Higher Charlson Comorbidity Score Research Articles

Comparative pharmacokinetics of polymyxin B in critically ill elderly patients with extensively drug-resistant gram-negative bacteria infections.

Introduction: Elderly patients are more prone to develop acute kidney injury during infections and polymyxin B (PMB)-associated nephrotoxicity than young patients. The differential response to PMB between the elderly and young critically ill patients is unknown. We aimed to assess PMB exposure in elderly patients compared with young critically ill patients, and to determine the covariates of PMB pharmacokinetics in critically ill patients. Methods: Seventeen elderly patients (age ≥ 65years) and six young critically ill patients (age < 65years) were enrolled. Six to eight blood samples were collected during the 12h intervals after at least six doses of intravenous PMB in each patient. PMB plasma concentrations were quantified by high-performance liquid chromatography-tandem mass spectrometry. The primary outcome was PMB exposure as assessed by the area under the concentration-time curve over 24h at steady state (AUCss, 0-24h). Results and Discussion: The elderly group had lower total body weight (TBW) and higher Charlson comorbidity scores than young group. Neither AUCss, 0-24h nor normalized AUCss, 0-24h (adjusting AUC for the daily dose in mg/kg of TBW) was significantly different between the elderly group and young group. The half-life time was longer in the elderly patients than in young patients (11.21 vs 6.56h respectively, p = 0.003). Age and TBW were the covariates of half-life time (r = 0.415, p = 0.049 and r = -0.489, p = 0.018, respectively). TBW was the covariate of clearance (r = 0.527, p = 0.010) and AUCss, 0-24h (r = -0.414, p = 0.049). Patients with AUCss, 0-24h ≥ 100mg·h/L had higher baseline serum creatinine levels and lower TBW than patients with AUCss, 0-24h < 50mg·h/L or patients with AUCss, 0-24h 50-100mg·h/L. The PMB exposures were comparable in elderly and young critically ill patients. High baseline serum creatinine levels and low TBW was associated with PMB overdose. Trial registration: ChiCTR2300073896 retrospectively registered on 25 July 2023.

1349. Unveiling the Link between COVID-19 and the Gut Microbiome in an Outpatient Cohort with Mild to Moderate Illness

Abstract Background As the acute phase of the COVID-19 pandemic subsides, an increasing number of individuals are recognized as having long COVID, affecting over 65 million people worldwide. Recent studies have suggested a potential link between long COVID and alterations in the gut microbiome. In this study, we examined the gut microbiome of a large outpatient cohort during acute phase of infection, with the ultimate goal of determining predictors of long-term COVID-19 health outcomes. Methods We conducted a study of 394 COVID-19 patients with positive SARS-CoV-2 testing from November 2020 to September 2021 at a multi-site healthcare system. Long COVID was defined as the persistence of symptoms for four weeks or more after illness onset. DNA extraction was performed using the MoBio PowerSoil Pro DNA isolation kit. Samples were sequenced using shotgun metagenomics. Stool SARS-CoV-2 RNA was tested using qRT-PCR of the E gene, and stool ELISA was performed for calprotectin levels. Standard biostatistical tools in R (v 4.2.3) were used for statistical analysis. Results Of the 394 COVID-19 patients, 84 (21%) had long COVID, with fatigue being the most common persistent symptom (Table 1). No significant differences were seen in age, BMI, and antibiotic use. Those with long COVID were more likely to be female, had higher Charlson's comorbidity scores, more severe index illnesses. However, the two groups had no difference in SARS-CoV-2 stool PCR positivity or stool calprotectin levels (Table 2). Principal coordinate analysis of Bray Curtis dissimilarities revealed that patients with long COVID had a distinct microbial composition compared with those without long COVID during the acute phase of infection (ANOSIM R2= 0.005, P= 0.01). Categorizing patients by number of long COVID symptoms showed significant differences among groups (ANOSIM R2=0.1, P=0.007), mainly between patients with &amp;gt;3 symptoms and those with 0-1 symptoms (Bonferroni, P= 0.018). Alpha diversity was lower in patients with &amp;gt; 3 symptoms, although this was not statistically significant (Shannon diversity, two-way-ANOVA, P=0.051). Figure 1 Conclusion Long COVID patients show distinct gut microbial composition during the acute phase of infection, suggesting a potential role in predicting long-term COVID health outcomes. Disclosures John C. O'Horo, Sr., MD, MPH, Janssen Pharmaceuticals.: Grant/Research Support|nference: Grant/Research Support Purna C. Kashyap, MD, Intrinsic Medicine: Advisor/Consultant|Novome Biotechnologies: Advisor/Consultant|Pendulum Therapeutics: Advisor/Consultant

Rates of surgery and adjuvant chemotherapy use in patients with stage IB to IIIA non-small cell lung cancer: A provincial population-based study.

134 Background: The current standard of treatment for early-stage (IB to IIIA) non-small cell lung cancer (NSCLC) include surgery and adjuvant chemotherapy. The objective of this study is to identify rates of adherence to guideline recommended surgery and adjuvant chemotherapy treatment for early-stage NSCLC for patients living in Ontario, the most populous province of Canada. Methods: A retrospective population-based study using linked administrative data through ICES was completed that included all adult patients with a diagnosis of stage IB to IIIA NSCLC made from 2010 to 2020 in Ontario. Rates of surgery and chemotherapy completion were calculated using available OHIP (Ontario Health Insurance Plan) billing codes. Logistic multivariate regressions were completed to assess for any predictors for completion of surgery and chemotherapy. Results: A total of 24,237 eligible patients were included. By cancer staging, there were 6,495 (26.8%) stage IB, 7,156 (29.5%) stage II, and 10,586 (43.7%) stage IIIA NSCLC patients. Within 180 days of diagnosis, surgery was completed for 9,929 (41.0%) of patients, by cancer staging were 4090/6495 (63.0%), 3719/7156 (52.0%), and 2120/10586 (20.0%) for IB, II, and IIIA respectively. The median time from diagnosis to surgery was 49 days (IQR 23-77 days). Amongst patients who completed surgery, 3344/9929 (33.7%) underwent at least 1 cycle of adjuvant chemotherapy within 180 days. Having advanced age (p&lt;0.001), high Charlson comorbidity score (p&lt;0.001), and low income (p&lt;0.001) are predictors for poor uptake for both chemotherapy and surgery. Being male also reduces the likelihood of undergoing surgery (p&lt;0.001). Conclusions: In our population-based study, less than half of the patients with early-stage (IB-IIIA) NSCLC underwent surgical resection and chemotherapy. These low treatment rates are concerning and may be contributing to suboptimal outcomes. Our findings indicate that elderly individuals with multiple comorbidities and those with low incomes are at the highest risk of not receiving appropriate chemotherapy and surgery. Our data highlight the need for quality improvement strategies aimed at identifying and enhancing treatment uptake within this patient population.

Bacillus Calmette-Guerin (BCG) therapy is safe and effective in non-muscle invasive bladder cancer (NMIBC) patients with immunomodulating conditions

IntroductionBacillus Calmette-Guerin (BCG) is the most effective therapy available to treat high-risk nonmuscle invasive bladder cancer (NMIBC) patients. However, for patients with immunomodulating conditions BCG is a relative contraindication due to efficacy and safety concerns. To our knowledge, no population-level study evaluating the efficacy and safety profile of BCG for immunomodulated patients exists. MethodsNMIBC patients aged 66 years or older were identified in the Surveillance, Epidemiology, and End Results (SEER) – Medicare database from 1975–2013. All patients completed adequate BCG (at least 5 plus 2 treatments completed within 12 months of diagnosis). Two groups were defined: an immunomodulated population identified by immunomodulating conditions such as solid-organ transplantation, HIV, and autoimmune conditions, and an immunocompetent group. The primary endpoint was 5-year progression-free survival defined as progression to systemic chemotherapy, checkpoint inhibitors, radical or partial cystectomy, metastasis, or cancer-specific death. A safety analysis was performed as a secondary outcome. ResultsIn a total of 4,277 patients with NMIBC who completed adequate BCG, 606 (14.2%) were immunomodulated. The immunomodulated group was older at diagnosis (P < 0.001), more likely to be female (P < 0.001), more likely to live in a metropolitan area (P < 0.001), and had higher Charlson comorbidity scores (P < 0.001). There were no differences in progression to chemotherapy (P = 0.17), checkpoint inhibitors (P > 0.99), radical cystectomy (P = 0.40), partial cystectomy (P = 0.93), metastasis (P = 0.19), cancer-specific death (P = 0.18) or 5-year total bladder cancer progression (P = 0.30) between the groups. For the safety analysis, rates of disseminated BCG were similar between immunomodulated and immunocompetent patients (0.7% vs. <1.8%, P = 0.51). On multivariable analysis 5-year total bladder cancer progression (HR 1.07 [CI 0.88–1.30]) was similar between the groups. ConclusionRates of bladder cancer progression and disseminated BCG complications 5-years after BCG therapy were similar regardless of immunomodulation status. These findings suggest that BCG intravesical therapy can be offered to immunomodulated patients with high-risk NMIBC although theoretical infectious complication risks remain.

Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life.

Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA. Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture. Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%-80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05-1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21-1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77-3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10-1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49-0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort. Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.

Real-World Data of Adherence and Drug Survival of Biologics in Treatment-Naïve and Treatment-experienced Adult Patients with Rheumatoid Arthritis.

Biologic disease-modifying anti-rheumatics drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) are important treatments for rheumatoid arthritis (RA). As more of these drugs become available, there is a greater need to assess their real-world adherence and drug survival. Treatment-naïve and treatment-experienced patients with RA who initiated treatment with bDMARDs and tofactinib during 2015-2018 in a large Israeli health maintenance organization were included. Adherence and time to treatment suspension were recorded. Odds for adherence were estimated using a multivariable logistic regression model. Risk for treatment suspension was estimated using a mixed-effect Cox proportional hazard model. The analysis included 753 eligible patients (61.8% treatment-naïve) treated with 1287 treatment episodes (tofacitinib 24.2%, tocilizumab 17.5%, etanercept 16.0%, adalimumab 10.4%, abatacept 9.9%, rituximab 9.0%, golimumab 6.9%, certolizumab pegol 3.6%, infliximab 1.9%, and sarilumab 0.5%). Good adherence was measured for almost all drugs, yet over 50% of all treatment episodes were suspended. Older age was associated with reduced risk for treatment suspension while higher number of primary care visits and higher Charlson's comorbidity score were associated with increased risk. Compared to etanercept, treatment with adalimumab, certolizumab, or rituximab was associated with increased risk for treatment suspension (HR 1.68 95% CI 1.27-2.22, HR 1.62 95% CI 1.00-2.60, and HR 2.72 95% CI 2.02-3.67, respectively). Treatment choice primarily depends on disease activity and prognosis. Real-world data, showing differences in drug survival of bDMARDs and tsDMARD, can also be used in the variety of considerations when choosing treatment. Future studies could separate patients with RA into subgroups, which would also account for potential drug survival differences and enable personalized therapy.

Thirty-Day Unplanned Hospital Readmissions in Patients With Cancer and the Impact of Social Determinants of Health: A Machine Learning Approach.

Develop a cancer-specific machine learning (ML) model that accurately predicts 30-day unplanned readmissions in patients with solid tumors. The initial cohort included patients 18 years or older diagnosed with a solid tumor. Two distinct cohorts were generated: one with and one without detailed social determinants of health (SDOHs) data. For each cohort, data were temporally partitioned in 70% (training), 20% (validation), and 10% (testing). Tree-based ML models were developed and validated on each cohort. The metrics used to evaluate the model's performance were receiver operating characteristic curve (ROC), area under the ROC curve, precision, recall (R), accuracy, and area under the precision-recall curve. We included 13,717 patients in this study in two cohorts (5,059 without SDOH data and 8,658 with SDOH data). Unplanned 30-day readmission occurred in 21.3% of the cases overall. The five main non-SDOH factors most highly associated with an unplanned 30-day readmission (R, 0.74; IQR, 0.58-0.76) were: number of previous unplanned readmissions; higher Charlson comorbidity score; nonelective index admission; discharge to anywhere other than home, hospice, or nursing facility; and higher anion gap during the admission. Neighborhood crime index, neighborhood median home values, annual income, neighborhood median household income, and wealth index were the main five SDOH factors important for predicting a high risk for an unplanned hospital readmission (R, 0.66; IQR, 0.56-0.72). The models were not directly comparable. Key drivers of unplanned readmissions in patients with cancer are complex and involve both clinical factors and SDOH. We developed a cancer-specific ML model that with reasonable accuracy identified patients with cancer at high risk for an unplanned hospital readmission.

#2968 PROGNOSIS OF CRESCENTIC GLOMERULONEPHRITIS IN ADULTS

Abstract Background and Aims Crescentic glomerulonephritis (C-GN) is characterized by severe glomerular inflammation and injury that leads to crescent formation, rapid loss of kidney function and severe prognosis in absence of prompt immunosuppressive therapy. Depending on the histological findings, there are three main types of C-GN: anti-glomerular basement membrane antibody GN (anti-GBM GN), immune complex GN, and pauci-immune GN. This study aims to assess whether the kidney and vital outcome are different among the three histologic types of crescentic GN. Method This unicentric, retrospective study included seventy-six subjects [50% males, 55 (95%CI 52 to 60) years; eGFR 9.6 (95%CI 7.8-13.7) mL/min and proteinuria 1.9 (95%CI 1.5 to 2.6) g/g] that had undergone a kidney biopsy between 1st January 2008 and 31st December 2017 and had a histologic diagnosis of crescentic glomerulonephritis (crescent formation in more than 50% of the glomeruli). The subjects were followed for a mean of 47.6 (95%CI 33.5 to 61.6) months. Primary endpoints were the need of renal replacement therapy initiation (RRT) and all cause death. Kaplan-Meier method was used to evaluate kidney and patients’ survival and variables related to kidney and vital outcome were evaluated by multivariate Cox proportional hazard modelling. Patients were stratified in three groups according to the type of C-GN: pauci-immune GN (n=58 pts.), anti-GBM GN (n=9 pts.) and immune-complex GN (n=9 pts.). Results No demographic differences were found among the three groups. Except for a higher frequency of solid neoplasia in immune-complex GN group (2.7% vs 1.3% in pauci-immune GN vs. 0% in anti-GBM GN; P = .001), no other differences regarding the clinical or laboratory data were identified. Immunosuppressive treatment was very frequent, in more than 80% of subjects, regardless of the group, corticotherapy and cyclophosphamide being the most common immunosuppressive agents. During the follow-up period, 54% of subjects needed RRT and 19.2% died. The frequency of RRT initiation or death was not different among the three groups (P = .9 and P = .4). The univariate time-dependent analysis showed similar survival times among the analysed groups (log rank =0.9) (Figure 1). In the multivariate analysis, the only independent predictor of RRT was lower baseline eGFR (OR 0.49 (95%CI 0.31 to 0.78), P = .03). Time to death did not differ among groups (log rank P = .4) (Figure 2). The only independent predictor of death was higher Charlson comorbidity score (OR 56.8 (95%CI 6.3 to 512), p&amp;lt;0.001) in the Cox analysis. Conclusion In this cohort of subjects with crescentic glomerulonephritis, although limited by the low number of subjects, the kidney and vital prognosis seem to be similar indifferent of the histologic type of crescentic glomerulonephritis.

Real-world registry-based study on apremilast use in psoriasis and psoriatic arthritis in Finland

Objectives This study assessed the position of apremilast in the treatment pathway of psoriasis (PsO) and psoriatic arthritis (PsA) in Finnish clinical practice, compared the characteristics of apremilast and biologic therapy users, evaluated persistence with apremilast and identified factors influencing treatment discontinuation. Method This retrospective study used data from Finnish national health registries. The target group was identified based on L40* diagnosis and medication records between 2015 and 2018. Treatment persistence was analysed using Kaplan–Meier curves and Cox regression. Results Of eligible patients (PsO 31 202; PsA 12 386), 1% (n = 471) used apremilast and 10% (n = 4214) biologics, apremilast users being older (mean age 55.9 vs 52.4 years, p < 0.001) with a higher Charlson comorbidity score (0.71 vs 0.54, p < 0.001). Most patients switched to apremilast from conventional synthetic therapy (PsO 75%; PsA 76%); 47% of patients remained on apremilast during the observation period (PsO 58%; PsA 42%). Most patients discontinuing apremilast switched to biologics (PsO 51%; PsA 51%). Apremilast persistence increased with age (p = 0.042) and was higher in PsO than in PsA (median 14 vs 11 months; p = 0.005). Compared to prior conventional synthetic therapy, prior biologic therapy decreased persistence (hazard ratio for discontinuation 2.15, 95% confidence interval 1.42–3.25). Conclusion In Finnish clinical practice, apremilast is mainly used between conventional synthetic therapy and biologics, with at least as high treatment persistence as reported in previous studies. Apremilast users were older with higher comorbidity burden than biologics users.

PD46-10 GENDER DISPARITIES IN UPPER TRACT UROTHELIAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023PD46-10 GENDER DISPARITIES IN UPPER TRACT UROTHELIAL CELL CARCINOMA Jeffrey Orf, Mohammad Mahmoud, and Zachary Hamilton Jeffrey OrfJeffrey Orf More articles by this author , Mohammad MahmoudMohammad Mahmoud More articles by this author , and Zachary HamiltonZachary Hamilton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003359.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Previous literature has demonstrated the existence of gender disparities for urothelial cell carcinoma (UCC) of the bladder including higher stage at presentation in women, higher rates of complications, and worsened survival. Similar outcomes are not well characterized for upper tract urothelial carcinoma (UTUC). Our goal was to analyze patterns of presentation, neoadjuvant chemotherapy (NAC) use and survival outcomes for UTUC across genders. METHODS: The National Cancer Database was queried for all patients with UTUC of the renal pelvis from 2004 to 2016 undergoing nephroureterectomy. Patients were stratified based on female or male sex. Demographics, clinical stage and use of NAC were evaluated. Outcomes including 30 and 90 day readmission, positive margins, and mortality were analyzed. RESULTS: 31,411 patients were identified with 58.6% male and 41.4% female. Females were older (72.4 vs 70.1 years, p<0.001), and more likely to be of black race (p<0.001). Males were more likely to have higher Charlson comorbidity scores (p<0.001). Clinical tumor and nodal stage did not vary between men and women, however women were more likely to present with high grade disease (p<0.001). Outcomes including positive margin, 30 day readmission, and all-cause mortality did not differ based on sex. When stratified by pT stage, we found females to have improved median survival time with pT0/1 (99 vs 91 months, p=0.02) but there was no gender difference for median survival with pT2-4 disease or when accounting for all pT stages together (Figure). On a subset analysis of patients with high grade disease receiving NAC, we found females were more likely to downstage to pT0 disease (11.2 vs 2.9%, p<0.001) CONCLUSIONS: The gender disparities previously reported with UCC of the bladder are not readily evident with UTUC of the renal pelvis. Taken together, this suggests the underlying urothelial histopathology does not contribute to UCC gender disparity; however, unmeasured diagnostic and clinical factors are contributory. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1173 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Orf More articles by this author Mohammad Mahmoud More articles by this author Zachary Hamilton More articles by this author Expand All Advertisement PDF downloadLoading ...

Low-Volume Home Haemodialysis and In-Centre Haemodialysis: Comparison of Dialysis Adequacy in Obese Individuals.

Background Although frequent low-flow, low-volume haemodialysis using the NxStage System One is now well-established as an option for home therapy of end-stage chronic kidney disease, its ability to deliver adequate dialysis in people with high BMI remains questionable. This doubt may lead to obese individuals being denied the potential benefits of this modality. To establish if this doubt is justified, we compared dialysis adequacy in two groups of obese individuals; one receiving standard thrice-weekly in-centre haemodialysis and the other receiving frequent haemodialysis at home using the NxStage System One. Methods This is a retrospective observational cohort study of 105 adult dialysis patients with obesity (BMI ≥ 30 kg/m2). All had been on dialysis for at least six months. Fifty-five patients receiving in-centre haemodialysis were compared with 50 patients receiving home haemodialysis using NxStage System One. Dialysis adequacy (standard Kt/V calculated by the Daugirdas equation) was compared between the two groups. The clinical characteristics, laboratory test results, and treatment regimens of each group were also compared. Results The in-centre haemodialysis group was older (63.6 ± 12.8 years vs. 58.5 ± 10.9 years, p=0.033) and had a higher Charlson comorbidity score (5.9 ± 2.1 vs. 4.5 ± 2.5, p=0.003). Standard Kt/V was significantly higher in the home haemodialysis group (2.4 ± 0.5) than in the in-centre haemodialysis group (2.2 ± 0.2) (p = 0.006). The mean serum inorganic phosphate was significantly lower in the home haemodialysis group than in the in-centre haemodialysis group (1.6 ± 0.4 mmol/l vs. 1.8 ± 0.5 mmol/l, p = 0.010). There were no statistically significant differences in the usage of antihypertensives, phosphate binders, or erythropoiesis-stimulating agents between the two groups. Conclusions In this study, dialysis adequacy (expressed as standard Kt/V) was superior to that of standard thrice-weekly in-center haemodialysis delivered by frequent low-volume home haemodialysis using the NxStage System One. Hesitancy about recommending frequent low-volume home haemodialysis to obese individuals is therefore unjustified.

512. The relationship of Clostridioides difficile in-vitro antibiotic resistance, prior exposure to antibiotics and ribotype: A single center study

Abstract Background Antibiotic exposure is the most important risk factor for Clostridioides difficile associated diarrhea (CDAD). Little information has been reported on the relationship between prior antibiotic exposure, antibiotic resistance of C. difficile, and isolate ribotype. Methods C. difficile isolates were collected from the stools of patients with CDAD. Isolates were ribotyped by PCR-based fragment analysis. Susceptibility testing was performed using Clinical &amp; Laboratory Standards Institute (CLSI) recommended methods. MIC results were interpreted using European Committee on Antimicrobial Susceptibility Testing (EUCAST) epidemiologic cut off values or the CLSI breakpoints. Demographic data and antibiotic exposure in the 30 days period prior to C. difficile isolation were collected via retrospective chart review. Results Of a total of 490 C. difficile isolates, 335 (67.3%) isolates were resistant to one or more antibiotics (Table 1). Patients who had higher Charlson Comorbidity Score (CCI) and who had hospital associated CDAD were more likely to receive antibiotics (Table 2). Moxifloxacin resistance was significantly associated with prior fluoroquinolone exposure (OR 2.5, CI 95% 1.5-4.1). Fluoroquinolone use was associated with vancomycin resistance (OR 2.7, CI 95% 1.3-5.6) and rifampin resistance (OR 1.9, CI 95% 1.2-3). Infection with a clindamycin resistant isolate was more likely to be hospital acquired (p = 0.006). We identified 54 different ribotypes (Figure 1). Prior treatment with aminopenicillins increased the odds of acquiring ribotype 053-163 (OR 2.9, 95% CI 1.0-8.2) and ribotype 002 (OR 3.2; CI 95% 1.0-10) (Table 3). .Prior treatment with cephalosporins had an increased risk of 014-020 (OR 2.0, CI 95% 1.2-3.3); prior treatment with carbapenems was associated with ribotype 106 (OR 2.3, CI 95% 1.2-4.4). Isolation of ribotype 027 following prior treatment to fluroquinolones was marginally significant (p = 0.054). Conclusion Specific antibiotic exposure may select for infection by specific C. difficile ribotypes, which can often lead to infection with resistant strains. Prior fluoroquinolone treatment, in particular, was associated with an increased risk of isolating multi-drug resistant strains. Disclosures Cheleste M. Thorpe, MD, Actelion: Grant/Research Support|Deinove: Advisor/Consultant|General Mills: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Grant/Research Support|Summit: Advisor/Consultant|Summit: Grant/Research Support David R. Snydman, MD, Merck: Advisor/Consultant|Merck and Company: Grant/Research Support|Prolacta: Advisor/Consultant|Prolacta: Grant/Research Support|Seres: Advisor/Consultant|Seres Health: Grant/Research Support|Summit Plc: Grant/Research Support|Takeda: Advisor/Consultant|Takeda: Grant/Research Support|Visterra: Advisor/Consultant.

Determinants of Overall Survival (OS) of Waldenstrom Macroglobulinemia (WM): A National Cancer Database (NCDB) Analysis of over 14,000 Patients Treated between Years 2004 and 2017

Introduction: Real world outcome data for Waldenstrom Macroglobulinemia (WM) is limited due to relatively rare and indolent nature of this B cell Non-Hodgkin lymhoplasmacytic lymphoma. In this retrospective analysis, we utilized National Cancer Data Base (NCDB) to identify variables contributing to the overall survival (OS) of over 14,000 WM patients treated at Commission on Cancer (CoC)-accredited cancer centers across USA. Methods: From NCDB, 14,295 WM patients diagnosed and treated during 2004-2017 were identified and included in the analysis after excluding entries with missing relevant values. For OS, univariate analysis was used first to summarize and assess the potential survival factors individually, and multivariate Cox regression analysis with backward elimination was utilized to identify the most important survival factors. In addition, Kaplan-Meier survival curves of patient cohort were also produced for OS. SAS version 9.4 was used to analyze the data. Results: The baseline characteristics of the patients are shown in Table 1A. Multivariate Cox regression analysis with backward elimination method revealed that there were 10 significant independent survival factors including age, sex, race, Charlson comorbidity score (CC), income, facility type, insurance, chemotherapy, sequence number, and year-of-diagnosis (Table 1B). Older patients were more likely to die compared to younger patients with age <55 (55≤age<65: HR=1.43, p<0.0001; 65≤age<75: HR=1.89, p<0.0001; and age≥75: HR=4.29, p<0.0001); male were more likely to die compared to female (HR=1.17, p<0.0001); blacks were more likely to die compared to white (HR=1.28, p<0.0001); patients with CC ≥1 had higher chance to suffer death compared to patients with CC =0 (HR=1.72, p<0.0001); patients at lower income area were more likely to die compared to patients at ≥$63,000 income area ($48,000 - $62,999: HR=1.16, p<0.0001; $38,000 - $47,999: HR=1.23, p<0.0001; and <$38,000: HR=1.30, p<0.0001); patients at other facility type were more likely to die compared to patients at Academic/Research program (HR=1.09, p=0.0019); and patients with other insurance were more likely to die compared to patients with private insurance (PI) with (HR=1.31, p<0.0001), patients with insurance unknown status were also more likely to pass away compared to patients with PI (HR=1.26, p=0.0207); there was no significant difference in survival between patients with multi-agent chemotherapy and with single/unknown agent (HR=1.02, p=0.6436), and patients without chemotherapy were less likely to die compared to patients with single/unknown agent (HR=0.83, p<0.0001); patients with sequence number of not-zero (defined as > 1 malignant sites) were more likely to die compared to patients with sequence number of zero (single malignant site) with (HR=1.19, p<0.0001). And finally, patients diagnosed between 2004 and 2010 were more likely to die compared to patients diagnosed between 2011 and 2017 (HR=1.25, P<0.0001). Kaplan-Meier estimate (Figure 1A) showed that OS rate at 1, 3, and 5 years were 88.0%, 76.3%, and 65.8%, respectively. Figure 1B shows that the OS was worse for those with co-morbidities as reflected by CC ≥1. Conclusion: In this large real-world retrospective analysis, we demonstrate racial, demographics and socioeconomic differences impacting the outcomes of WM patients. Older WM patients, male sex, black race, higher CC and lower income were significantly associated with lower OS. Patients with access to PI and academic centers had better OS but those with non-PI and treated at non-academic centers had inferior OS. In terms of disease specific factors, WM patients with higher tumor burden (>1 malignant sites) and those needing therapy had worse OS compared to patients with lower tumor burden and those observed without therapy. Interestingly, patients diagnosed between 2011 and 2017 had superior OS compared to the patients diagnosed between 2004 and 2010 likely due to advancement in therapy over time. Cancer disparity data specific to WM are lacking and our study highlights the importance of socioeconomic, demographics and racial factors in the prognosis of patients with WM in addition to the standard disease and treatment specific prognostic variables. Since the social determinants of health can greatly impact outcomes in WM, improving access to high quality care could potentially help overcome the observed disparity in the outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Association of Textbook Outcome and Surgical Case Volume with Long-Term Survival in Patients Undergoing Surgical Resection for Pancreatic Cancer.

Current literature has identified textbook outcome (TO) as a quality metric after cancer surgery. We studied whether TO after pancreatic resection has a stronger association with long-term survival than individual hospital case volume. Patients undergoing surgery for pancreatic adenocarcinoma from 2010 to 2015 were identified from the National Cancer Database. Hospitals were stratified by volume (low less than 6, medium 6 to 19, and high 20 cases or more per year), and overall survival data were abstracted. We defined TO as adequate lymph node count, negative margins, length of stay less than the 75th percentile, appropriate systemic therapy, timely systemic therapy, and without a mortality event or readmission within 30 days. The association of TO and case volume was assessed using a multivariable Cox regression model for survival. Overall, 7270 patients underwent surgery, with 30.7%, 48.7%, and 20.6% performed at low-, medium-, and high-volume hospitals, respectively. Patients treated at low-volume hospitals were more likely to be Black, be uninsured or on Medicaid, have higher Charlson comorbidity scores, and be less likely to achieve TO (23.4% TO achievement vs 37.5% achievement at high-volume hospitals). However, high hospital volume was no longer associated with overall survival once TO was added to the multivariable model stratified by volume status. Achievement of TO corresponded to a 31% decrease in mortality (hazard ratio 0.69; p < 0.001), independent of hospital volume. Improved long-term survival after pancreatic resection was associated with TO rather than high hospital volume. Quality improvement efforts focused on TO criteria have the potential to improve outcomes irrespective of case volume.

Prevalence of Advanced Care Planning in Emergency General Surgery: Do We Know Our Patient’s Goals?

INTRODUCTION: Advanced care planning (ACP) promotes the delivery of goal-concordant, patient-centered surgical care. There is opportunity to increase ACP adoption in surgery. We hypothesized that, on the emergency general surgery (EGS) service, most patients were not engaged in ACP discussions. METHODS: All patients admitted to the EGS service in 2019 were included. The primary outcome was having electronic health record ACP documentation (advance directive, physician order for life-sustaining treatment form [POLST], or ACP note). Multivariate analysis was conducted to identify predictors of ACP. RESULTS: Among 734 patients, the prevalence of ACP on admission was 15% (n = 109), and the prevalence of ACP completed during the hospitalization was 6% (n = 44). Only 27% (n = 12) of inpatient ACP was completed in the hospital before EGS procedures. Most documentation included advanced directives and POLST uploaded before admission (60%, n = 93), and 39 (22%) constituted ACP notes by the surgical team. Multivariable analysis demonstrated increasing age, Medicaid or Medicare insurance, increased length of stay, and institution-concordant primary care were associated with an increased odds of having ACP (Fig. 1); low English language proficiency, an increasing neighborhood deprivation index, and a higher Charlson Comorbidity score were all associated with lower odds of having ACP documentation (Fig. 1).Figure 1CONCLUSION: Integration of ACP for patients receiving EGS care is limited, with significant variation in terms of type of documentation. Little documentation is done in the context of their acute surgical condition. Further study is needed to identify opportunities and barriers to increasing ACP uptake into EGS workflows.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database.

BACKGROUNDThere are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.AIMTo determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.METHODSWe performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis. RESULTSThe thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.CONCLUSIONWe found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Prolonged use of newly prescribed gabapentin after surgery.

Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults. We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients >65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity. Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin. More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.

Trends and costs of stereotactic body radiation therapy in metastatic non-small cell lung cancer.

BackgroundThe purpose of this study is to describe stereotactic body radiation therapy (SBRT) use, outcomes, hospitalizations and costs compared to patients receiving chemotherapy among patients with metastatic non-small cell lung cancer (NSCLC).MethodsUsing the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified patients aged ≥66 with metastatic NSCLC treated with SBRT as first-line treatment between 2004 and 2014. Multivariable logistic regression identified covariates associated with SBRT. Overall survival (OS) between SBRT and chemotherapy was compared using the Kaplan-Meier estimator and Cox proportional hazards regression. To compare hospitalizations and associated costs, we matched patients treated with SBRT to those with comparable prognostic factors receiving chemotherapy.ResultsWe identified 215 patients with metastatic NSCLC who received SBRT and 12,486 patients who received chemotherapy as first-line treatment. SBRT use increased from 0.5% to 3% and was associated with older age, female sex, poor disability status, and lower T- and N-stage. OS increased with SBRT, female sex, higher income and decreased with higher Charlson Comorbidity Score ≥2, poor disability status, higher T-stage and higher N-stage. Among a matched sample, SBRT patients underwent fewer hospitalizations vs. chemotherapy patients (73% vs. 81%, P=0.02). Among those hospitalized, SBRT patients incurred higher hospitalization costs ($33,063 vs. $23,865, P<0.001) but costs per month of survival were similar.ConclusionsSBRT is increasing among Medicare patients with metastatic NSCLC. Our findings suggest that SBRT may play a role in management of select metastatic NSCLC patients in addition to standard-of-care chemotherapy.

Association of pulmonary hypertension with survival and neurologic outcomes in adults with in-hospital cardiac arrest

BackgroundPulmonary hypertension (PH) has been associated with poor survival in multiple cardiopulmonary conditions, however its association with outcomes in cardiac arrest remains unknown. We aimed to evaluate the association of PH with survival and neurologic outcomes in adults with in-hospital cardiac arrest (IHCA). MethodsThe study population included adults with IHCA undergoing resuscitation at an academic tertiary-care medical center from 2011 to 2019. Patients were classified based upon the presence versus absence of PH, defined as a pulmonary artery systolic pressure >35 mmHg on pre-arrest echocardiogram. Survival to discharge and favorable neurological outcome (defined as a Glasgow Outcome Score of 4–5) served as the primary and secondary outcomes of interest respectively. ResultsOf the 371 patients studied, 203 (54.7%) had PH while 168 (45.3%) did not. Patients with PH had higher Charlson Comorbidity Score with higher rates of multiple baseline comorbidities. They also had worse multi-chamber enlargement, left ventricular diastolic dysfunction, right ventricular systolic dysfunction, and valvular heart disease compared to non-PH patients. Rates of survival to discharge (11.5% vs 10.9%, p = 0.881) and favorable neurologic outcome (8.0% vs 6.2%, p = 0.550) were similar in PH and non-PH patients respectively. In multivariable analysis, PH was not associated with survival to discharge (OR 1.23, 95%CI 0.57–2.65) or favorable neurologic outcome (OR 1.69, 95%CI 0.64–4.45). ConclusionsIn this contemporary registry of adults with IHCA, while PH was associated with a higher risk patient profile, it was not associated with survival or neurologic outcomes in this population.

Factors associated with acute kidney injury among patients with cancer treated with immune checkpoint inhibitor therapy: A population-based study.

2584 Background: Cancer immune checkpoint inhibitor (ICI) therapy may be associated with kidney immune-related adverse events (IRAEs) and other causes of acute kidney injury (AKI). In clinical trials, the frequency of AKI events was uncommon, however, further real-world study is warranted. Methods: We evaluated the proportion of AKI events among patients with advanced cancer (bladder, head and neck, lung, kidney and malignant melanoma) treated with ICI therapy in Ontario, Canada from 2012 - 2018. AKI was defined by a rise in the concentration of serum creatinine as per Kidney Disease: Improving Global Outcomes (KDIGO) criteria. A multivariable regression model was used to identify predictors of AKI while accounting for the competing risk of death. Results: A total of 4,380 patients received ICI therapy. In follow-up, 1,283 (29%) had recorded AKI event (any stage AKI) and 289 (7%) had a severe AKI event (≥ stage 2). Median time to AKI was 6 months (Interquartile Range 2-16 months) and ≤ 1 % of patients received dialysis therapy. Within 30 days of any observed AKI event, 853 (58%) discontinued ICI therapy, 372 (29%) were hospitalized and 266 (21%) died. Mortality was significantly higher among patients who experiencing a severe AKI event (≥ stage 2) as compared to patients with a less severe AKI event (stage 1) or no observed AKI event. Among patients alive at 30 days following an AKI event, 14% received an outpatient corticosteroid or immunosuppressive therapy prescription, 7% had a visit with a nephrologist. Characteristics associated with a higher risk of AKI included female sex, bladder or kidney cancer (reference malignant melanoma), history of hypertension or diabetes, higher Charlson comorbidity score, a baseline estimated glomerular filtration rate less than 30 mL/min/1.73 m2, or outpatient prescription for either a proton pump inhibitor or non-steroidal anti-inflammatory drug. Among patients with an AKI event and treatment discontinuation, re-challenge of ICI therapy was infrequent (16%) with a significant risk of a recurrent AKI event (57%). Conclusions: In a population-based study among patients with cancer receiving ICI therapy, the rate of AKI was common (29%) but severe AKI was less frequent (7%). Rates of ICI discontinuation, hospitalization and death are substantial following an AKI event. Kidney function should be monitored carefully among patients undergoing ICI therapy who have common risk factors for developing renal disease. Nephrology consultation may be optimized among patients who develop a severe AKI event, especially among individuals who are considered for ICI therapy re-challenge.