Greater Percentage Of Patients Research Articles

The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery.

The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery. Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included. Median operative times were significantly longer for both RA-SG (89 vs. 62min; p < 0.0001) and RA-RYGB (141 vs. 105min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach. Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.

Association between central and peripheral circulating tumor cell (CTC) clusters in oral squamous cell carcinoma (OSCC): A prospective, observational study.

e15548 Background: Around 90% of cancer-related mortalities are caused by tumor metastasis. CTC clusters, which constitute an intermediate stage of metastasis, have not been studied extensively in head &amp; neck cancers. The mortality rate of oral cancers remains alarmingly high, despite multimodality treatment. The aim of the study is to identify the presence of CTC clusters in patients with Oral Squamous Cell Carcinoma (OSCC) and to correlate their presence with clinical and pathological factors. Methods: Fifty patients diagnosed with histologically proven OSCC, treatment naïve, and underwent surgery at HCG Cancer Centre, Bangalore, were consented and enrolled in the study. An IRB-approved protocol allowed for the collection of 10 ml of blood from central (jugular) and peripheral veins intra-operatively, prior to tumor removal. The culturing of CTC clusters was done using ellipsoidal microwell plates maintained at hypoxic conditions, at the Institute of Bioinformatics, Bangalore. After fourteen days of culturing, the cells were fixed and stained for DAPI, Pan-CK and CD45. The CTC clusters were classified into Loose, Tight and very Tight based on the median gray values obtained from DAPI staining on ImageJ software. Clinical data was collected from patient records and subjected to analysis using Descriptive statistics. Results: From the 50 patients included in the study, 22 (44%) patients exhibited tight clusters in central blood, while only 13 (26%) patients exhibited tight clusters in peripheral blood. A higher clinical stage was observed in a greater percentage of patients with tight clusters in central blood (early: 45.5% versus late: 54.5%), but the same findings could not be inferred with pathological staging (early stage: 59.1% versus late stage: 40.1%). No significant correlation with adverse pathological features was noted. Conclusions: This observational study provides an insight into the varying biological behaviours of similarly grouped cancers, which is based on the standard TNM staging. The study forms the basis for the hypothesis of tight clusters in the central and peripheral circulation, correlating with loco-regional and distant metastasis respectively, thus leading to poorer disease-free and overall survival rates.

Treatment patterns and outcomes by age in metastatic melanoma: A study of the National Cancer Database.

12037 Background: Metastatic melanoma carries poor prognosis and traditional chemotherapy has limited efficacy. Immune checkpoint inhibitors (ICI) have drastically improved disease outcomes since first approved in 2011. Elderly patients were underrepresented in landmark early trials of ICI leading to limited clinical trial data on efficacy and treatment patterns in this population. We aimed to examine the real-world IO outcomes and demographics of elderly patients in the National Cancer Database. Methods: We queried the database for patients with stage IV melanoma diagnosed between 2011-2015 with survival data available. Patients were divided into receipt of immunotherapy (IO) or no receipt of IO; those without documentation were excluded. Cases were separated into 3 cohorts of age at diagnosis (60 years-old or younger, 61-74 years-old, and 75 years-old and greater). Descriptive variables were compared by Chi-squared analysis and survival analyses were performed by Kaplan-Meier method and log-rank test. Results: 11,265 cases met inclusion criteria: 4,117 aged 60 or less, 3,940 aged 61-74, and 3,208 aged 75 or older. Those receiving immuno-oncologic agents (IO) in all age groups showed a longer median OS (mOS) than those who did not receive IO (mOS overall 17.28 v 7.49; p &lt;0.01). Survival was longer in all age cohorts when IO was received compared to not received; ages less than 60 (mOS 20.3 v 9.2m; p&lt;0.01), ages 61-74 (mOS 15.5 v 7.8m; p&lt;0.01), and ages 75 or greater (mOS 14.4 v 5.8m; p&lt;0.01). A greater percentage of patients received IO in younger than older cohorts, 20.1% in ≥ 75, 37.6% in 61-74, and 42.3% in ≤ 60; p &lt;0.01. Additional descriptive variables shown in the table were compared between the cohorts include care at academic or integrated cancer network, uninsured, Charlson-Deyo Comorbidity Index (CDCI) of 2 or greater, and documented inclusion of palliative care treatment. Conclusions: Substantial survival benefit is realized with IO in all age cohorts although elderly cohorts did not receive IO as often as younger cohort. Elderly patients experienced lower rates of care at academic/network cancer programs, lower uninsured rate, and higher CDCI. [Table: see text]

Khorana score as a predictive tool of venous thromboembolism in cancer patients in rural practice.

e24049 Background: The Centers for Disease Control and Prevention (CDC) estimates that 60,000 to 100,000 Americans die from venous thromboembolism (VTE) annually, costing the U.S. healthcare system $7–10 billion each year. VTE is a leading cause of mortality in cancer patients, and risk is particularly elevated in rural areas, where cancer death rates are higher than in metropolitan areas. The Khorana score has been shown to predict VTE incidence before starting treatment and as such identify those patients that would benefit most from VTE prophylaxis. We aimed to replicate the utility of the Khorana score on a rural population of cancer patients to help address VTE in advance. Methods: From our electronic health records system, we extracted data from cancer patients (age ≥ 18 years) who had begun chemotherapy from 2017-January through 2019-August. Patients who were pregnant, had undergone hormonal therapy or major surgeries within three months prior to VTE diagnosis, or had a history of coagulation disorders or VTE prior to starting chemotherapy were excluded. A Khorana score (0—6, interval = 1) was calculated for each prior to their starting chemotherapy and was used for VTE risk stratification, 0 – low; 1,2 – intermediate; ≥3 – high. We hypothesized that VTE occurrence during the first 6 months following the start of treatment would be positively associated with risk category. Results: The 144, mostly female (64%), cancer patients meeting inclusion had a mean age of 75 years (range 48—95) and VTE risk stratification: 10% (15) high, 67% (96) intermediate, and 23% (33) low. In the first 6 months of starting treatment, 6% (9/144) developed VTE, with a prevalence of 20% (3/15) amongst patients stratified as high risk, 5% (5/96) of intermediate, and 3% (1/33) of the low risk group. A linear-by-linear association of the observed Khorana scores with VTE occurrence implies a meaningful positive association between VTE risk stratification by Khorana score and VTE, chi-square (1,144) = 4.018, p = .045. Conclusions: The trend of higher VTE prevalence in intermediate and high risk patients supports the observed positive association between Khorana score VTE risk category and a greater percentage of patients experiencing VTEs with increasing risk. This trend may likely be amplified with application to a larger number of patients. The study limitations include the lack of diversity of organ affection and sample size, specifically upon risk stratification. However, initiating a discussion about the risks and benefits of VTE prophylaxis prior to starting treatment is of outmost importance.

Tonsillectomy in multiple sclerosis patients: Retrospective, case-controlled, exploratory study

BackgroundPrevious studies have shown an effect of tonsillectomy and greater risk for future autoimmune diseases. Currently there are only few outdated analyses of tonsillectomy and multiple sclerosis (MS) risk. ObjectiveTo investigate the prevalence of tonsillectomy in MS patients and healthy controls (HCs). MethodsA total of 1000 subjects (779 MS patients and 221 HCs) completed a structured study questionnaire regarding MS diagnosis, age of onset, history of tonsillectomy, and age of tonsillectomy. In a subgroup of patients with available electronic medical records, Expanded Disability Status Scale (EDSS) scores at the time of recruitment and 5-years later were collected. Statistical analyses were performed with χ2 test, odds ratio (OR), Student's t-test, Mann-Whitney U test, and ordinal regression.. ResultsThe MS population had a greater percentage of patients with history of tonsillectomy when compared to HCs [39.5% vs. 31.7%, OR 1.411 (CI 1.027–1.938), p = 0.034], driven by participants aged 50 or older [45.7% vs. 36.1%, OR 1.495 (CI 1.037–2.155) p = 0.031]. There was no difference of the age at tonsillectomy (median 8.0 vs. 6.5 years old, p = 0.26). However, the RRMS patients had their tonsillectomy procedure performed significantly later when compared to HCs (median 6.5 vs. 9.0 years old, p = 0.049). In an analysis of RRMS patients with available longitudinal data (n = 459), patients with a history of tonsillectomy were significantly older and had a longer disease duration (p < 0.001 and p = 0.025). After adjusting for the demographic differences, no history of tonsillectomy remained significant predictor of lower EDSS score categories both at the first (estimate = -0.467, Wald = 6.68, 95% CI -0.82 to -0.11, p = 0.01) and second timepoint (estimate = -0.376, Wald = 4.4, 95% CI -0.73 to -0.02 p = 0.037). ConclusionWhen compared to HCs, a greater percentage of MS patients underwent tonsillectomy. The role of tonsils, its relationship with early infection rates and/or antibiotic use in MS should be further investigated.

Impact of team‐based care on appropriate statin therapy prescribing in ***HIV‐infected patients

AbstractIntroductionStatins have historically been underutilized in patients living with ***HIV infection (PLWH) despite reported rates of cardiovascular disease twice that of the general population.ObjectiveTo evaluate the impact of team‐based pharmacy services on appropriate statin prescribing compared with standard care in an HIV primary care clinic.MethodsA retrospective chart review of adult PLWH was conducted for appropriate statin prescribing according to 2013 American College of Cardiology/American Heart Association cholesterol guidelines. Patient outcomes were stratified by team‐based care defined as physician/pharmacy collaboration, and standard care defined as primary care without clinical pharmacy services. The primary outcome was the percentage of patients receiving appropriate statin therapy in the two groups. Secondary outcomes included percentage of patients receiving appropriate statin therapy, number of patients indicated for therapy but untreated, and achievement of low‐density lipoprotein (LDL) goal reduction. Chi‐square analysis was used for nominal comparisons, and logistic regression was used to identify predictors of appropriate statin prescribing.ResultsThree hundred fifty‐two charts were screened, 114 of which met inclusion criteria. Eighty‐nine patients (61%) received team‐based care and 25 (22%) received standard care. Appropriate statin prescribing was observed in a greater percentage of patients in the team‐based care group compared with the standard care group (86% vs 54%, respectively; P &lt; .001). More patients receiving team‐based care were also prescribed statin therapy when indicated (98% vs 88%; P &lt; .001). Team‐based care was a predictor of appropriate statin prescribing (odds ratio 10.31, P &lt; .001); however, LDL goal reduction was achieved in &lt;30% in both groups.ConclusionPatients living with HIV infection receiving team‐based care that included a clinical pharmacist were significantly more likely to be prescribed appropriate statin therapy compared with patients receiving standard care. Nonetheless, achieving goal LDL reduction remained a challenge in these patients regardless of approach to care (team‐based vs standard).

Monthly maintenance protocol Bacillus Calmette-Guerin as a viable alternative to Southwest Oncology Group maintenance protocol in nonmuscle-invasive bladder cancer: A prospective randomized study.

Introduction:Bladder cancer is the most common malignancy of the urinary tract, and recurrence following transurethral resection poses the biggest challenge. Intravesical Bacillus Calmette–Guerin (BCG) maintenance with the Southwest Oncology Group (SWOG) protocol remains the gold standard but with poor patient compliance.Materials and Methods:The present study aims to compare the SWOG maintenance protocol with a monthly maintenance protocol comprising 12 monthly doses of intravesical BCG. Patients are included in the study only if induction BCG is completed and cystoscopy at 3 months is negative. All patients receive 80 mg BCG in each dose with strict cystoscopic surveillance every 3 months.Results:Patient demographics and tumor characteristics were similar in the two groups. There were no statistically significant differences in outcome in terms of recurrence, progression, and adverse reactions in both the groups. Although a larger number of patients in the SWOG maintenance group were lost to follow-up, the difference was not statistically significant proportions.Conclusion:From this study, we can conclude that monthly maintenance BCG for 1 year is comparable in terms of outcome with SWOG protocol maintenance BCG. A greater percentage of patients in the monthly maintenance protocol completed the treatment as planned.

Treatment Mode Preferences in Rheumatoid Arthritis: Moving Toward Shared Decision-Making.

PurposeCurrent knowledge of the reasons for patients’ preference for rheumatoid arthritis (RA) treatment modes is limited. This study was designed to identify preferences for four treatment modes, and to obtain in-depth information on the reasons for these preferences.Patients and MethodsIn this multi-national, cross-sectional, qualitative study, in-depth interviews were conducted with adult patients with RA in the United States, France, Germany, Italy, Spain, Switzerland, the United Kingdom, and Brazil. Patients’ strength of preference was evaluated using a 100-point allocation task (0–100; 100=strongest) across four treatment modes: oral, self-injection, clinic-injection, and infusion. Qualitative descriptive analysis methods were used to identify, characterize, and summarize patterns found in the interview data relating to reasons for these preferences.Results100 patients were interviewed (female, 75.0%; mean age, 53.9 years; mean 11.6 years since diagnosis). Among the four treatment modes, oral administration was allocated the highest mean (standard deviation) preference points (47.3 [33.1]) and was ranked first choice by the greatest percentage of patients (57.0%), followed by self-injection (29.7 [27.7]; 29.0%), infusion (15.4 [24.6]; 16.0%), and clinic-injection (7.5 [14.1]; 2.0%). Overall, 56.0% of patients had a “strong” first-choice preference (ie, point allocation ≥70); most of these patients chose oral (62.5%) vs self-injection (23.2%), infusion (10.7%), or clinic-injection (3.6%). Speed and/or ease of administration were the most commonly reported reasons for patients choosing oral (52.6%) or self-injection (55.2%). The most common reasons for patients not choosing oral or self-injection were not wanting to take another pill (37.2%) and avoiding pain due to needles (46.5%), respectively.ConclusionThese data report factors important to patients regarding preferences for RA treatment modes. Patients may benefit from discussions with their healthcare professionals and/or patient support groups, regarding RA treatment modes, to facilitate shared decision-making.

Health Insurance Status Impacts Rates of Overall Survival in Philadelphia-Positive Acute Lymphoblastic Leukemia

Introduction: The Philadelphia chromosome is associated with a poor prognosis in patients with acute lymphoblastic leukemia (ALL). Prior to the use of hematopoietic stem cell transplantation (HSCT) and tyrosine kinase inhibitors (TKIs), Philadelphia-positive (Ph+) ALL patients were found to have an overall survival (OS) rate of less than 20% over the course of 3 years (Thomas et al., Blood 2004). While modern day therapies including allogeneic HSCT and newer-generation TKIs such as dasatinib have led to significant improvements in OS for this population, these treatments have variable accessibility due to costs for patients with limited to no health insurance. Methods: We performed a retrospective study at the Norris Comprehensive Cancer Center and Los Angeles County Hospital, both associated with the University of Southern California, to investigate outcomes in Ph+ ALL adults with different types of health insurance. Individuals included in the study were diagnosed with Ph+ ALL between 2004-2019. Health insurance options included private insurance, Medicare, Medicaid, or no insurance. Treatment modalities included allogeneic HSCT followed by maintenance TKI therapy or combination chemotherapy plus a TKI. The former was preferred if patients met the key transplant eligibility criteria of insurance coverage and caregiver availability at home. Patient OS was defined as the time from diagnosis of Ph+ ALL until patient death. Statistical analysis was performed using the Fisher's exact probability test with two-tailed p-values &lt;0.05 deemed significant. Results: A total of 81 patients with Ph+ ALL were included in this study. Forty-seven patients (58%) were male and the median age at the time of diagnosis was 45 years (range 20-70). Two groups of patients were compared: those with either Medicare or private insurance (M/P) versus those with Medicaid or no insurance (M/N). Thirty-three patients (40.7%) were included in the M/P group and 48 patients (59.2%) in the M/N group. In comparing rates of OS, the 1-year OS was 100% vs. 85.1% (p = 0.038), 2-year OS was 96.2% vs. 75.8% (p = 0.033), and 3-year OS was 88.2% vs. 59.2% (p = 0.049) for M/P patients compared to M/N patients, respectively (Figure 1). In terms of treatment, there was a significant difference in the number of patients eligible to undergo allogeneic HSCT as 20 patients (60.6%) in the M/P group were able to be transplanted in contrast to 15 patients (31.3%) in the M/N group (p = 0.012). There were similar rates of caregiver availability to support HSCT between both groups; 24 M/P patients (72.7%) lived with a caregiver versus 33 M/N patients (68.8%) in comparison (p = 0.806). Furthermore, there were significantly more patients in the M/P group who were able to be treated with the newer-generation TKI dasatinib instead of the older agent imatinib compared to M/N patients (100% vs. 85.4%, p = 0.038). Conclusion: With the emergence of allogeneic HSCT and newer-generation TKIs, the rates of OS in the Ph+ ALL population improved dramatically from the prior era (Fielding et al., Blood 2009). However, barriers still exist to receiving these modern therapies, one of the most formidable being sufficient insurance coverage of costs. This study demonstrated that the Ph+ ALL population in the M/P group had significantly higher rates of OS at the 1-year, 2-year, and 3-year marks compared to those in the M/N group. Furthermore, there were also a greater percentage of patients in the former group who were able to undergo allogeneic HSCT during the study period. While eligibility for allogeneic HSCT depended on caregiver availability in addition to insurance status, there were similar rates of caregivers between the two groups, thus implying that this factor had no major impact on the differing rates of HSCT. Dasatinib was previously shown to have increased potency in inhibiting the in vitro growth of cells with wild-type BCR-ABL compared to imatinib, making it a preferred choice for TKI therapy (Li, Leukemia &amp; Lymphoma 2008). There were again significantly more M/P patients than M/N patients who were able to be treated with dasatinib rather than imatinib. Given that health insurance status was found to be correlated with rates of OS, allogeneic HSCT, and the availability of newer-generation TKIs, it remains a critical point of discussion in the treatment of Ph+ ALL patients from all socioeconomic backgrounds. Disclosures No relevant conflicts of interest to declare.

The evolving role of occupational therapists in adult critical care in England

Purpose A recent paradigm-shift in patient care advocates for long-term recovery and quality of life in survivors of critical illness. Evidence suggests that occupational therapists in critical care can contribute to recovery in areas such as functional outcomes, length of stay and delirium, although poor role understanding can limit service-utilisation. The purpose of this study is to investigate current and future roles and practices of critical care occupational therapists in the UK. Design/methodology/approach Occupational therapists with clinical experience in adult critical care were invited to participate in a mixed-methods design using a locally developed online questionnaire and semi-structured interviews, concurrently. Descriptive statistics were generated through SPSS. Qualitative data were analysed using the framework approach. Findings Twelve occupational therapists participated in the survey element, with five continuing to interview. Occupational therapists described a multifaceted role in critical care where the majority reported practice in upper limb function, seating/positioning, cognition, psychosocial sequelae and discharge planning. Role and internal characteristics impacted on service delivery. It is envisaged that earlier intervention in a greater percentage of patients, a greater evidence-base, raising awareness and adequate staffing will be features for future development. Originality/value This study provides new insight into the current role and practices of adult critical care occupational therapists in England and generates insights into their role in addressing physical and non-physical morbidity for this patient cohort. Findings are preliminary in nature; however, future research is warranted to evaluate the effectiveness of interventions.

Clinical And Economic Burden Of Eosinophilic COPD In A Large Retrospective US Cohort.

PurposeWe sought to describe clinical and economic outcomes for COPD patients by blood eosinophil (EOS) count.MethodsThis retrospective cohort study of COPD patients used data from the Practice Fusion electronic medical records (EMR) database linked to Symphony Health Solutions transactional pharmacy, medical, outpatient, and inpatient claims data to evaluate COPD-related and all-cause health care resource utilization and cost in the 12-month period following the date of each patient’s greatest recorded blood eosinophil count during the 27-month period from January 2014 to March 2016. A post-index moderate exacerbation was defined as an outpatient or emergency care visit for COPD and a prescription for oral corticosteroid and/or antibiotics within 10 days of the visit. Severe exacerbation was defined as an inpatient hospitalization with COPD as primary diagnosis.ResultsOf 48,090 EMR patients, 39,939 (83.1%) had a charge in the claims data both pre- and post-index (mean age 67.2 years, 58.3% female), 17,397 (43.6%) had EOS ≥220 cells/µL. Moderate and severe exacerbations were more frequent for patients with EOS≥220 cells/µL compared with those with EOS <220 cells/µL (moderate: 6.8% vs 6.1%, p<0.05; severe: 3.1% vs 2.5%, p<0.001). After adjustment for baseline clinical characteristics, each 100-unit increase in EOS count was associated with a significant 2.24% increase in total all-cause costs and 4.54% increase in total COPD-related costs (p<0.001 for both). COPD-related costs were significantly greater for patients with an EOS count of ≥220 cells/µL compared with those with EOS <220 cells/µL (p<0.001). These costs appear to have been driven by a greater percentage of patients in the ≥220 cells/µL cohort with COPD-related resource use including hospitalization, office visits, ambulatory procedures and pharmacy prescriptions.ConclusionCOPD patients with EOS counts ≥220 cells/µL were more likely to have had moderate or severe exacerbations and greater cost of care than those with EOS <220 cells/µL.

Epidemiological profile of patients with fistula in ano

RationaleThere is a lack of consistent national data on the evaluation of the epidemiological profile of patients with anal fistula. ObjectiveTo evaluate the epidemiological profile of patients with anal fistula at a center specialized in coloproctology. MethodA cross-sectional, retrospective study was carried out between 2016 and 2018 of patients who underwent surgical procedures for the treatment of fistula in ano by the Department of Coloproctology of the Regional Hospital of Mato Grosso do Sul. Age, gender, disease duration, number of procedures, association with Crohn's disease and other comorbidities were evaluated. The data were tabulated and submitted to statistical treatment considering p<0.05. Results93.2% of the patients were less than 60 years old, 66.7% were male, 88.9% had the disease less than one year, the most frequent procedures were fistulotomy (55.6%) and fistulectomy (36.8%), with a greater percentage of patients having undergone only one procedure (74.4%), 8.5% had Crohn’s disease, 7.7% systemic hypertension and 3.4% had diabetes mellitus. ConclusionIn the studied group, there was a predominance of anal fistulae in men under 60 years old and without comorbidities, diagnosed for up to one year, most of them submitted to fistulotomy or fistulectomy at one time. Patients operated after one year of illness and also those with Crohn’s disease were submitted mainly to curettage+seton and multiple procedures.

780. Inpatient Addiction Medicine Consultations at the Urban/Rural Frontier: Improving Quality of Care and Linkage to Outpatient Services for Patients with Substance Use Disorder in Central Kentucky

BackgroundWhen persons with opioid use disorder (OUD) are hospitalized with medical complications (e,g. endocarditis, viral hepatitis) they frequently do not receive medications for the underlying OUD. In recent years, a number of hospitals have implemented addiction medicine consultation (AMC) services to help address this treatment gap, though these are all in large urban centers. AMCs provide comprehensive substance use disorder (SUD) assessments, manage SUDs, initiate pharmacotherapy for OUD, and arrange linkage to ongoing treatment. The aim of this study was to describe the initial implementation and outcomes of a new AMC at the University of Kentucky Hospital, a 945-bed tertiary referral center with a large rural catchment.MethodsThe Addiction Consultation and Education Service(ACES) began October, 2018 and was comprised of several physicians and an APRN. A patient navigator assisted with prior authorizations and outpatient linkage. ACES referred to a new bridge clinic at the University for ongoing office-based opioid treatment as well as to community programs and licensed opioid treatment programs. Patient demographics, SUD diagnoses, and comorbidities (including details of the injection-related infections) are collected from the electronic health record, as well as key process metrics including: time-to-consultation and medication initiation, length of stay(LOS), discharge against medical advice(AMA), and details of linkage to outpatient services.ResultsFrom October-December, 91 patients were seen, 73 met DSM-5 criteria for OUD, 82 had a medical complication of SUD, and 53 lived in rural counties (Rural-Urban Continuum Codes 4–9). Average LOS was 19.5 days. Among OUD patients, 71% underwent buprenorphine/naloxone induction, 9% were started on methadone. Less than 6% of patients started on buprenorphine or methadone left against medical advice.ConclusionAMCs are a key part of providing comprehensive care for persons hospitalized with infectious complications of substance use. Initiating medication for OUD likely decreases rates of discharge against medical advice. Compared with other AMCs, a greater percentage of patients seen by ACES resided in rural counties. Establishing a bridge clinic prior to starting an AMC is critical to ensure ongoing care.Disclosures All authors: No reported disclosures.

Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma

BackgroundNivolumab plus ipilimumab or nivolumab alone resulted in longer progression-free and overall survival than ipilimumab alone in a trial involving patients with advanced melanoma. We now report 5-year outcomes in the trial.MethodsWe randomly assigned patients with previously untreated advanced melanoma to receive one of the following regimens: nivolumab (at a dose of 1 mg per kilogram of body weight) plus ipilimumab (3 mg per kilogram) every 3 weeks for four doses, followed by nivolumab (3 mg per kilogram every 2 weeks); nivolumab (3 mg per kilogram every 2 weeks) plus ipilimumab-matched placebo; or ipilimumab (3 mg per kilogram every 3 weeks for four doses) plus nivolumab-matched placebo. The two primary end points were progression-free survival and overall survival in the nivolumab-plus-ipilimumab group and in the nivolumab group, as compared with the ipilimumab group.ResultsAt a minimum follow-up of 60 months, the median overall survival was more than 60.0 months (median not reached) in the nivolumab-plus-ipilimumab group and 36.9 months in the nivolumab group, as compared with 19.9 months in the ipilimumab group (hazard ratio for death with nivolumab plus ipilimumab vs. ipilimumab, 0.52; hazard ratio for death with nivolumab vs. ipilimumab, 0.63). Overall survival at 5 years was 52% in the nivolumab-plus-ipilimumab group and 44% in the nivolumab group, as compared with 26% in the ipilimumab group. No sustained deterioration of health-related quality of life was observed during or after treatment with nivolumab plus ipilimumab or with nivolumab alone. No new late toxic effects were noted.ConclusionsAmong patients with advanced melanoma, sustained long-term overall survival at 5 years was observed in a greater percentage of patients who received nivolumab plus ipilimumab or nivolumab alone than in those who received ipilimumab alone, with no apparent loss of quality of life in the patients who received regimens containing nivolumab. (Funded by Bristol-Myers Squibb and others; CheckMate 067 ClinicalTrials.gov number, NCT01844505.)

Headache due to spontaneous spinal cerebrospinal fluid leak secondary to cerebrospinal fluid-venous fistula: Case series.

Cerebrospinal fluid-venous fistula is an uncommon cause of spontaneous spinal cerebrospinal fluid leak (SSCSFL). We aim to describe the clinical presentation, imaging evaluation, treatment and outcome of SSCSFL secondary to cerebrospinal fluid-venous fistula. A retrospective review was undertaken of SSCSFL cases secondary to cerebrospinal fluid-venous fistula confirmed radiologically or intraoperatively, seen at our institution from January 1994 to March 2019. Cases with undetermined SSCSFL etiology, alternative etiology or unconfirmed fistula were excluded. Forty-four of 156 patients met the inclusion criteria (31 women, 13 men). Mean age of symptom onset was 52.6 years (SD 8.7, range 33-71 years). Headache was the presenting symptom in almost all, typically daily (69%), and most often in occipital/suboccipital regions. Headache character was most commonly pressure (38%), followed by throbbing/pulsing (21.4%). Orthostatic headache worsening occurred in 69% and an even greater percentage of patients (88%) reported Valsalva-induced headache exacerbation or precipitation. Headache occurred in isolation to Valsalva maneuvers in 12%. Of 37 patients with documented cerebrospinal fluid opening pressure, 13% were <6 cmH2O; 84%, 7-20 cmH2O; and one, 25 cmH2O. Fistulas were almost exclusively thoracic (95.5%). Only one patient responded definitively to epidural blood patch (EBP). Forty-two patients underwent surgery. Most improved following surgery; 48.7% were completely headache free and 26.8% had at least 50% improvement. In our series, cerebrospinal fluid-venous fistula was associated with a greater occurrence of Valsalva-induced headache exacerbation or precipitation than orthostatic headache and did not respond to EBP. Surgery provided significant improvement. Cerebrospinal fluid-venous fistula should be considered early in the differential diagnosis of Valsalva-induced ("cough") headache.

530 Electrolyte Shifts of NER1006 Bowel Preparation for Colonoscopy in the Elderly Are Transient and Well-Tolerated

INTRODUCTION: Bowel preparation safety is important, especially in the elderly. The 1L PEG-based bowel preparation NER1006 is indicated for colon cleansing in preparation for colonoscopy in adults. An analysis of data from a phase 3 randomized study was conducted, subgrouping patients by age (≤65 and &gt;65 y). METHODS: Adults undergoing colonoscopy were randomly assigned to receive NER1006 or oral sodium sulfate (OSS; evening/morning split-dosing) with total minimum volume requirements of 64 oz (NER1006) and 96 oz (OSS). Safety assessments included monitoring adverse events (AEs) and clinical laboratory testing. Plasma electrolyte levels were measured at baseline, Day 2 (day of colonoscopy), Day 4 ± 1, and Day 9 ± 1. The safety population included all patients who received ≥1 study dose. Upper limit of normal cut-off values were 145 mmol/L (sodium), 105 mmol/L (chloride), and 5 mmol/L (potassium). RESULTS: The safety population included 262 (NER1006) and 265 (OSS) patients. Most patients were aged ≤65 y (NER1006, n=214; OSS, n = 217). In patients &gt;65 y, the most common AEs were nausea (10.4%) and vomiting (8.3%) with NER1006 and decreased glomerular filtration rate (6.3%) with OSS. Mean baseline sodium levels were similar for NER1006 and OSS in patients ≤65 y (141 mmol/L) and &gt;65 y (140 mmol/L). A greater percentage of patients &gt;65 y with normal baseline sodium levels had high sodium levels ( &gt;145 mmol/L) on Day 2 with NER1006 (48.9%) vs OSS (6.5%); shifts were transient and 93.5% of NER1006-treated patients had normal sodium levels by Day 4 (mean, 141 mmol/L). In patients ≤65 y in NER1006 group, 37.6% had a shift in sodium levels from normal at baseline to high at Day 2 (mean, 144.5 mmol/L) vs 3.7% with OSS; 90.9% of NER1006-treated patients had normal sodium levels by Day 4 (mean, 141.3 mmol/L). Chloride levels transiently increased from baseline in 27.7% (&gt;65 y) and 19.2% (≤65 y) of patients at Day 2 with NER1006; 84.8% and 83.8% had normal levels by Day 4. At least 95% of NER1006-treated patients in both age groups had normal potassium levels from baseline through Day 9. Hyperuricemia was not reported in either age or treatment group. No electrolyte shifts resulted in clinical sequelae. CONCLUSION: NER1006 was generally well tolerated regardless of age. Transient increases in sodium and chloride levels were observed on the day of colonoscopy, but changes were not clinically meaningful and levels returned to normal in most patients by Day 4. Funding: Norgine BV/Salix Pharmaceuticals.

2830 Bowel Preparation Quality in a Multiethnic Population in a Safety Net Hospital

INTRODUCTION: Colonoscopy is the only colorectal cancer screening modality that permits direct visualization of the entire colon and removal of polyps. Low-quality bowel preparation has been associated with lower adenoma detection rates, increased procedure time, and increased hospital cost. An inadequate preparation limits the diagnostic accuracy and overall efficacy of colonoscopy. Factors that contribute to inadequate bowel preparations include age, male sex, inpatient status, low socioeconomic status, low English proficiency, obesity, diabetes, and cirrhosis. We investigated the complex relationship between socioeconomic factors and medical comorbidities on the quality of inpatient colonoscopy preparation. METHODS: We conducted a retrospective chart review of inpatient colonoscopies between October 2017 and April 2019. All patients received a single-dose preparation of polyethylene glycol. We collected data including demographics, medical history, indication, and bowel preparation. A Boston Bowel Preparation Score of 6 or above or an Aronchick score of “good” or “excellent” was used to define an adequate preparation. RESULTS: A total of 230 patients were included in the final analysis (Table 1). An inadequate bowel preparation was reported in 16.1% of our inpatient colonoscopies. Within the inadequate preparation group, a greater percentage of patients were male (17.3% vs. 12.3%), had low English proficiency (18.3% vs.15.3%), were not diabetic (17.7% vs.12.3%), and did not have prior bowel surgery (16.4% vs. 0.0%). Within the age, race/ethnicity, and insurance subgroups, patients who were age 80+ (21.4%), Asian-American (25%), unreported race/ethnicity (29.4%), uninsured (25%), and prisoners (22.8%) had a greater percentage of inadequate preparation (Table 2). A logistic regression was performed to assess the effects of age, sex, race/ethnicity, insurance, English fluency, diabetes, restricted mobility, and prior surgery on bowel preparation. The logistic regression model was not statistically significant. CONCLUSION: No significant socioeconomic or medical predictors of bowel preparation were found in this inpatient population which is in contrast to prior literature. While less than 20% of our patient population had inadequate bowel preparation, this is still significant in the broader context of quality, safety, and healthcare costs. Identifying strategies to increase the quality of bowel preparation still remains at the forefront of our field.

BLOOD EOSINOPHIL COUNT GROUP SHIFTS IN ASTHMA: KINETICS AND INFLUENCE OF ORAL CORTICOSTEROIDS

SESSION TITLE: Asthma: From Blood Biomarkers to Biologics and Disease Burden SESSION TYPE: Original Investigations PRESENTED ON: 10/21/2019 1:30 PM - 2:30 PM PURPOSE: We previously reported shifts in blood eosinophil count (BEC) group with repeated BEC measurements for individual patients with asthma (Ann Allergy Asthma Immunol 2018;121[Suppl 5]:S39‒40). In this analysis, we evaluated the kinetics of BEC group shifts and the influence of oral corticosteroids (OCS) on these shifts. METHODS: We evaluated adult patients with severe, uncontrolled asthma from the placebo cohort of the pooled Phase III SIROCCO (Lancet 2016;388:2115‒27; 48 weeks) and CALIMA (Lancet 2016;388:2128‒41; 56 weeks) studies. Patients were divided by baseline BEC into <150 cells/μL, ≥150–<300 cells/μL, and ≥300 cells/μL groups. Timing of initial shift from baseline BEC group to a different BEC group was determined at Weeks 4, 8, 24, and 40 and at end of treatment. Baseline characteristics were described based on the presence or absence of a shift in BEC group. RESULTS: A total of 739 patients were evaluated. Of those, 260 (35%) did not shift BEC group from baseline, 474 (65%) shifted to a different BEC group during the study, and five patients did not have post-baseline values. The percentage of patients who moved to a different group from baseline was greatest for the ≥150–<300 cells/μL group (88%, 149/170), followed by the <150 cells/μL group (70%, 99/141) and the ≥300 cells/μL group (53%, 226/428). Of patients who shifted groups during the study (n=474), 47% (n=225), 69% (n=329), and 86% (n=410) did so by Week 4, 8, and 24, respectively. Patients with baseline BEC <150 cells/μL shifted the fastest (to ≥150 cells/μL), with 59% (58/99) shifting at Week 4, compared with 55% (82/149) shifting from ≥150–<300 cells/μL to either <150 or ≥300 cells/μL, 38% (85/226) shifting from ≥300 cells/μL to <300 cells/μL. Baseline characteristics that differed for patients who shifted BEC groups vs. those who did not included BEC (median cells/μL [range]: 320 [0–2,690] vs. 520 [0–4,494]), OCS use (17% [n=78] vs. 11% [n=29]), nasal polyposis (15% [n=72] vs. 28% [n=72]), and past polypectomy (10% [n=47] vs. 19% [n=50]). A greater percentage of patients who used OCS shifted BEC groups vs. those who did not use OCS, with 91% (21/23) vs. 87% (128/147) for the ≥150–<300 cells/μL group, 84% (16/19) vs. 68% (83/122) for the <150 cells/μL group, and 61% (41/67) vs. 51% (185/361) for the ≥300 cells/μL group. CONCLUSIONS: Patients in the ≥150–<300 cells/μL group at baseline had the greatest tendency to shift to another BEC group. Patients with OCS use also have a greater tendency to shift to a different BEC group regardless of BEC baseline values. CLINICAL IMPLICATIONS: A single BEC measurement may be insufficient to inform whether a patient has a clinical diagnosis of eosinophilic asthma. DISCLOSURES: Employee relationship with AstraZeneca Please note: >$100000 Added 03/12/2019 by William Cook, source=Web Response, value=Salary Employee relationship with AstraZeneca Please note: >$100000 Added 03/12/2019 by Ian Hirsch, source=Web Response, value=Salary No relevant relationships by James Kreindler, source=Web Response Consultant relationship with AstraZeneca Please note: $20001 - $100000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Consulting fee Ad Boards relationship with AstraZeneca Please note: $20001 - $100000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Fees Speaker/Speaker's Bureau relationship with AstraZeneca Please note: $20001 - $100000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Fees Ad Boards relationship with Sanofi Please note: $5001 - $20000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Fees Ad Boards relationship with GSK Please note: $5001 - $20000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Fees Grants for Clinical Trials relationship with Sanofi Please note: $20001 - $100000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Grant/Research Support Grants for Clinical Trials relationship with GSK Please note: $20001 - $100000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Grant/Research Support Grants for Clinical Trials relationship with AstraZeneca Please note: >$100000 Added 03/12/2019 by Njira Lugogo, source=Web Response, value=Grant/Research Support Advisory Committee Member relationship with SANOFI Please note: $5001 - $20000 Added 03/15/2019 by Njira Lugogo, source=Web Response, value=Honoraria Advisory Committee Member relationship with Astra Zeneca Please note: $20001 - $100000 Added 03/15/2019 by Njira Lugogo, source=Web Response, value=Honoraria Advisory Committee Member relationship with GSK Please note: $5001 - $20000 Added 03/15/2019 by Njira Lugogo, source=Web Response, value=Consulting fee Consultant relationship with TEVA Please note: $5001 - $20000 Added 03/15/2019 by Njira Lugogo, source=Web Response, value=Consulting fee Employee relationship with AstraZeneca Pharmaceuticals LP Please note: >$100000 Added 03/13/2019 by Ubaldo Martin, source=Web Response, value=Salary Shareholder relationship with AstraZeneca Please note: >$100000 Added 03/12/2019 by Frank Trudo, source=Web Response, value=Salary

666 Outcomes Following Therapeutic Drug Monitoring of Vedolizumab

INTRODUCTION: Therapeutic drug monitoring (TDM) of biologic therapies is increasingly used in the management of inflammatory bowel disease (IBD). It is established that for anti-tumor necrosis factor medications, a dose escalation will have a positive clinical response in up to 86% of those with low serum drug concentrations. However, it is unknown if trough concentration predicts response to VDZ dose escalation. The objective of this study was to evaluate the impact of TDM on clinical outcomes in patients with IBD treated with VDZ. METHODS: This was a retrospective study of patients with IBD treated at two institutions (University of Minnesota, University of Maryland) with VDZ who had a VDZ trough concentration post induction between November 2016 and October 2018. A positive response was defined as improvement in the factor that was the etiology of dose escalation and categorized as clinical response, biomarker (i.e., CRP) response, or endoscopic response. An a priori VDZ trough concentration of 10 ug/ml was chosen as the cut off for a low level. Data was collected including demographics, disease characteristics, management changes and outcomes. VDZ concentration was performed using a commercial test (Inform Diagnostics, Irving, TX). Student's t-test and Fisher's exact test were used for continuous and categorical variables respectively in JMP Pro 14.0.0. RESULTS: 48 trough concentrations were obtained in 43 patients. 51.2% had Crohn's disease while 48.8% had ulcerative colitis/indeterminate colitis. Following TDM, 62.5% (30/48) of patients underwent a dose change: 23 dose escalations, 5 stoppages and 2 dose de-escalations. 65% (13/20) of dose escalations (3 had inadequate follow-up) had a positive response to dose adjustment: 8 symptomatic response, 1 biologic response and 4 endoscopic response. Among those with a low VDZ trough &lt;10 ug/ml, 75% (9/12) improved following dose escalations versus 50% (4/8) of those with VDZ trough ≥10 ug/ml (P = 0.356). The mean CRP prior to dose escalation was 7.0 mg/L (SD = 10.2) compared to 6.4 mg/L post dose escalation (SD = 12.3) (P = 0.863). CONCLUSION: TDM in VDZ results in frequent clinical management changes. While there was a greater percentage of patients that demonstrated clinical improvement following dose escalation with low drug levels, the difference was not statistically significant. Larger cohorts are needed to evaluate the impact of TDM with VDZ as our study was underpowered to identify small to moderate differences based on the pre-determined low VDZ level.

P1520Management and outcome of women with NSTEMI. Have there been any changes in recent years?

Abstract Introduction Women have been less represented in every NSTEMI clinical trial. Moreover, it has been observed that this group of patients have usually received less revascularization and evidence based treatment, therefore presenting with a greater long and short-term mortality. Purpose The purpose of our study is to analyze the presence of differences in baseline characteristics, management and outcome of women with NSTEMI during the last decade. Methods and results Retrospective study including 861 women admitted for NSTEMI between 2003 and 2015 in our center. We divided 2 groups according to hospitalization period (2003–2008 and 2009–2015) with a medium follow up of 4.5±2.9 years. Baseline characteristics and treatment at discharge are described on table 1. We noticed a greater use of statins and ACEI/ARB on the second period as well as a greater percentage of patients receiving early revascularization. It is remarkable on women a non-significant reduction of heart failure hospitalization at follow up (6.8% vs 4.5%; p=0.091), neither differences on 30-day mortality (1.3% vs 0,4%) or 1-year mortality (7.1% vs 5.8%). However, long-term mortality for the second group is reduced (HR 0.69; CI 95% 0.52–0.89), even after performing a multivariate analysis (HR 0.64; CI 95% 0.48–0.85). Characteristic Population (n=861) 2003–2008 (n=395) 2009–2015 (n=466) p-value Age (years) 73±12 73±12 72±12 0.316 Hypertension 629 (73.1%) 285 (72.2%) 344 (73.8%) 0.318 Hypercholesterolemia 414 (48.1%) 190 (48.1%) 224 (48.1%) 0.523 Killip class 0.292 I 664 (77.1%) 299 (75.7%) 365 (78.3%) II 143 (16.6%) 74 (18.7%) 69 (14.8%) III 47 (5.5%) 20 (5.1%) 27 (5.8%) IV 4 (0.5%) 2 (0.5%) 2 (0.4) GRACE score 129±32 130±37 128±33 0.897 Early PCI 249 (29.3%) 76 (19.2%) 173 (38.0%) &lt;0.005 Treatment at discharge AAS 698 (81.1%) 313 (79.2%) 385 (82.6%) 0.120 Clopidogrel 465 (54.0%) 221 (55.9%) 244 (52.4%) 0.162 ACEI/ARB 466 (54.1%) 191 (48.4%) 275 (59.0%) 0.001 Beta-blocker 509 (59.1%) 238 (60.3%) 271 (58.2%) 0.290 Statins 643 (74.7%) 275 (69.6%) 368 (79.0%) 0.001 Conclusions In recent years, early interventionist management and greater use of evidence-based therapies have been observed in women with NSTEMI. This has been associated with a lesser long-term mortality, although short-term events have remained the same.