Charlson Comorbidity Research Articles

Obesity, diabetes, hypertension and severe outcomes among inpatients with coronavirus disease 2019: a nationwide study

ObjectivesInitial studies of individuals with coronavirus disease 2019 (COVID-19) revealed that obesity, diabetes and hypertension were associated with severe outcomes. Subsequently, some authors showed that the risk could vary according to age, gender, co-morbidities and medical history. In a nationwide retrospective cohort, we studied the association between these co-morbidities and patients' requirement for invasive mechanical ventilation (IMV) or their death. MethodsAll French adult inpatients with COVID-19 admitted during the first epidemic wave (February to September 2020) were included. When patients were diagnosed with obesity, diabetes or hypertension for the first time in 2020, these conditions were considered as incident co-morbidities, otherwise they were considered prevalent. We compared outcomes of IMV and in-hospital death according to obesity, diabetes and hypertension, taking age, gender and Charlson's co-morbidity index score (CCIS) into account. ResultsA total of 134 209 adult inpatients with COVID-19 were included, half of them had hypertension (n = 66 613, 49.6%), one in four were diabetic (n = 32 209, 24.0%), and one in four were obese (n = 32 070, 23.9%). Among this cohort, IMV was required for 13 596 inpatients, and 19 969 patients died. IMV and death were more frequent in male patients (adjusted oods ratio (aOR) 2.0, 95% CI 1.9–2.1 and aOR 1.5, 95% CI 1.4–1.5, respectively), IMV in patients with co-morbidities (aOR 2.1, 95% CI 2.0–2.2 for CCIS = 2 and aOR 3.0, 95% CI 2.8–3.1 for CCIS ≥5), and death in patients aged 80 or above (aOR 17.0, 95% CI 15.5–18.6). Adjusted on age, gender and CCIS, death was more frequent among inpatients with obesity (aOR 1.2, 95% CI 1.1–1.2) and diabetes (aOR 1.2, 95% CI 1.1–1.2). IMV was more frequently necessary for inpatients with obesity (aOR 1.9, 95% CI 1.8–2.0), diabetes (aOR 1.4, 95% CI 1.3–1.4) and hypertension (aOR 1.7, 95% CI 1.6–1.8). Comparatively, IMV was more often required for patients with the following incident co-morbidities: obesity (aOR 3.5, 95% CI 3.3–3.7), diabetes (aOR 2.0, 95% CI 1.8–2.1) and hypertension (aOR 2.5, 95% CI 2.4–2.6). ConclusionsAmong 134 209 inpatients with COVID-19, mortality was more frequent among patients with obesity and diabetes. IMV was more frequently necessary for inpatients with obesity, diabetes and hypertension. Patients for whom these were incident co-morbidities were particularly at risk. Specific medical monitoring and vaccination should be priorities for patients with these co-morbidities.

Risk for stroke and myocardial infarction with abiraterone versus enzalutamide in metastatic prostate cancer patients

BackgroundAbiraterone and enzalutamide use is associated with significant cardiovascular (CV) morbidity in clinical trials, but the magnitude and clinical relevance of this association in real-world prostate cancer (PC) population remain unknown.Materials and methodsWe retrospectively reviewed the MarketScan claims databases (1 January 2013 to 30 September 2018) to identify adults with diagnosis of metastatic PC who received treatment with androgen deprivation therapy (ADT) and novel antiandrogen agents (abiraterone or enzalutamide). The primary CV outcome measure was composite outcome of acute myocardial infarction (MI) or stroke. Secondary outcomes were individual risks of MI or stroke. We used an intention-to-treat approach to analyze the CV outcomes associated with drug exposure among patients with metastatic PC. Cox regression model was used to estimate the independent association of two drugs with CV risk after adjustment for age, baseline atrial fibrillation, and Charlson Comorbidity Index.ResultsA total of 6294 patients with metastatic PC who were treated with ADT and either abiraterone or enzalutamide were included in the final analysis. Of these, 4017 (63.8%) patients used abiraterone and 2217 (32.2%) patients used enzalutamide. During the study period, 255 (6.3%) primary endpoint events occurred, resulting in an incidence rate of 4.3 per 100 patient-years. In multivariable analysis, abiraterone use was associated with a 31% increased risk of MI or stroke compared to enzalutamide (hazard ratio 1.31; 95% confidence interval 1.05-1.63; P = 0.01). The incidence rate was similar in patients who switched initial therapy from abiraterone to enzalutamide or vice versa (5.0 versus 5.6 per 100 patient-years, respectively).ConclusionsTo our knowledge, this is the first real-world assessment of MI and stroke among metastatic PC patients receiving novel anti-androgens. Our findings of increased MI and stroke risk with abiraterone compared with enzalutamide are consistent with data from clinical trials and suggest that enzalutamide may be preferable for prostate cancer patients at high CV risk.

Depression, Anxiety, Somatization Disorder, and Adjustment Disorder in Older Patients with Exudative Age-related Macular Degeneration

Purpose: The aim of this study was to analyze the prevalence of depression, anxiety, somatization disorder, and adjustment disorder in older patients diagnosed with exudative age-related macular degeneration (AMD) and to evaluate the relationship between exudative AMD and psychological disease.Methods: The 2016 Health Insurance Review and Assessment Service-Aged Patient Sample was applied in this study. The subjects were divided into two groups: AMD patients undergoing intravitreal injection treatment and a control group. Comorbidities were evaluated using the Charlson Comorbidity Index.Results: A total of 1,319,052 subjects were selected, of which 3,134 were in the exudative AMD group receiving intravitreal injections. The average age of the subjects was 74.7 ± 6.7 years, and 41.8% were male. In patients with exudative AMD, the prevalence of depression, anxiety, somatization disorder, and adjustment disorder were 16%, 20%, 0.5%, and 0.4%, respectively; in particular, the prevalence of depression and adjustment disorder were significantly higher than in the control group. In multivariate regression analysis, exudative AMD was a significant factor of depression (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.08-1.31, p < 0.001) and adjustment disorder (OR 2.47, 95% CI 1.47-4.18, p < 0.001). However, the association between AMD and anxiety or somatization disorder was not statistically significant.Conclusions: Exudative AMD showed a significant association with psychiatric disease, such as depression, and requires close clinical attention.

Effects of Oral Management on Elderly Patients with Pneumonia.

In this study, we examined the factors influencing the presence or absence of dental intervention in patients with pneumonia in an acute-care hospital, focusing on oral intake and its status. Observational study. Teikyo University School of Medicine, Mizonokuchi Hospital. Patients ≥65 years of age who were admitted to the Teikyo University School of Medicine, Mizonokuchi Hospital between January 1, 2018 and December 31, 2019 with pneumonia who were referred to the Department of Rehabilitation with suspected dysphagia were included in the study. Fifty patients who underwent dental intervention were compared with 50 controls who had received no dental interventions prior to the opening of the dental department. Time series matching was retrospectively performed using the Oral Health Assessment Tool (OHAT). From the medical records, age at admission, sex, pneumonia severity classification (age, dehydration, respiratory failure, orientation disturbance, and blood pressure [A-DROP] score), body mass index, Charlson's Comorbidity Index, OHAT, functional oral intake scale (FOIS) score at admission and discharge, and the length of hospital stay were retrieved; FOIS level ≥4 was defined as established oral intake. The number of patients in the control group before matching was 179. Twelve patients with missing information and seven patients who died in the hospital were excluded from this study. Multivariable logistic regression analysis showed that dental intervention (odds ratio 3.0, p = 0.014) was associated with the establishment of oral intake at discharge. Multiple logistic regression analysis showed that dental intervention was a significant factor for FOIS at discharge (p = 0.002) and the length of hospital stay (p = 0.039). Oral management with dental intervention was associated with establishing oral intake and reducing hospital stay in patients with pneumonia, regardless of pneumonia severity or comorbidities.

Can We Predict Unplanned Intensive Care Unit Admission in Hip and Knee Arthroplasty?

AbstractPreoperative risk stratification remains important for both patient safety and cost-effective allocation of resources in total joint arthroplasty. Limited literature exists investigating risk factors for unplanned intensive care unit (ICU) admission following arthroplasty. Therefore, the purpose of this study was to assess a broader spectrum of factors that may increase the risk of ICU admission across multiple surgical settings. We retrospectively reviewed 18,169 patients who underwent a hip (40.7%) or knee (59.3%) arthroplasty procedure (primary: n = 13,384, 90%; revision: n = 1,485, 10%) between August 1, 2015, and January 31, 2019, across nine sites at a single institution. Patient demographics, laboratory data, surgical parameters, and preoperative scores on the Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) were recorded. A univariate analysis was conducted to identify differences between patients who required an ICU admission and those with no ICU involvement. Logistic regression was then used to generate predicted risk of ICU Involvement. A total of 147 patients (0.99%) required an ICU admission. Increasing age, higher Charlson's comorbidity index, American Society of Anesthesiologists (ASA) class 3 or greater, elevated blood urea nitrogen (BUN), elevated creatinine, decreased preoperative hemoglobin level, general anesthesia, surgical setting, revision procedure, and lower baseline scores on the KOOS Quality of Life (QOL) subscale (17 vs. 22.5, p = 0.032), VR-12 physical component score (PCS; 24.4 vs 27.1, p = 0.001), and VR-12 mental component score (MCS; 45.9 vs. 49.6, p = 0.003) were associated with a statistically significant increase in the risk of ICU admission. As performance of arthroplasty shifts in both the setting of care and the complexity of patients, identifying patients most at risk of requiring higher acuity of care is important. Preoperative assessment of comorbidities, kidney function, surgical setting, KOOS QOL subscale score, and VR-12 scores may provide guidance for the improvement of value-based care pathways.

Epidemiology and clinical characteristics of COVID- 19 patients requiring critical care in a Tertiary care teaching hospital.

Background and Aims:We describe the epidemiological and clinical characteristics, and 28 day outcome of critically ill COVID-19 patients admitted to a tertiary care centre in India.Material and Methods:We included 60 adult critically ill COVID-19 patients in this prospective observational study, admitted to the intensive care unit (ICU) after obtaining ethics committee approval and informed consent. Demographics, clinical data, and treatment outcome at 28 days were assessed.Results:Demographic characteristics of the COVID-19 patients reveal that compared to the survivors, the non-survivors were significantly older [57.5 vs. 47.5 years], had more comorbid disease [Charlson's comorbidity index 4 vs. 2], higher Apache II scores [19 vs. 8.5], and had significantly higher percentage of smokers. Diabetes mellitus and hypertension were the most common comorbidities. Dyspnea, fever, and cough were the most common presenting symptoms. Total leucocyte count as well as blood lactate level were significantly higher in non-survivors. Around 47% patients had severe ARDS, and 60% patients required invasive mechanical ventilation. 28 day ICU mortality was 50%, with a mortality of 75% in patients receiving invasive mechanical ventilation. Mortality was higher in males than females (57% vs. 33%). Acute kidney injury and septic shock were the most common non-pulmonary complications during ICU stay. Incidence of liver dysfunction, septic shock, and vasopressor use was significantly higher in the non-survivors.Conclusion:This study demonstrates a high 28 day mortality in severe COVID-19 patients. Further well designed prospective studies with larger sample size are needed to identify the risk factors associated with poor outcome in such patients.

Risk Factors for Bleeding, Including Platelet Count Threshold, in Newly Diagnosed ITP Patients

Introduction: Bleeding is a main cause of morbidity and mortality in adult immune thrombocytopenia (ITP). Treatment is indicated in case of bleeding or of low platelet count. However, the threshold of platelet count associated with bleeding and therefore to initiation of treatment is debated. Most of guidelines recommend the threshold of <30 x 109/L. However, some authors recommend other thresholds, as low as 10 x 109/L. Moreover, the risk factors for bleeding are not well known in ITP. The aim of this study is to assess the risk of bleeding by platelet count and to identify these risk factors.Methods: We studied all the patients included between June 2013 and December 2016 in the CARMEN (Cytopénies Auto-immunes : Registre Midi-PyréneEN) registry. This multicenter registry is aimed at the prospective follow-up of all incident ITP adults in the French Midi-Pyrénées region (South-West of France, 3 million inhabitants). Each investigator follows every patient newly diagnosed for ITP in routine visit or hospital stay and detailed information on patients' characteristics and management of ITP are recorded prospectively. We also included all adult patients newly diagnosed for ITP at the French National Referral Center for autoimmune cytopenias (Créteil) from November 2015 to December 2016 where data are prospectively recorded in the same database. ITP was defined by platelet count <100 x 109/L and exclusion of other causes of thrombocytopenia. We described the frequency of any bleeding, of mucosal bleeding and of severe bleeding (defined by macroscopic hematuria, gastrointestinal or central nervous system bleedings) at ITP onset by platelet count and by subgroups of interest: age groups (according to quartiles: ≤45, 45-64, 65-79 and ≥80 years), sex, arterial hypertension, history or current symptoms of gastroduodenal ulcer, Charlson's comorbidity score, exposure to non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet drugs, anticoagulant drugs and serotonin reuptake inhibitors (SRIs). Lastly, we assessed in the whole cohort the factors associated with any bleeding, mucosal bleeding and severe bleeding using multivariate logistic regression analysis.Results: 302 newly diagnosed ITP adults were prospectively included in the study. Median age was 66 years, 49.7% were females, 46.8% had a Charlson's score ≥1, 3.7% had a history or current symptoms of gastroduodenal ulcer, 16.0% had secondary ITP, 19.5% were exposed to antiplatelet drugs, 7.6% to anticoagulant drugs, 7.6% to NSAIDs and 6.6 to SRIs at the time of diagnosis. Median platelet count was 18 x109/L. At diagnosis, 57.9% experienced any bleeding symptom, 30.1% mucosal bleeding, and 6.6% severe bleeding (including 4 central nervous system bleedings).The rates of bleeding, mucosal bleeding and severe bleeding by platelet count is shown in Figure 1. The rate of any bleeding was >50% if platelet count was <20 x109/L. The rate of mucosal bleeding was >40% if platelet count was <10 x109/L. In contrast, a similar risk of severe bleeding was observed with all platelet count categories. Only slight differences were observed in other subgroups, except an increased frequency of any bleeding in case of exposure to NSAIDs, as well as an increased rate of severe bleeding in elderly and patients exposed to anticoagulant drugs and SRIs.In multivariate analysis, the factors associated with any bleeding at ITP diagnosis were a low platelet count (<10 x109/L vs. >20 x109/L: OR, 46.3, 95% CI: 19.4-110.6; between 10 and 19 x109/L vs. >20 x109/L: OR, 5.1, 95% CI: 2.3-11.2), female sex (OR for males, 0.4, 95%CI: 0.2-0.8) and exposure to NSAIDs (OR, 4.4, 95 %CI: 1.1-18.7). Only a low platelet count was associated with mucosal bleeding (<10 x109/L vs. >20 x109/L: OR, 6.2, 95% CI: 3.4-11.6; between 10 and 19 x109/L vs. >20 x109/L: OR, 2.6, 95% CI: 1.1-6.1). Lastly, only exposure to anticoagulant drugs was associated with severe bleeding (OR, 4.5, 95% CI: 1.4-14.4). Analyses restricted to primary ITPs led to similar results.Conclusion: Platelet counts <20 x109/L and <10 x109/L were thresholds with major increased risk for both any and mucosal bleedings. Platelet count, female sex and exposure to NSAIDs should be considered to assess the risk of any bleeding. In contrast, severe bleeding seemed not linked to platelet count but to individual factors, particularly exposure to anticoagulant. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Association of Monoclonal Gammopathy with Progression to End-Stage Renal Disease Among a National Cohort of US Veterans

Introduction : Testing for monoclonal proteins may be undertaken as part of the diagnostic evaluation for chronic kidney disease. However, the clinical significance of monoclonal gammopathy detected in this context is often uncertain. Here we examined the association of a positive test for monoclonal protein with progression to end-stage renal disease (ESRD) (dialysis or kidney transplant) among United States (US) veterans.Methods : We used national Veterans Health Administration (VA) clinical and administrative data to identify and characterize a national cohort of veterans with at least one serum creatinine measurement within the VA between October 1, 2000 and September 30, 2001. We used a text search algorithm for keywords pertaining to monoclonal protein contained in laboratory test results in the VA Corporate Data Warehouse within a two-year window of serum creatinine measurement to identify cohort members who had at least one test for monoclonal proteins (serum protein or urine electrophoresis or immunofixation), and to score test results as positive, negative, or unclassifiable. The text-search algorithm was validated by manual review of a random selection of 2% of records (training set) by an attending hematologist. A second manual review of a random selection of 737 records provided a validation set for the search algorithm, demonstrating a sensitivity of 0.73 (95% confidence interval (CI)) of 0.66-0.79, and specificity of 0.94 (95% CI 0.91-0.96), excluding unclassifiable tests. Patients were followed from the time of their first serum creatinine measurement during fiscal year 2001 through September 30, 2011 for the outcome of ESRD using linked data from the US Renal Data System, a national registry for ESRD. Cox proportional hazards regression stratified by glomerular filtration rate (eGFR ml/min/1.73 m2) was used to estimate hazard ratios (HR) with 95% CI for ESRD for patients with a positive vs. negative paraprotein test adjusted for age, sex, race, diabetes, congestive heart failure, vascular disease, and Charlson comorbidity index.Results : Among a cohort of over 2.1 million veterans with a serum creatinine test, we identified 19,993 who underwent paraprotein testing. Overall, 96% of the cohort were male, 69% were ≥ 55 years old, and 23% were ≥ 75 years old. Of those tested, 4,112 (20.5%) had a positive test, 14,541 had a negative test (72.7%) and 6.7% were unclassifiable. Among those with an eGFR <60, 2% (n=8,293) underwent paraprotein testing, as compared with 0.7% (N=11,700) of those with an eGFR≥60. For all levels of eGFR, the crude incidence of ESRD was higher among patients who were tested vs. not tested. For patients with eGFR ≥60 who underwent testing for monoclonal gammopathy, there was an increased crude rate of ESRD among those with a positive vs. negative test result (4.9 vs 2.2 per 1,000 person years) with an adjusted HR of 2.01 (95% CI 1.50-2.71). For patients with lower levels of eGFR, in whom the absolute rate of ESRD was much higher, the adjusted HR for ESRD for those with a positive vs negative test result was attenuated and varied little by eGFR (Figure).Conclusions : Among a large national cohort of US veterans, the risk of progression to ESRD in patients with a reduced eGFR who were tested for monoclonal gammopathy was similar regardless of whether the test result was positive or negative. Although there was an increased risk of ESRD among patients with preserved eGFR, the absolute risk of ESRD in these patients was very low. Evaluating different paraprotein sub-types and correlation with quantitative test results, including serum free light chain (kappa/lambda) ratios may further improve assessment of renal prognosis in patients with monoclonal gammopathy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Persistence with Generic Imatinib for Chronic Myeloid Leukemia: A Matched Cohort Study

Background: Generic imatinib (GI) has been approved for use in Canada and other countries based on bioequivalence. A high rate of GI discontinuation has been reported to be related to intolerance (Islamagic E, et al. Clin Lymphoma Myeloma Leuk. 2017;17:238) but no clinical studies have been conducted to determine whether GI is clinically comparable to branded imatinib (BI) for chronic myeloid leukemia (CML). In Quebec, GI was approved and reimbursed in early 2013 and was mandated to replace BI for patients with public drug coverage later the same year. We compared persistence on GI to that on BI in a matched cohort study.Methods: Patients who started GI between 2013 and 2016 were selected from the Quebec CML registry. Each was matched with a BI user who had recorded use of BI at the same calendar date, had the closest duration of prior BI use and closest age. In both cohorts, patients who previously received therapy other than imatinib for their CML were excluded. Matched pairs were followed until switch in therapy, death, withdrawal of consent or end of study (31 December 2016). Kaplan-Meier curves were constructed to evaluate persistence, defined as time until switch in therapy, between GI and BI users. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for treatment discontinuation or switch with GI, comparing GI with BI, adjusting for sex, obesity, smoking, alcohol consumption, and Charlson comorbidity index.Results: A total of 167 matched pairs were included; mean age (SD) and mean duration (SD) of prior BI therapy was similar between GI and BI users (57.2 (14.4) and 58.3 (13.4) years and 6.1 (4.2) and 5.7 (4.5), respectively). At 42 months, 72.8% (95% CI, 63.4.5%-81.7%) of GI users and 88.9% (95% CI, 82.8%-93.6%) of BI users persisted with their TKI (Figure, P= 0.03). Overall, GI use was associated with an increased risk of switch (HR, 2.13; 95% CI, 1.18-3.86), compared with BI. In GI users, 36 patients switched therapy, 11 for suboptimal response (defined as loss of response, including loss of MMR or failure to achieve a milestone) and 25 for intolerance, which included 21 switching back to BI. Most (63.5%) of the switches occurred in the first year of GI use, and most for intolerance (66.7%, n=24). Of note, there were seven grade 3 adverse events in GI users (fatigue, weakness, nausea and vomiting, diarrhea, muscle cramps). Among BI users, 17 patients switched for suboptimal response (n=8), and intolerance (n=9). Of note, in GI and BI users respectively, 13 and 4 patients stopped therapy in deep molecular response.Discussion: In this matched cohort study with close to 4 years of follow-up, GI users were twice more likely to stop their TKI than users of BI users, marking lower persistence. In most terminations of GI use, the patients reverted to BI, and intolerance was the main cause for TKI switch. Future studies are warranted to investigate the safety profile of GI. [Display omitted] DisclosuresBusque:Pfizer: Honoraria; Paladin: Honoraria; Bristol Myer Squibb: Honoraria; Novartis Canada Inc.: Honoraria. Assouline:Novartis Canada Inc.: Honoraria; Bristol Myer Squibb: Speakers Bureau; Pfizer: Speakers Bureau; Paladin: Speakers Bureau; Janssen: Honoraria.

Bisphosphonate treatment and the risk of atypical femoral fracture among patients participating in a Fracture Liaison Service of a tertiary medical center.

Atypical femoral fractures (AFF) are a rare complication of bisphosphonate (BP) treatment. We evaluated the correlation between BP exposure and AFF risk among hip fracture patients. This retrospective nested case-control study included patients over age 50years, operated for osteoporotic hip fracture between July 2014 and November 2018, who attended our Fracture Liaison Service. We classified fracture radiographs and compared demographic, clinical, biochemical, and drug purchase data between patients with AFF and those with typical osteoporotic hip fracture (controls). To correct for the younger age of patients with AFF, we matched each case (AFF) with three controls according to age ([Formula: see text] 1year) and sex and performed a conditional logistic regression model. Of 989 patients, 31 (3%) had AFF. Patients with AFF were younger than those with inter-trochanteric fractures (mean ± SD: 72.3 ± 10.3 vs. 80.2 ± 9.6years, p < 0.001). Following matching, the mean Charlson's Comorbidity Index (CCI) was lower in the AFF than in the control group (2.9 ± 3.7 vs. 4.7 ± 4.2; p = 0.030) and a higher proportion of them were treated with BP for 5years or more (58.1 vs. 16.0%; p < 0.001). Among patients admitted with hip fracture who were treated with BP for 5years or more, the odds ratio of this fracture being atypical was significantly higher compared with no BP treatment (21.7; 95% CI-4.1-113.9). Patients with AFF compared to typical hip fractures showed better baseline medical conditions irrespective of their younger age. Five years of BP treatment may be associated with an increased risk for AFF, though the absolute risk remains very low.

Nonsteroidal anti-inflammatory drugs prevent gastric cancer associated with the use of proton pump inhibitors after Helicobacter pylori eradication.

Background and AimProton pump inhibitors (PPIs) are a potential cause of gastric carcinogenesis after Helicobacter pylori eradication. Thus, appropriate management including chemoprevention is required. The aim of this study was to evaluate the association between nonsteroidal anti‐inflammatory drugs (NSAIDs) and the incidence of post‐eradication gastric cancer in PPI users.MethodsA multicenter retrospective cohort study was conducted. Patients who used a PPI (≥30 days) after H. pylori eradication between 2014 and 2019 were analyzed in nine hospital databases. Gastric cancer incidence was a primary outcome, and their association with NSAIDs use and clinical factors was evaluated. Hazard ratios were adjusted by age, sex, smoking, and Charlson Comorbidity Index.ResultsDuring the mean follow‐up period of 2.38 years, 1.13% (31/2431) of all patients developed gastric cancer. The cumulative incidence of gastric cancer in PPI users was 0.25% at 1 year, 0.51% at 3 years, and 1.09% at 5 years in the NSAID users and 0.89% at 1 year, 2.32% at 3 years, and 3.61% at 5 years in nonusers. NSAIDs were associated with a lower gastric cancer risk (adjusted hazard ratio = 0.28, P = 0.005). No gastric cancer was observed in the cyclooxygenase‐2 inhibitor users (n = 256). NSAID use with high dose and long duration was significantly associated with a lower incidence of gastric cancer.ConclusionNSAIDs were associated with a 60% decrease in the gastric cancer incidence in H. pylori‐eradicated PPI users, with dose and duration response effects. NSAIDs may be effective for chemoprevention against PPI‐related gastric cancer.

Out of Hospital Sudden Death in a Rural Population: Low Rates of ICD Underutilization Among Decedents.

Implantable cardioverter defibrillators (ICDs) reduce mortality in patients at risk for life-threatening arrhythmias. Implantation of ICDs in rural or economically disadvantaged populations is suspected to be low. This study examined Out of Hospital Premature Natural Death (OHPND) and electronic medical record (EMR) data to identify rates of non-implantation of ICDs among decedents in eastern North Carolina. OHPND cases in 2016 were identified using mortality data and matched with EMRs. Those meeting criteria for ICD implantation based on chart review were adjudicated by two electrophysiologists to determine whether they qualified for implantation. Comorbidity burden was established using Charlson's Comorbidity Index (CCI). Out of 1316 OHPND cases, 967 (73.4%) had EMR records. Chart review identified 70 (7.2%) potential ICD candidates with a LVEF ≤35 of which 5 (7.1%) did not meet criteria because LVEF subsequently improved. Of the remaining 65 patients, 32 (49.2%) already received an ICD, and 33 patients (50.7%) met criteria but had not received one. Reasons for non-implantation included: limited life expectancy secondary to comorbidities, principally chronic kidney disease (CKD) (N=11, 17%), physician non-adherence to guidelines (N=9, 14%), loss to follow-up (N=7, 11%), patient refusal (N=5, 8%), and death before commencing medical therapy (N=1, 2%). Among our cohort of 967 individuals who died unexpectedly, nine (0.9%) patients may have avoided death with an ICD. This study using decedent data shows low rates of ICD-underutilization in a rural population and emphasizes the role of advanced comorbidities such as CKD in ICD-underutilization.

Assessment of differences in demographic characteristics and clinical diagnoses among black and white oncology patients with COVID.

e18711 Background: Health disparities between black and white COVID-positive patients are well documented. To help address these disparities, clinicians need to understand the specific health challenges faced by black COVID patients compared to their white counterparts. These challenges are understudied in the oncologic setting. Hence, we present the demographic and clinical features of black COVID-positive cancer patients compared to whites. Methods: We used ConcertAI’s database of oncology EMR data, which includes clinical data from CancerLinQ Discovery. We conducted two-sample t-tests and chi-squared tests to measure the differences in black and white COVID-positive cancer patients across age, gender, ethnicity, state, region, ECOG, BMI, all cancer indications, stage, and Charlson comorbidities. COVID positivity was defined using claims data. Only relevant significant results are reported to save space. Results: Table summarizes the differences in 429 black and 980 white cancer patients with COVID. Black patients were younger, more likely to have an elevated BMI, and have a higher prevalence of breast cancer, congestive heart failure, diabetes, multiple myeloma, peptic ulcer disease, and renal disease. They also had less melanoma. Results were statistically significant at 0.05 level. Analyzing only black patients by COVID status shows very similar results. Conclusions: Black cancer patients suffer from multiple comorbid conditions that increase their risk of adverse outcomes when infected with COVID-19. The CDC lists eight comorbidities that put patients at a higher risk of severe COVID infection. Black patients in our cohort have a higher prevalence of four out of eight of these conditions—elevated BMI, renal disease, congestive heart failure, and diabetes. Clinicians should inspect for these comorbidities while treating this at-risk population. [Table: see text]

Multi-drug resistance and other predictors for mortality in severe sepsis and sepsis chock due to Gram-negative and Gram-positive pathogens in a tertiary care hospital in Brazil: a retrospective matched case vs case vs control study design

Introduction: Infections, mainly bloodstream infections (BSI), acquired in the intensive care unit (ICU) are associated with significant rates of morbidity and mortality, especially when caused by pathogens. The objectives the study were to determine risk factors and mortality rates in 30 days for patients with BSI caused by microorganisms resistant versus microorganisms susceptible to antimicrobials. Methods: A case-vs-control study was carried out, in which patients were identified with BSI acquired in the ICU. Control patients were paired, considering: age, acute mean severity classification (ASIS), and chronic disease scores, Charlson's Comorbidity Index (CHARLSON) both ≥ 3. Results: Retrospective cohort study of 531 patients, 254 with bloodstream infection (BSI), and 277 uninfected controls during hospital stay. Of those infected, 181 presented multidrug-resistant isolates (MDR) and 73, isolates susceptible to antibiotics. The univariate analysis showed statistically significant frequencies for BSIs, when compared with controls, of isolates resistant to multiple drugs and susceptible. There was also significance in the mortality rate among patients with resistant and susceptible pathogens (40.3% vs 34.2%, P&lt;0.05). Multivariate analysis showed that only trauma and previous use of antibiotics were independent risk factors for BSIs in critically ill patients with infection, both by MDR and antibiotic-sensitive isolates. Conclusion: Mortality and bacteremia were higher in BSIs due to antibiotic-resistant isolates in a cohort of intensive care patients. The lack of financial and human resources results in multiple barriers in developing countries like Brazil and the prevention of these infections becomes a major challenge.

Is Ultra Hypofractionated Radiation Therapy a Safe and Effective Treatment for Invasive Bladder Cancer in the Elderly?: A Retrospective Single Institution Review.

The aim was to determine the efficacy, safety, and tolerability of weekly ultra hypofractionated radiation therapy for older unfit patients with invasive bladder cancer. We retrospectively analyzed a cohort of patients with muscle invasive bladder cancer deemed unfit for chemoradiation therapy and thus treated with 6 weekly doses of 6 Gy using intensity modulated radiotherapy. Charlson comorbidity was calculated retrospectively. Cystoscopy and computed tomography were used to evaluate local control and toxicity using the common terminology criteria. Survival outcomes were estimated using the Kaplan-Meier method. Twenty-two patients with a median age of 84 (range: 70 to 96) years were included. The median comorbidity index was 6±1.5 SD. Nineteen (90%) patients received the full 36 Gy dose. Median follow-up was 10±7 months (range: 6 to 27 mo). Local control in the bladder was achieved in 16 of 19 evaluable patients (84%). One-year overall survival was 62.5%, 1 patient had a retroperitoneal nodal recurrence and 3 patients developed distant metastasis. Grade 3 genitourinary and gastrointestinal toxicity was observed in 4 (18%) and 1 (4.5%) patients, respectively. Weekly ultra hypofractionated intensity modulated radiotherapy with image guidance and bladder training is an effective, safe, and well-tolerated regimen for older patients with invasive bladder cancer unfit for radical treatment.

Schizophrenia hospitalization in the US 2005-2014: Examination of trends in demographics, length of stay, and cost.

Primarily we aimed to examine the crude and standardized schizophrenia hospitalization trend from 2005 to 2014. We hypothesized that there will be a statistically significant linear trend in hospitalization rates for schizophrenia from 2005 to 2014. Secondarily we also examined trends in hospitalization by race/ethnicity, age, gender, as well as trends in hospitalization Length of Stay (LOS) and inflation adjusted cost.In this observational study, we used Nationwide Inpatient Sample data and International Classification of Diseases, Eleventh Revisions codes for Schizophrenia, which revealed 6,122,284 cases for this study. Outcomes included crude and standardized hospitalization rates, race/ethnicity, age, cost, and LOS. The analysis included descriptive statistics, indirect standardization, Rao-Scott Chi-Square test, t-test, and adjusted linear regression trend.Hospitalizations were most prevalent for individuals ages 45–64 (38.8%), African Americans were overrepresented (25.8% of hospitalizations), and the gender distribution was nearly equivalent. Mean LOS was 9.08 days (95% confidence interval 8.71–9.45). Medicare was the primary payer for most hospitalizations (55.4%), with most of the costs ranging from $10,000-$49,999 (57.1%). The crude hospitalization rates ranged from 790–1142/100,000 admissions, while the US 2010 census standardized rates were 380–552/100,000 from 2005–2014. Linear regression trend analysis showed no significant difference in trend for race/ethnicity, age, nor gender (P > .001). The hospitalizations’ overall rates increased while LOS significantly decreased, while hospitalization costs and Charlson's co-morbidity index increased (P < .001).From 2005–2014, the overall US hospitalization rates significantly increased. Over this period, observed disparities in hospitalizations for middle-aged and African Americans were unchanged, and LOS has gone down while costs have gone up. Further studies addressing the important disparities in race/ethnicity and age and reducing costs of acute hospitalization are needed.

POS-349 WHICH PARAMETERS BEST PREDICT REHOSPITALIZATION FROM A SECOND HIP FRACTURE EVENT FOR PATIENTS LIVING WITH CKD ADMITTED FOLLOWING HIP FRACTURE? A 6-YEAR PROSPECTIVE ANALYSIS

Greater frequency of falls and subsequent hip fractures are observed for people living with chronic kidney disease (CKD) compared to those without CKD. The cause of increased falls risk is multifactorial. Many patients living with CKD are frail, sarcopenic and have numerous medical co-morbidities. Fracture risks following a fall could be exacerbated by mineral bone disease secondary to CKD. There is usually a marked deterioration in functional status for patients living with CKD following hip fracture, even after rehabilitation. A reduced baseline function increases risk for further falls and hip fracture events. Worsened morbidity and mortality outcomes are expected in patients with CKD following recurrent trauma and rehospitalization. The most useful clinical assessment tool to predict for rehospitalization from a second hip fracture event amongst this patient group remains unestablished. Patients with CKD G3b-5 admitted from home to a tertiary hospital in North West UK with hip fracture between Jun 2013 and Dec 2019 were included. Individuals with previous hip fractures prior to study commencement were excluded. Parameters assessed on hospital admission for each patient included the Clinical Frailty Scale (CFS), Charlson’s Co-morbidity Index (CCI), Chronic Kidney Disease Frailty Index Laboratory Score (CKD FI-LAB), Karnofsky Performance Status Scale, Sernbo Score, Nottingham Hip Fracture Score, Estimated VO2 Peak, ASA Physical Status Classification System Score and Abbreviated Mental Test Score. Rehospitalization events from a second hip fracture during the study period were recorded. Receiver Operating Characteristic (ROC) curve analyses were performed to evaluate the ability of individual scoring tools to predict for rehospitalization from a second hip fracture event amongst patients with CKD admitted following their first hip fracture. A total of 397 patients met inclusion criteria of which 42 patients (10.6%) were receiving long-term dialysis. Mean Estimated Glomerular Filtration Rate (eGFR) for non-dialysis patients was 37.4±14.9mL/min/1.73m2. 37 patients (9.3%) sustained a second hip fracture leading to rehospitalization during the study period and the mean age difference between first and second hip fracture events is 1.4 yrs (p=0.032). Area under a curve (AUC) values from ROC curve analyses are shown in the table. Tabled 1PredictorAUC Value95% CIClinical Frailty Scale0.940.87-1.00Charlson's Co-morbidity Index0.900.84-0.97Chronic Kidney Disease Frailty Index Laboratory Score0.890.82-0.96Karnofsky Performance Status Scale0.840.77-0.91Sernbo Score0.820.75-0.88Nottingham Hip Fracture Score0.800.73-0.87Estimated VO2 Peak0.790.72-0.86ASA Physical Status Classification System Score0.700.63-0.76Abbreviated Mental Test Score0.630.56-0.70 Open table in a new tab Assessment tools evaluating frailty and co-morbidity status (CFS, CCI and CKD FI-LAB) displayed the strongest predictive ability for rehospitalization events from a second hip fracture in patients with CKD following initial hip fracture. Future studies should aim to optimize frailty needs and address medical co-morbidities in the CKD population during early phases of post-trauma rehabilitation. An effective multidisciplinary team input throughout this process may reduce further falls and fracture risks.

POS-348 Predicting difficulties with direct home discharge following hip fracture for patients living with CKD: Insights from a 6-year prospective study

Patients with chronic kidney disease (CKD) are at higher risk of falls and sustaining hip fractures compared to those without CKD. Worse clinical outcomes are observed in CKD groups, exacerbated by frailty, sarcopenia and other co-morbidities. Arranging discharge to own home following hip fracture is often difficult for older patients living with CKD. Patients with CKD usually have markedly deteriorated functional status following acute trauma and basic rehabilitation requirements cannot be holistically supported within a home environment. The most useful clinical assessment tool to predict for non-home discharge in patients with CKD following hospitalization with hip fracture remains unknown. Patients with CKD G3b-5 admitted from home to a tertiary hospital in North West UK with hip fracture between Jun 2013 and Dec 2019 were included. Parameters assessed on hospital admission for each patient included Clinical Frailty Scale (CFS), Charlson’s Co-morbidity Index (CCI), Chronic Kidney Disease Frailty Index Laboratory Score (CKD FI-LAB), Karnofsky Performance Status Scale, Sernbo Score, Nottingham Hip Fracture Score, Estimated VO2 Peak, ASA Physical Status Classification System Score and Abbreviated Mental Test Score. Patients who did not directly return home after hospitalization following hip fracture were discharged to a residential home, nursing home, specialist rehabilitation unit in the region or another district general hospital for ongoing rehabilitation needs. Receiver Operating Characteristic (ROC) curve analyses were performed to evaluate the ability of individual scoring tools to predict non-home discharge following hip fracture in patients with CKD admitted from home. A total of 225 patients met study inclusion criteria. The mean age was 81.6±10.1 yrs and the female:male ratio was 1.7:1. 33 patients (14.7%) were on long-term dialysis. 30-day in-hospital mortality was 5.9%. Following hip fracture hospitalization, 117 patients (52.0%) directly returned home on discharge. 13 patients (5.8%) were discharged to residential home, 51 patients (22.7%) to nursing home, 22 patients (9.8%) to a specialist rehabilitation unit in the region and 12 patients (5.3%) were repatriated to a district general hospital closer to the patient’s pre-admission residence. Difference in 1-year mortality rate between the non-home discharge cohort and those directly discharged home from hospital was +16.2% (p<0.001). Area under a curve (AUC) values from ROC analyses are shown in the table. Tabled 1PredictorAUC Value95% CIClinical Frailty Scale0.950.88-1.00Charlson's Co-morbidity Index0.920.85-0.99Chronic Kidney Disease Frailty Index Laboratory Score0.890.82-0.96Karnofsky Performance Status Scale0.850.78-0.92Sernbo Score0.840.77-0.91Nottingham Hip Fracture Score0.790.72-0.85Estimated VO2 Peak0.780.71-0.84ASA Physical Status Classification System Score0.690.62-0.75Abbreviated Mental Test Score0.660.59-0.73 Open table in a new tab Frailty and co-morbidity assessment tools (CFS, CCI and CKD FI-LAB) displayed the best predictive ability for non-home discharge following hip fracture in patients with CKD. Difficulty with direct home discharge is associated with significant mortality over the short term. Future research should explore holistic, multi-modal and multi-disciplinary interventions that aim to improve outcomes of patients with CKD at risk of extensive post-trauma rehabilitation needs.

Mortality and critical conditions in COVID-19 patients at private hospitals: weekend effect?

The aim of the study was to find factors associated with the mortality of admission to the intensive care unit (ICU) in patients with COVID-19. Retrospective observational study with a database of 1987 patients with COVID-19 who had attended the emergency department of a private hospital network between February 2020 and April 2020 were analyzed. Clinical variables and some laboratory parameters were studied. The Charlson and Elixhauser comorbidity indices were calculated. The dependent variables were mortality and admission to the ICU. A descriptive and correlational analysis was performed. Logistic regression models and Kaplan-Meier survival curves were established. Positive correlations were observed between age, creatinine, and D-dimer levels, as well as with the scores obtained with the Charlson and Elixhauser indices. Differences in the levels of these parameters were also observed when analyzing variables such as mortality, sex or admission to the ICU. Mortality was associated with high creatinine and D-dimer levels and advanced age. Survival curves indicated longer survival in patients not admitted to the ICU, admitted to the hospital during the week, and in those with lower creatinine and D-dimer levels. Mortality in Spanish patients with COVID-19 admitted to private hospitals was associated with high creatinine and D-dimer levels and advanced age. Longer survival was obtained on weekdays. This study provides valuable information on the management and nursing care of these patients in order to optimize resources in pandemic situations.

Asthma Patients Who Stop Asthma Biologics Have a Similar Risk of Asthma Exacerbations as Those Who Continue Asthma Biologics

There is limited information about outcomes associated with stopping asthma biologics. To compare outcomes in people who stopped or continued asthma biologics. We identified a cohort of people with asthma who stopped or continued asthma biologics in the Optum Labs Database Warehouse, using a propensity matching method for case and control groups with the variables of age, sex, race, region, insurance, income, specialist access, Charlson comorbidity, specific medical conditions, pre-index exacerbation count, pre-index rescue inhaler pharmacy fills, and pre-index inhaled corticosteroid with or without long-acting β-agonist pharmacy fills. Primary outcome used to assess failure of stopping was an increase of 50% or more in the asthma exacerbation rate in the 6 months after discontinuing the biologic compared with the 6-month period before biologic initiation. Among a cohort of 4960 asthma biologic users, 1249 were observed to stop use after 6 to 12 months of use. We identified a matched cohort of 1247 stoppers and 1247 people who continued biologic use for at least 18 months. In the first 6 months after stopping or sham stopping, 10.2% of stoppers and 9.5% of continuers had an increase of 50% or more in asthma exacerbations. We found a similar adjusted odds of failing among stoppers and continuers (odds ratio= 1.085; 95% confidence interval, 0.833-1.413). An increase in asthma exacerbations is infrequently observed in people who stopped asthma biologics and was observed at similar rates as in matched controls who continued asthma biologics.