High-risk Comorbidities Research Articles

Managing the delivery of quality cancer care during the COVID-19 pandemic in a small community cancer clinic.

45 Background: The global pandemic resulting from COVID-19 has resulted in over 400,000 deaths and nearly 7 million active cases at the time of writing this abstract (World Health Organization, 2020). This Public Health Emergency (PHE) represents an unprecedented challenge for oncologists and cancer patients alike. They are met with the challenge of providing uninterrupted care to cancer patients, a predicament that includes a balance between the use of immunosuppressive chemotherapy, it’s potential impact on contracting COVID-19 and the risk of cancer progression. Liang et al reported that cancer patients were not only at very high risk of contracting COVID -19, but also at a much higher risk of complications and death. Our medium sized oncology practice rapidly adapted to meet the challenge to continue to provide care. Methods: Employee and patient safety: Implement CDC recommendations in waiting room, infusion suites and supply of PPE. Categorize patients into priorities based on severity and need of treatment. Implement telehealth. Implement care in accordance to Cancer Patients Assessment and Treatment Priority Determination (top, intermediate and low priority)–Table. As a part of our initial strategy, we discussed the risk and balance of postponing chemotherapy or elective surgery for stable cancer patients during the first phase of closures. We also focused on more intensive surveillance in the older patient population or those with multiple high-risk comorbidities. For patients in complete remission on maintenance therapy, we balanced risk and benefit of stopping chemotherapy. In other patients, we considered the option of switching their chemotherapy regimen from IV to oral therapies, where clinically appropriate, to decrease the frequency of clinic visits and potential exposure. In cases where the option of non-immunosuppressive oral therapy is existed, we implemented the same. Results: Our clinic continues to provide uninterrupted care since the declaration of PHE. We saw a drop of 25% patient volume in March and 35% in April. However, with instant adaptation and implementation of CDC recommendations patient volume reached back to pre COVID 19 related emergency. None of our employees, their dependents nor any of our patients have contracted COVID-19 to date (according to DHEC feedback) at the time of writing. We had a total of 5082 patients visits (1261 chemo visits). Conclusions: By implementing the right steps and precautions, it is possible to provide continued care for and protect staff, physicians and patients. [Table: see text]

Parkinsonian gait in elderly people: Significance of the threshold value of two and more falls per year.

Parkinsonism in the elderly presents a major risk factor for recurrent falls (2 and more falls per year), which is associated with increased morbidity. The main objective was to investigate explanatory variables relating to the risk of being recurrent fallers (RF) in persons with parkinsonian gait. Seventy-nine among 172 eligible persons were enrolled in this prospective study, the findings of which were analyzed at 12 months. Motor and non-motor features, as well as follow-up interviews to identify falls, loss of ability to walk, fluctuating cognition, traumatic falls, all-cause hospitalizations and deaths were collated and results compared between non RF (zero and one fall per year) and RF. Bayesian model averaging was used to predict the probability of patients being RF from their medical history as well as from cognitive assessment, gait velocity, vision and posture. N=79, 0.58 men, 50% had Parkinson's disease, 14% other neurodegenerative parkinsonian syndrome, 23% vascular parkinsonism and 13% Lewy body disease, 58% were RF. Median age 81.2 years and median MMSE 25/30. A history of falls and of hallucinations, median odds ratio respectively 9.06 (CI 2.34-38.22), 4.21 (CI 1.04-18.67) were associated with the highest odds ratios along with fluctuating cognition and abnormal posture. Two or more falls a year was a relevant threshold to distinguish a population with a high risk of comorbidity. The whole history of falls, hallucinations and fluctuating cognition can be considered predictive of recurrent falls in elderly people with parkinsonian gait and provide a tracking tool for patient management.

Imported melioidosis in the United Kingdom: Increasing incidence but continued under-reporting

Melioidosis, caused by the environmentally-acquired bacterium Burkholderia pseudomallei, is increasingly recognised as a globally significant public health problem, although difficult to diagnose and manage. We aimed to review all cases diagnosed in the UK since 2010, when notification became a legal requirement. This was compared with statutory reporting to assess completeness of surveillance. A novel dataset was compiled comprising routinely collected clinical and demographic details for isolates of B. pseudomallei referred to Public Health England’s reference laboratory. Isolates were cross-referenced with an existing database of mandatory reports of B. pseudomallei made under the Health Protection (Notification) Regulations 2010 to determine completeness of surveillance. The literature was also searched for missed non-referred or reported cases. Forty-six UK cases of melioidosis were identified from January 2010-July 2019. The majority of affected patients were male (65.2%); median age was 53. Four had cystic fibrosis. Other co-morbidities were poorly captured by current surveillance mechanisms. Respiratory disease, sepsis and abscess formation were the most common presenting features. Eighteen had acquired infection in Thailand; two cases were associated with travel to Nigeria. 40 UK cases were confirmed as B. pseudomallei by the reference laboratory. Nineteen of the identified cases were not found on the database of notified causative agents. Five patients had been notified with no confirmatory isolate received. Discordance between mandatory notification and isolate referral emphasises the challenges in routine epidemiological surveillance, even in a well-resourced, high-income country. The wide variety of presentations highlights the difficulties in clinical diagnosis. Cases identified following travel to Africa add further evidence that the disease is more widespread than previously thought. Sixteen patients required intensive care management, underlining challenges faced in resource limited settings. Individualised pre-travel counselling should be performed in travellers with high-risk comorbidities such as cystic fibrosis.

CLINICAL OUTCOMES AND HEALTHCARE RESOURCE UTILIZATION IN ADULT HIGH-RISK PATIENTS WITH NONCYSTIC FIBROSIS BRONCHIECTASIS USING HIGH FREQUENCY CHEST WALL OSCILLATION AND POSITIVE EXPIRATORY PRESSURE THERAPY

SESSION TITLE: Obstructive Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: In current clinical practice, airway clearance therapy is important in the overall management of patients with bronchiectasis. We aimed to compare healthcare resource utilization (HCRU) and costs among adults with high risk bronchiectasis after initiation of high frequency chest wall oscillation (HFCWO) and positive expiratory pressure (PEP) therapy. METHODS: A pre-post analysis of two mutually exclusive cohorts was conducted using the PharMetrics Health Plan Claims Database. Adult patients with Non-CF bronchiectasis, a high-risk Bronchiectasis Aetiology and Comorbidity Index (BACI) score of >6, and a claim for HFCWO or PEP between 2009 - 2018 were included. Clinical outcomes, HCRU and costs were measured in the 12-months pre- and post-index periods in each cohort. Comparisons to baseline data were conducted using McNemar’s test for categorical and Wilcoxon signed-rank test for continuous variables. RESULTS: In the HFCWO cohort (N=147), the mean age was 56.4 years (SD=14); 64% were females. COPD (88%) and asthma (72%) were common comorbidities. At one-year follow-up from initiation of HFCWO therapy, there was a statistically significant reduction in mean all-cause (22%, P=0.04) and disease-specific hospitalizations, (73%, P=0.01) compared to baseline. All-cause and disease-specific bronchoscopies reduced by 69% (P<0.0001) and 75% (P<0.001), respectively. Chest X-ray use reduced by 25% (P<0.001) and 38% (P=0.02), respectively. Disease-specific laboratory use decreased by 31% (P<0.01). Oral and IV antibiotics use reduced by 8% (P=0.03) and 63% (P=0.01), respectively. Pulmonologist visits reduced by 11% (P<0.01). Disease-specific ED visits trended down. All-cause inpatient costs decreased significantly from $23,774 to $12,028 (P<.01). In the PEP cohort (N=138), mean age was 63.7 years (SD=14); 59% were females. COPD (74%) and asthma (58%) were common comorbidities. At one-year follow-up from initiation of PEP therapy, mean all-cause and disease-specific hospitalizations trended up. Physician office visits increased by 17% (P=0.03). Use of hypertonic saline nebulization increased (P=0.01). Oral antibiotic use reduced by 11% (P=0.02) while IV antibiotic use did not change. All-cause and disease-specific bronchoscopies trended down. Disease-specific ED visits, chest X-ray, and laboratory use all trended up. Mean disease specific outpatient costs increased (P=0.04). Median disease-specific total costs increased significantly (P=0.04) CONCLUSIONS: In high risk bronchiectasis patients, HFCWO significantly improves clinical outcomes by reducing hospitalizations, antibiotics use and other health care resource utilization measures. High risk bronchiectasis patients started on PEP therapy had less favorable outcomes. CLINICAL IMPLICATIONS: In bronchiectasis patients with a high risk BACI score, HFCWO therapy should be considered for airway clearance as it has been shown to improve clinical and economic outcomes. DISCLOSURES: Advisory Board relationship with Insmed Please note: $1001 - $5000 by Ashwin Basavaraj, source=Web Response, value=Honoraria Consultant relationship with Hill-Rom Please note: $1001 - $5000 by Ashwin Basavaraj, source=Web Response, value=Consulting fee Employee relationship with Hill-Rom Company Inc. Please note: >$100000 Added 06/01/2020 by Brian Becker, source=Web Response, value=Salary Stock Ownership relationship with Hill-Rom Company Inc. Please note: $20001 - $100000 Added 06/01/2020 by Brian Becker, source=Web Response, value=Stock Ownership No relevant relationships by Mitch Dekoven, source=Web Response Employee relationship with Hillrom Please note: >$100000 Added 06/01/2020 by Angela Murray, source=Web Response, value=Salary No relevant relationships by Drishti Shah, source=Web Response Employee relationship with Hillrom Please note: >$100000 Added 06/01/2020 by Carlos Urrea, source=Web Response, value=Salary Employee relationship with Hill-Rom Inc Please note: >$100000 Added 05/31/2020 by Missy Wanjala, source=Web Response, value=Salary

Rivaroxaban and Aspirin in Patients With Symptomatic Lower Extremity Peripheral Artery Disease

Patients with symptomatic lower extremity peripheral artery disease (LE-PAD) experience an increased risk of major vascular events. There is limited information on what clinical features of symptomatic LE-PAD prognosticate major vascular events and whether patients at high risk have a greater absolute benefit from low-dose rivaroxaban and aspirin. To quantify the risk of major vascular events and investigate the response to treatment with low-dose rivaroxaban and aspirin among patients with symptomatic LE-PAD based on clinical presentation and comorbidities. This is a subanalysis of a previously reported subgroup of patients with symptomatic LE-PAD who were enrolled in a large, double-blind, placebo-controlled randomized clinical trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies [COMPASS]) in 602 centers in 33 countries from March 2013 to January 2020. Data analysis was completed from May 2016 to June 2020. A combination of low-dose rivaroxaban and aspirin compared with aspirin alone. Thirty-month incidence risk of myocardial infarction, stroke and cardiovascular death (MACE), major adverse limb events (MALE) including major vascular amputation, and bleeding. The COMPASS trial enrolled 4129 patients with symptomatic LE-PAD (mean [SD] age, 66.8 [8.8] years; 2932 men [71.0%]). The 30-month Kaplan-Meier incidence risk of MACE or MALE, including major amputation, was 22.6% in those with prior amputation (this outcome was observed in 54 patients), 17.6% (n = 15) in those with Fontaine III or IV symptoms, and 11.8% (n = 142) in those with previous peripheral artery revascularization, classifying these features as high-risk limb presentations. The 30-month incidence risk of MACE or MALE, including major amputation, was 14.1% (n = 118) in those with kidney dysfunction, 13.5% (n = 67) in those with heart failure, 13.4% (n = 199) in those with diabetes, and 12.8% (n = 222) in those with polyvascular disease, classifying these features as high-risk comorbidities. Among patients with either high-risk limb presentations or high-risk comorbidities, treatment with rivaroxaban and aspirin compared with aspirin alone was associated with an estimated 4.2% (95% CI, 1.9%-6.2%) absolute risk reduction for MACE or MALE, including major amputation, at 30 months. Although the estimated absolute risk increase of major bleeding was higher with rivaroxaban and aspirin in combination than aspirin alone (2.0% [95% CI, 0.5%-3.9%]) for patients with either high-risk limb presentation or high-risk comorbidity, the estimated absolute risk increase of fatal or critical organ bleeding was low in this high-risk group (0.4% [95% CI, 0.2%-1.8%]), such that the net clinical benefit was estimated to be 3.2% (95% CI, 0.6%-5.3%). Patients with LE-PAD with high-risk limb presentations or high-risk comorbidities had a high incidence of major vascular events. For these patients, treatment with rivaroxaban and aspirin in combination compared with aspirin alone led to a large absolute reduction in vascular risk.

Access to Care Matters: Remote Health Care Needs During COVID-19.

Background: The coronavirus disease 2019 (COVID-19) pandemic is straining health care worldwide with >31 million confirmed cases. Currently, 1 in every 100 U.S. residents and 245,000 in New York City are confirmed positive. The Bronx, with high-risk comorbidities, due in part to socioeconomic factors, has seen disproportionately higher rates of COVID-19-related complications. Poor health care access is exacerbated as in-person visits now pose viral transmission risk. There has been limited discourse regarding widespread disparities underlying transitions to telemedicine. Methods: We review perspectives in recent literature on telemedicine and its potential within neurology. Results: While telemedicine has reduced strain on in-person visits, preliminary reflections highlight implementation successes and challenges. Conclusions: To provide effective care beyond this crisis, fundamental changes in training, technological accessibility, and health care policy are needed. We propose open access to telehealth training, screening of patient's potential technological inequities and socioeconomic insecurities, and advocacy to secure broad long-term access to telehealth care.

Return Hospital Admissions Among 1419 COVID-19 Patients Discharged from Five U.S. Emergency Departments.

Although many ED patients with known or suspected Covid-19 require hospital admission, the majority are discharged home. Concern for surges in hospital occupancy compel emergency providers to preserve inpatient resources and discern which patients benefit most from admission. Even in the absence of surge conditions, patients may prefer to recover at home if safe to do so. However, some patients with Covid-19 experience delayed decompensation.

The Perfect Storm: COVID-19 Health Disparities in US Blacks.

Coronavirus disease 2019 (COVID-19) accounts for over 180,000 deaths in the USA. Although COVID-19 affects all racial ethnicities, non-Hispanic Blacks have the highest mortality rates. Evidence continues to emerge, linking the disproportion of contagion and mortality from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a result of adverse social determinants of health. Yet, genetic predisposition may also play a credible role in disease transmission. SARS-CoV-2 enters cells by interaction between SARS-CoV-2 spike protein and the receptor molecule angiotensin converting enzyme 2 (ACE2) expressed on the surface of the target cells, such that polymorphisms and the expression level of ACE2 influence infectivity and consequent pathogenesis of SARS-CoV-2. Genetic polymorphisms in other multiple genes, such as acetylcholinesterase (AChE) and interleukin-6, are also closely associated with underlying diseases, such as hypertension and type 2 diabetes mellitus, which substantially raise SARS-CoV-2 mortality. However, it is unknown how these genetic polymorphisms contribute to the disparate mortality rates, with or without underlying diseases. Of particular interest is the potential that genetic polymorphisms in these genes may be influencing the disparity of COVID-19 mortality rates in Black communities. Here, we review the evidence that biological predisposition for high-risk comorbid conditions may be relevant to our ability to fully understand and therefore address health disparities of COVID-19 deaths in Blacks.Electronic supplementary materialThe online version of this article (10.1007/s40615-020-00871-y) contains supplementary material, which is available to authorized users.

Adjuvant Chemotherapy and Tumor Sidedness in Stage II Colon Cancer: Analysis of the National Cancer Data Base.

Background: Current guidelines recommend discussion of adjuvant chemotherapy (AC) for stage II colon cancer (CC) with high-risk features despite lacking conclusive randomized trial data. We examined AC administration in this population and its effect on overall survival (OS) for available patient, tumor, and treatment characteristicsMethods: Using National Cancer Data Base, a cohort of 42,971 stage II CC patients diagnosed from 2004 to 2009, who underwent surgery with curative intent, was identified. Chi-square test and multivariate logistic regression were used to analyze baseline characteristics and to calculate odds of chemotherapy administration, respectively. Survival analysis was conducted using Kaplan Meier survival analysis with log-rank test and Cox proportional hazards regression modeling.Results: AC was administered to 26% patients. The use decreased with advancing age and elderly patients received more single-agent than multi-agent chemotherapy (3 vs. 2.4%, p < 0.0001). Major predictors of AC use included pT4 status, evaluation of <12 lymph nodes, high grade tumors, positive resection margins, age <65 years, left sided tumors, and low comorbidity score. AC was associated with improved OS regardless of high-risk features (pT4, undifferentiated histology, <12 lymph node evaluation, or positive resection margins), tumor location, age, gender, comorbidity index, chemotherapy regimen or type of colectomy (adjusted HR: single-agent 0.55, multi-agent 0.6; p < 0.0001). In subgroup analysis, AC use compensated for the survival differences otherwise seen between left and right sided tumors in the non-chemotherapy population.Conclusion: AC in stage II CC was associated with improved OS regardless of age, chemotherapy type or high-risk features. It improved 5-years OS irrespective of tumor location and seemed to compensate for the survival difference seen between right and left sided tumors noted in the non-chemotherapy group.

Insights Into the Controversial Aspects of Adiponectin in Cardiometabolic Disorders.

In 2016, the World Health Organization estimated that more than 1.9 billion adults were overweight or obese. This impressive number shows that weight excess is pandemic. Overweight and obesity are closely associated with a high risk of comorbidities, such as insulin resistance and its most important outcomes, including metabolic syndrome, type 2 diabetes mellitus, and cardiovascular disease. Adiponectin has emerged as a salutary adipocytokine, with insulin-sensitizing, anti-inflammatory, and cardiovascular protective properties. However, under metabolically unfavorable conditions, visceral adipose tissue-derived inflammatory cytokines might reduce the transcription of the adiponectin gene and consequently its circulating levels. Low circulating levels of adiponectin are negatively associated with various conditions, such as insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. In contrast, several recent clinical trials and meta-analyses have reported high circulating adiponectin levels positively associated with cardiovascular mortality and all-cause mortality. These results are biologically intriguing and counterintuitive, and came to be termed "the adiponectin paradox". Adiponectin paradox is frequently associated with adiponectin resistance, a concept related with the downregulation of adiponectin receptors in insulin-resistant states. We review this contradiction between the apparent role of adiponectin as a health promoter and the recent evidence from Mendelian randomization studies indicating that circulating adiponectin levels are an unexpected predictor of increased morbidity and mortality rates in several clinical conditions. We also critically review the therapeutic perspective of synthetic peptide adiponectin receptors agonist that has been postulated as a promising alternative for the treatment of metabolic syndrome and type 2 diabetes mellitus.

Molecular and Cellular Mechanisms of Arthritis in Children and Adults: New Perspectives on Applied Photobiomodulation.

Juvenile idiopathic arthritis and adult rheumatoid arthritis are two major groups with chronic joint pain and inflammation, extra-articular manifestations, and high risk of comorbidities, which can cause physical and ocular disability, as well as create great socio-economic pressure worldwide. The pathogenesis of arthritis manifested in childhood and adulthood is multifactorial, unclear, and overly complex, in which immunity plays an important role. Although there are more and more biological agents with different mechanisms of action for the treatment of arthritis, the results are not as expected, because there are partial responses or non-responsive patients to these compounds, high therapeutic costs, side effects, and so on; therefore, we must turn our attention to other therapeutic modalities. Updating knowledge on molecular and cellular mechanisms in the comparative pathogenesis of chronic arthritis in both children and adults is necessary in the early and correct approach to treatment. Photobiomodulation (PBM) represents a good option, offering cost-effective advantages over drug therapy, with a quicker, more positive response to treatment and no side effects. The successful management of PBM in arthritis is based on the clinician’s ability to evaluate correctly the inflammatory status of the patient, to seek the optimal solution, to choose the best technology with the best physical parameters, and to select the mode of action to target very precisely the immune system and the molecular signaling pathways at the molecular level with the exact amount of quantum light energy in order to obtain the desired immune modulation and the remission of the disease. Light is a very powerful tool in medicine because it can simultaneously target many cascades of immune system activation in comparison with drugs, so PBM can perform very delicate tasks inside our cells to modulate cellular dysfunctions, helping to initiate self-organization phenomena and finally, healing the disease. Interdisciplinary teams should work diligently to meet these needs by also using single-cell imaging devices for multispectral laser photobiomodulation on immune cells.

Endovascular Treatment Versus Surgery in Long Occlusions of the Superficial Femoral Artery about 50 Cases

Surgical treatment is considered the gold standard for the management of complex lesions in FSA and is currently in competition with the improvement of new endovascular techniques. The aim of this work is to compare the two revascularization techniques in terms of efficacy, morbidity and mortality, which is based on a retrospective study of 50 cases of long FSA occlusions treated either by surgical treatment or by endovascular, at the vascular surgery department of Avicenna military hospital in Marrakech during the period between January 2014 to December 2016. The mean age of our patients was higher in the endovascular treatment group compared to the surgical treatment group, (68.5 years versus 62.3) respectively, we noted a male predominance in both groups. Critical lower extremity ischaemia was the most common reason for consultation in both groups: 76.7% in the endovascular treatment group and 80% in the surgical treatment group. All the patients had received the necessary explorations to assess the lesion as well as the extension of the atherosclerotic disease. The technique was successful in 100% of cases, without any major postoperative complications or death, the average length of hospital stay was lower in the endovascular treatment group: one day compared to 4 days in the surgical treatment group. The primary and secondary patency at 12 months were similar in the two groups (73.3% versus 75%) and (83.3% versus 85%) respectively. Thanks to the improvement of endovascular techniques, the management of long occlusions of the superficial femoral artery therefore appears to be an attractive alternative to surgical treatment, more particularly for patients with high surgical risk and presenting numerous comorbidities.

Compassionate use of JAK1/2 inhibitor ruxolitinib for severe COVID-19: a prospective observational study

Overwhelming inflammatory reactions contribute to respiratory distress in patients with COVID-19. Ruxolitinib is a JAK1/JAK2 inhibitor with potent anti-inflammatory properties. We report on a prospective, observational study in 34 patients with COVID-19 who received ruxolitinib on a compassionate-use protocol. Patients had severe pulmonary disease defined by pulmonary infiltrates on imaging and an oxygen saturation ≤ 93% in air and/or PaO2/FiO2 ratio ≤ 300 mmHg. Median age was 80.5 years, and 85.3% had ≥ 2 comorbidities. Median exposure time to ruxolitinib was 13 days, median dose intensity was 20 mg/day. Overall survival by day 28 was 94.1%. Cumulative incidence of clinical improvement of ≥2 points in the ordinal scale was 82.4% (95% confidence interval, 71–93). Clinical improvement was not affected by low-flow versus high-flow oxygen support but was less frequent in patients with PaO2/FiO2 < 200 mmHg. The most frequent adverse events were anemia, urinary tract infections, and thrombocytopenia. Improvement of inflammatory cytokine profile and activated lymphocyte subsets was observed at day 14. In this prospective cohort of aged and high-risk comorbidity patients with severe COVID-19, compassionate-use ruxolitinib was safe and was associated with improvement of pulmonary function and discharge home in 85.3%. Controlled clinical trials are necessary to establish efficacy of ruxolitinib in COVID-19.

Asthma among hospitalized patients with COVID-19 and related outcomes

BackgroundSeveral underlying conditions have been associated with severe acute respiratory syndrome coronavirus 2 illness, but it remains unclear whether underlying asthma is associated with worse coronavirus disease 2019 (COVID-19) outcomes.ObjectiveGiven the high prevalence of asthma in the New York City area, our objective was to determine whether underlying asthma was associated with poor outcomes among hospitalized patients with severe COVID-19 compared with patients without asthma.MethodsElectronic heath records were reviewed for 1298 sequential patients 65 years or younger without chronic obstructive pulmonary disease who were admitted to our hospital system with a confirmed positive severe acute respiratory syndrome coronavirus 2 test result.ResultsThe overall prevalence of asthma among all hospitalized patients with COVID-19 was 12.6%, yet a higher prevalence (23.6%) was observed in the subset of 55 patients younger than 21 years. There was no significant difference in hospital length of stay, need for intubation, length of intubation, tracheostomy tube placement, hospital readmission, or mortality between patients with and without asthma. Observations between patients with and without asthma were similar when stratified by obesity, other comorbid conditions (ie, hypertension, hyperlipidemia, and diabetes), use of controller asthma medication, and absolute eosinophil count.ConclusionsAmong hospitalized patients 65 years or younger with severe COVID-19, asthma diagnosis was not associated with worse outcomes, regardless of age, obesity, or other high-risk comorbidities. Future population-based studies are needed to investigate the risk of developing COVID-19 among patients with asthma once universal testing becomes readily available.

Novel Temperature Trajectory Subphenotypes in COVID-19

Novel Temperature Trajectory Subphenotypes in COVID-19

Preexisting Comorbidities Predicting COVID-19 and Mortality in the UK Biobank Community Cohort.

BackgroundHospitalized COVID-19 patients tend to be older and frequently have hypertension, diabetes, or coronary heart disease, but whether these comorbidities are true risk factors (ie, more common than in the general older population) is unclear. We estimated associations between preexisting diagnoses and hospitalized COVID-19 alone or with mortality, in a large community cohort.MethodsUK Biobank (England) participants with baseline assessment 2006–2010, followed in hospital discharge records to 2017 and death records to 2020. Demographic and preexisting common diagnoses association tested with hospitalized laboratory-confirmed COVID-19 (March 16 to April 26, 2020), alone or with mortality, in logistic models.ResultsOf 269 070 participants aged older than 65, 507 (0.2%) became COVID-19 hospital inpatients, of which 141 (27.8%) died. Common comorbidities in hospitalized inpatients were hypertension (59.6%), history of fall or fragility fractures (29.4%), coronary heart disease (21.5%), type 2 diabetes (type 2, 19. 9%), and asthma (17.6%). However, in models adjusted for comorbidities, age group, sex, ethnicity, and education, preexisting diagnoses of dementia, type 2 diabetes, chronic obstructive pulmonary disease, pneumonia, depression, atrial fibrillation, and hypertension emerged as independent risk factors for COVID-19 hospitalization, the first 5 remaining statistically significant for related mortality. Chronic kidney disease and asthma were risk factors for COVID-19 hospitalization in women but not men.ConclusionsThere are specific high-risk preexisting comorbidities for COVID-19 hospitalization and related deaths in community-based older men and women. These results do not support simple age-based targeting of the older population to prevent severe COVID-19 infections.

High-Risk Comorbidity Influences Prognosis in Early Gastric Cancer after Noncurative Endoscopic Submucosal Dissection: A Retrospective Study

Background: There are few studies reporting the clinical outcomes of noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) from the perspective of patient health condition/status. Thus, the aim of this study was to investigate clinical outcomes of noncurative ESD considering not only curability but also patient factors such as advanced age, comorbidities, and nutritional status. Methods: Between April 2007 and March 2012, 95 patients who underwent noncurative ESD for EGC were enrolled in the study. Patients were categorized by treatment after ESD: additional gastrectomy (49 patients) and follow-up (46 patients). Clinical outcomes were evaluated between the 2 groups for overall survival (OS). Results: The absence of lymphovascular involvement and age ≥80 years were significantly associated with decision-making for observation after noncurative ESD. The OS rates were higher in female patients, patients with better Eastern Cooperative Oncology Group performance status (≤1) or low-risk comorbidity (Charlson Comorbidity Index [CCI ≤ 2]), patients with ulcerative findings, and those who underwent radical gastrectomy. Multivariate Cox proportional hazards analysis indicated that presence of a high-risk comorbidity (CCI ≥ 3) was a significant prognostic factor (hazard ratio: 16.43, p = 0.024) in patients who underwent noncurative ESD for EGC. Conclusion: High-risk comorbidity is the primary prognostic parameter in terms of patient factors after noncurative ESD for EGC. The CCI should be considered as a prognostic factor in patients who underwent noncurative ESD for EGC.

Supplementation of Low Ratio n-6:n-3 PUFA Reduces Body Fatness in Young Obese Balinese Women: A Randomized Study with Optimized Energy Regulation

Background and Objectives: Obese Indonesians, including Balinese, are at higher risk of comorbidities like, CVD, diabetes, non-alcoholic fatty liver disease. Urban Balinese are changing their diet from traditional to fast foods and the like that are high in saturated fats. Nutritional modification, such as increasing n-3 PUFA content in the diet, may aid in managing body fat accumulation-related diseases. This study investigated the effects of supplementation of n-6:n-3 PUFA with ratio of 2:1 on body fat reduction in young obese Balinese women. Methods and Study Design: Sixty-six young obese Balinese women, aged 18-25, were randomly assigned equally into Intervention and Control groups, supplemented with 2100 mg:1100 mg and 240 mg:100 mg of n-6:n-3 PUFAs, respectively. Data were collected at baseline, 6, and 12 weeks of intervention. BMI, waist circumference (WC), waist-to-height ratio (WHtR), conicity index, triglyceride concentrations, and Lipid Accumulation Product (LAP) were measured. Participants were advised to maintain &lt;1500-Kcal daily energy intake and participate in a guided low-impact aerobics once a week. Results: After 12-weeks supplementation, all body fat indices (BMI, WC, WHtR, conicity index, and LAP), decreased significantly weather were unadjusted or adjusted by the reduced of energy intake in the Intervention group. Otherwise, in the Control group only some of WC indices (WC, WHtR, and conicity index) decreased stasticically. BMI and WC of the Intervention group decreased significantly more than the Control group. Conclusion: Twelve-week intervention with high-dose of low n-6:n-3 PUFAs ratio and restriction energy intake, reduced body fatness selectively in young obese Balinese women.

What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA. In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA. All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant. For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort. These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles. Level III, therapeutic study.

Examining the spatial variations of co-morbidity among young children in Ethiopia

BackgroundAddressing the issues of childhood comorbidity remains a crucial global public health issue due to its consequences in child wellbeing. This study aims to account for nonlinear, spatial effect and to evaluate spatial variation in childhood co-morbidity at cluster level while controlling for important risk factors.MethodsUsing the 2016 Ethiopia DHS data, a multinomial logistic model was assessed by linear, nonlinear and random effects. The study also employed a spatial analysis tool which is Getis-Ord to identify hotspot areas of child comorbidity at the cluster level. The model with fixed, nonlinear and spatial effects identified as the best model to identify risk factors related to the coexistence of childhood illnesses.ResultsThe results indicated that statistically significant high hotspots of comorbidity were found in Tigray and Oromia whereas low hotspots were found in Harari and Somali regions. Children between 10 and 15 months old were at high risk of co-morbidity in Ethiopia. Besides, our findings revealed that being male children, not-breastfed children, from households lack of toilet facility, children from households who use spring water, children born first, children from working mother, anemic children and children from uneducated mother are at high risk of multiple illnesses.ConclusionsComorbidity in childhood is not random in the country, with high hotspots of comorbidity in the regions of Tigray and Oromia. The results show a critical upshot for a combined morbidity control method for decreasing children’s illnesses and death. The maps remain novel to design appropriate healthcare interventions at regional as well as cluster level. Regions with high hotspots of child comorbidity should be considered for health healthcare interventions.