Multiple Medical Comorbidities Research Articles

Characteristics and Factors Associated With Nonoperative Management and Hospital Outcomes After Hip Fractures Among Community-Dwelling Older Adults: Retrospective Analysis.

Nonoperative treatment is used at varying rates among older adults with hip fractures despite the high mortality. This retrospective analysis of 7803 patients 65 and older admitted with hip fractures is to estimate the odds of nonoperative treatment and in-hospital mortality after hip fractures among community-dwelling older adults. 13.6% underwent nonoperative treatment. Compared to the group with operative treatment, the nonoperative group had a higher in-hospital mortality rate (6.51% vs. 1.32%, p < .0001). Male sex, nondisplaced fracture, and comorbidities of acute myocardial infarction, congestive heart failure, cerebrovascular disorder, dementia, and liver disease were associated with an increased likelihood of nonoperative treatment. Nonoperative treatment, advanced age, use of osteoporosis pharmacotherapy, multiple medical comorbidities, and hospital-acquired complications were associated with increased in-hospital mortality. Specific characteristics were associated with nonoperative management and in-hospital mortality among older adults with hip fractures. Additional research is necessary to improve the care of this vulnerable population.

Comparative Study between Ultrasound Guided Intraarticular Injection of Corticosteroids and Ultrasound Guided Genicular Nerve Block in Patients with Chronic Knee Pain

Abstract Background Chronic knee pain represents a major cause of disability and a burden on healthcare systems worldwide, being more prevalent in middle-aged and elderly patients. It can take a toll on patients’ daily life, keeps them from their favorite activities, saps of productivity, and diminishes overall quality of life. It can be caused by degenerative conditions, such as osteoarthritis (the most common cause), rheumatoid arthritis, crystalline arthritis and gout. lifestyle modification, pharmacologic management, and injections are the mainstay of therapy for elderly patients having chronic symptomatic knee pain with multiple medical comorbidities who do not wish/fit for surgical options. Intra-articular corticosteroid injection (IACSI) was commonly adopted to alleviate chronic knee pain and was traditionally performed blindly depending only on anatomical land marks. Recently, Genicular nerve block (GNB) has recently emerged as a novel alternative treatment for chronic knee pain. Both Intra-articular corticosteroid injection (IACSI) and Genicular nerve block (GNB) can be carried out under Ultrasound guidance as a safer, cheaper and more feasible imaging modality for guidance as it provides real-time imaging for the knee structures in a dynamic manner giving the ability to do interventional procedures and providing more effective clinical results when compared to blind injections. Aim of the Work Illustrate the technical aspects, the indications and the methodology of local therapies for chronic knee pain performed by interventional radiologists and provide current evidence. Assess the efficacy of Ultrasound (US) guided intraarticular corticosteroids injection and Genicular nerve block to control moderate and advanced chronic knee pain. Compare the immediate and short-term symptomatic and functional improvement obtained after both techniques. Patients and Methods The study was carried out on 30 patients of symptomatic chronic knee pain with radiologically proven knee joint arthritis (26 of them had osteoarthritis, 3 had gout arthritis and one patient had rheumatoid arthritis), all of them were not responding to medical treatment. They were divided into two groups (intraarticular corticosteroids injection group and Genicular nerve block one) both procedures were performed under ultrasound guidance to identify target points for injection. GNB target points for injection where close to the superior lateral, superior medial and inferior medial genicular arteries while target point for the IACSI group was the suprapatellar bursa. All procedures were performed with a spinal needle (22 G) introduced under ultrasound guidance till reaching the desired target points at both groups. Then injection of a mixture of Lidocaine, Bupivacaine hydrochloride and Triamcinolone Acetonide was done. Results In our study, in IACSI group the mean of initial VAS was 80.7±10.3 compared to 81.3±7.7 in GNB group. The mean VAS significantly dropped to be 20.7±5.3 in IACSI group compared to 18.3±5.9 in GNB group. After 2 weeks, it was 34.3±8.4 and 27.7±8.2 respectively. After 4 weeks, it increased to 40±8.7 and 33.7±9.3 respectively. At 8 weeks, it was obviously increased to 75.3±10.3 and 66.7±11.4 respectively and the effect returned gradually till nearly the baseline at 8 weeks. In our study, in IACSI group the mean of initial OKS was 48.6±7.4 compared to 50.1±7.6 in GNB group. After 2 weeks, it was markedly decreased to 25.5±3.9 and 22.7±6.8 respectively. After 4 weeks, it increased to 31.1±3.5 and 27.±6.9 respectively. At 8 weeks, it was obviously increased to 44.1±7.1 and 39.3±6.1 respectively and the effect returned gradually till nearly the baseline at 8 weeks. Conclusion Ultrasound guided genicular nerve block with a mixture of corticosteroid and local anesthetic is an effective, radiation free method to alleviate chronic knee pain and improve knee joint function. US guided intra-articular corticosteroid injection through suprapatellar approach is also an effective method to relive chronic knee pain and inflammation and to improve knee joint functional capacity. Both procedures are effective in alleviation of chronic knee pain for up to 4 weeks with marked decrease in VAS score after 2 weeks and slight increasing trend towards 4 weeks. The favorable effect returned gradually till nearly the baseline at 8 weeks. Genicular nerve block is more effective than intra-articular corticosteroid injection in both pain alleviation and improving knee joint function. The earlier the Kellgren- Lawrence score is, the more reduction in chronic knee pain and the more improvement of joint function is achieved after both procedures.

Circumferential correction of spinal deformity and instability secondary to bacterial spondylodiscitis

BackgroundSpinal deformity as a sequela of non-tuberculous spondylodiscitis is a rarely discussed clinical entity. Sagittal plane deformity, segmental instability, and persistently active infection overlap in these patients resulting in severe restriction in activity and quality of life. The presence of multiple medical co-morbidities restricts surgical options but nonoperative care may be ineffective and result in persistent, refractory discitis for years. We describe our experience with vertebrectomy and long-segment fixation for patients with post-infectious thoracic or lumbar deformity. MethodsA retrospective chart review of 23 consecutive patients who underwent vertebrectomy and long-segment fixation for thoracic or lumbar deformity secondary to nontuberculous bacterial spondylodiscitis was performed. Pre-, peri- and postoperative data is compiled and analyzed with a focus on the perioperative management algorithm to safely perform an extensive reconstruction in this very sick patient population. ResultsExtremely low preoperative quality of life was evident with 87% (20/23) of patients bedridden primarily due to pain despite 70% (16/23) of patients being strong enough to ambulate (Frankel D or E). Most patients (87%) already had an identified infection under adequate treatment either through blood cultures, prior biopsy or decompressive surgery. A single-stage posterior-only was the primary surgical approach utilized in the majority (83%) of cases. Complications were present in 100% of patients, most commonly perioperative anemia and hypotension requiring vasopressor support and aggressive blood product replacement. One in-hospital mortality occurred secondarily to pulmonary embolism. Mean preoperative segmental angle was 18±10 degrees of kyphosis which was corrected to 1±9 degrees of lordosis (p=0.001). The mean correction of the segmental angle was 19 degrees (standard deviation 23 degrees). Visual analogue scale scores improved from a pre-operative value of 8.8±0.9 to a post-operative value of 2.5±1.4 (p<0.001), which was obtained at the last outpatient follow-up (mean 631 days after surgery). Full self-care including ambulation was achieved in 18/23 (78%) patients, and the infection was successfully treated in 22/23 (96%) patients after long-term antibiotics. ConclusionsPatients with refractory spondylodiscitis on appropriate care and antibiotics are typically considered extremely poor surgical candidates despite non-operative care often being ineffective. Post-infectious deformity may also be so severe as to preclude a limited surgical treatment strategy. This study suggests that extensive circumferential reconstruction for deformity secondary to bacterial spondylodiscitis can be effective in restoring these extremely sick patients to self-care and ambulatory status.

Spinal Arachnoid Web

Case Presentation: We describe a case of a 57-year-old male with multiple medical comorbidities who presented to the emergency department with a two-week history of upper back pain with associated numbness. Physical exam demonstrated sensory loss in a bilateral third and fourth thoracic dermatome distribution. The diagnosis of spinal arachnoid web was made based on neurological exam and imaging findings. Discussion: Spinal arachnoid web is a rare diagnosis, but consideration is important, as early recognition and surgical intervention can resolve symptoms and prevent worsening neurological sequelae.

Scalp Reconstruction With Free Tissue Transfer as a Palliative Surgical Intervention in a High-Risk Population.

Microvascular reconstruction of the scalp is frequently indicated in patients with locally advanced tumors, among other etiologies, in a relatively high-risk, older patient population that often has multiple medical comorbidities. A retrospective analysis was performed on patients undergoing microvascular scalp reconstruction at Emory University Hospital and Grady Memorial Hospital between 2011 and 2021. Patient demographics, wound characteristics, operative details, and complications were recorded. Statistical analysis using univariate and multivariate models was performed. Forty-two patients underwent 45 microvascular scalp reconstructive procedures during the study period. The median age was 63 years. Wounds were predominantly oncologic (n=38, 84.4%) and frequently involved deeper structures [calvarium (n=38, 84.4%), dura (n=17, 37.8%)]. At a median follow-up of 350 days, 33 patients (73.3%) had healed flaps, 9 (20.0%) had wound healing issues but ultimately successful reconstruction, and 3 (6.7%) experienced flap failure. Most patients (n=33, 80.9%) were discharged home or to a rehabilitation facility, while the remaining 8 patients (19.1%) were discharged to hospice or died. The 30-day mortality was 4 patients (8.9%) and the 6-month mortality was 8 patients (20.5%). There was a statistically significant difference in 30-day mortality (P=0.0001) on univariate analysis and 6-month mortality (P=0.003) on both univariate and multivariate analysis for patients >70 years. While age >70 years is a risk factor for mortality in patients undergoing microvascular scalp reconstruction, mortality was commonly related to underlying disease processes rather than complication of surgery. Microvascular reconstruction for scalp defects has a high success rate and can be offered as a palliative procedure for patients with locally advanced cancers, advanced age, and multiple comorbidities.

Characterizing Trauma Patients with Delays in Orthopaedic Process Measures.

Early operative intervention in orthopaedic injuries is associated with decreased morbidity and mortality. Relevant process measures (e.g. femoral shaft fixation <24 hours) are used in trauma quality improvement programs to evaluate performance. Currently, there is no mechanism to account for patients who are unable to undergo surgical intervention (i.e. physiologically unstable). We characterized the factors associated with patients who did not meet these orthopaedic process measures. A retrospective cohort study of patients from 35 ACS-COT verified Level 1 and Level 2 trauma centers was performed utilizing quality collaborative data (2017-2022). Inclusion criteria were adult patients (≥18 years), ISS ≥5, and a closed femoral shaft or open tibial shaft fracture classified via the Abbreviated Injury Scale version 2005 (AIS2005). Relevant factors (e.g. physiologic) associated with a procedural delay >24 hours were identified through a multivariable logistic regression and the effect of delay on inpatient outcomes was assessed. A sub-analysis characterized the rate of delay in "healthy patients". We identified 5,199 patients with a femoral shaft fracture and 87.5% had a fixation procedure, of which 31.8% had a delay, and 47.1% of those delayed were "healthy." There were 1,291 patients with an open tibial shaft fracture, 92.2% had fixation, 50.5% had an irrigation and debridement and 11.2% and 18.7% were delayed, respectively. High ISS, older age and multiple medical comorbidities were associated with a delay in femur fixation, and those delayed had a higher incidence of complications. There is a substantial incidence of surgical delays in some orthopaedic trauma process measures that are predicted by certain patient characteristics, and this is associated with an increased rate of complications. Understanding these factors associated with a surgical delay, and effectively accounting for them, is key if these process measures are to be used appropriately in quality improvement programs. Level III; Therapeutic/Care Management.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital.

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment. This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors. Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant. A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC. IV Laryngoscope, 2024.

349 Addressing the Gaps in Diabetic Foot Ulcer Management: Prediction and Prevention

OBJECTIVES/GOALS: Globally, diabetes affects 537 million people and 15-25% will develop a foot ulcer in their lifetime. Diabetic foot ulcers (DFU) tend to be chronic and non-healing due to the poor wound healing environment, leading to infection or amputation. Our study aims to develop a method to predict and prevent DFU formation. METHODS/STUDY POPULATION: Our preliminary plan is to develop a method to detect high plantar pressures, coupled with the ability to automatically adjust an orthotic device to offload excess pressure. Our current aim is to create a “smart orthotic” which will link with foot mapping technology to automatically offload high pressure areas, reducing the need for a separate clinic visit for orthotic adjustment. We aim to prove that our device will normalize plantar pressure distribution, which will prevent callus and subsequent DFU formation. The current target population includes those with diagnosed diabetes and are ambulatory. RESULTS/ANTICIPATED RESULTS: With our technology, we anticipate normalization of plantar pressure distribution in a more frequent fashion than is currently done. Because annual orthotic fittings, which is current standard of care, do not provide regular enough adjustments to match the rate of diabetic foot structural changes and peak plantar pressure redistribution, our device will address two gaps in management. One, patients will receive near-instantaneous changes in plantar pressure offloading, allowing for near continuous orthotic customization. Secondly, our device would reduce the clinical appointment burden, which would be especially important for patients with multiple medical comorbidities or experience other barriers to accessing healthcare. DISCUSSION/SIGNIFICANCE: While DFUs are commonplace and their complications are well recognized, there still exists a gap in ulcer prevention. Our proposed solution will redistribute pathologic plantar pressures, allow for more frequent monitoring, automatic therapy, and aid in the management of high ulcer risk patients.

Identifying Subgroups of Youth Suicide Decedents Based on Clinical Profiles of Psychiatric and Medical Diagnoses: A Latent Class Analysis

PurposeTo identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic profiles to inform tailored youth suicide prevention efforts. MethodsThis study linked Ohio Medicaid and death certificate data for Medicaid enrolled youth aged 8–25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. ResultsThree latent classes were identified. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was confined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. DiscussionInternalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized.

Delayed ulnar artery pseudoaneurysm presentation after percutaneous cardiac intervention: A case report and review of the literature.

Here we present a case of a 62-year-old female with a delayed ulnar artery pseudoaneurysm presentation after cardiac catheterization. A 62-year-old woman with multiple medical comorbidities including end-stage renal disease (ESRD) on hemodialysis (HD) and atrial fibrillation on tablet apixaban who presented 8weeks after cardiac catheterization through right ulnar artery access with a pulsatile mass, pain, and tingling of her right-hand fingers. Ultrasound exam confirmed presence of ulnar artery pseudoaneurysm with >2cm active chamber. This pseudoaneurysm was repaired via forearm exploration, evacuation of hematoma, and primary repair with non-absorbable sutures. We report a case of delayed ulnar artery pseudoaneurysm presentation following cardiac catheterization through the right ulnar artery. Open surgical repair offers a definitive addressal of ulnar artery pseudoaneurysm and removes ulnar nerve compressive neuropathy with less risk of distal embolization in patients with delayed pseudoaneurysm presentation whenever ultrasound-guided thrombin injection (UGTI) is contraindicated.

Role of epinephrine in attenuating cytokine storm, decreasing ferritin, and inhibiting ferroptosis in SARS-CoV-2

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for coronavirus disease 2019. It presents one of the most threatening pandemics in the history of humanity. The mortality and morbidity represent an unprecedented challenge to the modern medical era. SARS-CoV-2 results in acute respiratory distress syndrome, high concentrations of proinflammatory mediators, cytokine storm (CS) due to massive release of cytokines, hypercoagulation, and hemoglobin disintegration. Dysregulation of iron homeostasis, iron overload as indicated by high ferritin level, and ferroptosis are major factors in the pathogenesis of the disease. We report a case of SARS-CoV-2 in which the use of epinephrine (Epi) resulted in an unexpected attenuation of CS, decreasing ferritin level and inhibiting ferroptosis.Case presentationA 64-year-old male patient with a history of multiple medical comorbidities had been diagnosed with SARS-CoV-2. Further evaluation showed marked increase in inflammatory markers, severe hyperferritinemia, and lymphopenia in laboratory blood tests. The characteristic score of CS was strongly positive, and in addition to regular treatment, the patient received Epi due to development of acute generalized skin rash, severe itching, and edema of lips and tongue. Epi may have successfully terminated not only the acute cutaneous condition, but also have attenuated CS, decreased ferritin level, and other inflammatory markers in addition to complete patient’s recovery.ConclusionEpinephrine may attenuate CS and inhibit ferroptosis which is an iron-dependent, non-apoptotic mode of cell death. Epi interacts with ferric and/or ferrous iron and built a stable complex that impedes activation of beta-adrenergic receptors. Epi may cause marked decrease of ferritin and other inflammatory markers. Epi may be used to decrease iron overload which is associated with many medical diseases like type 2 diabetes mellitus and cardiometabolic diseases such as coronary heart disease and cerebrovascular disease. As a new clinical indication extensive studies are required for further assessment and possible therapeutic uses.

Increasing Prevalence of Cerebral Palsy Among Two-Year-Old Children Born at

ObjectiveTo evaluate changes in prevalence and severity of cerebral palsy (CP) among surviving children born at <27 weeks of gestation over time and to determine associations between CP and other developmental domains, functional impairment, medical morbidities, and resource utilization among two-year old children who were born extremely preterm. Study DesignRetrospective cohort study using prospective registry data, conducted at 25 centers of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Participants were children born at <27 weeks of gestation and followed at 18 through 26 months corrected age (CA) from 2008 through 2019. Outcomes of interest were changes in prevalence of any CP and severity of CP over time, and associations between CP and other neurodevelopmental outcomes, functional impairment, and medical comorbidities. Adjusted logistic, linear, multinomial logistic, and robust Poisson regression evaluated the relationships between child characteristics, CP severity, and outcomes. ResultsAmong 6,927 surviving children with complete follow-up data, 3,717 (53.7%) had normal neurologic examinations, 1,303 (18.8%) had CP, and the remainder had abnormal neurologic examinations not classified as CP. Adjusted rates of any CP increased each year of the study period (aOR 1.11 per year, 95% CI 1.08-1.14). Cognitive development was significantly associated with severity of CP. Children with CP were more likely to have multiple medical comorbidities, neurosensory problems, and poor growth at follow-up. ConclusionsThe rate of CP among surviving children who were born extremely preterm increased from 2008 through 2019. At 18 to 26 months CA, neurodevelopmental and medical comorbidities are strongly associated with all severity levels of CP.

Robotic-assisted surgery for endometrial cancer: a comparison of surgical and oncologic outcomes in patients with low and high BMI at an Indian tertiary care center

The robotic-assisted surgery for endometrial cancer (EC) is becoming increasingly important, owing to the superior surgical outcomes. However, efficacy data from India is limited, particularly for older women who are obese. We undertook this study to compare the surgical outcomes of robotic-assisted surgery among Indian EC patients with a BMI of < 30 and ≥ 30 kg/m2. A retrospective chart review was conducted for the period of May 2016 to October 2020. Data on patient demographics, medical history, clinical characteristics, and perioperative outcomes were collected by a single senior surgeon, followed by statistical analysis. A total of 99 patients; 39 in the BMI group < 30 and 60 in the BMI group ≥ 30 kg/m2 were included in the study. The mean age of the BMI groups < 30 and ≥ 30 kg/m2 was 60.92 ± 10.43 and 58.90 ± 8.52 years respectively (P = 0.2944). The mean total operating time was slightly higher in the BMI group < 30 kg/m2 (P = 0.8552) but the difference was not statistically significant. Similarly, the mean blood loss (P = 0.2041), length of hospital stays (P = 0.6564), early (P = 0.7758) and delayed complications (P = 0.1878) were less in the BMI group < 30 kg/m2 but the difference was not statistically significant either. At a median follow-up of 22.3 months, the number of recurrences (5.13% vs 3.33%) and deaths (2.56% vs 1.67%) were more in BMI < 30 kg/m2 group. Our study suggests that obese older women predisposed to multiple medical co-morbidities and surgical complications would especially benefit from robotic-assisted technology regardless of their BMI.

The Combined Influence of Maternal Medical Conditions on the Risk of Primary Cesarean Delivery.

Background Common maternal medical comorbidities such as hypertensive disorders, diabetes, tobacco use, and extremes of maternal age, body mass index, and gestational weight gain are known individually to influence the rate of cesarean delivery. Numerous studies have estimated the risk of individual conditions on cesarean delivery. Objective To examine the risk for primary cesarean delivery in women with multiple maternal medical comorbidities to determine the cumulative risk they pose on mode of delivery. Study Design In this population-based retrospective cohort study, we analyzed data from Ohio live birth records from 2006 to 2015 to estimate the influence of individual and combinations of maternal comorbidities on rates of singleton primary cesarean delivery. The exposures were individual and combinations of maternal medical conditions (chronic hypertension [CHTN], gestational hypertension, pregestational diabetes, gestational diabetes, tobacco use, advanced maternal age, and maternal obesity) and outcomes were rates and adjusted relative risk (aRR) of primary cesarean delivery. Results There were 1,463,506 live births in Ohio during the study period, of which 882,423 (60.3%) had one or more maternal medical condition, and of those 243,112 (27.6%) had primary cesarean delivery. The range of rates and aRR range of primary cesarean delivery were 13.9 to 29.3% (aRR 0.78-1.68) in singleton pregnancies with a single medical condition, and this increased to 21.9 to 48.6% (aRR 1.34-3.87) in pregnancies complicated by multiple medical comorbidities. The highest risk for primary cesarean occurred in advanced maternal age, obese women with pregestational diabetes, and CHTN. Conclusion A greater number of maternal medical comorbidities during pregnancy is associated with increasing cumulative risk of primary cesarean delivery. These data may be useful in counseling patients on risk of cesarean during pregnancy.

Predictors and Outcomes of Discordance Between Initial Clinical Diagnosis and Amyloid‐PET Results in the Imaging Dementia—Evidence for Amyloid Scanning (IDEAS) Study

AbstractBackgroundDiscordance between the clinical diagnosis of AD by experts after a comprehensive evaluation and AD pathology on autopsy remains common. We sought to identify clinical situations where amyloid‐PET would be most valuable as a diagnostic tool by identifying predictors associated with discordance between initial clinical diagnosis and amyloid‐PET results.MethodIDEAS was a real‐world study that assessed the clinical utility of amyloid‐PET in 11,829 participants (age 76±6, 51% female, MMSE 24.5±5) across 595 US sites. Participants met amyloid‐PET Appropriate Use Criteria and completed pre/post‐PET visits where specialists documented clinical diagnosis. Diagnosis‐PET discordance was defined as either an initial AD diagnosis pre‐PET with a negative amyloid‐PET, or non‐AD diagnosis with positive amyloid‐PET. Univariate logistic regressions were performed to identify predictors and outcomes of discordance in the total sample and in subgroups stratified by pre‐PET diagnosis (AD/non‐AD).ResultDiagnosis‐PET discordance occurred in 40% of total participants, including 36%(n = 3323/9115) with an initial AD diagnosis and negative amyloid‐PET and 52%(n = 1409/2714) with an initial non‐AD diagnosis and positive amyloid‐PET. In the total sample (Figure 1), predictors associated with greater discordance included non‐White race (Black/African American: OR 1.26; 95%CI [1.04‐1.53]; Asian: (1.62[1.23‐2.13]) and more medical comorbidities (each comorbidity: 1.07[1.05‐1.07]). Predictors associated with less discordance included older age (5‐year increase: 0.91[0.89‐0.94]), female sex (0.91[0.85‐0.98]), dementia severity (vs MCI: 0.70[0.65‐0.75]), greater disease duration ( = 3yr: 0.83[0.77‐0.90]), greater physician diagnostic confidence (0.89[0.86‐0.89]), AD medication use (0.64[0.59‐0.69]), and family history of dementia (0.89[0.81‐0.97]). Practice features associated with less discordance included using image quantification (0.90[0.81‐0.99]), using multimodal imaging (0.90[0.82‐0.97]), and greater physician time( = 50%) in dementia care (0.92[0.86‐0.99]). Subgroup analyses (Figure 2) identified additional predictors associated with greater discordance in those initially diagnosed with AD included Hispanic ethnicity (1.35[1.10‐1.66]), living alone (1.16[1.04‐1.30]), and non‐English primary language (1.22[1.01‐1.47]).ConclusionThe high frequency of discordance supports the clinical utility of AD biomarkers. Amyloid‐PET may be most valuable to support AD diagnosis in participants who are early in the disease course, younger, from underrepresented racial/ethnic groups, live alone, have multiple medical comorbidities, and lack a suggestive family history. The risk of discordance may be reduced by using image quantification, multimodal imaging, and highly specialized providers.

Predictors and Outcomes of Discordance Between Initial Clinical Diagnosis and Amyloid‐PET Results in the Imaging Dementia—Evidence for Amyloid Scanning (IDEAS) Study

AbstractBackgroundDiscordance between the clinical diagnosis of AD by experts after a comprehensive evaluation and AD pathology on autopsy remains common. We sought to identify clinical situations where amyloid‐PET would be most valuable as a diagnostic tool by identifying predictors associated with discordance between initial clinical diagnosis and amyloid‐PET results.MethodIDEAS was a real‐world study that assessed the clinical utility of amyloid‐PET in 11,829 participants (age 76±6, 51% female, MMSE 24.5±5) across 595 US sites. Participants met amyloid‐PET Appropriate Use Criteria and completed pre/post‐PET visits where specialists documented clinical diagnosis. Diagnosis‐PET discordance was defined as either an initial AD diagnosis pre‐PET with a negative amyloid‐PET, or non‐AD diagnosis with positive amyloid‐PET. Univariate logistic regressions were performed to identify predictors and outcomes of discordance in the total sample and in subgroups stratified by pre‐PET diagnosis (AD/non‐AD).ResultDiagnosis‐PET discordance occurred in 40% of total participants, including 36%(n = 3323/9115) with an initial AD diagnosis and negative amyloid‐PET and 52%(n = 1409/2714) with an initial non‐AD diagnosis and positive amyloid‐PET. In the total sample (Figure 1), predictors associated with greater discordance included non‐White race (Black/African American: OR 1.26; 95%CI [1.04‐1.53]; Asian: (1.62[1.23‐2.13]) and more medical comorbidities (each comorbidity: 1.07[1.05‐1.07]). Predictors associated with less discordance included older age (5‐year increase: 0.91[0.89‐0.94]), female sex (0.91[0.85‐0.98]), dementia severity (vs MCI: 0.70[0.65‐0.75]), greater disease duration (≥3yr: 0.83[0.77‐0.90]), greater physician diagnostic confidence (0.89[0.86‐0.89]), AD medication use (0.64[0.59‐0.69]), and family history of dementia (0.89[0.81‐0.97]). Practice features associated with less discordance included using image quantification (0.90[0.81‐0.99]), using multimodal imaging (0.90[0.82‐0.97]), and greater physician time(≥50%) in dementia care (0.92[0.86‐0.99]). Subgroup analyses (Figure 2) identified additional predictors associated with greater discordance in those initially diagnosed with AD included Hispanic ethnicity (1.35[1.10‐1.66]), living alone (1.16[1.04‐1.30]), and non‐English primary language (1.22[1.01‐1.47]).ConclusionThe high frequency of discordance supports the clinical utility of AD biomarkers. Amyloid‐PET may be most valuable to support AD diagnosis in participants who are early in the disease course, younger, from underrepresented racial/ethnic groups, live alone, have multiple medical comorbidities, and lack a suggestive family history. The risk of discordance may be reduced by using image quantification, multimodal imaging, and highly specialized providers.

527. A Descriptive, Retrospective Analysis of COVID-19 Antibody Therapy and its Effects on Morbidity and Mortality in Patients Receiving B-cell Depleting Therapies

Abstract Background Patients receiving B-cell-depleting therapies (BCDT) are at an increased risk for severe COVID-19. Passive antibody therapy (PAT), including COVID-19 convalescent plasma (CCP) and monoclonal antibodies (MAB), is hypothesized to be an effective treatment in this population. However, real-world data on their effectiveness is limited. Methods We conducted a retrospective chart review of patients who contracted COVID-19 within a year from their last BCDT treatment and later received PAT (Table 1). Response to treatment was assessed by 90-day COVID-related mortality and all-cause morbidity, defined through number of hospitalizations (Figure 1).Table 1.Inclusion and exclusion criteria.Figure 1.Patient flow. Sixty-five patients met initial criteria. Five were excluded from analysis due to non-COVID related death within 90 days from COVID diagnosis. Cause of death was established in the chart and confirmed by review of two investigators. Results From 60 included patients, the majority were Caucasians (97%), females (57%), and vaccinated (67%) (Table 2). Most patients received rituximab (53%) for treatment of a hematological malignancy (37%) or multiple sclerosis (37%) (Figure 2). Overall morbidity (3/39, 7.7%) and mortality (3/60, 5%) were low. All hospitalized and deceased patients were elderly Caucasian males receiving rituximab for underlying hematological malignancy. All deceased patients received inpatient treatment, 2 with CCP and one with MAB (Figure 3).Table 2.Basic characteristics of passive antibody therapy recipients. Demographics, vaccination status and number of comorbidities excluding the condition which is the indication for B-cell depleting therapy.Figure 2.Type of B-cell depleting therapy and indication for use.Evaluated B-cell depleting therapies are rituximab (n=32), ocrelizumab (n=21), obinutuzumab (n=6), ofatumumab (n=1). Evaluated underlying indications for B-cell depleting therapy are hematological malignancy (n=22), multiple sclerosis (n=22); rheumatoid arthritis (n=9) and others (n=7). Others include scleroderma (n=1), systemic lupus (n=2), granulomatosis with polyangiitis (n=4).Figure 3:Treatment location and type of passive antibody therapy.All patients treated outpatient (39) received monoclonal antibodies. Of inpatients (21), 14 received COVID-19 convalescent plasma. Of patients treated as outpatient, 3 were hospitalized, with only 1 hospitalized for a COVID-related illness. Conclusion COVID-19 patients undergoing BCDT and treated with PAT had low morbidity and mortality in our study, suggesting a possible benefit of PAT in this patient population. All deaths occurred in patients hospitalized at the time of treatment with PAT, implying advanced COVID-19 infection and highlighting the importance of early PAT administration. All deceased patients and 2/3 hospitalized patients were receiving rituximab, suggesting that rituximab may be a risk factor for severe COVID (Figure 4). All deceased and hospitalized patients had an underlying hematological malignancy, suggesting that the presence of hematologic malignancy may impact the outcome of COVID-19. In our study, elderly Caucasian males with multiple medical comorbidities and underlying hematological malignancy treated with BCDT, particularly rituximab, may have an increased risk for severe COVID-19. Early PAT administration may improve outcomes in this group of patients, and they should be prioritized for treatment when access to PAT is limited.Figure 4:Type of B-cell depleting therapy and mortality. All deaths were among patients being treated with rituximab for hematological malignancy. Disclosures All Authors: No reported disclosures

Wearable technology interventions in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is associated with multiple medical and psychological comorbidities. Therefore, future strategies to improve COPD management and outcomes are needed for the betterment of patient care. Wearable technology interventions offer considerable promise in improving outcomes, but prior reviews fall short of assessing their role in the COPD population. In this systematic review and meta-analysis we searched ovid-MEDLINE, ovid-EMBASE, CINAHL, CENTRAL, and IEEE databases from inception to April 2023 to identify studies investigating wearable technology interventions in an adult COPD population with prespecified outcomes of interest including physical activity promotion, increasing exercise capacity, exacerbation detection, and quality-of-life. We identified 7396 studies, of which 37 were included in our review. Meta-analysis showed wearable technology interventions significantly increased: the mean daily step count (mean difference (MD) 850 (494–1205) steps/day) and the six-minute walk distance (MD 5.81 m (1.02–10.61 m). However, the impact was short-lived. Furthermore, wearable technology coupled with another facet (such as health coaching or pulmonary rehabilitation) had a greater impact that wearable technology alone. Wearable technology had little impact on quality-of-life measures and had mixed results for exacerbation avoidance and prediction. It is clear that wearable technology interventions may have the potential to form a core part of future COPD management plans, but further work is required to translate this into meaningful clinical benefit.

Outpatient Hip and Knee Arthroplasty Can be Safe in Patients With Multiple Medical Comorbidities via Use of Evidence-Based Perioperative Protocols.

Outpatient Hip and Knee Arthroplasty Can be Safe in Patients With Multiple Medical Comorbidities via Use of Evidence-Based Perioperative Protocols.

Quality of life measures in children with Down syndrome with disorders of gut-brain interaction.

Down syndrome (DS) is associated with multiple medical comorbidities. Perhaps related to such, caregivers of individuals with DS report lower quality of life (QoL) compared to individuals without DS. It has been shown that disorders of gut-brain interaction (DGBI) such as functional constipation (FC) and irritable bowel syndrome (IBS) are common in individuals with DS. We measured caregiver-reported QoL in individuals with DS with a DGBI and compared them to individuals with DS without a DGBI via a cross-sectional national survey. All measures of QoL were lower in those with DS who meet criteria for a DGBI compared to those with DS without a DGBI. Males and females with DS and at least one DGBI had similar QoL scores. While FC was the most common DGBI seen in individuals with DS, there was no difference in any aspect of QoL in subjects with FC when compared to individuals with other DGBIs. However, all measures of QoL were lower in those with IBS compared to individuals with other DGBIs. These findings suggest that management of gastrointestinal symptoms from DGBIs, particularly IBS, may serve as a target for increasing QoL in a notable subset of individuals with DS.