Group Of Older Patients Research Articles

P2746Survival of people with valvular heart disease in the community (OxValve-Survive)

Abstract Background Valvular heart disease (VHD) occurs commonly in older patients (>65 years) but the majority is mild disease, which is of uncertain importance. Understanding the impact of VHD on mortality in this older group of patients would help determine its relevance and aid the appropriate use of healthcare resources. OxValve is a cohort study in Oxfordshire screening people aged 65 and over for VHD. Over 4,009 participants were recruited between August 2009 and May 2016 and screened using echocardiography to establish the presence and severity of VHD. AIMS To report survival in the OxValve cohort, and to investigate whether people with VHD are at increased risk of death. Methods The OxValve cohort was linked to Office for National Statistics mortality data to obtain date and cause of death. Cox regression was used to investigate the association of any VHD, VHD of significant severity, and VHD subtypes with all-cause and cause-specific mortality, adjusting for potential confounders including age, sex, socioeconomic status, smoking, and comorbidities. Results Linked mortality data was available for 3,511 OxValve participants up to September 2018 (median 5.85 years follow-up). VHD was present in 2,645 (75.3%) participants and of these 288 (8.2%) had significant VHD. In total, 311 (8.9%) participants had died. Cancer was the commonest cause of death (n=135), followed by cardiovascular disease (n=75) and respiratory disease (n=35). After adjustment for age and other covariates, mild to moderate VHD was not associated with increased all-cause mortality (HR 1.16, 95% CI: 0.89 to 1.50). However, VHD of significant severity (moderate or severe disease) was associated with a nearly two-fold higher risk of death overall (HR 1.92, 95% CI: 1:38 to 2.67) including increased CVD mortality (HR 2.25, 95% CI: 1.21 to 4.18). DISCUSSION Mild to moderate VHD was very common, but was not associated with increased mortality. Significant VHD was however associated with a two-fold reduction in survival. Further research is required to understand the natural history of VHD, how to identify those with progressive disease and when to intervene. Acknowledgement/Funding NIHR Biomedical Research Centre, Oxford

Factors Influencing Aphasia Outcome in Patients with Occlusive Stroke

AbstractBackground: Aphasia related to ischemic stroke is a major health problem affecting the quality of life profoundly.Aim of Study: Is to assess factors influencing aphasia outcome in patients with occlusive stroke and the role of functional magnetic resonance imaging in detection the patterns of post-stroke language recovery.Patients and Methods: This was a prospective cohort study done at Neuropsychiatry Department and Center of Psychiatry, Neurology and Neurosurgery, Diagnostic Radiol-ogy, Tanta University, from January 2017 to January 2018. Aphasia Rapid Test (ART) at day 1 and follow-up at day 8 which is a bed side clinical test to assess aphasia severity, Diffusion Tensor Imaging (DTI) and fMRI were done at day 8 to assess aphasia severity. A total of 34 cases were finally included in this study after fulfilling the inclusion and exclusion criteria, 12 patients who had receptive or global aphasia, were not suitable for fMRI, their native language Arabic, age Results: The total number of the studied patients was 34 of them 18 patients (52.9%) were males and 16 patients were females (47.1%). The age of the studied patients ranged from 28-79 years. The older group of patients had severe language disability also those with global aphasia and perisylvian lesion, risk factors as HTN, DM, Cardiac Disease, Dyslipidemia had worse prognosis, those with no reconstruction of the Arcuate Fasiculus in DTI and fMRI data analysis showed negative effect of the site contralateral to lesion.Conclusion: Age was a significant factor with the higher age group had the worst prognosis regarding aphasia. Large lesion sizes and those with damage to strategic language areas had a bad prognosis. fMRI and DTI were the cornerstone of our study and they were a highly reliable tools in the prognosis of language outcome, with those who had activity in the perilesional and bilateral activity (perilesional and contralateral homotopic) in fMRI to have better outcome than those with only contralateral activity, also DTI to delineate the AF and the degree of its integrity and reconstitution.

Anticoagulation Patterns in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention in an Academic Center.

A common dilemma facing physicians treating patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) is the management of oral anticoagulation (OAC) therapy, because there is also an indication for dual antiplatelet therapy in these patients. The purpose of this study was therefore to evaluate anticoagulation patterns in this patient population in an attempt to identify patterns of risk factors that may influence OAC prescribing habits. This retrospective study entailed a review of a total of 4,648 patients from two academic hospitals who underwent PCI between 2008 and 2016. We ultimately included 211 patients who had AF and an indication for OAC. Chart review revealed patients’ risk factors, CHA2DS2-VASc and HAS-BLED scores, and antithrombotic regimens. Only 105 (49.8%) patients who met the indications for OAC were actually placed on OAC post-PCI. There was no significant relationship between discharge on OAC and HAS-BLED score (t = 0.14; p = 0.44) or CHA2DS2-VASc score (t = 0.76; p = 0.22). Patients younger than 65 years of age were prescribed more triple therapy (56% versus 33%; p < 0.01) or any OAC (69% versus 41%; p < 0.01) on discharge in comparison with patients 65 years of age or older. The older patient group had a significantly higher average CHA2DS2-VASc score (4.4 versus 3.2; p < 0.01) and a higher average HAS-BLED score (2.8 versus 2.4; p < 0.01). Ultimately, this study indicated that less than half of AF patients with an indication for OAC were placed on OAC post-PCI. There was no association between discharge on OAC and CHA2DS2-VASc score, HAS-BLED score, or any other individual risk factor, with the exception of age.

Pendular energy transduction in the different phases of gait cycle in post-stroke subjects

MainTo analyze spatiotemporal gait parameters and the body center of mass (CoM) energy transduction at self-selected speed walking in a group of older patients with stroke. MethodsA cross-sectional study, fifteen subjects with 4.06 years post ̵stroke hemiparesis (eleven men and four women) and fifteen healthy subjects (four men and eleven women) participate in this study. Pendulum-like determining variables; Recovery (R) and Congruity percentage (%Cong) were analyzed in addition to immediate pendular re-conversion (Rint) during the phases in which the gait cycle is usually divided in clinical evaluations. ResultsHealthy subjects walked faster that stroke group (p = 0.001). %Cong was significantly higher in post-stroke respect to healthy subjects (p = 0.05). Rint showed significant differences between the groups for all phases (p = 0.05). The relation between speed and R was confirmed, for healthy (r = 0.67, p = 0.006) and post-stroke subjects (r = 0.851, p = 0.001), %Cong y Rint (r = −0.79, p = 0.001), (r = −0.93, p = 0.001) and periods of double support (r = −0.76, p = 0.001), (r = 0.69, p = 0.004) respectively. ConclusionAlteration of pendular mechanism in subjects post-stroke is associated mainly with energy transduction; mechanical energy recovered during double support phases in healthy and post-stroke subjects follows a different trend, in post-stroke subjects, a longer duration of the double support is associated with less energy loss.

Frequency of hepatitis C virus infection in a single institution in Mexico with a focus on birth-cohort population

Background and rationale for the study. The generation of people born before 1965 is a high-risk group for developing chronic hepatitis C virus (HCV) infection.Aim. To report the experience on single institution of HCV infection under birth-cohort or baby boomers effect.Material and methods. We used a cross-sectional design of consecutive subjects older than 18 years referred for serological evaluation for anti-HCV and detection of HCV RNA.Results. A total of 7,658 people were included. The global prevalence of HCV antibody was 4.5% (344/7658). The frequency with anti-HCV antibodies were 74 (10.9%), 158 (7.3%), and 112 (2.3%) for people born before 1945, 1945-1965, and 1966-1992, respectively (p < 0.01). The subjects HCV RNA-positive were 88.9%, 68.7%, and 44.4%, respectively (p < 0.001). The viral load was > 100,000 IU/mL in 74.4% of those positive for HCV RNA. Groups of older patients and anti-VHC, with year of birth before 1965, are more likely to show reactivity to HCV RNA and significant viral load (OR 10.0, CI 95% 4.8 to 20.1).Conclusion. We observed a high prevalence of unrecognized chronic HCV infection. The prevalence of HCV infection in people born before 1945 was twice the value of those born after 1965. Further studies are needed to determine the impact on health care services. Future work should focus on determining the appropriate model for the care of people at risk of chronic HCV.

Dysphagia from aneurogeriatric point of view : Pathogenesis, diagnosis and management.

Dysphagia is becoming increasingly more common in aging societies and, like the classical geriatric syndromes, it is arelevant functional impairment. The prevalence of dysphagia is highest in the group of old patients with neurological disorders, particularly in patients with stroke, dementia and Parkinson's disease. In the various neurological diseases of older people disease-specific factors often have adecisive influence on the clinical management of dysphagia. In addition, the concept of primary and secondary presbyphagia plays an important role in understanding age-related dysphagia. Whereas at the organ level of the International Classification of Functioning, Disability and Health (ICF) model, the diagnosis and treatment of dysphagia in neurogeriatrics have already made progress, more research is needed on the levels of activity/mobility, social environment, personal factors and the environment. This article summarizes the pathophysiological aspects as well as the current evidence for diagnosis and treatment of neurogeriatric dysphagia. Due to its high clinical relevance dysphagia should be added to the geriatric syndromes as "impaired swallowing".

Use of Radiographic Criteria for Proximal Humeral Head Migration After Dislocation of the Shoulder to Identify Damage to Its Rotator Cuff

Objective. To assess whether radiographic criteria for proximal humeral head migration can be used as screening of damage to the rotator cuff after dislocation in patients over 45 years of age.Material and methods. The study included the results of a follow-up of 101 patients after shoulder dislocation without signs of damage to the rotator cuff before injury. Damage to the rotator cuff was assessed using MRI, followed by a correlation analysis between the results of measuring the height of the subacromial space with radiography and MRI.Results. Signs of cranial migration of the humeral head are detected statistically significantly more frequently in the group of older patients than in that of young ones (F=0.009; p&lt;0.05). MRI study statistically significantly more often revealed signs of damage to the rotator cuff in the older patients than in the young ones (F=0.009; p&lt;0.05). There was a high correlation between the humeral head migration index and the MRI measurements of the acromiohumeral interval (r=0.93, p&lt;0.05).Conclusion. The acromiohumeral index, as well as MRI, can be used as a criterion for rotator cuff injury. This study has shown that the older patients have a 19-fold higher risk for damage to the rotator cuff from a dislocated shoulder (95% CI 6.93–52.11). Thus, attention should be paid to the presence of radiographic signs of rotator cuff injury in all patients after dislocation of the shoulder.

The depressive effects of androgen deprivation therapy in locally advanced or metastatic prostate cancer: a comparative study

Aim To investigate association of androgen deprivation therapy (ADT) with depression and the effect of depression on cognitive functions in men with locally advanced or metastatic prostate cancer. Methods A total of 144 patients were evaluated in a prospective, comparative study. Group1 consisted of 72 patients with locally advanced or metastatic prostate cancer who received complete ADT treatment continuously for 12 months and group2 (control group) consisted of 72 patients who underwent radical prostatectomy without any additional treatment. MoCA (The Montreal Cognitive Assessment) and HAM-D (Hamilton depression rating scale) tests were used to assess the effects of ADT on depression and cognitive functions. Results According to post-treatment results of MoCA test, patients had lower mean total scores in both the groups. The deficits were especially prominent in the areas of language ability and short-term memory capacity. In the comparison of two groups according to HAM-D tests, the scores were significantly higher in group1 at baseline-6 month, at baseline-12 month and at 6–12 month follow-up period (p = .003, p < .001, p = .023).There was a relationship between depression and deterioration of language and memory functions at 6th (p < .001, p = .002) and 12th months (p < .001, p = .046). Attention function was deteriorated in these patients at 6th (p < .001) and 12th months (p < .001). Conclusions ADT causes increase in depression and the deterioration of cognitive functions. ADT should be given carefully to these older group of patients with concomitant morbidities.

Detection of alcohol abuse in older patients with cancer: The integration of alcohol screening questionnaires in the comprehensive geriatric assessment.

We aimed to evaluate the feasibility of implementing an alcohol screening questionnaire as part of the comprehensive geriatric assessment (CGA) by reporting the prevalence of alcohol abuse in a group of older patients with cancer in a Belgian cancer centre. Patients were recruited at the Geriatric Oncology Clinic of the Kortrijk Cancer Centre and were evaluated by use of a CGA. Two alcohol screening questionnaires were integrated into the CGA: the Cutdown-Annoyed-Guilty-Eye-opener (CAGE) questionnaire and the Alcohol Use Disorders Identification Test-screening version (AUDIT-C). 193 patients with a mean age of 77.7 years were included in the analyses. Abnormal scores on the CAGE were detected in 6.3% of males and 1.2% of women. Abnormal results on the AUDIT-C were noticed in 30.0% of men, and in 21.7% of women. A regression analysis could not find a significant effect of the CAGE questionnaire when entered as predictor for CGA domain scores. Regarding the AUDIT-C, significant results were detected for predicting the score of the Geriatric-8 questionnaire and polypharmacy in men, and the Independent Activities of Daily Living questionnaire in women. No association with one-year survival was detected for either alcohol screening questionnaire. It is feasible to implement an alcohol screening questionnaire as part of a CGA as results indicated a rather high level of alcohol abuse in this cohort.

Outcomes of younger patients diagnosed with locally advanced rectal cancer.

500 Background: The incidence of rectal cancer is higher in the older population. In developed nations there has been a rise in incidence in young onset rectal cancer (yRC). We evaluated and compared the presentation and survival outcomes of treatments for locally advanced rectal cancer in yRC patients to that of older patients. Methods: All cases of rectal cancers referred to a large tertiary referral cancer centre in Western Sydney between 2009-2016 were examined. Patient demographics, presenting symptoms, treatment, clinico-pathological characteristics, progression free survival (PFS) and overall survival (OS) were obtained. Under 50 years old was used as the cut-off age for defining yRC. Results: One hundred sixty-two patients were identified, 33 in the yRC and 129 in the older patient group. The median age at diagnosis was 62 (24 – 92). Median follow-up was 40 months. There was no difference in presenting symptoms between the two groups, with per rectal bleeding being the most common symptom at presentation. 17.5% of yRC presented with stage IV disease, compared with 22.1% of older patients. yRC were more likely to complete neoadjuvant therapy (97% vs 81%; P=0.02). yRC were more likely to proceed to surgery (91% vs 72%, P=0.02). There were no significant differences in surgical outcomes, including complications and postoperative TNM staging. yRC were more likely to have microsatellite high tumours (18% vs 4%; P=0.01). No statistical differences were seen in survival outcomes (PFS 57.1 vs 62.9 months, P=0.26; OS 85.1 Vs 92.8 months, P=0.57) between older and yRC patients. Eight progressions (eight deaths) were observed in the yRC group and 40 progressions (36 deaths) were observed in the older patient group. Conclusions: 20% of rectal cancers were considered yRC. These patients were more likely to complete neoadjuvant therapy and proceed to surgery. In this cohort, median PFS and OS were longer compared to the older patient group, although this was not statistically significant. yRC were more likely to have MMR deficiency. Patients under 50 years with alarm symptoms including per rectal bleeding require vigilance in investigations to allow for earlier detection and appropriate management of rectal cancer.

ACUTE KIDNEY INJURY IN ELDERLY PATIENTS

In the elderly, impairment of kidney function occurs. Renal diseases overlap with anatomic and functional changes related to age-related involutionary processes. Mortality among patients with acute renal injury is approximately 50%, despite advances in treatment and diagnosis of AKI. To assess the incidence of acute kidney injury in elderly patients and to analyze the causes of acute renal failure depending on age. A retrospective analysis included medical documentation of patients hospitalized in the Nephrology Clinic during the 6-month period. During this period 452 patients were hospitalized in the clinic. A group of 77 patients with acute renal failure as a reason for hospitalization was included in the study. The prerenal form was the most common cause of AKI in both age groups. In both age groups, the most common cause was dehydration; in the group of patients up to 65 years of age, dehydration was 29.17%; in the group of people over 65 years - 43.39%. Renal replacement therapy in patients with AKI was used in 14.29% of patients. In the group of patients up to 65 years of age hemodialysis was 16.67% and above 65 years of age. -13.21% of patients. The average creatinine level in the group of younger patients at admission was 5.16 ± 3.71 mg / dl, in the group of older patients 3.14 ± 1.63 mg / dl. The size of glomerular filtration GFR in the group of younger patients at admission was 21.14 ± 19.54 ml / min, in the group of older patients 23.34 ± 13.33 ml / min. The main cause of acute kidney injury regardless of the age group was dehydration. Due to the high percentage of AKI in the elderly, this group requires more preventive action, not only in the hospital but also at home.

The need for palliative care among patients with chronic diseases: a situational diagnosis in a university hospital

Abstract Objective: To perform a situational diagnosis of a population hospitalized with chronic non-communicable diseases (NCD) who are potentially entitled to palliative care in a university hospital. Method: A quantitative study with document analysis was carried out. The analyzes were categorized by the following variables: baseline diagnosis, age, sex, readmission and PPS (Palliative Performance Scale) score. Results: Over two months of research among 631 hospitalized patients, 198 patients who were potentially entitled to palliative care were identified; 113 (57.1%) of whom were older adults. Cancer was the disease with the highest incidence among the surveyed, with 95 cases, and was more recurrent in the older patient group, with 52 cases (62.1%). Similarly, multiple hospitalizations were more prevalent in the older population, and patients diagnosed with strokes had the longest hospitalizations. Conclusion: The situational diagnosis carried out was relevant as it identified a group of patients, the majority of whom were older, who may be neglected in terms of their right to palliative care and an improved quality of death.

PSTAT3 expression associated with survival and mammographic density of breast cancer patients

BackgroundConstitutive activation of STAT3 have been shown in several tumor types including breast cancer. We investigate STAT3 expresion as possible molecular marker for breast cancer early detection, as well as prognostic factor for determination of tumor agressiveness. MethodsIn this study we measure p(Y705)STAT3 expression in tumor and adjacent tissue of breast cancer patients by Western blot. For relapse-free survival (RFS) and overall survival (OS) we used Log-Rank test. ResultsWe show that average expression of p (Y705) STAT3 in tumor tissue is higher compared to adjacent tissue. Moreover, we found that patients with HER2 positive receptors had significantly higher pSTAT3 expression compared to HER2 negative patients. We showed that patients with high mammographic density had significantly higher tumor expression of pSTAT3 compared to patients with low mammographic density. Also, we show that pSTAT3 expression correlates with longer RFS in the entire group of patients, as well as in the group of ER positive, in lymph node positive and in older group of breast cancer patients (with age over 50). Furthermore, in the entire group of patients, in ER positive, in lymph node positive and in older group of patient, high expression of pSTAT3 showed a better survival than low expression of pSTAT3. ConclusionConsidering that the expression of pSTAT3 is associated with longer RFS and survival, it can be used as prognostic tools for determination of group of breast cancer patients with low-risk.

Dose-Adjusted Intensive Chemotherapy Is Safe and Tolerable in Older Patients with Ph-Negative Acute Lymphoblastic Leukemia

BackgroundThe outcomes of older adults with acute lymphoblastic leukemia (ALL) remain poor when compared to younger ALL patients [PMID 19897583, 28419558, 22409379, 10653870]. Asparaginase (Asp) induces death of human lymphoblasts, and effective asparagine depletion is associated with improved outcomes in ALL. PEG-Asparaginase (PEG-Asp), which has a longer half-life than Asp, is a key component of the intensive chemotherapeutic regimens utilized for treatment of pediatric and younger adult ALL [PMID 29450465]. Frequently, older patients with Ph-negative ALL are not offered PEG-Asp containing pediatric chemotherapy regimen because of concerns related to tolerability and safety in this population [PMID 28355969].MethodsThe Adult Leukemia Program at Mount Sinai Hospital developed an age-based, dose-adjusted, CALGB 10403 based intensive chemotherapy regimen for adults (≥40 years) with a diagnosis of Ph-negative ALL. For patients up to 60 years, prednisone (PRD) dose was reduced from 60 to 40 mg/m2/day from D1 to D28, and PEG-Asp reduced from 2500 to 1000 units/m2 (D4). For patients aged 61 years and above, PRD was further reduced to 25 mg/m2/day, and PEG-Asp to 1000 units/m2 on D4. In CD20+ ALL, rituximab x 8 doses were added to the regimen. CNS-prophylaxis consisted of intrathecal methotrexate at D1, D8 and D29 during induction, and during subsequent courses of chemotherapy based on the CALGB 10403 protocol. A PEG-Asp oriented supportive care plan was developed to prevent and treat Asp-related adverse effects. After the administration of PEG-Asp, Antithrombin III (ATIII) and fibrinogen levels were monitored on the same day, twice a week, for at least two weeks. If ATIII levels were < 70% and/or fibrinogen levels < 120 mg/dL, levels were corrected with the administration of ATIII concentrate and/or cryoprecipitate, respectively.ResultsTwelve patients with a median age of 58 years (45 - 76) were evaluable, and three patients were ≥ 70 years. Nine patients had B-cell ALL and three T-cell ALL. Three patients had a white blood cell count > 30 x103/µL at diagnosis. An ECOG status ≤ 2 at diagnosis was described in all patients, and all of them had multiple complex cytogenetic and molecular abnormalities. Ten patients had significant co-morbidities at diagnosis, including diabetes, hypertension, previous history of cancer, coronary artery disease, obesity, alcohol related chronic pancreatitis, and chronic diarrhea. Nine out of the twelve patients (75%) attained a bone marrow morphological complete remission (CR) at the end of induction (EOI), three of them with detectable minimal residual disease (MRD) that became undetectable after completing course II. Of the three patients who had ≥5% bone marrow blasts at EOI, one attained a CR with undetectable MRD at the end of course IA and another when switched to blinatumomab, and the third one died of progressive disease. No patient experienced early death. Five patients underwent allogeneic hematopoietic stem cell transplantation (HCT) while in CR (age range 46 to 60 years) and four remain in CR at last follow up (median 489 days, range 181 - 841), and one died of relapsed disease 67 days post-HCT. The other six patients who are receiving chemotherapy are alive and in remission at last follow up (median 272 days, range 52 - 639).The common adverse effects associated with PEG-Asp administration in this older group of patients were asymptomatic hypofibrinogenemia and depleted ATIII levels requiring supplementation (n=8), severe hyperbilirubinemia (n=1), and non-life-threatening venous thrombosis (n=1). Severe allergic reaction, clinical pancreatitis and cognitive impairment were not observed.ConclusionThis age-based dose-adjusted PEG-Asp containing regimen was associated with an encouraging CR rate and a tolerable and manageable adverse event profile in this older patient population with significant co-morbidities. Treatment related mortality was 0%. Ten of 12 patients are currently in sustained remission, either with chemotherapy alone or following allogeneic HCT (median follow up 422 days, range 52 to 841 days). Treatment optimization for older patients with ALL utilizing an intensified, age-adjusted PEG-Asp containing induction and consolidation therapy regimen is associated with favorable outcomes and provides an effective bridge to potentially curative therapies such as HCT. Further prospective evaluation is under way. DisclosuresKremyanskaya:Incyte: Research Funding. Mascarenhas:Incyte: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Research Funding; Promedior: Research Funding; Janssen: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Merck: Research Funding; CTI Biopharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Research Funding.

The Conundrum of Hydroxyurea Use and Health Care Utilization in Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is a chronic condition associated with a decreased lifespan. Studies in adult and pediatric SCD populations have shown that hydroxyurea (HU) reduces the frequency and intensity of SCD painful events and decreases morbidity. Follow-up studies of MSH patients also showed cost effectiveness and improved survival for HU user. Adequate dosing and continuous daily adherence to HU use are necessary to achieve these benefits. The NIH Consensus Statement on HU Treatment for SCD had identified non-adherence as a major barrier to the effectiveness of HU therapy.The overarching aim of the study wasto describe the pattern of HCU and health quality indicators (HQI) in a SCD population at different ages of the transition period-data submitted in another abstract-. Here we present data supporting patterns of HU utilization and cost in three different SCD patient age-groups.Methods: We conducted a retrospective data analysis of health insurance claims from a single health plan for service dates 04/01/2016 through 03/21/2017. Members meeting the claims-based definition of SCD (those with any sickle cell related ICD 9/10 CM diagnosis code on two or more separate encounters on distinct dates during the study period) with 12 months of continuous membership were included in the analysis. Only members ages 11-35 years were selected based on study aims and then stratified into three groups representing pre-transition (Group A: 11-18 yr.), transition (Group B: 19-26 yr.), and adult (Group C: 27-35 yr.). Data obtained include demographics, utilization patterns such as: number and cost of Emergency Room (ED) visits, ED reliance rate and total cost of care. Health quality indicators (HQI) such as: hydroxyurea (HU) use, calculated HU medication possession ratio (MPR), influenza (Flu) vaccination status, and total cost and number of visits for PCP and specialists were also obtained. An ED ratio reliance ratio above 0.33 was considered an indicator of excessive reliance. HU medication possession ratio (MPR) of 1.0 was considered complete adherenceResults: One hundred-fourty-four patients, 88 (61%) female, fit the inclusion criteria. Patient number was similarly distributed in all groups: A: 50, B: 48, and C: 46. Medicaid was the primary insurance for 123 (85%) patients, followed by Commercial 15 (10%), and Medicare 6 (5%). The % of HU prescription filled was less than 4 in all three groups, the younger patients -pre-transition group- had 37 % vs. 33% for each of the two group of older patients. HU medication possession ratio was similar and low for all three groups: A=.27, B=.26 and C=.28; 1.0. Those on HU independently of the age groups had a lower rates of both lower and Higher ED reliance rate than those not on HU. For those on HU, the older patients-group C- was the only one with increase of higher ED reliance with compared with those with lower ED reliance (A: 7 vs. 12; B: 5 vs. 7 and C: 9 vs. 4). The Total Cost of Care of the pre-transition group was similar ~$22,000 between those prescribed HU and those not on HU. The total cost of care was twice as much for those study subjects on HU than for those on group B and C ($44,941 and $42,633). Those not on HU in the groups B and C had the lower total care cost ($25,817 and $17,763).Conclusion: After 20 years of HU approval by the FDA as a disease modifying therapy for SCD, analysis of insurance data regarding HU use, adherence and cost of care in SCD patients before, during and after transition from Pediatric to adult care, still reveals poor adherence and higher overall total care cost but, and lower ED reliance. This Conundrum supports the needs further emphasis on increasing education towards use and adherence to HU therapy, while continuing to develop new therapeutic interventions towards disease modification and cure. DisclosuresNo relevant conflicts of interest to declare.

Effectiveness and Safety of Roux-en-Y Gastric Bypass in Elderly Patients\u2014Systematic Review and Meta-analysis

IntroductionAs the population ages, there is more interest in bariatric surgery for older patients. There are controversies regarding the safety and effectiveness of surgical weight loss in this population.AimThe aim of this study was to compare the safety and efficacy of Roux-en-Y gastric bypass in patients over the age of 60 years with younger patients.MethodsThe available literature was searched for eligible studies up to February 2018. Inclusion criteria were reports on mortality, morbidity, percentage excess weight loss (%EWL), remission of diabetes, remission of hypertension, and remission of obstructive sleep apnea. Random effects meta-analyses were performed.ResultsThe initial search yielded 2000 references. The final meta-analysis involved nine studies and revealed significant differences in mortality (odds ratio 4.38, 95% confidence interval [1.25, 15.31], p = 0.02), morbidity (OR 1.88, CI [1.07, 3.30], p = 0.03), %EWL (mean difference − 5.86, 95% CI [− 9.15, − 2.56], p < 0.001), and remission of comorbidities.ConclusionHigher mortality and morbidity were found in the group of older patients. The analysis suggested lower effectiveness of Roux-en-Y gastric bypass for weight loss and improvement in comorbidity in older patients when compared with younger patients.

Assessment of usability and viability in clinical practice of the Nabelia mHealthCare Platform to support integrated care management of patients with pulmonary hypertension

Introduction : Pulmonary hypertension (PH) is a rare, life-threating disease that requires complex long term management, often involving coordination of actions across different agencies and jurisdictions. This is a challenging scenario to the effective delivery of care. Adoption of an integrated care (IC) approach with a sensible use of enabling technology can be a way of successfully dealing with this complexity. Aims : a) To assess the usability and potential feasibility in clinical practice of the Nabelia mHealthCare Platform, in the IC management of patients with Pulmonary Hypertension and; b) to identify areas in need of improvement in collaboration with patients and professionals Material and method : This qualitative research study involved two distinct groups chosen for convenience: 1) Patients’ group, patients with a pulmonary arterial hypertension (HAP) diagnose and/or chronic thromboembolic hypertension (HPTEC); and, 2) Health professionals’ group. In both groups, we carried out : 1) user tests followed by administration of a questionnaire (adaptation of the SUMI questionnaire items); 2) Focus groups sessions (1 patients, 1 professionals). A total of 23 people participated in this study (12 patients, 7 practitioners and 4 nurses). Informed consent was obtained from all participants. The study was completed by a heuristic assessment of the platform that was undertaken by a specially trained researcher. Results : Professionals highlighted that the Platform facilitated: 1) the sharing of information (notably in the case of treatment prescribed), 2) coordination of actions (remote monitoring data) and 3) communication with patients. Patients’ appraisals of the platform differed. Globally, it was viewed as an interesting tool and patients especially valued the accessibility to the information about their condition and the easiness to share this information with the different health professionals. Perceptions on the benefits of using the mobile application to manage everyday life depended on patients’ age and treatments’ complexity. Thus, younger patients were more favorable towards its use while elders were more reluctant. Heuristic evaluation. The aspects that were best ranked where those related with the clarity of the interface (adequate management of spaces and text, visual structure of the information, easily recognizable links), consistency in its design (elements, actions, language, navigation), and architecture (organizational system, elements and terms used in the navigation menu). Usability elements in need of attention were those related with system status, information flow, aid in its actions, clarity of information, control by user, readability and configuration. The application is easy to learn and uses standard tags and a language close to professionals with helpful graphics though in some parts readability could be improved. Control of the application by the user was acceptable at the current status of development. Conclusions : At its current stage of development the Nabelia mHealthCare Platform has a good usability and can be potentially applied in the management of patients with pulmonary hypertension. Professionals and patients think that the application facilitates the management of the disease, allows closer follow-up and monitoring and improves coordination across levels of health care. Attention to acceptance and usability issues in the group of older patients is, however, required.

Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort

BackgroundEndovascular aneurysm repair (EVAR) has decreased the perioperative mortality for patients undergoing abdominal aortic aneurysm repair and has increased the rates of elective aneurysm repair in the elderly. However, Medicare will not cover abdominal aortic aneurysm screening for beneficiaries over 75 years of age. Consequently, abdominal aortic aneurysm treatment in this population depends on incidental detection. Targeted coverage for screening in this population, however, might be beneficial for a subgroup of patients. MethodsTo identify a subset of elderly patients who would potentially benefit from an expanded screening policy, we reviewed all patients greater than 75 years old undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2016. We used Cox regression with multivariable fractional polynomials to construct a risk model for 5-year survival in elderly patients to identify a subpopulation who might benefit the most from screening and performed internal validation using the bootstrapping technique. ResultsWe identified 10,676 patients greater than 75 years old undergoing elective EVAR. Although perioperative mortality varied with age, it was only 2.1% in the oldest group of patients (>85 years). Significant predictors included in our final risk model for 5-year survival in the elderly included age, aortic diameter, hemoglobin, current smoking, white race, body mass index, renal function, congestive heart failure, statin use, chronic obstructive pulmonary disease, and ejection fraction. The risk model produced risk scores ranging from a possible −2 to 33. The mean and median risk score were 6.9 and 6.0, respectively, with a right skew. We categorized the risk scores into four groups: −2 to 4 points, 5-8 points, 9-13 points, and more than 13 points, with associated 5-year survivals of 88%, 79%, 68%, and 49%, respectively. The model showed adequate discrimination and calibration, with a C-statistic of 0.69 and a calibration score of 0.99 (predicted 5-year survival of 0.78 compared with an observed 5-year survival of 0.77) and a Brier score of 0.15. Internal validation demonstrated an optimism-corrected C-statistic of 0.69 and a calibration slope of 1.0. ConclusionsElective EVAR in elderly patients chosen to undergo repair is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening into all but the highest risk group based on expected postoperative 5-year survival to justify removing this Medicare coverage restriction.

PS02.179: NUTRITIONAL STATUS DIFFERENCES BETWEEN YOUNG AND ELDERLY PATIENTS UNDERGOING SURGERY FOR ESOPHAGEAL AND GASTROESOPHAGEAL JUNCTION CANCER

Abstract Background Esophageal cancer patients often suffer from malnutrition. Older people constitute a group of patients more susceptible to nutritional status deterioration. The aim of this study is to investigate the differences in nutritional status between elderly patients and patients younger than 65 years of age with esophageal and gastroesophageal junction cancer. Methods The study sample consisted of 73 patients with esophageal (n = 11) and gastroesophageal junction cancer (n = 62) who were admitted for surgery in the First Department of Surgery, Laikon General Hospital, Athens, Greece, between September 2015 and December 2017. Patients were divided into 2 groups according to their age, those younger than 65 years (n = 39) and those older than 65 years (n = 34). The preoperative assessment of nutritional status was based on Patient Generated Subjective Global Assessment (PG-SGA), laboratory tests, anthropometric measurements, handgrip strength, unintentional weight loss during the last six months and Skeletal Muscle Index (SMI) derived from analysis of CT scans. Results Malnutrition and sarcopenia were more prevalent in the group of older patients compared to the group of younger ones (73.5% vs 41%, P &lt; 0.05 and 60% vs 35.3%, P &lt; 0.05). PG-SGA was significantly higher in elderly patients (12.35 vs 8.23, P &lt; 0.05), while SMI and handgrip strength were significantly lower in elderly patients (48.47 cm2/m2 vs 55.5 cm2/m2, P &lt; 0.05 and 31 kg vs 39.1 kg, P &lt; 0.05 respectively). Among the laboratory tests, albumin, hemoglobin and hematocrit were lower in the group of older patients (3.86 g/dL vs 4.15 g/dL, P &lt; 0.05, 12.25 g/dL vs 13.17 g/dL, P &lt; 0.05 and 36.5 vs 39.5, P &lt; 0.05, respectively), whereas platelet-to-lymphocyte ratio was higher (205.4 vs 156.2, P &lt; 0.05). Concerning anthropometric measurements, corrected mid arm muscle area and calf circumference were lower in older patients (42.15 cm2 vs 49.26 cm2, P &lt; 0.05 and 34.86 cm vs 36.89 cm, P &lt; 0.05, respectively), whereas no significant differences were observed in Body Mass Index values and unintentional weight loss between the two groups. Conclusion Geriatric patients with esophageal and gastroesophageal junction cancer have more compromised nutritional status compared to their younger counterparts. Preoperative nutritional assessment should be performed in all such patients in order to detect those who will benefit from perioperative nutritional support. Disclosure All authors have declared no conflicts of interest.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P125. Comparing the impact of elderly age on outcomes following cervical spinal fusion: a statewide analysis with two-year follow-up

BACKGROUND CONTEXT Cervical spinal fusion (CF) is employed for treating degenerative spine diseases, which are age-related conditions. Despite the age-dependent nature of these conditions, there is little evidence comparing the outcomes of elderly adults to active adults. It is possible that patient age has a significant effect on postoperative outcomes following cervical spinal fusion. PURPOSE This study evaluated the: (1) demographics, (2) complications, (3) length of stay, (4) hospital charges, (5) reoperations and (6) readmissions following cervical spinal fusion. We hypothesized that elderly patients will experience poorer outcomes compared to younger adults after cervical spinal fusion. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE All patients 45-64years and ≥80years of age who underwent elective cervical spinal fusion between 2009 and 2011 and were eligible for at least two year follow-up were identified from the New York Statewide Planning and Research Cooperative System (SPARCS). A total of 14,578 patients were included, 3.4% of which were ≥80years old and 96.6% of which were 45-64years old. OUTCOME MEASURES Demographic information, complications, length of stay, hospital charges, reoperations and readmissions METHODS The New York Statewide Planning and Research Cooperative System (SPARCS) database was utilized to identify all elective cervical spinal fusions performed from 2009 to 2011 by ICD-9-CM code. Demographics including age, sex and race as well as perioperative factors, and two year postoperative complication, reoperation and readmission rates were collected for all patients. This cohort was then placed in two groups based on age: 45-64years and ≥80years. Patients outside of these ages were excluded. These two groups were then compared with univariate analysis. Regression models were developed and attempted to identify potential predictive factors for two-year postoperative outcomes. RESULTS A total of 14,578 patients were included, with 96.6% 45-64years (Younger) and 3.4% ≥ 80years (Older) old at time of surgery. Older patients were more commonly male (54.0vs. 50.1%, p CONCLUSIONS This study compared outcomes between patients ≥80years old and patients 45-64years old following cervical spinal fusion. The older patient group had higher two-year complication and reoperation rates. Patient age was a significant predictor for higher complication and revision rates. This study should assist spine surgeons preoperatively in risk-stratifying and counseling patients for postoperative outcomes after cervical spinal fusion.