Higher Charlson Index Research Articles

Can the Charlson comorbidity index help to guide DOAC dosing in patients with atrial fibrillation and improve the efficacy and safety of treatment? A subanalysis of the MAS study

BackgroundFrailty influences the effectiveness and safety of anticoagulant therapy in patients with atrial fibrillation (AF). The age-weighted Charlson comorbidity index may offer a valuable tool to assess the risk of adverse events in AF patients treated with direct oral anticoagulants (DOACs). This sub-analysis of MAS trial data aimed to assess whether using the Charlson index, instead of the standard criteria, would have led to different dosing and improved adverse event occurrence during treatment. MethodsThe MAS study looked for a relationship between DOAC levels assessed at baseline and adverse events during follow-up. The study is described in detail elsewhere. ResultsAmong the 1,657 patients studied, 832 (50.2 %) had a relatively low Charlson index (up to 6, general median class), of whom 132 (15.9 %) were treated with reduced doses. Conversely, among the 825 patients with a high Charlson index (≥7), 257 (31.1 %) received standard doses. A weak but statistically significant positive correlation (r = 0.1413, p < 0.0001 by ANOVA) was observed between increasing Charlson classes and DOAC levels standardized to allow comparability among drug results. However, no significant differences were found in the incidence or number of adverse events during follow-up, or in other parameters, between patients with low and high Charlson's scores. ConclusionsUtilizing the Charlson index would have led to notable differences in DOAC dosing compared to standard criteria. However, we found no evidence that its use would have improved the prediction of adverse events in AF patients enrolled in the MAS study.

Management and outcomes for older women with early breast cancer treated with primary endocrine therapy (PET)

BackgroundThis study reports the detailed management and outcomes of women treated with Primary Endocrine Therapy (PET) in a large prospective UK cohort of older women (≥70) with breast cancer. MethodsThis was an unplanned secondary analysis of a prospective, multicentre, observational study (The Age Gap study). Data were collected at baseline and regular intervals on patient, tumour and treatment characteristics with tumour RECIST response category recorded. Direct study follow-up was 24 months with longer-term survival data obtained from the UK cancer registry. ResultsThe Age Gap study recruited 3316 women across 56 breast units. Primary endocrine therapy (PET) was initiated for 505/3316 (15 %) women; median age was 84 (IQR 79–88) with median follow-up 41.9 months (IQR 27–60). Death occurred in 205/505(40.6 %) patients, 160/205; 78 % non- Breast Cancer related, 45/205; 21.9 % Breast Cancer related. Multivariate analysis identified older age (HR-1.055(95 % Confidence Interval: 1.029–1.084); P < 0.001) and higher Charlson Index (HR-1.166 (1.086–1.252); P < 0.001) as risk factors for all-cause mortality, but conversion to surgery (HR-0.372(0.152–0.914); P = 0.031) was protective. Grade 3 cancer (G1 vs G3 HR-0.28 (0.094–0.829); P = 0.022 & G2 vs G3 HR-0.469 (0.226–0.973); P = 0.042), axillary positivity (axilla positivity HR-2.548 (1.321–4.816); P = 0.005) and change of endocrine therapy (HR-3.010 (1.532–5.913); P = 0.001) were associated with worse breast cancer specific survival (BCSS). RECIST category was not significantly associated with either overall survival or BCSS (P > 0.05). ConclusionEarly disease response and change of endocrine therapy are not significantly associated with overall survival, conversion to surgery is linked to improved outcome. Prognosis is largely determined by age and comorbidity in older women treated with PET.

#2209 Hypoglycemia induced by hemodialysis in diabetic and non-diabetic patients, how to prevent it? A prospective study

Abstract Background and Aims Hemodialysis-induced hypoglycemia, a documented complication associated with adverse clinical outcomes, including mortality, is linked to factors such as impaired gluconeogenesis, inadequate nutritional status, reduced insulin clearance, glucose loss to the dialysate, and autonomic neuropathy. Glycemic variability is recognized as an independent risk factor for morbidity and mortality. This study aims to investigate the incidence of hypoglycemia during hemodialysis (HD) by exploring protocol-related factors and their impact, such as in-nutrition during HD. Additionally, the study seeks to examine the relationship between nutritional and inflammatory statuses and variations in intradialytic glycemia in both diabetic and non-diabetic patients. Method This prospective study, conducted between September and December 2023, examined the glycemic profiles of HD patients at a hospital HD program. All patients undergo hemodialysis with a dialysate containing 100 mg/dL of glucose. Plasma glucose levels were assessed at the start, 2:30 hours post-initiation, and the end of sessions. Following the 2:30-hour mark, patients received a meal (523 Kcal). Glycose variability was computed by averaging blood glucose differences across all sessions. Data collected included demographics, hemodialysis specifics, and lab results. Inflammatory and nutritional statuses were evaluated using lab tests at the study's beginning and conclusion [ferritin, protein C reactive (PCR), interleukin 6 (IL-6) and albuminemia, urea, creatinemia, cholesterol, respectively]. Anthropometric measurements and bioimpedance assessments were performed, with values averaged for better representation. Categorical variables are shown with frequencies/percentages, and continuous variables with means/standard deviations or medians/interquartile ranges for skewed distributions. The study used repeated measures ANOVA for glycemic profiles, correlation analyses for outcome influences on glycemia, and parametric/non-parametric tests for relations in diabetic and non-diabetic groups. Significance was set at p&amp;lt;0.05, analyzed with SPSS version 29 for Mac OS 13. Results 63 patients, 67.2% (n=43) were males, the medium age was 72.0±11.8 and 50.8% (n=32) had diabetes. Among 9072 measurements, hypoglycemia was observed in 0.07% (n=6) of diabetic patients and 0.01% (n=1) in non-diabetic individual. The initial blood glucose measurement was 139.5±260.0 mg/dL, the second was 117.05±35 mg/dL, and the third was 132.8±21.3 mg/dL. Significant differences were observed in all measurements [F (1.17, 73.58)=23.62; p&amp;lt;0.001]. The mean glycemic variation between the first and second measurements was 23.8±46.0 mg/dL, and for the third measurement was 5.5±71.5 mg/dL. There was no significant correlation found between glycemic and nutritional parameters neither between inflammatory parameters. In the subgroup analysis comparing diabetic and non-diabetic patients, the diabetic group demonstrated lower serum creatinine levels (6.8±2.7 mg/dL) and total cholesterol (137.4±35.6 mg/dL), coupled with a higher Charlson Index (8.2±1.7). These differences were statistically significant (p=0.055, p=0.035, p&amp;lt;0.001). In the subsequent analysis, no other statistically significant associations were observed. Conclusion Contrary to what is described in the literature, the studied population exhibited a very low incidence of hypoglycemic events. This underscores the importance of nutrition during HD, along with the use of a glucose-containing dialysate, as an effective preventive measure against intradialytic hypoglycemia. Careful consideration of these factors is warranted to prevent adverse health consequences for our patients. It is plausible that diabetic patients may face an elevated risk of malnutrition, necessitating heightened concern and a more proactive preventive approach.

A retrospective case-control study to evaluate the use of beta-lactam desensitization in the management of penicillin-allergic patients: a potential strategy for Antimicrobial Stewardship Programs.

Introduction: Penicillin allergy labels (PAL) are common in the hospital setting and are associated with worse clinical outcomes. Desensitization can be a useful strategy for allergic patients when alternative options are suboptimal or not available. The aim was to compare clinical outcomes of patients with PAL managed with antibiotic desensitization vs. those who received alternative non-beta-lactam antibiotic treatments. Methods: A retrospective 3:1 case-control study was performed between 2015-2022. Cases were adult PAL patients with infection who required antibiotic desensitization; controls were PAL patients with infection managed with an alternative antibiotic treatment. Cases and controls were adjusted for age, sex, infection source, and critical or non-critical medical services. Results: Fifty-six patients were included: 14 in the desensitization group, 42 in the control group. Compared to the control group, desensitized PAL patients had more comorbidities, with a higher Charlson index (7.4 vs. 5; p = 0.00) and more infections caused by multidrug-resistant (MDR) pathogens (57.1% vs. 28.6%; p = 0.05). Thirty-day mortality was 14.3% in the desensitized group, 28.6% in the control group (p = 0.24). Clinical cure occurred in 71.4% cases and 54.8% controls (p = 0.22). Four control patients selected for MDR strains after alternative treatment; selection of MDR strains did not occur in desensitized patients. Five controls had antibiotic-related adverse events, including Clostridioides difficile or nephrotoxicity. No antibiotic-related adverse events were found in the study group. In multivariate analysis, no differences between groups were observed for main variables. Conclusion: Desensitization was not associated with worse clinical outcomes, despite more severe patients in this group. Our study suggests that antibiotic desensitization may be a useful Antimicrobial Stewardship tool for the management of selected PAL patients.

Respiratory syncytial virus burden and risk factors for severe disease in patients presenting to the emergency department with flu-like symptoms or acute respiratory failure

BackgroundPredictors of Respiratory Syncytial Virus (RSV) infection and determinants of RSV unfavorable outcomes are still unclear. We assessed RSV burden and investigated the risk factors associated with RSV positive swab and RSV severe disease. MethodsA retrospective, single center, cohort study included all consecutive patients referred to the emergency department of L. Sacco University Hospital (Milan) with flu-like symptoms or acute respiratory failure (aRF) tested per protocol for SARS-CoV-2, RSV, Influenza A (InvA) during the 2022–2023 autumn/winter season. Clinical characteristics and patients’ outcomes were registered. Respiratory failure, need for respiratory support, shock, sepsis or in-hospital death defined severe disease. Main findingsThe analysis included 717 patients (65.1% negative swab, 14.1% InvA, 8.5% RSV, 8.6% SARS-CoV-2, 3.6% other viruses). Compared with the study cohort, RSV patients had the highest occurrence of aRF (62.7%) and severe disease (70.5%); mortality was similar to InvA (6.6% vs 5.9%, p = 0.874). Compared with InvA patients, RSV patients were older (p = 0.009), had higher Charlson index (p = 0.001), higher prevalence of chronic heart failure (p = 0.001) and were more frequently on ICS (p = 0.026) and immunosuppressants (p = 0.018). Heart failure [OR (95%CI):3.286 (1.031–10.835); p = 0.041], chronic exposure to ICS [OR (95%CI):2.377 (1.254–4.505); p = 0.008] and immunosuppressants [OR (95%CI):3.661 (1.246–10.754); p = 0.018] predicted RSV infection. Glycaemia ≥120 mg/dL [OR (95%CI):5.839 (1.155–29.519); p = 0.033], leucocytes ≥8000 cells/μL [OR (95%CI):5.929 (1.090–32.268); p = 0.039], and past/active smoking [OR (95%CI):7.347 (1.301–41.500); p = 0.024] predicted severe RSV disease. ConclusionsRSV infection is associated with significant mortality and morbidity. Preventive strategies for RSV infection such as vaccination are highly warranted, especially in older patients with cardiovascular and chronic respiratory conditions.

Impact of frailty on clinical outcomes and resource utilization of hospitalizations for renal stone surgery.

Frailty is reportedly associated with poorer outcomes among surgical patients. Using a coding-based frailty tool, we investigated the impact of frailty on clinical outcomes and resource utilization for urolithiasis hospitalizations. A cohort study using the 2018 National Inpatient Sample database. All adult elective hospitalizations for urolithiasis were included in the study. The study population was categorized into FRAIL and non-frail (nFRAIL) cohorts using the Johns Hopkins Adjusted Clinical Groups frailty clusters. The association between frailty and clinical and financial outcomes was evaluated using multivariate regression models. About 1028 (14.9%) out of 6900 total hospitalizations were frail. Frailty was not associated with a significant increase in the odds of in-hospital mortality (adjusted odds ratio (aOR) 1.73, 95% CI 0.15-20.02) or length of hospital stay, but was associated with a lower chance of surgery within 24h of admission (aOR 0.65, 95% CI 0.48-0.90, P = 0.008). A higher Charlson index was independently associated with an over 100% increase in the odds of in-hospital mortality (aOR 2.091, 95% CI 1.53-2.86, P < 0.001). Frail patients paid $15,993 higher in total hospital costs and had a higher likelihood of non-home discharges (aOR 4.29, 95% CI 2.74-6.71, P < 0.001) and peri-operative complications (aOR 1.77, 95% CI 1.14-2.73, P = 0.01). Frailty was correlated with unfavorable outcomes, except mortality and prolonged hospital stay. Incorporating frailty evaluation into risk models has the potential to enhance patient selection and preparation for urolithiasis intervention.

Impact of peritoneal dialysis strategy on technique and patient survival.

The aim of this study was to evaluate the impact of peritoneal dialysis (PD) strategy on technique and patient survival. This was a retrospective, single-center study conducted on consecutive patients with chronic kidney disease who underwent PD between January 2009 and December 2019. The study sample was stratified into four different groups according to PD technique [automated (APD) or manual (CAPD)] and icodextrin use (yes versus no). The primary endpoints were survival of both technique and patient. A total of 531 patients were included in the analysis. Mean±standard deviation age was 60.6±14.6 years, 68.4% (363) were men and 34.8% (185) had diabetes. The median technique survival time was 19 (15) months. A total of 185 (34.8%), 96 (18.1%), 99 (18.7%) and 151 (28.4%) patients were included in the CAPD/No-Icodextrin, CAPD/Icodextrin, APD/No-Icodextrin and APD/Icodextrin study groups, respectively. Throughout the study, 180 (33.9%) patients underwent renal transplant, 71 (13.4%) were changed to hemodialysis and 151 (28.4%) died. Age [hazard ratio (HR) 0.975, 95% confidence interval (CI) 0.960-0.990, P=.001] and incidence of early peritoneal infection (HR 2.440, 95% CI 1.453-4.098, P=.001) were associated with technique survival, while age (HR 1.029, 95% CI 1.013-1.045, P<.001), Charlson Index (HR 1.192, 95% CI 1.097-1.295, P<0.001), use of icodextrin (HR 0.421, 95% CI 0.247-0.710, P<.001) and APD/Icodextrin (HR 0.499, 95% CI 0.322-0.803, P=.005) were associated with patient survival. Icodextrin use and APD/Icodextrin had a positive impact on patient survival, while older age and higher Charlson Index had a negative one. Age and incidence of early peritoneal infection significantly impacted on technique survival.

Safety and efficacy of two-drug combination in elderly patients with locally advanced non-small cell lung cancer and validation of the Charlson Index as a predictor of survival.

The best platinum-based chemotherapy regimen remains to be determined in elderly patients treated with definitive chemoradiotherapy for advanced non-small cell lung cancer (NSCLC). Predictive indexes for toxicity and survival are also needed to give the safest and most effective treatment for this population. This is a retrospective cohort study. Patients with histologically confirmed stage IIIA, IIIB or IIIC NSCLC over 70 years of age, treated with radiotherapy and chemotherapy, were included. Patients from two cancer centers treated between 12/2006 and 08/2019 were included in the data analysis. Fifty-eight patients were enrolled in the study. The median age was 76.6 years [interquartile range (IQR): 71.6-83.4]. Thirty-nine patients were treated with concomitant chemoradiotherapy and 19 with a sequential strategy. The chemotherapy regimen consisted in a combination of platinum and taxanes. At a median follow-up of 52 months (IQR: 7-69), the 2-year progression-free survival (PFS) and overall survival (OS) were 35.5% and 66.9%, respectively. Male sex and a high Charlson index were identified as independent prognostic factors for worse OS. Acute grade 3-5 toxicities occurred in 34.4% of patients, including 1 grade 5 toxicity, and grade 3-4 late toxicities occurred in 17.2% of patients. In the whole cohort a high Charlson index was the only predictive factor for a higher risk of grade 3-5 acute toxicities (statistical trend in the concurrent cohort, P=0.06). The Charlson index correlated with toxicity and survival in elderly patients treated with chemoradiotherapy in locally advanced NSCLC. The addition of taxanes to platinum chemotherapy was safe in the present study and warrants further exploration.

Role of statins in clinical evolution of octogenarian patients admitted due to COVID-19

Introduction and objectivesCOVID-19 (Coronavirus disease 2019) causes high mortality in elderly patients. Some studies have shown a benefit of statin treatment in the evolution of this disease. Since there are no similar publications in this population group, the aim of this study is to analyze in-hospital mortality in relation to preadmission treatment with statins in an exclusively elderly population of octogenarian patients. Materials and methodsA single-center retrospective cohort study was performed including a total of 258 patients ≥80 years with hospital admission for confirmed COVID-19 between March 1 and May 31, 2020. They were divided into two groups: taking statins prior to admission (n = 129) or not (n = 129). ResultsIn-hospital mortality due to COVID-19 in patients ≥80 years (86.13 ± 4.40) during the first wave was 35.7% (95% CI: 30.1%–41.7%). Mortality in patients previously taking statins was 25.6% while in those not taking statins was 45.7%. Female sex (RR 0.62 [0.44–0.89]; P = .008), diabetes (RR 0.61 [0.41–0.92]; P = .017) and pre-admission treatment with statins (RR 0.58 CI 95% [0.41–0.83]; P = .003) were associated with lower in-hospital mortality. Severe lung involvement was associated with increased in-hospital mortality (RR 1.45 IC95% [1.04–2.03]; P = .028). Hypertension, obesity, age, cardiovascular disease and a higher Charlson index did not, however, show influence on in-hospital mortality. ConclusionsIn octogenarian patients treated with statins prior to admission for COVID-19 in the first wave, lower in-hospital mortality was observed.

Profiling complete regression after pre-operative therapy in gastric cancer patients using clinical and pathological data

IntroductionThe consistent use of pre-operative treatment before surgery for gastric cancer (GC) has resulted in increased rates of complete response. However, factors associated with response have been scantly investigated. MethodsPatients with GCs treated between 2017 and 2022 undergoing pre-operative treatment followed by resection were included. Clinicopathological data were analyzed for the association with tumor regression grades (TRG); secondary outcomes included the short-term overall (OS), disease-free (DFS) and disease specific survival (DSS). ResultsAmong 108 patients, 35.1% had an intestinal histotype GC, and 70.4% were treated with FLOT. Complete tumor regression (TRG1) was documented in 6.5% of patients. Univariable analyses documented that a higher pre-operative albumin (p = 0.04) and the expression of HER2 (p = 0.01) were associated to TRG1. In the multinominal regression model, the log-odds of being classified as TRG1 increased with the expression of HER2 by 170.247 times and with higher pre-operative albumin by 34.525 times, while with a higher Charlson Index and a diffuse hystotipe reduced it by 25.467 times and 3759.126 times, respectively. Among 49 patients (mean follow-up: 17.1 months), TRG1-2 was associated to better OS, DFS and DSS curves compared to TRG 3-5 (respectively p < 0.01, p 0.007 and p < 0.01), altogether with the reported negative impact of comorbidities in OS and DSS multivariable analyses (respectively p 0.04 and p 0.006). The random survival forest further confirmed the impact of HER2 and comorbidity on DSS. ConclusionA better clinical profile, HER2 expression and intestinal histotype significantly correlated with GC regression. A complete-major response was an independent factor for survival.

#5785 ACUTE KIDNEY INJURY AS A RISK FACTOR FOR THE DEVELOPMENT OF CHRONIC KIDNEY DISEASE AND MORTALITY IN HOSPITALIZED PATIENTS

Abstract Background and Aims Acute kidney injury (AKI) is a complication that affects more than 5% of all hospital admissions and up to one third of patients admitted to critical care units. This entity, whose incidence is on the rise, remains a major cause of morbidity and mortality. In addition, AKI has been linked as an independent risk factor for mortality, especially in severe forms, and of those patients who survive, a percentage will develop chronic kidney disease (CKD) during follow-up. We conducted this study to analyse the incidence of CKD at 6 and 12 months follow-up in hospitalized patients with AKI, to identify possible risk factors leading to its development and to determine mortality in this group of patients. Method This is a retrospective study of a cohort of cases with AKI (baseline eGFR &amp;gt;60 mL/min/1.73 m2 without previous structural damage) from our hospital, taking place from June 2020 to February 2021. Regarding the evolution of the AKI, four possibilities were considered: recovery of normal kidney function, development of CKD at 6 months, development of CKD at 12 months or death during follow-up. Results We studied 148 patients (55% male), with a median age of 83 years (74-87). Thirty-six patients (24.3%) developed CKD at 6 months follow-up and 30 patients (20.3%) at 12 months. Forty-one patients (27.7%) died within the first 12 months following de episode of AKI. The risk factors identified for development of CKD at 12 months were older age (85 vs 77; p = 0.03), higher serum lactate dehydrogenase levels at admission (246 U/L vs 201 U/L; p = 0.04) and at 3 months (252 U/L vs 192,5 U/L; p = 0.039), and eGFR &amp;lt; 60 mL/min/1.73 m2 at 1 week (74,5 vs 57; p = 0.004) and at 3 months (79 vs 50; p &amp;lt; 0.001) of follow-up. Identified risk factors and predictors of AKI-associated mortality were older age (84 vs 80,5; p = 0.018), concomitant oncological pathology (10,8% vs 7,4%; p = 0,018), higher Charlson index (6 vs 5, p &amp;lt;0.001), higher AKI stage (p = 0.042), lower serum albumin levels at first (3.35 g/dL vs 3.90 g/dL; p = 0.014) and at third month (3,2 g/dL vs 4 g/dL; p &amp;lt; 0.001) of follow-up. Conclusion Our study showed a high incidence of CKD in patients who have had an episode of AKI. Several risk factors for development of CKD were identified, being the older age and the greater length of recovery period from AKI the most useful predictors in the clinical practice. AKI-associated mortality was very high in those older patients with higher comorbidity and persistence of AKI. Despite advances, we need non-classical biomarkers for early diagnosis and more effective therapeutic measures to avoid this high prevalence of CKD and mortality.

Influence of increase in hospital costs on mortality for pleural mesothelioma in teaching hospitals: A nationwide analysis.

e20533 Background: Rural and non-teaching hospitals are known to have a lower budget compared to urban-teaching hospitals. Pleural mesothelioma is an aggressive and rare malignancy, and it remains unknown whether treatment in institutions with higher revenue or reimbursement rates impacts outcomes. This study sought to elucidate if such a difference in outcomes exists. Methods: A retrospective cohort analysis of adults admitted from 2016 to 2020 with the primary diagnosis of pleural mesothelioma was conducted. Data was extracted from the National Inpatient Sample Database. We compared outcomes such as mortality, length of stay (LoS), and total charges in teaching versus non-teaching hospitals. Results: We identified 7,320 patients that met inclusion criteria; 84% were admitted to teaching hospitals, and the remaining 16% to non-teaching facilities ( p &lt; 0.001). Elderly patients were the most afflicted group, with a mean age of 72 to 74 years ( p 0.009). No differences in sex, race, or primary insurance distribution were noted ( p 0.067; p 0.731; p 0.801, respectively). The mean hospital LoS was 6.4 days in non-teaching hospitals compared to 7.7 days in teaching hospitals ( p 0.0061). In addition, Asians ( p 0.016), those with a median household income of 65,000 to 85,999 ( p 0.021), higher Charlson index ( p &lt; 0.001), and those admitted to large to medium size hospitals ( p 0.011; p 0.001, respectively) had a positive linear relation to LoS. Moreover, total hospital charges were greater in teaching hospitals (120,100 USD) in comparison to non-teaching hospitals (73,883 USD) ( p &lt; 0.001). Mortality did not differ based on teaching status ( p 0.643). However, Native Americans and those with higher Charlson comorbidity index were more likely to die ( aOR 21, p 0.004; aOR 1.32, p &lt; 0.001, respectively). Conclusions: Hospital teaching status does not impact mortality in patients admitted with malignant pleural mesothelioma, even though teaching hospitals incur higher expenses on average. It does not come as a surprise due to this condition's known high mortality rate, late presentation in advanced stages, and resistance to current therapies. Prevention is key in a deadly disease, and more research is needed to offer a better prognosis; even though current regimens have shown improvement in survival, curative therapies are still unavailable. Even though asbestos is subject to strict regulations in the United States, it is not banned. We should revisit the idea of a complete ban; those most affected tend to have the least access to healthcare and need a safer work environment. Decreasing exposure to known carcinogens should also be a priority, as there is no better medicine than preventive medicine. Interestingly, mortality was greater in Native Americans compared to other races; the underlying causes are broad and need more research and better characterization of MM.

Incidence of Instability Following Primary Total Hip Arthroplasty Continues to Decline in the Medicare Population

BackgroundInstability has been the primary cause of failure following primary total hip arthroplasty (THA) leading to revision hip surgery. The purpose of this study was to determine if instability rates have further declined following advances in primary THA, including dual mobility articulations, direct anterior approaches, advanced technologies, and improved knowledge of the hip-spine relationships. MethodsUsing the 5% Medicare Part B claims data from 1999 to 2019, we identified 81,573 patients who underwent primary THA for osteoarthritis. Patients who experienced instability at 3 months, 6 months, 1 year, and 2 years were identified. Multivariate cox regression analyses evaluated the effect of patient and procedure characteristics on the risk of instability. ResultsInstability at 1 year following primary THA declined from approximately 4% in 2000 to 2.3% in 2010 and 1.6% in 2018. The leading cause of revision surgery was infection (18.6%), followed by periprosthetic fracture (14%), mechanical loosening (11.5%), and instability (9.4%). High-risk groups for instability continue to include increased age, higher Charlson index, obesity, lumbar spine pathology, and neurocognitive disorders. ConclusionInstability is no longer the leading etiology of failure following primary THA with a decline of approximately 40% over the past decade. Infection, periprosthetic fracture, mechanical loosening, and then instability are now the leading causes of failure. Multiple factors may play a role in the decline of instability, including increased use of dual mobility articulations, direct anterior approaches, improved knowledge of the hip-spine relationships, and use of advanced technologies.

Association Between Opening a Palliative Care Unit and Hospital Care for Patients With Serious Illness.

Background: Palliative care units (PCUs) are devoted to intensive management of symptoms and other palliative care needs. We examined the association between opening a PCU and acute care processes at a single U.S. academic medical center. Methods: We retrospectively compared acute care processes for seriously ill patients admitted before and after the opening of a PCU at a single academic medical center. Outcomes included rates of change in code status to do-not-resuscitate (DNR) and comfort measures only (CMO) status, and time to DNR and CMO. We calculated unadjusted and adjusted rates and used logistic regression to assess interaction between care period and palliative care consultation. Results: There were 16,611 patients in the pre-PCU period and 18,305 patients in the post-PCU period. The post-PCU cohort was slightly older, with a higher Charlson index (p < 0.001 for both). Post-PCU, unadjusted rates of DNR and CMO increased from 16.4% to 18.3% (p < 0.001) and 9.3% to 11.5% (p < 0.001), respectively. Post-PCU, median time to DNR was unchanged (0 days), and time to CMO decreased from 6 to 5 days. The adjusted odds ratio was 1.08 (p = 0.01) for DNR and 1.19 (p < 0.001) for CMO. Significant interaction between care period and palliative care consultation for DNR (p = 0.04) and CMO (p = 0.01) suggests an important role for palliative care engagement. Conclusions: The opening of a PCU at a single center was associated with increased rates of DNR and CMO status for seriously ill patients.

Papel de las estatinas en la evolución clínica de los pacientes octogenarios ingresados por COVID-19

Introduction and objectivescoronavirus disease 2019 (COVID-19) causes high mortality in elderly patients. Some studies have shown a benefit of statin treatment in the evolution of this disease. Since there are no similar publications in this population group, the aim of this study is to analyze in-hospital mortality in relation to preadmission treatment with statins in an exclusively elderly population of octogenarian patients. Materials and methodsA single-center retrospective cohort study was performed including a total of 258 patients ≥80 years with hospital admission for confirmed COVID-19 between March 1 and May 31, 2020. They were divided into two groups: taking statins prior to admission (n=129) or not (n=129). ResultsIn-hospital mortality due to COVID-19 in patients ≥80 years (86.13±4.40) during the first wave was 35.7% (95% CI: 30.1–41.7%). Mortality in patients previously taking statins was 25.6% while in those not taking statins was 45.7%. Female sex (RR 0.62 [0.44-0.89]; p=0.008), diabetes (RR 0.61 [0.41-0.92]; p=0.017) and pre-admission treatment with statins (RR 0.58 95% CI [0.41-0.83]; p=0.003) were associated with lower in-hospital mortality. Severe lung involvement was associated with increased in-hospital mortality (RR 1.45 95% CI [1.04-2.03]; p=0.028). Hypertension, obesity, age, cardiovascular disease and a higher Charlson index did not, however, show influence on in-hospital mortality. ConclusionsIn octogenarian patients treated with statins prior to admission for COVID-19 in the first wave, lower in-hospital mortality was observed.

MP02-02 15 YEARS OF FOURNIER'S RISK FACTORS, MICROBIOLOGY, AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP02-02 15 YEARS OF FOURNIER'S RISK FACTORS, MICROBIOLOGY, AND OUTCOMES Jubin Matloubieh, Rutul Patel, Meenakshi Davuluri, Ethan Fram, Richard Maiman, and Franklin Lowe Jubin MatloubiehJubin Matloubieh More articles by this author , Rutul PatelRutul Patel More articles by this author , Meenakshi DavuluriMeenakshi Davuluri More articles by this author , Ethan FramEthan Fram More articles by this author , Richard MaimanRichard Maiman More articles by this author , and Franklin LoweFranklin Lowe More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Factors associated with (a/w) Fournier’s Gangrene (FG) are not fully known. We aim to assess FG risk factors (rf), scoring systems, microbiology, and outcomes. METHODS: Retrospective FG patient (pt) medical data from 2007-21 at our institution were obtained. Means were compared via t tests and associations via chi square analysis. RESULTS: Of 132 FG pts, 14% died of FG, 47% were discharged (dc) home and 39% were dc to nursing facility (NH). 9% had orchiectomy, 22% suprapubic tube (SPT), 19% colostomy, 12% thigh pouch (TP), 29% wound closure, and 22% flap/graft use (Table 1). Frequent culture isolates were E. coli, Bacteroides, Streptococcus, Enterococcus, and Candida (Figure 1). Higher FG Severity Index (FGSI) was a/w colostomy, TP, and dc to NH. Lower FGSI was a/w dc home. Higher Uludag FGSI (UFGSI) was a/w colostomy, TP, dc to NH, and FG death. Lower UFGSI was a/w dc home. Lower surgical APGAR (sAPGAR) was a/w colostomy. Higher Charlson index (CI) was a/w FG death. Lower CI was a/w dc home. Actinomyces was a/w closure and f/g. Bacteroides was a/w shorter intensive care unit (ICU) stay, colostomy, and fewer vasopressors. Candida was a/w FG death, longer hospital stay, and shorter time to death (TtoD). Pseudomonas was a/w shorter TtoD, SPT, and TP. Proteus was a/w orchiectomy and FG death. Streptococcus was a/w dc home, longer ICU stay, and longer TtoD. Interestingly, lower hemoglobin A1c (A1c) was a/w orchiectomy and FG death, while higher A1c was a/w f/g. Culture-discordant empiric antibiotics were a/w longer hospital stay and intubation. CONCLUSIONS: This is the largest series on FG scoring systems and the first to compare microbiology with outcomes. FGSI and UFGSI were most a/w outcomes. CI was a/w some outcomes, but this may stem from age as a CI factor. sAPGAR was less a/w outcomes suggesting divergent management of FG vs. trauma. FG microbiology is a/w multiple outcomes and shows a shift away from prior pathogens. These findings and unexpected findings like higher A1c being a/w FG death warrant further study into whether reassessing empiric antibiotics or nutritional optimization may improve outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e10 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jubin Matloubieh More articles by this author Rutul Patel More articles by this author Meenakshi Davuluri More articles by this author Ethan Fram More articles by this author Richard Maiman More articles by this author Franklin Lowe More articles by this author Expand All Advertisement PDF downloadLoading ...

Nutritional indices may have prognostic value in elderly critically ill patients with sepsis

Aim: Nutritional indicators are associated with adverse outcomes in critically ill elderly patients. In this study, we aimed to evaluate the prognostic potential of prealbumin and albumin in the prediction of mortality in elderly patients with sepsis. &#x0D; Material and Method: A total of 108 patients who developed intensive care unit-acquired sepsis were divided into two groups: Survivors (n=72) and Non-survivors (n=36). &#x0D; Results: Patients in the Non-survivors group were often older (68 vs 74) and presented lower prealbumin (15.1 vs 11), and higher Charlson index (4 vs 6), Sequential Organ Failure Assessment (SOFA) score (8.5 vs 10), C-reactive protein (CRP) (68.8 vs 91) and procalcitonin (PCT) (6 vs 8.4) (p&lt; 0.05). The area under the curve of PCT was the highest at 0.74. Prealbumin presented the best sensitivity (75%) and 12 mg/dL cut-off value, while PCT had the best specificity (75%) and a cut-off value of 7 ng/mL. Although prealbumin was negatively correlated to SOFA score in a significant way (r=-0.226, p=0.019), White blood cells, CRP, and PCT were positively correlated to SOFA score (r=0.198, p=0.040; r=0.233, p=0.015; r=0.286, p=0.003, respectively). In addition, a weak negative correlation was observed between prealbumin and CRP and PCT (r=-0.203, p=0.037; r=-0.215, p=0.026, respectively). Multivariate analysis showed that a reduction in serum prealbumin levels compared to steady prealbumin greater than 4 mg/dL increased the risk of death by 85% (aHR: 1.85, 95% CI: 1.05-2.56, p=0.029). &#x0D; Conclusion: Changes in serum prealbumin in the acute phase of sepsis may assist in determining the risk of mortality and in the administration of specific treatment in critically ill elderly patients.

Antibiotics Used for COVID-19 In-Patients from an Infectious Disease Ward.

although the prevalence of bacterial co-infections for COVID-19 patients is very low, most patients receive empirical antimicrobial therapy. Furthermore, broad spectrum antibiotics are preferred to narrow spectrum antibiotics. in order to estimate the excess of antibiotic prescriptions for patients with COVID-19, and to identify the factors that were correlated with the unjustified antibiotic usage, we conducted an observational (cohort) prospective study in patients hospitalized with COVID-19 at the National Institute for Infectious Diseases "Prof. Dr. Matei Bals", Bucharest, on an infectious disease ward, from November 2021 to January 2022. To evaluate the prevalence of bacterial co-infection in these patients, all positive microbiology results and concomitant suspected or confirmed bacterial co-infections, as documented by the treating doctor, were recorded. The patients were grouped in two categories: patients who received antibiotics and those who did not receive antibiotics, justified or not. from the 205 patients enrolled in the study, 83 (40.4%) received antibiotics prior to being admitted to the hospital. 84 patients (41.0%) received antibiotics during their hospitalization; however, only 32 patients (15.6%) had signs and symptoms suggestive of an infection, 19 (9.3%) presented pulmonary consolidation on the computed tomography (CT) scan, 20 (9.7%) patients had leukocytosis, 29 (14.1%) had an increased procalcitonin level and only 22 (10.7%) patients had positive microbiological tests. It was observed that patients treated with antibiotics were older [70 (54-76) vs. 65 (52.5-71.5), p = 0.023, r = 0.159], had a higher Charlson index [4 (2-5) vs. 2 (1-4), p = 0.007, r = 0.189], had a severe/critical COVID-19 disease more frequently [61 (72.6%) vs. 38 (31.4%), p &lt; 0.001, df = 3, X2 = 39.563] and required more oxygen [3 (0-6) vs. 0 (0-2), p &lt; 0.001, r = 0.328]. empirical antibiotic treatment recommendation should be reserved for COVID-19 patients that also had other clinical or paraclinical changes, which suggest a bacterial infection. Further research is needed to better identify patients with bacterial co-infection that should receive antibiotic treatment.

1023. Thrice is Nice: Thrice Weekly Ertapenem Versus Daily Ertapenem in Patients on Hemodialysis

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) has challenges: venous access complications, cost, and non-adherence. Venous line preservation is an added concern for patients on hemodialysis (HD). While ertapenem is dosed 500 mg daily post-HD, there is limited data on dosing it as 1 gm thrice weekly. This study compares disposition and outcome in patients treated with these two regimens. Methods IRB approved, retrospective cohort study. Inclusion: adult patients on intermittent HD, admitted 6/1/20 to 7/31/21, and discharged with ertapenem either with daily (daily group) or thrice weekly (TIW group) dosing. Data were reported using descriptive statistics and bivariate analysis. Primary endpoints: discharge delay after medical stability. Secondary endpoints: efficacy (readmissions, alterations in antibiotics, and mortality) and safety (line or drug – related adverse events including line infection and seizure). Results 33 patients included: 10 daily and 23 TIW. Baseline characteristics were similar. Median (IQR) age: 57 (48-64) daily and 63 (47-70) TIW, P=0.552. Both groups had a high median Charlson index (IQR): 5 (4-5) daily and 4 (2-5) TIW, P=0.287. Primary reason for ertapenem use was infection from extended-spectrum beta lactamase producing organism: 60% daily and 52% TIW. The TIW group had significantly fewer lines placed (80% daily vs. 22% TIW, p=0.05). Median (IQR) length of stay in days was similar: 7 (6–15) daily and 8 (6-8) TIW, P=0.773. Discharge delays were similar (10% daily vs 9% TIW, P=1.0). Most patients were discharged home (60%). More patients received ertapenem at the dialysis center or infusion clinic in the TIW group (78% TIW vs 30% daily, P=0.016). There was no difference in safety and efficacy endpoints including readmission, mortality, alternation in antibiotics, and line infection. Conclusion In this study’s cohort, ertapenem thrice weekly dosing led to a decrease in line placement without compromising efficacy and safety. Disclosures All Authors: No reported disclosures.

Retrospective study of risk factors for mortality in critically ill patients with COVID-19

Background: Mortality associated with COVID-19 varies in various reports, with minimal data on the factors associated with in-hospital mortality. Objective: To identify the risk factors for in-hospital death of patients with COVID-19 in an intensive care unit (ICU) in Qatar. Methods: A retrospective observational study of patients confirmed with COVID-19 and admitted to the medical-surgical ICU at The Cuban Hospital was carried out from April 12, 2020, to September 12, 2020. From patients’ electronic medical records, demographic, clinical, laboratory, and radiology data was collected. Results: 275 patients with COVID-19 were admitted to the ICU, and 32 (11.6%) died. 56.1% were men, and the mean age was 52.2 years. According to the univariate analysis, patients with diabetes mellitus with end-organ damage (37.5%), cardiovascular disease (31.3%), dementia (9.4%), kidney disease (28.1%), chronic obstructive pulmonary disease (31.3%), and higher Charlson index had higher mortality. According to the multivariate analysis, an increase of mortality risk by 9% was observed for each additional year of age (Odds ratio [OR] 1.09; 95% confidence interval [CI] 1.04–1.14), patients on mechanical ventilation (OR 27.33; 95% CI 3.21–232.46), and those with adult respiratory distress (OR 15.85; 95% CI 1.45–172.82) and elevated procalcitonin (OR 7.30; 95% CI 1.25–42.58), and the PiO2/FiO2 ratio between 100 and 299 decreased the risk of death by 92% (OR 0.08; 95% CI 0.02–0.39), in comparison to a PiO2/FiO2 ratio less than 100 or greater than 300. Conclusion: The study provides evidence about the risk of mortality among COVID-19 patients with a significant contribution of age, respiratory failure, and co-infections.