Comorbidity Measures Research Articles

ASA score is an independent predictor of 1-year outcome after moderate-to-severe traumatic brain injury

Abstract Purpose This study aimed to investigate whether incorporating pre-injury health status, measured by the American Society of Anesthesiologists (ASA) score, improves outcome prediction models for moderate-to-severe traumatic brain injury (msTBI) patients. Methods We conducted a retrospective single-center study of msTBI patients (2005–2021). The primary outcome was 1-year Glasgow Outcome Scale (GOS, dichotomized as GOS1-3 (unfavorable) vs. 4–5 (favorable)), and secondary outcome was 90-day mortality. Logistic regression evaluated the contribution of ASA score to the International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) core + CT outcome prediction model incorporating age, admission GCS, pupillary reactivity, Marshall CT classification, hypoxia, hypotension, epidural hematoma, and subarachnoid hemorrhage. Results Among the 720 adult patients that were included 51% had an unfavorable GOS at 1 year. The 90-day mortality was 19%. ASA score and TRISS were independently associated with both outcomes (p < 0.001). Incorporating the ASA score to our IMPACT model significantly enhanced its explanatory value of dichotomized GOS (35% vs. 32% variance explained, p < 0.001) and improved the model’s prognostic accuracy. Conclusion In this retrospective single-center cohort study, we found that ASA score improves existing prognostic models for msTBI. Incorporating this simple comorbidity measure could enhance outcome prediction and support more personalized acute management. Future prospective studies are needed to validate these results.

Quantifying the Relationship Between At-Home Shoulder Physiotherapy Participation and Outcome: What can a Watch Tell Us?

Exercise-based physiotherapy is an established treatment of rotator cuff injury. Objective assessment of at-home exercise is critical to understand its relationship with clinical outcomes. This study uses the Smart Physiotherapy Activity Recognition System to measure at-home physiotherapy participation in patients with rotator cuff injury based on inertial sensor data captured from smart watches. Relationships between participation and clinical outcomes, long-term durability of outcome improvements, and factors predictive of participation were evaluated. Patients participated in a 12-week rotator cuff physiotherapy program in a prospective single-center study. Patients wore smart watches during supervised weekly in-clinic physiotherapy sessions and while performing exercises at home. Demographic information and rotator-cuff diagnosis were collected at baseline and assessed as predictors of physiotherapy participation. Outcome measures (pain, disability [Disabilities of the Arm, Shoulder and Hand], strength, range of motion) were collected over duration of treatment and at 12-month follow-up (pain and disability). Machine learning algorithms identified and classified periods of exercise to evaluate participation and adherence. One hundred ten patients enrolled and initiated treatment, with 92 patients included in the analysis. All outcomes showed significant improvements from baseline at each time point. Mean total weekly at-home participation decreased from 35.6 ± 28.9 minutes in weeks 0 to 4 to 28.9 ± 25.7 minutes in weeks 8 to 12 (t = 2.23, P = 0.023). For the full cohort, significant relationships were found between physiotherapy participation and disability, manual strength, external rotation, internal rotation, and abduction. Significant predictors of participation included greater age, being unmarried, diagnosed rotator cuff tear, and measures of self-efficacy, social support, and comorbidity. Higher participation rates led to significant improvements in outcomes for partial thickness/no-tear patients but not for full-thickness tears. Machine learning methods applied to data collected from smart watches enabled objective assessment of physiotherapy participation in the home setting. Although most patients improved with physiotherapy, patients with full-thickness rotator cuff tears were not similarly responsive to higher exercise volumes.

Pre-treatment Pulmonary Function Testing Has Limited Utility In B-cell Lymphoma Treated with CD19 CAR T-cells.

Pulmonary function tests (PFT) are recommended for hematopoietic cell transplantation (HCT) evaluation. However, their prognostic value in chimeric antigen receptor T-cell (CAR-T) therapy remains unclear. We assessed the predictive significance of PFTs and pulmonary comorbidity classifications, per the Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI), in B-cell lymphoma patients undergoing autologous CD19-CAR-T therapy. Single-center retrospective analysis encompassing 192 patients with relapsed/refractory (R/R) B-cell lymphoma, treated with commercial and point-of-care CD19-directed CAR-T therapy. Pre-therapy PFT were conducted, and patients were stratified into 3 HCT-CI-based pulmonary comorbidity grades, utilizing forced expiratory volume in 1 second (FEV1) and single-breath diffusing capacity for carbon monoxide (DLCO). Outcomes and toxicities were evaluated using univariate and multivariable Cox regression, logistic regression, Kaplan-Meier method, and spline models. Pulmonary comorbidity measures were not correlated with overall response rates or immune-toxicities, including cytokine release syndrome grade>2 and immune effector cell-associated neurotoxicity grade>2. Categorical FEV1, DLCO, and pulmonary comorbidity level did not correlate with overall survival (p=0.3, p=0.4, p=0.6, respectively) or progression free survival (PFS) (p=0.058, p>0.9, p=0.2, respectively). FEV1 as continuous measure was associated with reduced PFS in a multivariable model (HR 0.87 [95% CI 0.78-0.96], p=0.007). Spline modeling demonstrated a linear correlation between FEV1 and PFS. Categorical FEV1, DLCO, and pulmonary comorbidity level failed to predict therapy efficacy or toxicity. FEV1 as continuous measure was the sole PFT measure associated with PFS, independent of OS or severe toxicities.

Cohort Profile: Baseline Characteristics of Veterans from Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) - an Embedded Pragmatic, Cluster Randomized Trial in the United States.

AIM-Back is an embedded pragmatic clinical trial (ePCT) with cluster randomization designed to increase access and compare the effectiveness of two different non-pharmacological care pathways for low back pain (LBP) delivered within the Veteran Administration Health Care System (VAHCS). This manuscript describes baseline characteristics of AIM-Back participants as well as the representativeness of those referred to the AIM-Back program by sex, age, race, and ethnicity, relative to Veterans with low back pain at participating clinics. To be eligible for AIM-Back, Veterans were referred to the randomized pathway at their clinic by trained primary care providers (Referral cohort). Veterans from the Referral cohort that participated in the study included: 1) an Electronic Health Record (EHR) sample of Veterans enrolled in the program (i.e., attended initial AIM-Back visit with no consent required) and a Survey sample of Veterans that were consented for further study. Descriptive statistics for age, race, ethnicity, sex, high-impact chronic pain (HICP), a comorbidity measure, post-traumatic stress diagnosis (PTSD) and opioid exposure were reported for the Referral cohort and by sample; mean baseline PROMIS pain interference, physical function and sleep disturbance scores were reported by sample. Additional measures of pain, mental health and social risk were reported on the Survey sample. Participation to prevalence ratios (PPRs) were calculated for sex, age, race, and ethnicity by clinic to describe representativeness of the Referral cohort. Across 17 randomized primary care clinics, the Referral cohort included 2767 unique Veterans with n=1817 in the EHR sample, n=996 in the Survey sample and n=799 of the EHR sample (44%) were also in the Survey sample. High rates of HICP were observed in the EHR and Survey samples (>59%). Mean scores (SD) based on self-reported PROMIS Pain Interference (63.2 (6.8), 63.1 (6.6)) and PROMIS Physical Function (37.1 (5.3), 38.1 (5.8)) indicated moderate impairment in the EHR sample and Survey sample respectively. Approximately 10% of the EHR sample had documented opioid use in the year leading up to the AIM-Back referral. At most clinics, older Veterans (>=65 years) were underrepresented in the Referral cohort compared to those with LBP visits at clinics (PPRs < 0.8). The AIM-Back trial will conduct analysis to examine the comparative effectiveness of the two care pathways and identify individual characteristics that may improve responses to each pathway. The trial is expected to complete 12-month follow-up data collection by December 2024, with subsequent analyses and publications providing insights into optimizing non-pharmacological care for Veterans with LBP. NCT04411420 ( clinicaltrials.gov ). Strengths: Embedded features (e.g., EHR documentation and clinical staff serving as interventionist) of the AIM-Back trial have potential to facilitate implementation of these care pathways more broadly in Veteran's Health Administration clinics and in health systems outside the Veteran's Health AdministrationParticipating clinics were in 10 states providing regional geographic representation across the study.Trial was delivered within an integrated health system optimal for consistent documentation templates and data extraction across the trial sites.Limitations: Due to clinical personnel's role in participant recruitment, sample biases may exist in those referred to the program and/or those who agreed to participate in additional surveysThese findings may not be generalizable to older aged Veterans due to our lower enrollment of those 65+.

Assessing 1-Year Comorbidity Prevalence and Its Survival Implications in Medicare Beneficiaries Diagnosed with Cancer: Insights from a New SEER-Medicare Resource.

Almost half of Medicare beneficiaries diagnosed with cancer from 1992 to 2005 had at least one comorbid condition. Conditions affect a range of domains from clinical decision-making to quality of life, which are important to consider when conducting cancer research. We introduce a new Surveillance, Epidemiology, and End Results (SEER)-Medicare resource to facilitate using claims data for patients with cancer. We use the SEER-Medicare resource to estimate prevalence of comorbidities, 5-year survival rate by cancer site, stage, age and comorbidity severity, and prevalence of surgery by comorbidity for breast, prostate, colorectal and lung cancers. Overall, the most prevalent comorbidities in the year prior to cancer diagnosis were diabetes (27%), chronic obstructive pulmonary disease (22%), peripheral vascular disease (14%), and congestive heart failure (12%). Comorbidity severity had a greater impact on the probability of dying from noncancer causes than dying from cancer. Severity of comorbidity and age consistently increased the probability of noncancer death. The percentage of persons receiving surgery tended to be lower among those with severe comorbidity. This study demonstrates the utility of new SEER*Stat databases that contain Medicare beneficiaries and claims-based measures of comorbidity. Our results demonstrate that comorbidity is common among older persons diagnosed with cancer and the impact of comorbidity on the probability of dying from cancer varies by cancer site, stage at diagnosis, and age. Comorbidity is common among persons with cancer and affects survival. Future research on the impact of comorbidity among cancer survivors is facilitated by new databases.

Clinical Variables Associated With Impaired Consciousness in Hospitalized COVID-19 Patients.

Impaired consciousness is associated with complications and mortality in COVID-19 patients. We study factors associated with impaired consciousness as measured by the Glasgow Coma Scale (GCS) in COVID-19 patients. This is a retrospective study of 604 patients with COVID-19 in the metropolitan New York City area. We study the association of demographics, comorbidity, disease severity, treatment management, and laboratory measurements with both GCS nadir during hospitalization and GCS at discharge. Age was significantly associated with severe GCS nadir during hospitalization and at hospital discharge. Body mass index comorbidity was significantly associated with severe GCS at hospital discharge. Sedation treatment was significantly associated with both moderate and severe GCS nadir during hospitalization. Glucose nadir was significantly associated with severe GCS nadir during hospitalization. Sodium level at admission was associated with decreased relative risk while BUN peak level during hospitalization was associated with increased relative risk for severe GCS on discharge. We found that factors from demographics, comorbidity, treatment management, and laboratory measurements were associated with GCS while disease severity was not significantly associated with GCS. These findings can guide clinicians for treatment approaches for the early identification of impaired consciousness and its degrees of severity in COVID-19 patients.

Cardiovascular comorbidities, mental health, and physical activity in persons with multiple sclerosis

ABSTRACT This study examined the associations among cardiovascular comorbidities, symptoms of depression and anxiety, and physical activity in persons with multiple sclerosis. Participants with multiple sclerosis (N = 217) completed demographic, cardiovascular comorbidity, depression, and anxiety self-report measures, and wore an accelerometer for 7 days. We examined the bivariate, non-parametric correlations among the variables and conducted parametric, independent samples t-tests when examining the differences in variables based on cardiovascular comorbidity status. Bivariate correlation analysis indicated that there were statistically significant associations between anxiety scores, but not depression scores, and cardiovascular comorbidities. Physical activity, especially moderate-to-vigorous physical activity (MVPA), was correlated with cardiovascular comorbidities. There were small significant differences based on hyperlipidemia status in anxiety scores (p = 0.015, d = -0.42), MVPA (p < 0.001, d = 0.44), and steps/day (p < 0.001, d = 0.50), and based on hypertension status in anxiety scores (p = 0.010, d = -0.35), depression scores (p = 0.046, d = -0.26), MVPA (p = 0.003, d = 0.41), and steps/day (p < 0.001, d = 0.53). The findings indicate that there are significant associations among cardiovascular comorbidities, symptoms of depression and anxiety, and physical activity in persons with multiple sclerosis. Physical activity, specifically MVPA, may be a target for managing those outcomes in persons with multiple sclerosis.

Skin picking disorder in sexual minority individuals

BackgroundSkin picking disorder (SPD) is common, but little is known about whether or how it differs in sexual minorities. We explored whether sexual minority individuals differ from heterosexual individuals in terms of skin picking and comorbidities. We also evaluated potential differences between gay or lesbian and bisexual individuals. Methods293 participants with SPD completed an online survey. Sexual minority participants were compared to heterosexual participants on demographics, how often they picked their skin, and validated self-report measures of SPD and comorbidities. Gay or lesbian and bisexual participants were compared on the same variables. ResultsSexual minority status was associated with more body-focused repetitive behavior (BFRB) impairment and a greater likelihood of picking 7 days per week. Heterosexual participants reported more alcohol misuse, aggression, and compulsive sexual behavior than sexual minority participants. The groups did not differ in overall BFRB severity or rates of other disorders. Gay or lesbian and bisexual participants did not differ in SPD or comorbidities. ConclusionsThe rate of sexual minority individuals in this study (37.9%) is much higher than the rate in the community (about 10%). Sexual minority individuals with SPD may present with unique clinical symptoms. Treatments should be tailored for this population.

A network analysis of eating disorder, PTSD, major depression, state-trait anxiety, and quality of life measures in eating disorder patients treated in residential care.

The network approach in the eating disorder (ED) field has confirmed important links between EDs and posttraumatic stress disorder (PTSD) symptoms. However, studies including comorbid symptoms are scarce, which limits our understanding of potentially important connections. We hypothesised that anxiety, depression and poor quality of life (QOL) would provide a more complete picture of central, maintaining factors. Network analysis using R was performed in 2178 adult ED patients (91% female) admitted to residential treatment. Assessments included the ED Examination Questionnaire (EDEQ), the Eating Disorders Inventory (EDI-2), the PTSD Checklist for DSM-5 (PTSD clusters (PCL-5)), the Patient Health Questionnaire (PHQ-9), the Spielberger State-Trait Anxiety Scale (STAI), and the ED QOL Scale (EDQOL), which measure symptoms of EDs, PTSD, major depression, state-trait anxiety, and QOL, respectively. EDI-2 ineffectiveness showed the highest centrality (expected influence) followed by EDI-2 interoceptive awareness, STAI state anxiety, EDEQ shape concern, EDQOL psychological subscale, and PTSD cluster D (hyperarousal) symptoms. Eating Disorder Quality of Life psychological and physical-cognitive subscales and PHQ-9 major depressive, STAI state anxiety and PCL-5 PTSD cluster E (negative alterations in mood and cognition) symptoms showed the highest bridge expected influence, suggesting their interactive role in maintaining ED-PTSD comorbidity. This is the first network analysis of the interaction between ED and PTSD symptoms to include the comorbid measures of depression, anxiety, and QOL in a large clinical sample of ED patients. Our results indicate that several symptom clusters are likely to maintain ED-PTSD comorbidity and may be important targets of integrated treatment.

Revisiting the Obesity Paradox: Insights from Pulmonary Embolism Patient Outcomes

Background: Obesity is an epidemic in the US and has been associated with increased incidence and severity of cardiovascular disease and increased risk for pulmonary embolism (PE). However, the evidence of its effect on outcomes in PE patients remains equivocal. We aimed to investigate the impact of obesity on adverse in-hospital outcomes in PE. Methods: This study conducted a comprehensive analysis of the National Inpatient Sample (NIS) database, focusing on adult patients (aged ≥18 years) with a discharge diagnosis of PE (ICD-10 code: I26) from 2016 to 2020. We specifically identified obese patients using the Elixhauser comorbidity measure within NIS and compared them to non-obese patients in terms of adverse in-hospital outcomes. Results: Between 2016 and 2020, there were 1,940,294 discharges for PE, with 436,505 patients (22%) identified as obese. A rising trend of obesity among PE patients was observed, increasing from 21.5% in 2016 to 24.3% in 2020. Obese patients, when compared to their non-obese counterparts, were more female (57.4% vs 49.1%, p&lt;0.001), younger (mean age 58.4 ± 15.1 years vs 64.0 ± 17.1 years, p&lt;0.001), and African American (21.2% vs 17.5%, p&lt;0.001). They also had higher rates of comorbid conditions like CHF (25.1% vs 21.2%, p&lt;0.001), hypertension (70.6% vs 58.2%, p&lt;0.001), diabetes (37.2% vs 21.5%, p&lt;0.001), and renal failure (16.2% vs 14.7%, p&lt;0.001). Obese patients were more likely to receive systemic thrombolytics (3.80% vs. 2.31%, p&lt;0.001), undergo surgical thrombectomy or embolectomy (0.24% vs. 0.16%, p&lt;0.001), and receive catheter-directed thrombectomy or thrombolysis (3.04% vs. 1.37%, p&lt;0.001). Paradoxically, despite these comorbidities and complications, obese patients demonstrated lower mortality rates (4.58% vs 7.60%, p&lt;0.001), mechanical intubation (7.71% vs 8.90%, p&lt;0.001), and shock requiring pressor support (1.73% vs 2.14%, p&lt;0.001). After adjusting for demographic factors, all comorbidities, and reperfusion therapies, the analysis consistently showed a reduced adjusted odds ratio for in-hospital mortality among obese patients (OR 0.63, 95% CI 0.61-0.65, p&lt;0.001). Conclusions: Analyzing nearly two million inpatient cases of PE, our study revealed an intriguing association between obesity and reduced in-hospital mortality rates in PE patients. Notably, despite a higher prevalence of comorbidities and more frequent need for reperfusion interventions, obese patients exhibited lower mortality rates and fewer complications, such as the need for mechanical intubation and shock. This survival advantage in obese individuals persisted even after adjusting for potential confounders. These findings align with a similar study conducted on the German nationwide inpatient database and reflect the broader concept of the ‘obesity paradox,’ previously observed in cardiovascular diseases and chronic obstructive pulmonary diseases. However, whether these results indicate a true protective effect of obesity, a ‘lean paradox,’ or are due to unidentified confounders remains a subject for further investigation.

Food Addiction Screening, Diagnosis and Treatment: A Protocol for Residential Treatment of Eating Disorders, Substance Use Disorders and Trauma-Related Psychiatric Comorbidity.

Food addiction, or ultra-processed food addiction (UPFA), has emerged as a reliable and validated clinical entity that is especially common in individuals seeking treatment for eating disorders (EDs), substance use disorders (SUDs) and co-occurring psychiatric disorders (including mood, anxiety and trauma-related disorders). The clinical science of UPFA has relied on the development and proven reliability of the Yale Food Addiction Scale (YFAS), or subsequent versions, e.g., the modified YFAS 2.0 (mYFAS2.0), as well as neurobiological advances in understanding hedonic eating. Despite its emergence as a valid and reliable clinical entity with important clinical implications, the best treatment approaches remain elusive. To address this gap, we have developed and described a standardized assessment and treatment protocol for patients being treated in a residential program serving patients with psychiatric multi-morbidity. Patients who meet mYFAS2.0 criteria are offered one of three possible approaches: (1) treatment as usual (TAU), using standard ED treatment dietary approaches; (2) harm reduction (HR), offering support in decreasing consumption of all UPFs or particular identified UPFs; and (3) abstinence-based (AB), offering support in abstaining completely from UPFs or particular UPFs. Changes in mYFAS2.0 scores and other clinical measures of common psychiatric comorbidities are compared between admission and discharge.

GLA:D to Be Walking Better: Change in Self-Reported Difficulty Walking After Exercise Therapy and Education in Persons With Knee Osteoarthritis.

Difficulty walking is a primary reason that individuals with knee osteoarthritis (OA) seek care. We examined the change in self-reported difficulty walking after participating in the Good Life With Osteoarthritis in Denmark (GLA:D) 8-week education and exercise program and assessed patient factors associated with improvement in difficulty walking. This was a registry-based cohort study of individuals in Denmark with knee OA who enrolled in GLA:D. Assessments were administered at baseline, program completion (~3 months), and 12 months. Our prespecified primary outcome was change in self-reported difficulty walking assessed using the EuroQol 5-dimension 5-level walking item. Exposures included sociodemographic factors, measures of OA illness severity, comorbidities, and psychological factors. In those with baseline moderate/severe difficulty walking, using multivariable regression analysis, we assessed the relationship between exposures of interest and improvement to no/slight difficulty walking. We included 5262 participants. Of 2178 (41.4%) individuals with baseline moderate/severe difficulty walking, 51.4% and 58.3% reported no/slight difficulty walking at 3 and 12 months, respectively. Greater self-efficacy, younger age, female sex, lower BMI, less intense knee pain, and better function at baseline were associated with greater likelihood of improvement in difficulty walking, whereas severe difficulty walking at baseline and back pain intensity were associated with decreased likelihood of improvement. More than half of those with baseline difficulty walking experienced substantial improvement after completing GLA:D and this improvement was maintained at 12 months. Several patient factors were associated with the outcome, suggesting that some individuals may require additional support and extended treatment.

Evaluation of body mass index, ponderal index, visceral cross-sectional area, subcutaneous fat cross-sectional area, and liver volume as predictive factors for obesity-related comorbidities: a retrospective cohort study

BackgroundThe body mass index is an imperfect clinical measure of obesity that should be used in conjunction with other valid measures of weight-related risk. We studied whether there is a superior measure of obesity-related comorbidities. MethodsRecords of bariatric clinic patients who had an abdominal computed tomography (CT) within one year of visit were reviewed. The presence of obesity-related comorbidities was determined at the time of the scan. Body mass index (BMI) and ponderal index (PI) were calculated, and CT scans were reviewed to determine the visceral cross-sectional area (VCSA), subcutaneous fat cross-sectional area (SFCSA), and liver volume (LV). Data was analyzed using the Kruskal-Wallis test and Mann-Whitney U test. ResultsA higher number of comorbidities were found to be associated with a larger BMI (p=0.011), VCSA (p=0.014), SFCSA (p=0.007), and LV (p=0.014), but not a larger PI (p=0.11). Of the 16 comorbidities assessed, VCSA and LV were associated with more than BMI and SFCSA. However, each measure could be associated with different comorbidities. A higher BMI was associated with increased insulin use (p=0.034), HTN (p=0.007), and history of OSA (p=0.015), none of which were associated with PI. BMI and PI were the only measures associated with a history of DVT/PE (both p<0.01). Only SFCSA was found to be associated with GERD (p=0.029). VCSA (p=0.038) and LV (p=0.001) were associated with NAFLD. ConclusionNo measure could account for all obesity-related comorbidities, implying the need for targeted measurements. However, the ponderal index was the least effective measure.

Abstract PO5-18-02: A Population-Based Analysis of the Impact of Omission of Anthracyclines in the Neoadjuvant Setting on the Risk of Mortality

Abstract Background Most patients with high-risk non-metastatic breast cancer are treated with neoadjuvant chemotherapy (NAC), which includes the administration of anthracyclines. The omission of anthracyclines was shown to be associated with excellent outcomes in selected patients. However, the extent to which anthracyclines are omitted among a population of women treated with NAC and its impact on mortality remain unclear. Objective To investigate the extent to which anthracyclines are omitted among a population of patients with invasive breast cancer treated with NAC and to examine the impact of non-anthracycline NAC on risks of breast cancer-specific and all-cause mortality. Methods We performed a retrospective population-based cohort analysis using patient-level health administrative data. The cohort includes women aged ≥18 years with stage I – III invasive breast cancer diagnosed between January 2012 and December 2020, treated with NAC and surgery. Patients were excluded if they received &amp;lt; 50% of the planned chemotherapy regimen, had bilateral breast cancer and/or a previous malignancy. The exposure of interest was anthracycline versus non-anthracycline NAC regimen. The primary and secondary endpoints were breast cancer-specific mortality and overall (all-cause) mortality. Multivariable Cox proportional hazards models adjusted by propensity score, and clinical/pathologic variables including a measure of comorbidity was performed to examine impact of omission of anthracyclines on outcomes. Cumulative incidence curves were generated to calculate the 5-year cumulative incidence of breast cancer and all-cause mortality for the whole cohort and in subset analyses, stratified by stage and receptor subtype. Results The cohort includes 4,180 women. Median follow was 62 months (IQR 44-85) and median age was 51 years (IQR 43-60). Most patients had low co-morbidities (96.0%), Stage II (44.1%) or Stage III (47.7%) disease, underwent mastectomy (72.6%), had axillary node dissection (64.4%) and received post-operative radiotherapy (88.8%). 279 (6.7%) individuals were treated with a non-anthracycline NAC and 3,901 (93.3 %) received an anthracycline NAC. Women who received non-anthracycline NAC were older (median 62 years vs. 50 years; p&amp;lt; 0.001), more likely to have stage I-II disease (77.0% vs. 51.3%; p&amp;lt; 0.001), and more likely to have triple-negative breast cancer (TNBC) (14.0% vs. 24.4%; p&amp;lt; 0.001) than those who received anthracyclines.On propensity adjusted multivariable analysis, factors associated with an increased risk of BC mortality include Stage III (HR 9.3, 95%CI 4.5 - 19.2, p&amp;lt; 0.0001) or stage II at presentation (HR 2.57 95% CI 1.24, 5.34, p=.01) (ref: stage I) or triple negative subtype (HR 3.7 95% CI 3.03, 4.51, p&amp;lt; .0001) (ref: hormone positive/HER2-). There was no significant difference in the relative risks of BC death (HR 0.8, 95% CI 0.5-1.27) or all-cause mortality (HR 0.85, 95% CI 0.60-1.21) for patients selected for treatment without anthracyclines compared to those treated with anthracyclines.Overall, among individuals selected for treatment without or with anthracycline NAC there was no significant difference in the 5-year cumulative incidence of BC (15.4% vs 10.5%, P=.05) or all-cause mortality (16.4% vs 11.9%, P=.07). However, the 5-year cumulative incidence of BC specific death (31.8% vs 16.5%, p=.03) and 5-year cumulative incidence of all-cause death (31.8% vs. 18.2%, p=.06) was higher among 420 women with HER2+ Stage III breast cancer who received non-anthracycline versus anthracycline-based chemotherapy. No difference was observed for other subgroups. Conclusions The omission of anthracyclines in NAC for individuals with stage III HER2+ breast cancer was associated with higher cumulative risks of breast cancer and all-cause mortality but no difference was observed for other subgroups. Further research is warranted to better understand in whom anthracyclines can be safely omitted. Citation Format: Danilo Giffoni M. M. Mata, Rinku Sutradhar, Matthew Castelo, Lena Nguyen, Danielle Rodin, Ezra Hahn, Omolara Fatiregun, Cindy Fong, Sabina Trebinjac, Andrea Eisen, Lawrence Paszat, Katarzyna Jerzak, Eileen Rakovitch. A Population-Based Analysis of the Impact of Omission of Anthracyclines in the Neoadjuvant Setting on the Risk of Mortality [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 PO5-18-02.

Tools used to measure the impact of comorbidities on surgical outcomes in children with complex chronic conditions: A scoping review.

To identify and describe assessment tools used to measure the impact of comorbidities on postoperative outcomes in children with complex chronic conditions (CCC). This was a scoping review using five electronic databases. The search was conducted in March 2022 by a medical librarian. There were no date or language restrictions. Included studies were full-text articles published in peer-reviewed journals that described a tool used to measure the impact of comorbidities in children with CCC to assess postoperative outcomes. A standardized data charting tool was used. A total of 2157 articles were retrieved. Five studies reporting on six comorbidity measures met inclusion criteria. All were cohort studies and were secondary analyses of data from an administrative database (n = 4) or a patient registry (n = 1). Sample sizes ranged from 645 to 25 747 participants. One paper described the assessment of reliability. Only one form of validity - predictive validity - was assessed in three papers for five measures. Findings from this scoping review revealed a paucity of comorbidity assessment tools validated for use with children with CCC; significant conceptual and measurement challenges exist in the current scientific literature. Five studies used formal risk assessment approaches to evaluate postoperative outcomes in children with complex chronic conditions. Conceptual and methodological differences between comorbidity indexes and risk prediction models are explicated. Further development of prediction science is needed for determining postoperative outcomes. Enhanced preoperative comorbidity assessment will identify children at risk of poor outcomes.

Emergency Department Visits Before Cancer Diagnosis Among Women at Mayo Clinic

ObjectiveTo determine associations of incident cancer diagnoses in women with recent emergency department (ED) care. Patients and MethodsA retrospective cohort study analyzing biological females aged 18 years and older, who were diagnosed with an incident primary cancer (12 cancer types studied) from January 1, 2015, to December 31, 2021, from electronic health records. The primary outcome was a cancer diagnosis within 6 months of a preceding ED visit. Secondary outcomes included patient factors associated with a preceding ED visit. ResultsOf 25,736 patients (median age of 62 years, range 18-101) diagnosed with an incident primary cancer, 1938 (7.5%) had an ED visit ≤6 months before a diagnosis. The ED-associated cancer cases were highest in lung cancer (n=514, 14.7%) followed by acute lymphoblastic leukemia (n=22, 13.3%). Patient factors increasing the likelihood of ED evaluation before diagnosis included 18-50 years of age (OR=1.32; 95% CI, 1.09-1.61), Elixhauser score (measure of comorbidities) >4 (OR=17.90; 95% CI, 14.21-22.76), use of Medicaid or other government insurance (OR=2.10; 95% CI, 1.63-2.69), residence within the institutional catchment areas (OR=3.18; 95% CI, 2.78-3.66), non-Hispanic Black race/ethnicity (OR=1.41; 95% CI, 1.04-1.88), and established primary care provider at Mayo Clinic (OR=1.45; 95% CI, 1.28-1.65). The ED visits were more likely in those who died within 6 months of diagnosis (n=327, 37.8%) than those who did not die (n=1611, 6.5%). ConclusionPatient characteristics identified in this study offer opportunities to provide cancer risk assessment and health navigation, particularly among individuals with comorbidities and limited health care access.

Comparison of Comorbidity Models Within a Population-Based Cohort of Older Adults With Non-Hodgkin Lymphoma.

Compare the association of individual comorbidities, comorbidity indices, and survival in older adults with non-Hodgkin lymphoma (NHL), including in specific NHL subtypes. Data source was SEER-Medicare, a population-based registry of adults age 65 years and older with cancer. We included all incident cases of NHL diagnosed during 2008-2017 who met study inclusion criteria. Comorbidities were classified using the three-factor risk estimate scale (TRES), Charlson comorbidity index (CCI), and National Cancer Institute (NCI) comorbidity index categories and weights. Overall survival (OS) and lymphoma-specific survival, with death from other causes treated as a competing risk, were estimated using the Kaplan-Meier method from time of diagnosis. Multivariable Cox models were constructed, and Harrel C-statistics were used to compare comorbidity models. A two-sided P value of <.05 was considered significant. A total of 40,486 patients with newly diagnosed NHL were included. Patients with aggressive NHL had higher rates of baseline comorbidity. Despite differences in baseline comorbidity between NHL subtypes, cardiovascular, pulmonary, diabetes, and renal comorbidities were frequent and consistently associated with OS in most NHL subtypes. These categories were used to construct a candidate comorbidity score, the non-Hodgkin lymphoma 5 (NHL-5). Comparing three validated comorbidity scores, TRES, CCI, NCI, and the novel NHL-5 score, we found similar associations with OS and lymphoma-specific survival, which was confirmed in sensitivity analyses by NHL subtypes. The optimal measure of comorbidity in NHL is unknown. Here, we demonstrate that the three-category TRES and five-category NHL-5 scores perform as well as the 14-16 category CCI and NCI scores in terms of association with OS and lymphoma-specific survival. These simple scores could be more easily used in clinical practice without prognostic loss.

A modified Hospital Frailty Risk Score for patients with cirrhosis undergoing abdominal operations.

Existing tools for perioperative risk stratification in patients with cirrhosis do not incorporate measures of comorbidity. The Hospital Frailty Risk Score (HFRS) is a widely used measure of comorbidity burden in administrative dataset analyses. However, it is not specific to patients with cirrhosis, and application of this index is limited by its complexity. Adult patients with cirrhosis who underwent nontransplant abdominal operations were identified from the National Inpatient Sample, 2016-2018. Adjusted associations between HFRS and in-hospital mortality and length of stay were computed with logistic and Poisson regression. Lasso regularization was used to identify the components of the HFRS most predictive of mortality and develop a simplified index, the cirrhosis-HFRS. Of 10,714 patients with cirrhosis, the majority were male, the median age was 62 years, and 32% of operations were performed electively. HFRS was associated with an increased risk of both in-hospital mortality (OR=6.42; 95% CI: 4.93, 8.36) and length of stay (incidence rate ratio [IRR]=1.79; 95% CI: 1.72, 1.88), with adjustment. Using lasso, we found that a subset of 12 of the 109 ICD-10 codes within the HFRS resulted in superior prediction of mortality in this patient population (AUC = 0.89 vs. 0.79, p < 0.001). While the 109-component HFRS was associated with adverse surgical outcomes, 12 components accounted for much of the association between the HFRS and mortality. We developed the cirrhosis-HFRS, a tool that demonstrates superior predictive accuracy for in-hospital mortality and more precisely reflects the specific comorbidity pattern of hospitalized patients with cirrhosis undergoing general surgery procedures.

Emerging wearable technologies for multisystem monitoring and treatment of Parkinson's disease: a narrative review.

Parkinson's disease (PD) is a chronic movement disorder characterized by a variety of motor and nonmotor comorbidities, including cognitive impairment, gastrointestinal (GI) dysfunction, and autonomic/sleep disturbances. Symptoms typically fluctuate with different settings and environmental factors and thus need to be consistently monitored. Current methods, however, rely on infrequent rating scales performed in clinic. The advent of wearable technologies presents a new avenue to track objective measures of PD comorbidities longitudinally and more frequently. This narrative review discusses and proposes emerging wearable technologies that can monitor manifestations of motor, cognitive, GI, and autonomic/sleep comorbidities throughout the daily lives of PD individuals. This can provide more wholistic insight into real-time physiological versus pathological function with the potential to better assess treatments during clinical trials and allow physicians to optimize treatment regimens. Additionally, this narrative review briefly examines novel applications of wearables as therapy for PD patients.

Medication-based Comorbidity Measures and Prostate Cancer Treatment Selection

IntroductionWe aimed to assess the association between comorbidities and prostate cancer management. Patients and methodsWe studied 12,603 South Australian men diagnosed with prostate cancer between 2003 and 2019. Comorbidity was measured one year prior to prostate cancer diagnosis using a medication-based comorbidity index (Rx-Risk). Binomial logistic regression analyses were used to assess the association between comorbidities and primary treatment selection (active surveillance, radical prostatectomy (RP), external beam radiotherapy (EBRT) with or without androgen deprivation therapy (ADT), brachytherapy, ADT alone, and watchful waiting (WW)). Certain common comorbidities within Rx-Risk (cardiac disorders, diabetes, chronic airway diseases, depression and anxiety, thrombosis, and chronic pain) were also assessed. All models were adjusted for sociodemographic and tumor characteristics. ResultsLikelihood of receiving RP was lower among men with Rx-Risk score ≥3 (odds ratio (OR) 0.62, 95%CI:0.56-0.69) and Rx-Risk 2 (OR 0.80, 95%CI:0.70-0.92) compared with no comorbidity (Rx-Risk ≤0). Men with high comorbidity (Rx-Risk ≥3) were more likely to have received ADT alone (OR 1.76, 95%CI:1.40-2.21), EBRT (OR 1.30, 95%CI:1.17-1.45) or WW (OR 1.49, 95%CI:1.19-1.88) compared with Rx-Risk ≤0. Pre-existing cardiac and respiratory disorders, thrombosis, diabetes, depression and anxiety, and chronic pain were associated with lower likelihood of selecting RP and higher likelihood of EBRT (except chronic airway disease) or WW (except diabetes and depression and anxiety). Cardiac disorders and thrombosis were associated with higher likelihood of selecting ADT alone. Furthermore, age had greater effect on treatment choice than the level of comorbidity. ConclusionHigh comorbidity burden was associated with primary treatment choice, with significantly less RP and more EBRT, WW and ADT alone among men with higher levels of comorbidity. Each of the individual comorbid conditions also influenced treatment selection.