Electronic Medical Charts Research Articles

Association Between Epidural Analgesia and Cancer Recurrence or Survival After Surgery for Renal Cell Carcinoma: A Propensity Weighted Analysis.

Whether epidural anesthesia and analgesia (EA) is beneficial for postoperative cancer outcomes remains controversial and we conducted this historical cohort study to evaluate the association between EA and long-term outcomes following surgery for renal cell carcinoma (RCC). We collected patients receiving RCC surgery from 2011 to 2017 and followed up them until February 2020. Patient attributes, surgical factors and pathological features were gathered through electronic medical chart review. The association between EA and recurrence-free and overall survival after surgery was evaluated using Cox regression models with inverse probability of treatment weighting (IPTW) to balance the observed covariates. The median follow-up time for the 725 included patients was 50 months (interquartile range: 25.3–66.5) and 145 of them (20%) received perioperative EA. We demonstrated EA use was associated with better recurrence-free survival [IPTW adjusted hazard ratio (HR): 0.64, 95% confidence interval (CI): 0.49–0.83, p < 0.001] and overall survival [IPTW adjusted HR: 0.66, 95% CI: 0.49–0.89, p = 0.006] in patients receiving surgical resection for RCC. More prospective studies are needed to verify this connection between EA and superior cancer outcomes after RCC surgery.

Care in the time of COVID-19: impact on the diagnosis and treatment of breast cancer in a large, integrated health care system.

PurposesTo delineate operational changes in Kaiser Permanente Northern California breast care and evaluate the impact of these changes during the initial COVID-19 Shelter-in-Place period (SiP, 3/17/20–5/17/20).MethodsBy extracting data from institutional databases and reviewing electronic medical charts, we compared clinical and treatment characteristics of breast cancer patients diagnosed 3/17/20–5/17/20 to those diagnosed 3/17/19–5/17/2019. Outcomes included time from biopsy to consultation and treatment. Comparisons were made using Chi-square or Wilcoxon rank-sum tests.ResultsFewer new breast cancers were diagnosed in 2020 during the SiP period than during a similar period in 2019 (n = 247 vs n = 703). A higher percentage presented with symptomatic disease in 2020 than 2019 (78% vs 37%, p < 0.001). Higher percentages of 2020 patients presented with grade 3 (37% vs 25%, p = 0.004) and triple-negative tumors (16% vs 10%, p = 0.04). A smaller percentage underwent surgery first in 2020 (71% vs 83%, p < 0.001) and a larger percentage had neoadjuvant chemotherapy (16% vs 11%, p < 0.001). Telehealth utilization increased from 0.8% in 2019 to 70.0% in 2020. Times to surgery and neoadjuvant chemotherapy were shorter in 2020 than 2019 (19 vs 26 days, p < 0.001, and 23 vs 28 days, p = 0.03, respectively).ConclusionsDuring SiP, fewer breast cancers were diagnosed than during a similar period in 2019, and a higher proportion presented with symptomatic disease. Early-stage breast cancer diagnoses decreased, while metastatic cancer diagnoses remained similar. Telehealth increased significantly, and times to treatment were shorter in 2020 than 2019. Our system continued to provide timely breast cancer treatment despite significant pandemic-driven disruption.

Perfil genético-clínico dos pacientes atendidos no ambulatório de doenças raras de um hospital pediátrico de Curitiba, Paraná

Introduction: Rare diseases are chronic, progressive conditions with a low frequency of occurrence in the population. They can be divided into two groups: diseases of genetic origin and of non-genetic origin. Currently, molecular genetic tests are widely used to screen and diagnose patients with rare diseases. This study aims to describe the genetic/clinical profile of patients seen at the Rare Diseases Outpatient Clinic of a referral pediatric hospital in southern Brazil. Methodology: This retrospective descriptive quantitative study looked into data from paper and electronic medical charts of patients seen at the Rare Diseases Outpatient Clinic and genetic test results of included patients stored in the platform of the hospital’s Clinical Analysis Laboratory. Results and Discussion: The study included 553 patient medical charts. Prevalence of male patients and aged between zero and 11 years was greater. The most commonly reported symptoms were dysmorphisms and congenital malformations (12.5%), developmental delay (11.0%) and seizures (10.5%). Only 24.7% of the molecular genetic tests presented altered results. Alterations were more notably seen in genes PHKA2, G6PC, FBP1, and CTNS. The number of altered test results was lower than expected. The greater availability and popularization of these tests can be noticed by the increase in the number of tests ordered. Increased awareness about molecular genetic testing is very positive and may help healthcare teams improve patient quality of life.

878. Telemedicine Implementation in a Midwestern HIV Clinic: One Year Outcomes

BackgroundDuring the COVID-19 pandemic, we realized the importance of limiting in-clinic interactions with patients who were stable on antiretroviral therapy to promote social distancing. Our HIV clinic adopted telemedicine practices, in line with the HHS Interim Guidance for COVID-19 and Persons With HIV. Several HIV clinics reported lower viral suppression rates during the pandemic. We aim to describe the implementation process as well as year one outcomes of telemedicine at our clinic.MethodsIn March 2020, we created telemedicine protocols; we also designed and continuously updated algorithms for determining patient eligibility for telemedicine based on recent viral loads and last clinic visit. We monitored outcomes through electronic medical record chart reviews between May 1, 2020, and April 30, 2021. We collected patient demographics, and federal poverty level (FPL) information. We collected baseline and post-intervention rates of viral load suppression (VLS, defined as HIV RNA < 200 copies per mL), medical visit frequency (MVF, defined as percentage of patients who had one visit in each 6 months of the preceding 24 months with at least 60 days between visits) and lost to care (LOC, no follow up within 12 months period).ResultsWe conducted a total of 2298 ambulatory medical visits; 1642 were in person and 656 (29%) were telemedicine visits. Out of those, 2177 were follow up visits (649, 30% telemedicine). There was no difference of telemedicine utilization based on race (28% in African Americans vs. 32% in Whites); ethnicity (30% in Hispanic vs. 30% in Hon-Hispanic); gender (24% in females vs. 30% in males); or FPL (28% in FPL < 200% vs. 31% in FPL >200%). By the end of April 2021, overall clinic VLS rate was 94%, MVF was 48%, and there were 40 patients LOC compared to 92%, 49%, and 43 patients in April 2020, respectively.ConclusionTelemedicine was a safe alternative to routine in-person HIV care during the COVID-19 pandemic. We observed similar rates of utilization across demographic and FPL status. Applying selection criteria, viral suppression and retention in care rates were not adversely impacted by shift to telemedicine modality. Disclosures All Authors: No reported disclosures

676. Impact of Stratified Testing Algorithm Utilizing Rapid Testing and Polymerase Chain Reaction (PCR) Tests for Viral Infections

BackgroundIn 2017, the multiplex respiratory viral panel (RVP) test was the only test available for patients (pts) with respiratory symptoms in our emergency department (ED). In 2018, the more rapid influenza/respiratory syncytial virus (Flu/RSV) test was incorporated in a stratified testing algorithm (STA) – depending on clinical features and physician discretion, pts underwent either Flu/RSV or RVP. We analyzed the STA impact by comparing data between winters of 2017 and 2018.MethodsIn a retrospective, single-center cohort study in suburban NY, admitted pts ≥18 years diagnosed with viral infections (by either test) were included. We excluded pts diagnosed at another hospital, admitted to intensive care or observation (< 24 hours) units and pts with missing data. Data was collected through electronic medical chart review.Primary outcomes were clinical evaluation time [time between triage and test order]; laboratory-turnaround (lta) time (between order and result); ED length of stay [EDLOS] (between admit order and bed assignment). Secondary outcomes included isolation time (between result to start of isolation precautions), treatment time (between result to influenza treatment). Outcome differences were assessed using Chi-Square and Mann-Whitney rank sum tests for categorical and continuous variables, respectively.Results734 pts were included in the study [368 in 2017; 366 in 2018]. Median age was 75 years and 55.9% were female. After implementing the STA, EDLOS was significantly lower [Table 1], with no significant differences in other parameters. Lta times were slightly higher after implementation [25 minutes (2017) v/s 29 minutes (2018)].Table 1. Differences in clinical and laboratory turnaround times among patients admitted with viral infections in winters of 2017 and 2018 ConclusionA stratified diagnostic algorithm may have reduced EDLOS, but without significant differences in other outcomes. A higher lta time might have been due to testing constraints, heterogeneous pt populations or other confounders. Prospective studies will help assess the real-world impact of such algorithms.Disclosures Prashant Malhotra, MBBS, MD,FACP, FIDSA, Gilead Sciences (Scientific Research Study Investigator, Other Financial or Material Support, Site PI for a industry funded multi center research study)

Changes to telehealth practices in primary care in New Brunswick (Canada): A comparative study pre and during the COVID-19 pandemic.

BackgroundDuring the COVID-19 pandemic, telehealth technologies were used in the primary health care setting in New Brunswick as a means to continue providing care to patients while following public health guidelines. This study aimed to measure these changes and examine if they improved timely access to primary care. A secondary goal was to identify which telehealth technologies were deemed sustainable by primary care providers.MethodsThis was a comparative study on the use of telehealth technology before and during the COVID-19 pandemic. Between April 2020 and November 2020, 114 active primary care providers (family physicians or nurse practitioners) responded to the online survey.ResultsThe findings illustrated an increase in the use of telehealth technologies. The use of phone consultations increased by 122%, from 43.9% pre-pandemic to 97.6% during the pandemic (p < 0.001). The use of virtual consultation (19.3% pre-pandemic vs. 41.2% during the pandemic, p < 0.001), emails and texts also increased during the pandemic. Whereas the more structural organizational tools (electronic medical charts and reservation systems) remained stable. However, those changes did not coincide with a significant improvement to timely access to care during the pandemic. Many participants (40.1%) wanted to keep phone consultations, and 21.9% of participants wanted to keep virtual consultations as part of their long-term practice.InterpretationThe observed increase in the use of telehealth technologies may be sustainable, but it has not significantly improved timely access to primary care in New Brunswick.

Risk factors of lower urinary tract injury with laparoscopic sacrocolpopexy

BACKGROUNDLower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy.OBJECTIVEThe primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy.STUDY DESIGNThis was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios.RESULTSA total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m2 (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48–160.38; P=.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05–23.19; P=.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21–8227; P=.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury.CONCLUSIONAlthough lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.

Clinical Outcomes of COVID-19 in Hematological Malignancies in Jordan : Tertiary Cancer Center Experience

Introduction: The COVID-19 infection has a devastating clinical outcome among individuals with immunocompromised states, particularly those with malignancies. The impact of the coronavirus pandemic on patients with hematological malignancies in low and middle-income countries is not well studied. Herein, we sought to report the clinical outcomes of the COVID-19 infection in patients with hematological malignancies treated at a single institution.Methods: Electronic medical record charts of patients diagnosed with hematological malignancies (leukemia, lymphoma, and multiple myeloma) were reviewed. Patients who were diagnosed with laboratory-confirmed SARS-CoV-2 infection by Real-Time Polymerase Chain Reaction test between April 2020 and October 2020 were identified as the subjects of this study. The demographic data, including tumor characteristics, laboratory results, anti-cancer treatments, patient outcomes (need for hospitalization, ICU admission, complications, and mortality), were extracted and analyzed.Results: We identified 89 patients diagnosed with hematological malignancies who were infected with COVID-19 during the eligibility period. The median age at the time of diagnosis was 54 years (range, 19-80 years). Fifty-two patients (58%) were male, and 37 patients (42%) were female. Of the 89 cases, 41 patients (46%) were diagnosed with lymphoma, 27 patients (30%) had leukemia, 21 patients (24%) had multiple myeloma. 84 patients (94%) received prior anti-cancer treatment, such as: chemotherapy (n=47, 53%), immunotherapy (n= 4, 4%), chemoimmunotherapy (n=26, 29%), and tyrosine kinase inhibitors (n=3, 3%). At the time of COVID-19 diagnosis, 52 patients (58%) had active malignancy, while 37 patients (42%) were in remission. Fifty-nine patients (66%) had comorbidities, with hypertension (n=32, 36%) being the most commonly reported comorbidity, followed by diabetes mellitus (n=25, 28%) and ischemic heart disease (n=8, 9%). The most encountered presentations were: fever (n=32, 36%) followed by cough (n=31, 35%), shortness of breath (n=21, 23%), aches (n=6, 7%), fatigue (n=6, 7%), and ageusia (n=6, 7%). Forty subjects (45%) were hospitalized, 11 patients (12%) were eventually admitted to the intensive care unit (ICU). Notably, the hospitalization and ICU admission rates were higher among the people aged more than 53 years (n= 24, 59%; n=9, 82%, respectively). Among the 89 patients, complications were recognized in 36% of the patients (n=32), with sepsis (n=12, 13%), acute kidney injury (n=11, 12%), and cardiovascular complications (n=3, 3%) being the most prevalent complications. The median time interval between the date of COVID-19 diagnosis and the last follow-up date was 3 months (range, 2 days-6.4 months). At the time of the last follow-up, 64 patients (72%) remained alive, and 25 patients (28%) succumbed to COVID-related complications.Conclusion: The COVID-19 infection has deteriorated clinical outcomes among patients with hematological malignancies, which could be attributed to the high incidence of infections, increased risk of hospitalizations/ICU admissions, and other COVID-related complications. Such high morbidity and mortality rates necessitate future studies to outline the potential risk factors for COVID-related complications and modifications in the plan of care, including evaluation of the effect of vaccination on the outcome of these patients. DisclosuresNo relevant conflicts of interest to declare.

The Associations between Perioperative Blood Transfusion and Long-Term Outcomes after Stomach Cancer Surgery.

Simple SummaryStomach cancer is a common malignancy and one of the leading causes of cancer death in Taiwan. Although tumor characteristics are the main determinants of oncological outcomes, modulation of the immune system may also play some role in cancer progression. Despite the hypothesis that perioperative blood transfusion may suppress the immune reactivity and promote tumor recurrence, the role of perioperative transfusion in the prognosis of stomach cancer remains controversial. To fill this gap, we designed this retrospective study using sound analytical approaches to investigate the impact of perioperative transfusion on oncologic outcomes after curative resection for stomach cancer. We demonstrated that perioperative transfusion was associated with inferior disease-free and overall survival after stomach cancer surgery and a dose-response relationship was also noted between the amount of transfusion and risk of cancer recurrence or mortality.Background: Whether perioperative packed red blood cell (pRBC) transfusion is associated with inferior long-term outcomes after stomach cancer surgery remains controversial. Methods: This research used a retrospective cohort study. Patients with stage I~III stomach cancer undergoing tumor resection were collected at a tertiary medical center. Patient characteristics, surgical features and pathologic findings were gathered from an electronic medical chart review. The associations of perioperative pRBC transfusion with postoperative disease-free and overall survivals were evaluated using Cox regression analysis with an inverse probability of treatment weighting (IPTW). Restricted cubic spline functions were employed to characterize dose-response relationships between the amount of transfusion and cancer outcomes after surgery. Results: Among the 569 patients, 160 (28.1%) received perioperative pRBC transfusion. Perioperative transfusion was associated with worse disease-free survival (IPTW adjusted HR: 1.42, 95% CI: 1.18–1.71, p < 0.001) and overall survival (IPTW adjusted HR: 1.27, 95% CI: 1.05–1.55, p = 0.014). A non-linear dose-response relationship was noted between the amount of transfusions and worse disease-free or overall survival. Conclusions: Perioperative pRBC transfusion was associated with worse disease-free and overall survival after stomach cancer surgery, and strategies aiming to minimize perioperative transfusion exposure should be further considered to reduce the potential risk.

74 Central venous line-related thrombosis in neonates: A population-based study

Abstract Primary Subject area Neonatal-Perinatal Medicine Background The incidence of central venous line (CVL)-related thromboembolism (TE) in neonates is rising dramatically. The mainstay of treatment in neonatal thrombosis is anticoagulant therapy. However, management of neonatal CVL-related TE is particularly complex, as the higher risk of systemic and intracranial bleeding, especially in premature babies, must be balanced with the thrombotic risks, including death, or morbidity such as organ dysfunction, post-thrombotic syndrome, and neurodevelopmental sequelae. There is a paucity of evidence regarding the epidemiology of neonatal CVL-related thrombosis, to help clinicians identify neonates at high-risk of CVL-related thrombosis, as well as to tailor treatment based on the risks and benefits of anticoagulants in neonates. Objectives The objectives of this retrospective cohort study are: 1) to determine the main risk factors of CVL-related TE in neonates admitted to the neonatal intensive care unit (NICU); and 2) to compare the effectiveness and safety between different antithrombotic treatment modalities for neonatal CVL-related TE using the Canadian Neonatal Network (CNN) database and electronic medical chart review. Design/Methods Neonates ≤ 28 days of life admitted to the NICU for ≥ 24 hours requiring a CVL with TE confirmed by imaging were included in the study. The main effectiveness outcome is the resolution of TE, whereas the main safety outcome is the apparition of a major bleeding. In this study (n=39), we compared the effectiveness and safety outcomes according to antithrombotic treatment modalities (conservative vs. anticoagulation). Results The median gestational age is 35[26-38] weeks, and the mean birth weight is 2096±1110 g. CVL responsible for TE was umbilical venous catheter (28%), umbilical arterial catheter (46%), peripherally inserted central catheter (PICC line) (8%), and peripheral arterial catheter (18%). The anticoagulation therapy is more effective to achieve a partial and complete resolution of TE than the conservative treatment after a mean follow-up of 7 weeks (p=0.02). However, there were no differences according to antithrombotic treatment group regarding safety outcome assessed by major bleedings (p=0.2). Conclusion Our results tend to suggest that anticoagulation therapy is more effective to achieve resolution of CVLs-related TE than conservative treatment without compromising the safety of neonates. However, a large multicentric study is required to evaluate the risks and benefits of anticoagulants in neonates.

Laboratory Analysis of Antiphospholipid Antibodies with Clinical Correlation: A Hospital-Based 10 Year Study

Abstract Introduction/Objective Antiphospholipid syndrome (APS) is an autoimmune disorder and its diagnosis requires both laboratory evaluation of antiphospholipid antibodies (APAs) and clinical correlation. This study focused on the laboratory analysis of APS with clinical correlation in a hospital-based patient population. Methods/Case Report From 2010-2020, immunological studies for APAs were performed at Department of Pathology, William Beaumont Hospital – Troy, Michigan and patients with positive results were selected for further analysis. Four APAs were included: IgG and IgM beta-2 glycoprotein I antibodies (IgG B2GA and IgM B2GA), and IgG and IgM anticardiolipin antibodies (IgG ACA and IgM ACA). Clinical information was collected from hospital electronic medical chart with focus on thromboembolism and abortion history, autoimmune disorders, antithrombotic therapies and other studies. Results (if a Case Study enter NA) There were 167 patients, 136 females and 31 males (F/M=4.4). The median age for females was 50 and for males, 57. Overall, B2GA was present more than ACA (102/81) in females, and ACA was present slightly more than B2GA (20/17) in males. IgM APAs were much more common than IgG APAs; IgM B2GA/IgG B2GA: 87/32 (p&amp;lt;0.01) and IgM ACA/IgG ACA: 81/20 (p&amp;lt;0.01). Most APAs were at the low-intermediate titer range and increased APAs titer correlated with decreased positive rate: APAs titer at 20-40, 41-80 and &amp;gt;80 with positive results at 115, 61 and 44 respectively. In addition to documented autoimmune disorders, pregnancy miscarriage was a common clinical condition (24/66) in females at age &amp;lt;45. But for females at age &amp;gt;45, vascular thrombosis became more common (18/70). Vascular thrombosis was a common clinical disease in males (16/31) followed by autoimmune disorders (10/31). Most patients with vascular thrombosis received antithrombotic therapies. Conclusion Female patients positive for APAs was significantly more and younger than males in this study. IgM B2GA was the most common type of APAs followed by IgM ACA. IgG B2GA and IgG ACA were much less common. In younger female patients autoimmune disorders and abortion were the most common clinical conditions. In older female and male patients, autoimmune disorders and vascular thrombosis were the most common clinical conditions. The titer of APAs detected was at low-intermediate range in most patients. The relationship between the titer of APAs and clinical conditions needs further study.

Direct Oral Anticoagulants (DOACs)-Based Versus Warfarin-Based Antithrombotic Regimens in Patients with Atrial Fibrillation Underwent Successful Coronary Stenting at Siriraj Hospital

Objective: To investigate the 1-year bleeding outcome between direct oral anticoagulants (DOACs)-based regimens and warfarin-based regimens in real-world practice in Thai patients with atrial fibrillation (AF) and significant coronary artery disease (CAD). Materials and Methods: The present study was a retrospective study. The authors reviewed the electronic medical charts of patients treated at the Siriraj Hospital between January 1, 2012 and October 31, 2019. The inclusion criteria were patients with AF and significant CAD that underwent percutaneous coronary intervention (PCI) with a stent and were prescribed or planned to prescribe anticoagulants after the PCI. The primary end point was the International Society on Thrombosis and Hemostasis (ISTH) bleeding during a 1-year follow-up period after successful coronary stenting. The trial assessed for the difference in the bleeding outcome and composite efficacy end point of myocardial infarction, ischemic stroke, and systemic embolism between patients that received warfarin-based regimen and those that received DOACs-based regimen. Results: The prevalence of patients that received additional oral anticoagulation was 5.1% (679/13,306 patients). One hundred seventy patients met the study inclusion and exclusion criteria. The incidence of the primary end point was 9.0% in the warfarin-based regimen compared with 8.1% in the DOACs-based regimen (p=1.000). The incidence of the composite efficacy end point was 8.3% in the warfarin-based regimen compared with 0% in the DOACs-based regimen (p=0.124). Conclusion: In patients with AF and significant CAD that underwent PCI, the use of a DOACs-based regimen had no statistically significant difference in bleeding outcome but associated with lower ischemic endpoint. However, due to the limited study sample size, the study had insufficient power to declare the results statistically significant. Keywords: Coronary artery disease; Atrial fibrillation; DOAC; Warfarin

Signs of dysphagia and associated outcomes regarding mortality, length of hospital stay and readmissions in acute geriatric patients: Observational prospective study.

Dysphagia is a prevalent disorder in acute geriatric patients. This observational prospective study aimed at investigating adverse clinical outcomes linked to signs of dysphagia, including mortality, length of hospital stay (LOS), readmissions, among patients aged≥65 years at a Danish acute medical unit (AMU). Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS), as described in the preceding cross-sectional study. Data for the follow-up was twice retrieved from electronic medical charts 30 days and 90 days after the patients' primary admission to the hospital. Statistical analysis included non-parametric tests of independence and proportional hazards modelling. 444 patients were recruited, 334 of whom completed the dysphagia screening with 144 (43.1%) showing signs of dysphagia. Patients with signs of dysphagia, compared to those without, experienced higher mortality after 30 days (12.5% vs. 1.6%, p<0.001) and 90 days (21.5% vs. 5.8%, p<0.001), longer LOS (median [Q1; Q3]: 4 [2; 8] vs. 3 [1; 6] days, p=0.004), more total hospital days (THD) during both the 30-day and 90-day follow-up (for 90d: median [Q1; Q3]: 6 [2.25; 12] vs. 4 [2; 9] days, p=0.007), but no significant difference in frequency of readmissions. Multivariate proportional hazards modelling revealed signs of dysphagia, low performance status and high comorbidity to be independent risk factors for mortality. High comorbidity and low hemoglobin, but not signs of dysphagia, were revealed as independent risk factors for readmission. Dysphagia is a notable risk factor linked to increased mortality and length of hospital stay (LOS) for acute geriatric patients in general, not just those suffering from stroke, head and neck cancer or neurodegenerative diseases. Further research is needed to investigate the effectiveness and feasibility of systematic dysphagia screening within this population.

P-200: Pomalidomide-based chemotherapy in plasmacytoma at relapse

<h3>Background</h3> Plasmacytoma at the time of relapse of multiple myeloma is associated with poor response and survival. However, data on the activity of the recently available new drug or drug combinations in RRMM with plasmacytoma in the real-world clinical practice is limited. Pomalidomide and dexamethasone (Pd) with or without cyclophosphamide is an active therapeutic combination in relapsed and refractory multiple myeloma (RRMM) after 2 lines of previous line of therapy <h3>Method</h3> This study aimed to analyze the clinical outcome of the pomalidomide-based regimen in RRMM with plasmacytoma. Clinical data of 221 patients who were treated with Pd with or without cyclophosphamide from 7 hospitals participating in the Korean multiple myeloma working party were retrospectively analyzed by electronic medical chart review. All the of patients were previously treated with at least 2 lines of therapies including bortezomib and lenalidomide in most of the patients. Plasmacytoma was diagnosed by the computed tomography, magnetic resonance imaging or FDG-PET scan <h3>Result</h3> Twenty-nine patients among the 221 patients analyzed (13.1%) had plasmacytoma at the time of pomalidomide-based chemotherapy. Patients were previously treated with a median 4 lines of therapy (range, 2-14), including bortezomib, lenalidomide, autologous stem cell transplantation in 97%,100%, and 52% of the patients, respectively. 14 patients were treated with Pd and 15 patients had been treated with Pd and cyclophosphamide (PCd). Median number of sites of plasmacytoma involvement was 2 (range, 1-9), including paraskeletal and soft tissue involvement in 83% and 52% of the patients. Sites of soft tissue involvement were: 5 pleura, 4 lymph nodes, 4 subcutaneous, 3 liver, 3 muscle, 2 pancreas, 1 kidney, 1 pericardium, 1 peritoneum, 1 adrenal gland, and 1 stomach. 50% patients (13 among the 26 response evaluable patients) had responded to Pd with or without Cy: 2 complete response, 2 very good partial response, 9 partial response, 1 stable disease, 2 minimal response, and 10 progressive disease. Patients who were treated with PCd showed a better response compared with Pd therapy (53% versus 29%, P=0.264). After a median follow-up of 9.33 months (range, 0.30-52months), patients with plasmacytoma versus no plasmacytoma showed a progression-free survival of 3.57 (95% CI, 0.35-6.78 months) versus 8.40 months (95% CI, 7.00-9.80 months) (P=0.002) and an overall survival of 3.33 (95% CI, 0.00-7.82 months) versus 19.67 months (95% CI, 13.39-25.95 months) (P=0.001). <h3>Conclusion</h3> RRMM patients with plasmacytoma was responsive after pomalidomide-based chemotherapies. The addition of cyclophosphamide to Pd seemed to result in a better response compared with Pd only. However, RRMM patients with plasmacytoma had poorer survival compared with patients without plasmacytoma even after Pd with or without cyclophosphamide.

Retrospective Pediatric Telepalliative Care Experience.

Background: Rady Children's Hospital (RCH) offers an outpatient pediatric palliative clinic that began offering telepalliative care in 2016. Objectives: This study describes demographics of parents receiving pediatric telepalliative care, patient/family satisfaction with telepalliative care, and patient/family perspectives. Design: Retrospective electronic medical record chart review (2016-2020) of telepalliative patients at RCH (San Diego, USA), including satisfaction surveys. Documented quotes from telepalliative care consultations were analyzed thematically. Results: Fifty-six patients were seen through 181 telepalliative visits. Demographics: Forty-three percent were female and 32% were Hispanic/Latino. Ages ranged from 3 months to 25 years. Average Palliative Performance Scale was 47%. Seventy-nine percent used gastrostomy tubes for nutrition, but only 29% used home ventilation. Eighty-two percent completed a Physician Order for Life-Sustaining Treatment. Goals for 84% of patients were for life prolongation and attempt resuscitation. Visits averaged 86 minutes. Twenty-five surveys were returned: 92% felt very satisfied and 96% said the video visit was the same, better, or much better than an in-person visit. Sixty-four percent said the video visit was more convenient and 68% felt the video visit was safer. Identified themes from telepalliative consultations included advocacy for their child, challenges surrounding care for children with complex medical needs, medical team communication, caregiver support, facing uncertainty, and decision making. Conclusions and Implications: Pediatric patients receiving telepalliative care varied in demographics, functional status, and goals of care. Telepalliative care can provide good quality of care and patient satisfaction. In a telepalliative setting, parents were able to communicate challenging aspects of care including navigating uncertainty, finding support, and decision making.

Interstitial Lung Disease at High Resolution CT after SARS-CoV-2-Related Acute Respiratory Distress Syndrome According to Pulmonary Segmental Anatomy

Background: The purpose of this study was to evaluate High-Resolution CT (HRCT) findings in SARS-CoV-2-related ARDS survivors treated with prolonged low-dose methylprednisolone after hospital discharge. Methods: A total of 44 consecutive patients (M: 32, F: 12, average age: 64), hospitalised in our department from April to September 2020 for SARS-CoV-2-related ARDS, who had a postdischarge CT scan, were enrolled into this retrospective study. We reviewed the electronic medical charts to collect laboratory, clinical, and demographic data. The CT findings were evaluated and classified according to lung segmental distribution. The imaging findings were correlated with spirometry results and included ground glass opacities (GGOs), consolidations, reticulations, bronchiectasis/bronchiolectasis, linear bands, and loss of pulmonary volume. Results: Alterations in the pulmonary parenchyma were observed in 97.7% of patients at HRCT (median time lapse between ARDS diagnosis and HRCT: 2.8 months, range 0.9 to 6.7). The most common findings were linear bands (84%), followed by GGOs (75%), reticulations (34%), bronchiolectasis (32%), consolidations (30%), bronchiectasis (30%) and volume loss (25%). They had a symmetric distribution, and both lower lobes were the most affected areas. Conclusions: A reticular pattern with a posterior distribution was observed 3 months after discharge from severe COVID-19 pneumonia, and this differs from previously described postCOVID-19 fibrotic-like changes. We hypothesized that the systematic use of prolonged low-dose of corticosteroid could be the main reason of this different CT scan appearance.

Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study.

BackgroundTo improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options.MethodsThe retrospective cohort study included stage II–III esophageal cancer patients diagnosed during 2010–2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests.ResultsAmong the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72–80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference =0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P<0.001). A complication of the procedure was recorded in 85% of stent patients and 74% of J-tube patients (P<0.001). Among those who received no procedure initially, 25% received one later, compared with 15% of J-tube patients and 70% of stent patients who received a second procedure (P<0.001). Progression to surgery was observed in 65% of patients with no procedure, 51% of patients with J-tube, and 40% of stent patients, P=0.28).ConclusionsFor stage II–III esophageal cancer patients starting chemotherapy, this study gives evidence that stents were associated with significant %TWL and risk of reintervention. Although J-tube patients returned to baseline weight sooner than those with no procedure, they experienced complications from their J-tubes. For esophageal cancer patients undergoing curative-intent treatment and with acceptable levels of weight loss, no procedure at all may be superior to placing a J-tube in terms of complications, weight loss, and progression to curative-intent surgery.

Effect of epidural analgesia on long-term outcomes after curative surgery for pancreatic cancer: A single-center cohort study in Taiwan.

Whether epidural anesthesia and analgesia (EA) improves long-term outcomes after pancreatic cancer surgery remains controversial. We conducted this retrospective cohort study to investigate the influence of EA on cancer recurrence and overall survival after surgery for pancreatic cancer. We conducted an electronic medical chart review of patients with pancreatic cancer who underwent curative resection at our hospital from 2008 to 2017 and were followed up until December 2019. Patient demographics, anesthetic and surgical characteristics, and pathologic features were also collected. The effects of EA on postoperative cancer recurrence and overall survival were evaluated using proportional hazards regression models with inverse probability of treatment weighting (IPTW) based on propensity scores to balance unequal distributions of observed covariates. For sensitivity analysis, multivariable regression modeling and quintile-stratified propensity adjustments were also used. Among the 252 included patients, the median follow-up period was 15.9 months (interquartile range 6.8-28.2 months), and 88 (35%) received EA after pancreatic cancer surgery. EA was not associated with greater cancer recurrence (IPTW adjusted HR: 0.98; 95% CI, 0.78%-1.24%; p = 0.87) or all-cause mortality (IPTW adjusted HR: 1.02; 95% CI, 0.82%-1.27%; p = 0.85) after pancreatic cancer resection. In sensitivity analysis, both the multivariable and stratified Cox regression analyses failed to demonstrate significant effects of EA on cancer recurrence and survival after surgery. There were no significant associations between EA and cancer recurrence and overall survival after curative surgery for pancreatic cancer. Prospective studies should be considered to elucidate the relationship between EA and cancer outcomes after pancreatic cancer surgery.

A Retrospective Case Series of Difficult Percutaneous Dorsal Column Stimulator Epidural Lead Placement for Failed Back Surgery Syndrome

BACKGROUND: Percutaneous dorsal column stimulator lead placement is a well-established procedure for a variety of neuropathic disease processes, including failed back surgery syndrome (FBSS). Although previous spine surgeries and patient-specific pathology can make lead placement difficult, there are very few studies or case reports documented in the literature describing these challenges and outcomes. CASE REPORT: A retrospective electronic medical record chart review was conducted of 6 patients with FBSS who failed more conservative interventional therapies and otherwise multimodal analgesia as deemed by both patient and practitioner. CONCLUSION: Postsurgical changes in the epidural space, including fibrosis and scar tissue formation, made driving leads very challenging and compromised final lead placement as well as number of leads placed. KEY WORDS: Neuromodulation, failed back surgery syndrome, dorsal column stimulation

Characteristics of patients presenting to emergency department for primary atrial fibrillation or flutter at an academic medical center

ObjectiveIn the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations. MethodsWe performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale. ResultsA total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted. ConclusionDeveloping a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care.