Deyo-Charlson Comorbidity Index Research Articles

Impact of treatment setting on survival outcomes in undifferentiated pancreatic carcinoma: An analysis of the National Cancer Database.

e16333 Background: Undifferentiated carcinoma of the pancreas is a rare and highly aggressive form of pancreatic cancer, characterized by its low degree of cellular differentiation. The prognosis for this condition remains poor, with median survival times typically not exceeding one year. While existing research indicates that treatment at academic institutions may lead to improved survival outcomes compared to non-academic settings, there is scant research on this topic in the context of undifferentiated carcinoma of the pancreas. Addressing this research gap, this study analyzes data from the National Cancer Database (NCDB) to compare long-term survival rates between patients treated at academic institutions and those at other facilities. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with undifferentiated carcinoma of the pancreas from 2004 to 2019 using the histology code 8020 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, ANOVA, and Chi-Square tests were performed. Data was analyzed using SPSS version 27 and statistical significance was set at α = 0.05. Results: In this analysis of 284 patients, 124 (43.7%) received care at academic centers, while 160 (56.3%) were treated at non-academic institutions. Individuals treated at academic centers had a significantly extended mean overall survival of 27 months compared to 13.9 months for those treated elsewhere (p < 0.05). Additionally, patients at academic centers were more likely to be insured, undergo surgical interventions, receive chemotherapy, and be initially diagnosed at a different facility (p < 0.05). Conversely, patients at non-academic centers were more likely to be white, live closer to their care facility, and exhibit greater metastatic regional lymph nodes (p < 0.05). However, there was no significant association between treatment at academic centers and variables such as median income, cancer grade, and Charlson-Deyo Comorbidity Index (CDCI) (p > 0.05). Conclusions: This study revealed that individuals with undifferentiated carcinoma of the pancreas receiving treatment at academic centers exhibit a significantly improved overall survival rate compared to those treated at non-academic centers. This disparity in survival rates might be attributed to the higher prevalence of chemotherapeutic treatments and surgical interventions at academic institutions. While these observations are based on correlational data, they underscore the necessity for further investigation to establish causality.

Impact of treatment setting on survival outcomes in undifferentiated pancreatic carcinoma: An analysis of the National Cancer Database.

e16333 Background: Undifferentiated carcinoma of the pancreas is a rare and highly aggressive form of pancreatic cancer, characterized by its low degree of cellular differentiation. The prognosis for this condition remains poor, with median survival times typically not exceeding one year. While existing research indicates that treatment at academic institutions may lead to improved survival outcomes compared to non-academic settings, there is scant research on this topic in the context of undifferentiated carcinoma of the pancreas. Addressing this research gap, this study analyzes data from the National Cancer Database (NCDB) to compare long-term survival rates between patients treated at academic institutions and those at other facilities. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with undifferentiated carcinoma of the pancreas from 2004 to 2019 using the histology code 8020 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, ANOVA, and Chi-Square tests were performed. Data was analyzed using SPSS version 27 and statistical significance was set at α = 0.05. Results: In this analysis of 284 patients, 124 (43.7%) received care at academic centers, while 160 (56.3%) were treated at non-academic institutions. Individuals treated at academic centers had a significantly extended mean overall survival of 27 months compared to 13.9 months for those treated elsewhere (p < 0.05). Additionally, patients at academic centers were more likely to be insured, undergo surgical interventions, receive chemotherapy, and be initially diagnosed at a different facility (p < 0.05). Conversely, patients at non-academic centers were more likely to be white, live closer to their care facility, and exhibit greater metastatic regional lymph nodes (p < 0.05). However, there was no significant association between treatment at academic centers and variables such as median income, cancer grade, and Charlson-Deyo Comorbidity Index (CDCI) (p > 0.05). Conclusions: This study revealed that individuals with undifferentiated carcinoma of the pancreas receiving treatment at academic centers exhibit a significantly improved overall survival rate compared to those treated at non-academic centers. This disparity in survival rates might be attributed to the higher prevalence of chemotherapeutic treatments and surgical interventions at academic institutions. While these observations are based on correlational data, they underscore the necessity for further investigation to establish causality.

Impact of neoadjuvant immunotherapy on postoperative complications after surgery for rectal cancer.

Despite the increasing use of immunotherapy in treating various cancer types, there is still limited understanding of its impact on surgical complications. We used a national database to examine the difference in surgical outcomes for rectal cancer patients who received standard neoadjuvant chemoradiation plus neoadjuvant immunotherapy and patients who received neoadjuvant chemoradiation only. This retrospective cohort study used the National Cancer Database (NCDB). We selected patients aged 18-90 with T1-3, N1-2, and M0 rectal cancer who underwent curative-intent surgery between 2010 and 2020. We performed a 1:1 propensity match to control for patient age, sex, Charlson-Deyo comorbidity index, surgical approach, and tumor site. Our primary outcome was difference in surgical outcomes (hospital length of stay, unplanned 30-day readmission, 30-day mortality) between the two groups. Secondary outcomes included days from diagnosis to surgery and pathologic outcomes. Our study included 26 229 patients, of which 126 received immunotherapy in addition to chemoradiation and 26 103 received only chemoradiation. In our matched population of 125 pairs of patients, patients who received immunotherapy and chemoradiation underwent surgery later compared to patients who only received chemoradiation (median 245 vs. 144 days, p < 0.001). There were no significant differences in median length of stay (5 vs. 5 days, p = 0.202), unplanned 30-day readmission (7 vs. 9, p = 0.617), and 30-day mortality (0 vs. 1, p = 1.000) between the two groups. Neoadjuvant immunotherapy for rectal cancer is not associated with adverse surgical outcomes. This work can help clinicians optimize treatment protocols and move closer toward strategies tailored to specific patient profiles.

National trends in the treatment of adult diffuse midline gliomas: a rare clinical scenario.

Diffuse midline gliomas (DMG) include all midline gliomas with a point mutation to the histone H3 gene resulting in the substitution of a lysine with a methionine (K27M). These tumors are classified as World Health Organization grade 4 with a mean survival between 9- and 19-months following diagnosis. There is currently no standard of care for DMG, and palliative radiation therapy has been proven to only extend survival by months. Our current study aims to report current treatment trends and predictors of the overall survival of DMG. We searched the National Cancer Database for adult patients treated for DMG from 2016 to 2020. Patients were required to have been treated with primary radiation directed at the brain with or without concurrent chemotherapy. Univariable and multivariable Cox regressions were used to determine predictors of overall survival. Of the 131 patients meeting the inclusion criteria, 113 (86%) received radiation and chemotherapy. Based on multivariable Cox regression, significant predictors of survival were Charlson-Deyo comorbidity index and race. Patients with a Charlson-Deyo score of 1 had 2.72 times higher odds of mortality than those with a score of 0. Patients not identifying as White or Black had 2.67 times higher odds of mortality than those identifying as White. The median survival for all patients was 19 months. Despite being considered ineffective, chemotherapy is still administered in most adult patients diagnosed with DMG. Significant predictors of survival were Charlson-Deyo comorbidity index and race.

Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty?

BackgroundThe optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA. MethodsUsing an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience. ResultsThe risk of complications correlated more closely to the CDI (odds ratio (OR) 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table 1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table 2] [Figures 1A and 1B]. ConclusionsChronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.

Factors Associated With Margin Positivity After Lung Resection Surgery

IntroductionThe purpose of this study is to utilize a representative national sample to investigate the factors associated with margin positivity after attempted surgical resection. Given the changes in surgical approaches to lung cancer for the last 10 years, margin positivity and outcomes between robotic, video assisted thoracoscopic surgery (VATS) and open surgical resections may vary. MethodsThis retrospective cohort study utilized the National Cancer Database. Patients with non–small-cell lung cancer, 18 or older and who had a surgical lung resection between 2010 and 2019 were included. Demographic data, along with patient-level clinical variables were extracted. Patient-level outcome variables including 30-day, 90-day mortality and readmission rates were analyzed. Univariable and multivariable logistic regression was utilized to assess factors associated with margin positivity. ResultsA total of 226,884 patients were identified. Of the total cohort, 9229 had positive margins (4.2%). Patients with positive margins had statistically significant increased 30-day, 90-day mortality, as well as increased readmission rate. Older age, male sex, patients undergoing an open resection, patients who underwent a wedge resection, higher clinical stage, larger tumor size, squamous and adenosquamous histologies, and higher Charlson-Deyo Comorbidity Index were all associated with having a positive margin after resection. ConclusionIn conclusion, there was no difference in margin positivity when comparing robotic and VATS resection, however, open resection had increased rates of margin positivity. Increasing tumor size, clinical stage, squamous and adenosquamous histologies, male sex, and patients undergoing a wedge resection were all associated with increased rates of margin positivity.

Risk of depression and anxiety in 7.302 patients with sarcoidosis: a nationwide cohort study.

The aim was to investigate the association between sarcoidosis and anxiety and/or depression (A/D) in patients with sarcoidosis and comparators matched on age, gender, residency, and cohabitation status. Patients with newly diagnosed sarcoidosis between 2001 and 2015 were identified in the Danish National Patient Register. Cases were matched 1:4 with non-sarcoidosis comparators. We estimated the cumulative incidence of A/D using the Cumulative Incidence Function and the subdistribution hazard ratio (sHR) for A/D using the Fine-Gray subdistribution hazard model. Estimates were adjusted for socio-economic status and Deyo-Charlson Comorbidity Index. We identified 7.302 cases and 26.145 matched comparators. The cumulative incidence of A/D after five years was 6.0% (95%CI 5.5-6.4) for cases and 4.2% (95%CI 4.0-4.4) for matched comparators. The cumulative incidence was higher among cases for both males and females and in all age-groups compared with the matched comparators. The adjusted-sHR for A/D was 1.38 (95%CI 1.24-1.53). The adjusted-sHR for A/D was 1.51 (95%CI 1.30-1.75) for male cases and 1.25 (95%CI 1.08-1.45) for female cases compared with the matched comparators. The adjusted-sHR for A/D was higher for cases in all age-groups compared with the matched comparators, although not statistically significant among cases aged 30-39 years (a-sHR 1.15; 95%CI 0.92-1.44). Sarcoidosis cases had a higher risk of A/D compared with matched comparators during 18 years of follow-up. The risk of developing A/D was greater for male and female cases and within all age-groups compared with the matched comparators.

Immunotherapy Initiation at the End of Life in Patients With Metastatic Cancer in the US

While immunotherapy is being used in an expanding range of clinical scenarios, the incidence of immunotherapy initiation at the end of life (EOL) is unknown. To describe patient characteristics, practice patterns, and risk factors concerning EOL-initiated (EOL-I) immunotherapy over time. Retrospective cohort study using a US national clinical database of patients with metastatic melanoma, non-small cell lung cancer (NSCLC), or kidney cell carcinoma (KCC) diagnosed after US Food and Drug Administration approval of immune checkpoint inhibitors for the treatment of each disease through December 2019. Mean follow-up was 13.7 months. Data analysis was performed from December 2022 to May 2023. Age, sex, race and ethnicity, insurance, location, facility type, hospital volume, Charlson-Deyo Comorbidity Index, and location of metastases. Main outcomes were EOL-I immunotherapy, defined as immunotherapy initiated within 1 month of death, and characteristics of the cohort receiving EOL-I immunotherapy and factors associated with its use. Overall, data for 242 371 patients were analyzed. The study included 20 415 patients with stage IV melanoma, 197 331 patients with stage IV NSCLC, and 24 625 patients with stage IV KCC. Mean (SD) age was 67.9 (11.4) years, 42.5% were older than 70 years, 56.0% were male, and 29.3% received immunotherapy. The percentage of patients who received EOL-I immunotherapy increased over time for all cancers. More than 1 in 14 immunotherapy treatments in 2019 were initiated within 1 month of death. Risk-adjusted patients with 3 or more organs involved in metastatic disease were 3.8-fold more likely (95% CI, 3.1-4.7; P < .001) to die within 1 month of immunotherapy initiation than those with lymph node involvement only. Treatment at an academic or high-volume center rather than a nonacademic or very low-volume center was associated with a 31% (odds ratio, 0.69; 95% CI, 0.65-0.74; P < .001) and 30% (odds ratio, 0.70; 95% CI, 0.65-0.76; P < .001) decrease in odds of death within a month of initiating immunotherapy, respectively. Findings of this cohort study show that the initiation of immunotherapy at the EOL is increasing over time. Patients with higher metastatic burden and who were treated at nonacademic or low-volume facilities had higher odds of receiving EOL-I immunotherapy. Tracking EOL-I immunotherapy can offer insights into national prescribing patterns and serve as a harbinger for shifts in the clinical approach to patients with advanced cancer.

Incidence of Motoric Cognitive Risk Syndrome and Associated Factors in Older Adults in Türkiye.

Motoric cognitive risk syndrome (MCRS) is characterized by slow gait and subjective cognitive decline. It is a predementia syndrome associated with an increased risk of dementia and mortality. To investigate the incidence of MCRS and its associated factors in older adults in Türkiye. A retrospective study. This study enrolled community-dwelling older adults admitted to the geriatric outpatient clinic. Participants were assessed for MCRS according to previously described criteria. Logistic regression analysis was conducted to evaluate the association among MCRS and demographic features, clinical status, and geriatric syndromes. Of the 1,352 older adults examined, 577 met the inclusion criteria, and the mean age was 75.2 years. The overall incidence of MCRS was 7.8%. The MCRS group was predominantly older, female, and unmarried, with polypharmacy and higher Deyo-Charlson comorbidity index and Yesavage geriatric depression scale scores than the non-MCRS group. In the multivariate model, significant associations were found between MCRS and age and polypharmacy [odds ratios (OR), 2.22; 95% confidence interval (CI), 1.04-4.71, p = 0.039; OR, 2.02; 95% CI, 1.02-3.99, p = 0.043, respectively]. The overall incidence of MCRS was found in 7.8% of older adults. Advanced age and polypharmacy are risk factors associated with MCRS.

Charlson-Deyo Comorbidity Index as a Novel Predictor for Recurrence in Non-Muscle-Invasive Bladder Cancer.

To test the association between the Charlson-Deyo Comorbidity Index (CCI) and the recurrence of non-muscle-invasive bladder cancer (NMIBC). NMIBC (Ta, T1, TIS) patients who underwent transurethral resection of bladder tumor (TURB) between 2010 and 2018 were identified within a retrospective data repository of a large university hospital. Kaplan-Meier estimates and uni- and multivariable Cox regression models tested for differences in risk of recurrence according to low vs. high comorbidity burden (CCI ≤ 4 vs. >4) and continuously coded CCI. A total of 1072 NMIBC patients were identified. The median follow-up time of the study population was 55 months (IQR 29.6-79.0). Of all 1072 NMIBC patients, 423 (39%) harbored a low comorbidity burden vs. 649 (61%) with a high comorbidity burden. Overall, the rate of recurrence was 10% at the 12-month follow-up vs. 22% at the 72-month follow-up. In low vs. high comorbidity burden groups, rates of recurrence were 6 vs. 12% at 12 months and 18 vs. 25% at 72 months of follow-up (p = 0.02). After multivariable adjustment, a high comorbidity burden (CCI > 4) independently predicted a higher risk of recurrence (HR 1.42, 95% confidence interval (CI) 1.06-1.92, p = 0.018). After multivariable adjustment, the hazard of recurrence increased by 5% per each one-unit increase on the CCI scale (HR 1.05, 95% CI 1.00-1.10, p = 0.04). Comorbidities in NMIBC patients are common. Our data suggest that patients with higher CCI have an increased risk of BC recurrence. As a consequence, patients with a high comorbidity burden should be particularly encouraged to adhere to NMIBC guidelines and conform to follow-up protocols.

The effect of the anticholinergic burden on mortality following elective cardiac surgery

Objective The cumulative effect of drugs with anticholinergic properties may pose a significant risk in the post-discharge period of patients who have undergone elective cardiac surgery. The aim of this study was to investigate the association between anticholinergic burden and 6-month postdischarge mortality in older cardiac surgery patients. Methods This study performed a retrospective longitudinal analysis of patients undergoing elective cardiac surgery at a tertiary care centre from January 2021 to January 2022. The Deyo-Charlson comorbidity index (D-CCI) was used to estimate the burden of comorbidities. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale (ACB) and Drug Burden Index (DBI) scale. All-cause postdischarge mortality was determined from electronic medical records. Results A total of 255 older adults who had undergone elective cardiac surgery and had been followed up for at least 6 months were included in this study. Approximately 12.5% (n = 32) of older patients died within 6 months of discharge. In multivariate Cox regression analysis, ACB (HR:1.31, 95%CI:1.10–1.56 p = 0.01) and DBI (HR:2.08, 95%CI:1.27–3.39 p = 0.01) showed significantly increased risk of 6-month postdischarge mortality after adjusting for several possible confounders (age, gender, D-CCl, and American Society of Anaesthesiologists (ASA) score). Overall event-free survival differed significantly between patients undergoing cardiac surgery based on anticholinergic burden according to the group-stratified ACB and DBI scales (χ2: 5.907, log-rank test, p = 0.015 and χ2: 15.389, log-rank test, p < 0.001 respectively). Conclusion The anticholinergic burden is associated with 6-month all-cause post-discharge mortality in older cardiac surgery patients. A deprescribing approach should be considered, especially for older adults in the perioperative period. TRIAL REGISTRATION The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT05312684 Registered on 5 April 2022.

Survival Outcomes of Rural Patients with Mantle Cell Lymphoma

Background Mantle cell lymphoma (MCL) is a rare and aggressive malignancy, representing approximately 6-8% of all non-Hodgkin lymphomas, and is generally associated with poor outcomes. Patients (pts) with MCL often require intensive up-front treatment with consideration for stem cell transplant consolidation. Due to geographic limitations, pts living in rural areas with MCL may not have access to specialized treatment centers experienced in managing this rare disease. There is a paucity of data available evaluating the impact of rurality in MCL, and it is unknown how population density and access to major metropolitan centers and their healthcare systems may impact survival outcomes. Methods The National Cancer Database was used to identify MCL pts diagnosed from 2004-2020. Demographic and treatment characteristics were compared by county level measures of rurality and urban influence, categorized into metropolitan (metro), non-metropolitan urban (urban), and non-metropolitan rural (rural) counties. These data are provided from the 2013 Department of Agriculture Economic Research service data Rural-Urban Continuum Codes which uses population, population density, and commuting distance to determine these codes. Pts without rurality data or who were not treated at the reporting facility were excluded. Kaplan Meier and adjusted Cox regression survival analysis were used to compare overall survival by rural-urban codes. Results Of the 29,464 pts with MCL identified, 83.4% (N= 24,849) resided in metro counties, 14.6% (N=4,356) resided in urban counties, 1.9% (N=573) resided in rural counties. Non-metro pts were more likely to be male (70.7% male metro vs 73.0% and 72.1% for urban and rural counties, respectively), with similar age at diagnosis across county types (median age of 68 for metro pts and 69 for rural pts). Rural pts had a higher burden of comorbidities, as determined by the Charlson-Deyo comorbidity index (11.3% of rural pts with a score of 2 or greater, compared to 8.7% urban, and 7.9% of metro pts). Pts from metro counties were more likely to have private insurance (38.5% metro vs. 32.4% for urban and 28.6% for rural pts), where non-metro pts were more often uninsured (3.3% of rural, vs 2.4% of metro) or Medicare insured (61.6% rural vs 53.4% of metro pts). Notably, pts were less likely to be managed with active surveillance if they were from a rural county (4.8% vs 6.9% of metro pts), and were more likely to receive systemic disease related therapy at diagnosis (90.6% rural vs 85.2% metro). With a median follow up of 42 months, pts from metro counties had a median overall survival (OS) of 70.6 months (95% confidence interval (CI) 68.6-72.7), which was significantly longer than those from urban (61.1 months [95% CI 56.4-65.9], p&amp;lt;0.001) and rural counties (59.8 months [95% CI 54.0-65.6], p&amp;lt;0.001). The survival disparity was persistent for metro, urban, rural pts at 1-year (81%, 80%, and 78% respectively, p&amp;lt;0.001), 5-years (54%, 50%, 50% respectively, p&amp;lt;0.001) and 10-years (36%, 30%, 29% respectively, p=0.066). When referenced to pts from metro counties on Cox regression, non-metro counties had a greater risk of all-cause mortality, with hazard ratio (HR) of 1.13 (95% CI 1.08-1.18; p&amp;lt;0.001) for urban and 1.14 (95% CI 1.02-1.28; p=0.024) for rural pts. When adjusted for age and Charlson-Deyo comorbidity score this survival disparity persisted, with a HR of 1.12 (95% CI 1.07-1.17), p&amp;lt;0.001 for urban pts and HR 1.05 (95% CI 0.94-1.18), p=0.408, for rural pts, when referenced to pts from metro counties. Discussion We demonstrate a population density-based survival disparity in MCL pts, finding that pts living in more rural counties have worse survival outcomes. Rural pts had a higher comorbidity burden and were more likely to be underinsured. Additionally, they received less active surveillance, which may indicate delays in diagnosis and/or consultation with an oncologist. Given the rapidly evolving treatment landscape of MCL, these data support the need for efforts to improve healthcare access for MCL pts, such as earlier referrals to academic centers with expertise in MCL management, expanded access to telehealth, rural partnerships with academic medical centers, and programs that support patient and family travel.

A National Cancer Database Analysis of Demographics, Treatment Patterns and Survival Trends of Patients with Plasmablastic Lymphoma in US: Does Ethnicity Predict Enhanced Outcomes?

Background: Plasmablastic lymphoma (PbL) is an exceedingly rare, aggressive non-Hodgkin lymphoma with overlapping features of myeloma and lymphoma diagnosed most commonly in immunocompromised individuals, especially in the setting of human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV) infection ( Int J Lab Hematol PMID 36074710). Pathologically, it is characterized by lacking CD20 and PAX5 expression with the presence of CD38, CD138, MUM1/IRF4, Blimp1, and XBP1 expression ( Blood Lymphat Cancer PMID 31360094). There is no established standard of care ( Blood PMID 25636338). Due to the disease's rarity, limited information is available on PbL, especially when focusing on underrepresented minorities. This study aims to describe the demographics, treatment patterns, and survival outcome differences in Hispanic (HI) versus non-Hispanic (NH) patients in the United States with PbL. Methods: Data was analyzed on patients with PbL in the US reported to the NCDB between 2010 and 2019. Sociodemographic and treatment characteristics were compared between ethnic groups. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) between HI and NH populations. Multivariate analysis and propensity score matching were performed with adjustment for age, stage, co-morbidity score, insurance status, type of facility and great circle distance. Results: Between 2010 and 2019, 1624 patients were diagnosed with PbL with 16% identified as HI. HI were diagnosed at a younger median age of 48 years as compared to NH at 58 years. Diagnosis was made predominately in males (78%) with no statistical difference between HI and NH. Most HI and NH were white (92% and 74% in HI and NH, respectively) with increased racial diversity among NH. 17% of all patients identified as black with 1% HI and 21% NH. Regarding income, 32% HI had an income less than $38,000 versus 23% NH; whereas, 31% NH had an income greater than $63,000 versus 20% HI [p=0.017]. 38% HI had a Charlson-Deyo Comorbidity Index score ≥ 2 as compared to 27% NH [p&amp;lt;0.001]. Table 1 provides additional information on demographics. 45% of all patients had stage IV disease at the time of diagnosis. 86% of all patients received treatment with no statistical difference among HI and NH [p=0.246]. 67% of HI were treated at academic/research programs compared to 50% of NH [p=0.004]. The median distance between the patient's residence and treatment facility was 6.9 miles for HI versus 9.8 miles for NH [p=0.001]. The survival probability at 2, 5, and 10 years for HI was 59%, 52%, and 42%, respectively as compared to NH was 47%, 37%, and 31%, respectively. The median survival time (MS) was 9.4 years in HI versus 1.4 years in NH [p &amp;lt;0.001]. Figure 1 shows the Kaplan Meier curve comparing overall survival (OS) between HI versus NH.When adjusted on multivariate analysis, there were no independent variables associated with better or worse OS; moreover, propensity matched analysis showed no MS difference between HI vs NH (1.79 years versus 1.17 years). Conclusion: This hospital-based analysis noted that HI presented with PbL at a younger age than NH; however, HI more frequently had a higher Charlson-Deyo Comorbidity Index score than NH. There was no statistical difference in the stage at diagnosis between HI and NH. Additionally, HI had a lower income and no medical insurance as compared to NH suggesting HI possibly had inferior access to medical resources. Paradoxically, HI had significantly higher OS rates. Further insight into the disease's intrinsic characteristics, as well as biological factors, is needed to gain a better understanding of these poor outcomes.

Association of time to resection with survival in patients with colon cancer.

Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7days from diagnosis were excluded. Patients were classified into Early (< 25days) and Delayed (≥ 25days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. Patients with CC who underwent resection ≥ 25days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Did the Comprehensive Care for Joint Replacement Bundled Payment Program Impact Sex Disparities in Total Hip and Knee Arthroplasties?

BackgroundSex disparities have been noted across various aspects of total hip/knee arthroplasty (THA/TKA). Given incentives to standardize care, bundled payment initiatives including the Comprehensive Care for Joint Replacement (CJR) program may reduce disparities. This study aimed to assess the CJR program’s impact on sex disparities in THA/TKA care and outcomes. MethodsThis retrospective cohort study included 259,673 THAs (61.7% women) and 506,311 TKAs (64.0% women) from a large national database (2013 to 2017). Sex disparities were assessed for care and outcomes related to the period (1) before surgery, (2) during hospitalization for THA/TKA, and (3) after discharge. Disparities were reported as women:men ratios. Difference-in-differences analyses estimated the impact of the CJR program on pre-existing sex disparities. ResultsFor both THA and TKA, women were less likely than men to present with a Charlson-Deyo comorbidity index >0 (women:men ratio 0.88 to 0.92), but were more likely to require blood transfusions (women:men ratio 1.48 to 1.79) and be discharged to institutional postacute care (women:men ratio 1.50 to 1.66). Difference-in-differences models demonstrated that the CJR bundled payment program reduced sex disparities in institutional postacute care discharges (THA: −2.28%; 95% confidence interval [CI] −4.20 to −0.35%, P = .02; TKA: −2.07%; 95% CI −3.93 to −0.20%; P = .03) and THA 90-day readmissions (−1.00%, 95% CI −1.88 to −0.13%, P = .02), indicating a differential impact of CJR in women versus men for some outcomes. ConclusionsWhile sex disparities in THA/TKA persist, the CJR program demonstrates potential to impact such differences. Future research should focus on how potential mechanisms could be leveraged to reduce disparities.

Recent trends and risk factors associated with Clostridioides difficile infections in hospitalized patients with inflammatory bowel disease.

Clostridioides difficile infections (CDIs) are common among patients with inflammatory bowel disease (IBD) and can mimic and exacerbate IBD flares, thus warranting appropriate testing during flares. To examine recent trends in rates of CDI and associated risk factors in hospitalized IBD patients, which may better inform targeted interventions to mitigate the risk of infection. This is a retrospective analysis using the Nationwide Readmissions Database from 2010 to 2020 of hospitalized individuals with Crohn's disease (CD) or ulcerative colitis (UC). Longitudinal changes in rates of CDI were evaluated using International Classification of Diseases codes. Multivariable logistic regression evaluated the association between patient- and hospital-related factors and CDI. There were 2,521,935 individuals with IBD who were hospitalized at least once during the study period. Rates of CDI in IBD-related hospitalizations increased from 2010 to 2015 (CD: 1.64%-3.32%, p < 0.001; UC: 4.15%-5.81%, p < 0.001), followed by a steady decline from 2016 to 2020 (CD: 3.15%-2.27%, p < 0.001; UC: 5.04%-4.27%, p < 0.001). In multivariable models, CDI was associated with the Charlson-Deyo comorbidity index, public insurance, and hospital size. CDI was associated with increased mortality. Rates of CDI among hospitalized patients with IBD had initially increased, but havedeclined since 2015. Increased comorbidity, large hospital size, public insurance, and urban teaching hospitals were associated with higher rates of CDI. CDI was associated with increased mortality in hospitalized patients with IBD. Continued vigilance, infection control, and treatment of CDI can help continue the trend of declining infection rates.

Perioperative complications after total shoulder arthroplasty in patients with neurological disorders

BackgroundTotal shoulder arthroplasty (TSA) is an effective procedure to treat end stage osteoarthritis of the shoulder. Outcomes in patients with neurologic disorders are not well documented. Previous studies have shown that TSA in patients with Parkinson’s disease was successful in alleviation of pain, but the overall shoulder function results were poor. We would like to extend this to include more neurologic symptoms. The purpose of this study is to determine the perioperative and the early postoperative outcomes in patients with neurologic disorders undergoing TSA. MethodsThe Nationwide Readmission Database was used to identify all available primary anatomic TSA (aTSA) and reverse TSA (rTSA) occurring the US from 2011 to 2019 resulting in a total of 428,761 cases of TSA, with 209,789 being aTSA and 218,972 being rTSA. Relevant ICD9 and ICD10 codes identified 3602 (0.8%) patients to have at least 1 neurological disease. Both one way analysis of variance and Chi-squared analyses were used for demographic and comorbidity comparisons. For outcomes analyses, a Chi-squared/Fisher’s Exact Test and binary logistic regression were used, which accounted for patient age, sex, primary payer, and Charlson-Deyo comorbidity index. Fisher’s Exact Test was used to confirm significance in all low sample size parameters. ResultsSignificant differences in several demographic categories were found between patients with and without neurological disorders receiving TSA including age (P < .001), sex (P < .001), zip-code income quartile distribution (P < .001), and the primary payer distribution (P < .001). At 180 days, the presence of a neurological condition was significantly predictive of higher rates of extended hospital stay (aTSA: P < .001, rTSA: P < .001) and non–home discharge following both aTSA and rTSA (aTSA: P < .001, rTSA: <0.001). The presence of a neurologic condition was predictive of significantly higher 180-day all-cause complication (P < .001) and mortality rates (P < .001) in patients undergoing rTSA, however this was not seen in those undergoing aTSA. Regarding perioperative complications, in patients undergoing aTSA and rTSA the presence of a neurological condition was significantly predictive of increased complication rates. ConclusionThis study demonstrates that patients with neurologic disorders undergoing TSA are at increased risk for perioperative complications, extended hospital stay, non–home discharge, and mortality out to 180 days. This information is helpful for both patients and surgeons when making an informed decision regarding TSA. Identifying patients with preexisting neurologic disorders before TSA can assist in tailoring preoperative and postoperative management of these patients to improve both short-term and long-term outcomes.

Role of Brachytherapy in Adjuvant Radiation Practices for FIGO Stage II Endometrial Cancer

FIGO stage II endometrial adenocarcinoma (EAC) involves the cervical stroma but is otherwise confined to the uterus. Management involves total hysterectomy and bilateral salpingo-oophorectomy (TH/BSO) followed by risk-adapted adjuvant therapy which may include radiation and chemotherapy (CHT). We sought to investigate whether patients with FIGO II EAC undergoing adjuvant radiation benefit from addition of vaginal cuff brachytherapy (VCB). The National Cancer Database was queried to identify patients with FIGO II EAC diagnosed in 2010-2019 who received TH/BSO followed by adjuvant EBRT alone, VCB alone, or EBRT+VCB. Patients <18 years old or with <6 months follow-up were excluded. Clinical and demographic data were compared by treatment received using two-sided Z-tests and χ2 tests. Predictors of VCB were identified using multinomial logistic regression. Multivariate regression was used to identify predictors of death. Survival was evaluated with Kaplan-Meier estimators and Cox proportional hazards modeling. A total of 6152 women with FIGO II EAC met inclusion criteria. After TH/BSO, 1792 (29%) patients received EBRT alone, 2428 (40%) received VCB alone, and 1923 (31%) received EBRT+VCB. Lymphovascular space invasion (LVSI) was present in 2224 (36%) patients, of which 751 (34%) received EBRT alone, 698 (31%) received VCB alone, and 775 (35%) received EBRT+ VCB. CHT was given to 548 (31%) treated with EBRT alone, 248 (16%) with VCB alone, and 414 (21%) with EBRT+VCB. Positive surgical margins (+SM) were present in 211 patients (3%), of which 92 (44%) were treated EBRT alone and 70 (33%) with EBRT+VCB. Compared to EBRT alone, relevant relative risk ratios (RRR) of receiving VCB alone include grade 2 (RRR -0.25, p = 0.020) or 3 (RRR -0.41, p = 0.004) disease, single agent CHT (RRR -0.83, p = 0.001), and LVSI (RRR -0.56, p<0.001). RRR of receiving EBRT+VCB include age>70 (RRR -0.37, p = 0.022), grade 3 disease (RRR 0.30, p = 0.024), and single (RRR -0.42, p = .046) or multi- (RRR -0.24, p = 0.026) agent CHT. Predictors of death in the study cohort include age 50-69 (OR 1.8, p<0.001) and >70 (OR 4.1, p<0.001), Charlson-Deyo Comorbidity Index ≥1 (OR 1.4, p<0.001), grade 2 (OR 1.8, p<0.001) or 3 (OR 3.0, p<0.001) disease, cervical stromal invasion (OR 1.4, p = 0.001), and LVSI (OR 1.5, p<0.001). Compared to EBRT alone, both VCB alone (OR 0.81, p = 0.023) and EBRT+VCB (OR 0.70, p<0.001) were associated with decreased risk of death. Five-year overall survival in patients receiving EBRT alone was 77.9% (95% CI 75.8-79.8%), whereas VCB alone and EBRT+VCB were 84.8% (83.2-86.2%, log rank p<0.001) and 82.9% (81.0-84.6%, log rank p<0.001) respectively. Survival differences remained significant when isolating patients with LVSI, grade 3, and +SM. VCB as monotherapy or in combination with EBRT in patients with FIGO II EAC was associated with improved survival. Inclusion of adjuvant VCB maintains an important role in treating patients with FIGO II EAC.

Treatment at Twilight: An Analysis of Therapy Patterns and Outcomes in Adults 80 Years and Older With Advanced or Metastatic NSCLC

IntroductionThe aim of this study is to evaluate treatment patterns, survival outcomes, and factors influencing systemic treatment decisions in adults 80 years and older with NSCLC. MethodsThis was a retrospective National Cancer Database study evaluating outcomes in adults aged 80 years and older with advanced NSCLC. Patients were analyzed on the basis of systemic therapy, including none, chemotherapy or immunotherapy (IO) alone, and chemotherapy plus IO (chemotherapy + IO). Median overall survival (OS) was compared using Kaplan-Meier methodology. Hazard ratio with 95% confidence interval (CI) was used to assess differences in outcomes, and OR with 95% CI was used to assess factors contributing to systemic therapy provision. ResultsPatients 80 years and older (OR = 1.135 [95% CI: 1.127–1.142], p = 0.000), females (OR = 1.129 [95% CI: 1.085–1.175], p < 0.001), blacks (OR = 1.272 [95% CI: 1.179–1.372], p < 0.001), non-Hispanic whites (OR = 1.210 [95% CI: 1.075–1.362], p = 0.002), and those with increasing Charlson-Deyo Comorbidity Index score (p < 0.001) were less likely to receive systemic therapy. Median OS for no therapy, IO alone, chemotherapy alone, and chemotherapy plus IO was 2.63 (95% CI: 2.57–2.69), 10.68 (95% CI: 9.96–11.39), 12.35 (95% CI: 11.98–12.72), and 14.03 (95% CI: 13.87–14.88) months, respectively. In chemotherapy alone, mean OS was 1.12 months (95% CI: 0.55–1.70) (p < 0.001) longer with multiagent versus single agent. There was no difference between IO plus single agent versus IO plus multiagent chemotherapy (0.67 mo [95% CI −1.18 to 2.54], p = 1.00). ConclusionsAge, comorbidities, patient race, and sex affected systemic therapy provision. Multiagent chemotherapy and chemotherapy plus IO significantly improved survival; with the latter, survival was similar with IO plus single or multiagent chemotherapy.

Trends in and Prognostic Significance of Time to Treatment in Pancreatic Cancer: A Population-Based Study.

The association of time to treatment (TTT) with survival remains unclear in pancreatic adenocarcinoma (PDAC). In this study, we evaluate the recent trends in TTT, causes for delay, and its effect on survival. We included patients with PDAC of all stages from the National Cancer Database (2004-2020) who underwent either surgery or chemotherapy/radiotherapy (CT/RT). TTT was defined as the duration between tissue diagnosis and first treatment. Linear regression (β) was used to study the temporal trends in time delay. A total of 239,638 patients were included. The median TTT was 25days. Using multivariable analysis, we found that increasing age (OR 1.48), female gender (OR 1.04), Black race (OR 1.3), lower educational status (OR 1.2), Medicaid, Medicare insurance, and uninsured (OR 1.2, 1.5, and 1.2, respectively), treatment at academic centers (OR 1.3), higher Charlson-Deyo comorbidity index (OR 1.2), and CT/RT (OR 1.5) were associated with increased TTT. There was a steady rise in median TTT from 21 to 28days between 2004 and 2020 (β = 0.3), suggestive of a worsening trend. Concurrently, there was an increasing trend in utilization of neoadjuvant CT/RT between 2004 and 2020 in early-stage PDAC. On Cox regression, TTT delay was associated with poor overall survival in stage I-IV patients (HR 1.1, 1.1, 1.09, and 1.53, respectively). Delayed treatment approaching 2months was observed in 10% of the population. The rising temporal trend in TTT may be attributed to the increasing shift toward neoadjuvant CT/RT in early-stage PDAC and/or the increasing use of tissue biopsy prior to surgery.