these patients are scant. A retrospective whole-population Western Australian cohort of adultpatients with CHD aged 18 to 64 years was created and followed from January 2000 to December 2017 using linked hospital data. Stroke incidence rates within the adult cohort with CHD were calculated and compared with the general population via direct standardization. A nested case-control design assessed predictors of ischemic and hemorrhagic stroke within the cohort. Among 7916 adults with CHD, 249 (3.1%) incident strokes occurred at a median age of 47 years; 186 (2.3%) ischemic, 33 (0.4%) hemorrhagic and 30 (0.4%) unspecified strokes. Ischemic and hemorrhagic stroke incidence was, respectively, 9 and 3 times higher in adults with CHD than the general population. Absolute risk was low with annual rates of 0.26% (ischemic) and 0.05% (hemorrhagic). Highest rates were observed in adults with shunt and left-sided lesions. Predictors of ischemic stroke in adults with CHD included recent cardiac surgery, left-sided valve repair/replacements, shunt lesions, and traditional risk factors (hypertension, infective endocarditis, peripheral vascular disease, and tobacco use). Mental health disorders and increasing Charlson's comorbidity scores were strongly associated with higher risk of ischemic and hemorrhagic stroke. The CHA2DS2VASc score was associated with ischemic stroke incidence. This study provides the first population-based stroke incidence estimates for adults with CHD in Australia, showing elevated stroke risk across different CHD lesions. It highlights the potential clinical importance of managing comorbidities, especially mental health.

The association of hospitalist medical procedure service with operational efficiency at an academic medical center.

We examined the impact of a hospital medicine medical procedure service (MPS) on hospital length of stay (LOS), postprocedure LOS, and completion of procedures on weekends. We included 4952 patients admitted to our large academic hospital between July 1, 2021 and July 31, 2023 who underwent thoracentesis, paracentesis, or lumbar puncture (LP). MPS performed 30% (1499) of these procedures. After adjusting for age, sex, body mass index, Charlson comorbidity score, and procedure type, procedure performance by MPS was associated with a shorter total hospital LOS (incidence rate ratio [IRR]: 0.93; 95% confidence interval [CI]: 0.87-0.99) and postprocedure LOS (IRR: 0.82; 95% CI: 0.76-0.88). Also, MPS-performed procedures were twice as likely to occur on weekends compared to non-MPS-performed procedures (odds ratio [OR]: 2.05; 95% CI: 1.75-2.41). These findings support the beneficial impact of MPS on operational efficiency, an important outcome for both patients and hospitals.

A Retrospective Single-Center Comparative Study Between Robot-Assisted and Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma on Perioperative Results, Overall Survival, and Recurrence Rate.

Introduction Patients with localized high-risk urothelial carcinoma of the upper urinary tract are advised radical nephroureterectomy, the surgical removal of the kidney and ureter, utilizing robot-assisted versus laparoscopic methods. This study aims to compare the surgical and oncological results of robot-assisted and laparoscopic radical nephroureterectomy for upper-tract urothelial carcinoma. Methods An observational retrospective cohort study compared 14 patients who had robotic-assisted nephroureterctomy (RAN) to 16 patients who had laparoscopic assisted nephroureterctomy (LAN). Results There was no significant difference in age, sex, glomerular filtration rate (GFR), creatinine, Charlson comorbidity score, length of hospital stays, or the need to convert to an open approach. However, there was a statistical difference between the two procedures in terms of lymph dissection (p-value of 0.037) and the length of the procedure (p-value of 0.09). Conclusions The robotic approach has significantly higher use for lymph node dissection, while laparoscopic radical nephroureterectomy has a shorter operation time.

Cervical cancer screening utilization among kidney transplant recipients, 2001-2018.

Kidney transplant recipients (KTRs) have elevated risks of cervical pre-cancers and cancers, and guidelines recommend more frequent cervical cancer screening exams. However, little is known about current trends in cervical cancer screening in this unique population. We described patterns in the uptake of cervical cancer screening exams among female KTRs and identified factors associated with screening utilization. This retrospective cohort study included female KTRs between 20-65 years old, with Texas Medicare fee-for-service coverage, who received a transplant between January 1, 2001, and December 31, 2017. We determined the cumulative incidence of receiving cervical cancer screening post-transplant using ICD-9, ICD-10, and CPT codes and assessed factors associated with screening utilization, using the Fine and Gray model to account for competing events. Subdistribution hazards models were used to assess factors associated with screening uptake. Among 2,653 KTRs meeting the inclusion and exclusion criteria, the 1-, 2-, and 3-year cumulative incidences of initiating a cervical cancer screening exam post-transplant were 31.7% (95% confidence interval (CI), 30.0-33.6%), 48.0% (95% CI, 46.2-49.9%), and 58.5% (95% CI, 56.7-60.3%), respectively. KTRs who were 55-64 years old (vs. <45 years old) and those with a higher Charlson Comorbidity Score post-transplant were less likely to receive cervical cancer screening post-transplant. Cervical cancer screening uptake is low in the years immediately following a kidney transplant. Our findings highlight a need for interventions to improve cervical cancer screening utilization among KTRs.