Greater Comorbidity Burden Research Articles

554 Cluster analysis of circulating plasma biomarkers in prurigo nodularis reveals a distinct systemic inflammatory signature in African Americans

Prurigo nodularis (PN) is a chronic inflammatory skin disease associated with intense pruritus and a significant reduction in quality of life. Emerging evidence suggests that African American (AA) PN patients have a greater comorbidity burden, unique clinical disease phenotype, and worse prognosis than other racial groups. However, there are limited data on the pathogenesis to explain this disparity. To characterize the systemic immune dysregulation in PN, plasma levels of 12 cytokine biomarkers, representing a variety of immune functions, were measured in 20 PN (12 AA, 8 Caucasian) and 15 healthy control (10 AA, 5 Caucasian) patients. PN patients were clustered using the unsupervised machine learning algorithm Partitioning Around Medoids, resulting in two clusters of PN patients with non-inflammatory (cluster 1) and inflammatory (cluster 2) plasma profiles. Continuous and categorical variables were compared with Mann-Whitney U and Pearson’s χ2, respectively. Cluster 2 had more African Americans (67% vs. 18%, P=0.027), higher itch numeric scores (9.5 ± 0.9 vs. 8.3 ± 1.2, P=0.036), and a more significant reduction in quality of life as reflected by higher Dermatology Life Quality Index scores (21.9 ± 6.4 vs. 13.0 ± 4.1, P=0.015). Compared to controls, cluster 2 had higher IL-4 (P=0.019), IL-5 (P=0.017), IL-10 (P=0.010), IL-12 (P=0.010), IL-17A (P=0.023), and IFN-α (P=0.036). Compared to cluster 1, cluster 2 had higher IL-1a (P=0.001), IL-4 (P=0.002), IL-5 (P=0.037), IL-6 (P=0.028), IL-10 (P=0.003), IL-17A (P=0.037), IL-22 (P=0.002), IL-25 (P=0.002) and IFN-α (P=0.036). These findings suggest that African American PN patients have a novel inflammatory signature characterized by greater systemic immune dysregulation resulting in higher itch intensity and lower quality of life.

Factors associated with delays in revascularization in patients with chronic limb-threatening ischaemia: population-based cohort study.

Prompt revascularization in patients with chronic limb-threatening ischaemia (CLTI) is important, and recent guidance has suggested that patients should undergo revascularization within 5 days of an emergency admission to hospital. The aim of this cohort study was to identify factors associated with the ability of UK vascular services to meet this standard of care. Data on all patients admitted non-electively with CLTI who underwent open or endovascular revascularization between 2016 and 2019 were extracted from the National Vascular Registry. The primary outcome was interval between admission and procedure, analysed as a binary variable (5 days or less, over 5 days). Multivariable Poisson regression was used to examine the relationship between time to revascularization and patient and admission characteristics. The study analysed information on 11 398 patients (5973 open, 5425 endovascular), 50.6 per of whom underwent revascularization within 5 days. The median interval between admission and intervention was 5 (i.q.r. 2-9) days. Patient factors associated with increased risk of delayed revascularization were older age, greater burden of co-morbidity, non-smoking status, presentation with infection and tissue loss, and a Fontaine score of IV. Patients admitted later in the week were less likely undergo revascularization within 5 days than those admitted on Sundays and Mondays (P < 0.001). Delays were slightly worse among patients having open compared with endovascular procedures (P = 0.005) and in hospitals with lower procedure volumes (P < 0.001). Several factors were associated with delays in time to revascularization for patients with CLTI in the UK, most notably the weekday of admission, which reflects how services are organized. The results support arguments for vascular units providing revascularization to have the resources for a 7-day service.

Abstract P618: Cardiac Amyloidosis and Risk of Ischemic Stroke

Background and Purpose: Cardiac amyloidosis is increasingly recognized as an important cause of heart failure. Given the paucity of data on cerebrovascular complications of cardiac amyloidosis, we evaluated whether cardiac amyloidosis is associated with ischemic stroke. Methods: We performed a retrospective cohort study of Medicare beneficiaries using a 5% sample of inpatient and outpatient claims from January 1, 2008 through October 1, 2015. We identified patients with cardiac amyloidosis using International Classification of Diseases, 9th Revision, Clinical Modification ( ICD-9-CM ) code 277.3x in combination with a diagnosis code for heart failure or cardiomyopathy. The primary outcome was ischemic stroke, identified by a previously validated ICD-9-CM code algorithm. We used survival statistics to determine incidence rates. Cox proportional hazard analysis, adjusted for demographics, vascular risk factors, and the Elixhauser comorbidity index, was used to study the risk of ischemic stroke. Results: Among 1.8 million beneficiaries with mean follow-up of 4.6 years (standard deviation ±2.2), 454 (0.03%) had a diagnosis of cardiac amyloidosis. Patients with cardiac amyloidosis were older (78.1±7.4 versus 73.4±7.7 years) and had a greater comorbidity burden than those without the diagnosis. A total of 63,627 (3.6%) developed an ischemic stroke in the entire cohort. The incidence of ischemic stroke was 47 per 1,000 patients per year in those with cardiac amyloidosis compared to 7.8 per 1,000 patients per year in those without cardiac amyloidosis. In the adjusted Cox regression analysis, cardiac amyloidosis was associated with an increased risk of ischemic stroke (HR, 2.4; 95% confidence interval, 1.6-3.6). Conclusions: In a large heterogenous cohort of elderly patients, cardiac amyloidosis was associated with a 2.5-fold heightened risk of ischemic stroke.

Patterns and predictors of oral anticancer agent utilization in diverse metastatic renal cell carcinoma patients.

279 Background: Availability of targeted oral anti-cancer agents (OAA) has transformed care delivery for metastatic renal cell carcinoma (RCC) patients. Our objective was to identify patterns and predictors of OAA use within the 12 months after metastatic RCC was detected to understand the extent of real-world adoption of these treatment advances. Methods: We used a novel, North Carolina, registry-linked multi-payer claims data resource to examine patterns of use of sorafenib, sunitinib, pazopanib, everolimus, axitinib, cabozantinib, and levantinib in a cohort of metastatic RCC patients diagnosed over 10 years (2006-2015, with claims through 2016). Patients were required to have 12 months of pre- and post-metastatic-index-date continuous enrollment. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) and 95% confidence limits (CLs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences (RD) in OAA use. Results: Our population-based study of 713 patients demonstrated relatively low (37%) OAA use at any time during the 12 months post-metastatic-index date among publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Lower OAA use was observed among patients who were older, frailer, and with greater comorbidity burden. Other patient-level characteristics, such as sex, race, rurality and type of insurance were not significant predictors of OAA use. Conclusions: These data underscore the importance of distinguishing clinically appropriate from potentially poor-quality care and warrant additional studies to understand in more depth the system, provider and patient level drivers of these patterns.

Interaction of stroke volume and myocardial phenotype in patients with severe aortic stenosis referred for intervention: outcome data from the BSCMR AS700 study

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf The BSCMR Valve Consortium Background Patients with low-flow aortic stenosis (LF-AS) have higher mortality than those with high-flow severe AS. The conventional echocardiographic definition of LF-AS is an indexed stroke volume (SVi) &amp;lt;35ml/m2. Whether this cut-off translates to cardiac magnetic resonance (CMR), and how CMR SVi associates with myocardial remodelling (volume/function/scar) and survival is unclear. Purpose To determine the association between CMR SVi, myocardial remodelling and survival in severe symptomatic AS. Methods In a multi-centre longitudinal outcome study of patients with severe AS listed for either surgical (SAVR) or transcatheter aortic valve intervention (TAVI) at six cardiothoracic centres, survival was assessed and stratified by SVi. Patients underwent preprocedural echocardiography and CMR between January 2003 and May 2015. Standardised core-lab analyses on pre-procedural CMR for biventricular volumes, function and scar quantification were performed. All-cause and cardiovascular mortality were tracked for a minimum of two years after AVR. Results A total of 674 patients with severe AS (age 75 ± 14years; 63% male, aortic valve area 0.4 ± 0.1 cm2/m2) were included. Patients with low SVi by CMR &amp;lt;35ml/m2 were older and had a greater burden of comorbidities (atrial fibrillation [AF], diabetes, high BMI). Independent predictors of SVi were age, AF, increased left atrial volume, aortic valve regurgitant fraction and left ventricular mass (LV) mass index (by CMR). There was no difference in SVi with choice of intervention (TAVI vs SAVR) or presence of late gadolinium enhancement. In multivariate analysis (Table 1), SVi was associated with cardiovascular mortality in the whole cohort (HR 0.97, 95%CI 0.95-0.99, p = 0.02), and all-cause mortality after TAVI (HR 0.97, 95%CI 0.95-0.99, p = 0.006) but not SAVR (p = 0.6). Adjusted mortality hazard increases below 50ml/m2 and plateaus between 35-40ml/m2 (Figure 1A), adjusted for LGE, STS score (Society of Thoracic Surgery score) and wall thickness. Conclusion SVi by CMR is an independent predictor of cardiovascular mortality. Mortality hazard increases progressively below a SVi of 50mL/m2. Abstract Figure 1

Effect of comorbidities on survival in patients >80 years of age at onset of renal replacement therapy: data from the ERA-EDTA Registry.

The number of elderly patients on renal replacement therapy (RRT) is increasing. The survival and quality of life of these patients may be lower if they have multiple comorbidities at the onset of RRT. The aim of this study was to explore whether the effect of comorbidities on survival is similar in elderly RRT patients compared with younger ones. Included were 9333 patients ≥80 years of age and 48 352 patients 20-79 years of age starting RRT between 2010 and 2015 from 15 national or regional registries submitting data to the European Renal Association-European Dialysis and Transplantation Association Registry. Patients were followed until death or the end of 2016. Survival was assessed by Kaplan-Meier curves and the relative risk of death associated with comorbidities was assessed by Cox regression analysis. Patients ≥80 years of age had a greater comorbidity burden than younger patients. However, relative risks of death associated with all studied comorbidities (diabetes, ischaemic heart disease, chronic heart failure, cerebrovascular disease, peripheral vascular disease and malignancy) were significantly lower in elderly patients compared with younger patients. Also, the increase in absolute mortality rates associated with an increasing number of comorbidities was smaller in elderly patients. Comorbidities are common in elderly patients who enter RRT, but the risk of death associated with comorbidities is less than in younger patients. This should be taken into account when assessing the prognosis of elderly RRT patients.

Preoperative Predictors and Costs of 30‐Day Readmission Following Inpatient Pediatric Tonsillectomy in the United States

ObjectivesTo understand national trends in 30‐day postoperative readmission following inpatient pediatric tonsillectomy and adenoidectomy.Study DesignRetrospective cohort study.SettingNationwide Readmissions Database.MethodsWe used the Nationwide Readmissions Database to identify and analyze 30‐day readmissions following inpatient tonsillectomy from 2010 to 2015. Using the International Classification of Disease codes, we identified 66,652 patients and analyzed the incidence, causes, risk factors, and costs of 30‐day readmission.ResultsOf 66,652 patients who underwent inpatient tonsillectomy, 2660 (4.0%) experienced a readmission. Readmitted patients were more commonly aged &lt;2 years (23.4 vs 10.6%, P =. 01) and had a greater burden of comorbidities, including preoperative anemia (3.9 vs 1.3%, P &lt;. 001), coagulopathy (3.5 vs 1.4%, P &lt;. 001), and neurologic disorders (19.1 vs 6.6%, P &lt;. 001). Readmitted patients experienced higher rates of postoperative complications (17.4 vs 9.0%, P &lt;. 001) and had a longer length of stay (4.5 vs 2.2 days, P &lt;. 001). Index cost of hospitalization was higher among readmitted patients ($14,129 vs $7307, P &lt;. 001), and each readmission cost an additional $7576. Postoperative hemorrhage (21.3%) and dehydration (17.7%) were the 2 most common causes for readmission. Independent predictors of readmission included age &lt;3 years, multiple comorbidities, and postoperative neurologic complications. The incidences of tonsillectomies and readmissions declined during the study period, most notably between 2010 and 2012.ConclusionReadmission after inpatient tonsillectomy and adenoidectomy places a substantial financial burden on the health care system. Targeted strategies to improve preoperative assessment and optimize postoperative care may prevent readmission, reduce unnecessary health care expenditures, and improve patient outcomes.

Lung Sestamibi Uptake on Myocardial Perfusion Imaging and Outcomes in Chronic Kidney Disease

Background and Objectives: In patients with CKD and end-stage kidney disease (ESKD), cardiac stress testing has low sensitivity and specificity for coronary disease. Alternate markers that are derived during the stress testing may enhance the predictive characteristic of stress testing. The objective was to examine the predictive characteristic of lung-to-heart ratio (LHR) in patients with CKD and ESKD. Design, Setting, Participants, and Measurements: Retrospective parallel cohort of ESKD and CKD not on dialysis (CKD-ND) who underwent stress testing with nuclear myocardial perfusion imaging utilizing sestamibi tracer and regadenoson. Stress LHR was calculated by the processing software and reported. Patients were analyzed by tertile of LHR (≤0.28, 0.29–0.32, ≥0.33). The primary outcome was a composite of all-cause mortality, hospitalization for myocardial infarction or unstable angina, or revascularization. Results: There were 144 CKD-ND and 145 ESKD patients. Patients with ESKD had greater comorbidity burden than CKD-ND. Stress tests were more often performed for pre-operative risk assessment among ESKD versus CKD-ND (53.8 vs. 5.6%, p < 0.001). ESKD patients more likely had ischemia identified on stress testing (19.3 vs. 8.3%, p = 0.001). Mean LHR was 0.31 (Standard deviation – SD: 0.09) and was similar across CKD-ND stages and ESKD. Primary outcome in the lowest (23%) and highest (33.3%) LHR tertile was higher than the middle tertile (12.8%); p = 0.005. This finding was similar between CKD-ND and ESKD and persisted in multivariable analysis. Conclusions: LHR ≤0.28 and ≥0.33 are independently associated with higher risk for death in patients with CKD-ND and ESKD. Future studies are warranted to understand the association of extreme LHR values and outcomes in this high-risk population.

The Relationship Between Fall Risk and Hospital-Based Therapy Utilization Is Moderated by Demographic Characteristics and Insurance Type

ObjectiveTo investigate whether indicators of patient need (comorbidity burden, fall risk) predict acute care rehabilitation utilization, and whether this relation varies across patient characteristics (ie, demographic characteristics, insurance type). DesignSecondary analysis of electronic health records data. SettingFive acute care hospitals. ParticipantsAdults (N=110,209) admitted to 5 regional hospitals between 2014 and 2018. InterventionsNot applicable. Main Outcome MeasuresOccupational therapy (OT) and physical therapy (PT) utilization. Logistic regression models determined whether indicators of patient need predicted OT and PT utilization. Interactions between indicators of need and both demographic factors (eg, minority status, presence of significant other) and insurance type were included to investigate whether the relation between patient need and therapy access varied across patient characteristics. ResultsGreater comorbidity burden was associated with a higher likelihood of receiving OT and PT. Relative to those with low fall risk, those with moderate and high fall risk were more likely to receive OT and PT. The relation between fall risk and therapy utilization differed across patient characteristics. Among patients with higher levels of fall risk, those with a significant other were less likely to receive OT and PT; significant other status did not explain therapy utilization among patients with low fall risk. Among those with high fall risk, patients with VA insurance and minority patients were more likely to receive PT than those with private insurance and nonminority patients, respectively. Insurance type and minority status did not appear to explain PT utilization among those with lower fall risk. ConclusionsPatients with greater comorbidity burden and fall risk were more likely to receive acute care rehabilitation. However, the relation between fall risk and utilization was moderated by insurance type, having a significant other, and race/ethnicity. Understanding the implications of these utilization patterns requires further research.

Gender Differences in Predictive Factors of Older Adults’ IADL Recovery Following Hip Fracture

After hip fracture, older adults experience poor functional outcomes including a lack of IADL recovery. Gender differences exist in risk, incidence, mortality, and complication rates; yet, analyses of predictive factors of IADL especially by gender are often not conducted. The purpose of this study was to investigate gender differences in predictive factors of IADL recovery for older adults at two and six months following hip fracture. This secondary analysis used data (n=326 with IADL of n=399) the Baltimore Hip Studies (BHS-7 cohort). Participants were >65 years of age and community-dwelling. Men were sequentially enrolled; women were frequency-matched. Data analysis required building a shared parameter model was built that incorporated an ordinal logistic regression within a generalized linear mixed-effects model, in conjunction with a time-to-event hazards regression model for the time to death or withdrawal. Predictive factors included: age, race, marital status, and comorbidities; physical function; cognitive status (3MS); and psychosocial function (depression [CES-D], resilience, fear of falling, social participation, and perceived health status. Results indicated that higher age (OR 1.1 95% CI 1.05, 1.15, p< .01), greater comorbidity burden (OR 1.31 95% CI 1.08, 1.6, p < .01), poorer baseline Lower Physical ADL ( OR 1.8 95% CI 1.54, 2.15, p< .01), better cognitive function (OR 0.95 95% CI 0.9, 1; p= 0.047) and poorer LPADL recovery (OR 1.27 95% CI 1.07, 1.5, p< .05) significantly impacted IADL recovery. The stratified (by gender) model was not as strong as the full model, but did indicate some gender differences may exist.

Implications of peripheral oedema in heart failure with preserved ejection fraction: a heart failure network analysis.

AimsHeart failure with preserved ejection fraction (HFpEF) is a heterogeneous condition, and tissue congestion manifested by oedema is not present in all patients. We compared clinical characteristics, exercise capacity, and outcomes in patients with HFpEF with and without oedema.Methods and resultsThis study was a post hoc analysis of pooled data of patients with left ventricular ejection fraction of ≥50% enrolled in the DOSE, CARRESS‐HF, RELAX, ATHENA, ROSE, INDIE, and NEAT trials. Patients were dichotomized by the severity of oedema. Cox proportional hazard regression and generalized linear regression models were used to assess associations between oedema, symptoms, and clinical outcomes. The ambulatory cohort included 393 patients (228 with and 165 without oedema), and the hospitalized cohort included 338 patients (249 with ≥moderate oedema and 89 with mild or none). Among ambulatory patients, patients with oedema had a higher body mass index (35.2 kg/m2 [inter‐quartile range, IQR 30.5, 41.6] vs. 31.6 kg/m2 [IQR 27.9, 36.3], P < 0.001), greater burden of co‐morbidities, higher intravascular pressures estimated on physical examination (elevated jugular venous pressure: 50% vs. 24.7%, P < 0.001), poorer renal function (creatinine: 1.2 mg/dL [IQR 0.9, 1.5] vs. 1 mg/dL [IQR 0.8, 1.3], P = 0.003), and lower peak VO2 (adjusted mean difference −1.04 mL/kg/min, 95% confidence interval [−1.71, −0.37], P < 0.003). Among hospitalized patients, despite greater in‐hospital fluid/weight loss in the ≥moderate oedema group, there was no difference in the improvement in dyspnoea by the visual analogue scale or well‐being visual analogue scale from baseline to 3–4 days and no statistically significant difference in the rate of 60 day rehospitalization/death (adjusted hazard ratio 1.44, 95% confidence interval [0.87, 2.39], P = 0.156).ConclusionsPatients with HFpEF and oedema display higher body mass, greater burden of co‐morbidities, and more severe exercise intolerance, but clinical responses to treatment appear similar. Further research is required to better understand the nature of volume distribution in different HFpEF phenotypes.

Abstract 15226: The Impact of Chronic Obstructive Pulmonary Disease on In-hospital Outcomes Following Left Ventricular Assist Device Implantation

Background: Chronic obstructive pulmonary disease (COPD) is well-known cause of ventricular dysfunction. However, in the setting of patients with advanced heart failure undergoing left ventricular assist device (LVAD) implantation, there is paucity data on COPD influence on in-hospital outcomes. Methods: This retrospective cohort study based on the Nationwide Inpatient Sample included all patients above 18 years all who underwent LVAD implantation from 2011 to 2017. All data was weight as recommended by Healthcare Cost and Utilization Project.Multivariate logistic regression was used to evaluate the impact of COPD on in-hospital outcomes. Results: A total of 25,503 patients underwent LVAD implantation, of those 13.8% had a pre-existing diagnosis of COPD. Individuals with COPD were older (median 62 vs. 58 years, p&lt;0.001), more commonly male (82% vs. 76.4%, p&lt;0.001). Patient with COPD had a greater burden of comorbidities confirmed by significant higher rate of hypertension, diabetes, atrial tachyarrhythmias, dyslipidemia, prior stroke, coronary and peripheral artery diseases, pulmonary hypertension, and chronic kidney disease (p&lt;0.001 for all). No significant difference was found in in-hospital stroke, infections, short-term percutaneous mechanical circulatory support, implant related complications, and LVAD thrombosis. There was a significant higher rate of inpatient acute kidney injury, major bleeding, cardiac complications, thromboembolism, and cardiac arrest in patients without COPD (p&lt;0.05 for all outcomes). Compared to patients without COPD, individuals with COPD had a lower mortality (6.2% vs. 12.4%; OR 0.59; C.I. 0.512-0.685; p&lt;0.05). Conclusion: Patients with COPD undergoing LVAD implantation have higher comorbidities, however, it is not associated with increase in-hospital all-cause mortality.Further studies are needed to analyze the differences found between these two groups in more detail.

Contemporary Practice Patterns of Tyrosine Kinase Inhibitor Use Among Older Patients with Chronic Myeloid Leukemia in the United States

Contemporary Practice Patterns of Tyrosine Kinase Inhibitor Use Among Older Patients with Chronic Myeloid Leukemia in the United States

Effect of alirocumab on incidence of atrial fibrillation after acute coronary syndromes: insights from ODYSSEY OUTCOMES

Abstract Background Atrial fibrillation (AF) is a marker of risk in patients presenting with acute coronary syndromes (ACS). The potential effect of inhibiting proprotein convertase subtilisin/kexin type 9 (PCSK9) on the incidence of AF is unknown. Methods The ODYSSEY OUTCOMES trial compared randomized treatment with the PCSK9 inhibitor alirocumab or placebo in patients with recent ACS and residual dyslipidaemia despite optimal statin therapy. The current analysis determined: 1) whether alirocumab treatment influenced incident AF; 2) whether a history of AF influenced the risk of major adverse cardiovascular events (MACE); and 3) whether there was interaction between AF at baseline and randomized treatment on MACE. AF was determined from the medical history and investigator reports of adverse events. Results Of 18,924 participants, 662 (3.5%) had a history of AF at randomization and 18,262 (96.5%) had no history of AF. Of the latter category, 499 (2.7%) had incident AF. Older age, randomization in South America or Eastern Europe, history of heart failure or myocardial infarction, and higher body mass index were factors associated with incident AF. Treatment with alirocumab or placebo did not influence incident AF (2.2% vs 2.6%, respectively; hazard ratio 0.90, 95% confidence interval 0.75–1.08; Figure). Patients with a history of AF had a greater burden of comorbidities, including cerebrovascular disease, peripheral artery disease, hypertension and heart failure; they also had higher rates of MACE (Table). There was no significant interaction between AF and randomized treatment on risk of MACE (P interaction=0.78) Conclusions Although treatment with alirocumab did not significantly modify the risk of incident AF after ACS in this analysis, future studies with more sensitive and systematic methods of ascertainment may be warranted. History of AF is a strong predictor of risk of recurrent MACE after ACS. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Sanofi, Regeneron Pharmaceuticals, Inc

Ischemic heart disease is more prevalent in low-income-countries and more often undertreated: data from report-hf

Abstract Background The pathogenic role of ischemic heart disease (IHD) in heart failure is well known. However, little is known about the global differences in the prognostic significance and treatment patterns of IHD in acute heart failure (AHF). Methods We prospectively enrolled 18,553 patients with AHF from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic etiology of the AHF event or coronary revascularization were classified as IHD. Differences in clinical characteristics, treatment and outcome were analyzed. Results Compared to 9,344 (50%) patients without IHD, the 9,189 (50%) patients with IHD were older, more often had a left ventricular ejection fraction [LVEF] &amp;lt;40%, (HFrEF) and decompensated chronic HF (DCHF) and had a greater comorbidity burden. Despite patients from lower-income countries having a higher prevalence of IHD (55% vs. 45% in high-income countries), only 27% of patients with IHD from low-income countries were treated with medicines commonly prescribed for HF (Figure A) compared to 16% of patients with IHD from high income countries. After correction for clinical confounders and medication use, patients with IHD had a shorter “door-to-nitrates and -diuretics time” and worse 1-year mortality (hazard ratio: 1.18, 95% CI: 1.09, 1.27, Figure B) irrespective of geographic region (Pinteraction &amp;gt;0.1). We found a significant interaction for prognosis (Pinteraction &amp;lt;0.001) between IHD and HF diagnosis (DCHF vs. new-onset HF) as well as HF subtype (HFrEF vs. HF with preserved ejection fraction) respectively, such that IHD conveyed worse outcomes in patients with new-onset HF and HFrEF respectively in all world regions. Conclusion In this large global contemporary cohort of patients with AHF, IHD was more common in patients from low income countries, conveyed worse 1-year mortality, particularly in patients with new onset HF and patients with HFrEF. Despite worse outcomes, patients in regions with the greatest burden of IHD were more often undertreated. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Novartis

S0867 The Association Between Patient Activation and Health-Related Quality of Life Among Individuals With Crohn’s Disease

INTRODUCTION: Patient activation (PA) is an individual’s knowledge, skill, and confidence in managing their health. There is limited data demonstrating higher PA is associated with better health-related quality of life (HRQoL) in patients (pts) with Crohn’s Disease (CD). METHODS: This study examined the association between PA and HRQoL in US adults with CD by analyzing data from Kantar’s US 2017 National Health and Wellness Survey (online self-administered survey). Stratified random sampling based on gender, age and race/ethnicity was used to ensure the sample was representative of the US adult population. PA was measured using the Patient Activation Measure (PAM®; 0–100 scale) that segments pts into 1 of 4 activation levels; higher levels represent higher activation: L1-disengaged and overwhelmed; L2-becoming aware but still struggling, L3-taking control and gaining control, L4-maintaining behaviors and pushing further. Sociodemographics and comorbidities were collected as covariates. HRQoL was assessed with SF-36v2. Minimal important difference (MID) was 3 points for mental and physical component summary (MCS and PCS) scores and 0.041 points for SF-6D health utilities index (derived from SF-36v2 items). Linear regression models compared differences in HRQoL between PAM levels without post-hoc adjustment while controlling for covariates. RESULTS: 374 respondents had a self-reported physician diagnosis of CD (mean age 49.4 years; 54.0% male. 23, 43, 175, and 133 respondents were PAM L1, L2, L3, and L4, respectively. Lower PAM was associated with younger age and greater comorbidity burden. After controlling for covariates, pts with PAM L1 vs. pts with PAM L4 had significantly lower MCS scores (P = 0.001) but did not have statistically significant differences on PCS scores (P = 0.090). Other health domains significantly lower for L1 vs. L4 groups were general health, physical functioning, role physical, vitality, social functioning, role emotional, and mental health (all P < 0.05). SF-6D was also significantly lower for L1 vs. L4. Differences between L1 and L4 met MIDs for PCS, MCS, and SF-6D metrics. Significant differences were also found between L2 and L4 on general health (P = 0.003) and vitality (P = 0.019). CONCLUSION: Lower PA was associated with poorer HRQoL. Pts with CD at the highest level of PA had meaningfully higher HRQoL scores than pts at the lowest level of PA. Future research should identity interventions that can improve levels of activation as it may help reduce HRQoL impairments.Table 1

Characteristics of Rotator Cuff Repairs Revised to Shoulder Arthroplasty.

Successful repair of a torn rotator cuff may prevent progression to rotator cuff arthropathy. However, previous studies have shown a substantial rate of failure after rotator cuff repair and characteristics of surgically repaired rotator cuffs that go on to shoulder arthroplasty have not been fully elucidated. The purpose of this study was to determine the patient characteristics and rate at which patients who underwent rotator cuff repair progressed to shoulder arthroplasty. This was a retrospective study of patients who underwent rotator cuff repair in a large, closed healthcare system in 2008. The EMR was queried for rotator cuff repair CPT with ICD-9 codes for rotator cuff. The resultant dataset was then cross-referenced with a separate internal shoulder arthroplasty registry to determine which patients went onto shoulder arthroplasty. Demographic variables, descriptors of tear pathology and repair characteristics were collected and compared between patients who subsequently underwent shoulder arthroplasty and those that did not. A total of 882 rotator cuff repair patients were included within this study. Of the initial 882 cuff repairs, there were 12 patients (1.4%) that went on to have arthroplasty. Patients who underwent shoulder arthroplasty after rotator cuff repair were significantly older at time of surgery and had greater comorbidity burdens. Patients who ended up with shoulder arthroplasty had the procedure an average of 4.77 ± 3.28 (SD) years after rotator cuff repair, with 11 of 12 patients having a diagnosis of rotator cuff arthropathy at the time of shoulder replacement. In a closed system, tracking rotator cuff repairs over 9.1 years revealed a small number that went on to subsequent shoulder arthroplasty. Patients who underwent shoulder arthroplasty were significantly older and had greater comorbidity burdens than those who did not. Patients who underwent shoulder arthroplasty usually either had shoulder arthroplasty within 1 year or after 5 years. Enhanced understanding of which patients may progress to arthroplasty may provide a better initial choice of operative intervention in those patients.

Associations between Cell-Free Mitochondrial DNA and Inflammation, and Their Clinical Implications for Patients on Hemodialysis: A Prospective Multicenter Cohort Study

Background: Cell-free mitochondrial DNA (cf-mtDNA) has recently been in the spotlight as an endogenously produced danger molecule that can potentially elicit inflammation. However, its clinical and prognostic implications are uncertain in patients undergoing hemodialysis. Methods: We examined the association of baseline cf-mtDNA categorized as tertiles with health-related quality of life (HRQOL), inflammatory cytokines, and mortality in a multicenter prospective cohort of 334 patients on hemodialysis. To better understand cf-mtDNA-mediated inflammation, we measured cytokine production after in vitro stimulation of bone marrow-derived macrophages (BMDMs) with mtDNA. Results: The higher cf-mtDNA tertile had a longer dialysis vintage, a greater comorbidity burden, and increased levels of inflammatory markers, including high-sensitivity-C-reactive protein, tumor necrosis factor-alpha, CXCL16, and osteoprotegerin. In particular, mtDNA augmented inflammatory cytokine release from BMDMs by lipopolysaccharide, the levels of which are reported to be increased in hemodialysis patients. Although the patients with higher levels of cf-mtDNA generally had lower (poorer) scores for HRQOL, cf-mtDNA was not associated with all-cause mortality in hemodialysis patients. Conclusion: cf-mtDNA was correlated with poor clinical status and modestly associated with impaired quality of life in patients on hemodialysis. In proinflammatory milieu in end-stage renal disease, these associations may be attributed to the boosting effects of cf-mtDNA on inflammation.

Newly-diagnosed diabetes and admission hyperglycemia predict COVID-19 severity by aggravating respiratory deterioration

AimsWe investigated whether pre-existing diabetes, newly-diagnosed diabetes, and admission hyperglycemia were associated with COVID-19 severity independently from confounders. MethodsWe retrospectively analyzed data on patients with COVID-19 hospitalized between February and April 2020 in an outbreak hospital in North-East Italy. Pre-existing diabetes was defined by self-reported history, electronic medical records, or ongoing medications. Newly-diagnosed diabetes was defined by HbA1c and fasting glucose. The primary outcome was a composite of ICU admission or death. Results413 subjects were included, 107 of whom (25.6%) had diabetes, including 21 newly-diagnosed. Patients with diabetes were older and had greater comorbidity burden. The primary outcome occurred in 37.4% of patients with diabetes compared to 20.3% in those without (RR 1.85; 95%C.I. 1.33–2.57; p < 0.001). The association was stronger for newly-diagnosed compared to pre-existing diabetes (RR 3.06 vs 1.55; p = 0.004). Higher glucose level at admission was associated with COVID-19 severity, with a stronger association among patients without as compared to those with pre-existing diabetes (interaction p < 0.001). Admission glucose was correlated with most clinical severity indexes and its association with adverse outcome was mostly mediated by a worse respiratory function. ConclusionNewly-diagnosed diabetes and admission hyperglycemia are powerful predictors of COVID-19 severity due to rapid respiratory deterioration.

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. MethodsThe 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. ResultsOf an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (β: $2,398, P < .001). ConclusionUsing the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.