Patient Comorbidity Status Research Articles

Readmission rate and early complications in patients undergoing total knee arthroplasty: A retrospective study

BACKGROUND Total knee arthroplasty (TKA) can improve pain, quality of life, and functional outcomes. Although uncommon, postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery. Identification of the risk factors for complications and readmissions after TKA, taking into account common causes, temporal trends, and risk variables that can be changed or left unmodified, will benefit this process. AIM To assess readmission rates, early complications and their causes after TKA at 30 days and 90 days post-surgery. METHODS This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1, 2017, and February 28, 2022. Of the 633 patients, 28 were not contactable, leaving 609 who met the inclusion criteria. Both inpatient and outpatient hospital records were retrieved, and observations were noted in the data collection forms. RESULTS Following TKA, the 30-day and 90-day readmission rates were determined to be 1.1% (n = 7) and 1.8% (n = 11), respectively. The unplanned visit rate at 30 days following TKA was 2.6% (n = 16) and at 90 days was 4.6% (n = 28). At 90 days, the unplanned readmission rate was 1.4% (n = 9). Reasons for readmissions included medical (27.2%, n = 3) and surgical (72.7%, n = 8). Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group (P = 0.922), body mass index (BMI) (P = 0.633), unilateral vs bilateral TKA (P = 0.696), or patient comorbidity status (30-day P = 0.171 and 90-day P = 0.813). Reoperation rates after TKA were 0.66% (n = 4) at 30 days and 1.15% (n = 8) at 90 days. The average length of stay was 6.53 days. CONCLUSION In this study, there was a low readmission rate following TKA. There was no significant correlation between readmission rate and patient factors such as age, BMI, and co-morbidity status.

The nonadherence to prescriptions among type 2 diabetes patients, and its determining factors

<b>Aim</b>: The aim is to clarify the prevalence of nonadherence to antidiabetic therapies among type 2 diabetes mellitus (T2DM) patients and identify its causes.<br /> <b>Methods</b>: A three-part questionnaire (general background, Knowledge-Attitude-Practice section, and non-adherence reasons) was developed. In total 324 diabetic patients were surveyed via telephone. The evaluation of patient adherence included both direct questions on adherence and a summary of patient responses to non-adherence comments. The analysis was performed on StataCorp Stata 14.2, and included descriptive analysis, simple and multivariate logistic regression.<br /> <b>Findings:</b> Among the sociodemographic variables, age group, work level, and alcohol consumption may influence medication adherence. The comorbidity status of patients was also of relevance. Both variables had stronger relationships with adherence to anti-diabetic treatments compared to those with no comorbidities or no additional medicines. A strength of the study is that it addresses various medical diseases and attitudes about them, as well as a wide range of causes for non-adherence to non-diabetic medications.

2952. Impacts of an evidence-based, pre-populated order panel on antimicrobial prescribing trends in ambulatory patients with community-acquired pneumonia

Abstract Background Optimizing antimicrobial regimens for outpatients with community-acquired pneumonia (CAP) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, antibiotic order panel for outpatient respiratory syndromes was implemented in the Mayo Clinic Enterprise on 1/4/2021. For CAP, it provides national guideline adherent regimens (i.e., selection, dosing, and durations) by patient comorbidity and beta-lactam allergy status. We aimed to assess impacts of panel use on antibiotic prescribing in outpatients with CAP. Methods This retrospective review included Mayo Clinic outpatient encounters from Minnesota in 2021 and 2022. Eligible encounters used a CAP-related primary ICD-10 code, conveyed intention to treat CAP in encounter notes, and were performed by primary care, emergency department, or urgent care clinicians who managed ≥1 CAP patient with the panel and ≥1 without the panel during the study period. Encounters were excluded if patients were already receiving antibiotics at the time of encounter. The primary outcome was adherence (drug and duration) to guideline recommendations. Secondary outcomes included utilization rate by agent and therapy duration. Outcomes were analyzed with Kruskal-Wallis rank sum and Pearson’s chi-squared tests (α level = 0.05). Results 352 encounters (134 panel vs. 218 non-panel) were included. Prescribing was guideline adherent in 61.9% and 29.4% (p< 0.01) of panel and non-panel encounters, respectively. The most common reason for guideline non-adherence during panel use was inappropriate drug selection (n = 45/51, 88.2%). This was predominantly driven by use of the incorrect section of the treatment panel based on patient comorbidity status (n = 30/45, 66.7%). Individual antibiotic utilization rates differed between panel and non-panel cohorts (Table 1), with higher rates of amoxicillin and amoxicillin/clavulanate use and lower rates of azithromycin and doxycycline use in the panel cohort. Durations >5 days were more common in the non-panel as compared to the panel cohort (34.4% vs. 7.5%, p < 0.01). Conclusion Use of a pre-populated antimicrobial order panel in outpatients with CAP resulted in greater adherence to national guideline recommendations. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun: Grant/Research Support|Cidara: Grant/Research Support|Scynexis: Grant/Research Support

EPID-23. FACILITY VOLUME STATUS IS PREDICTIVE OF SURVIVAL AND TREATMENT RECOMMENDATIONS IN PATIENTS WITH INTRACRANIAL MENINGIOMA

Abstract INTRODUCTION There is a growing body of evidence demonstrating improved survival outcomes for patients with CNS neoplasms who are treated at high volume facilities (HVFs) as compared to low volume facilities (LVFs). METHODS The National Cancer Database (NCDB) was queried for adult patients who sought treatment for intracranial meningioma between 2004 and 2019 at one of 1,500 Commission on Cancer-accredited facilities. Data reported included patient sociodemographic information, patient comorbidity status, and relevant tumor characteristics. After patients were stratified by facility volume, the Mann-Whitney U and Fisher exact tests were used for bivariate analysis of both continuous and categorical variables. Multivariate Cox proportional hazard model and log-rank test were used to determine whether there was any association between facility volume and overall survival. RESULTS In total, 336,115 patients diagnosed with meningioma were included; 23,207 (6.9%) patients were treated at an HVF and 312,908 (93.1%) patients were treated at an LVF. On bivariate analysis, patients covered by private insurance were more likely to have been treated at an HVF (50.9% vs 36.8%, p=0.0043). Furthermore, with respect to county-based geographic trends, patients treated at HVFs were more likely to reside in an urban area (14.5% vs 11.6%, p=0.027). With respect to clinical characteristics, these patients had relatively larger tumors (4.22±10.47 cm vs. 4.11±11.03 cm, p< 0.001). On multivariate analysis, significant survival benefits were observed for patients treated at HVFs (HR = 0.977, 95% CI 0.973–0.982, p < 0.001). Patients treated at LVFs were significantly less likely to receive radiotherapy (OR = 0.988, 95% CI 0.985-0.992, p < 0.001) as compared to patients treated for intracranial meningioma at HVFs. CONCLUSION Our results indicate that – for patients who underwent treatment for intracranial meningioma during the 15-year study period – treatment recommendations differed and appeared to be associated with a survival disadvantage at LVFs.

Unicompartmental knee arthroplasty: A French multicenteric retrospective descriptive study from 2009 to 2019 with projections to 2050

IntroductionUnicompartmental knee arthroplasty (UKA) is a reliable and reproducible procedure. While some surgeons have incorporated it into their therapeutic armamentarium, others do not use it routinely, leading to a large disparity in practice. The objective of this study was to investigate in France the epidemiology of UKA from 2009 to 2019 to identify: (1) the evolution of growth trends by sex and age, (2) the evolution of the state of comorbidity of patients during the operation, (3) the evolution of trends according to the regions, (4) the projection best suited to the observations at 2050. HypothesisOur hypothesis was that in France, an increase would be observed over the period studied, differing according to the characteristics of the population. Materials and methodThe study was conducted in France over the 2009-2019 period for each gender and age group. The data was taken from the NHDS (National Health Data System) database, which includes all the procedures carried out in France. Based on the collection of procedures performed, the incidence rates (per 100,000 inhabitants) and their evolution were deduced, as well as the indirect assessment of the patient's comorbidity status. Using linear, Poisson, and logistic projection models, incidence rates were projected to the years 2030, 2040, and 2050. ResultsBetween 2009 and 2019, the incidence rate of UKA increased sharply (from 12.76 to 19.57; +53%), the growth was different in men (from 10.78 to 20.34; +89%) and women (from 14.61 to 18.85; +29%). The male/female sex ratio increased from 0.69 in 2009 to 1.0 in 2019. The increase was greatest among men under 65 (from 4.9 to 9.9; +100%) and lowest among women over 75 (from 41.2 to 40.5; –2%). Over the period studied, the proportion of patients with mild comorbidities (HPG1) increased (from 71.7% to 81.1%) at the expense of the other classes with more severe comorbidities. This dynamic was observed for all age groups: 0–64 years (from 83.3% to 90%), 65–74 years (from 81.4% to 88.4%), 75 years and over (38 .2% to 52.6%) regardless of sex. There was a strong disparity between the regions with a change in the incidence rate ranging from –22% (from 29.8 to 23.1) for Corsica to +251% (from 13.9 to 48.7) for Brittany. The proposed projection models suggested an increase in the incidence rate of +18% in logistic regression, +103% in linear regression by 2050. DiscussionOur study showed strong growth in the number of UKAs in France over the period studied, being highest in young men. The proportion of patients with fewer comorbidities increased for all age groups. A disparity in inter-regional practice was identified, with indications that remain ambiguous and differ according to the practitioner. We can expect continued growth in the years to come, adding to the care burden. Level of evidenceIV; Descriptive epidemiological study.

The Prediction of Survival Outcome and Prognosis Factor in Association with Comorbidity Status in Patients with Colorectal Cancer: A Research-Based Study.

Colorectal carcinoma (CRC) is rising exponentially in Asia, representing 11% of cancer worldwide. This study analysed the influence of CRC on patients’ life expectancy (survival and prognosis factors) via clinicopathology data and comorbidity status of CRC patients. Methodology: A retrospective study performed in HUSM using clinical data from the Surgery unit from 2015 to 2020. The demographic and pertinent clinical data were retrieved for preliminary analyses (data cleansing and exploration). Demographics and pathological characteristics were illustrated using descriptive analysis; 5-year survival rates were calculated using Kaplan–Meier methods; potential prognostic variables were analysed using simple and multivariate logistic regression analysis conducted via the Cox proportional hazards model, while the Charlson Comorbidity Scale was used to categorize patients’ disease status. Results: Of a total of 114 CRC patients, two-thirds (89.5%) were from Malay tribes, while Indian and Chinese had 5.3% each. The 50–69.9 years were the most affected group (45.6%). Overall, 40.4% were smokers (majorly male (95.7%)), 14.0% ex-smokers, and 45.6% non-smokers (p-value = 0.001). The Kaplan–Meier overall 5-year median survival time was 62.5%. From the outcomes, patients who were male and >70 years had metastasis present, who presented with per rectal bleeding and were classified as Duke C; and who has tumour in the rectum had the lowest survival rate. Regarding the prognosis factors investigated, “Gender” (adjusted hazard ratio (HR): 2.62; 95% CI: 1.56–7.81, p-value = 0.040), “Presence of metastases” (HR: 3.76; 95% CI: 1.89–7.32, p-value = 0.010), “Metastasis site: Liver” (HR: 5.04; 95% CI: 1.71–19.05, p-value = 0.039), “Lymphovascular permeation” (HR: 2.94; 95% CI: 1.99–5.92, p-value = 0.021), and “CEA-level” (HR: 2.43; 95% CI: 1.49–5.80, p-value = 0.001) remained significant in the final model for multiple Cox proportional hazard regression analyses. There was a significant mean association between tumour grades and the patient’s comorbidity status. Conclusions: Histopathological factors (gender, metastases presence, site of metastases, CEA level, and lymphovascular permeation) showed the best prognosis-predicting factors in CRC.

Turkey real-life data: demographic features, treatment results and effects of comorbidities in chronic myeloid leukemia.

Aim:This study aimed to identify patient characteristics, treatment patterns and outcomes and to evaluate the effects of presence of comorbidities at diagnosis in chronic phase (CP)-chronic myeloid leukemia (CML) patients in Turkey.Materials & methods:Hospital records between 2005 and 2018 were retrospectively reviewed.Results:Of 861 CP-CML patients included, 31% had at least one comorbidity at diagnosis. Sex, cardiovascular disease status at diagnosis and molecular (at least major) and cytogenetic (partial and complete) responses were the independent predictors of survival.Conclusion:The response rates of CP-CML patients to the tyrosine kinase inhibitors were satisfactory. In addition to tolerability and side effect profiles of drugs, comorbidity status of patients should also be considered in treatment choice in CML patients.

The impact of comorbidities on selexipag treatment effect in patients with pulmonary arterial hypertension: insights from the GRIPHON study.

AimsThe number of pulmonary arterial hypertension (PAH) patients with comorbidities is increasing and there are limited data on response to PAH‐targeted therapies in this population. These post hoc analyses explored the effect of selexipag in PAH patients with cardiovascular comorbidities in the GRIPHON study.Methods and resultsRandomized patients (n = 1156) were classified using three methods: (i) by subgroups defined according to previously published comorbidity count and restrictive haemodynamic criteria: Subgroup A (<3 comorbidities and haemodynamic criteria met; n = 962) and Subgroup B (≥3 comorbidities and/or haemodynamic criteria not met; n = 144); comorbidities included body mass index ≥30 kg/m2, essential hypertension, diabetes, history of coronary artery disease; (ii) by number of comorbidities, with addition of atrial fibrillation (0, 1, 2, 3, 4, or 5); (iii) by presence of individual comorbidities. Selexipag to placebo hazard ratios (HR) and 95% confidence intervals (CI) for morbidity/mortality (primary composite endpoint) were estimated using Cox regression adjusting selexipag effect for baseline covariates. Approximately half of the patients in GRIPHON (n = 584; 50.5%) had comorbidities. Selexipag reduced the risk of a morbidity/mortality event compared with placebo in both Subgroup A (HR 0.66, 95% CI 0.53, 0.82) and Subgroup B (HR 0.50, 95% CI 0.26, 0.96), with no evidence of an inconsistent treatment effect between subgroups (interaction p = 0.432). Consistent results were observed in analyses by number and by specific type of comorbidity.ConclusionSelexipag reduces the risk of a morbidity/mortality event vs. placebo irrespective of patient comorbidity status, suggesting that comorbidity status does not influence the treatment effect of selexipag.

Postoperative Complications of Minimally Invasive Intramedullary Nail Fixation Versus Plate Fixation for Distal Fibular Fractures in Elderly Patients: A Retrospective Double Cohort Study in a Geriatric Trauma Unit in the Netherlands

Intramedullary fixation using a fibular nail is a minimally invasive alternative to conventional plate fixation that provides superior biomechanical strength and allows immediate full weightbearing postoperatively. The study aim was to compare the postoperative complications of minimally invasive intramedullary fibular nail fixation to plate fixation for Lauge-Hansen supination external rotation type 4 (Weber B) fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the Netherlands. A retrospective cohort study was performed including patients aged 65 years or older with a Lauge-Hansen supination external rotation type 4 (Weber B) fracture treated with either intramedullary fibular fixation or plate fixation between January 2017 and January 2019. A total number of 58 patients were included with a mean age of 73.9 years (range 65-95). The intramedullary fixation-cohort (n=13) had a significantly higher mean age (82.5 vs 71.4 years, p=.002) and Charlson Co-morbidity Index (4.7 vs 3.6, p=.005) compared to the plate fixation-cohort (n=45). The total number of postoperative complications was lower after intramedullary fixation (n=2, 15%) compared to plate fixation (n=15, 33%), although this relative difference was not significant (p=.307). All 2 complications observed after intramedullary fixation were wound infections demanding no debridement or implant removal. No implant related complications, hospital-acquired complications or mortality were observed after intramedullary fixation. Despite the higher mean age and co-morbidity status of patients treated with minimally invasive intramedullary fibular nailing, the total number of postoperative complications was lower after intramedullary fixation compared to plate fixation. This technique might be a promising alternative in selected patients.

Assessment of Disease Severity and Comorbidity Status in Patients with Occupational Polyneuropathy of Upper Extremities

Introduction: Occupational polyneuropathy of upper extremities induced by physical overload is often registered among workers of various occupations. Yet, modern science lacks up-to-date results of a comprehensive assessment of the condition of such patients in terms of occupational disease severity and the presence of concomitant non-occupational diseases. Objective: To establish severity of the occupational disease and comorbidity status in workers of various occupations, to assess their significance for planning measures aimed at professional rehabilitation of patients. Materials and methods: Severity of occupational polyneuropathy and comorbidity status were established in agricultural, construction, industrial, and mining workers. Results: In all cohorts of workers, occupational polyneuropathy is generally registered in middle-aged and elderly people usually experiencing moderate symptoms; in most cases, it is combined with other occupational diseases of the musculoskeletal system and the peripheral nervous system. Miners suffering from this type of polyneuropathy are often diagnosed with chronic industrial bronchitis. Of non-occupational disorders, ischemic heart disease, hypertension, dorsopathies, and osteoarthritis of various sites prevail in all occupational cohorts and limit the ability of patients to work. Discussion: The severity of polyneuropathy and comorbidity status of patients from different occupational cohorts vary and this fact shall be taken into account when planning medical and professional rehabilitation of workers, which is usually hampered due to imperfection of the current regulations on examining professional suitability, according to which occupational peripheral neuropathy cases shall not stop working in conditions of physical overload. Conclusions: It is critical to attend to the flaws of current regulations, which impede effective rehabilitation of patients with occu¬pational polyneuropathy and other associated diseases.

Comorbidity-Driven Risk across Preparative Regimens for Allogeneic Hematopoietic Stem Cell Transplantation

Background:Comorbidities are an important consideration when selecting preparative regimens for allogeneic hematopoietic stem cell transplantation (HSCT). We hypothesized that the impact of individual comorbidities on the risk of non-relapse mortality (NRM) varies between conditioning regimens. Therefore, we retrospectively analyzed the risk associated with pre-transplant comorbidities and NRM across standard preparative HSCT regimens.Methods: The study included adult patients transplanted for all indications between 2006 and 2015 at a single large academic medical center who were treated with any of the following conditioning regimens: Fludarabine + 2 days Busulfan (Flu/Bu2), Fludarabine + 4 days Busulfan (Flu/Bu4), Fludarabine + Melphalan (Flu/Mel), or Fludarabine + Treosulfan (Flu/Treo). Patient comorbidity status was determined using the guidelines set out in the hematopoietic cell transplantation comorbidity index (HCT-CI, Sorror et. al, 2005) with the following modifications: renal disease was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 instead of a serum creatinine >2 mg/dL; obesity constituted a body-mass index > 30 kg/m2 rather than > 35 kg/m2. Additional comorbidities not included in the HCT-CI, such as hypertension, hyperlipidemia, and HBV or CMV seropositivity, were also assessed.The hazard associated with individual comorbidities was evaluated in each regimen using cause-specific Cox regressions for 2-year non-relapse mortality (NRM), in a multivariate analysis adjusted for age, disease risk and donor type. Comorbidities were assessed in a given regimen if positive in 10 or more patients treated with that regimen. Finally, the cumulative incidence of NRM was plotted and compared using the Fine and Gray test.Results: A total of 692 patients was included in the analysis, with a median age of 59 years. Patients underwent conditioning with Flu/Treo (42%), Flu/Bu2 (23%), Flu/Mel (17%), or Flu/Bu4 (18%). Grafts were obtained from matched sibling donors in 45% of cases.Comorbidities associated with increased risk varied between the four conditioning regimens (Figure 1). While both Flu/Bu4 and Flu/Treo are considered high-intensity regimens, cardiac disease and hypertension were independent risk factors for NRM (Hazard Ratio [HR] 3.9 [1.5-10.3], p = 0.002 and 3.5 [1.2-10.6], p = 0.024, respectively) only in patients conditioned with Flu/Bu4. Cumulative incidence of NRM in patients treated with Flu/Bu4 with and without cardiac disease was 33.3% (95% CI 18.6-59.7), versus 11.4% (6.5-20.0, p = 0.006), respectively. A diagnosis of diabetes also had an increased risk for NRM in Flu/Bu4 (HR 3.3 [1.2-8.7], p = 0.017) but not in Flu/Treo (1.4 [0.7-3.0], p= 0.314), though the confidence interval in the former was rather wide. Additional risk was seen in the Flu/Treo regimen with active infection at time of transplantation (HR 3.6 [1.8-7.2], p < 0.001), and in the Flu/Mel and Flu/Treo regimens with severe pulmonary disease (HR 4.2 [1.7-10.7], p = 0.002). Few patients (9/124 [7%]) with severe pulmonary disease received Flu/Bu4, and therefore the risk for NRM was not calculated in this population.An HCT-CI score of 3 or greater was associated with increased risk in Flu/Mel (2.4 [1.2-4.5], p=0.010) and Flu/Treo (1.8 [1.1-2.9], p = 0.018) conditioning. However, no clear hazard was observed for the HCT-CI score in the Flu/Bu2 and Flu/Bu4 settings.Conclusion: It is common practice to group preparative regimens by conditioning intensity, however our analysis demonstrates that individual comorbidities may have effects unique to a particular conditioning regimen. Cardiac disease, for example, imparts additional hazard in the setting of Flu/Bu4 conditioning, whereas it may not increase non-relapse mortality in other reduced-toxicity or reduced-intensity contexts. The understanding of the roles played by individual comorbidities in relationship with different conditioning regimens may be a factor for consideration when selecting a conditioning regimen, allowing for the personalization of therapy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

EVALUATION OF PHARMACOTHERAPY PROTOCOLS FOR COVID 19 PATIENTS IN BAQIYATALLAH HOSPITAL AND THEIR OUTCOMES

Purpose: The propagation of the new coronavirus, COVID 19, is still a major priority for many countries around the world. Because of the lack of effective certain antiviral therapy for COVID 19. Special medicinal protocols are needed in medical centers to reduce the mortality rate. Methods: Due to constant change of national pharmacotherapy protocols for COVID-19 patients, this study compares the outcomes of three specific pharmacotherapy regimens (Table 1) and the combination of all 3 regimens for management of 614 COVID-19 patients hospitalized in Baqiyatallah hospital in Tehran, this hospital became a referral centers for receiving COVID 19 patients in Iran. Results: The more reliable result of treatments belongs to regimen 3 which indicated 98.26% recovered patients and 1.15% mortality rate and the lowest period of hospitalization with 4.4±0.21 days’ duration. Conclusion: It seems that regimen 3 (with a special combination of antiviral and Azithromycin ant anti-inflammatory drugs) had the best result in improving patients with COVID 19 and this result has not conflict with the comorbidity status of patients.

Risk of cardiovascular mortality with androgen deprivation therapy in prostate cancer: A secondary analysis of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Randomized Controlled Trial.

For men with radiation-managed prostate cancer, there is conflicting evidence regarding the association between androgen deprivation therapy (ADT) and cardiovascular mortality (CVM), particularly among those who have with preexisting comorbidities. The objective of this study was to analyze the association between ADT and CVM across patient comorbidity status using prospectively collected data from a large clinical trial. In total, 1463 men were identified who were diagnosed with clinically localized, intermediate-risk/high-risk prostate cancer (T2b-T4, Gleason 7-10, or prostate-specific antigen >10 ng/mL) from 1993 to 2001 and managed with either radiation therapy (RT) alone or RT plus ADT during the randomized Prostate, Lung, Colon, and Ovarian (PLCO) Cancer Screening Trial. Adjusted hazard ratios (aHRs) for cause-specific mortality (prostate cancer-specific mortality vs other-cause mortality-including the primary end point of CVM [death from ischemic heart disease, cerebrovascular accident, or other circulatory disease]) were determined using Fine and Gray competing-risk regression analysis and stratified by comorbidity history. There was no difference in the risk of 5-year CVM between ADT plus RT and RT alone (2.3% vs 3.3%, respectively; aHR, 0.69; 95% CI, 0.38-1.24; P = .21) overall or on subgroup analysis among men with a history of ≥1 preexisting comorbidities (3.2% vs 5.3%, respectively; aHR, 0.83; 95% CI, 0.43-1.60; P = .58), ≥2 preexisting comorbidities (6.9% vs 8.3%, respectively; aHR, 0.95; 95% CI, 0.40-2.25; P = .90), or cardiovascular disease/risk factors (3.6% vs 4.3%, respectively; aHR, 0.85; 95% CI, 0.44-1.65; P = .63). These results were all similar when each component of CVM was analyzed separately-either cardiac, stroke, or other vascular mortality (P > .05). This study provides prospectively collected evidence that the use of ADT plus RT, compared with RT alone, is not associated with an increased risk of CVM, even among subgroups of men who have preexisting comorbidities and cardiovascular disease.

Treatment Contraindications Based on Comorbidity Status in Patients With Melanoma in the United States

Melanoma incidence has increased in the United States over the past few decades, and disparities in patient treatment have been described. Although most patients with melanoma are good candidates for curative treatment, some are considered poor candidates for treatment because of comorbid conditions. We examined whether patient demographics influence treatment contraindication in melanoma. The National Cancer Database (NCDB) was used to identify patients with melanoma from 2004 through 2015. Multivariate logistic regression was used to determine independent associations, adjusted for confounders. We excluded patients who did not receive treatment for reasons and patients with unknown treatment status. A total of 499,092 patients met the inclusion criteria. Of these, 525 (0.1%) had Treatment contraindicated because of comorbid conditions (TCBC) and 498,567 (99.9%) received treatment. Multivariate logistic regression showed higher odds of TCBC in patients with government insurance (OR=1.34, 95%CI=03-1.73; p=0.03) and patients without insurance (OR=2.75, 95%CI=1.76-4.29; p<0.001) than patients with private insurance. Demographic disparities affects treatment decision in oncological patients. Our study demonstrated a significantly higher likelihood of "nontreatment because of comorbid conditions" among melanoma patients with government insurance or without insurance. Greater efforts are needed to address inequalities in melanoma treatment in the United States.

Albumin and the fibrinogen-to-albumin ratio: Biomarkers for the acute phase response following total knee arthroplasty.

PurposeComplications following total knee arthroplasty (TKA) lead to patient morbidity and cost. While acute phase reactants, such as c-reactive protein (CRP) and fibrinogen, have been used to predict complications following TKA, the extent and duration of changes in albumin levels following TKA are unknown. It is hypothesized that like CRP and fibrinogen, albumin, and the fibrinogen/albumin ratio (FAR) represent useful measures of the acute phase response (APR) following TKA. The purpose of this study was to describe the longitudinal course of albumin and FAR in healthy patients following TKA, relative to established biomarkers, and examine if the variance in albumin or FAR correlates with patient comorbidities.MethodsThis retrospective cohort study of patients undergoing TKA at a tertiary medical center. CRP, fibrinogen, and albumin values were collected pre- and post-operatively. An age-adjusted Charlson comorbidity index (CCI) was utilized as a measure of patient comorbidity status.ResultsThe median preoperative albumin value was 4.3 g/dL, which dropped to 3.6 g/dL on postoperative day 1 following TKA. The albumin value returned to 93% of the baseline by postoperative week 2. The course of albumin inversely mirrored the course of CRP (r = -0.41). Median preoperative FAR was 0.087 g/L, which rose to 0.130 g/L by postoperative week 2 and returned to baseline by postoperative week 6. While preoperative FAR strongly correlated with postoperative week 2 values (r = 0.74), there was a weak positive correlation between age-adjusted CCI and pre-operative FAR (r = 0.24) in patients undergoing primary TKA.ConclusionAlbumin levels follow a predictable postoperative decline that inversely correlates with CRP in healthy patients following TKA. Given the low cost and abundance of laboratories offering albumin levels, direct albumin levels and/or albumin ratios such as FAR may be underutilized biomarkers for monitoring the APR following TKA.

Low visceral adipose tissue regulatory T cells are associated with higher comorbidity severity in patients undergoing bariatric surgery.

Adipose tissue (AT) inflammation is linked to the development of type 2 diabetes (T2DM) and atherosclerosis in murine models of obesity. Reduced AT regulatory T cells (Tregs), which are anti-inflammatory immune cells, play an important part in this pathogenesis, and we have shown that AT-Tregs are inversely correlated to increasing body-mass-index. The purpose of this study was to evaluate the association between AT-Treg abundance and comorbidity status in patients undergoing bariatric surgery (BS). Visceral (intra-abdominal) AT was harvested at that time of primary BS (n = 80) and collagenase digested. AT-Treg abundance (CD4+/CD25+/FOXP3+) was characterized using flow cytometry from the AT stromal vascular fraction. The median AT-Treg abundance (3.03%) was utilized to define high (High-Tregs, n = 39) and low AT-Treg (low-Tregs, n = 38) abundance within this cohort. These two groups were compared in terms of baseline demographic data, preoperative obesity-related comorbidities, glycemic parameters, including insulin resistance (HOMA-IR). Age, excess body weight, and sex were not different between groups. Prevalence of hypertension, hyperlipidemia, or T2DM preoperatively were not different between groups. Compared to High-Tregs, patients with low-Tregs were more likely to have insulin-dependent type 2 diabetes (12.5% vs 2.9%, p = 0.04). Within patients with T2DM, low-Treg patients had higher plasma insulin levels compared to high-Tregs (31.8 (28.4-56.5) vs 15.5 (10.1-23.1), p = 0.04) and trended towards higher insulin resistance (HOMA-IR) (9.0 (5.3-18.3) vs 3.5 (2.2-7.7), p = 0.08). Within those diagnosed with hyperlipidemia, preoperative statin use was higher in Low-Treg patients compared to the control cohort (91% vs 50%, p = 0.056). Low-Treg patients with hypertension were more likely to need 2 + anti-hypertensive agents preoperatively compared to their counterparts (71% vs 44%, p = 0.058). Within bariatric candidates, lower visceral AT-Treg abundance was associated with increased baseline medication requirements for type 2 diabetes, hypertension, and hyperlipidemia. This suggests that reduced AT-Tregs may be associated with higher obesity-related comorbidity severity.

RISK FACTORS FOR CORONARY ARTERIES DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Now health care professionals who manage patients and stick to holistic patient-cantered approach are facing the problem of “polymorbidity”. The most common conditions complicating rheumatic diseases are cardiovascular diseases, interstitial lung disease, osteoporosis, chronic kidney disease, malignancies and depression. Despite the success in treatment of rheumatoid arthritis, the mortality rate in this category of patients remains higher than in the general population. This is associated with the acceleration of atherosclerosis progression and the early-age onset of coronary arteries disease. Therefore, rheumatoid arthritis is considered as a predictor of coronary arteries disease. The incidence of myocardial infarction, heart failure, and sudden coronary death in patients with rheumatoid arthritis is found to be 3 to 5 times higher than in the general population. The purpose of the present study was to estimate and evaluate comorbidity status in patients with rheumatoid arthritis. The study was performed at the at the Regional Medical and Diagnostic Centre of Rheumatologic Diseases, M.V. Sklifosovskyi Poltava Regional Clinical Hospital, which is the clinical base of the Department of Family Medicine and Therapy, Ukrainian Medical Stomatological Academy. The study included 135 patients with rheumatoid arthritis aged 32 – 65, who made up the main group. The control group consisted of 30 patients without autoimmune diseases, inflammatory conditions and other diseases in acute phase. All patients stated the consent to participate in the study in writing. During the study, all the participants passed through clinical examination including blood tests, urine tests, blood biochemistry, electrocardiography, echocardiography, X-rays of the joints, and ultrasound examinations (by using an apparatus of class “Radmir ultima”). 68.2% of the patients in the main group suffering from rheumatoid arthritis were found out to have different comorbidities compared with the control group. Cardiovascular diseases and especially coronary arteries disease were detected in 42.3% of cases and found out as the most prevalent comorbid diseases in the patients with rheumatoid arthritis. We also revealed the high prevalence of dyslipidemia (73, 4% of cases). It is necessary to underline that 75% of patients in the main group were diagnosed to have even 2 or more comorbidities. According to the results obtained, the majority of the patients suffering from rheumatoid arthritis have comorbidities, which can seriously affect the course of rheumatic diseases and influence the treatment. Management of patients with rheumatoid arthritis and comorbid conditions should be supported by rheumatologists, family doctors, internists in order to evaluate all polymorbidities in their interactions and to provide proper assistance for patients in making their therapeutic course decisions. Of course, this requires novel data from experts to improve diagnostic and treatment approaches of rheumatoid arthritis in its early stage.

Validation of the AAST EGS grading system for perforated peptic ulcer disease

Perforated peptic ulcer disease (PPUD) including both duodenl and gastric ulcers is a severe disease and outcomes are influenced by comorbidities and physiology. We validated the AAST EGS grading system at two diverse centers (Mayo Clinic, USA and Pietermaritzburg, South Africa). Dual-center review of historic data (2010-2016) of adults with PPUD was performed. Preoperative, procedural, and postoperative data were abstracted. ASA, Boey, PULP and AAST EGS grades were generated. Comparative, multivariable, and pairwise analyses were performed. There were 306 patients, 42% female with a mean (±SD) age of 56 ±20 years. Overall, the patints were categorized into the following AAST EGS grades: I (30, 10%), II (38, 12%), III (104, 34%), IV (76, 2e%), V (58, 18.9%). Initial management included: midline laparotomy (51%, n=157), laparoscopy (18%, n=58), laparoscopy converted to laparotomy (1%, n=3), and endoscopy (30%, n=88). Duration of stay increased with AAST EGS grade. In United States cohort, factors predictive for 30-day mortality included AAST EGS grade and patient comorbidity status. The AAST EGS grade was comparable to other scoring systems (Boey, PULP, and ASA). Differences exist between centers for management of PPUD and their outcomes; however, the AAST EGS grade can be utilized to stratify thedisease severity of the patient and this demonstrates initial construct validity in a United States but not in a South African population.

Risk assessment in emergency general surgery.

Patients with emergency general surgery (EGS) diseases display variable severity. The extent of disease can be amplified by comorbidity or dramatic changes in presenting physiology. Estimating the extent of disease severity in order to adequately provide prognosis, determine optimal operative or non-operative management, and plan for potential outcomes is difficult. A variety of risk factors have been studied for specific diseases but these criteria may not be universally applied. This limits the generalizability of prior work. The American Association for the Surgery of Trauma (AAST) created a grading system wherein uniform definitions could be applied to begin to measure disease severity in a granular manner. This review presents some of the initial work focused on the validation and incorporation of the AAST EGS grading system. The authors evaluate several diseases wherein the AAST EGS grade has been applied. Finally the work concludes with a review of several inclusive risk estimation tools. Taken together, the ability to measure disease severity - whether by anatomic changes, physiologic disturbance, or patient comorbidity status - will provide a better method to appraise, research, and improve patient care for several EGS conditions.

Is Robot-assisted Surgery Contraindicated in the Case of Partial Nephrectomy for Complex Tumours or Relevant Comorbidities? A Comparative Analysis of Morbidity, Renal Function, and Oncologic Outcomes

BackgroundAvailable comparisons between open partial nephrectomy (OPN) and robot-assisted partial nephrectomy (RAPN) are scarce, incomplete, and affected by non-negligible risk of bias. ObjectiveTo compare RAPN and OPN. Design, setting, and participantsThis was an observational study of 472 patients diagnosed with a cT1–2cN0cM0 renal mass and treated with RAPN or OPN assessed in two prospective institutional databases. Outcome measurements and statistical analysisThe study outcomes were morbidity, complications, warm ischaemia time, renal function, positive surgical margins, and oncologic outcomes. Propensity score matching for age at diagnosis, gender, Charlson comorbidity index, preoperative estimated glomerular filtration rate (eGFR), single kidney status, tumour size and side, total PADUA score, any individual PADUA score item, and year of surgery was used to account for baseline confounders. The effect of surgical approach was estimated using linear and logistic regressions for continuous and categorical outcomes. An interaction test was used for subgroup analyses. Results and limitationsRelative to OPN, RAPN was associated with lower rates for overall (21% vs 36%; p<0.0001) and major (3% vs 9%; p=0.03) complications. This benefit was consistent in patients with high PADUA scores, high CCI, large tumours, and low preoperative eGFR (all p>0.05, interaction test). No difference between the groups was observed for warm ischaemia time, postoperative and 1-yr eGFR, and positive surgical margins (all p>0.05). After median follow-up of 41 mo, there was no difference between the groups for the 5-yr rates of local recurrence-free, systemic progression-free, and disease-free survival (all p>0.05). ConclusionsRAPN is associated with overall better perioperative morbidity and lower rates of complications, regardless of characteristics such as tumour complexity and patient comorbidity status. Functional and oncologic outcomes are equal after RARP and OPN. Patient summaryRobot-assisted partial nephrectomy is associated with a better morbidity profile than open partial nephrectomy (OPN) and provides the same cancer control and renal function preservation observed after OPN.