Patient Charlson Comorbidity Index Research Articles

Risk rate of major adverse cardiovascular event and charlson comorbidity index in patients undergoing coronary CTA with symptoms suggesting chronic coronary syndrome compared to a reference population

Abstract Background Approximately 12,000 patients annually undergo a coronary computed tomography angiography (CTA) due to symptoms suggestive of chronic coronary syndrome (CCS) in the Western part of Denmark (3.2 million inhabitants) (1). The purpose of this study was to examine the burden of comorbidity and the risk of a major adverse cardiovascular events (MACE)(2) in a large population of patients investigated using coronary CTA compared to a reference population. Methods Patients undergoing first-time coronary CTA from 2008 to October 2022 with symptoms suggestive of CCS were included from the Western Denmark Heart Registry (WDHR). A positive coronary CTA was defined as having a diameter stenosis of ≥ 50% stenosis(1). A reference population was generated matching the CTA population 1:5 based on birth year, gender and municipality using data from national registries. Results are presented in 4 groups; as patients with a positive coronary CTA and their reference population and patients with a negative coronary CTA and their reference population. Information on MACE was obtained from the national patient registry as a composite of acute myocardial infarct (AMI), stroke, revascularization, cardiovascular mortality and all-cause mortality and calculated as risk rates per 1000 persons one year after the coronary CTA examination. A Charlson comorbidity index (CCI)(3) was also calculated. Results From the WDHR 94,207 patients, (Mean age 58±11, 48% men) with a first-time coronary CTA on indication CCS were included. Among all conducted coronary CTA scans 18,290 (19.4%) were positive (>50% stenosis). In the analyses of CCI 90,074 patients from the WDHR were matched with 450,345 controls. Patients with both a positive and negative coronary CTA examination had significantly higher CCI than their matching reference population (Table 1). In table 2 risk rates of a MACE are presented after one year following the coronary CTA examination; in this analysis 53,610 patients from the WDHR were matched with 268,040 controls. The risk of AMI was higher among both patients with and without suspected stenosis compared to their respective reference population., However, the risk of all-cause mortality was higher in both the reference populations. The risk rate of revascularization after a positive coronary CTA was, as could be expected, much higher compared to all other groups as this was a result of the examination. Conclusion In this large study of patients referred to coronary CTA we found a higher incidence of AMI and revascularization in both patients with and with suspected stenoses compared to a reference population. However, we also found a lower mortality rate in both groups compared to a reference population. This could indicate a more well treated population, but a direct causality cannot be concluded from this study and further research is needed to better understand this association.Charlson comorbidity indexMACE events

Evaluation of the Charlson Comorbidity Index as a prognostic tool for assessing the severity of hand infections

The Charlson Comorbidity Index (CCI) is used for the prognostic analysis of comorbidities. Comorbidities, especially diabetes mellitus, are a decisive factor for the development and course of hand infections. This study aimed to determine the CCI in patients with hand infections in order to examine how comorbidities influence the course and severity of hand infections. Ninety patients with hand infections requiring surgery but without previous antibiotic treatment were studied prospectively. The respective CCI was determined on admission to hospital. A total score of zero points was defined as "low", a score of one to three as "medium" and a score of four to nine points as a "high" index. Age, CRP level, duration of inpatient stay and the number of performed surgeries were documented and statistically evaluated. The median CCI was 0,5 points with a range of 0-9 points. The most common comorbidity was diabetes mellitus without end-organ damage, followed by heart failure and chronic lung disease. Patients with a low total score (median 51 years) were significantly younger than those with a medium score (median 60 years; p=0,018) or a high score (median 66,5 years; p=0,018). In addition, patients with a low or medium score had a shorter hospital stay (median 6 vs. 11,5 days; plow=0,003; pmean=0,005), required fewer surgeries (median 1 vs. 3 surgeries; plow=0,002; pmean=0,003) and had a lower CRP level (median 8,3 mg/l vs. 7,1 mg/l vs. 86,25 mg/l; plow=pmean=0,001) than those with a high index. A significant positive correlation was found between the CCI and patient age (Spearman's ρ=0,367; p<0,001) as well as the length of hospital stay (Spearman's ρ=0,261; p=0,013), the number of surgeries (Spearman's ρ=0,219; p=0,038) and the CRP level (Spearman's ρ=0,212; p=0,045). The CCI is an appropriate questionnaire for the prognostic assessment of the course and severity of hand infections, particularly with regard to the length of hospital stay, the number of surgeries and the CRP level.

P-079 RISK FACTORS FOR BOWEL RESECTION IN PATIENTS WITH INCARCERATED INGUINAL HERNIA. RETROSPECTIVE CLINICAL STUDY

Abstract Backgraund Early recognition of the risk of bowel resection of patients with incarcerated groin hernia(IGH) will facilitate the clinical decision making of surgeons and improve the outcomes of patients. This study aimed to reveal the risk factors of bowel resection in patients with incarcerated inguinal hernia. Materyal methods We retrospectively collected 312 patients who underwent emergency hernia repair surgery for IGH between January 2017 and October 2022. The patients were categorized into those who received bowel resection and those who did not require bowel resection Data analysis was approved by the local ethics committee. Patient characteristics, laboratory and radiological examinations, surgery data, and postoperative outcomes were compared between patients with and without bowel resection. Risk factors for bowel resection were assessed with univariate and multivariate analysis. Results Univariate analysis identified 7 variables that were significantly associated with bowel resection among patients with IGH. On multivariate analysis, Charlson comorbidity index (CCI) odds ratio [OR] = 0.751, 95% confidence interval [CI] 0.592 0.953, P = .018), Gender (OR = 4.071, 95% CI 1.749/9.475, P = 0.001) and C-reactive protein(CRP) (OR = 0.321, 95% CI 0.145–0.708, P = 0.005) were identified as independent risk factors for bowel resection among patients with IGH. Conclusion In this study, an elavated CRP, gender and high CCI in patients with bowel obstruction due to IGH are associated with an increased risk of bowel resection. Based on our findings, surgeons should prioritize prompt emergency surgical repair for patients who present with elevated CRP and high CCI concurrent with IGH.

Chronic Obstructive Pulmonary Disease and Sleep Apnea Syndrome – a Multidisciplinary Problem of Clinical Medicine

Obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD) are more common pathologies in clinical practice, which are accompanied very often by cardiovascular comorbidity. The objective: to analyze the clinical features of chronic obstructive pulmonary disease course in combination with the risk of sleep apnea syndrome. Materials and methods. 47 patients with COPD III degree of bronchial obstruction, group E participated in the study: 9 (19.1%) women and 38 (80.9%) men. The study participants were divided into two groups: I group (COPD) – 32 persons, II group (COPD + apnea syndrome) – 15 individuals. Clinical, spirographic laboratory, X-ray, ultrasound, and electrocardiographic examinations were performed to the patients, the STOP-Bang questionnaire was used to determine the risk of sleep apnea syndrome development, and the influence of bronchial obstruction on the daytime sleepiness (Epworth scale) and depression (Beck questionnaire) was studied. Results. The analysis of the results of the study presented that among the examined patients with COPD 32 (68.1%) subjects were identified with a high risk of sleep apnea syndrome. In this cohort of patients there were signs of daytime sleepiness according to the Epworth scale, and according to the Beck questionnaire they scored more than 10 points, that is, a mild level of depression of situational or neurotic origin was found. It was found that among patients with COPD in combination with the risk of night apnea (II group), coronary heart disease was diagnosed in 24 (75%) cases, arterial hypertension – in 22 (68.8%) cases, diabetes – in 15 (46.9%). At the same time, the prevalence of these nosologies in patients with COPD without the risk of night apnea was significantly (p&lt;0.05) lower. The Charlson comorbidity index in patients with COPD and risk of apnea was within 3–4 points, 10-year survival was within 77–53%. Conclusions. The high risk of apnea syndrome according to the results of the screening questionnaire, excessive daytime sleepiness, and depressive states in patients with COPD should prompt primary care physicians to refer such patients to a comprehensive polysomnography examination to confirm OSAS. After all, COPD, OSAS and cardiovascular comorbidity are characterized by a more unfavorable clinical course and prognosis than each of these diseases separately.

Correlation Between Biomarkers and Age-Adjusted Charlson Comorbidity Index in Patients With COVID-19: A Cross-Sectional Study in a Tertiary Care Center in South India.

Background Coronaviruses, generally known to cause a mild degree of respiratory illness have in the recent past caused three serious disease outbreaks. The world is yet to be released from the grip of the most recent coronavirus disease 2019 (COVID-19) pandemic due to emerging mutant strains. Age, presence of comorbidities, clinical severity, and laboratory markers such as C-reactive protein and D-dimer are some of the factors being employed to prioritize patients for hospital care. It is known that comorbidities themselves are an outcome of inflammation and can induce a pro-inflammatory state. Our study aims to elucidate the influence of age and comorbidities on laboratory markers in patients with COVID-19. Methodology This is a single-center retrospective study of patients with a laboratory diagnosis of COVID-19 admitted to our hospital between September 21, 2020, and October 1, 2020. A total of 387 patients above the age of 18 years were included in the analysis and categorized based on the age-adjusted Charlson comorbidity index (ACCI) score into group A (score ≤4) and group B (score >4). Demographic, clinical, and laboratory factors as well as outcomes were compared. Results Group B exhibited higher intensive care unit admission and mortality, as well as statistically significant higher mean values of most laboratory markers. A correlation was also observed between the ACCI score and biomarker values. On comparison between the two groups regarding cut-offs predicting mortality for laboratory determinants, no consistent pattern was observed. Conclusions A correlation between age, the number of comorbidities, and laboratory markers was observed in our analysis of COVID-19-affected patients. Aging and comorbid conditions can produce a state of meta-inflammation and can thereby contribute to hyperinflammation in COVID-19. This can be an explanation for the higher risk of COVID-19-related mortality in older individuals and those with underlying comorbidities.

How long is too long: A retrospective study evaluating the impact of the duration of noninvasive oxygenation support strategies (high flow nasal cannula & BiPAP) on mortality in invasive mechanically ventilated patients with COVID-19.

We investigated the association of noninvasive oxygenation support [high flow nasal cannula (HFNC) and BiPAP], timing of invasive mechanical ventilation (IMV), and inpatient mortality among patients hospitalized with COVID-19. Retrospective chart review study of patients hospitalized with COVID-19 (ICD-10 code U07.1) and received IMV from March 2020-October 2021. Charlson comorbidity index (CCI) was calculated; Obesity defined as body mass index (BMI) ≥ 30 kg/m2; morbid obesity was BMI ≥ 40 kg/m2. Clinical parameters/vital signs recorded at time of admission. 709 COVID-19 patients underwent IMV, predominantly admitted from March-May 2020 (45%), average age 62±15 years, 67% male, 37% Hispanic, and 9% from group living settings. 44% had obesity, 11% had morbid obesity, 55% had type II diabetes, 75% had hypertension, and average CCI was 3.65 (SD = 3.11). Crude mortality rate was 56%. Close linear association of age with inpatient-mortality risk was found [OR (95% CI) = 1.35 (1.27-1.44) per 5 years, p<0.0001)]. Patients who died after IMV received noninvasive oxygenation support significantly longer: 5.3 (8.0) vs. 2.7 (SD 4.6) days; longer use was also independently associated with a higher risk of inpatient-mortality: OR = 3.1 (1.8-5.4) for 3-7 days, 7.2 (3.8-13.7) for ≥8 days (reference: 1-2 days) (p<0.0001). The association magnitude varied between age groups: 3-7 days duration (ref: 1-2 days), OR = 4.8 (1.9-12.1) in ≥65 years old vs. 2.1 (1.0-4.6) in <65 years old. Higher mortality risk was associated with higher CCI in patients ≥65 (P = 0.0082); among younger patients, obesity (OR = 1.8 (1.0-3.2) or morbid obesity (OR = 2.8;1.4-5.9) (p<0.05) were associated. No mortality association was found for sex or race. Time spent on noninvasive oxygenation support [as defined by high flow nasal cannula (HFNC) and BiPAP] prior to IMV increased mortality risk. Research for the generalizability of our findings to other respiratory failure patient populations is needed.

Cytokine Levels and Severity of Illness Scoring Systems to Predict Mortality in COVID-19 Infection.

Various scoring systems and cytokines have been cited as predicting disease severity in COVID-19 infection. This study analyzed the link between mortality rate, levels of cytokines, and scoring systems such as the Glasgow Coma Scale (GCS), Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Charlson Comorbidity Index in patients infected with COVID-19. Adult patients infected with COVID-19 were followed up in the intensive care unit (ICU) and analyzed prospectively. We measured serum cytokine levels (Interleukin-10 (IL-10), Interleukin-8 (IL-8), Interleukin-6 (IL-6), Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α) and High mobility group box 1 (HMGB-1)) and recorded GCS, APACHE II, SOFA, and Charlson comorbidity index scores on admission to the ICU. Receiver operating curve (ROC) analysis was performed to predict mortality from IL-1β, IL-6 IL-10, IL-8, TNF-α, and HMGB-1 values. Study participants were grouped as follows: Group A, survivors, and Group B, deceased, during the 28-day follow-up. The mean age was 65.69 (±13.56) in Group A (n = 36) and 70.85 (±10.06) in Group B (n = 27). The female/male ratio was 23/40. Age, sex, body mass index (BMI), comorbid illnesses, GCS, APACHE II, SOFA, and Charlson scores, duration of hospitalization or ICU admission, therapeutic choices, and lymphocyte, PMNL, NLR, platelet, D-dimer, fibrinogen, GGT, CRP, procalcitonin, and lactate levels were similar between the groups. The frequency of acute kidney injury (AKI) was higher in Group B (p = 0.005). Serum IL-10, IL-8, IL-6, IL-1β, TNF-α, HMGB-1, ferritin, and LDH values were higher, and PaO2/FiO2 was lower in Group B than in Group A. ROC analysis showed that there was an association between serum IL-1β (>1015.7), serum IL-6 (>116.7), serum IL-8 (>258.4), serum IL-10 (>247.5), serum TNF-α (>280.7), and serum HMGB-1 (>23.5) and mortality. AKI gave rise to a greater risk of mortality (odds ratio: 7.081, p = 0.014). Mortality was associated with serum IL-10, IL-8, IL-6, IL-1β, TNF-α, and HMGB-1 but not with GCS, APACHE II, SOFA, or Charlson comorbidity index scores. AKI increased the risk of mortality by seven times. Our findings suggest that cytokine levels (serum IL-10, IL-8, IL-6, IL-1β, TNF-α, and HMGB-1) were predictors of mortality in COVID-19 infection. In addition, our results might give an opinion about the course of COVID-19 infection.

Prognostic role of demographic indicators and Charlson comorbidity index in oxygen-dependent patients with coronavirus disease (COVID-19)

Aim. The aim of our work is to establish the prognostic significance of demographic indicators and the Charlson comorbidity index (CCI) in oxygen-dependent patients with coronavirus disease (COVID-19). Material and methods. The research included 211 oxygen-dependent patients with COVID-19: I group – 94 patients who recovered; II group – 117 patients, the disease ended fatally. We used the WHO age classification when analyzing the age structure of patients. The Charlson comorbidity index was calculated for each patient. The patients were divided into groups Statistical data processing was carried out in the program Statistica for Windows 13 (StatSoft Inc., No. JPZ804I382130ARCN10-J). Results. It was established that the median age of the ІІ group patients was higher (P &lt; 0.001) than patients the I in group. Elderly patients were more often registered in the ІІ group than among patients in group I (25.6 % vs. 8.5 %, P = 0.001). Middle-aged patients were more often registered in the І group than among patients in the II group (34.0 % vs. 19.4 %, P = 0.02). According to the result of the ROC analysis, the prognostic value of the age of the patients was established, namely, under conditions of age &gt;66 years (AUC = 0.636, Р = 0.002), the probability of a fatal outcome of COVID-19 was significant. Analysis of the influence of comorbid conditions on the risk of COVID-19 fatal outcome in oxygen-dependent patients according to the CCI showed that the absence of comorbid pathology was more common among patients of group I than among patients of group II (12.8 % vs. 2.6 %, P = 0.004). The level of CCI in patients of the II group significantly exceeded the corresponding indicator of the patients of the I group (P &lt; 0.01), who recovered. According to the obtained result of the ROC analysis, the prognostic value of this indicator was established, namely under the conditions of the CCI index &gt;5 in oxygen-dependent patients with COVID-19 (AUC = 0.652, P &lt; 0.001) the probability of fatal outcome of the disease was significant. Conclusions. In oxygen-dependent patients with COVID-19, patient age and comorbidity are associated with disease outcome. Under conditions of age &gt;66 years (AUC = 0.636, P = 0.002) and the Charlson comorbidity index &gt;5, the probability of a fatal outcome of the disease is significant (AUC = 0.652, P &lt; 0.001).

Bowel cleansing efficacy of 1L NER1006versus macrogol and 3L polyethylene glycol using split-dose administration.

Colonoscopies are an important diagnostic technique in the detection of colorectal cancer and colonic disease. Adequate examination is dependent on the degree of mucosal visibility, with poor cleansing impeding the detection of neoplasms. These patients require shorter colonoscopy surveillance intervals, longer hospital stays, and increased healthcare costs-rendering a screening colonoscopy cost-ineffective. In Australia and the Gold Coast Hospital and Health Service (GCHHS), macrogol and 3L of polyethylene glycol are the preferred regimen given its safety profile and efficacy. Yet, little is known locally about the use of the new low-volume bowel preparation NER1006 (Plenvu) given its recent registration with the Therapeutic Goods of Australia (TGA). The primary outcome assessed the bowel cleansing efficacy of NER1006 compared with 7 days of macrogol and 3L of polyethylene glycol using the Boston Bowel Preparation Scale (BBPS), while also assessing the influence of notable patient characteristics such as age, gender, body mass index (BMI), and the patients Charlson comorbidity index (CCI). Secondary outcomes assessed the polyp detection rate and procedural factors including cecal intubation, scope withdrawal time, and rebooking rates. Data from all patients who underwent an outpatient colonoscopy procedure at GCHHS between 1 July 2020 and 30 September 2020 were analyzed. Patients were aged 50-74 years of age and were referred for a screening colonoscopy due to a positive fecal occult blood test (FOBT) result from the National Bowel Cancer Screening Program. Of the 238 patients who met the inclusion criteria, 108 patients received NER1006 and 130 patients received macrogol and 3L polyethylene glycol. NER1006 achieved superior overall (P< 0.001) and right-sided colon cleansing (P= 0.016). There was an even distribution of males and females (P= 0.118), the mean age of both cohorts was <65 years of age. The macrogol and 3L polyethylene glycol group had a statistically higher BMI (P< 0.001) and CCI (P< 0.001). Cecal intubation success was achieved in both cohorts (≥95%) and scope withdrawal time was ≥6min, polyp detection was non-superior (P= 0.824), but superior in NER1006 when BBPS ≥6 (P= 0.002). Rebooking rates were significantly lower in the NER1006 group (P= 0.013). This study demonstrated that NER1006 was superior in terms of overall and right-sided bowel cleansing as a primary endpoint. Patient factors demonstrated to be independent predictors of inadequate bowel preparation. Future studies should aim to explore the safety and tolerability of NER1006 while also assessing the bowel cleansing effectiveness in patients with a high BMI and comorbidity index.

Obesity and COVID-19 Outcomes in a Primarily Black Population

Background: Studies have noted higher COVID-19 mortality with more severe obesity in populations that included a small percentage of Black patients. Methods: We retrospectively analyzed COVID-19 outcomes associated with obesity in our largely African American patient population. A total of 1101 symptomatic patients with a positive COVID-19 laboratory test March 5 to June 3, 2020, were categorized into weight groups based on body mass index (BMI). Of these patients, 679 (61.7%) were Black. A total of 355 (32.2%) patients had overweight and 516 (46.9%) had obesity. Results: BMI was an independent risk factor for intubation and an independent predictor for ICU length of stay and intubation days. An unexpected observation was favorable outcomes in mild obesity compared with normal weight and more severe obesity, likely a result of older age and higher Charlson comorbidity index in patients with normal BMI compared with patients with mild obesity. Conclusions: In a diverse primarily Black population, comorbidities were a concern for adverse COVID-19 outcomes and COVID-19 outcomes were significantly worse with moderate and severe obesity.

Common Biomarkers Associated with Delirium in Hospitalized Patients with COVID-19 at the Epicentre of Turkish Coronavirus Outbreak: A Case-Control Study.

To investigate the differences in biochemical characteristics between Coronavirus Disease 2019 (COVID-19) patients with and without delirium in non-intensive care (IC) COVID-19 units was aimed. This study was designed as an observational, single-centered, and case-control study consisting of 43 delirious patients and matched 45 non-delirious patients admitted to non-IC COVID-19 units. Delirium was diagnosed by a consultant psychiatrist according to the DSM-5 delirium diagnostic criteria. Independent variables such as laboratory tests at the time of admission, clinical features, and patient characteristics were obtained from electronic medical records by researchers. In the primary analyses, binomial logistic regression models were used to investigate the factors associated with delirium, which was identified as the outcome variable. Multivariate logistic models were then adjusted for potential confounding factors, including age, gender, history of neurocognitive disorders and Charlson Comorbidity Index (CCI). We observed higher levels of urea, d-dimer, troponin-T, proB-type natriuretic peptide, and CCI in patients with delirium compared to patients without delirium. We also observed lower levels of estimated glomerular filtration rate (eGFR), serum albumin, and O2 saturation and a decrease in the length of stay at the hospital. After adjusting for confounding factors such as gender, age, and comorbidity, we found that urea (adjusted estimate=0.015; 95% Confidence Interval [CI]=0.058-0.032, P=0.039), urea/creatinine ratio (adjusted estimate=0.008; 95% CI=0.002-0.013, P=0.011), and troponin-T (adjusted estimate=0.066; 95% CI=0.014-0.118, P=0.014) were independent biomarkers associated with delirium. Delirium is associated with higher urea levels and urea/creatinine ratios in COVID-19 patients. In addition, the relationship between troponin-T and delirium may help understand the potential link between the brain and the heart in COVID-19. Additional multi-centred studies with larger sample sizes are needed to generalise these results.

Prognostic value of the age-adjusted Charlson comorbidity index in patients over 60 years old with laryngeal squamous cell carcinoma

Objective: To evaluate the value of the age-adjusted Charlson comorbidity Index (ACCI) in predicting the prognosis and guiding the clinical treatment of laryngeal squamous cell carcinoma (LSCC) in patients over 60 years old. Methods: Retrospective analysis of 249 cases of LSCC in Shanxi Provincial Cancer Hospital and First Hospital of Shanxi Medical University from 2008 to 2015 was performed. There were 234 males and 15 females, aged from 60 to 88 years. The clinical characteristics, treatment information and follow-up data were collected. ACCI was used to score the comorbidities of the patients. Receiver operating characteristic (ROC) curve was drawn and the patients were divided into high ACCI group and low ACCI group according to the cut-off value of ACCI. Prognostic factors were analyzed. Kaplan-Meier method was used for survival analysis, rank sum test was used for comparison between groups, χ2 test was used for enumeration data. Results: Overall survival (OS) was 54.6%, progression-free survival (PFS) was 59.4%, and cancer-specific survival (CSS) was 58.6%. Both the median survival time and PFS time were 60 months. The best cutoff point of the ACCI group was 5. Cox multivariate analysis showed that ACCI was an independent risk factor for OS, PFS and CSS (OR=1.553, 1.499 and 1.534,respectively, all P<0.05). In the high ACCI group, OS (χ2=4.120 and 4.115,P<0.05) and CSS (χ2=4.510 and 5.009,P<0.05) of patients treated with surgery plus radiotherapy and patients with radiotherapy alone were better than those of patients with surgery alone (P<0.05). But in the low ACCI group, there was no significant difference in prognosis among the three treatment regimens (P>0.05). Conclusion: High ACCI offors important prognostic information for LSCC in patients over 60 years old, and can guide clinical treatment options.

Comparing the Predictors of Functional Outcomes After Arthroscopic Rotator Cuff Repair Modified Frailty Index, Clinical Frailty Scale, and Charlson Comorbidity Index

Background:The incidence of rotator cuff tears increases with age, and operative management is usually required in patients with persistent symptoms. Although several studies have analyzed the effect of age and comorbidities on outcomes after rotator cuff repair, no study has specifically examined the consequence of frailty.Purpose:To determine the best frailty/comorbidity index for predicting functional outcomes after arthroscopic rotator cuff repair.Study Design:Cohort study; Level of evidence, 3.Methods:The authors conducted a retrospective cohort study of 340 consecutive patients who underwent unilateral arthroscopic rotator cuff repair at a tertiary hospital between April 2016 and April 2018. All patients had undergone arthroscopic double-row rotator cuff repair with subacromial decompression by a single fellowship-trained shoulder surgeon. Patient frailty was measured using the Modified Frailty Index (MFI), Clinical Frailty Scale (CFS), and Charlson Comorbidity Index (CCI), calculated through retrospective chart review based on case notes made just before surgery; patient age and sex were also noted preoperatively. Functional outcomes using the Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), University of California Los Angeles (UCLA) Shoulder Score, and visual analog scale for pain were measured preoperatively and at 3, 6, 12, and 24 months postoperatively.Results:The MFI was a consistent significant predictor in all functional outcome scores up to 24 months postoperatively (P < .05), unlike the CFS and CCI. Sex was also a significant predictor of postoperative OSS, CSS, and UCLA Shoulder Score, with male sex being associated with better functional outcomes. Patients with higher MFI scores had slower functional improvement postoperatively, but they eventually attained functional outcome scores comparable with those of their counterparts with lower MFI scores at 24 months postoperatively.Conclusion:The MFI was found to be a better tool for predicting postoperative function than was the CFS or CCI in patients undergoing arthroscopic rotator cuff repair. The study findings suggest that a multidimensional assessment of frailty (including both functional status and comorbidities) is important in determining functional outcomes after arthroscopic rotator cuff repair.

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study.

BackgroundGeneralized weakness and fatigue are underexplored symptoms in emergency medicine. Triage tools often underestimate patients presenting to the emergency department (ED) with these nonspecific symptoms (Nemec et al., 2010). At the same time, physicians’ disease severity rating (DSR) on a scale from 0 (not sick at all) to 10 (extremely sick) predicts key outcomes in ED patients (Beglinger et al., 2015; Rohacek et al., 2015). Our goals were (1) to characterize ED patients with weakness and/or fatigue (W|F); to explore (2) to what extent physicians’ DSR at triage can predict five key outcomes in ED patients with W|F; (3) how well DSR performs relative to two commonly used benchmark methods, the Emergency Severity Index (ESI) and the Charlson Comorbidity Index (CCI); (4) to what extent DSR provides predictive information beyond ESI, CCI, or their linear combination, i.e., whether ESI and CCI should be used alone or in combination with DSR; and (5) to what extent ESI, CCI, or their linear combination provide predictive information beyond DSR alone, i.e., whether DSR should be used alone or in combination with ESI and / or CCI.MethodsProspective observational study between 2013–2015 (analysis in 2018–2020, study team blinded to hypothesis) conducted at a single center. We study an all-comer cohort of 3,960 patients (48% female patients, median age = 51 years, 94% completed 1-year follow-up). We looked at two primary outcomes (acute morbidity (Bingisser et al., 2017; Weigel et al., 2017) and all-cause 1- year mortality) and three secondary outcomes (in-hospital mortality, hospitalization and transfer to ICU). We assessed the predictive power (i.e., resolution, measured as the Area under the ROC Curve, AUC) of the scores and, using logistic regression, their linear combinations.FindingsCompared to patients without W|F (n = 3,227), patients with W|F (n = 733) showed higher prevalences for all five outcomes, reported more symptoms across both genders, and received higher DSRs (median = 4; interquartile range (IQR) = 3–6 vs. median = 3; IQR = 2–5). DSR predicted all five outcomes well above chance (i.e., AUCs > ~0.70), similarly well for both patients with and without W|F, and as good as or better than ESI and CCI in patients with and without W|F (except for 1-year mortality where CCI performs better). For acute morbidity, hospitalization, and transfer to ICU there is clear evidence that adding DSR to ESI and/or CCI improves predictions for both patient groups; for 1-year mortality and in-hospital mortality this holds for most, but not all comparisons. Adding ESI and/or CCI to DSR generally did not improve performance or even decreased it.ConclusionsThe use of physicians’ disease severity rating has never been investigated in patients with generalized weakness and fatigue. We show that physicians’ prediction of acute morbidity, mortality, hospitalization, and transfer to ICU through their DSR is also accurate in these patients. Across all patients, DSR is less predictive of acute morbidity for female than male patients, however. Future research should investigate how emergency physicians judge their patients’ clinical state at triage and how this can be improved and used in simple decision aids.

Increasing Comorbidity and Frailty is Not Associated with Early Postoperative Complications among Men Undergoing Artificial Urinary Sphincter or Sling Implantation: A Real-World Application of NSQIP® Data to Reconstructive Urology.

Urologists may be hesitant to surgically treat urinary incontinence in comorbid genitourinary cancer survivors. We assessed the relationship between comorbidities and 30-day perioperative outcomes following artificial urinary sphincter and sling implantation. Using the National Surgical Quality Improvement Program, patients with CPT codes for artificial urinary sphincter and sling implantation were identified between 2007 and 2015. The patient's Charlson comorbidity index and Frailty Index scores were calculated based on ICD-9 codes. The primary outcome was presence of perioperative complications. The association between Charlson comorbidity index and Frailty Index and each primary outcome was investigated using multivariate logistic regression models. We queried 1,370 and 1,018 records with artificial urinary sphincter and sling implantation, respectively. The median Charlson comorbidity index for artificial urinary sphincter patients was 4.0 (Q1 3, Q3 5), while for sling patients it was 3.0 (Q1 3, Q3 4). In the artificial urinary sphincter cohort, 47% had 1 Frailty Index condition, whereas 25% had 2 or more Frailty Index conditions. In the sling group, 42% had 1 Frailty Index condition, while 19% had 2 or more Frailty Index conditions. The event rate for overall complications was 5.4% and 3.0% in the artificial urinary sphincter and sling cohort, respectively. After adjusting for covariates in both the artificial urinary sphincter and sling cohort Charlson comorbidity index or Frailty Index was not associated with the odds of having a complication. The presence of increased comorbidities or frailty is not associated with short-term postoperative complications among men undergoing artificial urinary sphincter or sling implantation.

Extra-hepatic comorbidity burden significantly increases 90-day mortality in patients with cirrhosis and high model for endstage liver disease

BackgroundWe examined how extra-hepatic comorbidity burden impacts mortality in patients with cirrhosis referred for liver transplantation (LT).MethodsAdults with cirrhosis evaluated for their first LT in 2012 were followed through their clinical course with last follow up in 2019. Extra-hepatic comorbidity burden was measured using the Charlson Comorbidity Index (CCI). The endpoints were 90-day transplant free survival (Cox-Proportional Hazard regression), and overall mortality (competing risk analysis).ResultsThe study included 340 patients, mean age 56 ± 11, 63% male and MELD-Na 17.2 ± 6.6. The CCI was 0 (no comorbidities) in 44%, 1–2 in 44% and > 2 (highest decile) in 12%, with no differences based on gender but higher CCI in patients with fatty and cryptogenic liver disease. Thirty-three (10%) of 332 patients not receiving LT within 90 days died. Beyond MELD-Na, the CCI was independently associated with 90-day mortality (hazard ratio (HR), 1.32 (95% confidence interval (CI) 1.02–1.72). Ninety-day mortality was specifically increased with higher CCI category and MELD ≥18 (12% (CCI = 0), 22% (CCI = 1–2) and 33% (CCI > 2), (p = 0.002)) but not MELD-Na ≤17. At last follow-up, 69 patients were alive, 100 underwent LT and 171 died without LT. CCI was associated with increased overall mortality in the competing risk analysis (Sub-HR 1.24, 95%CI 1.1–1.4).ConclusionsExtra-hepatic comorbidity burden significantly impacts short-term mortality in patients with cirrhosis and high MELD-Na. This has implications in determining urgency of LT and mortality models in cirrhosis and LT waitlisting, especially with an ageing population with increasing prevalence of fatty liver disease.

Multi-Center Retrospective Evaluation of High-Dose Cytarabine Based Induction Versus CPX-351 Induction in Patients with Secondary AML

BACKGROUND Secondary AML (sAML) that develops after an antecedent hematologic disorder or exposure to genotoxic therapy is associated with a poor prognosis and historical long-term survival rates of 5-10% (Granfeldt Østgård et al. 2015). Liposomal daunorubicin and cytarabine (CPX-351) was recently FDA approved for the treatment of sAML, based on a randomized phase III trial that found a higher complete remission (CR) rate, event-free survival (EFS), and overall survival (OS) with CPX-351 compared to 7+3 chemotherapy (Lancet et al. 2018). Retrospective studies conducted in this patient population suggest that high-dose cytarabine (HIDAC)-based regimens may also be safe and effective in sAML (Vulaj et al. 2018, Talati et al. 2018). With an average wholesale price of up to $150,000 for induction, CPX-351 represents a large financial burden when compared to HIDAC-based regimens. Because HIDAC-based regimens employ older, generic medications, and sAML is a relatively rare diagnosis, it is unlikely these two induction strategies will be compared prospectively. This real-world, multicenter study retrospectively compared clinical outcomes in patients with sAML receiving CPX-351 and HIDAC-based regimens. METHODS Adult patients with newly diagnosed sAML treated between January 2013 and January 2019 from 7 academic medical centers (University of Michigan n=73, MD Anderson Cancer Center n=27, Barnes Jewish Hospital n=22, University of North Carolina n=21, Huntsman Cancer Institute n=9, University of Rochester n=9, Indiana University n=8) were divided into 2 cohorts based on induction regimen: HIDAC-based or CPX-351. Demographics, disease characteristics, and outcomes were collected in accordance with the institutional review board approved protocol. The primary endpoint of composite complete response/complete response with incomplete count recovery (CR/CRi) as well as secondary efficacy endpoints were defined using 2003 International Working Group Criteria. For the primary endpoint, a sample of 96 patients was established a priori as necessary to demonstrate non-inferiority of HIDAC-based regimens using a non-inferiority margin of 7.5% and historical CR/CRi rates or 65% and 47.7% for HIDAC-based and CPX-351 respectively. Chi-square or Fisher's exact tests were utilized to evaluate dichotomous variables. Continuous variables were analyzed via Student's t-test or Mann-Whitney U test. Kaplan-Meier analysis with log-rank test was performed to estimate progression-free survival (PFS) and overall survival (OS). RESULTS A total of 169 patients were included (HIDAC-based: n=75; CPX-351: n=94). HIDAC-based regimen distribution was as follows: fludarabine/cytarabine ± G-CSF (n=73) and clofarabine/cytarabine ± G-CSF (n=2). Baseline characteristics were well balanced (table 1) with the exception of a higher Charlson Comorbidity Index in patients who received HIDAC-based therapy. The median age of all patients was 67 years and the majority of patients had sAML due to an antecedent hematologic disorder. CR/CRi rate was numerically higher and non-inferior with HIDAC-based therapy (62.7%) compared with CPX-351 (47.9%) (p=0.002 [one-sided for non-inferiority]). Median OS was 10.06 vs 10.59 months and median EFS was 5.56 vs 4.11 months with HIDAC-based regimens compared with CPX-351, respectively. Thirty-day mortality (1.3 vs 8.5%; p=0.039) and confirmed infection in induction (56% vs 74.5%; p=0.012) were significantly higher with CPX-351. Additionally, the time to absolute neutrophil count (ANC) and platelet count (PLT) recovery in CR/CRi were significantly longer with CPX (ANC: 18 vs 35.5 days; p&lt;0.001; PLT: 23 vs 37.5 days; p&lt;0.001). CONCLUSIONS HIDAC-based regimens yield CR/CRi rates that are non-inferior to CPX-351 in patients with sAML with similar EFS and OS. In a primarily elderly population, HIDAC-based therapy demonstrates greater tolerability with lower induction mortality, infection rates, and a more favorable duration of cytopenias. With non-inferior efficacy, better tolerability, and significantly lower cost, HIDAC-based regimens may be preferred to CPX-351 in patients with sAML. Disclosures Klaus: Jazz Pharmaceuticals: Other: Advisory Board, Speakers Bureau. Clark:Elliott Benson Research: Consultancy. Pettit:Samus Therapeutics: Research Funding.

Prognostic Effects of Pretreatment Statuses at Diagnosis in Patients with Chronic Myeloid Leukemia: Results of the New Target Observational Study 1

Prognostic Effects of Pretreatment Statuses at Diagnosis in Patients with Chronic Myeloid Leukemia: Results of the New Target Observational Study 1

Untangling operational failures of the Status Epilepticus Severity Score (STESS).

To uncover clinical characteristics leading to false outcome prediction of the Status Epilepticus Severity Score (STESS), a validated and broadly used clinical scoring system for outcome prediction in status epilepticus (SE). From 2005 to 2016, adult patients with SE treated at the University Hospital Basel, Switzerland, were included. To assess independent associations of variables differing between patients with false and correct prediction of death (STESS ≥ 3), multivariable logistic regression models were computed using automated selection. Among 467 patients, 12% died. The median STESS was 3 (interquartile range 2-4). Regarding prediction of death, the STESS was false-positive in 51% and false-negative in 1%. Patients surviving despite having a STESS ≥3 had less fatal etiologies, less nonconvulsive SE with coma, and lower Charlson Comorbidity Index, Simplified Acute Physiology Score II, and Acute Physiology and Chronic Health Evaluation II scores. In multivariable analyses, odds for survival were high with SE types other than nonconvulsive status with coma and low with an increasing Charlson Comorbidity Index in patients with a STESS ≥ 3 (odds ratio [OR]for survival 4.23, 95% confidence interval [CI] 2.33-9.60; and ORfor survival 0.86, 95% CI 0.75-0.98). In patients with SE types other than nonconvulsive with coma, the STESS was mainly increased because they were frequently older than 65 years and had no seizure history. The STESS frequently and inadequately predicts death especially in patients with SE other than nonconvulsive with coma and few comorbidities. Clinicians are urged to interpret a STESS ≥3 with caution in such patients.

Charlson Comorbidity Index in patients with systemic lupus erythematosus in Egypt and its relation with disease characteristics

Background: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder associated with various comorbid conditions. Here, we assessed the burden of comorbidity in patients with SLE in Egypt using the Charlson Comorbidity Index (CCI) and determined its association with the disease characteristics. Patients and Methods: In this retrospective study, data of patients with SLE in Egypt were collected from the medical records. This included demographic data, clinical characteristics, comorbidities, and baseline SLE disease activity index (SLEDAI) and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) scores at the last visit. The CCI score was calculated for each patient. The data of deceased patients were also collected. Results: Overall, 152 patients were included in this study. The most common comorbidities excluded from the CCI were serious infections (27%) and hypertension (23%); the most common comorbidities included in the CCI, apart from the connective tissue disease, were moderate or severe renal disease (12.5%), peptic ulcer (9.9%), and diabetes mellitus (9.9%) without end-organ damage. The mean CCI score was 1.9 and was significantly correlated with the disease duration, SLEDAI, and SDI. The death rate was 7.9%; the most common cause of death was infection (50%). Death was significantly associated with a high score of SLEDAI, SDI, and CCI. The mortality rate was higher in patients with SLE along with hypertension, renal affection, hyperlipidemia, infection, and tumors (P Conclusion: Patients with SLE in Egypt experienced comorbidities and high CCI scores that affected their survival.