Treatment Of High-risk Patients Research Articles

Therapy-Related Myeloid Neoplasms: Complex Interactions among Cytotoxic Therapies, Genetic Factors, and Aberrant Microenvironment.

Therapy-related myeloid neoplasm (t-MN), characterized by its association with prior exposure to cytotoxic therapy, remains poorly understood and is a major impediment to long-term survival even in the era of novel targeted therapies due to its aggressive nature and treatment resistance. Previously, cytotoxic therapy-induced genomic changes in hematopoietic stem cells were considered sine qua non in pathogenesis; however, recent research demonstrates a complex interaction between acquired and hereditary genetic predispositions, along with a profoundly senescent bone marrow (BM) microenvironment. We review emerging data on t-MN risk factors and explore the intricate interplay among clonal hematopoiesis, genetic predisposition, and the abnormal BM microenvironment. Significance: t-MN represents a poorly understood blood cancer with extremely poor survival and no effective therapies. We provide a comprehensive review of recent preclinical research highlighting complex interaction among emerging therapies, hereditary and acquired genetic factors, and BM microenvironment. Understanding the risk factors associated with t-MN is crucial for clinicians, molecular pathologists, and cancer biologists to anticipate and potentially reduce its incidence in the future. Moreover, better understanding of the molecular pathogenesis of t-MN may enable preemptive screening and even intervention in high-risk patients.

Comparative Study Of BISAP Score With APACHE-II Scoring System To Determine The Severity Of Acute Pancreatitis

Introduction: Acute pancreatitis (AP) is a significant abdominal emergency characterized by inflammation of the pancreas, primarily due to autodigestion by pancreatic enzymes. Early severity assessment is crucial for management, as severe cases lead to complications and mortality. While various scoring systems exist, the Bedside Index for Severity in Acute Pancreatitis (BISAP) and APACHE-II (Acute Physiology and Chronic Health Evaluation) scores are commonly used, each with unique advantages and limitations in severity prediction. Objective: This study aims to compare the effectiveness of BISAP and APACHE-II scores in predicting acute pancreatitis severity, helping clinicians optimize treatment decisions. Methods: This observational study was conducted at SMS Hospital, Jaipur, involving 76 patients diagnosed with AP based on clinical, biochemical, and imaging criteria. Participants were assessed using both BISAP and APACHE-II scoring within 24 hours of admission, with a focus on accuracy in predicting severe cases and outcomes. Results: Among participants, the mean age was 43 years, and 84.2% were male. Gallstone disease was the leading cause of AP (55.2%), followed by alcohol (34.2%). BISAP scores ≥3 was associated with significantly higher mortality, highlighting BISAP’s predictive accuracy. The mean BISAP score was 1.86 ± 1.09, while the APACHE-II score was 6.97 ± 5.66, indicating more severe classifications using BISAP. The study found a moderate positive correlation between BISAP and APACHE-II scores, though only BISAP scores significantly predicted patient outcomes. Conclusion: BISAP offers a rapid and accurate assessment tool for AP severity, especially suitable for early intervention in high-risk patients. Compared to APACHE-II, BISAP is simpler, cost-effective, and demonstrates a high negative predictive value, making it more practical for acute settings.

Percutaneous Coronary Intervention in High-Risk Patients

Ischemic heart disease (IHD) with severe coronary artery disease (SYNTAX score >22 points) in combination with various comorbidities is often a reason for refusal of coronary artery bypass grafting in such patients. Thus, a new term has emerged, "high-risk percutaneous coronary intervention"; however, the criteria, indications and results of these interventions have not yet been sufficiently studied. Therefore, according to current clinical guidelines, the treatment tactics for this patient cohort is determined by the decision of a council, the so-called Heart Team. This analytical review summarizes the criteria for high-risk percutaneous coronary interventions based on the literature, and describes the effect of various comorbidities on the results of direct myocardial revascularization.

Clinical risk factors of bevacizumab-related hypertension in patients with metastatic colorectal cancer: a retrospective study.

Bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor, is widely used as a first-line treatment for metastatic colorectal cancer (mCRC), with hypertension being a common adverse effect. However, there is limited data on the predisposing factors contributing to bevacizumab-induced blood pressure (BP) elevation. This study aims to identify clinical risk factors associated with bevacizumab-related hypertension in patients with mCRC. This retrospective study included 178 patients treated between January and June 2020. Demographic data and medical histories were extracted from hospital electronic medical records. Among the 178 patients, 54 (30.3%) developed bevacizumab-related hypertension, with a median onset time of 48days. Univariate and multivariate analyses identified pre-existing hypertension [odds ratio (OR), 3.30; 95% confidence interval (CI), 1.56-6.99] and age ≥60years (OR, 2.04; 95% CI, 1.00-4.17) as independent risk factors for bevacizumab-related hypertension. The area under the receiver operating characteristic (ROC) curve was 0.66 (95% CI, 0.57-0.75, P < 0.001). The median overall survival (OS) for the cohort was 30.53months (95% CI, 22.23-38.84). No significant differences in OS were observed between patients with and without bevacizumab-related hypertension (31.13 vs. 27.87months, P = 0.86). Pre-existing hypertension and age ≥60years are significant clinical risk factors for bevacizumab-related hypertension in mCRC patients. Bevacizumab-related hypertension did not affect overall survival. Clinicians should closely monitor BP within the first 2months of bevacizumab treatment in high-risk patients.

TCT-76 Percutaneous Coronary Intervention in High-Risk Patients With High Syntax Score Left Main Coronary Disease: 17-Year Long-Term Follow-Up Real World Experience of a Single Center Without On-Site Cardiac Surgery

TCT-76 Percutaneous Coronary Intervention in High-Risk Patients With High Syntax Score Left Main Coronary Disease: 17-Year Long-Term Follow-Up Real World Experience of a Single Center Without On-Site Cardiac Surgery

Assessing the Utility of Prediction Scores PAINT, ISARIC4C, CHIS, and COVID-GRAM at Admission and Seven Days after Symptom Onset for COVID-19 Mortality.

The COVID-19 pandemic underscores the need for accurate prognostic tools to predict patient outcomes. This study evaluates the effectiveness of four prominent COVID-19 prediction scores-PAINT, ISARIC4C, CHIS, and COVID-GRAM-at two critical time points: at admission and seven days post-symptom onset, to assess their utility in predicting mortality among hospitalized patients. Conducted at the Clinical Emergency Hospital Pius Brînzeu in Timișoara, this retrospective analysis included adult patients hospitalized with confirmed SARS-CoV-2 infection. Eligible patients had complete data for the scores at both time points. Statistical analysis involved ROC curves and logistic regression to assess the scores' predictive accuracy for mortality. The study included 215 patients, split into 139 survivors and 76 non-survivors. At admission, the PAINT, ISARIC4C, CHIS, and COVID-GRAM scores significantly differentiated between the survival outcomes (p < 0.0001). The best cutoff values at admission were 6.26 for PAINT, 7.95 for ISARIC4C, 5.58 for CHIS, and 0.63 for COVID-GRAM, corresponding to sensitivities of 85.47%, 80.56%, 88.89%, and 83.33% and specificities of 77.34%, 82.12%, 75.01%, and 78.45%, respectively. By day seven, the cutoff values increased, indicating deteriorating conditions in patients who eventually succumbed to the virus. The hazard ratios at admission for exceeding these cutoffs were significant: PAINT (HR = 3.45), ISARIC4C (HR = 2.89), CHIS (HR = 4.02), and COVID-GRAM (HR = 3.15), highlighting the scores' abilities to predict severe outcomes. One week post symptom onset, these scores' predictive values and corresponding hazard ratios increased, further validating their prognostic significance over time. The evaluated COVID-19 prediction scores robustly predict mortality at admission and become more predictive by the seventh day of symptom onset. These findings support the use of these scores in clinical settings to facilitate early identification and intervention for high-risk patients, potentially improving patient outcomes during the ongoing global health crisis.

Risk Factors for Adverse In-Hospital Outcomes in Patients With Traumatic Blunt Thoracic Aortic Injuries Undergoing Thoracic Endovascular Aortic Repair (TEVAR): An Analysis of the US Nationwide Inpatient Sample.

Thoracic endovascular aortic repair (TEVAR) is a treatment for traumatic blunt thoracic aortic injury (BTAI) with good survival rates and safety. However, there is limited study on the risk factors for in-hospital mortality and complications. This study aimed to identify risk factors associated with poor in-hospital outcomes after TEVAR. This is a population-based, retrospective observational study. Data of adults ≥20 years admitted for BTAI who received TEVAR were extracted from the Nationwide Inpatient Sample (NIS) database 2005 to 2018. The primary outcome was in-hospital mortality, and the secondary outcomes were length of stay (LOS) and unfavorable discharge (ie, non-routine discharge, including nursing homes or long-term care facilities). Associations between study variables and in-hospital outcomes were determined using univariate and multivariable logistic and linear regression analyses. Data of 1095 participants (representing 5360 hospitalized patients in the United States) were analyzed. Multivariable analysis revealed that older age (adjusted odds ratio [aOR]=1.02) and having at least 1 perioperative complication (aOR=4.01) were significantly associated with increased risk for in-hospital mortality. Patients with at least 1 perioperative complication (aOR=11.19) had significantly increased odds for prolonged LOS. Risk for unfavorable discharge was significantly increased by older age (aOR=1.02), household income at quartile 2 (aOR=1.58), Charlson Comorbidity Index (CCI) 2 to 3 (aOR=1.66), and having at least 1 complication (aOR=3.94). Complications including perioperative cerebrovascular accident (CVA) (aOR=2.75), venous thromboembolism (VTE) (aOR=2.87), pneumonia (aOR=3.93), sepsis (aOR=4.69), infection (aOR=4.49), respiratory failure (aOR=4.55), mechanical ventilation (aOR=3.27), and acute kidney injury (AKI) (aOR=3.09) significantly predicted prolonged LOS. In adults with traumatic BTAI undergoing TEVAR, advanced age and perioperative complications are risk factors for poor in-hospital outcomes. Acute kidney injury, CVA, respiratory failure, and sepsis are strong predictors of prolonged LOS, unfavorable discharge, and in-hospital mortality. The study identifies advanced age and perioperative complications as key risk factors for poor in-hospital outcomes in patients undergoing TEVAR for BTAI. Clinicians should be vigilant in managing these patients, particularly those with comorbidities, to mitigate risks. The findings suggest a need for tailored perioperative care strategies to improve survival rates and reduce complications. This research highlights the critical importance of early identification and intervention in high-risk patients, offering an innovative approach to refining TEVAR protocols and enhancing patient outcomes in trauma care.

Clinical Management of Primary Aldosteronism: An Update.

Despite carrying an excess risk of cardiovascular events, primary aldosteronism (PA) is a commonly overlooked secondary form of arterial hypertension. An increased awareness of its high prevalence and broader screening strategies are urgently needed to improve its detection rate and allow early diagnosis and targeted treatment. For patients with unilateral PA, these measures can correct hyperaldosteronism and ensure cure of hypertension, even when resistant to drug treatment, thus preventing adverse cardiovascular events. Among these, atrial fibrillation is the most common, but left ventricular hypertrophy, stroke, chronic kidney disease, and myocardial infarction also occur more often than in patients with hypertension and no PA. Young patients, who have higher chances of being cured long term, and high-risk patients, such as those with stage III or resistant hypertension, are those who will benefit most from an early diagnosis of PA. Therefore, the implementation of strategies to detect PA by a simplified diagnostic algorithm is necessary. In the patients who seek for surgical cure, adrenal vein sampling is key for the identification of unilateral PA and the achievement of optimal outcomes. Unfortunately, being technically demanding and poorly available, adrenal vein sampling represents the bottleneck in the workup of PA. Considering the novel knowledge generated in the past 5 years in many studies, particularly in the AVIS-2 study (Adrenal Vein Sampling International Study-2), based on 4 decades of experience at our center and on the last guidelines, we herein provide an update on the management of PA with recommendations for drug treatment and strategies to avoid adrenal vein sampling wherever it is poorly, or not, available.

The Evolving Role of Bispecific Antibodies in Diffuse Large B-Cell Lymphoma.

The advent of targeted therapies such as monoclonal antibodies, adoptive T-cell therapies, and antibody-drug conjugates (ADCs) dramatically changed the treatment landscape of diffuse large B-cell lymphoma (DLBCL) over the last two decades. Rituximab was the first one approved. Chimeric antigen receptor T-cells are currently approved as second-line treatment in patients with DLBCL refractory to first-line chemo-immunotherapy. Polatuzumab, a CD79b-targeting ADC, is approved as first-line treatment in high-risk patients in combination with chemo-immunotherapy. Bispecific antibodies (BsAbs) are a novel category of drugs that are also changing the treatment paradigm of patients with DLBCL. They are engineered to bind to two different targets at the same time. To date, two BsAbs (glofitamab and epcoritamab) are approved as monotherapy in third-line treatment in DLBCL. Combination strategies with chemotherapy, immunotherapy, and ADCs are currently under investigation with encouraging results in first-line or subsequent lines of treatment. In the following review, we focus on the structure of BsAbs, the mechanism of action, clinical efficacy, and the mechanisms of resistance to BsAbs.

The predictive value of the MASCC score in patients with febrile neutropenia.

e23059 Background: Febrile neutropenia (FN) is a life-threatening complication in patients receiving cytotoxic chemotherapy. Guidelines classify FN as a one-time oral temperature of greater than 38.3°C or sustained temperature greater than 38°C for ≥ 1 hour with an absolute neutrophil count (ANC) of less than 500 cells/μL or an ANC expected to decrease to less than 500 cells/μL within a 48-hour period. This condition has a high rate of hospitalization and mortality. Currently, the Multinational Association of Supportive Care in Cancer (MASCC) risk score is used to classify patients as high or low risk. The current study outlines the predictive role of MASCC scoring in risk stratifying patients with FN at our institution. Methods: This is a single-center, retrospective observational study. IRB approval was obtained for this study. Electronic medical record data was reviewed to record mortality, length of stay (LOS), and antimicrobial use as primary outcomes with age at time of admission, sex, race, type of malignancy, any confirmed infection diagnosis, MASCC risk score, and subspecialist consultation as predictors of outcomes. Results: 220 records of possible FN episodes were screened, 160 were excluded leaving a total of 60 patients for review. The median age was 72.5 with 28 males and 32 females. Overall mortality rate was 10%.33 patients (55%) did not have an identifiable source of infection. Among the 27 patients with confirmed infection, 7 were associated with COVID-19, 12 had gram negative rod (GNR) sepsis and 8 were other bacterial infections. Patients with GNR sepsis had the highest mortality risk in which 4 of the 12 (33%) died. LOS was also significantly longer in patients with GNR sepsis. Lower MASCC scores were associated with identification of GNR sepsis. Of the patients with MASCC score of &lt; 24, significantly more patients 7/20 (35%) developed GNR sepsis compared to 5/40 (12.5%) of those with MASCC score of 24 or greater (p = .004). Patients with GNR sepsis received a mean 5.7 days of broad spectrum antibiotics compared to 3 days in those without, (p &lt; 0.001). Those with no identified infection had significantly lower LOS (4.5 days) compared to the groups with GNR sepsis (11.1 days) or other bacterial infections (10.1 days). Conclusions: Febrile neutropenia is a complication of cytotoxic chemotherapy that warrants special attention due to high mortality rates. We found lower MASCC scores were associated with GNR sepsis and that in the setting of FN these patients had higher mortality rates and longer LOS. This highlights the importance of risk stratification with MASCC index scoring as early recognition and treatment of high risk patients could lead to improved patient outcomes.

A Cohort Retrospective Study on Factors Associated with Mortality in Multiple Trauma

Trauma is one of the major causes of death and disability worldwide, and a high percentage (50-60%) of trauma patients die from injuries before reaching the hospital. The aim of this study is to investigate the relation of some pre-hospital factors related to the mortality of multi-trauma patients. In this retrospective cross-sectional study, multiple trauma patients referred to the emergency department of our center (a trauma center in the west of Iran) from 2021 to 2022 were included. Demographic and clinical information was collected and recorded using hospital registry information. The collected data were statistically analyzed using SPSS version 25 software. Of 2876 trauma patients included, 2119 cases (73.7%) were men and 757 cases (26.3%) were women. The mean and standard deviation of the age of patients, by gender, in men and women were 20.23 ± 38.63 and 24.01 ± 49.97, respectively. 25 women and 22 men died due to trauma. The most common mode of transportation to the hospital was by private vehicle and ground ambulance with a frequency of 1517 and 1302 respectively. Also, 342 people were injured due to overturning ,748 people were injured due to collision and 1786 people were injured due to other types of trauma. The most common cause was road traffic accidents and falling was the most common second cause of trauma. Based on multivariable logistic regression, the variables of gender, mechanism of Injury and ISS (Injury severity score) had a significant effect on the mortality rate of patients. The most rate of mortality was in elderly women and in vehicle collisions. It seems necessary to conduct focused investigations on how to provide preventive measures in this group of society. Also, in addition to trying to modify factors causing collisions, conducting studies on initial advanced treatment interventions in high-risk patients in the field may reduce the death rate of trauma patients and it’s burden on the health system.

Variables that predict hospital stay and the outcome of Fournier gangrene at King Abdulaziz University Hospital: a retrospective study

BackgroundThe aggressive nature of Fournier gangrene and the associated health issues can result in a more complex clinical course and potentially a longer hospital stay. This study aimed to assess factors that affect the length of hospital stay (LHS) and its relation to the outcome of Fournier gangrene patients.MethodsA retrospective study was performed at King Abdulaziz University Hospital (KAUH), Saudi Arabia, on patients diagnosed with Fournier gangrene between 2017 and 2023. Data about length of hospital stay (LHS), age, BMI, clinical and surgical data and outcome was obtained.ResultsThe mean age of the studied patients was 59.23 ± 11.19 years, the mean body mass index (BMI) was 26.69 ± 7.99 kg/m2, and the mean duration of symptoms was 10.27 ± 9.16 days. The most common presenting symptoms were swelling or induration (64%), 88% had comorbidities with diabetes mellitus (DM) (84%), and 76% had uncontrolled DM. of patients, 24% had a poly-microbial infection, with E. coli being the most common (52%). The mean length of hospital stay (LHS) was 54.56 ± 54.57 days, and 24% of patients had an LHS of more than 50 days. Longer LHS (> 50 days) was associated with patients who did not receive a compatible initial antibiotic, whereas shorter LHS was associated with patients who received Impenem or a combination of vancomycin and meropenem as alternative antibiotics following incompatibility. Reconstruction patients had significantly longer LHS and a higher mean temperature. However, none of the studied variables were found to be predictors of long LHS in the multivariate regression analysis.ConclusionKnowledge of the values that predict LHS allows for patient-centered treatment and may be useful in predicting more radical treatments or the need for additional treatment in high-risk patients. Future multicenter prospective studies with larger sample sizes are needed to assess the needed variables and predictors of long LHS.

Identification of metabolic components of carotid plaque in high-risk patients utilizing liquid chromatography-tandem mass spectrometry.

Carotid atherosclerosis is a chronic progressive vascular disease that can be complicated by stroke in severe cases. Prompt diagnosis and treatment of high-risk patients are quite difficult due to the lack of reliable clinical biomarkers. This study aimed to explore potential plaque metabolic markers of stroke-prone risk and relevant targets for pharmacological intervention. Carotid intima and plaque sample tissues were obtained from 20 patients with cerebrovascular symptoms of carotid origin. An untargeted metabolomics approach based on liquid chromatography-tandem mass spectrometry was utilized to characterize the metabolic profiles of the tissues. Multivariate and univariate analysis tools were used. A total of 154 metabolites were significantly altered in carotid plaque when compared with thickened intima. Of these, 62 metabolites were upregulated, whereas 92 metabolites were downregulated. Support vector machines identified the 15 most important metabolites, such as N-(cyclopropylmethyl)-N'-phenylurea, 9(S)-HOTrE, ACar 12:2, quinoxaline-2,3-dithiol, and l-thyroxine, as biomarkers for high-risk plaques. Metabolic pathway analysis showed that abnormal purine and nucleotide metabolism, amino acid metabolism, glutathione metabolism, and vitamin metabolism may contribute to the occurrence and progression of carotid atherosclerotic plaque. Our study identifies the biomarkers and related metabolic mechanisms of carotid plaque, which is stroke-prone, and provides insights and ideas for the precise prevention and targeted intervention of the disease.

Abstract PO4-02-05: Elevated tumor to aorta ratio of Hounsfield units and late recurrence in patients with estrogen receptor positive breast cancer

Abstract Background) More than half of the recurrent disease in breast cancer will happen more than 5 years after initial diagnosis in breast cancer, especially in patients with ER positive disease. Higher proportions of late recurrence lead to escalated treatment and/or or extended treatment for high risk patients. However, it is unclear what characteristics make whom as high risk patients. This study aimed to assess initial tumor vascularity as a prognostic marker for late recurrence. Methods) Female patients with estrogen receptor positive breast cancer who were diagnosed breast cancer between 2003 and 2018 and disease-free at 5 years after primary breast cancer at Wonju Severance Hospital, Korea, were included. Clinocopathological characteristics were collected. Hounsfield units(HU) on contrast-enhanced computed tomography(CT) was used as a marker indicating tumor vascularity. Tumor to aortic arch ratio(TAR) of HU on contrast enhanced CT was applied to enhance objectivity of measurement. Patients were categorized according to the cut-off values retrieved from the receiver operating characteristic curve. Kaplan-Meier curves were generated to compare recurrence-free survival (RFS) and overall survival (OS). Hazard ratio(HR) with confidence interval(CI) was derived with Cox’s proportional hazard model to analyze univariate and multivariate risk factors. Results) The final cohort included 451 patients with a mean age of 56.21 ± 11.2 (22-83) years. Two third of patients had estrogen receptor positive disease and a quarter of patients had HER2 overexpressed disease. Initial TAR was 0.345 ± 0.108 (range, 0.062 - 1.114). Patients with recurrence free survival(RFS)-related events had significantly higher TAR than patients who did not(0.39 ± 0.097 vs. 0.34 ± 0.108, p=0.012). Patients with overall survival(OS)-related events also had higher TAR than patients who did not(0.408 ± 0.096 vs. 0.342 ± 0.107, p=0.002). Cutoff value of 0.408 was driven from area under the receiver operating characteristic curve. Patients with TAR higher than 0.408 showed significantly worse RFS(p=0.001) and OS(p&amp;lt; 0.001) than patients who had TAR equal or lower than 0.408. Hazard ratio(HR) of TAR in late recurrence was 6.17 (CI, 4.89 – 9.23, p=0.003), suggesting it is an independent factor. Other independent factors were age (HR, 1.502; CI, 10.14 – 10.91; p=0.006), tumor size (HR, 1.268; CI, 1.071 – 1.502; p=0.006), and metastatic nodal disease (HR, 2.770; CI, 1.176 – 6.526; p=0.020). Conclusion) TAR of primary tumor was significantly related with patients RFS and OS. Patients with high TAR larger than 0.408 showed worse RFS and OS than patients who did not. According to the Cox proportional hazard model, TAR was an independent factor along with age, tumor size, and metastatic nodal disease, suggesting late recurrence may rather be influenced by clinical factor Citation Format: Airi Han, Hyang Suk Choi, Seok Hahn, In-jeoung Cho, Seung Taek Lim, Jong-In Lee. Elevated tumor to aorta ratio of Hounsfield units and late recurrence in patients with estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-02-05.

The Association Between Mental Disorders and Postoperative Outcomes of Scoliosis Surgery: A Systematic Review and Meta-analysis.

Mental disorders may adversely impact postoperative recovery in scoliosis surgery. However, study findings have been inconsistent and a systematic synthesis is lacking. We searched PubMed, Embase, PsycINFO, and Cochrane Library for studies examining associations between preoperative mental disorders, assessed by various scales, such as the Patient Health Questionnaire (PHQ), the Modified Somatic Perception Questionnaire (MSPQ), and the State-Trait Anxiety Inventory (STAI), and postoperative outcomes, such as pain, disability, quality of life, and satisfaction, in scoliosis surgery. Random-effects meta-analyses pooled standardized mean differences (SMDs) in postoperative outcomes between patients with and without mental disorders. Twelve observational studies were included for the systematic review, and 5 studies were included in the meta-analysis. The meta-analysis demonstrated significantly worse postoperative outcomes in patients with mental disorders compared to those without (SMD -1.96, 95% confidence interval [CI] -3.08 to -0.84, P < 0.001). Significant heterogeneity was present (I2 = 76%). Review of included studies found mental disorders linked to higher preoperative pain/disability and lower quality of life/satisfaction, as well as worse postoperative scores on these outcomes. Moderating factors identified included mental disorder severity, treatment specifics, and patient demographics. Preoperative mental disorders, especially depression and anxiety, are associated with significantly worse postoperative pain, disability, quality of life, and satisfaction in scoliosis surgery. This association may be mediated by psychological factors, such as catastrophizing, self-criticism, and kinesiophobia, and biological factors, such as inflammation, neuroendocrine changes, and central sensitization. Routine psychological screening and interventions for high-risk patients may improve postoperative outcomes but not necessarily surgical effectiveness. Further research is warranted to confirm these findings and elucidate optimal treatment approaches.

Percutaneous Tricuspid Valve Repair: The Triclip.

Tricuspid regurgitation is an often overlooked, but severe cardiac valvular disease associated with significant morbidity and poor quality of life. Tricuspid valve surgery is the only treatment that prevents progression of the disease but is often complicated or made impossible by perioperative risk factors. Due to the high-risk nature, tricuspid valve surgery is typically only done for severe tricuspid regurgitation at the time of left heart surgery, leaving many patients untreated. Medical therapy is limited primarily to diuretic agents, which are often unsuccessful in alleviating symptoms. Treatment of tricuspid regurgitation with transcatheter edge-to-edge repair has emerged after the success of this technique in mitral valve pathologies. This percutaneous procedure parallels surgical principles previously used for valve repair but eliminates the need for cardiac surgery, thus having the potential to serve as an alternative treatment in high-risk patients. The TriClip (Abbott Labs) device is an example of this therapy and the subject of this review.

403 Epithelial hypoxia maintains colonization resistance against Candida albicans

OBJECTIVES/GOALS: Antibiotic treatment sets the stage for intestinal domination by Candida albicanswhich is necessary for development of invasive disease, but the resources driving this bloom remain poorly defined. We sought to determine these factors in order to design novel prophylaxis strategies for reducing gastrointestinal (GI) colonization. METHODS/STUDY POPULATION: We initially developed a generalizable framework, termed metabolic footprinting to determine the metabolites C. albicanspreferentially uses in the mouse GI tract. After identifying the metabolites C. albicansutilizes, we usedin vitro growth assays in the presence and absence of oxygen to validate out metabolomics findings. We next determined if a probiotic E. coli that utilizes oxygen would reduce C. albicanscolonization compared to a mutant E. coli that could not respire oxygen. Finding that oxygen was a necessary resource, we utilized germ-free mice to determine if Clostridiaspp. known to reduce GI oxygen would prevent C. albicanscolonization. Lastly, we sought to see if 5-aminosalicylic acid (5-ASA) could prevent C. albicanscolonization. RESULTS/ANTICIPATED RESULTS: We found that C. albicans preferentially utilizes simple carbohydrates including fructo-oligosaccharides (e.g., 1-kestose), disaccharides (e.g., β-gentiobiose), and alcoholic sugars (e.g., sorbitol) and is able to grow in vitro on minimal media supplemented with either of these nutrients. However, in the hypoxic environment that is found in the “healthy” colon, C. albicans cannot utilize these nutrients. We next found that pre-colonization in a mouse model with a probiotic E. coli significantly reduced C. albicanscolonization, but the mutant E. coli had no effect on colonization. We next showed that Clostridia supplementation restored GI hypoxia and reduced C. albicanscolonization. Remarkably, we found that 5-ASA significantly reduced GI colonization of C. albicans. DISCUSSION/SIGNIFICANCE: We have shown that C. albicans requires oxygen to colonize the GI tract. Importantly, we found that 5-ASA can prevent an antibiotic mediated bloom of C. albicans by restoring GI hypoxia, which warrants additional studies to determine if 5-ASA can be used as an adjunctive prophylactic treatment in high risk patients.

Analysis of Risk Prediction Models to Identify Patients at High Risk of Urinary Incontinence

Introduction: Urinary incontinence (UI) is a common health problem and is often undiagnosed in hospital patients. UI can cause complications such as urinary tract infections, dermatitis, and decreased quality of life. This study aims to apply a risk prediction model to identify patients at high risk of experiencing UI at Tengku Peukan General Hospital, Southwest Aceh, Indonesia.&#x0D; Methods: This study used a prospective cohort design. Data was collected from 100 patients hospitalized at Tengku Peukan General Hospital, Southwest Aceh. A risk prediction model was developed using logistic regression. Model performance is measured by AUC-ROC values and accuracy.&#x0D; Results: The risk prediction model developed had an AUC-ROC value of 0.85 (95% CI: 0.78-0.92) and an accuracy of 82%. The most significant risk factors for UI are age, gender, history of UI, and use of diuretic medications.&#x0D; Conclusion: This risk prediction model can help nurses and doctors identify patients who are at high risk of experiencing UI at Tengku Peukan General Hospital, Southwest Aceh. Early intervention in high-risk patients can help prevent UI complications and improve the patient's quality of life.

Possibilities of Transfistula Ultrasound in Predicting Intraoperative Bleeding in Patients with Infected Pancreatic Necrosis

Introduction. Assessing the risk of intraoperative bleeding is of great importance in the treatment of patients with infected pancreatic necrosis.The aim of the study — determine the role of transfistula ultrasound in assessing the risk of intraoperative bleeding in patients with infected pancreatic necrosis.Materials and methods. From 2015 to 2019, 193 people with infected pancreatic necrosis were treated at Regional Clinical Hospital No. 2 (Krasnodar). At stage 1, drains of various diameters were installed in all patients; at stage 2, necrotic tissue was removed using transfistula videoscopic necrosequestrectomy in 48 patients (24.9 %). Before performing instrumental necrosequestrectomy, a developed diagnostic method was used — transfistula ultrasound scanning — to determine the relationship between the location of foci of necrosis in the pancreas and blood vessels in 22 patients (11.4 %; group 1); the method was not used in 26 people (13.5 %; group 2).Results. The number of accesses created into the omental bursa was as follows: 141 patients (73.1 %) had 3 accesses, 52 people (26.9 %) had 2 accesses; into the retroperitoneal space: 102 patients (52.8 %) had 2 accesses, 51 people (26.4 %) had 1 access. Transfistula videoscopic necrosequestrectomy was performed 35 and 37 times in groups 1 and 2, respectively (p &gt; 0.05). Transfistula ultrasound scanning to assess the risk of intraoperative bleeding was used 33 times in patients in group 1. In group 1, intraoperative bleeding was observed in 5 patients (23.8 %), in group 2 — in 7 patients (26.9 %) (p &gt; 0.05). The volume of blood loss was (436.0±83.6) and (887.0±41.8) ml in groups 1 and 2, respectively (p &lt; 0.05). There were no cases of death due to intraoperative bleeding in either group.Discussion. Transfistula ultrasound scanning makes it possible to stratify patients: into a high-risk group (with intimate adjacency of necrosis to vessels), medium (at a distance of up to 15 mm) and low-risk (with a distant location). In this regard, interventions in high-risk patients were carried out in the X-ray operating room to allow for endovascular hemostasis, which made it possible to reduce the volume of blood loss, as well as to create a supply of transfusion media in advance to replenish the volume of blood volume.Conclusion. The developed method of direct transfistula ultrasound scanning makes it possible to assess the risk of intraoperative bleeding in patients with infected pancreatic necrosis to achieve timely hemostasis and compensate for acute blood loss.

Ticagrelor with or without aspirin following percutaneous coronary intervention in high-risk patients with concomitant peripheral artery disease: A subgroup analysis of the TWILIGHT randomized clinical trial

The optimal antiplatelet regimen after percutaneous coronary intervention (PCI) in patients with peripheral artery disease (PAD) is still debated. This analysis aimed to compare the effect of ticagrelor monotherapy versus ticagrelor plus aspirin in patients with PAD undergoing PCI. In the TWILIGHT trial, patients at high ischemic or bleeding risk that underwent PCI were randomized after 3 months of dual antiplatelet therapy (DAPT) to aspirin or matching placebo in addition to open-label ticagrelor for 12 additional months. In this post-hoc analysis, patient cohorts were examined according to the presence or absence of PAD. The primary endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke. Endpoints were assessed at 12 months after randomization. Among 7,119 patients, 489 (7%) had PAD and were older, more likely to have comorbidities, and multivessel disease. PAD patients had more bleeding or ischemic complications than no-PAD patients. Ticagrelor monotherapy compared to ticagrelor plus aspirin was associated with less BARC 2, 3, or 5 bleeding in PAD (4.6% vs 8.7%; HR 0.52; 95%CI 0.25-1.07) and no-PAD patients (4.0% vs 7.0%; HR 0.56; 95%CI 0.45-0.69; interaction P-value .830) and a similar risk of death, MI, or stroke in these 2 groups (interaction P-value .446). Despite their higher ischemic and bleeding risk, patients with PAD undergoing PCI derived a consistent benefit from ticagrelor monotherapy after 3 months of DAPT in terms of bleeding reduction without any relevant increase in ischemic events. CLINICAL TRIAL REGISTRY INFORMATION:: https://www. gov/study/NCT02270242.