Charlson Index Score Research Articles

Characteristics and outcomes of patients with moderate multivalvular disease in the context of tricuspid regurgitation

Abstract Background The clinical features and the long-term prognosis of patients with moderate tricuspid regurgitation (TR) in the context of concomitant moderate left-sided valvular disease (VD) are poorly characterized. Purpose This study sought to describe the characteristics and the outcomes of patients with combined moderate TR and moderate mitral or aortic VD. Methods Baseline clinical and follow-up data were collected from 2110 patients with moderate TR in combination with a moderate left-sided VD diagnosed at our centers from January 2012 to July 2020; the final cohort was divided in 4 groups as shown in Figure 1. The primary endpoint was all-cause death; secondary EP was the first occurrence of heart failure (HF) hospitalization. Results Group 1 patients (1529, 72.5%) had the highest prevalence of chronic kidney disease (897, 66%) and lowest left ventricular systolic function (LVEF <50%, 298, 21%), as detailed in Table 1. Coronary artery disease was most prevalent in Group 2 patients (43, 41%), which also presented with the lowest average Charlson Index scores (3.95±1.87) and most prevalent dyspnea symptoms (44, 41%). Group 3 patients (41, 1.9%) were the oldest (82±7 years), had the highest rate of comorbidities (mean Charlson score 5.2±1.6), atrial fibrillation (20, 54%) and pulmonary hypertension (17, 46%). Eventually, Group 4 patients (422, 20%) were the youngest (74±13 years), more commonly female (279, 66%) and with the highest right ventricular dysfunction rate (TAPSE < 17 mm, 114, 40%). After a median follow-up of 2.1 years, the primary endpoint occurred in 895 (42.4%) patients, with a significantly higher incidence in Group 3 patients (p<0.001) (Figure 1). The secondary endpoint occurred in 316 (15.0%) patients and, similarly, significantly more frequently in Group 3 patients (p=0.01). Subgroup analysis for the primary and secondary endpoint in patients with preserved ejection fraction (LVEF > 50%) confirmed the results of the primary analysis, with Group 3 as the cohort with the most adverse outcomes. Conclusions Patients with significant TR frequently exhibit concurrent left-sided VD, identifying distinct patient subgroups with varying clinical profiles. Notably, TR combined with moderate AS is associated with the most severe clinical presentation and the poorest long-term prognosis, even in patients with preserved LVEF.Figure 1.

Primary data on symptom burden and quality of life among elderly patients at risk of dying during unplanned admissions to an NHS hospital: a cohort study using EuroQoL and the integrated palliative care outcome scale.

Older people account heavily for palliative care needs at the population level and are growing in number as the population ages. There is relatively little high-quality data on symptom burden and quality of life, since these data are not routinely collected, and this group are under-recruited in primary research. It is unclear which measurement tools are best suited to capture burdens and experience. We recruited a cohort of 221 patients aged 75 + years with poor prognosis who had an unplanned admission via the emergency department in a large urban hospital in England between 2019 and 2020. Risk of dying was assessed using the CriSTAL tool. We collected primary data and combined these with routine health records. Baseline clinical data and patient reported quality of life outcomes were collected on admission and reassessed within the first 72h of presentation using two established tools: EQ-5D-5L, EQ-VAS and the Integrated Palliative Outcomes Scale (IPOS). Completion rate was 68% (n = 151) and 33.1% were known to have died during admission or within 6 months post-discharge. The vast majority (84.8%) reported severe difficulties with at least one dimension of EQ-5D-5L at baseline and improvements in EQ-VAS observed at reassessment in 51.7%. The baseline IPOS revealed 78.2% of patients rating seven or more items as moderate, severe or overwhelming, but a significant reduction (-3.6, p < 0.001) in overall physical symptom severity and prevalence was also apparent. No significant differences were noted in emotional symptoms or changes in communication/practical issues. IPOS total score at follow up was positively associated with age, having comorbidities (Charlson index score > = 1) and negatively associated with baseline IPOS and CriSTAL scores. Older people with poor prognosis admitted to hospital have very high symptom burden compared to population norms, though some improvement following assessment was observed on all measures. These data provide valuable descriptive information on quality of life among a priority population in practice and policy and can be used in future research to identify suitable interventions and model their effects.

Suppressive antibiotic therapy for infectious endocarditis

ObjectivesSuppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE. MethodsWe conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT. ResultsThe MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95–457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse. ConclusionMortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

Combined Hip Procedure Versus Open Reduction and Internal Fixation for Displaced Acetabular Fractures in Patients Older than 75 years: A Matched Cohort Study

Objective: To compare surgical outcomes between combined hip procedure (CHP: open reduction and internal fixation [ORIF] with total hip replacement) and ORIF alone for the treatment of displaced acetabular fractures in a geriatric population. Design: Retrospective case–control study. Setting: Academic Level 1 trauma center. Patients: Consecutive patients from 2012 till 2020 with acetabular fractures fitting inclusion criteria were enrolled. Intervention: Combined hip procedure or ORIF alone for displaced acetabular fractures. Main Outcome Measurement: Revision surgery at the latest follow-up, defined as the need for implant revision in the CHP group and conversion to total hip replacement in the ORIF group. Results: The need for revision surgery was lower in the CHP group (12.5%) compared with the ORIF alone group (25%). The median time for conversion to total hip replacement in the ORIF alone group was 2.6 years. Ten-year survivorship was significantly higher in the CHP group (85.7% vs. 45.8%, P &lt; 0.01). Patients in the CHP group presented with higher American Society of Anesthesiologists and Charlson index scores and had more marginal impaction and concomitant femoral head fractures. Conclusions: In patients older than 75 years presenting with a displaced acetabular fracture with marginal impaction or femoral head fracture, survivorship of CHP is higher than ORIF alone. A combined hip procedure should be considered in such patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

CORONET online risk assessment tool and Charlson comorbidity index in predicting fatalities in cancer patients with COVID-19

Purpose of the study. Сomparing and evaluating the prognostic potential of the CORONET online risk assessment tool and the Charlson Comorbidity Index in predicting mortality in cancer patients with COVID-19.Materials and methods. The results are drawn from the data of 168 case histories of cancer patients who were undergoing inpatient treatment for COVID-19 at the University Clinical Hospitals of Sechenov University between March 2020 and February 2022. The study was conducted as part of the program of the world-class research center “Digital Biodesign and Personalized Healthcare” of Sechenov University, with participation in the ESMO-CoCARE Registry project. Patients with a history of solid or hematologic malignancies were included in the study; their treatment period before the study was 5 years or less. The age ranged from 37 to 100 years, the median age was 69 years. The CORONET online risk assessment tool and the Charlson comorbidity index were used to objectify the severity of multimorbidity status and prognosis of fatal outcomes in cancer patients with COVID-19.Results. It was demonstrated that statistically significant effects on the prognosis of mortality in patients with cancer were: age, percentage of saturation on admission, treatment in intensive care units (ICU), National Early Warning Score 2 (NEWS2) distress syndrome severity scale score, computed tomography (CT) assessment of disease course severity, decreased blood albumin and platelet counts, and increased blood neutrophil counts in both categorical and immediate indicator value formats. In addition, it was determined that as the number of comorbidities increased, the probability of mortality increased significantly, odds ratio (OR) = 2.162 (CI 95 % 1.016–4.600; p = 0.045). The CORONET calculator score yields one of the highest OR values among all established statistically significant predictors,20.410 (CI 95 % 4.894–85.113; p &lt; 0.001). For oncopathology in COVID-19 patients, the Charlson index score shows statistical significance as a predictor of mortality, OR =1.396 (CI 9 5 % 1.105–1.765; p = 0.005).Conclusion. The obtained advantages in using the CORONET online decision support tool over the Charlson comorbidity index in predicting mortality in cancer patients with COVID-19 are recognized as convincing.

A single centre retrospective analysis of the management and outcomes of cardiac device-related infective endocarditis

Abstract Background/intro Cardiac device-related infective endocarditis (CDRIE) is a rare but serious complication of cardiac device insertion with a high mortality rate. Cardiac devices are increasingly being implanted in older patients amid an ageing population with more comorbidities. Our centre is a large cardiac surgery referral centre in London. The centre implants a large number of cardiac devices per year (an average of 2168 per year from 2016 - 2019). The IE multidisciplinary team (IE MDT) manages approximately 150 IE referrals from the region per year. Purpose We aimed to describe a cohort of patients with CRDIE, referred to the IE MDT over 5 years (2015-2020), to generate a contemporary representation of patients with CDRIE. Methods We carried out a retrospective review of all referrals to the IE MDT between 2015 and 2020, identifying all patients with CDRIE - infection extending to the electrode leads, cardiac valve lead(s) or endocardial surface (ESC). All patients who were discussed at the IE MDT between October 2015 and March 2020 were screened, based on inclusion criteria according to the ESC's definition of CDRIE. Patients who had an infection of the cardiac device pocket with no evidence of IE were excluded. Results 60 out of 928 IE patients had confirmed CRDIE after discussion in the IE MDT from 10/2015 and 03/2020. The average age of the cohort was 70.3 (male =44, 73%). 61.7% of the devices were PPM (n=37), 10% were ICD, 20% were CRT-D, and 8.3% were CRT-P. The average duration of device therapy before removal was 64 months. 66.7% of devices were extracted (n=40) and 33.3% were managed medically (n=20). 43.3% of the cohort had prosthetic valves (n=26), and 13.3% of the total cohort had tissue aortic valve implants (TAVI) (n=8). 85% had a transesophageal echo (TOE) procedure (n=51) and 61.7% went on to have a PET CT scan (n=37). The overall inpatient mortality was 25% (n=15), rising to 45% at 12 months (n=27). Patients managed medically had a significantly higher mortality at 6 and 12 months compared to those who received an extraction and antibiotics (figure 1). There was no difference in left or right ventricular systolic function pre- and post- treatment on average or degree of tricuspid regurgitation. Medically managed patients were frailer by Charlson Index (average Charlson Index score 3) than surgically managed patients (average Charlson Index score 2). Conclusions In a retrospective assessment of CRDIE, we found that there is a low incidence of CRDIE complicating cardiac device insertion at BHC when compared to the national average. We found that surgical removal improves the likelihood of survival at 6 and 12 months when compared to medical management in those with a severe Charlson score, suggesting that even in cases of frailty and multiple morbidities, device extraction is preferable (figure 2).Survival curve of all CDRIE patientsSurvival curve in the severely frail

#4162 COMPARISON OF EGFR CYSTATIN C AND EGFR CREATININE IN RECENTLY HOSPITALISED INDIVIDUALS

Abstract Background and Aims Creatinine and cystatin C are endogenous biomarkers that can be used to estimate glomerular filtration rate (GFR). Cystatin C may be less dependent on age, gender and muscle mass. The comparative performance of these markers in patients recently hospitalised patients with acute kidney injury (AKI), who may have experienced changes in body composition, is unclear. Method Two matched cohorts of hospitalised individuals who had survived to 90 days after admission were recruited. The cohorts consisted of people who had sustained AKI during hospital admission and those who had not, and were matched 1:1 for age, baseline eGFR stage and diabetes. Serum creatine and serum cystatin C were measured at 3 months after hospitalisation and eGFR calculated using CKD EPI creatinine (eGFRcr) and CKD EPI cystatin C (eGFRcys) equations. Difference between the measures (eGFRdiff) was calculated as eGFRcys-eGFRcr and percentage difference (eGFR%diff) was relative to the mean of both eGFR measures. Primary outcome was mortality after 5 years of prospective follow up. Univariable survival analyses were conducted with the Kaplan Meier method and comparisons were performed with the log rank test, and a fully adjusted multivariable analysis performed with Cox proportional hazards model. Results 854 individuals were recruited, matched, and had paired creatinine and cystatin C measurements. 427 (50%) had sustained AKI. Median eGFRcys was lower than eGFRcr (53.5ml/min/1.73 m2 [34.4-85.4] vs 68.4ml/min/1.73 m2 [52.6-84.7], p&amp;lt;0.001). eGFRcys and eGFRcr were correlated (r = 0.486, p&amp;lt;0.001) but Bland Altman analysis showed variable bias across the eGFR range. More individuals had an eGFR &amp;lt;60ml/min using eGFRcys (57%) compared with eGFRcr (35.6%). There was a graded relationship between eGFR%diff and outcome, with a shorter survival time (Figure 1) and higher proportion of deaths at 5 years (Q1 64 (30.0%), Q2 54 (25.4%), Q3 41 (19.2%), Q4 (31 (14.6%), p&amp;lt;0.001) in the first quartile. Cox proportional hazards analysis showed that eGFR%diff was an independent predictor of 5-year mortality after adjustment for age, Charlson index score and albuminuria (adjusted OR 0.995 [0.992-0.998], p = 0.002). Conclusion Cystatin C eGFR measures were lower than creatinine eGFR measures in recently hospitalised individuals. Lower eGFRcys relative to eGFRcr was independently associated with increased mortality. A larger difference between eGFRcys and eGFRcr may reflect loss of muscle mass (resulting in relatively lower serum creatinine) in somebody who has recently had an acute illness. Further, these results confirm how eGFRcr may over-estimate kidney function and potentially miss patients with failed renal recovery at 3-months after AKI. The difference between eGFRcys and eGFRcr may be helpful in identifying people at greater risk of early mortality after an acute illness.

Prevalence and prognosis of frailty in patients &amp;gt;70 years old with acute coronary syndrome referred to invasive angiography

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Rigshospitalet Research Foundation Background The number of older patients is increasing world-wide. Older patients have a higher risk of complications related to acute coronary syndrome (ACS) treatment and are more often frail. Yet, they are often missing in clinical trials, which leads to a knowledge gap in current guidelines when treating older ACS patients. Frailty scoring may be a better tool than conventional risk scores to assess prognosis. Previous studies have proposed that a patient’s biological age instead of chronological age could be used to better guide the treatment strategy in older ACS patients. Potentially frailty scoring can be used to decide a patient’s biological age. Purpose We wanted to investigate the prevalence of frailty in a consecutive population of ACS patients ≥70 years referred to invasive angiography at a tertiary centre. Furthermore, we wanted to investigate whether frail patients had a worse 12-month outcome compared to non-frail patients. Methods From September 2020 to September 2021 all patients ≥70 years referred to our institution with ACS were, when logistically possible, undergoing bedside frailty scoring using the clinical frailty scale (CFS). The CFS scoring was performed at the time of admission by nurses at the department. Patients were divided into three frailty groups depending on their CFS score: Robust (1-3), Vulnerable (4) and Frail (5-9). Patients were followed for 12 months. Results During the study period, 691 patients ≥70 years old with ACS were admitted. Of the 451 (65%) patients who had a frailty assessment, 70 (16%) patients were frail, 77 (17%) were vulnerable and 304 (67%) were robust. Frail and vulnerable patients were older (frail: 80.9 (5.6) years, vulnerable: 78.5 (5.7) years and robust: 76.7 (4.8) years, p&amp;lt;0.001), had more comorbidities, defined as a higher Charlson index score (frail: 4.5 [4.0-5.0], vulnerable: 4.0 [4.0-6.0] and robust: 4.0 [3.0-4.0], p&amp;lt;0.001) and longer hospitalisation (frail: 5 [3-9.2] days, vulnerable: 8 [3.5-14.0] days and robust: 5 [3-7] days, p=0.021). Furthermore, frail and vulnerable patients less frequently underwent revascularisation during their first admission (frail: 58.9%, vulnerable: 65.1% and robust: 77.9%, p&amp;lt;0.001). In 12-month follow-up, frail and vulnerable patients had a higher cumulated incidence of all-cause mortality compared to robust patients (p&amp;lt;0.001), figure 1. Frail patients had more than four times the risk of 12-month all-cause mortality compared to robust patients (HR 4.16 (2.12-8.15), p&amp;lt;0.001). The association remained significant after adjustment for age and comorbidities (HR 2.71 (1.30-5.64), p=0.008), as well as for GRACE score (HR 2.98 (1.50-5.90), p=0.002), table 1. Conclusion In patients ≥70 years old with ACS and referred to invasive angiography, frailty according to the CFS score had a prevalence of 16%. Frail and vulnerable patients had more than four times the risk of all-cause mortality in 12-month follow-up.

Effects of Medicare wellness visits on health promotion outcomes

The American older adult population has the highest historical prevalence of chronic disease and underuses wellness visit benefits. Little is known about how Medicare wellness visits (MWVs) affect health outcomes. The aim of this retrospective case-control study was to examine how MWVs affect health outcomes by measuring two kinds of data for case and control groups at baseline versus 15 months: (1) the differences in blood pressure, fasting lipids, and glucose levels and (2) the completion frequencies for seven screenings and vaccinations. Informed by Pender's Health Promotion Model, this design used purposively matched samples from a large American Midwestern Medicare population active between January 2013 and January 2016, with a total sample size of 252, consisting of the case group ( N = 120) and control group ( N = 132). The case and control group samples were matched according to gender, age, marital status, Charlson index scores, smoking status, and pharmaceutical classes. The two groups, case (MWV recipients) and matched control (MWV nonrecipients), were compared at different time points using a doubly multivariate repeated-measures analysis procedure. Descriptive statistics were computed to compare completion frequencies between groups. A doubly repeated multivariate analysis of variance (MANOVA) and descriptive statistics revealed significant differences between the case and control group for three of the four health outcomes. The case group had increased completion frequencies in pneumococcal vaccination. Additional research controlling for more variables is warranted to better understand MWV efficacy on health outcomes. Primary care providers need to study how MWVs affect longitudinal health outcomes.

Outcomes for Hospitalized Aggressive and Violent Patients When Physical Restraints Are Introduced.

Hospital outcomes among patients acting aggressively or violently have not been extensively studied in the United States. The aims of the study are to determine rates of physical restraint use among hospitalized patients who are aggressive/violent and to characterize associations with mortality and utilization metrics. National Inpatient Sample databases from 2016 to 2019 were analyzed with multivariable regression to compare aggressive/violent patients in whom physical restraints were or were not used. Prevalence of physical restraint use, in-hospital mortality, length of stay, and total hospital charges were measures. A total of 40,309 hospitalized patients were coded as having aggressive/violent behavior, of whom 4475 (11.1%) were physically restrained. Physically restrained patients were younger (mean age ± standard error, 42.6 ± 0.64 versus 45.7± 0.41; P < 0.01), more frequently male (71.0% versus 65.4%; P < 0.01), and had less comorbidity (Charlson Index score >3: 7.9% versus 12.5%; P < 0.01) than unrestrained patients. Patients with physical restraints had higher odds of in-hospital mortality (adjusted odds ratio, 2.4, confidence interval [CI], 1.0-5.7; P = 0.04) and lower odds of being discharged to home (adjusted odds ratio, 0.46; CI, 0.38-0.56; P < 0.01) compared with unrestrained patients. Longer hospital stays (adjusted mean difference, 4.1 days CI, 2.1-6.0; P < 0.01) and higher hospitalization charges (adjusted mean difference, $16,996; CI, 6883-27,110; P < 0.01) were observed for those who were physically restrained. Physically restrained aggressive/violent patients had worse in-hospital outcomes compared with their unrestrained counterparts. Avoiding physical restraints whenever possible should be considered when managing this confrontational yet vulnerable patient population. When restraints are needed, providers must thoughtfully bear in mind heightened risks for worse outcomes.

Before-and-After Study of the First Four Years of the Enhanced Recovery after Surgery (ERAS®) Programme in Older Adults Undergoing Elective Colorectal Cancer Surgery.

The aim of this study was to determine whether the inclusion of older patients undergoing elective colorectal cancer resection in the Enhanced Recovery After Surgery (ERAS®) programme could improve clinical outcomes during hospital admission. A before-and-after study in ≥70-year-old patients electively admitted for colorectal cancer resection was designed. In total, 213 patients were included in the ERAS® group, and 158 were included in the control group. The average age was 77.9 years old (SD 5.31) and 57.14% of them were men, with a Charlson Index score of 3.42 (SD 3.32). The ERAS® group presented a lower transfusion rate of 42 (19.7%), compared to 75 (47.5%) in the control group (p &lt; 0.001). The crude odds ratio (OR) for transfusion was 0.27 (95% CI 0.17-0.43; p &lt; 0.001), and the adjusted odds ratio was 0.26 (95% CI 0.14-0.48; p &lt; 0.001). The ERAS® group had a lower percentage of patients with moderate-severe malnutrition on admission, at 23.4% (37 patients) against 36.2% in the control group (42 patients) (p = 0.023), with an OR of 0.47 (95% CI 0.29-0.75; p &lt; 0.002) and an adjusted OR of 0.48 (95% CI 0.29-0.78; p = 0.003). The number of patients who required admission to the intensive care unit (ICU) was also markedly lower: 54 from the ERAS® group (25.4%) versus 71 from the control group (44.9%) (p &lt; 0.001). The inclusion of ≥70-year-old adults in the ERAS® programme resulted in a decrease in transfusions, number of erythrocyte concentrates transfused, and number of ICU admissions, along with improved nutritional status.

Final Results from UKALL60+ (NCT01616238), a UK National Cancer Research Institute Trial for Older People with De Novo Acute Lymphoblastic Leukaemia

Background Improvements in outcome for older patients with Acute Lymphoblastic Leukaemia (ALL) have not kept pace with those for younger persons. Whether there is a survival benefit to more 'intensive’ chemotherapy for older patients and what is the 'pay-off’ in terms of adverse events and duration of inpatient hospitalisation is unclear. Few ALL trials recruit older individuals, with 55 or 60 years being common upper age limits. UKALL60+ (NCT 01616238) a UK National Cancer Research Institute Adult ALL subgroup study, was designed to investigate the safety, tolerability and outcomes of varied intensity chemotherapy protocols for patients ≥ 60 years (y) (55y with comorbidities, no upper age limit) with de novo ALL. Methods Physicians/patients with BCR::ABL1 negative ALL chose freely between three trial chemotherapy pathways; B: based on the UKALL14 adult ALL regimen, but modified to reduce common toxicities eg asparaginase was excluded and dose intensity of certain drugs eg anthracyclines, intravenous (IV) methotrexate were reduced C: the intensive in-patient regimen as used in HOVON100 and D: a regimen designed to be delivered as an 'outpatient', wherein vincristine was the only IV-administered agent. A, tyrosine kinase inhibitor combined with modest intensity chemotherapy was offered for patients with BCR::ABL+ ALL. Regimens A-D all included two full years of maintenance therapy. E was a registration-only pathway with free choice of therapy. Baseline characteristics collected included Charlson index, ECOG, Karnofsky, IADL and CRASH scores. The primary end point was complete remission (CR) rate. Secondary end points included EFS and OS at 1 year, treatment related mortality (TRM), minimal residual disease (MRD) response (patient-specific Ig/TCR quantification by PCR, performed in a central laboratory), adverse event (AE) rates, duration of inpatient hospitalisation and assessment of the relationship between baseline characteristics and treatment option chosen. Quality of life was assessed throughout; data are not yet analysed. Results Between 01/2013 and 11/2018, 126 patients aged 55-83y were recruited, of whom 5 were ineligible (misdiagnosis) leaving 121 analysable. Fifteen pursued registration only, whereas 106/121 elected treatment pathways A-D. Patient characteristics as well as main outcome measures are shown in panel (i). Those receiving regimen D were significantly older than those allocated to B (73 vs 67y p=0.0001). They were moderately more dependent (IADL score 27 vs 28, p =0.04) with slightly higher Charlson index (8 vs 7, p=0.038), suggesting a mix of drivers for therapy selection. Induction CR rate was 92% for pathway A recipients (BCR::ABL1+), 70.6% for B (intermediate intensity), 55.6% for C (most intensive) and 47.6% for D (least intensive), with the latter low rates being due to TRM and lack of disease response, respectively. Strikingly few (N=22, 18.2%, overall) patients achieved an MRD negative remission, with zero complete MRD responses in the low intensity pathway D. Median EFS (mo) was A 23.0 (11.8 - 54.3), B 18.1 (11.3 - 24.2), C not reached, and D 10.9 (5.0 - 13.2). AE forms were available for 102/106 patients. Grade 3/4 AEs rates were equivalent across the pathways; A 22/25 (88%), B 45/49 (91.8%), C 7/8 (87.5%) and D 19/20 (95%), although febrile neutropenia was uncommon in A 3/23(12%) and D 3/20 (15%) but common in B 23/49 (46.9%) and C 6/8(75%). Duration of hospitalisation as a percentage of total time on therapy was A 6%, B 14%, C 24%, and D 8% (p=0.026). Most inpatient days were during induction: 23%, 62%, 76% and 32% respectively (p<0.001). We compared the survival of all UKALL60+ participants to the N=65 patients >60 y treated on the UKALL14 study for patients aged 25-65 y between 05/2012 and 07/2017. Although remission rates were higher for those >60y treated on UKALL14 (87.3%), neither EFS (panel ii) nor OS differed between the trials, suggesting that outcome after chemotherapy treatment is poor across the board for older patients with ALL. Conclusion Our prospective trial data suggest that maximising chemotherapy intensity in older patients with ALL does not confer long-term clinical benefit for the majority of patients. Older patients should be counselled carefully as to the likely outcome of treatment with chemotherapy alone and offered novel therapies or trials of those agents as de novo therapy, wherever possible. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prognostic role of pre-treatment serum ALB in Patients with oropharyngeal cancer: A retrospective cohort study.

The morbidity of oropharyngeal cancer (OPC) is continuing to rise in numerous developed countries. An accurate prognostic assessment is needed to evaluate the malignant degree or risk classification to optimize treatment. Albumin (ALB) as an independent prognostic indicator of cancer survival has been established in previous studies. This study investigated the prognostic value of pre-treatment serum ALB in OPC patients. The clinicopathological data of 246 patients diagnosed with OPC from 2010 to 2019 were analyzed retrospectively. Analyze the relationship between ALB and clinicopathological characteristics of patients. The optimal cut-off values for ALB were determined via Cutoff Finder (Method for cutoff determination: Survival: significance (log-rank test)). To determine the independent prognostic factors, the Cox proportional hazards model was used to perform univariate and multivariate analyses of the serum ALB levels related to overall survival (OS) and disease-free survival (DFS). The optimal cut-off point for ALB was 39.15 g/L determined via Cutoff Finder. Serum ALB levels were significantly associated with age (P=0.047), Presence of comorbidity (P=0.009), Charlson score index (P=0.007), Hemoglobin (P<0.001), Neutrophil to Lymphocyte Ratio (P=0.002), Albumin-To-Alkaline Phosphatase Ratio (P<0.001), Alkaline phosphatase (P=0.005), T stage (P=0.016), and HPV status (P=0.002). In the univariate and multivariate analyses, ALB was found to be an independent prognostic indicator for DFS (HR =0.39, 95% CI:0.23-0.66, P=0.000) and OS (HR =0.46, 95% CI: 0.25-0.83, P=0.01) in OPC patients. Pre-treatment serum ALB could serve as a valuable prognostic biomarker for the prognostic stratification of OPC patients.

Sepsis-Induced Cardiomyopathy Detected With Focused Cardiac Ultrasound in the Emergency Department

BackgroundSepsis is a high mortality condition characterized by multi-organ dysfunction. Sepsis-induced cardiomyopathy (SIC) refers to cardiac dysfunction in sepsis. ObjectivesOur goal was to determine whether SIC can be detected in the emergency department (ED) using focused cardiac ultrasound (FCU). MethodsA retrospective analysis of adults presenting to a single ED with sepsis over a 21-month period was performed. Patients were included if they met clinical sepsis criteria, received an FCU by an emergency physician in the ED, and a baseline echocardiogram performed in the previous 12 months. SIC was defined as a significant decrease in estimated left ventricular ejection fraction (LVEF) by FCU relative to baseline. Demographic and outcome characteristics were compared between three cohorts: patients with normal baseline LVEF and no decrease on presentation, patients with decreased LVEF and no significant change, and those with a significant decrease in LVEF from their normal baseline (SIC). ResultsThere were 110 patients that met inclusion criteria: 89 patients (81%) in the normal LVEF group, 12 (11%) in the prior decreased LVEF group, and 9 (8%) in the SIC group. Unadjusted mortality at 90 days for patients with SIC (67%) and prior decreased LVEF (58%) was significantly higher than those with normal EF (29%) (p = 0.019). When adjusted for age, gender, Charlson Index score, and lactate > 4.0 mmol/L, SIC was associated with mortality at 90 days (odds ratio 6.1, 95% confidence interval 1.37–32.92). ConclusionSIC can be detected using FCU by emergency physicians in the ED and is associated with increased 90-day mortality.

Differences in Survival of Patients With COPD According to the New GesEPOC 2021 Classification of Phenotypes

IntroductionChronic obstructive pulmonary disease (COPD) is a respiratory pathology with high prevalence, morbidity and mortality. The Spanish COPD guideline (GesEPOC) recommends individualizing treatment according to phenotypes. The phenotype classification was updated in 2021. This study aimed to determine the survival of patients by this new classification and compare the predictive capacity of mortality compared to the previous version. MethodsThis observational study of COPD patients involved prospective follow-up for 6 years. Demographic and clinical data were collected at the beginning and evolutionary data at the end of the study. Patients were classified according to GesEPOC 2017 and GesEPOC 2021. Univariate survival analysis and multivariate analysis identified mortality risk factors. ResultsOf the 273 patients, 243 (89.0%) were male. Ninety-three patients (34.1%) died during follow-up. Regarding phenotypes, 190 patients (69.6%) were non-exacerbators, 69 (25.3%) belonged to the non-eosinophilic exacerbator phenotype and 14 (5.1%) were of the eosinophilic exacerbator phenotype. Compared with non-exacerbator patients, those with the non-eosinophilic exacerbator phenotype had lower survival (p=0.009). Risk factors independently associated with mortality were older age (p<0.001), non-eosinophilic exacerbator phenotype (p=0.017) and a high Charlson index score (p<0.001). The new classification presented a worse ability to predict mortality than the previous version (area under the curve 0.632 vs 0.566, p=0.018). ConclusionPatients with the non-eosinophilic exacerbator phenotype had worse prognoses. This phenotype, advanced age and high comorbidity were mortality risk factors. The GesEPOC 2021 classification predicts mortality worse than the 2017 version. These data must be considered for more individualized management of COPD patients.

Antibiotics Versus Appendectomy for Acute Appendicitis

Objective: To compare the efficacy of antibiotic treatment versus appendectomy in treatment of acute appendicitis. Study Design: Retrospective study Place and Duration of Study: Department of Surgery, Shahida Islam Medical Complex, Lodhran from 1st January 2021 to 31st March 2022. Methodology: One hundred patients of age &gt;18 years were enrolled after the complete assessment and confirmation of acute appendicitis. The clinical confirmation included the complete assessment of signs and symptoms of patients through Modified Charlson Index and Alvardo score. Patients were further divided into two groups with each group having 50 patients and matched for their clinical symptoms and duration. Group A had those patients who were only given antibiotics for the treatment of their acute appendicitis while Group B had those patients which were planned for appendectomy. A course of amoxicillin with clavulanic acid or fluoroquinolone was given for 7 to 10 days and the metronidazole/tinidazole was added in 60% of the cases. Patient’s data was recorded on well structured questionnaire. Results: The mean age was 37.5±11.2 years in group A and 38.1±10.9 years in group B. There were higher numbers of males in both groups. The average incidence of complications like perforation as well as peritonitis and surgical wound infection were significantly less in appendectomy patients and was reported as 17, 12 and 1% respectively. The long-term outcomes of antibiotic treatment plan for acute appendicitis showed requirement of appendectomy in 26% cases in group. Conclusion:Antibiotic treatment can be used effectively for acute appendicitis in selected patients with careful follow up/ monitoring for complications and as an interim treatment option for patient’s not opting for surgery or cannot undergo surgery, however appendectomy remains the most appropriate treatment for acute appendicitis overall. Keywords:Acute appendicitis, Antibiotics, Appendectomy, Efficacy

Treatment duration for central line-associated infection caused by Enterococcus spp.: a retrospective evaluation of a multicenter cohort.

Objective of this study was to assess the appropriate treatment duration for enterococcal central line-associated bloodstream infections (CLABSIs). This observational, retrospective, multicenter study conducted between 2011 and 2019 enrolled all hospitalized patients with monomicrobial enterococcal CLABSI. Those with infective endocarditis and non-survivors at least 7days from index blood culture (BC)were excluded. Primary endpoint was 30-day mortality. We enrolled 113 patients, of whom 59% were male, median age was 64 (SD ± 15) and median Charlson's index score 5 (IQR 3-8). Enterococcus faecalis and Enterococcus faecium were found in 51% and 44% of cases, respectively. Median treatment duration was 11days (IQR 6-17), and 32% of patients (n = 36) received ≤ 7days. Characteristics of patients receiving more or less than 7days of treatment were similar. Central line was removed in 82% (n = 93) of cases within a median of 3days (1-8). At both uni- and multivariate analysis, duration of antibiotic treatment > 7days was not associated with 30-day mortality [HR 0.41 (95% CI, 0.13-1.24), p = 0.12] even after adjustment with propensity score [HR 0.47 (95% CI 0.17-1.26), p = 0.13]. A 7-day treatment course appears to be safe in non-complicated enterococcal CLABSIs.

A retrospective multicentre study on dalbavancin effectiveness and cost-evaluation in sternotomic wound infection treatment: DALBA SWIT Study

To evaluate the cost-effectiveness of dalbavancin compared with standard of care (SoC) treatment as daptomycin or teicoplanin in patients with sternal wound infections (SWI). Multicentre retrospective study of patients diagnosed with SWI from January 2016 to December 2019 at two cardiac surgery facilities treated with dalbavancin, teicoplanin or daptomycin. Patients with SWI treated with dalbavancin were compared with SoC to evaluate resolution of infection at 90 and 180 days from infection diagnosis, length of stay (LoS) and management costs. 48 patients with SWI were enrolled, 25 (50%) male, median age 67 (60-73) years, Charlson index score 5 (4-7). Fifteen patients were treated with dalbavancin (31%) and 33 with SoC (69%): teicoplanin in 21 (63%), and daptomycin in 12 (37%). Staphylococcus species were the most frequent isolates (44, 92%), mostly (84%) resistant to methicillin. All patients were treated with surgical debridement followed by negative pressure wound therapy. Wound healing at day 90 and 180 was achieved in 46 (95.8%) and 34 (82.9%) of patients, respectively. A shorter length of hospitalization in patients treated with dalbavancin compared with SoC [12 (7-18) days vs 22 (12-36) days, p:0.009] was found. Treatment with dalbavancin resulted in total cost savings of €16 026 (95% CI 5976-26 076, P < 0.001). Savings were mainly related to the LoS that was significantly shorter in the dalbavancin group, generating significantly lower cost compared to SoC group. Dalbavancin treatment of sternal wound infections is effective and seems to reduce hospitalization length, leading to significantly lower costs.

Hospital mortality and length of stay differences in emergency medical admissions related to ‘on-call’ specialty

BackgroundThe outcomes of acute medical admissions have been shown to be influenced by a variety of factors including system, patient, societal, and physician-specific differences.AimTo evaluate the influence of on-call specialty on outcomes in acute medical admissions.MethodsAll acute medical admissions to our institution from 2015 to 2020 were evaluated. Admissions were grouped based on admitting specialty. Thirty-day in-hospital mortality and length of stay (LOS) were evaluated. Data was analysed using multivariable logistic regression and truncated Poisson regression modelling.ResultsThere were 50,347 admissions in 30,228 patients. The majority of admissions were under Acute Medicine (47.0%), and major medical subspecialties (36.1%); Elderly Care admitted 12.1%. Acute Medicine admissions were older at 72.9 years (IQR 57.0, 82.9) vs. 67.2 years (IQR 50.1, 80.2), had higher Acute Illness Severity (grades 4–6: 85.9% vs. 81.3%; p < 0.001), Charlson Index (> group 0; 61.5% vs. 54.6%; p < 0.001), and Comorbidity Score (40.7% vs. 36.7%; p < 0.001). Over time, there was a small (+ 8%) but significant increase in 30-day in-hospital mortality. Mortality rates for Acute Medicine, major medical specialties, and Elderly Care were not different at 5.1% (95% CI: 4.7, 5.5), 4.7% (95% CI: 4.3, 5.1), and 4.7% (95% CI: 3.9, 5.4), respectively. Elderly Care admissions had shorter LOS (7.8 days (95% CI: 7.6, 8.0)) compared with either Acute Medicine (8.7 days (95% CI: 8.6, 8.8)) or major medical specialties (8.7 days (95% CI: 8.6, 8.9)).ConclusionNo difference in mortality and minor differences in LOS were observed. The prior pattern of improved outcomes year on year for emergency medical admissions appears ended.

Anxiety, depression, health-related quality of life, and mortality among colorectal patients: 5-year follow-up.

PurposeHealth-related quality of life (HRQoL) measurement represents an important outcome in cancer patients. We describe the evolution of HRQoL over a 5-year period in colorectal cancer patients, identifying predictors of change and how they relate to mortality.MethodsProspective observational cohort study including colorectal cancer (CRC) patients having undergone surgery in nineteen public hospitals who were monitored from their diagnosis, intervention and at 1-, 2-, 3-, and 5-year periods thereafter by gathering HRQoL data using the EuroQol-5D-5L (EQ-5D-5L), European Organization for Research and Treatment of Cancer’s Quality of Life Questionnaire-Core 30 (EORTC-QLQ-C30), and Hospital Anxiety and Depression Scale (HADS) questionnaires. Multivariable generalized linear mixed models were used.ResultsPredictors of Euroqol-5D-5L (EQ-5D-5L) changes were having worse baseline HRQoL; being female; higher Charlson index score (more comorbidities); complications during admission and 1 month after surgery; having a stoma after surgery; and needing or being in receipt of social support at baseline. For EORTC-QLQ-C30, predictors of changes were worse baseline EORTC-QLQ-C30 score; being female; higher Charlson score; complications during admission and 1 month after admission; receiving adjuvant chemotherapy; and having a family history of CRC. Predictors of changes in HADS anxiety were being female and having received adjuvant chemotherapy. Greater depression was associated with greater baseline depression; being female; higher Charlson score; having complications 1 month after intervention; and having a stoma. A deterioration in all HRQoL questionnaires in the previous year was related to death in the following year.ConclusionsThese findings should enable preventive follow-up programs to be established for such patients in order to reduce their psychological distress and improve their HRQoL to as great an extent as possible.ClinicalTrials.gov Identifier:NCT02488161Supplementary InformationThe online version contains supplementary material available at 10.1007/s00520-022-07177-1.