Charlson’s Comorbidity Index Research Articles

Independent Predictors of Mortality Among Patients With NAFLD Hospitalized With COVID-19 Infection.

The impact of the coronavirus disease 2019 (COVID‐19) pandemic among patients with chronic liver disease is unknown. Given the high prevalence of nonalcoholic fatty liver disease (NAFLD), we determined the predictors of mortality and hospital resource use among patients with NAFLD admitted with COVID‐19 by using electronic medical records data for adult patients with COVID‐19 hospitalized in a multihospital health system who were discharged between March and December 2020. NAFLD was diagnosed by imaging or liver biopsy without other liver diseases. Charlson’s comorbidity index (CCI) and Elixhauser comorbidity index (ECI) scores were calculated. In the study sample, among the 4,835 patients hospitalized for COVID‐19, 553 had NAFLD (age: 55 ± 16 years, 51% male, 17% White, 11% Black, 58% Hispanic, 8% Asian, 5% from congregated living, 58% obese, 15% morbid obesity [body mass index ≥ 40], 51% type 2 diabetes, 63% hypertension, mean [SD] baseline CCI of 3.9 [3.2], and baseline ECI of 13.4 [11.3]). On admission, patients with NAFLD had more respiratory symptoms, higher body temperature and heart rate, higher alanine aminotransferase and aspartate aminotransferase than non‐NAFLD controls (n = 2,736; P < 0.05). Of the patients with NAFLD infected with COVID‐19, 3.9% experienced acute liver injury. The NAFLD group had significantly longer length of stay, intensive care unit use, and mechanical ventilation, with a crude inpatient mortality rate of 11%. In multivariate analysis, independent predictors of inpatient mortality among patients with NAFLD infected with COVID‐19 were older age, morbid obesity, ECI score ≥ 11, higher Fibrosis‐4 Index (FIB‐4) score, and oxygen saturation <90% (all P < 0.05), but not sex, race/ethnicity, or any individual comorbidity (all P > 0.05). Conclusion: Patients with NAFLD infected with COVID‐19 tend to be sicker on admission and require more hospital resource use. Independent predictors of mortality included higher FIB‐4 and multimorbidity scores, morbid obesity, older age, and hypoxemia on admission.

MO533WHICH PARAMETERS BEST PREDICT POSITIVE COVID-19 STATUS FOLLOWING HIP FRACTURE FOR PATIENTS LIVING WITH CKD?

Background and AimsPatients living with chronic kidney disease (CKD) are at greater susceptibility of sustaining hip fractures compared to those without CKD due to higher falls risk. Post-trauma clinical outcomes for patients living with CKD are exacerbated by frailty, co-morbidities and sarcopenia. Patients living with CKD may require lengthy hospitalization following hip fracture, considering the additional indications for extensive treatment and rehabilitation. A long hospital stay may bring greater risks of contracting COVID-19, given the magnitude of this current global pandemic. Complications from COVID-19 significantly increase mortality risks for older patients living with CKD after acute trauma, as a considerable proportion will have a poor baseline health and functional status. Our study aims to determine the most useful clinical and laboratory assessment tools to predict for a positive COVID-19 status following hospitalization with hip fracture in patients living with CKD.MethodPatients with CKDG3b-5 admitted from home to a tertiary hospital in North West UK with hip fracture between Feb and Dec 2020 were included. Each patient included in this study received at least one COVID-19 nasopharyngeal swab during their hospitalization. Parameters assessed on hospital admission for each patient included Clinical Frailty Scale (CFS), Charlson’s Co-morbidity Index (CCI), Chronic Kidney Disease Frailty Index Laboratory Score (CKD FI-LAB), Estimated VO2 Peak, Karnofsky Performance Status Scale, Sernbo Score, Nottingham Hip Fracture Score, ASA Physical Status Classification System Score and Abbreviated Mental Test Score. Receiver Operating Characteristic (ROC) curve analyses were performed to evaluate the ability of individual parameters to predict for a positive COVID-19 status following hip fracture in patients living with CKD. Events of 30-day mortality were recorded.Results92 patients met study inclusion criteria. The mean age was 84.6±7.8 years and the female:male ratio was 1.6:1. 7 patients (7.6%) were on long-term dialysis and the mean eGFR amongst non-dialysis patients was 36.5±13.8 ml/min/1.73m2. The median length of hospitalization was 17 days. 22 patients (23.9%) tested positive for COVID-19. Area under a Curve (AUC) values from ROC analyses are shown in Table 1. The difference in 30-day mortality rate between patients who tested positive for COVID-19 and those who tested negative was +6.8% (p<0.001).ConclusionFrailty and co-morbidity assessment tools (CFS, CCI and CKD FI-LAB) displayed the best predictive ability for positive COVID-19 status following hip fracture in patients living with CKD. A continuous, holistic multi-disciplinary team approach during hospitalization for comprehensive geriatric assessment and optimization of medical co-morbidities may improve outcomes, in anticipation of a potential lengthy hospital stay. To improve prognosis, research efforts should continue to explore avenues on reducing COVID-19 rates within this patient population.MO533 Table 1:AUC values to predict for positive COVID-19 status following hip fracture in patients living with CKDPredictorAUC Value95% ClClinical Frailty Scale0.940.87-1.00Charlson’s Co-morbidity Index0.920.86-0.99Chronic Kidney Disease Frailty Index Laboratory Score0.880.81-0.95Estimated VO2 Peak0.860.79-0.92Karnofsky Performance Status Scale0.840.77-0.91Sernbo Score0.800.74-0.87Nottingham Hip Fracture Score0.770.70-0.84ASA Physical Status Classification System Score0.740.67-0.81Abbreviated Mental Test Score0.650.58-0.72

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

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

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

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

Long-term survival, risk factors and causes of mortality in surgically treated chronic pancreatitis

Background/ObjectivesChronic pancreatitis (CP) is a complex disease with a high complications rate, poor quality of life and considerable mortality. Prospective investigations on long-term outcomes in chronic pancreatitis are scarce. Thus, we aimed to assess long-term survival, causes of death and impact of risk factors on survival in a cohort of surgically managed patients with chronic pancreatitis. MethodsAfter IRB approval, a prospective longitudinal cohort study with long-term follow-up (up to 19.6 years) was conducted. All consecutive single center patients operated between 1997 and 2019 were included. Data on health and social status, risk behavior, history of CP, indications for surgery, comorbidities and causes of death were collected. Survival analysis was performed using Kaplan-Meier analysis. Cox proportional multivariate hazard regression was used to assess the impact of risk factors on mortality. The results are reported as the hazard ratio (HR) with the 95% confidence interval (CI). The log-rank test was used to test for differences in survival between groups. ResultsA total of 161 patients with CP were subjected to operative management due to chronic pain or local complications of CP. Forty-eight patients (29.8%) died during the follow-up period. Mortality rate was 32.8 per 1000 patient-years (PY) since the diagnosis of CP. Standardized mortality ratio (SMR) was 1.8 (2.7 for the subgroup of continuous alcohol users). Median survival after surgical treatment was 13.3 years. Univariate analysis revealed the following risk factors on survival: preoperative and postoperative continuous moderate or heavy alcohol consumption, heavy smoking, age ≥50 years, Charlson’s comorbidity index (CCI) ≥4 and 2–3, unemployment, disability, insulin-dependent diabetes, pancreatic exocrine insufficiency (PEI), and low body mass index (BMI). In multivariate regression analysis lower survival was associated with continuous moderate/heavy alcohol consumption (hazard ratio (HR) 2.27), history of heavy smoking (HR 4.40), unemployment (HR 2.49), CCI 2–3 and ≥4 (HR 2.53 and HR 3.16, respectively), and BMI <18.5 (HR 4.01).Behavioral risk factors accounted for the vast majority of deaths due to chronic alcoholic liver disease (21 cases, 43.7%), smoking-related diseases (15 cases, 31.3%). CP-related mortality was 4.2%. ConclusionsLong-term outcomes of surgically treated chronic pancreatitis was associated with low CP-related mortality. Alcohol-related and smoking-related diseases caused the vast majority of deaths. Thus, surgery provides the best results in patients, preventing postsurgical relapse of original behavioral risks. For achieving this, ongoing postoperative support would be highly beneficial.

Tu1039 ADVERSE EVENTS AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC NEOPLASMS: A POPULATION-BASED STUDY

Endoscopic submucosal dissection (ESD) is an attractive method in the treatment of early gastric neoplasms. But adverse events (AEs) following gastric ESD is inevitable. Many studies addressing AEs were conducted based on single cohort. However, little is known about AEs associated with gastric ESD in population-based studies. This study aimed to identify incidence of AEs following gastric ESD and their risk factors using a large population-level database. We conducted a population-based study for ESD claims based on the Korean Health Insurance Review and Assessment database from 2013 to 2017. This study included subjects who underwent gastric ESD for benign and malignant gastric tumors. We measured incidence rates of bleeding, perforation and pneumonia within 30 days after gastric ESD. We determined the operational definition of each AE as diagnosis or treatment claim code related to AE. Pre-existing comorbidities were determined by Charlson’s comorbidity index (CCI) score calculated from the ICD-10 codes within 3 months before procedure. The logistic regression analysis was used to identify predictors of each adverse event. Finally, we analyzed about 72,647 ESD cases. Pooled incidence rates were 6.650% for bleeding, 0.291% for perforation, and 0.496% for pneumonia. All AEs were predominant in male (all P < 0.05). Bleeding and perforation occurred more frequently in the 40s and 50s than older people. In contrast, incidence of pneumonia steadily increased with age. All AE rates were higher in general hospitals than tertiary hospitals and hospitals. Likewise, as the CCI score increased, the incidence of all AEs increased (Table 1). This population-based study demonstrated that male and comorbid patients were risk factors for the all AEs associated with gastric ESD. In addition, we identified that age group and hospital setting affect the incidence of AEs.

Age related changes in the bone microstructure in patients with femoral neck fractures

BackgroundThe risk of femoral neck fracture progressively increases with age. However, the reasons behind this consistent increase in the fracture risk can't be completely justified by the decrease in the bone mineral density. The objective of this study was to analyze the correlation between various bone structural features and age. Study Design & MethodsA total of 29 consecutive patients who suffered an intracapsular hip fracture and underwent joint replacement surgery between May 2012 and March 2013 were included in this study. A 2 cm × 1 cm Ø cylindrical trabecular bone sample was collected from the femoral heads and preserved in formaldehyde. Bone mineral density (BMD), microarchitecture, organic content and crystallography were analyzed using a Dual-energy X-ray absorptiometry scan, micro-CT scan, and high resolution magic-angle-spinning-nuclear magnetic resonance (MAS-NMR), respectively. Statistical correlations were made using Spearman´s or Pearson´s correlation tests depending on the distribution of the continuous variables. ResultsThe mean patient age was 79.83 ± 9.31 years. A moderate negative correlation was observed between age and the hydrogen content in bone (1H), which is an indirect estimate to quantify the organic matrix (r = −0.512, p = 0.005). No correlations were observed between BMD, trabecular number, trabecular thickness, phosphorous content, apatite crystal size, and age (r = 0.06, p = 0.755; r = −0.008, p = 0.967; r = −0.046, p = 0.812; r = −0.152, p = 0.430, respectively). A weak positive correlation was observed between Charlson´s comorbidity index (CCI) and c-axis of the hydroxiapatite (HA) crystals (r = −0.400, p = 0.035). ConclusionThe femoral head relative protein content progressively decreases with age. BMD was not correlated with other structural bone parameters and age. Patients with higher comorbidity scores had larger HA crystals. The present results suggest that the progressive increase in the hip fracture risk in elderly patients could be partially explained by the lower bone protein content in this age group.

Prevalence and prognostic impact of comorbidities and peripheral blood indices in sarcomas

BackgroundThe prognostic impact of comorbidities in patients with sarcomas is not well defined. The aims of this study were to examine the implications of comorbidities and abnormal peripheral blood indices in patients with sarcomas.MethodsA population-based database was assembled to extract patients with sarcoma in Hong Kong between January 2004 and March 2018. Charlson’s Comorbidity Index (CCI) score and prevalence of comorbidities, neutrophil, lymphocyte and platelet counts at diagnosis were assessed. The prognostic values of CCI, neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) were estimated using Cox proportional hazard models. Restricted cubic spline plots were used to explore the association of baseline NLR and PLR with all-cause and cancer-specific mortality.ResultsAmong 3358 eligible patients with sarcomas, 52.2% died after a median 26 months of follow-up. The most common comorbidities were diabetes mellitus (9.8%) and cerebrovascular disease (4.8%). Patients with higher CCI had higher mortality (CCI=3 vs CCI=2; HR 1.49; 95% CI 1.19 to 1.87; p<0.01; CCI ≥7 vs CCI =2; HR 3.20; 95% CI 2.62 to 3.92; p<0.001). Abnormal NLR and PLR levels were associated with higher all-cause mortality (NLR: HR 1.698, p<0.001, 95% CI 1.424 to 2.025; PLR: HR 1.346, p<0.001, 95% CI 1.164 to 1.555) and cancer-related mortality (NLR: HR 1.648, p<0.001, 95% CI 1.341 to 2.024; PLR: HR 1.430, p<0.001, 95% CI 1.205 to 1.697).ConclusionsThis is the largest population-based soft-tissue or bone sarcoma cohort worldwide. Comorbidities have significant negative prognostic impact on the survival of patients with sarcomas. Moreover, NLR and PLR are robust prognostic factors, and abnormal NLR and PLR have negative effects yet non-linear effects on survival.

Survival after stereotactic radiotherapy in patients with early-stage non-small cell lung cancer

Introduction: Stereotactic radiotherapy (SBRT) is the treatment of choice for inoperable early stage non-small cell lung cancer (NSCLC). We report analyses of the influence of age on survival after SBRT.Methods and material: From 2005 to 2017, 544 previously un-irradiated patients with early stage NSCLC had SBRT. The data were analyzed in four age groups: A: –69 (176 pts), B: 70–74 (115 pts), C: 75–79 (131 pts) and D: 80 years or older (122 pts). Two SBRT dose regimes were used: 45 Gy/3F (N = 103) and 66 Gy/3F (N = 441).Results: All patients had a follow up (time to censoring, FU) of at least 16 months, the median FU being 48.0 months. The median age was 74.4 years. The overall survival (OS) was associated with age. The median OS was 50.7, 45.9, 45.4 and 33.0 months, and the 5-year OS was 45%, 32%, 33% and 18% in groups A, B, C and D, respectively. No difference was found between groups B and C, while OS in group A was significantly better than remaining groups, and the OS in group D significantly poorer. In multivariable analyses, OS was heavily influenced by age, Charlson’s comorbidity index (CCI) and performance status (PS). For lung cancer-specific survival (LCSS), only increasing tumor diameter and PS were associated with poor survival.Conclusions: The OS was influenced by age, but the study suggests that a cut point of 75 year is inappropriate in evaluating the effect of old age on survival. Poor PS was associated with poor OS. CCI influenced OS, but not LCSS, which was only affected by PS and tumor size.

Analysis of the risk factors for tracheostomy and decannulation after traumatic cervical spinal cord injury in an aging population.

Retrospective study. To investigate the risk factors associated with tracheostomy after traumatic cervical spinal cord injury (CSCI) and to identify factors associated with decannulation in an aging population. Advanced critical care and emergency center in Yokohama, Japan. Sixty-five patients over 60 years with traumatic CSCI treated between January 2010 and June 2017 were enrolled. The parameters analyzed were age, sex, American Spinal Injury Association impairment scale score (AIS) at admission and one year after injury, neurological level of injury (NLI), injury mechanism, Charlson's comorbidity index (CCI), smoking history, radiological findings, intubation at arrival, treatment choice, length of intensive care unit (ICU) stay, tracheostomy rate, improvement of AIS, decannulation rate, and mortality after one year. The study included 48 men (74%; mean age 72.8 ± 8.3 years). Twenty-two (34%), 10 (15%), 24 (37%), and 9 (14%) patients were classified as AIS A, B, C, and D, respectively. The tracheostomy group showed significantly more severe degree of paralysis, more patients with major fractures or dislocations, more operative treatment, longer ICU stay, poorer improvement in AIS score after one year and higher rate of intubation at arrival. AIS A at injury was the most significant risk factor for tracheostomy. The non-decannulation group had a significantly higher mortality. The risk factor for failure of decannulation was CCI. Risk factors for tracheostomy after traumatic CSCI were AIS A, operative treatment, major fracture/dislocation, and intubation at arrival. The only factor for failure of decannulation was CCI.

Predictors of successful discharge from intensive care units in older adults aged 80 years or older: A population-based study

BackgroundWe determined the long-term outcomes of adult intensive care unit (ICU) patients and investigated the predictors of successful discharge for ≥6 months among older adults aged ≥80 years in Taiwan. ObjectivesTo identify the predictors of ICU admission in patients aged ≥80 years and the predictors of and optimal cutoff predictive discharge score (PDS) for ICU successful discharge in patients aged ≥80 years. DesignA population-based retrospective cohort study. Settings and participantsMedical records of 282,269 individuals aged ≥80 years collected from the Taiwan National Health Insurance Research Database from 2001 to 2013. MethodsDemographic and clinical parameters, Charlson’s comorbidity index (CCI), hospital type, and post-discharge outcomes of ICU patients aged ≥80 years were obtained from their medical records. Multivariable logistic regression was used to analyze and identify the predictors of successful discharge and treatments received by critically ill patients aged ≥80 years admitted to the ICU. The optimal cutoff PDS for successful discharge in older adults were calculated by Youden Index.Results 65,756 ICU admissions were documented, of which 21% (n = 13,825) were for adults aged ≥80 years. The successful discharge rate among ICU patients aged ≥80 years (57.2%) was significantly lower than that among those aged 18–64 and 65–79 years (81.7% and 71.5%, respectively). Multivariable logistic regression analyses revealed the following predictors of successful discharge for ≥6 months after ICU admission in adults aged ≥80 years: younger age (adjusted odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.94–0.96), shorter ICU length of stay (adjusted OR = 0.90, 95% CI = 0.88–0.92), lower CCI (adjusted OR = 0.92, 95% CI = 0.90–0.93), and no life-sustaining treatments received (Cardiopulmonary resuscitation: adjusted OR = 0.75, 95% CI = 0.68–0.84; mechanical ventilation: adjusted OR = 0.63, 95% CI = 0.57–0.71; use of inotropic agents: adjusted OR = 0.37, 95% CI = 0.34–0.41). The optimal cutoff PDS in older adults was 6 (area under the receiver operating characteristic curve = 0.73, 95% CI = 0.72–0.74). ConclusionThis is the first population-based study investigating the post-discharge outcomes of ICU patients aged ≥80 years. Advanced age was a predictive factor of unsuccessful discharge from the ICU. Nevertheless, more than half of this vulnerable population survived for at least 6 months after discharge. Therefore, age should not be the sole criterion when considering ICU admission and deciding curative treatments for critically ill older adults. Comprehensive assessment and effective communication with patients and their families are also crucial in clinical decision-making for critically ill older adults.

Predicting morbidity after robotic partial nephrectomy: The effect of tumor, environment, and patient-related factors

PurposeTo investigate the effect of tumor and nontumor related parameters on perioperative outcomes of robotic partial nephrectomy (RPN). Patients and methodsPatients who underwent RPN for a localized renal tumor at 2 institutions between June 2010 and November 2016 were reviewed. RENAL and Mayo adhesive probability (MAP) scores were calculated and information on comorbid conditions including ASA score, performance status, Charlson’s comorbidity index (CCI), and history of cardiovascular disease was collected. Correlations between each variable and warm ischemia time, estimated blood loss (EBL), operative time, change in estimated glomerular filtration rate, and length of hospital stay were assessed. Logistic regression analyses were performed to identify the best predictors of overall complications, major complications, risk of conversion, and Trifecta achievement. ResultsA total of 500 patients were included. RENAL score was found to have a statistically significant (P<0.05) correlation with warm ischemia time, EBL, and change in estimated glomerular filtration rate. MAP score showed significant association (P<0.05) with operative time and EBL. CCI had a significant correlation (P<0.05) with length of hospital stay and postoperative complications. In multivariable analyses, MAP score as a continuous variable (OR = 7.66; P<0.001) and MAP risk group stratification (OR = 3.29; P = 0.005) were independent predictors of the risk of conversion. Major complications were significantly associated with the cardiovascular disease in both univariable (OR = 2.35; P = 0.01) and multivariable analysis (OR = 4.52, P = 0.01). Finally, the MAP score as a continuous variable was an independent factor of Trifecta achievement (OR = 0.56; P = 0.04). ConclusionPatients related factors were the most important determinants of postoperative complications after RPN. RENAL and MAP scores had some influence on intraoperative parameters.

Progression into sepsis: an individualized process varying by the interaction of comorbidities with the underlying infection

BackgroundDevelopment of sepsis is a process with significant variation among individuals. The precise elements of this variation need to be defined. This study was designed to define the way in which comorbidities contribute to sepsis development.MethodsThree thousand five hundred nine patients with acute pyelonephritis (AP), community-acquired pneumonia (CAP), intraabdominal infections (IAI) or primary bacteremia (BSI) and at least two signs of the systemic inflammatory response syndrome were analyzed. The study primary endpoint was to define how comorbidities as expressed in the Charlson’s comorbidity index (CCI) and the underlying type of infection contribute to development of organ dysfunction. The precise comorbidities that mediate sepsis development and risk for death among 18 comorbidities recorded were the secondary study endpoints.ResultsCCI more than 2 had an odds ratio of 5.67 for sepsis progression in patients with IAI between significantly higher than AP and BSI. Forward logistic regression analysis indicated seven comorbidities that determine transition into sepsis in patients with AP, four comorbidities in CAP, six comorbidities in IAI and one in BSI. The odds ratio both for progression to sepsis and death with one comorbidity or with two and more comorbidities was greater than in the absence of comorbidities.ConclusionsThe study described how different kinds of infection vary in the degree to which they lead to sepsis. The number of comorbidities that enhances the risk of sepsis and death varies depending on the underlying infections.

S28. Survival in patients admitted in an intensive care unit according to electroencephalographic patterns

Introduction The American Society of Neurophysiology implemented a standardized classification (ACNS Standardized) for the evaluation of cerebral electrical activity in critical patients. The interpretation of electroencephalogram (EEG) findings and clinical correlation is still in debate. AIM: To compare survival according to EEG periodic and not periodic pattern in patients hospitalized in an intensive care unit. Methods Retrospective cohort of patients over 16 years, in coma state, hospitalized consecutively at the intensive care unit (ICU) in a tertiary care hospital in Buenos Aires, Argentina, from 2014 to 2017. We included all patients with at least one 60 min EEG performed at the ICU, registered according to the International System 10/20. We excluded cases with extra-axial compression injuries. We used the ACNS Standardized guidelines (v.2012), Glasgow Outcome Scale (GOS) and Charlson’s comorbidity index (CCI). We describe the population according to a periodic pattern (PP) and not periodic (NoPP), and compared characteristics between them. We estimate survival during hospitalization at ICU using the Kaplan–Meier method and compared survival between groups with a log rank test. Results We included 60 patients, mean age was 57 years (SD 18), 41.7% (25) were female. The median stay in ICU was 28 days (IQR 11.5-48). Thirty percent (12) were classified as PP and 70% (48) as NoPP. Comparing baseline characteristics between groups PP vs NoPP, female proportion was (72.2% vs 28.6%; p = 0.01), age (66.1 vs 56.5 years; p = 0.23), CCI (1.5 vs 1; p = 0.58), etiology (intra-axial compressive injuries 11.1% vs destructive injuries 19%; p = 0.46) and time from ICU admission to first EEG (3 vs 4; p = 0.81), respectively. Survival in ICU was for PP vs NoPP was 61.29% (CI95% 33.3–80.4) vs 79.4% (CI95% 61.6–89.6) p = 0.11, respectively. Functional prognostic at discharge measured as GOS ⩽ 2 was 50% (9) and 38.1% (16) p = 0.41 for PP vs NoPP. Conclusion A lower in hospital survival was observed in patients admitted to the ICU with a periodic electroencephalographic pattern and a worse functional prognosis compared with patients with non-periodic pattern. Although this difference is not statistically significant, due to the small sample, we question if pattern detection can define clinical prognosis and mortality in patients at the intensive care unit.

Development and validation of an instrument for measuring the burden of medicine on functioning and well-being: the Medication-Related Burden Quality of Life (MRB-QoL) tool

ObjectiveMedication-related burden (MRB) is a negative experience with medicine, which may impact on psychological, social, physical and financial well-being of an individual. This study describes the development and initial validation...

Breast conserving surgery versus mastectomy: overall and relative survival—a population based study by the Danish Breast Cancer Cooperative Group (DBCG)

Background: Observational studies have pointed at a better survival after breast conserving surgery (BCS) compared with mastectomy. The aim of the present study was to evaluate whether this remains true when more extensive tumor characteristics and treatment data were included.Methods: The cohort included patients registered after primary surgery for early invasive breast cancer in the database of the Danish Breast Cancer Cooperative Group, in the period 1995–2012. The cohort was divided into three groups: (i) patients who primarily had a mastectomy, (ii) patients treated by BCS, and (iii) patients who primarily had BCS and then mastectomy [intention to treat (ITT) by BCS]. The association between overall mortality and standard mortality ratio (SMR) and risk factors was analyzed in univariate and multivariate Poisson regression models.Results: A total of 58,331 patients were included: 27,143 in the mastectomy group, 26,958 in the BCS group, and 4230 in the BCS-ITT group. After adjusting for patient and treatment characteristics, the relative risk (RR) was 1.20 (95% CI: 1.15–1.25) after mastectomy and 1.08 (95% CI: 1.01–1.15) after BCS first and then mastectomy, as compared to BCS. Statistically significant interactions were not observed for age, period of treatment, and nodal status, but patients with Charlson’s Comorbidity Index (CCI) score 2+ had no increased mortality after mastectomy, as opposed to patients with CCI 0–1. Loco-regional radiation therapy (RT) in node positive patients did not reduce the increased risk associated with mastectomy [RR = 1.28 (95% CI 1.19–1.38)].Conclusion: Patients assigned to BCS have a better survival than patients assigned to mastectomy. Residual confounding after adjustment for registered characteristics presumably explained the different outcomes, thus consistent with selection bias. Diversities in RT did not appear to explain the observed difference in survival after BCS and mastectomy.

Gait Speed rather than Dynapenia Is a Simple Indicator for Complex Care Needs: A Cross-sectional Study Using Minimum Data Set

The impact of dynapenia on the complexity of care for residents of long-term care facilities (LTCF) remains unclear. The present study evaluated associations between dynapenia, care problems and care complexity in 504 residents of Veterans Care Homes (VCHs) in Taiwan. Subjects with dynapenia, defined as low muscle strength (handgrip strength <26 kg), were older adults with lower body mass index (BMI), slow gait speed, and higher numbers of Resident Assessment Protocol (RAP) triggers. After adjusting for age, education, BMI, and Charlson’s comorbidity index (CCI), only age, education, BMI and gait speed were independently associated with higher numbers of RAP triggers, but not dynapenia or handgrip strength (kg). Dividing subjects into groups based on quartiles of gait speed, those with gait speed ≤0.803 m/s were significantly associated with higher complexity of care needs (defined as ≥4 RAP triggers) compared to the reference group (gait speed >1 m/s). Significantly slow gait speed was associated with RAP triggers, including cognitive loss, poor communication ability, rehabilitation needs, urinary incontinence, depressed mood, falls, pressure ulcers, and use of psychotropic drugs. In conclusion, slow gait speed rather than dynapenia is a simple indicator for higher complexity of care needs of older male LTCF residents.

Increased Risk of Anxiety or Depression After Traumatic Spinal Cord Injury in Patients with Preexisting Hyperlipidemia: A Population-Based Study.

Anxiety or depression (AD) is a common complication after traumatic spinal cord injury (tSCI). This study sought to investigate the role of preexisting hyperlipidemia in new-onset AD after tSCI using a longitudinal population database. This retrospective cohort study used Longitudinal Health Insurance Database data from January 1997 to December 2011. The case and comparison groups were individuals who experienced tSCI and who did and did not have preexisting hyperlipidemia, respectively. Kaplan-Meier curves were plotted, and log-rank test was used to compare the differences between these 2 groups. A Cox regression model was used to estimate the relative risk of AD. A total of 26,892 adult patients were enrolled in this study. After 1:3 matching with age and gender, it showed 1) tSCI patients with preexisting hyperlipidemia have a 1.32-fold adjusted hazard ratio (HR) compared with those without hyperlipidemia (P < 0.05); 2) The Kaplan-Meier plot in tSCI patients with hyperlipidemia were more likely to develop the new-onset AD than those without hyperlipidemia during the follow-up period (P= 0.0003); and 3) the stratified analysis showed the risk of AD among patients with tSCI aged 18-34 years (HR, 3.2; 95% confidence interval (CI) 1.2-8.9), male patients (HR, 1.3; 95% CI 1.1-1.6), and higher Charlson's comorbidity index (CCI) score (CCI > 2; HR, 1.9; 95% CI 1.2-2.9), and those with a history of stroke (HR, 1.7; 95% CI 1.0-2.7). Preexisting hyperlipidemia is an independent predictor of new-onset AD in patients with tSCI, especially in those who are younger, male, have a higher CCI score, and have stroke.

The impact of comorbidities on the management and prognosis of oropharyngeal and hypopharyngeal cancer patients in Taiwan

Background: Comorbidity is often associated with negative outcome of prognosis. The aim of this study was to investigate the prevalence and impact of comorbidities in a retrospective nationwide population-based study of patients with oropharyngeal and hypopharyngeal cancers in Taiwan. Materials and Methods: A total of 4733 oropharyngeal and hypopharyngeal cancer patients diagnosed in the period 2007–2010 were identified through the Taiwan Cancer Registry (TCR) database. By linking this data set to the National Health Insurance Research Database (NHIRD) and the Death Registry (DR), information on comorbidity and cause of death was obtained and adapted to the Charlson’s comorbidity index (CCI). The influence of comorbidity on overall survival and cancer-related death was evaluated by Kaplan–Meier estimates and Cox regressions. Results: There were 23.5% of patients with comorbidities during the year before cancer diagnosis. Patients with comorbidities are associated with lower survival rates for stage 3 and for oropharynx. Although there was a tendency that patients with comorbidities received less curative treatment within the same cancer stage, the statistical significance was not reached. The data suggest having a co-morbidity condition had a significant effect on all-cause death (age and gender adjusted hazard ratios = 0.68-0.40) but no significance in cancer-related deaths. Conclusion: The cancer management was not significantly different between patients’ comorbidity conditions. However, the larger differences between all-cause and cancer-specific survival rates in certain treatment groups emphasize the importance of managing other medical conditions in cancer patients.

Change in Patient-Reported Outcomes in Single-Unit Transfusion Comparable with Double-Unit Transfusion

▪IntroductionPatient blood management was developed to reduce allogeneic blood exposure and enhance patient outcomes. If transfusion is required in stable and non-bleeding hospitalized patients, prescribing one unit of red blood cells (RBC) followed by reassessment of clinical condition is recommended. Double-unit RBC transfusion, the routine practice in the past, is still widely practiced despite the advocate of restrictive transfusion strategy. One of the reasons could be a lack of evidence to support the optimal number of RBC units per transfusion. Blood transfusion is often performed to alleviate anemic symptoms. However, patient-reported outcomes were seldom measured to evaluate transfusion requirements.MethodThis was a single-center prospective study conducted during Mar to Jun 2016 in the medical department of a regional hospital of Hong Kong. Day-care and hospitalized patients requiring RBC transfusion were recruited. Patients with active bleeding or unstable hemodynamics were excluded. Subjects' demographics, recent transfusion history, comorbidities, transfusion trigger and the number of RBC units transfused were obtained. Patient-reported outcomes were measured on the day of transfusion (Day 0), and on Day 1 and 7 post-transfusion. Two health-related quality of life (HRQOL) instruments, i.e. Short-form 12 version 2 (SF12v2) and Functional Assessment of Cancer Therapy Anemia Subscale (FACT-AnS) in traditional Chinese, were administered to measure the general health status and anemic symptoms respectively. Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were then derived from SF12v2. The number of RBC units transfused in one week and post-transfusion hemoglobin (Hb) level were evaluated. Linear regressions were performed to study the relationship between the changes in PCS, MCS and FACT-AnS on Day 1 and Day 7 from Day 0 with the number of RBC units transfused. Factors associated with the number of RBC units transfused were controlled. Other predictors of the changes in HRQOL were included in the regression analysis.Results34 day-care and 67 hospitalized patients were recruited with HRQOL surveys completed on Day 0. The surveys were completed by 97 patients on Day 1 and 78 patients on Day 7. Forty-seven patients (47%), who were transfused with 2 or more units of RBC, were classified as double-unit group. The median transfusion trigger was 7.6 [IQR 7.0 - 7.9] g/dL in the single-unit group and 7.0 [IQR 6.2 - 7.8] g/dL in the double-unit group (p < 0.05). There was a trend of higher Charlson’s Comorbidity Index (CCI) (p = 0.09) in the single-unit group. Baseline PCS, MCS and FACT-AnS scores on Day 0 were comparable in both groups (p = 0.35, 0.45 and 0.15 respectively).The changes in HRQOL of all subjects were summarized in Table 1. FACIT-AnS improved after transfusion but the effect size was small (Cohen’s d < 0.5). There was improvement of PCS on Day 7. The change of MCS was non-significant.The mean number of transfused RBC in one week was 0.7 units less in the single-unit group (p < 0.001). The post-transfusion Hb level was 0.9g/dL (95% CI: 0.3, 1.6) and 1.1g/dL (95% CI: 0.2, 1.9) higher in the double-unit group on Day 1 and Day 7 respectively.Having controlled for transfusion trigger, CCI and RBC transfused during Day 1 to Day 7, the changes in HRQOL were not associated with the number of RBC units transfused (Table 2). Day-care patients had greater improvement in HRQOL on Day 1 but not on Day 7. The improvement of HRQOL in those having worse baseline scores was more significant. RBC use in the past 7 days was not associated with the change in patient-reported outcomes.ConclusionDouble-unit RBC transfusion was frequently performed, especially in patients with a lower Hb level. Blood transfusion could improve anemic symptoms but the effect on general health status was insignificant during early follow-up. The average number of RBC units transfused in one week was 28% less in the single-unit group. Post-transfusion Hb level was higher after double-unit transfusion, but there was no evidence it led to more significant improvement in patient-reported outcomes. Day-care patients had earlier improvement in HRQOL but the effect disappeared after one week. Patients with worse symptom score at baseline had greater improvement in HRQOL. It is proposed that the practice of single-unit RBC transfusion is appropriate in terms of alleviating anemic symptoms and reducing overall blood use. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.