Comorbidity Index Research Articles

Impact of the Charlson Comorbidity Index on Delirium Outcomes.

Introduction Delirium is a significant inpatient healthcare challenge and has a greater incidence among older adults with adverse healthcare outcomes. Yet there are limited established models for risk stratification. The objective is to determine the effectiveness of implementing the Charlson comorbidity index (CCI) score, which is calculated based on the assigned weight for various disease conditions, and to analyze the healthcare outcomes in older hospitalized adults with delirium. Methodology A retrospective cohort study of 214 elderly hospitalized patients between January 1, 2015, and December 31, 2016, with the diagnosis of delirium, was analyzed by grouping based on the severity of diseases as defined in CCI. The primary analysis outcome was to analyze all-cause inpatient mortality, length of hospital stay (in days), 30-day readmissions, and discharge destination in patients with delirium based on CCI scores using regression analysis and nonparametric tests. Secondary analysis included the prevalence and characteristics of delirium patients in different severity levels of CCI. Results Patients with the severe CCI category (with a total score of five and above) spent 10 days longer in the hospital than those who were categorized with mild delirium (p = 0.011). There is a strong association between in-hospital mortality and the severe CCI category (odds ratio (OR), 4.566; 95% CI, 1.17- 1.86 (p = 0.035)). Also, patients with severe CCI scores were 4.6 times more likely to die during hospitalization compared to patients with less severe comorbidities. There were no significant differences found for discharge destination (OR, 0.702; 95% CI, 371- 1.328 (p = 0.277)) and readmission risk (OR, 1.660; 95% CI, 0.664- 4.149 (p = 0.278)) among different CCI groups. Conclusions Length of stay and inpatient mortality were significantly higher among the severe CCI category compared to the mild category. Our study suggests that CCI can help clinicians, patients, and their families in prognostication and better understanding of goals of care conversations.

Optimizing individualized therapy decision-making in multiple myeloma (MM): integration and impact of the Revised Myeloma Comorbidity Index in the MM-tumor board

AbstractMultiple Myeloma (MM) is a hematological disease predominantly affecting elderly patients. The complexity of current treatment necessitates individualized approaches. Therein, functional assessment (FA) tools, such as the Revised Comorbidity Index (R-MCI) at our University- and Comprehensive Cancer Center Freiburg, play a crucial role. This study aimed to determine (a) the implementation of the R-MCI in our MM-tumor board (MM-TB), (b) its impact on treatment guidance at baseline and (c) potential changes during follow-up. This exploratory study investigated R-MCI coverage and distribution in a cohort of patients with multiple TB presentations. Among them, a follow-up patient cohort undergoing subsequent MM-therapy was analyzed to determine treatment adjustments and changes in patients’ condition measured by R-MCI alterations. During our 3-year assessment period, 565 patients were presented in our MM-TB, totaling 1256 TB-presentations. In the multiple TB presentation cohort, the median number of TB presentations was 3 (range: 2–12). R-MCI scores within the MM-TB were available in 94%, whereas in 6%, the R-MCI had not been integrated. Among these, potential failure to identify the need for treatment modifications was determined. In the follow-up cohort, patient characteristics were typical for referral/university centers. Dose reductions were performed in 55% and were more prevalent among patients with ≥ 4 vs. lesser TB presentations. Most patients (55%) showed a fitness stabilization or improvement via follow-up R-MCI. R-MCI integration in MM-TB exceeded > 90%, indicating its successful integration for treatment support. Our results underscore its value in guiding therapy decisions, providing a comprehensive assessment beyond age considerations.

Infective Endocarditis-Predictors of In-Hospital Mortality, 17 Years, Single-Center Experience in Bulgaria.

Despite enormous developments in medicine, infective endocarditis (IE) remains an ongoing issue for physicians due to increased morbidity and persistently high mortality. Our goal was to assess clinical outcomes in patients with IE and identify determinants of in-hospital mortality. Material and methods: The analysis was retrospective, single-centered, and comprised 270 patients diagnosed with IE from 2005 to 2021 (median age 65 (51-74), male 177 (65.6%). Native IE (NVIE) was observed in 180 (66.7%), prosthetic IE (PVIE) in 88 (33.6%), and cardiac device-related IE (CDRIE) in 2 (0.7%), with non-survivors having much higher rates. Healthcare-associated IE (HAIE) was 72 (26.7%), Staphylococci were the most prevalent pathogen, and the proportion of Gram-negative bacteria (GNB) non-HACEK was significantly greater in non-survivors than survivors (11 (15%) vs. 9 (4.5%), p = 0.004). Overall, 54 (20%) patients underwent early surgery, with a significant difference between dead and alive patients (3 (4.5%) vs. 51 (25.1%, p = 0.000). The overall in-hospital mortality rate was 24.8% (67). Logistic regression was conducted on the total sample (n = 270) for the period 2005-2021, as well as the sub-periods 2005-2015 (n = 119) and 2016-2021 (n = 151), to identify any differences in the trend of IE. For the overall group, the presence of septic shock (OR-83.1; 95% CI (17.0-405.2), p = 0.000) and acute heart failure (OR-24.6; 95% CI (9.2-65.0), p = 0.000) increased the risk of mortality. Early surgery (OR-0.03, 95% CI (0.01-0.16), p = 0.000) and a low Charlson comorbidity index (OR-0.85, 95% CI (0.74-0.98, p = 0.026) also lower this risk. Between 2005 and 2015, the presence of septic shock (OR 76.5, 95% CI 7.11-823.4, p = 0.000), acute heart failure (OR-11.5, 95% CI 2.9-46.3, p = 0.001), and chronic heart failure (OR-1.3, 95% CI 1.1-1.8, p = 0.022) enhanced the likelihood of a fatal outcome. Low Charlson index comorbidity (CCI) lowered the risk (OR-0.7, 95% CI 0.5-0.95, p = 0.026). For the period 2016-2021, the variable with the major influence for the model is the failure to perform early surgery in indicated patients (OR-240, 95% CI 23.2-2483, p = 0.000) followed by a complication of acute heart failure (OR-72.2, 95% CI 7.5-693.6. p = 0.000), septic shock (OR-17.4, 95% CI 2.0-150.8, p = 0.010), previous stroke (OR-9.2, 95% CI 1.4-59.4, p = 0.020) and low ejection fraction (OR-1.1, 95% CI 1.0-1.2, p = 0.004). Conclusions: Knowing the predictors of mortality would change the therapeutic approach to be more aggressive, improving the short- and long-term prognosis of IE patients.

Abstract A097: Racial and ethnic disparities in risk of persistent opioid use in a diverse cohort of breast cancer survivors and matched women without cancer

Abstract Background: Persistent opioid use (POU) in breast cancer survivors after they have completed active cancer treatment is an emerging area of concern. Disparities affecting the risk of POU remains understudied in breast cancer survivors. We evaluated disparities in examining the risk with POU in breast cancers survivors in the year after active cancer treatment along with a comparison group. Methods: We assembled a cohort of 14,347 female breast cancer (BC) survivors diagnosed in 2009-2019 treated for early-stage disease (in situ, local, regional), who had at least two opioid prescriptions after one year of survivorship and 51,369 age-matched women without cancer. Data were captured from the tumor registry, electronic health records, and pharmacy databases. The primary outcome was POU defined as continuously receiving at least 90 days supplies of opioids during follow-up. Patients were followed through the date once they met POU criteria, died, disenrolled from health plan, or reached study’s end (12/31/2021), whichever came first. We used the multivariable proportional hazard regression to estimate the association [hazard ratios (HR), 95% confidence interval (CI)] between race ethnicity and POU. Results: Overall, the cohort was diverse: 7% Asian/Pacific Islander (API); 14% Black; 28% Hispanic; and 50% White women. During a median follow-up of 6.4 years, 11134 (17%) women developed POU. Patients who developed POU had longer annualized median opioid duration, especially in Black patients (175 vs. 5 days) and were prescribed stronger opioids [median maximum daily morphine milligram equivalent (62.5 vs 42.9)], compared to those who did not develop POU. In the multivariable analyses adjusted for sociodemographic characteristics, opioid type, and other pain medications, Black, Hispanic and API women were 28%, 42% and 54% less likely to develop POU compared to White women [HR (95%CI): 0.72 (0.68-0.76), 0.58 (0.55-0.61), and 0.46 (0.42-0.52), respectively]. However, Black women were only 19% less likely [HR (95%CI): 0.81(0.72-0.92)] to develop POU compared to White women in BC survivors. Also, patients with older age, Elixhauser Comorbidity Index ≥3; smoking, type of opioid (Oxycodone and hydrocodone), and who used other psychiatric and pain medications had significantly greater POU risk. Conclusion: Findings suggest that women of color were less likely to develop POU. Further studies will include further examining clinical and pharmacological management which might have played a role in the race ethnicity groups. Citation Format: Lie Hong Chen, Rulin C. Hechter, Jiaxiao Shi, Zheng Gu, Moira Brady-Rogers, Rowan T. Chlebowski, Reina Hague. Racial and ethnic disparities in risk of persistent opioid use in a diverse cohort of breast cancer survivors and matched women without cancer [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A097.

Abstract C170: Unveiling sex differences in hospitalization rates for immune-related adverse events in older lung cancer patients treated with ICIs: A SEER-Medicare analysis

Abstract Introduction Immune checkpoint inhibitors (ICIs) offer substantial benefits for older adults with lung cancer (LCa) but they also pose risks of immune-related adverse events (irAEs), necessitating investigation into the demographic influences on hospitalization rates. Sex differences among older adults within this cohort are understudied. Our study aims to explore the gender differences in irAE-related hospitalizations among older adults. Methods We utilized Surveillance, Epidemiology, and End Results (SEER)-linked Medicare data to identify older adults diagnosed with primary LCa from 1999 to 2017 and treated with ICIs between 2011 and 2019. Patients were steroid-naïve and chemo-naïve for 3 and 12 months, respectively, prior to ICI initiation. ICD-9/10 diagnosis codes were used to identify irAEs post-ICI initiation and these diagnosis were flagged during the pre-ICI period for comparison. An adjusted negative binomial model compared irAE-hospitalization rates in the post-ICI period (0-6, 7-12, and 13-24 months) to those in the pre-ICI period (6 months prior), accounting for confounders. An interaction term between gender and treatment period was included to compare differences in rates between males and females. Results Of the 1,089 patients, 54% were female, 79.6% had Charlson Comorbidity Index (CCI) ≥1. Females had 59% higher rates of irAE-hospitalizations at baseline (95% CI: 1.18 – 2.14, p<0.001). Patients with CCI≥3 had a 141% higher rate for irAE- hospitalization compared to those with CCI=0. Specifically for males, compared to 6-months pre-ICI, the irAE-hospitalization rates were 187% higher 0-6 months post-ICI (IRR = 2.87, 95% CI: 1.20-3.74), 134% higher 7-12 months post-ICI (IRR = 2.34, 95% CI: 1.66-3.31), and 122% higher 13-24 months post-ICI (IRR = 2.22, 95% CI: 1.53-3.28). Similarly for females, compared to 6-months pre-ICI, the irAE-hospitalization rates were 123% higher 0-6 months post-ICI (IRR = 2.23, 95% CI: 1.27-3.75), 69% higher 7-12 months post-ICI (IRR = 1.69, 95% CI: 1.27-3.37), and 11% higher 13-24 months post-ICI (IRR = 1.11, 95% CI: 1.03-2.37). Age and race did not impact irAE-hospitalization rates among LCa patients. Conclusions The incidence of irAEs following ICI treatment is notably higher in the first six months post-ICI for both males and females, with males experiencing a higher rate of events across all post-treatment periods. Key factors influencing the rate of irAE-hospitalizations include the CCI and pre-treatment gender differences. These findings underscore the need for tailored post-ICI monitoring strategies to mitigate adverse events in vulnerable populations. Citation Format: Fnu Nikita, Swapnil Sharma, Amy Shaver, Krupa Gandhi, Scott W. Keith, Christina Steinbock- Malfer, Jennifer M. Johnson, Sarah Gordon, Grace Lu-Yao. Unveiling sex differences in hospitalization rates for immune-related adverse events in older lung cancer patients treated with ICIs: A SEER-Medicare analysis [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C170.

Maternal morbidity in postpartum severe preeclampsia by obstetric delivery volume

BackgroundPre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings. ObjectiveWe investigated the relationship between facility delivery volume and rates of nontransfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features. Study DesignThis is a retrospective cohort study using the Nationwide Readmissions Database (2015–2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was nontransfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and nontransfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, nontransfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery. ResultsThe cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25th percentile–75th percentile: 2.2–6.5). Nontransfusion SMM occurred in 7% of patients readmitted to facilities with >2000 deliveries compared to 9% with 1 to 2000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1000 deliveries, the odds of a nontransfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99). ConclusionNontransfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.

Referral to hepatology is lower in patients with excessive alcohol use who have mental health disorders despite a high fibrosis-4 index.

Alcohol use disorder (AUD) is a multifaceted disease, and integration of AUD treatment between mental health and hepatology is necessary to improve outcomes. We aimed to ascertain whether patients with excessive alcohol use (EAU) and high FIB-4, which is a non-invasive method to identify advanced liver disease, are appropriately referred to hepatology and detect which clinical barriers, if any, might pertain. Records of patients with excessive alcohol use between 2013 and 2023 were extracted from a large public system. Demographics, alcohol-related hospitalizations, mental health conditions, Charlson comorbidity index (CCI) and referral patterns were evaluated. Comparisons were made between those referred to hepatology versus not. 1131 subjects showed evidence of EAU but on further review, 189 were in alcohol-remission. The remaining 942 (636 men, age 55.7 ± 14.5 years, 548 white, 363 black, 19 Hispanic) subjects with CCI 2.61 ± 2.23 were further analyzed for FIB-4 score and referral patterns. 316 patients had active EAU and a high FIB-4, of whom only 116 (37%) were referred to hepatology. Patients with alcohol-related mental health concerns and admitted for trauma were less likely to be referred. Logistic regression showed referral was higher with alcohol-related liver hospitalizations (OR: 9.25, 95% CI: 4.90-17.47, p < 0.001), higher CCI (OR: 6.23, 95% CI: 3.00-12.94, p < 0.0001) and lower with mental health admissions (OR: 0.36, 95% CI: 0.15-0.48, p < 0.001) or mental health diagnoses (OR: 0.36, 95% CI: 0.15-0.82, p = 0.02) and increasing age (OR: 0.95, 95% CI: 0.92-0.97, p < 0.001). In a large public health system, almost 63% of patients with EAU and FIB-4 >2.67 are not referred to hepatology for evaluation. Patients not referred were more likely to have alcohol-related mental-health hospitalizations and mental health diagnoses, while those with liver-related hospitalizations and comorbidities were more likely to be referred. Greater education of mental health providers and for teams taking care of inpatients admitted with alcohol-related mental health concerns would better integrate care and improve outcomes for patients with higher risk for advanced liver disease.

Abstract C021: Racial and socioeconomic disparities in molecular diagnostics for NSCLC patients

Abstract Background: Targeted therapies have substantially changed the landscape of non-small cell lung cancer (NSCLC) outcomes. These drugs work by inhibiting specific molecular pathways, such as the epidermal growth factor receptor (EGFR) tyrosine kinase, the anaplastic lymphoma kinase (ALK), KRAS, and BRAF oncogenic pathways. Approximately 30% of NSCLC patients will have tumors with eligible targetable mutations, but a molecular test must be conducted to assess eligibility to these treatments. Disparities in molecular testing could be partially responsible for the disproportionate utilization of targeted therapy across race and socioeconomic status (SES). Methods: Surveillance, Epidemiology and End Results (SEER)-Medicare linked data was queried for NSCLC patients diagnosed from 2013 (the first year that standard guidelines for molecular testing in lung cancer were available) to 2016. Patients were limited to age over 66 years at diagnosis with continuous Part A and B coverage and no Part C coverage, for 1 year prior and 90 days post-diagnosis. The primary outcome was receipt of a molecular test based on claims data. Race, defined as white, Black or other, was the primary predictor variable. Demographic and clinical characteristics of those receiving vs not receiving a molecular test were compared using χ2 tests for categorical variables and t-tests for continuous variables. We also performed multivariable logistic regression to assess the association of molecular testing with race adjusting for sex, age, marital status, Charlson comorbidity index, histology, tumor site, stage, and census-level poverty indicator. Results: There were 28,511 NSCLC patients, of which 9,639 (33.8%) received some type of molecular testing. Black patients were significantly less likely than white patients to have received a molecular test (p&amp;lt;0.0001). Only 23.9% of Black patients underwent any molecular testing, compared to 34.6% of white patients. Patients living in census tracts with at least 10% of residents living in poverty were also less likely to receive a molecular test (p&amp;lt;0.0001). Patients who were female (p&amp;lt;0.0001), married (p&amp;lt;0.0001), with fewer comorbidities (p&amp;lt;0.0001), adenocarcinoma histology (p&amp;lt;0.0001), tumors located in the lower lobe (p&amp;lt;0.0001), diagnosed at a later stage (p=0.0001) were more likely to have molecular testing. After adjustment, Black patients (ORadj [odds ratio]: 0.65; 95% CI [confidence interval]: 0.59-0.72) and those living in areas with greater poverty (ORadj: 0.87; 95% CI: 0.82-0.91) were statistically significantly less likely to have received molecular testing. Conclusions: Disparities exist in comprehensive molecular diagnostics, and could explain, at least in part, the high mortality observed among Black NSCLC patients. Addressing barriers to molecular testing could increase uptake of targeted therapy treatment, decreasing disparities and improving patient outcomes. Citation Format: Stephanie Tuminello, Wiley Turner, Matthew Untalan, Raja Flores, Emaneula Taioli. Racial and socioeconomic disparities in molecular diagnostics for NSCLC patients [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C021.

Feasibility, Safety, and Factors Predicting Completion of CROSS Protocol–Based Neoadjuvant Chemoradiotherapy for Esophageal Squamous Carcinoma: Experience from an Indian Tertiary Care Cancer Center

Background Neoadjuvant chemoradiotherapy (NACRT) using the ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) protocol has improved esophageal cancer outcomes. This study reports the real-world experience of the CROSS regimen for esophageal squamous cell carcinoma (ESCC) regarding its feasibility, safety, and predictors of treatment completion from an Indian tertiary center. Methodology A retrospective review was conducted for patients with ESCC receiving CROSS (radiation dose: 41.4 Gy) or a modified CROSS (mCROSS; radiation dose: 45 Gy) protocol NACRT between 2015 and 2022. We studied the treatment tolerability, factors predicting NACRT completion, and the effect of completion of its chemotherapy component on the pathological outcomes. Results Of the109 patients (68.8% males; mean age, 56 ± 9 years; Charlson's comorbidity index [CCI] &gt;2, 19.3%; stage III–IVA, 58%; mean tumor length, 5.5 ± 2.1cm; CROSS, 70.6%; mCROSS, 29.4%), all except 4 completed radiotherapy but only 58 (53.2%) patients completed ≥4 cycles of chemotherapy. Forty-nine patients belonged to the “extended” CROSS trial inclusion criteria. Among the 60 patients who fulfilled the CROSS inclusion criteria, only 51.7% were able to complete ≥4 chemotherapy cycles. The commonest reason for noncompletion of chemotherapy was the occurrence of neutropenia (60.8%). Pretreatment hemoglobin (≥12 vs. &lt;12 g%; odds ratio [OR]: 2.76; 95% confidence interval [CI]: 1.10–6.96; p = 0.031), a low CCI (≤2 vs. &gt;2; OR: 2.98; 95% CI: 1.02–8.73; p = 0.047), and radiation therapy techniques (conformal vs. conventional; OR: 3.29; 95% CI: 1.14–9.50; p = 0.028) were associated with completion of chemotherapy (≥4 cycles). Although there was a trend toward improved R0 resection (95.7 vs. 91.4%), reduced node positivity (17.0 vs. 31.4%), and a high pCR (57.4 vs. 48.6%) in patients completing chemotherapy (≥4 cycles) compared with those not completing chemotherapy (&lt;4 cycles), these differences were statistically nonsignificant. Conclusion In this study, ESCC patients receiving the CROSS protocol NACRT could complete their radiotherapy component, but a significant proportion exhibited poor chemotherapy tolerance. Neutropenia was a major factor limiting chemotherapy delivery, but anemia, high CCI, and conventional radiation techniques were also associated with noncompletion of chemotherapy. The omission of a few chemotherapy cycles had no significant effect on the pathological response; however, its impact on cancer survival requires further evaluation.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study.

The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Analysis of the course and outcomes of COVID-19 at different stages of the pandemic in hemodialysis patients

The purpose of this study was a comparative analysis of the characteristics of the course and outcomes of COVID-19 in HD patients at different stages of the pandemic, focusing on the of the use of immunomodulatory therapy.Materials and methods. The retrospective study included 897 HD patients with COVID-19 (mean age 60.7 years, M 58.5%) who were hospitalized at Moscow City Hospital № 52. Group 1 (n=720) consisted of patients infected between the end of March 2020 and April 2021, group 2 (n=177) included patients hospitalized in May-December 2021. Each of group was divided into 2 subgroups based on treatment approaches. Subgroup 1a (n=231) included patients of the initial period of the pandemic who did not receive adequate immunomodulatory therapy, while Subgroup 1b (n=489) included patients of the late stage, were treated with IL-6 receptor blockers and corticosteroids. In group 2, 108 patients in Subgroup 2a received similar therapy, while 69 patients in Subgroup 2b were treated with neutralizing monoclonal antibodies in the early stages of the disease.Results. Mortality rates in Group 1 and Group 2 was 20.1% and 14.7%, respectively (p&lt;0.09). The incidence of unfavorable outcome was highest in Subgroup 1a and lowest in Subgroup 2b (31.2% vs 5.8%, p&lt;0.01). Mortality in Subgroups 1b and 2a was comparable (14.9% and 20.4%), despite more severe initial lung damage according to CT data in Subgroup 2a. In these patients, immunomodulators was more frequently combined with therapeutic plasma exchange (TPE). Independent risk factors for an unfavorable outcome were the progression of pulmonary pathology, with the transformation of stages CT 1-2 to CT 3-4, and a high comorbidity index.Conclusions. The use of immunomodulatory drugs imprtoved the effectiveness of COVID-19 treatment in patients with CKD5D. In severe cases, the most favorable outcomes were achieved with a combination of immunobiological drugs, corticosteroids, and TPE. An even more significant reduction in mortality was observed following the introduction of neutralizing monoclonal antibodies into clinical practice. Independent predictors of unfavorable outcome of COVID-19 in HD patients were a high comorbidity index and the progression of CT 1-2 into CT 3-4.

Loss of walking independence one year after primary total hip arthroplasty for osteonecrosis of the femoral head: incidence and risk prediction model

BackgroundAssessment of postoperative ambulation in osteonecrosis of the femoral head (ONFH) patients treated with total hip arthroplasty (THA) is limited. This study aimed to define the incidence and risk factors for losing walking independence (LWI) at one-year postoperatively in patients with ONFH undergoing primary THA, and to establish and validate a predictive nomogram.MethodsThis was a retrospective analysis of prospective collected data from patients admitted to a tertiary referral hospital with ONFH who underwent primary unilateral THA from October 2014 to March 2018. The Functional Independence Measure-Locomotion scale was used to quantify walking independence and was documented at a one-year continuous postoperative follow-up, which classified patients with a final score below 6 as LWI. Multivariate logistic regression identified independent risk factors for LWI, and a predictive nomogram was constructed based on the analysis results. The stability of the model was assessed using patients from April 2018 to April 2019 as an external validation set.Results1152 patients were enrolled in the study, of which 810 were used in the training cohort and the other 342 for the validation cohort. The incidence of LWI was 5.93%. Multivariate analysis revealed that age 62 years or older (odd ratio (OR) = 2.37, 95% confidence interval (CI) 1.07–5.24), Charlson’s comorbidity index 3 or higher (OR = 3.64, 95% CI 1.09–12.14), Association Research Circulation Osseous stage IV (OR = 2.16, 95% CI 1.03–4.54), reduced femoral offset (OR = 2.41, 95% CI 1.16–5.03), and a higher controlling nutritional status score (OR = 1.14, 95% CI 1.01–1.30) were independent risk factors of LWI. The nomogram had a concordance index of 0.773 and a Brier score of 0.049 in the training set, with corrected values of 0.747 and 0.051 after internal validation. The receiver-operating characteristic curve, calibration curve, Hosmer-Lemeshow test, and decision curve analysis all performed well in both the training and validation cohorts.ConclusionsThis study reported a 5.93% incidence of LWI and established a risk prediction model in patients undergoing THA for ONFH, supporting targeted screening and intervention to assist surgeons in assessing ambulation capacity and managing rehabilitation.

Non-HACEK gram-negative bacilli infective endocarditis: data from a retrospective German cohort study

Abstract Purpose Infective endocarditis caused by non-HACEK gram-negative bacilli (GNB-IE) is rare but associated with significant morbidity and case fatality. Evidence on optimal treatment and management is limited. We aimed to describe the characteristics and management of GNB-IE patients, investigating factors associated with disease acquisition and unfavorable outcomes. Methods We conducted a retrospective descriptive single-center study (tertiary care and referral hospital) between 2015 and 2021, including adult patients with definite GNB-IE. We reviewed demographic, clinical and microbiological data, focusing on predisposing factors, clinical outcomes and 1-year mortality. Results Of 1093 patients with probable or definite IE, 19 patients (median age 69 years) had definite GNB-IE, with an increasing incidence throughout the study period. Median age-adjusted Charlson Comorbidity Index score was 4 points. Prosthetic valve IE (PVIE) was present in 7/19 (37%) patients. Nosocomial acquisition occurred in 8/19 (42%) patients. Escherichia coli and Klebsiella pneumoniae were the most common pathogens. Beta-lactam (BL) based combination therapy was applied in 12/19 (63%) patients (58% BL + fluoroquinolone, 42% BL + aminoglycoside). Cardiac surgery was required in 8/19 (42%) patients (PVIE 71%, native valve IE 25%), primarily for embolism prevention and heart failure. Complications occurred in 14/19 (74%) patients. The in-hospital mortality rate was 21% (4/19); the one-year mortality rate was 44% (7/16). One-year mortality did not significantly differ between patients who underwent cardiac surgery and patients managed with anti-infective treatment alone (p = 0.633). Conclusions GNB-IE affects elderly patients with high comorbidity levels and recent health-care exposure. GNB-IE was associated with high complication rates and high mortality.

Differences in ischemic heart disease between males and females using predictive artificial intelligence models

&lt;b&gt;Background: &lt;/b&gt;Cardiovascular health and preventative strategies are influenced by the sex of the individuals. To forecast cardiac events or detect ischemic heart disease (IHD) early, machine-learning algorithms can analyze complex patient data patterns. Early detection allows for lifestyle changes, medication management, or invasive treatments to slow disease progression and improve outcomes.&lt;br /&gt; &lt;b&gt;Aim&lt;/b&gt;: To compare and predict the differences in the primary sources of IHD burden between males and females in various age groups, geographical regions, death versus alive, and comorbidity levels.&lt;br /&gt; &lt;b&gt;Methods: &lt;/b&gt;A predictive and retrospective design was implemented in this study. Electronic health records were extracted, which were equally distributed among males and females with IHD. The dataset consisted of patients who were admitted between 2015 and 2022. Two of the eight models generated by Modeler software were implemented in this study: the Bayesian network model, which achieved the highest area under curve score (0.600), and the Chi-squared automatic interaction detection (CHAID) model, which achieved the highest overall accuracy score (57.199%).&lt;br /&gt; &lt;b&gt;Results: &lt;/b&gt;The study sample included 17,878 men and women, 58% of whom had no comorbidities and 1.7% who died. Age, the Charlson comorbidity index score, and geographical location all predicted IHD, but age was more influential. Bayesian network analysis showed that IHD odds were highest in males 40-59 and females 60-79, with the highest mortality risk in females 80-100. North and south Jordan had higher IHD rates and middle-aged males from north and middle governorates had higher IHD rates according to CHAID.&lt;br /&gt; &lt;b&gt;Conclusion: &lt;/b&gt;By using artificial intelligence, clinicians can improve patient outcomes, treatment quality, and save lives in the fight against cardiovascular illnesses. To predict IHD early, machine-learning algorithms can analyze complex patient data patterns to improve outcomes.

A frailty census of older adults in the emergency department and acute inpatient settings of a model 4 hospital in the Mid-West of Ireland

Abstract Background Frailty is a risk factor for presentation to the ED, in-hospital mortality, prolonged hospital stays and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty. The aim of this cross-sectional study was to establish the prevalence of frailty and co-morbidities among older adults in an acute hospital setting. Methods Data collection was undertaken by clinical research nurses and advanced nurse practitioners experienced in assessing older adults. All patients aged ≥ 65 years and admitted to a medical or surgical inpatient setting between 08:00 and 20:00 and who attended the ED over a 24-h period were screened using validated frailty and co-morbidity scales. Age and gender demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CCI) and admitting specialty (medical/surgical) were collected. Descriptive statistics were used to profile the cohort, and p values were calculated to ascertain the significance of results. Results Within a sample of 413 inpatients, 291 (70%) were ≥ 65 years and therefore were included in the study. 202 of these 291 older adults (70%) were ≥ 75 years. Frailty was investigated using validated clinical cut-offs on the CFS (not frail &lt; 5; frail ≥ 5). Comorbidities were investigated using the Charlson Comorbidity Index (mild 1–2; moderate 3–4; severe ≥ 5). The median CFS was 6 indicating moderate frailty levels, and the median CCI score was 3 denoting moderate co-morbidity. In the inpatient cohort, 245 (84%) screened positive for frailty, while 223 (75%) had moderate-severe co-morbidity (CCI Mod 3–4, severe ≥ 5). No significant differences were observed across genders for CFS and CCI. In the ED, 81 patients who attended the ED were ≥ 65 years. The median CFS was 6 (moderate frailty), and the median CCI was 5 (severe co-morbidity level). Seventy-four percent (60) of participants screened positively for frailty (CFS ≥ 5), and 31% (25) had a CFS of 7 or greater (severely frail). Ninety-six percent (78) of patients had a moderate-severe level of comorbidity. No significant associations were found between the CFS and CCI and ED participants age, gender, and medical/surgical speciality usage. Conclusion There is a high prevalence of frailty and co-morbidity among older adults who present to the ED and require inpatient care. This may contribute to increased waiting times, lengths of stay, and the need for specialist intervention. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services, staff training in frailty care and multidisciplinary team resources across the hospital and community setting.

The long-term time course of septic arthritis.

The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus.

Comparison of Externally Transferred and Self-Recruited Patients with Hip and Knee Revision Arthroplasty at a Certified Maximum-Care Arthroplasty Center (ACmax).

According to the guidelines of the EndoCert initiative, certified maximum-care arthroplasty centers (ACmax) are obliged to admit patients from certified arthroplasty centers (AC) if these patients need to be transferred to the more specialized ACmax due to difficult replacement and revision procedures as well as after complications in primary care that are beyond the expertise of the smaller centers. This study investigated whether the cohort of transferred patients differed from the patients directly recruited at the ACmax for factors such as severity of diagnosis, comorbidities or outcome. The aim was to determine whether transferred patients increased the resource requirements for the ACmax. A total of 136 patients were included in the retrospective study and analyzed in terms of case severity, length of hospital stays (LOS), Diagnosis-Related Group charges, readmission rate and concomitant diseases. All patients were followed for up to 12 months after the initial hospital stay. There were significant differences between the groups of transferred and self-recruited patients. For example, transferred patients had a higher Patient Clinical Complexity Level (PCCL). Similarly, the increased Case Mix Index (CMI) of transferred patients indicated more intensive care during the inpatient stay. The higher values for the comorbidity indices also supported these results. This had an impact on the LOS and overall costs, too. The differences between the groups were also reflected by adverse events during the one-year follow-up. The higher percentage of patients with septic revisions, whose treatment is especially demanding, among transferred patients aggravated the differences even further. Thus, transferred patients were associated with increased resource requirements for the ACmax. While it serves patients' safety to transfer them to an ACmax with specialized expertise and greater structural quality, the care of transferred patients ties up considerable resources at the ACmax that might only be insufficiently reimbursed by the generalized tariffs.

Posterior Cruciate Ligament Preservation versus Posterior Cruciate Ligament Sacrifice: Comparing Patient Outcomes in Medial Congruent Total Knee Arthroplasty.

This study aimed to compare outcomes and complication rates between posterior cruciate ligament (PCL) retention and excision utilizing a medial congruent (MC) polyethylene insert in total knee arthroplasty (TKA) in a specialized ambulatory surgery center (ASC) dedicated to hip and knee arthroplasty. A retrospective review was performed between May 2023 and October 2023 analyzing 398 patients who underwent primary MC TKA by high-volume joint arthroplasty surgeons (n = 9) with either PCL preservation (n = 264) or sacrifice (n = 134) in a single free-standing ASC. Patients were matched chronologically on a 2:1 basis. Demographics, baseline function, 90-day complications, and patient-reported outcomes were recorded for each patient. There were no differences in preoperative baseline function or patient-reported outcome measures, Charlson Comorbidity Index, or American Society of Anesthesiologists class among patient groups. The PCL-preserve and PCL-sacrifice cohorts showed significant variation in 12-week postoperative Knee Injury and Osteoarthritis Outcome, Junior (KOOS, JR.) scores. Specifically, the number of patients who achieved the minimal clinically important difference (MCID) in KOOS, JR. scores was higher in the PCL-sacrifice group (p < 0.05). Yet, no complications within the 90-day period were associated with PCL status and other patient-reported outcomes. This study comparing outcomes between MC TKAs with PCL retention and sacrifice suggests that both techniques are viable options with similar functional outcomes, pain scores, and complication rates, which may have benefits in an ASC setting. The PCL-sacrifice group exhibited a statistically significant increase in patients who achieved the MCID in KOOS, JR. score compared with the PCL-preserving at early follow-up. Future research should employ prospective, randomized designs to further validate these findings and explore long-term implications.

The Impact of Frailty and Gender Differences on Hospitalization and Complications in Proximal Femoral Pathological Fractures: A Cross-Sectional Study.

Frailty associated with aging increases the risk of falls, disability, and death. The aim of this study is to explore gender-related disparities in the survival outcomes of pathological femoral fractures in older frail patients, while analyzing potential specific prognostic factors. This study is a retrospective observational analysis conducted at a single medical center. It enrolled all patients aged 65 and above who were admitted to our emergency department between 2016 and 2020 with a diagnosis of pathological femur fracture requiring surgical intervention. The primary study endpoint was evaluating gender-related differences in survival outcomes. The secondary endpoint involves investigating gender-specific prognostic factors through the analysis of clinical and laboratory parameters. The average Charlson Comorbidity Index (CCI) was slightly lower in men, but the difference was not statistically significant (p = 0.53). The Clinical Frailty Scale (CFS) showed similar results, with men and women 5.23 (SD 1.46), also not significant (p = 0.83). An evaluation comparing patients aged 75 years or younger to those older than 75 years found significant differences in health metrics. The average CCI was higher in the over 75 group compared to the under 75 group, with a p-value of 0.001. Similarly, the CFS average was also greater in the over 75 group than in the under 75 group, with a p-value of 0.0001. Complications were more frequent in patients over 75 and those with lower educational qualifications. The evaluation analyzed cardiac patients compared to a control group, revealing that the average age of cardiac patients was 75.22 years, while the control group was younger at 73.98 years (p = 0.5119). The CCI for cardiac patients averaged 6.53, significantly higher than 4.43 for non-cardiac patients (p = 0.0003). Frailty assessment is therefore essential in patients with pathological fracture of the proximal femur and is an important predictor of both gender differences and hospital complications. Enhancing gender analysis in this field is crucial to gather more robust evidence and deeper comprehension of potential sex- and gender-based disparities.

Utility guideline and considerations for the novel Hugo™ RAS (robotic-assisted surgery) system in colorectal surgery: surgical outcomes and initial experience in a tertiary center

PurposeA novel robotic platform—Hugo™ RAS (robotic-assisted surgery) system—has been introduced with several innovations that may prove advantageous for surgeons, such as an open console and four interchangeable modular arms. Our study aims to evaluate this platform’s safety, efficacy, and potential impact on the surgical treatment of colorectal pathology.MethodsPatients underwent robotic-assisted colorectal procedures with the Hugo™ RAS system at the General University Hospital of Elche from October 2023 to July 2024. Patient characteristics, intraoperative and postoperative variables, and robotic technical issues were recorded.ResultsForty consecutive patients were included (14 right, 13 left, and 8 rectum neoplasms; 4 left diverticulitis; and 1 ileocecal Crohn’s disease). The patients’ characteristics were as follows: median age, 69.5 years; 24 males and 16 females; 45% ASA III–IV; and Charlson Comorbidity Index > 5:42.5%.We recorded four medical (2 anemia, 1 phlebitis, and 1 admission to the intensive care unit) and three surgical (1 hematoma of the incision, 1 intestinal occlusion, and 1 dehiscence of the anastomosis) postoperative complications. We had no conversions neither open nor laparoscopic surgery. The average hospital stay was 3 days, with no mortality or readmission.ConclusionsThe Hugo™ RAS system is safe and feasible for colorectal procedures. The modularity of the arms provides the versatility of configurations adjusted depending on the patient’s body features and the surgeon’s preferences and greater adaptability to operating rooms. The open console is highly comfortable and ergonomic for the surgeon, allowing communication with the operating room environment.Trial registrationNCT06512480