Charlson Comorbidity Index Score Research Articles

Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure.

Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30days of life. This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. A total of 48,466 deceased patients diagnosed with heart failure on Medicare. Billed advance care planning services between the last 12months and last 30days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.

Predictors of Same-Day Discharge after Single-Port Transvesical Enucleation of the Prostate (STEP).

To determine the rate of outpatient cases and identify predictors for same-day discharge (SDD) after single-port transvesical enucleation of the prostate (STEP). Retrospective analysis of all consecutive STEP cases performed at a single center by three surgeons from February 2019 to October 2023. The cohort was categorized into SDD cases (<8 hours until discharge) and inpatient cases. Group comparisons were made and logistic regression was used to identify predictors of SDD. A total of 152 STEP cases were performed successfully without additional ports or conversions. Fifty-two patients were pre-planned admissions, leaving 100 planned outpatient cases, of which 86% were discharged on the same day (median length of stay of 4.7 hours). Comparing the groups, inpatient cases were older, had higher Charlson Comorbidity Index (CCI) scores, higher estimated blood loss (EBL) during surgery, and more intraoperative complications than SDD patients. Univariate logistic regression identified age and CCI as the predictors associated with SDD after STEP. Notably, there were no major postoperative complications or readmissions in either group. In our four-year experience with STEP, lower age and CCI score were significant predictors of SDD. The comprehensive evaluation criteria for discharge foster a safe recovery at home, coupled with a 0% rate of major postoperative complications and readmissions. These findings underscore the safety and efficacy of STEP, guiding patient counseling and surgeon expectations.

Relationship of oral bacterial number with medical hospitalization costs in analysis of Diagnosis Procedure Combination database from single institution in Japan

Oral bacteria are known to be associated with perioperative complications during hospitalization. However, no presented reports have clarified the relationship of oral bacterial number with medical costs for inpatients. The Diagnosis Procedure Combination (DPC) database system used in Japan provides clinical information regarding acute hospital patients. The present study was conducted to determine the association of oral bacterial numbers in individual patients treated at a single institution with length of hospital stay and medical costs using DPC data. A total of 2369 patients referred by the medical department to the dental department at Hiroshima University Hospital were divided into the low (n = 2060) and high (n = 309) oral bacterial number groups. Length of hospital stay and medical costs were compared between the groups, as well as the associations of number of oral bacteria with Charlson comorbidity index (CCI)-related diseases in regard to mortality and disease severity. There was no significant difference in hospital stay length between the low (24.3 ± 24.2 days) and high (22.8 ± 20.1 days) oral bacterial number groups. On the other hand, the daily hospital medical cost in the high group was significantly greater (US$1456.2 ± 1505.7 vs. US$1185.7 ± 1128.6, P < 0.001). Additionally, there was no significant difference in CCI score between the groups, whereas the daily hospital medical costs for patients in the high group treated for cardiovascular disease or malignant tumors were greater than in the low number group (P < 0.05). Multivariate regression analysis was also performed, which showed that oral bacterial number, age, gender, BMI, cardiovascular disease, diabetes, malignant tumor, and hospital stay length were independently associated with daily hospitalization costs. Monitoring and oral care treatment to lower the number of oral bacteria in patients affected by cardiovascular disease or cancer may contribute to reduce hospitalization costs.

AGE, DISEASE DURATION AND MULTIMORBIDITY AS PREDICTORS OF HYPOGLYCEMIA IN ELDERLY AND SENILE WOMEN WITH TYPE 2 DIABETES MELLITUS

AbstractAim – to study the relationship between age, duration of the disease and concomitant chronic non-infectious pathology with the risk of developing hypoglycemia in patients with type 2 diabetes mellitus (T2DM).Material and methods. The study involved 90 elderly and senile women (mean age 70.5 ± 6.2 years) with T2DM. A detailed history of the disease was collected from all study participants, and medical documentation was studied. The indicators of clinical blood test and biochemical blood test were studied, and the Charlson comorbidity index was calculated.Results. The prevalence of hypoglycemia among patients with T2DM was: 47% in the elderly and 75% in senile patients. The correlation index between the indicators “Patient’s age” and “Presence of hypoglycemia” was r = 0.2489 (p = 0.018), which indicates a statistical dependence of these values. When calculating χ2 (chi-square), the value obtained was χ2 = 5.513 (p = 0.018). One-way analysis of variance on these values shows a result of F-ratio = 5.811 at the significance level (p = 0.018), which confirms a significant relationship between the two variables. The correlation index was calculated for the indicators “Presence of cases of hypoglycemia” and “Existence of diabetes mellitus” (r = 0.3512 with a significance level of p = 0.0007). The data allows us to draw a conclusion about the statistical dependence of these values. The result of the χ2 test for trend was the value χ2 (trend) = 10.982, (p = 0.0009). The data presented indicate the relationship between these variables. The correlation between the indicators “Presence of cases of hypoglycemia” and “Charlson Comorbidity Index (scores)” is confirmed by the value r = 0.4020 (p = 0.0001). The relationship between these variables was revealed by calculating χ2 = 16.336, (p = 0.0059). Based on the χ2 test for trend, the value χ2 (trend) = 14.544, (p = 0.0001) was obtained. One-way analysis of variance for these indicators shows the result of F-ratio = 3.734 (p = 0.004).Conclusion. The patient's age, duration of T2DM and multimorbidity are significantly associated with the risk of hypoglycemia in patients with T2DM.

Stratifying Mortality Risk in Intensive Care: A Comprehensive Analysis Using Cluster Analysis and Classification and Regression Tree Algorithms

Abstract Background Machine learning (ML) can be promising for stratifying patients into homogeneous groups and assessing mortality based on score combination. Using ML, we compared mortality prediction performance for clustered and non-clustered models and tried to develop a simple decision algorithm to predict the patient’s cluster membership with classification and regression trees (CART). Methods Retrospective study involving patients requiring ICU admission (1st January 2011–16th September 2022). Clusters were identified by combining Charlson Comorbidity Index (CCI) plus Simplified Acute Physiology Score II (SAPS II) or Sequential Organ Failure Assessment (SOFA). Intercluster and survival analyses were performed. We analyzed the relationship with mortality with multivariate logistic regressions and receiver operating characteristic curves (ROC) for models with and without clusters. Nested models were compared with Likelihood Ratio Tests (LRT). Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) were compared for non-nested models. With the best model, we used CART to build a decision tree for patient’s membership. Results Our sample consisted of 2605 patients (mortality 59.7%). For both score combinations, we identified two clusters (A and B for CCI + SAPS II, α and β for CCI + SOFA). Belonging to cluster B/β was associated with shorter survival times (Peto-Peto p-values &lt; 0.0001) and increased mortality (Odds-ratio 4.65 and 5.44, respectively). According to LRT and ROC analysis, clustered models performed better, and CCI + SOFA showed the lowest AIC and BIC values (AIC = 3021.21, BIC = 3132.65). Using CART (β cluster positive case) the accuracy of the decision tree was 94.8%. Conclusion Clustered models significantly improved mortality prediction. The CCI + SOFA clustered model showed the best balance between complexity and data fit and should be preferred. Developing a user-friendly decision-making algorithm for cluster membership with CART showed high accuracy. Further validation studies are needed to confirm these findings.

Iatrogenic open humeral shaft fractures following functional bracing.

The treatment of closed humeral shaft fractures tends to be successful with functional bracing. Treatment failure due to iatrogenic conversion to an open fracture has not been described in the literature. We present a case series of patients that experienced open humeral shaft fractures after initially being treated with functional bracing for closed humeral shaft fractures and describe what factors are associated with this complication. This was a retrospective case series performed at three level 1 trauma centers across North America. All nonoperatively treated humeral shaft fractures were reviewed from 2001 to 2023. Patients were included if they sustained a humeral shaft fracture, > 18 years old, were initially treated non-operatively with functional bracing which subsequently converted to an open fracture. Eight patients met inclusion criteria. All included patients were eventually treated with irrigation, debridement, and open reduction and internal fixation. Outcomes assessed included mortality rate, time until the fracture converted from closed to open, need for further surgery, and bony union. Descriptive statistics were used in analysis. The eight included patients on average were 65 ± 21.4 years old and had a body mass index (BMI) of 25.6 ± 5.2. Six patients were initially injured due to a fall. Time until the fractures became open on average was 5.2 ± 3.6 weeks. Three patients (37.5%) died within 1.8 ± 0.6 years after initial injury. The average Charlson Comorbidity Index (CCI) score was 4.5 ± 3.4. Three patients (37.5%) had dementia. Common characteristics among this cohort included a history of visual disturbances (50.0%), cerebrovascular accident (50.0%), smoking (50.0%), and alcohol abuse (50.0%). Conversion from a closed to open humeral shaft fracture after functional bracing is a potentially devastating complication. Physicians should be especially cognizant of patients with a low BMI, history of falling or visual disturbance, dementia, age ≥ 65, decreased sensorimotor protection, and significant smoking or alcohol history when choosing to use functional bracing as the final treatment modality. IV.

Mortality of Patients With Sepsis Administered Piperacillin-Tazobactam vs Cefepime

Experimental and observational studies have suggested that empirical treatment for bacterial sepsis with antianaerobic antibiotics (eg, piperacillin-tazobactam) is associated with adverse outcomes compared with anaerobe-sparing antibiotics (eg, cefepime). However, a recent pragmatic clinical trial of piperacillin-tazobactam and cefepime showed no difference in short-term outcomes at 14 days. Further studies are needed to help clarify the empirical use of these agents. To examine the use of piperacillin-tazobactam compared with cefepime in 90-day mortality in patients treated empirically for sepsis, using instrumental variable analysis of a 15-month piperacillin-tazobactam shortage. In a retrospective cohort study, hospital admissions at the University of Michigan from July 1, 2014, to December 31, 2018, including a piperacillin-tazobactam shortage period from June 12, 2015, to September 18, 2016, were examined. Adult patients with suspected sepsis treated with vancomycin and either piperacillin-tazobactam or cefepime for conditions with presumed equipoise between piperacillin-tazobactam and cefepime were included in the study. Data analysis was conducted from December 17, 2022, to April 11, 2023. The primary outcome was 90-day mortality. Secondary outcomes included organ failure-free, ventilator-free, and vasopressor-free days. The 15-month piperacillin-tazobactam shortage period was used as an instrumental variable for unmeasured confounding in antibiotic selection. Among 7569 patients (4174 men [55%]; median age, 63 [IQR 52-73] years) with sepsis meeting study eligibility, 4523 were treated with vancomycin and piperacillin-tazobactam and 3046 were treated with vancomycin and cefepime. Of patients who received piperacillin-tazobactam, only 152 (3%) received it during the shortage. Treatment groups did not differ significantly in age, Charlson Comorbidity Index score, Sequential Organ Failure Assessment score, or time to antibiotic administration. In an instrumental variable analysis, piperacillin-tazobactam was associated with an absolute mortality increase of 5.0% at 90 days (95% CI, 1.9%-8.1%) and 2.1 (95% CI, 1.4-2.7) fewer organ failure-free days, 1.1 (95% CI, 0.57-1.62) fewer ventilator-free days, and 1.5 (95% CI, 1.01-2.01) fewer vasopressor-free days. Among patients with suspected sepsis and no clear indication for antianaerobic coverage, administration of piperacillin-tazobactam was associated with higher mortality and increased duration of organ dysfunction compared with cefepime. These findings suggest that the widespread use of empirical antianaerobic antibiotics in sepsis may be harmful.

Immature platelet fraction as a systemic inflammation marker in patients with chronic obstructive pulmonary disease.

Recently, there has been an increasing interest to find a simple, low cost, widely available biomarker for outcome predictors in chronic obstructive pulmonary disease (COPD). Absolute immature platelet count (AIPC), the percentage of AIPC to the total platelet count (immature platelet fraction [IPF%]), symptoms, spirometry results, age-dyspne-airflow obstruction index, and C-reactive protein tests of COPD patients and control group were recorded. Neutrophil/lymphocyte, monocyte/lymphocyte, and platelet/lymphocyte ratios and Charlson comorbidity index scores were calculated. One hundred and thirty-four COPD patients and 30 healthy control subjects were included in the study. Eighty-nine patients were in exacerbation (AECOPD) and 45 of them were in stable COPD period. There was a difference between IPF% values and AIPC of COPD group and control group (3.45 ± 2.41 vs. 2.04 ± 1.12, p = 0.01; 5.87 ± 2.45 vs. 5.20 ± 3.02, p = 0.01). A positive correlation was observed between IPF% with white blood cell count and neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, monocyte/lymphocyte ratio in all patients (r = 0.352, p < 0.001; r = 0.399, p < 0.001; r = 0.186, p = 0.032; r = 0.200, p = 0.021) and AECOPD (r = 0.356, p < 0.001; r = 0.414, p < 0.001; r = 0.239, p = 0.025; r = 0.273, p = 0.010). At a cut-off of 3.4, IPF% showed the highest accuracy in identifying COPD (sensitivity: 80.3%, specificity: 82.5%) using receiver-operating characteristic analysis. This is the first study to examine the relationship between AIPC, IPF%, and COPD. The higher IPF% values in COPD and the positive correlation between IPF% and other inflammatory markers are suggested that IPF may be an indicator of systemic inflammation in COPD.

Risk of adverse events in patients with bullous pemphigoid treated with oral corticosteroids in the United States

AbstractBackgroundThe potential association of long‐term oral corticosteroid (OCS) use with adverse events (AEs) in patients with bullous pemphigoid (BP) is not well characterized in a real‐world setting.ObjectiveTo evaluate the effect of OCS use and treatment duration on the incident AEs in patients with BP.MethodsThis retrospective cohort study used medical and pharmacy claims and patient enrollment data from IQVIA PharMetrics® Plus from 2006−2021. Eligible patients had a diagnosis of BP between 1 January 2006 and 30 June 2020 (≥2 claims for BP ≥ 30 days apart). Patients in the OCS cohort also had a claim for OCS use, ≥7.5 mg daily dose of prednisone or equivalent, and no claims for a nonoral systemic corticosteroid (CS) at any time during the study period. A control cohort of patients with BP not using OCS was also selected. Relative risk ratios were estimated between the incidence of AEs in OCS users with different exposure durations (short‐term, &lt;30 days; medium‐term, 30−90 days; long‐term, &gt;90 days) and nonusers by Poisson regression, after adjusting for age, sex, prior drug use, and baseline Charlson Comorbidity Index score within the follow‐up period.ResultsAt the 1‐year follow‐up, long‐term OCS users had a higher incidence of infections, cataract, osteoporosis, heart failure, depression or anxiety, and diabetes compared with OCS nonusers (p &lt; 0.05). Furthermore, compared with nonusers, long‐term users had increased 1‐year risks (risk ratio; 95% confidence interval) for heart failure (2.27; 1.50−3.44), diabetes (2.05; 1.30−3.24), osteoporosis (1.72; 1.23−2.41), and infection (1.50; 1.13−1.99). Long‐term OCS users also had increased 1‐year risks for heart failure (2.00; 1.21−3.28) and osteoporosis (1.70; 1.16−2.50) compared with short‐term OCS users.ConclusionLong‐term OCS use (≥7.5 mg) in patients with BP was associated with an increased risk of AEs. Study findings demonstrate a need for steroid‐sparing options with an improved safety profile.

Risk Factors and Outcomes of Patients Colonized with KPC and NDM Carbapenemase-Producing Enterobacterales

Carbapenemase-producing enterobacterales (CPE) poses an increasing threat in hospitals worldwide. Recently, the prevalence of different carbapenemases conferring carbapenem resistance in enterobacterales changed in our country, including an increase in New Delhi Metallo-beta-lactamase (NDM)-CPE. We conducted a comparative historical study of adult patients colonized with Klebsiella pneumoniae carbapenemase (KPC)-CPE (July 2016 to June 2018, a historical cohort) vs. NDM-CPE (July 2016 to January 2023). We identified patients retrospectively through the microbiology laboratory and reviewed their files, extracting demographics, underlying diseases, Charlson Comorbidity Index (CCI) scores, treatments, and outcomes. This study included 228 consecutive patients from whom a CPE rectal swab screening was obtained: 136 NDM-CPE positive and 92 KPC-CPE positive. NDM-CPE-colonized patients had a shorter hospitalization length and a significantly lower 30-day post-discharge mortality rate (p = 0.002) than KPC-CPE-colonized patients. Based on multivariate regression, independent risk factors predicting CPE-NDM colonization included admission from home and CCI &lt; 4 (p &lt; 0.001, p = 0.037, respectively). The increase in NDM-CPE prevalence necessitates a modified CPE screening strategy upon hospital admission tailored to the changing local CPE epidemiology. In our region, the screening of younger patients residing at home with fewer comorbidities should be considered, regardless of a prior community healthcare contact or hospital admission.

Predictive Factors of Cloxacillin Susceptibility in Primary Bacterial Spinal Infection.

Prognostic study. The objective of this study is to identify predictive factors for cloxacillin susceptibility in spinal infections. A retrospective analysis was conducted using data from January 1, 1997, to December 31, 2021. The study included patients presenting with back pain and either a positive bacterial culture from the spine or radiological evidence of spinal infection (spondylodiscitis and/or epidural abscess) along with positive bacterial blood culture. Among 171 patients (127 males, 44 females), 53.2% had Staphylococcus isolates, with 40.4% showing cloxacillin resistance. Lower globulin levels (<33.5g/L), recent hospitalization within 90days, and residence in an old age home predicted gram-positive bacteria with cloxacillin resistance and gram-negative bacteria as causative organisms (P<.05). The 30-day and 1-year all-cause mortality rates were 0% and 8.2%, respectively. Higher red cell distribution width (RDW >16.1%) and Charlson comorbidity index (CCI) scores predicted 1-year all-cause mortality (P<.05). Intensive care unit admission was required for 9.9% of patients. This study identified predictive factors for spinal infection by gram-positive bacteria with cloxacillin resistance and gram-negative bacteria. Patients with lower globulin levels (<33.5g/L), recent hospitalization within 90days, or residency in an old age home upon admission should avoid standalone cloxacillin therapy and consider antibiotics with gram-negative coverage. Higher RDW (>16.1%) and CCI scores were associated with increased 1-year all-cause mortality. These findings contribute to treatment decision-making and improving patient outcomes in spinal infections.

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes

With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies. To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies. This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons. Robotic-assisted or video-assisted lung lobectomy. The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator. The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process. In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

Abstract PO3-22-03: Effect of Radiation Therapy on Survival Outcomes in Elderly ER/PR Positive AJCC Stage T1 Breast Cancer Patients

Abstract Background: The CALGB 9343 study in 2004 reported that women &amp;gt;70 years of age with pT1NO hormone receptor positive breast cancer received no meaningful benefit from breast irradiation following lumpectomy. The effectiveness of adjuvant radiation therapy in node negative, T1 tumor patients has been limited to institutional experiences with relatively lack of information in population-based studies. In this hospital-based study using National Cancer Data Base (NCDB) from 2004 to 2020, we report on adjuvant radiation therapy (XRT) usage and the survival outcomes in stage IA, IB, IC breast cancer patients who received XRT versus those who did not. Materials and Methods: Patients in the National Cancer Database (NCDB) who were registered between 2004 and 2019 and followed up to the end of 2020 were used in this research. We evaluated a cohort of 126,156 female breast cancer patients of age &amp;gt;= 70 years with the American Joint Committee on Cancer (AJCC) stage TIA, TIB, and TIC. All patients were ER/PR positive, received hormonal therapy, all patients were either white or black, were either privately or Medicare insured, received hormonal therapy, and patients were receipt of adjuvant chemotherapy or not. Radiation statuses were grouped as no radiation, radiation only and/or radiation with boost. Other adjusted variables included: age, race, Charlson comorbidity index, payer status, income, education, distance traveled, diagnosing/treating facility, location of treatment and treatment delay. SAS for Windows 9.4 was used for all data management and statistical analysis. Multivariate Cox regression was used to assess the effect of the XRT on overall survival while adjusting for other factors. All p-values &amp;lt; 0.05 or 95% Confidence Limits of Hazards Ratio (HR) does not include 1 were considered statistically significant. Results: Among 126,156 female breast cancer patients, the age distribution was 47.87%, 31.72%, and 20.4% for age group of 70-74, 75-79, 80 or older, respectively. Ninety-three percent of patients were white. 89% of patients were Medicare and 11% were privately insured at diagnosis. 21% of patient were with the Charlson Comorbidity index score 1 or above. 10.77%, 34.42% and 54.81% of patients were AJCC Stage T1A, T1B, and T1C respectively. 11.7% of patients received chemotherapy and 57.9% of patients received radiation therapy. 54.38%, 59.59%, and 57.59% of T1a, T1b, and T1c patients received the XRT, respectively. In univariate analysis, the XRT demonstrated a statistically significant increase of 10-year survival by 9.75%, 9.8%, and 12.6% in T1a, T1b, and T1c (all p &amp;lt; 0.0001) patients respectfully. In multivariate cox regression analysis, age was a predictor of survival outcome with a HR at 1.65, 3.02 for 75-79, and 80 or older as compared to 70-74 years old, respectively. In addition, compared to patients who traveled less than 20 miles, the HR were 0.90 for patients travelled more than 20 miles. AJCC stage was also associated the survival, a HR of 1.05 (95% CI: 1.01-1.186) for T1b, 1.16 (95% CI: 1.11 – 1.21) for T1c as compared for T1a. Adjusting for other factors, the usage of radiation reduced the risk of dying by 25% (HR=0.75, 95% CI: 0.73-0.77) when compared to no radiation therapy. Conclusion: The current study has demonstrated that more than 54% of these patients received radiation therapy. In univariate analysis, the benefit of adjuvant radiation therapy is more than 9.7% for T1a, T1b, and T1c on 10-year overall survival which is statistically significant. Adjusting for other factors, patients receiving radiation therapy in these elderly population have a 25% less chance of dying as compared to no radiation therapy regardless of AJCC Stage. A further propensity score matching method would help assess the effectiveness of radiation therapy on these patients’ population. A randomized prospective clinical trial would be better to define the precise benefit of adjuvant radiation therapy in this elderly population. Table 1 Patients Demographic, Social Economic and Clinical Characteristics XX- XX Table 3 Hazard Ratios estimate from Multivariate Cox Regression XX- XX Radiation Effect on Overall Survival of Elderly Breast Cancer Patients by Stage T1A, T1B, T1C XX- XX Citation Format: Runhua Shi, Gary Burton. Effect of Radiation Therapy on Survival Outcomes in Elderly ER/PR Positive AJCC Stage T1 Breast Cancer Patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-22-03.

Exploring Risk Factors for Predicting 30-Day Postoperative Morbidity in Musculoskeletal Tumor Surgery.

Background: This study investigates the risk factors associated with postoperative complications in musculoskeletal tumor surgeries and evaluates the impact of benchmarking in enhancing surgical outcomes. Methods: Conducted at a tertiary referral center, this retrospective analysis included 196 patients who underwent surgeries for various musculoskeletal tumors, ranging from soft tissue to bone sarcomas. Patient and tumor characteristics, along with surgical interventions and outcomes, were comprehensively assessed using the Charlson Comorbidity Index and the Clavien-Dindo classification. Results: Key findings indicate that surgical reconstruction, ASA 3 status, bone tumor presence, and the need for multiple erythrocyte transfusions significantly increase postoperative morbidity. Notably, no significant correlation was found between the Charlson Comorbidity Index scores and the occurrence or severity of complications, challenging the utility of this index in predicting short-term surgical outcomes. Conclusions: This study highlights the importance of tailored surgical approaches and emphasizes rigorous preoperative assessments to mitigate risks and enhance patient care. Despite its insights, limitations include its retrospective nature and single-center scope, suggesting a need for broader, multicenter studies to generalize findings. Overall, our results underscore the necessity of integrating clinical assessments with benchmarking data to optimize outcomes in the complex field of musculoskeletal tumor surgery.

Abstract PO1-09-07: Outpatient mastectomy is a safe surgical option for patients treated in a rural Appalachian tertiary facility

Abstract Background The feasibility of the outpatient mastectomy in a rural setting is poorly characterized. Centers treating rural patient populations have unique challenges. Limited access to resources and distance to facilities that can care for post-surgical patients are two such challenges. The aim of this study is to analyze the efficacy and safety of an outpatient mastectomy program in our tertiary care facility treating rural Appalachian patients. Methods We performed a single-institution retrospective review of all patients with breast cancer over 18 years of age who underwent a mastectomy with or without immediate alloplastic breast reconstruction at JW Ruby Memorial Hospital from 2019-2022. Our primary objective was to determine the 30, 60, and 90-day readmission rates. Our secondary objective included an analysis of perioperative pain control variables to develop an enhanced recovery protocol. Data collected included age, ethnicity, prognostic factors, stage at diagnosis, surgical treatment, opioid and non-opioid based treatments pre- and postoperatively by milligram morphine equivalents (MMEs), comorbidities as analyzed by the Charlson comorbidity index (CCI) variables, and distance from the tertiary hospital. Results We identified thirty-two women between 2019-2022 who underwent same-day mastectomy at JW Ruby Memorial Hospital in Morgantown, West Virginia. The mean age was 55.4 years. The mean distance to the hospital was 22.1 miles with a maximum distance of 111 miles (SEM = 3.90). The mean CCI score was 2.9 (SEM = 0.51). Overall readmission rates at 30- 60- and 90-days were 6.3% (n = 2), 3.1% (n = 1) and 0%, respectively. One woman was readmitted eight days postoperatively from a unilateral mastectomy and sentinel lymph node biopsy without reconstruction for an expanding hematoma of the chest after resuming anticoagulation on postoperative day three. The other two patients were admitted for unrelated surgical reasons. Thus, readmission related to surgical complications alone was 3.1% (n = 1). Preoperatively, 90.6% (n = 29) of women received a local anesthetic block by the anesthesia provider. Neither a preoperative nor intraoperative block was given to the remaining three. Bilateral mastectomies occurred in 21.9% (n = 7) of women and 78.1% (n = 25) underwent unilateral mastectomy. Of these 32 women, 25.0% (n = 8) underwent immediate staged reconstruction with tissue expanders. There were no direct-to-implant reconstructions in this population. There were twenty-six sentinel lymph node biopsies and four axillary dissections performed. The mean MMEs received for the duration of the hospital encounter was 132 (SEM = 23.4). An enhanced recovery after surgery protocol was not used. Discussion Outpatient mastectomy is a safe and effective option for eligible patients living in rural settings. Factors such as the type of mastectomy, reconstruction, the patient's overall health status, and the availability of support at home can impact the feasibility of this approach. Careful patient selection and a multidisciplinary team including the patient, surgeon, and anesthesiologist should carefully assess the individual’s circumstances to determine if outpatient mastectomy is appropriate. Implementation of enhanced recovery after surgery protocols will be further investigated and guided by this study. Citation Format: Gregory Stimac, Kristin Lupinacci, Michael Cowher, Hannah Hazard-Jenkins. Outpatient mastectomy is a safe surgical option for patients treated in a rural Appalachian tertiary facility [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-09-07.

Remdesivir versus Favipiravir in Hospitalized Patients with Moderate to Severe COVID-19 Pneumonia: A Propensity Score-Matched Retrospective Cohort Study.

Remdesivir treatment was associated with a reduced 28-day mortality and recovery time among patients hospitalized with severe COVID-19. Favipiravir is broadly used to treat COVID-19. However, various studies have had conflicting results on the efficacy of favipiravir for COVID-19. We hypothesized that remdesivir is more effective in clinical outcomes regarding the 29-day mortality rates, length of stay, and recovery rate than favipiravir in patients with moderate to severe COVID-19 pneumonia. We performed a retrospective cohort study that included adult hospitalized COVID-19 pneumonia patients with hypoxemia. Patients were classified into two groups according to the antiviral drugs. Age, oxygen saturation, fraction of inspired oxygen, and Charlson comorbidity index were used for propensity score matching. The primary objective was to determine whether the type of antiviral agent is associated with 29-day mortality. Other outcomes were the 15-day recovery rate and the length of intensive care unit or hospital stay. A total of 249 patients with moderate to severe COVID-19 pneumonia were included. With an adjustment for propensity score-matched, there were 204 patients for further analysis (102 patients in each antiviral drug group). Remdesivir patients had higher Radiographic Assessment of Lung Edema (RALE) scores on Chest X-ray (14.32±9.08 vs 11.34±8.46; standardized mean difference =33.9%). The Charlson Comorbidity Index Scores were comparable. The prevalences of diabetes, obesity, hypertension, and non-HIV immunocompromised state were higher in the remdesivir group. Regarding the primary outcomes, after adjusting by diabetes, obesity, and RALE score, there was no difference in the 29-day mortality rate between both groups [26 patients (25.5%) in the remdesivir group vs 28 patients (27.5%) in the favipiravir group]. The Kaplan-Meier curve analysis at 29 days indicated no significant difference in cumulative survival rate. The two groups' adjusted hazard ratio was 0.72; 95% CI, 0.41 to 1.25, p=0.24. A Kaplan-Meier analysis on the 15-day cumulative survival rate observed a trend towards a higher survival rate in the remdesivir group (adjusted hazard ratio 0.41; 95% CI, 0.20 to 0.84; p= 0.02) The proportion of patients who recovered on day 15, the length of intensive care unit(ICU) stays, and the hospital stay were not different between remdesivir and favipiravir groups (62 patients (60.8%) vs 56 patients (54.9%), p=0.39; 11.48 ± 11.88 days vs 10.87 ± 9.31 days, p=0.69; and 16.64±14.28 days vs 16.59 ±11.31 days, p=0.98, respectively). In patients with moderate to severe COVID-19 pneumonia, Remdesivir did not demonstrate superior benefits over Favipiravir regarding 29-day mortality, 15-day recovery rates, or hospital and ICU stay lengths. However, further investigation into the 15-day cumulative survival rate revealed a trend towards improved survival in the Remdesivir group.

Evaluating Modern Spacer Options and Outcomes in Revision Hip Arthroplasty

IntroductionA two-stage revision continues to be the standard treatment for periprosthetic joint infection (PJI) in hip arthroplasty. The use of “functional” spacers may allow patients to return to daily living while optimizing their health for revision surgery. We aimed to evaluate the clinical outcomes of different spacer types regarding infection eradication, mechanical complications, and functional outcomes. MethodsPatients who have complete Musculoskeletal Infection Society (MSIS) criteria for diagnosis of PJI that underwent one-stage or two-stage revision were queried in an institutional surgical database between 2002 and 2022. Out of 286 patients, 210 met our inclusion criteria and were retrospectively reviewed for demographics, laboratory values, functional and patient-reported outcomes, and subsequent revisions. The study population had 54.3% females, a mean age of 61.7 years old, and a mean follow-up of 3.7 ± 3.2 years. There was no difference between age, body mass index (BMI), or Charlson Comorbidity Index (CCI) scores between each cohort. Spacers were categorized as nonfunctional static, nonfunctional articulating, or functional articulating. Functional spacers were defined as those that allowed full weightbearing with no restrictions. Delphi criteria were used to define revision success, and failure was defined as a recurrent or persistent infection following definitive surgery. ResultsThere was a significantly lower re-operation rate after a definitive implant in the functional articulating cohort (P = 0.003), with a trending higher infection eradication rate and a lower rate of spacer failure compared to the nonfunctional spacer cohort. At 5 years, functional articulating spacers had a 94.1% survivorship rate, nonfunctional articulating spacers had an 81.2% survival rate, and nonfunctional static spacers had a 71.4% survival rate. In the functional articulating spacer cohort, 14.6% had yet to get reimplanted, with an average follow-up time of 1.4 years. ConclusionWithin this large cohort of similar demographics, functional articulating spacers may result in better clinical outcomes and infection eradication during two-stage revision arthroplasty for PJI.

Associations between health-related quality of life and subsequent need for specialized palliative care and hospital utilization in patients with gastrointestinal cancer—a prospective single-center cohort study

BackgroundWe lack knowledge of which factors are associated with the risk of developing complex palliative care needs. The aim of this study was to investigate the associations between patient-reported health-related quality of life and subsequent referral to specialized palliative care (SPC) and hospital utilization.MethodsThis was a prospective single-center cohort study. Data on patient-reported outcomes were collected through the European Organization of Research and Treatment of Cancer Questionnaire-Core-15-Palliative Care (EORTC QLQ-C15-PAL) at the time of diagnosis. Covariates and hospital utilization outcomes were collected from medical records. Adjusted logistic and Poisson regression were applied in the analyses. Participants were newly diagnosed with incurable gastrointestinal cancer and affiliated with a palliative care case management intervention established in a gastroenterology department.ResultsOut of 397 patients with incurable gastrointestinal cancer, 170 were included in the study. Patients newly diagnosed with incurable gastrointestinal cancer experienced a substantial burden of symptoms. Pain was significantly associated with subsequent referral to SPC (OR 1.015; 95% CI 1.001–1.029). Patients with lower education levels (OR 0.210; 95% CI 0.056–0.778) and a Charlson Comorbidity Index score of 2 or more (OR 0.173; 95% CI 0.041–0.733) were less likely to be referred to SPC. Pain (IRR 1.011; 95% CI 1.005–1.018), constipation (IRR 1.009; 95% CI 1.004–1.015), and impaired overall quality of life (IRR 0.991; 95% CI 0.983–0.999) were significantly associated with increased risk of hospital admissions.ConclusionThe study indicates a need for interventions in hospital departments to identify and manage the substantial symptom burden experienced by patients, provide palliative care, and ensure timely referral to SPC.

Health Perceptions, Multimorbidity, and New Fractures and Mortality Among Patients With a Fracture

A high proportion of patients who sustain a fracture have multimorbidity. However, the association of multimorbidity with postfracture adverse outcomes, such as subsequent fractures and premature mortality, has not been widely explored. To examine the association of multimorbidity and self-rated health with subsequent fractures and mortality after fracture. This prospective cohort study included participants from New South Wales, Australia, in the Sax Institute's 45 and Up Study (n = 267 357). Participants were recruited from July 2005 to December 2009 and followed up from the date of the incident fracture until subsequent fracture, death, or the end of the study (April 2017), whichever occurred first, with questionnaire data linked to hospital admission and medication records. Data analysis was reported between March and September 2023. Charlson Comorbidity Index (CCI) score and self-rated health (SRH). The main outcomes were subsequent fracture or mortality after an incident fracture. Associations between SRH measures and subsequent fracture and mortality were also assessed. All analyses were stratified by sex given the different fracture and mortality risk profiles of females and males. Of 25 280 adults who sustained incident fractures, 16 191 (64%) were female (mean [SD] age, 74 [12] years) and 9089 (36%) were male (mean [SD] age, 74 [13] years). During a median follow-up time of 2.8 years (IQR, 1.1-5.2 years), 2540 females (16%) and 1135 males (12%) sustained a subsequent fracture and 2281 females (14%) and 2140 males (24%) died without a subsequent fracture. Compared with a CCI score of less than 2, those with a CCI score of 2 to 3 had an increased risk of subsequent fracture (females: hazard ratio [HR], 1.16 [95% CI, 1.05-1.27]; males: HR, 1.25 [95% CI, 1.09-1.43]) and mortality (females: HR, 2.19 [95% CI, 1.99-2.40]; males: HR, 1.89 [95% CI, 1.71-2.09]). Those with a CCI score of 4 or greater had greater risks of subsequent fracture (females: HR, 1.33 [95% CI, 1.12-1.58]; males: HR, 1.48 [95% CI, 1.21-1.81]) and mortality (females: HR, 4.48 [95% CI, 3.97-5.06]; males: HR, 3.82 [95% CI 3.41-4.29]). Self-rated health was also significantly associated with subsequent fracture and mortality. Those reporting the poorest health and quality of life had the highest subsequent fracture risks, and their mortality risks were even higher. In this cohort study, both CCI and SRH measures were associated with increased risk of subsequent fractures and mortality after fracture, underscoring the importance of managing the care of patients with comorbidities who sustain a fracture.

Preoperative MRSA screening using a simple questionnaire prior elective total joint replacement.

The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures. Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients. Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening. Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach.