Median Number Of Hospital Days Research Articles

Efficiency at Heart: Navigating the Hybrid Single-Ventricle Pathway

BackgroundSingle-ventricle cardiac defects (SVCDs) are among of the most health care resource–intensive congenital diseases. Although SVCDs are traditionally palliated using the Norwood pathway, in the last 2 decades select programs have used the hybrid strategy, which redistributes the operative and interstage risks. This study sought to characterize resource use for a cohort of patients with hybrid-palliated SVCD. MethodsAll patients with SVCDs who underwent palliation with the hybrid strategy and who were followed up exclusively at our institution (Columbus, OH) from January 2008 to December 2021 were included. End points were death, Norwood conversion, orthotopic heart transplantation, 6 months post-Fontan status, or 4 years of age in those patients who had not completed staged palliation. Primary end points included total days hospitalized, number of cardiology visits, echocardiograms, catheterizations, and advanced imaging performed. ResultsOf 135 patients with a diagnosis of SVCD, 72 survived for 6 months after the Fontan procedure. By patient-year for the entirety of the pathway, patients had a median hospital length of stay of 16 days (interquartile range [IQR], 12-25 days), 7 cardiology visits (IQR, 6-9), 8 echocardiograms (IQR, 7-10), and 0.7 catheterizations (IQR, 0.4-1.1). The interstage 1 period had the heaviest resource burden requiring intense cardiology follow-up and echocardiography surveillance. Cardiac catheterizations and advanced imaging were most prevalent during interstage 2 period, with a median of 2 (IQR, 1-2) catheterizations and 36 (40%) patients undergoing advanced imaging. The total median number of hospital days per patient was 63 days (IQR, 47-98.5 days). ConclusionsResource use for the care of patients with SVCDs is significant. The intensity of surveillance decreases as patients progress through the pathway. In comparison with published Norwood pathway data, resource intensity and use patterns in hybrid palliation are comparable.

Real-World Evaluation of Teclistamab for the Treatment of Relapsed/Refractory Multiple Myeloma (RRMM)

Introduction: Teclistamab (TEC) is a bispecific BCMA-CD3 directed T-cell antibody (BsAb), recently approved by EMA and FDA. Approval was based on the MajesTEC-1 study showing high overall response rates (≥PR in 63.0%) in heavily pretreated patients with relapsed multiple myeloma (RRMM). Few reports have described Real-World experience despite that TEC can induce unique side effects including cytokine release syndrome (CRS), neurotoxicity (ICANS) and a high incidence of infection (MajesTEC-1: incidence 76.4%; ≥Gr3: 44.8%). Thus, we performed a Real-World analysis of TEC therapy from 7 International Myeloma Foundation (IMF) associated MM academic centers. Methods: Patients treated with standard-of-care TEC were included. Data was collected until 7/28/2023. Results: 103 pts were included; median age 63 (range 33-91y); 15 pts. (14.5%) >75 yrs; 56.5% were male, 71.8% Caucasian, 11.6% Hispanic, and 12.6% Asian. Pts received a median of 6 PLT (range 1-16); 75% were triple-class-refractory (n=41/52 (79%), 30/85 (35%) had high-risk cytogenetics/FISH and 32/80 (40%) had 1q21 gain. At least 57/76 (75%) of pts would not have been eligible for MajesTEC-1 (mostly from prior BCMA (n=28 CAR-T, n=14 ADC; n=3 BsAb; n=5 CAR-T+ADC). 14 pts had CrCl <30ml/min with 2 on HD. Median number of hospital days was 8 (n= 72) but 31 patients were treated entirely as outpatients (Mayo clinic (MN, AZ, FL)). CRS was seen in 52 (50.4%) (all grade 1: except 6 Gr2, 1 Gr4), generally resolved within 24 hrs and was managed with tocilizumab alone (n= 27) or dex alone (n=9) or dex+toci (n=12). CRS was more common with inpatient (56.9%) vs outpatient (35.4%) TEC Rx. CrCl <30 ml, did not appear to alter the incidence or severity of CRS (50%; 1 Gr4). ICANS was infrequent (n=5; 4.85%), 1 pt with Gr 4-Sz requiring HD-steroids and TEC discontinuation). Infections were common, seen in 54 (52.4%) of patients, the majority were viral URI or CMV reactivation (n=26; 3 pts receiving CMV Rx, 1 pt with CMV organ disease). IVIG was given in 43/67 (64%) pts. The overall response rate for evaluable patients (n=82) was 63%; (sCR/CR 14; VGPR 23; PR 15; MR 2, SD 14; PD 14). In evaluable pts treated with prior BCMA (n=43), the ORR was 53% (sCR/CR 4; VGPR 14; PR 5; 1 MR; SD 10; PD 9). The most common reason for treatment discontinuation was PD (26.2%). 14 pts have died by the time of data cut-off (7/28/23), with the most common cause of death being disease progression. Conclusions: In this Real-World evaluation of TEC, a high ORR was seen, similar to the MajesTEC-1 study. Responses were rapid and are expected to deepen over time (median f/u 5m). CRS rates were similar to MajesTEC-1 and no new toxicity signal was noted. The rates of infection appear low but may be related to short follow-up. Details regarding the incidence and types of infection and the global use of IVIG will be described. With longer follow-up, additional efficacy/toxicity data will be presented.

Allogeneic Hematopoietic Stem Cell Transplantation in Elderly Patients: The Experience of the Spanish Group of Hematopoietic Transplantation and Cell Therapy (GETH-TC)

Introduction Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with significant toxicity and high risk of related mortality in older patients, especially when myeloablative conditioning is used. However, the upper limit of age for this procedure is not clearly defined. The aim of the study is to evaluate the safety and effectiveness of allo-HSCT in a cohort of elderly patients transplanted in Spain, considering non-relapse mortality (NRM), cumulative incidence (CI) of relapse, overall survival (OS) and progression-free survival (PFS). As secondary objectives, we evaluate the potential toxicity of allo-HSCT analyzing the days from infusion to hospital discharge, the number of readmissions within the first year, the CI of graft-versus-host disease (GvHD) and GVHD-free/relapse-free survival (GRFS). Finally, we also looked for prognostic factors significantly impacting OS. Methods We retrospectively analyzed 529 patients ≥65 years of age undergoing a first allo-HSCT between 2011 and 2020 in 17 Spanish centres, regardless of the indication and characteristics of transplantation. Subanalyses were performed according to chronological age (65-69 vs ≥70 years of age) and conditioning intensity (myeloablative vs non-myeloablative). Results Median age was 67.2 years (range 65.0-82.5) and 54 patients were ≥70 years. The most frequent indication was acute leukemia in 260 patients (49.1%). Clinical characteristics are shown in Table 1. Patients ≥70 years were more frequently male and had a lower HCT-CI than patients <70, without any other differences in patients' or transplant characteristics. The median follow-up was 51.2 months (range 9.3-139.6). At 1- and 4-years post-transplant, NRM were 24.3% (95%CI 21-28) and 32.0% (95%CI 28-36), CI of relapse were 21.4% (95%CI 18-25) and 29.1% (95%CI 25-33), OS were 61.2% (95%CI 57-65) and 43.4% (95%CI 39-48) and PFS were 54.3% (95%CI 50-58) and 38.9% (95%CI 35-43), respectively (Figure 1). No differences were found according to age group 65-69 vs ≥70 ( p=0.822, p=0.835, p=0.648 and p=0.743, respectively). Patients who had received myeloablative conditioning had lower CI of relapse (at 4 years post-transplant 19.3% vs. 30.7%, p=0.030), with no differences in NRM ( p=0.308), OS ( p=0.440) or PFS ( p=0.261). Regarding the duration of allo-HSCT admission, 486 patients were discharged alive, with a median number of hospital days from infusion to discharge of 22 (range 8-142). There were no differences based on age group ( p=0.635) or conditioning intensity ( p=0.606). Among 486 patients who were primary discharged, 320 (66.0%) needed a new readmission during the first-year post-transplant, with a median of 1 (range 0-6) up to day +100 and 2 (range 1-10) up to day +365. There were also no differences according to age ( p=0.789 and p=0.779, respectively) or conditioning intensity ( p=0.264 and p=0.818, espectively). Acute GvHD occurred in 265 patients (58.2%), 205 (45.1%) grades I-II and 60 (13.2%) grades III-IV. The CI of acute GvHD grades II-IV and grades III-IV at day +100 was 43.5% and 16.9%, respectively. A total of 174 patients (38.2%) developed chronic GvHD, 66 (14.6%) mild, 49 (10.8%) moderate and 56 (12.4%) severe. The CI of moderate-severe chronic GvHD at 1 and 2 years was 18.2% and 22.4%, respectively. According to age group, there were no differences in the CI of acute GvHD grades II-IV ( p=0.920), acute GvHD grades III-IV ( p=0.853) or chronic moderate-severe GvHD ( p=0.798). At 1- and 4-years after allo-HSCT, GRFS were 37.6% (95%CI 33-42) and 23.7% (95%CI 20-28), with no differences by age group ( p=0.569) or conditioning intensity ( p=0.707). In multivariate analysis, ECOG pretransplant ≥1 (HR 1.32, 95%CI 1-1.7; p=0.028), HCT-CI ≥3 (HR 1.34, 95%CI 1.1-1.7; p=0.016), high/very high DRI (HR 1.62, 95%CI 1.3-2.1; p<0.001) and no development of chronic GvHD (HR 2.99, 95%CI 2.3-3.9; p<0.001) were associated with worse OS. Age, gender, previous lines of treatment or autologous HSCT, donor type, stem cell source, conditioning intensity and development of acute GvHD did not influence OS. Conclusions Allo-HSCT is effective and safe at ages over 65 years, or even 70 years old. Myeloablative conditioning regimen may offer a lower risk of relapse without increasing toxicity. In our experience, ECOG, HCT-CI, DRI and chronic GvHD are more relevant parameters for post-transplant survival than chronological age.

Real-World Safety and Health Care Resource Utilization Analysis of Venetoclax and Hypomethylating-Agent Treatment for AML in an Academic-Affiliated Urban Community Oncology Network

Introduction Acute Myeloid Leukemia (AML) is a disease that affects predominantly older patients with a median age at diagnosis of 68 years. Elderly patients often have medical comorbidities and are ineligible for intensive induction chemotherapy. Recently, the FDA approved the combination of HMA/venetoclax for patients with newly diagnosed AML who are 75 years or older, or who have comorbidities precluding intensive induction chemotherapy. Through this retrospective analysis of patients treated at a metropolitan academic leukemia center and academic-affiliated community oncology practice network, our goal was to evaluate the safety and health care resource utilization of HMA/venetoclax treatment in a real-world experience. Methods We performed a retrospective analysis of patients treated for AML with HMA/venetoclax as standard-of-care at UCLA from 2018 to 2021. Patients treated with first-line HMA/venetoclax at UCLA community clinics (CC) and at UCLA main campus (academic centers, AC) and had a treatment record available in the electronic medical system were included. We specifically sought to collect safety parameters. Short-term efficacy outcomes were secondary endpoints. Results Thirty-three patients were eligible for analysis: eleven patients who received care in CC and 22 patients who were treated at AC. Baseline characteristics and treatment information are presented in Table 1. The average age was 76 years old for CC and 71 years old for AC. The proportion of patients older than 60 years old is 100% in CC, and 82% at AC. ECOG performance status was predominantly 0 and 1, irrespective of treatment location. Both groups have predominantly a secondary AML diagnosis (CC 64%, AC 59%). According to ELN 2017 criteria, 36.4% of CC had adverse risk disease, compared to 72% of AC patients. CC patients had median of 30% bone marrow blasts at diagnosis and AC had 59% blasts. Forty percent of CC patients and 64% of AC patients had baseline platelet counts <50x103/uL. Regarding treatment, eight out of 11 CC patients had consultation with a physician from the academic leukemia group. Twenty-seven percent of CC patients and 82% of AC patients were treated inpatient for cycle 1. Eighteen percent of CC patients and 66.6% AC patients received venetoclax at a starting dose lower than 400mg daily. Eighty-six percent of the dose reductions were due to concurrent azoles use. Finally, prophylactic antibiotics were used in 45% of CC patients compared to 64% of AC patients, and antifungal prophylaxis was used in 27% of CC patients compared to 64% of AC patients. Safety data, health care resource utilization, and clinical outcome information are reported in Table 2. The percentage of patients with grade 4 neutropenia duration >30 days after cycle 1 was 50% in CC vs. 43% at AC. There were no deaths before 30 days at CC and there were 2 deaths (10%) in AC. Thirty- to sixty-day mortality was zero in both groups. Thirty-six percent of CC patients and 59% of AC required hospitalization (infectious related: 43% CC, 52% AC; cytopenia: 29% CC, 10% AC). The median number of hospital days was 3 (range, 0-17) in CC, and 27 (range, 6-81) in AC; and 0% of CC vs. 18% of AC patients required an ICU stay. Regarding clinical response, bone marrow biopsy was done after cycle 1 in 91% of CC vs. 41% of AC patients. Of these patients, CR/CRi rate was 80% in CC patients vs. 56% in AC patients. Discussion Our study suggests that AML treatment with HMA/venetoclax can be administered safely in real-world community setting. The high number of CC patients that had consultation with AC group reflects the integrative collaborative practice model at our urban academic affiliated oncology community practice. Patients treated in CC tend to be older, with more favorable AML, and better BM function reserve at baseline. The CR rate for patients treated in CC is comparable to previously published data. The high number of patients treated inpatient for cycle one at AC likely indicates AC carries a more acutely ill AML patient population compared to CC, which likely resulted in more health care resource utilization. It is interesting to observe that in the CC group, 29% of the complications leading to hospitalization are from cytopenia, suggesting that health care resource utilization could be further optimized with pre-emptive transfusion scheduling. Limitations of this analysis include that this is a small, single center, retrospective analysis. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Drug-Induced Hepatitis in Children: The Experience of a Single Center in Romania.

Drug-induced liver injury (DILI) is uncommon but potentially lethal. Over 6 years, 2533 children with acute liver disease were identified in our center, 48 of which suffered from toxic hepatitis, and 40 exhibited DILI (22 paracetamol-related, 14 albendazole-related). The most affected children were in the 13–17-year-old age group. The mean time between drug ingestion and disease diagnosis was 25.4 h for paracetamol-related DILI and 21.6 days for the albendazole-related group. Clinical features were mostly gastrointestinal, jaundice being reported in 30% of the cases. Regarding the type of liver injury, for 70% of the patients it was hepatocellular (mostly paracetamol toxicity), for 11% cholestatic, and for 19% mixed (albendazole-related). The mean initial ALT value was 1020 U/L for all DILIs. Coagulopathy was only identified for the acetaminophen-related group. The median number of hospitalization days was 6.9 for DILI related to acetaminophen ingestion, compared with 7 for the idiosyncratic pattern. When applying the DILI severity index, 81% of the patients were categorized as having a mild hepatic ailment, while 19% had a moderate–severe or severe disease. No deaths were reported in the study group. The diagnosis of DILI involves the exclusion of other causes of liver injury; therefore, it is considered one of the most challenging diagnoses in hepatology.

Hypometilating Agents (HMA) As Salvage Therapy in Relapsed or Refractory AML: A 5-Center Retrospective Study

Introduction: 5-azacytidine and decitabine have been widely studied as first line chemotherapy in acute myeloid leukemia (AML) patients not eligible for allogenic stem cell transplantation, but data on their use as salvage chemotherapy are limited. We tried to define efficacy and feasibility of hypometilating agents (HMA) as salvage chemotherapy in patients without previous allogenic stem cell transplantation.Methods: We retrospectively reviewed clinical records of 35 patients treated with HMA as salvage therapy in our 5 institutions since their introduction in clinical practice for AML patients.Results: Median age was 68 years. 22 patients were men and 13 women. One patient was AML with t(9;11), 18 were AML MRC, 4 were therapy related AML, 12 were AML NOS. Two patients were favorable risk sec ELN 2017, 20 were intermediate, 11 were adverse risk. Cytogenetic risk was not available for 2 patients. 66% of patients received HMA as second line therapy for their disease, 23% as third line and 11% were beyond the third line. 29 patients were treated with azacitidine and 6 with decitabine. Six patients reached CR or morphologic leukemia free state (MLFS) or PR after HMA. All patients underwent intensive chemotherapy (i.e. FLAI or 3+7 like) as first line induction, and we excluded patients who had an HMA as first line chemotherapy and another one as second line. Median number of hospitalization days during HMA therapy was 11(1-78); median number of HMA cycles was 3 (range 1-31). 7 episodes of sepsis demonstrated by positive blood cultures and 3 fungal infections were recorded during HMA therapy. Median OS was 197 days from the starting of HMA and median EFS was 125 days. Median EFS in patients with adverse cytogenetic risk was 68 days, while median EFS in patient with favorable and intermediate risk was 207 days (p=0,0124). Median OS in patients with adverse cytogenetic risk was 181 days, while median OS in patient with favorable and intermediate risk was 307 days (p=0,0401).We did not find significant difference between median OS ed EFS in patients with refractory disease compared to relapsed patients. 31% of patients with adverse cytogenetic risk reached a stable disease with HMA therapy while 64% of patients with favorable/intermediate cytogenetic risk reached a response (CR, PR; MLFS) or a stable disease. We did not find significant differences between transfusion needs before and after salvage therapy but this could be due to the small size of our sample.Conclusion: HMA showed efficacy and a considerable OS in our patients. OS was significantly better in favorable/intermediate risk patients than adverse risk patients. Hospitalization was limited, and we can argue that this could lead to improved costs and quality of life, but further studies are needed. So HMA could be a good clinical option in a selected population of relapsed patients, especially in those not suitable for allogenic bone marrow transplantation, in whom the prognosis is generally extremely poor. Further studies are needed to define if there is a survival or quality of life advantage over other therapies. DisclosuresNo relevant conflicts of interest to declare.

Outcomes in Vaso-Occlusive Crisis Treatment in the Emergency Department Vs. Acute Care Observation Center

I NTRODUCTION: Acute painful vaso-occlusive crises (VOC) are the leading cause of emergency department (ED) encounters and hospital admissions for those with sickle cell disease (SCD). For SCD patients, the goal of the sickle cell acute care observation unit (ACOU) at University of Illinois Health (UIH) is to improve patient outcomes by providing immediate care for an uncomplicated VOC. At our urban hospital which cares for more than 500 adult SCD patients, a considerable portion of SCD patients, despite having access to the ACOU, continue to present to the ED for treatment of an uncomplicated VOC. In order to help improve our current system, this study investigated outcomes in SCD patients who receive care for an uncomplicated VOC in the ACOU versus the ED at UIH. METHODS: By querying the electronic medical record, a retrospective study was conducted to analyze outcomes of encounters from the ACOU and ED at UIH between October 2019 and December 2019, specifically including SCD patients ≥18 years old who received morphine for treatment of an uncomplicated VOC. Encounters for complicated VOCs such as acute chest syndrome and stroke were excluded. Endpoints collected include time to first dose of morphine, total milligrams (mg) of IV morphine equivalents given, number of total morphine doses, admission rates, subsequent hospital length of stay, and 30-day inpatient admission rates. Time to the first dose (log transformed) and total dose in mg were analyzed by linear mixed effects models. The number of doses and hospitalization days were analyzed by negative binomial mixed effects model. Admissions and 30-day admissions were analyzed by logistic mixed effects models. These models adjusted for age, gender, and severe Hb genotype (HbSS or HbS beta0-thalassemia) and treated patient identity as random effect. P values were obtained from Wald- test. RESULTS: The ACOU data set contains 394 patient encounters for 79 patients with a median age of 33 years (interquartile range [IQR], 28-40), 71% female, and 73% with severe sickle genotypes. The ED data set contains 391 patient encounters for 128 patients with a median age of 30 years (IQR, 26-41), 53% female, and 74% with severe sickle genotypes. In the ACOU, the median time to first dose of morphine was 49 minutes (IQR, 39-60) compared to 107 minutes (IQR, 71-194) in the ED. The time to first dose was significantly longer in the ED compared to the ACOU (eβ=2.5, p &amp;lt;2×10-16). There was no significant difference in the total number of morphine doses received nor the total mg of morphine received between the two locations. Admission rate from ACOU was 6.6% compared to 53% from ED (OR=0.019, p=2x10-16). Of those admitted, the median number of hospitalization days from the ACOU was 4 days (IQR, 2.3-5.8) and 4 days (IQR, 2.0-6.5) from the ED. There was no significant difference in hospitalization days (p=0.6). The 30-day admission rate was 55% from the ACOU compared to 58% from the ED. 30-day admission rate however had strong intra-patient correlation (i.e., a patient was likely re-admitted multiple times): 44% of patients from the ACOU had admissions within 30 days of their ACOU visit compared to 32% from the ED. Controlling for the intra-patient correlation, ACOU visits had a higher 30-day admission rate than ED visit (OR=2.8, p=0.0015). DISCUSSION: SCD patients treated for an uncomplicated VOC at the sickle ACOU at UIH had a significantly shorter time to initial dose of IV pain medication. The wait time in the ED before first dose of IV pain medication received was more than double than those treated in the ACOU. Patients treated for an uncomplicated VOC in ACOU and ED had similar hospitalization days without a statistically significant difference. The 30-day admission rate to the inpatient setting was comparable for those treated in the ED versus the ACOU. However, given that only 6.6% of patients from the ACOU were admitted during the study period, this suggests that most patients who use both the ED and ACOU tend to be subsequently admitted from the ED. SCD patients may be presenting to the ED for treatment of VOC if capacity in the ACOU is exceeded or are presenting outside of hours of operation (currently 2 shifts Monday through Saturday). Therefore, improving access to our ACOU by increasing capacity and hours of operation may subsequently also lead to a decrease in time to first dose of medication and decrease in the overall 30-day admission rate. Disclosures Gordeuk: Imara: Research Funding; CSL Behring: Consultancy, Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; Novartis: Consultancy; Ironwood: Research Funding.

Pregnancy Outcomes in Women With Percutaneous Nephrostomy Tube Placement for Renal Colic [32N

INTRODUCTION: Maternal and fetal outcomes in pregnant patients undergoing treatment of renal colic with percutaneous nephrostomy tubes (PCN) have not previously been described. We undertook this study to evaluate pregnancy outcomes in patients who had nephrostomy tubes placement during pregnancy. METHODS: Following IRB approval, we retrospectively identified women who had nephrostomy tubes placed during pregnancy at a single tertiary care center. Data were collected from maternal and newborn charts. Descriptive statistics were utilized to characterize pregnancy outcomes. RESULTS: During the study period (2014–2018), 41 patients underwent placement of nephrostomy tubes during pregnancy, however maternal and neonatal outcomes were available for only 13 patients. Median gestational age at PCN placement was 28.2 weeks. Prior to PCN placement, renal stones were identified on imaging in 53% of patients and median creatinine was 0.6 (range 0.44–1.06). Urinary tract infection (positive urine culture) was identified in 46% of patients. Median number of hospital days during pregnancy was 9 (range 3–19 days). 31% of patients delivered prior to 37 weeks (median 37, range 32w6d-40w4d). A total of 5 (38%) infants required NICU admission and 2 (15%) were diagnosed with neonatal abstinence syndrome (NAS). CONCLUSION: Although limited by follow up data, this is the largest case series to date describing PCN in pregnancy. The underlying renal disease necessitating PCN is associated with prolonged hospital stays, NICU admission, and treatment for NAS. Given these findings, our group is planning to conduct prospective studies to characterize pregnancy outcomes in women with symptomatic renal colic during pregnancy.

Feasibility of and Decreased Inpatient Hospital Days for Non-Hodgkin Lymphoma (NHL) and Hodgkin Lymphoma (HL) Patients with Outpatient BEAM Using Daily Etoposide and Cytarabine and Autologous Hematopoietic Stem Cell Transplantation (AHCT)

<h3>Introduction</h3> BEAM is a commonly used AHCT regimen for NHL and HL. The twice daily dosing of etoposide and cytarabine requires inpatient hospitalization, and pts remain inpatient until neutrophil recovery. We aimed to evaluate the feasibility and safety of outpatient BEAM with AHCT using daily etoposide and cytarabine. <h3>Methods</h3> We performed a retrospective analysis of patients treated with BEAM and AHCT in the outpatient transplant setting at Memorial Sloan Kettering Cancer Center from October 2018 to August 2019. Carmustine was given on day -6 (300mg/m2), etoposide (200mg/m2/dose) and cytarabine (400mg/m2/dose) daily from day -5 through day -2, and melphalan on day -1 (140mg/m2). Stem cell infusion and supportive care were performed per standard of care and institutional guidelines, including a delayed emesis prophylactic regimen of from D+1 to +7 after the first three pts. Packed red blood cells were given for hemoglobin <7g/dl and platelets for platelet counts <20K/mcl. <h3>Results</h3> For 18 pts, the median age was 38 (range 24-21) with 72% male. Lymphoma subtypes are shown in Figure 1. Median dose of CD 34+ cells infused was 6 × 10^6 CD34+cells/kg (range: 2.54-10.66). Cell infusions were given over 2 days in 3 pts. Washed cell infusions were administered to 6 pts. Median melphalan AUC was 6.2 (range 3.5-14, Figure 3). Median days to neutrophil engraftment was 9 (range: 8-12). Median number of platelet transfusions per pt was 4 (range: 2-8). Median packed red blood cells per pt was 1 (range: 0-6). Median number of days of grade2+ diarrhea was 3 (range: 0-11). Four pts (22%) required additional antiemetics outside the standard of care. Median weight lost per pt was 2.8kg (range: 0-10.3kg). Median number of intravenous fluid boluses was 5.5 (range: 1-10). Pts maintained a mean serum creatinine of 0.9mg/dl (range:0.7-1.5mg/dl). Engraftment syndrome was diagnosed in 44%. All patients were alive as of 9/30/19 with median follow-up of 62 days (range: 34-291). A total of 236 hospital days were saved using the outpatient regimen. Median number of hospital days saved per pt was 13. Fifteen pts required admission during the transplant course while 3 completed the transplant entirely outpt. Median day of hospital admission was +6 (range: +1 to +11). Reasons for admission are shown in Figure 2. Median number of inpt hospital days was 4 (range: 3-14). Ten pts returned to the outpatient stem cell transplant clinic for management prior to day 30. One pt was re-hospitalized prior to day 30. <h3>Conclusion</h3> BEAM using daily dosed etoposide and cytarabine with AHCT was not only feasible and safe for the outpatient setting, but also has the potential to reduce inpatient hospital days.

Outpatient BEAM Using Daily Etoposide and Cytarabine with Autologous Hematopoietic Stem Cell Transplantation for Lymphoma Is Feasible and Decreases Inpatient Length of Stay

Introduction: High dose therapy with carmustine, etoposide, cytarabine, and melphalan (BEAM) followed by autologous hematopoietic stem cell transplantation (AHCT) is the most common consolidation therapy for chemosensitive patients with relapsed/refractory Non-Hodgkin Lymphoma (NHL) and Hodgkin Lymphoma (HL) in the US. Inpatient hospitalization is usually required due to the twice daily dosing of etoposide and cytarabine, and patients remain admitted until neutrophil recovery. Utilizing our outpatient transplant program, we aimed to evaluate the feasibility and safety of outpatient BEAM with AHCT using daily dosed etoposide and cytarabine to enhance the patient experience and improve inpatient resource utilization. Methods: We performed a retrospective evaluation of patients treated in the outpatient setting at Memorial Sloan Kettering Cancer Center. Patients were eligible for outpatient AHCT if they did not have a clinical indication for inpatient continuous monitoring. Patients received BEAM conditioning consisting of carmustine on day -6 (300mg/m2), etoposide daily from day -5 through day -2 (200mg/m2/dose), cytarabine daily from day -5 through day -2 (400mg/m2/dose), and melphalan on day -1 (140mg/m2). AHCT on day 0, pegfilgrastim on Day +1, and supportive care were performed as per standard of care and institutional guidelines. Patients were seen daily by an advanced practice provider and HCT attending. Notably, service guidelines were revised to include a delayed emesis prophylactic regimen of oral dexamethasone (2mg bid) and lorazepam (0.5mg TID) from D+1 through D+7, which was initiated after the first three patients were treated. Patients were transfused packed red blood cells (pRBC) for hemoglobin &lt;7g/dl and platelets for &lt;20K/mcl. Results: From October 2018 to July of 2019, 13 patients (Hodgkin's lymphoma (n=5), mantle cell lymphoma (n=4), diffuse large B-cell lymphoma (n=2), T-cell lymphoma (n=2), and grey zone lymphoma (n=1)) were treated. The median age was 40 years (range 26-71), and the majority were male (69%). Median cell dose infused was 5.89 CD34+ cells/kg (range 2.53-10.66). Two patients received cell infusions over 2 days, and three patients received washed cell infusion products. Two patients completed transplant entirely outpatient; the remainder required hospitalization during their transplant course. Reasons for admission included neutropenic fever (n=4), nausea (n=2), tachycardia (n=2), hypoxia (n=1), and other (n=2). Patients were admitted on a median of Day +6 (range Day+1 - Day+11) and remained inpatient for a median of 4 days (range 3-14). Eight patients (62%) returned to the outpatient stem cell transplant clinic for management prior to day 30. One patient was re-hospitalized prior to day 30. The median number of hospital days saved was 13 days/per patient. In total, 170 hospital days were saved with this regimen. Engraftment and toxicities were similar to inpatient administration. Neutrophil engraftment occurred at a median of Day+9 (range 8-11) with a median of 6 days of ANC&lt;500 (IQR 8-11). Platelets comprised most of the transfusion support required, with a median of 4 platelet (range 2-8) and 2 pRBC (range 0-2) transfusions per patient. Grade 2 or higher diarrhea occurred for a median of 3.5 days (range 3-11) with 38% not having any diarrhea. A small percentage of patients required additional antiemetics outside the standard of care (23%). The median weight lost per patient was 2.5kg (range 0 - 10.3kg). Patients received intravenous fluid support with a median of 5 normal saline boluses (range 1-10). All patients maintained normal serum creatinine peri-transplant, with a median maximum serum creatinine of 0.9mg/dl (range 0.7-1.1). Six patients (46%) had engraftment syndrome. All patients were alive with a median follow-up of 91 days (range: 29-205). Conclusion: We found that BEAM followed by AHCT using daily dosed etoposide and cytarabine is feasible and safe for the outpatient setting with tolerability matching that of the traditional inpatient BEAM regimen. Moreover, this treatment method has the potential to reduce a considerable number of inpatient hospital days, while still safely maintaining a threshold for toxicity requiring inpatient admission. Disclosures Bhatt: Incyte: Consultancy. Landau:Pfizer: Membership on an entity's Board of Directors or advisory committees; Caelum: Membership on an entity's Board of Directors or advisory committees; Prothena: Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Karyopharm: Consultancy, Honoraria. Scordo:Angiocrine Bioscience, Inc.: Consultancy; McKinsey &amp; Company: Consultancy. Sauter:Juno Therapeutics: Consultancy, Research Funding; Kite/Gilead: Consultancy; Precision Biosciences: Consultancy; Genmab: Consultancy; Spectrum Pharmaceuticals: Consultancy; GSK: Consultancy; Celgene: Consultancy; Novartis: Consultancy; Sanofi-Genzyme: Consultancy, Research Funding. Giralt:Celgene: Consultancy, Research Funding; Takeda: Consultancy; Sanofi: Consultancy, Research Funding; Amgen: Consultancy, Research Funding. Shah:Amgen: Research Funding; Janssen: Research Funding.

HOSPITALIZATION RATES OF PATIENTS USING COMMUNITY MENTAL HEALTH CENTER SERVICES

Non-adherence to treatment and hospital admissions are the common problems in severe mental disorders. To determine the contribution of community mental health center (CMHC) services to increased hospitalization rates of patients previously diagnosed with severe mental disorders such as schizophrenia spectrum and other psychotic disorders and bipolar disorders. 356 patients diagnosed with bipolar disorder, schizophrenia, schizoaffective disorder, and unspecified schizophrenia spectrum and other psychotic disorders in accordance with the DSM–5 criteria and treated in the CMHC on the south coast of Turkey were included in this retrospective study.The hospitalization records of the patients were examined over three different periods. First and second period: two divided years which patients had not yet received CMHC services before registration. Third period: o ne-year, during which patients using CMHC services. A total of 356 patients were included in the study. SPSS 22.0 (IBM Corporation, Armonk, New York, United States) software was used in the analysis of variables. Normal distribution of data was assessed with the Shapiro–Wilk test. The diagnosis of the participants in the study were 157 (44%) schizophrenia, 35 (9.8%) schizoaffective disorder, 102 (28.7%) bipolar disorder and 62 (17.4%) unspecified schizophrenia spectrum and other psychotic disorders. As a result of the hospitalization rates , there was a significant difference between three periods. The median number of hospitalization days during the first episod was calculated as 1.0 (mean 13.9), the second period 0.7 (mean 18.59) and third period 0.6 (mean 5.83), respectively. The rate of hospitalization was 32.9% in the first period, 42.4% in the second period and 12.9% in the third period. This study provides the new evidence regarding the ability of primary services offered in the community mental health centers.

HOSPITALIZATION RATES OF PATIENTS USING COMMUNITY MENTAL HEALTH CENTER SERVICES

Non-adherence to treatment and hospital admissions are the common problems in severe mental disorders. To determine the contribution of community mental health center (CMHC) services to increased hospitalization rates of patients previously diagnosed with severe mental disorders such as schizophrenia spectrum and other psychotic disorders and bipolar disorders. 356 patients diagnosed with bipolar disorder, schizophrenia, schizoaffective disorder, and unspecified schizophrenia spectrum and other psychotic disorders in accordance with the DSM–5 criteria and treated in the CMHC on the south coast of Turkey were included in this retrospective study.The hospitalization records of the patients were examined over three different periods. First and second period: two divided years which patients had not yet received CMHC services before registration. Third period: one-year, during which patients using CMHC services. A total of 356 patients were included in the study. SPSS 22.0 (IBM Corporation, Armonk, New York, United States) software was used in the analysis of variables. Normal distribution of data was assessed with the Shapiro–Wilk test. The diagnosis of the participants in the study were 157 (44%) schizophrenia, 35 (9.8%) schizoaffective disorder, 102 (28.7%) bipolar disorder and 62 (17.4%) unspecified schizophrenia spectrum and other psychotic disorders. As a result of the hospitalization rates, there was a significant difference between three periods. The median number of hospitalization days during the first episod was calculated as 1.0 (mean 13.9), the second period 0.7 (mean 18.59) and third period 0.6 (mean 5.83), respectively.The rate of hospitalization was 32.9% in the first period, 42.4% in the second period and 12.9% in the third period. This study provides the new evidence regarding the ability of primary services offered in the community mental health centers.

Impact of early in-hospital medication review by clinical pharmacists on health services utilization.

BackgroundAdverse drug events are a leading cause of emergency department visits and unplanned admissions, and prolong hospital stays. Medication review interventions aim to identify adverse drug events and optimize medication use. Previous evaluations of in-hospital medication reviews have focused on interventions at discharge, with an unclear effect on health outcomes. We assessed the effect of early in-hospital pharmacist-led medication review on the health outcomes of high-risk patients.MethodsWe used a quasi-randomized design to evaluate a quality improvement project in three hospitals in British Columbia, Canada. We incorporated a clinical decision rule into emergency department triage pathways, allowing nurses to identify patients at high-risk for adverse drug events. After randomly selecting the first eligible patient for participation, clinical pharmacists systematically allocated subsequent high-risk patients to medication review or usual care. Medication review included obtaining a best possible medication history and reviewing the patient’s medications for appropriateness and adverse drug events. The primary outcome was the number of days spent in-hospital over 30 days, and was ascertained using administrative data. We used median and inverse propensity score weighted logistic regression modeling to determine the effect of pharmacist-led medication review on downstream health services use.ResultsOf 10,807 high-risk patients, 6,416 received early pharmacist-led medication review and 4,391 usual care. Their baseline characteristics were balanced. The median number of hospital days was reduced by 0.48 days (95% confidence intervals [CI] = 0.00 to 0.96; p = 0.058) in the medication review group compared to usual care, representing an 8% reduction in the median length of stay. Among patients under 80 years of age, the median number of hospital days was reduced by 0.60 days (95% CI = 0.06 to 1.17; p = 0.03), representing 11% reduction in the median length of stay. There was no significant effect on emergency department revisits, admissions, readmissions, or mortality.LimitationsWe were limited by our inability to conduct a randomized controlled trial, but used quasi-random patient allocation methods and propensity score modeling to ensure balance between treatment groups, and administrative data to ensure blinded outcomes ascertainment. We were unable to account for alternate level of care days, and therefore, may have underestimated the treatment effect in frail elderly patients who are likely to remain in hospital while awaiting long-term care.ConclusionsEarly pharmacist-led medication review was associated with reduced hospital-bed utilization compared to usual care among high-risk patients under 80 years of age, but not among those who were older. The results of our evaluation suggest that medication review by pharmacists in the emergency department may impact the length of hospital stay in select patient populations.

Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial.

Family caregivers of patients with chronic critical illness experience significant psychological distress. To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression. A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes. At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group. The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival. Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different. Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness. clinicaltrials.gov Identifier: NCT01230099.

P062: Impact of pharmacist-led medication review in the emergency department on downstream health services utilization

Introduction: Adverse drug events are a leading cause of Emergency Department (ED) visits and unplanned admissions. Up to 50% are misdiagnosed in the ED and on hospital wards leading to treatment delays. Our main objective was to evaluate the effect of pharmacist-led medication review in high-risk ED patients on the number of days in-hospital. Our hypothesis was that early pharmacist-led medication review may reduce the number of days spent in-hospital. Methods: We evaluated a quality improvement program that was implemented in three British Columbian EDs. During a 12-month period, nurses identified consecutive patients at high-risk for adverse drug events using a clinical decision rule integrated into triage algorithms. Clinical pharmacist research assistants enrolled consecutive eligible high-risk patients, and systematically allocated them to medication review or control. In the intervention group, pharmacists collected best possible medication histories, reviewed medications for appropriateness and adverse drug events, and communicated review results to patients and physicians. In the control group, nurses collected best-possible medication histories, and physicians referred patients to the ED pharmacist as needed. Ongoing care was determined by physicians who were not blinded to group allocation, but were unaware of the evaluation. We assessed outcomes using administrative health databases. The primary outcome was the number of days spent in-hospital over 30 days. We used inverse propensity score weighted regression modeling to assess the relationship between medication review and health outcomes. The sample size was limited by the duration of the quality improvement program. Results: Among 10,807 patients 6,416 received medication review in the ED and 4,391 usual care. The groups were balanced in terms of baseline characteristics. The median number of hospital days was 0.48 days (95% confidence interval [CI] 0.00-0.96) less in the medication review group compared to usual care (p=0.058). The difference was 0.60 days (95% CI 0.06-1.17; p=0.03) less among patients under 80 years old. There was no effect on ED revisits, number of admissions and readmissions, or mortality. Conclusion: Medication review was associated with a trend in reduced hospital-bed utilization. While limited by lack of randomization, our evaluation suggests that ED pharmacists may impact subsequent resource utilization.

Professional oral health care reduces oral mucositis pain in patients treated by superselective intra-arterial chemotherapy concurrent with radiotherapy for oral cancer.

Oral mucositis (OM) is a painful complication of radiation therapy (RT) for head and neck cancer. OM can compromise nutrition, require opioid analgesics and hospitalization for pain control, and lead to interruption of treatment. Severe oral mucositis appears inevitable in superselective intra-arterial chemotherapy concurrent with radiotherapy (SSIACRT), requiring management of OM for the patient. The objective of this study was to assess the utility of professional oral health care (POHC) for the management of OM in patients undergoing SSIACRT. Thirty-three patients were enrolled in this study. The first 17 patients underwent SSIACRT before we created an oral management team, and thus did not receive POHC. The remaining 16 patients received POHC. Fever duration, duration of oral feeding difficulty, opioid usage, duration of opioid administration, duration of hospitalization, and number of hospital days from the end of irradiation to discharge were compared between these two groups. Median total dose of morphine during SSIACRT, median number of hospital days from end of irradiation to discharge, and duration of hospitalization all differed significantly between groups (P < 0.05). Duration of opioid administration, fever duration, and duration of oral feeding difficulty did not differ significantly between groups. These findings indicate that POHC may reduce opioid use and shorten the hospital stay. Such results might be obtained through infection control by POHC. This report appears to be the first study to evaluate the efficiency of POHC in SSIACRT for oral cancer from the perspective of mucositis pain and opioid use.

Phase II Clinical Trial of Etanercept Plus Extracorporeal Photopheresis GVHD Prophylaxis Following Unrelated Donor Reduced Intensity Transplant

s / Biol Blood Marrow Transplant 21 (2015) S322eS354 S337 GVHD grading but were included for the other analyses. Initial treatment included beginning or increasing systemic steroids (69%), continuing calcineurin inhibitors (64%) or beginning topical treatment (52%). Additional treatment was added within the first 28 days for 31% patients. Median lines of treatment for the total duration of follow-upwere 1 (range 0-4). Of the evaluable patients, 63/85 and 56/66 had a clinical response (CR/PR) at 28 days and at 180 days respectively. 36% developed recurrence of LA GVHD after a documented CR. 26% developed chronic GVHD after LA GVHD at a median of 169 (range 25-383) days after diagnosis of LA GVHD. Median number of hospital days in the first 6 months after the diagnosis of LA GVHD was 15 (range 1-120) days. 25% had discontinued immunosuppressive therapy (IST) at the time of last follow-up with the median duration of IST being 12.8 (range 6.1-24.7) months after HCT. 9% relapsed and 22% died with themain causes of death being GVHD, infection ormulti organ failure. Median failure free survival (FFS) as defined by absence of relapse, death, addition of new IST or development of chronic GVHD was 3.6 months (95% CI: 1.7-6.8) (Figure). Median overall survival (OS) was 25.3 months. No patient/transplant or GVHD related factors emerged as significant predictors for FFS or OS in univariate analysis. Conclusions: The overall incidence of LA GVHD is low, but it is associated with prolonged immunosuppression, poor failure free and overall survival.

Factors affecting the length of stay of patients with traumatic spinal cord injury in Tianjin, China

PurposeTo describe the acute care length of stay (ACLOS) of adult patients with traumatic spinal cord injury (TSCI) in Tianjin, China, and identify the associated demographic and clinical factors.MethodsTSCI patients admitted to a general hospital in Tianjin, China from 2004 to 2007 were identified. The predictor variables were demographic and clinical factors, including age, gender, etiology, level of injury, severity, associated injuries, surgery, and complications. The outcome variable was ACLOS. Multivariable linear regression analysis models were used to examine the association between predictor and outcome variables.ResultsThis study included 631 TSCI patients. The mean ACLOS was 32.4 ± 37.7 days, with a range of 1–294 days. The median number of hospitalization days was 21 days. Admission to a suburban hospital surgery, urinary infection, poorer functional status, pressure ulcers, and associated injuries were significantly associated with ACLOS.ConclusionThis study examined the effect of epidemiological and clinical factors on ACLOS in Tianjin, China. The factors that influenced the ACLOS were different from factors reported in other studies. More studies are needed in China to determine the effect of these factors on ACLOS in TSCI patients and to propose a predictive model.

Radical Cystectomy in the Octogenarian Population: A Single Centre Experience

Introduction: Radical cystectomy is the treatment of choice for infiltrating non-metastatic bladder cancer. However there is reluctance to perform this surgery in the elderly due to morbidities associated. We sought to examine our institutional experience regarding radical cystectomy in the octogenarians. Patients and Methods: A total of 23 were 80 years or older in age (19 males and 4 females). Overall mortality, early and late morbidity were analyzed. Length of hospital stay, intensive therapy unit admissions, re-hospitalization and overall survival were assessed. Results: Median age at time of cystectomy was 83.5 years (range 80–90 years). Median follow-up time was 7.5 years (range 8–120 months). All patients had standard radical cystectomy. Median operative time was 3 hours (range 3–5 hours). Median number of blood transfusion units was 9 (range 4–14). Median preoperative and postoperative hemoglobin level was 12.5 (range 9.9–14) and 10.8 g/dl (8.7–12.2 g/dl) respectively. Admission to the intensive therapy unit was needed in 3 patients. Median number of hospitalization days following the cystectomy procedure was 23 days (range 5–90 days). Median survival time was 16 months and the actuarial survival at 1, 2 and 3 year was 66.7, 47.6 and 12% respectively. Conclusion: This study highlights the safety and feasibility of radical cystectomy in the treatment of bladder cancer in the octogenarians. It provides palliation of local symptoms and local cancer control. Future research should be directed towards comparing with the non-octogenarian cohorts with particular emphasis on oncological, functional and survival outcomes as end points.

Consequence of Dysphagia in the Hospitalized Patient

To determine if comorbid dysphagia in all hospitalized patients has the potential to prolong hospital stay and increase morbidity. Dysphagia is increasingly prevalent with age and comorbid medical conditions. Our research group has previously shown that dysphagia is a bad prognostic indicator in patients with stroke. Analysis of national database. The National Hospital Discharge Survey (NHDS), 2005-2006, was evaluated for presence of dysphagia and the most common comorbid medical conditions. Patient demographics, associated disease, length of hospital stay, morbidity and mortality were also evaluated. There were over 77 million estimated hospital admissions in the period evaluated, of which 271,983 were associated with dysphagia. Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection, and congestive heart failure. The median number of hospitalization days for all patients with dysphagia was 4.04 compared with 2.40 days for those patients without dysphagia. Mortality increased substantially in patients with dysphagia associated with rehabilitation, intervertebral disk disorders, and heart diseases. Dysphagia has a significant impact on hospital length of stay and is a bad prognostic indicator. Early recognition of dysphagia and intervention in the hospitalized patient is advised to reduce morbidity and length of hospital stay.