Functional Status Outcomes Research Articles

Self-Reported and Performance-Based Evaluations of Functional Status in Older Women With Breast Cancer.

To evaluate self-reported and performance-based functional status (FS) in older women with breast cancer according to stage and time of visit during treatment. 72 women with breast cancer aged 78 years or older and receiving any type of treatment at a midwestern outpatient clinic. FS was evaluated using grip strength, the Index of Activities of Daily Living (ADLs), the instrumental ADLs (IADLs) scale, and the Timed Up and Go Test (TUGT). Mixed models were fit for grip strength and the TUGT, and generalized estimating equations were used to fit binary logistic regressions for the Index of ADLs and the IADLs scale. Continuous FS outcomes were evaluated using means and standard deviations. Cancer stage and time of visit did not affect self-reported or performance-based FS scores. Most participants were considered independent on the Index of ADLs, the IADLs scale, and the TUGT, which did not change significantly between visits. Self-reported measures revealed less impairment. Monitoring FS using self-reported and performance-based measures can ensure that older patients receive timely support.

EP.FRI.204 Does Sarcopenia Increase the Risk of Needing a Stoma During Emergency Laparotomy?

Abstract Aims Sarcopenia is a multisystem disorder which can be diagnosed clinically and radiologically. It is associated with impaired functional status and inferior perioperative outcomes, in particular increased mortality following emergency laparotomy. This study aimed to show whether sarcopenia, as defined by low psoas muscle area (PMA) on pre-operative CT, was associated with increased need for stoma formation. Methods A retrospective analysis of consecutive emergency general surgical laparotomies over a 3-year period. PMA was measured on a single pre-operative CT image at L3 and normalized to vertebral body area to create a psoas muscle index (PMI). New stoma formation and perioperative outcomes were recorded from patient records. Cases were split by the median value into high “non-sarcopenic” and low “sarcopenic” PMI groups. Results 299 patients underwent emergency laparotomy between 01/01/2016 and 31/12/2018. 46 patients (30.67%) in the low psoas index group required a stoma compared with 37 (24.83%) in the higher group (p = 0.159). Survival was inferior in the sarcopenic group with a mean survival of 42 months compared to 48 months in the non-sarcopenic group (p = 0.032). Median follow-up was 43 months. Patients in the sarcopenic group were significantly older (Mean age 68 compared to 54 in the non-sarcopenic group, p = <0.001) but there was no difference in other baseline variables. Conclusions Sarcopenia does not significantly increase the risk of requiring a stoma during emergency laparotomy but does reduce survival.

Optimizing Preventive Adjuvant LINAC (OPAL) Radiation: A Phase II Trial of Daily Partial Breast Irradiation

<h3>Purpose/Objective(s)</h3> Twice daily accelerated partial breast irradiation (APBI) may confer worse long-term cosmetic outcome than daily whole breast irradiation (WBI). We hypothesized that daily partial breast irradiation would yield improved cosmetic outcomes without compromising tumor control. To test this hypothesis, we conducted a phase II trial to evaluate a ten-fraction regimen of daily PBI (OPAL regimen). <h3>Materials/Methods</h3> From 2017-2018, 149 women aged ≥ 50 with DCIS or early invasive, ER+ breast cancer were enrolled into a multi-institutional phase II trial that treated the partial breast to 35 Gy in 10 daily fractions. Patients with close margins (< 2 mm) also received a boost of 9 Gy in 3 daily fractions. Toxicities were evaluated using CTCAE v4.0 and physician-reported cosmesis was assessed using the RTOG scale. The Breast Cancer Treatment Outcomes Scale (BCTOS) assessed patient-reported cosmesis, breast pain, and functional status. Outcomes were assessed at baseline, 6 months, 1 year, and annually thereafter. The primary outcome was incidence of grade ≥ 2 toxicity within 6 months of PBI initiation. To facilitate a comparison of the OPAL regimen to WBI, we identified 176 patients with similar clinical-pathologic features from our prior trial of WBI+boost in which toxicities were also prospectively collected. Differences in cross-sectional outcomes between the OPAL trial and historical WBI+boost cohort were tested using chi-square test. Mixed effect growth curve models evaluated outcomes over time adjusting for relevant covariates. <h3>Results</h3> Median age was 64 years and median follow-up was 2 years. All 149 patients received 35 Gy in 10 daily fractions and 26 received a boost. One patient developed an in-field DCIS recurrence. For the primary outcome, grade ≥ 2 toxicity within 6 months of PBI initiation was 14.1% with OPAL compared to 71% in the WBI+boost cohort (<i>P</i> < 0.001). At two years post-radiation, fatigue (8% vs 16%), hyperpigmentation (18% vs 30%), breast edema (0% vs 9%), superficial fibrosis (18% vs 31%), deep fibrosis (6% vs 13%), nipple areolar changes (6% vs 17%), and breast atrophy (19% vs 35%) were less prevalent in patients treated with OPAL (all <i>P</i> < 0.05). At two years, 93% of patients treated with OPAL had excellent/good cosmetic outcome compared to 77% of patients treated with WBI+boost (<i>P</i> < 0.001). In multivariable longitudinal analysis, treatment with OPAL was associated with improved patient-reported cosmetic outcome (<i>P</i> < 0.001), functional status (<i>P</i> = 0.02), breast pain (<i>P</i> = 0.003) and physician-reported cosmetic outcome (<i>P</i> < 0.001). <h3>Conclusion</h3> Treatment with this novel daily PBI regimen of 35 Gy in 10 daily fractions with selective boost yielded better cosmetic and functional outcomes and less breast pain and toxicity than WBI+boost with median follow up of 2 years. Daily external beam partial breast irradiation with 10 or fewer fractions merits further prospective evaluation.

The Association of Preoperative Functional Status and Surgical Outcomes in a Prehabilitation Program for Surgical Oncology Patients

The Association of Preoperative Functional Status and Surgical Outcomes in a Prehabilitation Program for Surgical Oncology Patients

376 Management of Breast Cancer in elderly patients

Abstract Aim To evaluate the care and outcomes for women with breast cancer over the age of 70 and to compare our performance at AUH against the national outcomes. Method Using the online database at AUH we gathered the following data: age, TNM status, surgical management, histology, adjuvant treatment (radiotherapy, chemotherapy, hormone therapy, targeted therapy) and reasons for alterations in planned therapy. Results We audited 176 patients between 2018 and 2019. Age varied between 70 and 95 years old. 10 patients suffered from DCIS, 152 from invasive breast cancer and 14 from de novo metastatic breast cancer. 40% of patients with DCIS with underwent WLE, 40% underwent mastectomy and 20% were not offered an operation as they were unfit. Invasive breast cancer accounted for the majority of cases. 86% were ER/PR positive and 12.2% were Her-2 positive. 35.7% underwent mastectomy, 64.4% underwent WLE and 0.8% VAB excision. 51.7% had Sentinel node biopsy, 15.3% underwent axillary clearance and 1.7 % had axillary sampling. 7.9% of patients presented with metastatic disease. 2.6% of those patients had palliative radiotherapy. Primary endocrine therapy was commenced on 21.1% of patients. Factors that lead to PET were that 47% of patients were unfit for an operation, 20.6% refused surgical intervention, 11.7% had concurrent aggressive malignancy and 8.8% were inoperable. Conclusions Overall, successful results were achieved for this group of patients compared to the national outcomes. 99.4% of patients in our centre had triple assessment prior to MDT. Further review of functional status and service outcomes will be required to be audited.

Musculoskeletal case-mix adjustment in a UK primary/community care cohort: Testing musculoskeletal models to make recommendations in this setting

Benchmarking musculoskeletal (MSK) services is limited by the need to adjust for differences in patient characteristics/case-mix. Without this providers and services cannot be usefully compared. This paper investigates the predictive ability of case-mix adjustment models in a primary/community care cohort. ObjectivesTo investigate the predictive ability of two existing MSK case-mix adjustment models and compare to the predictive ability of an evidence informed and statistically informed model. MethodA secondary analysis of the ‘Subgrouping for Targeted Treatment in Musculoskeletal Conditions’ cluster randomised controlled trial data (n = 1211). Stepwise linear regression models were built and compared using available baseline variables. The MSK-HQ was used as the primary functional status outcome. ResultsTwo existing models were compared (UK National PROMs Model, US FOTO Model) using available variables. Of these models the modified US FOTO model showed the best predictive ability in this cohort predicting 44% of the variation in MSK-HQ outcome, the modified UK National PROMs model predicted 41%. A newly developed evidence informed model (Keele Model 1) performed no better than the existing models, and a statistically informed model (Keele Model 2) gave only an additional 2% increase in model power compared to the modified US FOTO model. ConclusionAll models showed strong predictive ability. The modified US FOTO model looks to be best suited to the UK primary/community care cohort of the existing models. This model performed so well that we recommend that this model is used in a UK setting moving forwards rather than development of an alternative UK model.

Chronic Nutrition Impact Symptoms Are Associated with Decreased Functional Status, Quality of Life, and Diet Quality in a Pilot Study of Long-Term Post-Radiation Head and Neck Cancer Survivors.

Background: As a result of tumor location and treatment that is aggressive, head and neck cancer (HNC) survivors experience an array of symptoms impacting the ability and desire to eat termed nutrition impact symptoms (NISs). Despite increasing cancer survival time, the majority of research studies examining the impact of NISs have been based on clinical samples of HNC patients during the acute phase of treatment. NISs are often chronic and persist beyond the completion of treatment or may develop as late side effects. Therefore, our research team examined chronic NIS complications on HNC survivors’ functional status, quality of life, and diet quality. Methods: This was a cross-sectional study of 42 HNC survivors who were at least 6 months post-radiation. Self-reported data on demographics, NISs, quality of life, and usual diet over the past year were obtained. Objective measures of functional status included the short physical performance battery and InBody© 270 body composition testing. NISs were coded so a lower score indicated lower symptom burden, (range 4–17) and dichotomized as ≤10 vs. >10, the median in the dataset. Wilcoxon rank sum tests were performed between the dichotomized NIS summary score and continuous quality of life and functional status outcomes. Diet quality for HNC survivors was calculated using the Healthy Eating Index 2015 (HEI-2015). Wilcoxon rank sum tests examined the difference between the HNC HEI-2015 as compared to the National Health and Nutrition Examination Survey (NHANES) data calculated using the population ratio method. Results: A lower NIS score was statistically associated with higher posttreatment lean muscle mass (p = 0.002). A lower NIS score was associated with higher functional (p = 0.0006), physical (p = 0.0007), emotional (p = 0.007), and total (p < 0.0001) quality of life. Compared to NHANES controls, HNC survivors reported a significantly lower HEI-2015 diet quality score (p = 0.0001). Conclusions: Lower NIS burden was associated with higher lean muscle mass and functional, physical, emotional, and total quality of life in post-radiation HNC survivors. HNC survivors reported a significantly lower total HEI-2015 as compared to healthy NHANES controls, providing support for the hypothesis that chronic NIS burden impacts the desire and ability to eat. The effects of this pilot study were strong enough to be detected by straight forward statistical approaches and warrant a larger longitudinal study. For survivors most impacted by NIS burden, multidisciplinary post-radiation exercise and nutrition-based interventions to manage NISs and improve functional status, quality of life, and diet quality in this survivor population are needed.

Spinal Meningiomas: Influence of Cord Compression and Radiological Features on Preoperative Functional Status and Outcome.

Simple SummaryPatients affected by spinal meningioma globally exhibit an excellent postoperative functional outcome despite tumor size and severity of spinal cord compression. This work aims to analyze the impact of tumor size and other radiological findings on clinical functional preoperative status and postoperative outcome. In this multicentric retrospective study involving 90 adult patients, we found that spinal cord and tumor occupancy as well as cord compression and tumor volume are correlated with low preoperative functional status. Higher tumor occupancy and tumor-canal volume ratio corresponded to lower postoperative neurological recovery. Cord re-expansion did not show any correlation with postoperative outcome, while preoperative signs of cord myelopathy were predictors of worse postoperative outcome. These findings suggest that these radiological features should be taken into consideration during preoperative counselling.Background: Radiological parameters predicting the postoperative neurological outcome after resection of a spinal meningioma (SM) are poorly studied, with controversial results. Methods: Observational multicenter cohort (2011–2018) of adult patients undergoing surgery for resection of SM. Tumor-canal volume ratio (TCR), the areas related to the cord and tumor occupancy at maximum compression, the presence of dural tail, calcifications, signs of myelopathy, and postoperative cord expansion were compared with the modified McCormick scale (mMCS) preoperative and at follow-up. Results: In the cohort (n = 90 patients), cord and tumor occupancy as well as cord compression and tumor volume showed a correlation with preoperative mMCS (p < 0.05, R −0.23; p < 0.001, R 0.35; p < 0.005, R −0.29; p < 0.001, R 0.42). Cord occupancy had a strong correlation with cord compression (p < 0.001, R 0.72). Tumor occupancy and TCR were correlated with relative outcome at follow-up (p < 0.005 R 0.3; p < 0.005 R 0.29). No correlation was found between cord re-expansion and clinical outcome at follow-up. Finally, a correlation was shown between preoperative signs of cord myelopathy and mMCS (p < 0.05 R 0.21) at follow-up. Conclusions: Larger tumors showed lower preoperative functional status and a worse clinical outcome. Moreover, preoperative T2 cord signal changes are correlated with a poorer outcome.

Functional Status and Adverse Outcomes in Ambulatory Patients Undergoing Above-Knee Versus Below-Knee Amputation in the Vascular Quality Initiative

Previous studies in the literature have demonstrated higher morbidity and mortality in patients undergoing above-knee (AKA) vs below-knee (BKA) amputations. However, very few studies have looked at the functional status between these two groups. Using a large national database, we hypothesize that patients undergoing BKA will be more likely to ambulate and have superior outcomes compared with AKA.

Improvements in Functional Status Among Survivors of Orthotopic Heart Transplantation Following High-risk Bridging Modalities.

The 2018 heart allocation change has resulted in greater frequency of high-risk bridging to orthotopic heart transplantation (OHT). Although survival has been studied in these patients, functional status outcomes are less established. This study evaluated changes in functional status of OHT survivors based on bridging strategy. Adults (≥18 y) undergoing OHT between January 2015 and March 2020 were stratified by bridging modality: no bridging, inotropes only, intra-aortic balloon pump (IABP), temporary ventricular assist device (VAD), durable VAD, and extracorporeal membrane oxygenation (ECMO). Using paired analysis, the Karnofsky performance scale (0-100) was utilized to compare differences in function at listing, transplant, and follow-up. In total, 13 142 patients underwent OHT. At the time of both listing and transplant, patients requiring IABP, temporary VAD, and ECMO displayed the lowest functional status (each median 20) compared with other groups (P < 0.001). Among survivors, the median performance status at follow-up was ≥80 for all groups, indicating total functional independence with no assistance required. Substantial improvement in Karnofsky score occurred from transplant to follow-up in survivors bridged with IABP (40), temporary VADs (60), and ECMO (50) (each P < 0.001). Among survivors with at least 90-day follow-up, the median Karnofsky score was 90 regardless of bridging modality. Despite a higher mortality risk, critically ill patients who survive OHT after bridging with high-risk modalities experience acceptable functional status outcomes. These findings are important to place in the context of the impact that the 2018 allocation change has had on the landscape of OHT in the United States.

Long-Term Clinical and Functional Outcomes of Distally Based Sural Artery Flap: A Retrospective Case Series

BackgroundReconstruction of soft tissue defects around the lower leg, foot and ankle is a challenge for orthopedic surgeons. These defects commonly occur as a result of trauma, infection and tumor excision. Sural artery neurovascular island flap is a relatively thin, pliable and insensate flap with minimum donor-site morbidity and acceptable aesthetic outcome. MethodsA retrospective analysis of a case series was conducted, all operated by a single surgeon over a period of 25 years from July 1996 to February 2020. Data were collected through a structured proforma; the variables included were as follows: demographic data, mechanism of injury, defect site and size, size of flap, hospital stay, complications, outcome of flap and functional status of limb. Data analysis was performed by using SPSS version 25.0. ResultsWe included 89 patients out of 106, with 92 distally based sural artery flaps. The flap coverage was divided in two groups: group I for leg (n=41) and group II for foot (n=51). The mean flap dimension in leg was 9.98 ± 2.2 cm and 12.15 ± 3 cm in foot. Postoperatively functional outcomes were assessed using a self-designed tool and graded as excellent in 79 cases (leg=38; foot=41), good in 10 cases (leg=2; foot=8), fair in 3 cases (leg=1; foot=2) and poor in zero cases. All flaps survived uneventfully. ConclusionThe reverse sural artery flap is versatile and reliable, and can be performed easily with good knowledge and using a microsurgical technique. It is useful for the reconstruction of soft tissue defects around the lower third of the leg, dorsum of the foot, malleoli and hind foot. The functional range of motion of the ankle is not compromised because of the flap's supple and pliable nature. The reverse sural artery flap is ideal for the coverage of the foot, ankle and lower one third of the leg. This flap is insensate and not suitable for the weight-bearing area of the heel.

Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study.

To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes. Case series with planned data collection. Two tertiary care academic hospitals. The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables. Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; P = .030) and complex discharge planning (OR, 5.7; 95% CI, 1.34-24.2; P = .018). The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.

Evaluation of Clinical Outcomes Following Minor Amputations in Australia – An Important Consideration for Timing of Revascularisation

Vascular patients with tissue loss requiring minor amputations could be an early sign of a terminal event. The long-term outcomes and timing of revascularisation for these patients are not well-studied. The aim of this study was to determine the clinical outcomes following minor amputations. Primary outcomes were functional status, limb loss, and mortality. Secondary outcomes compared immediate and delayed revascularisation. A retrospective analysis of 200 vascular patients who required minor amputations at Austin Hospital, Melbourne was performed over 5 years. Demographics, details of revascularisation, functional status, and clinical outcomes such as recurrent tissue loss, limb loss and death were recorded. Of the entire cohort requiring minor amputations, 118 (59%) patients underwent revascularisation. 111 (94%) revascularisation procedures were performed within 90 days of minor amputation. Over all 5-year limb preservation was 89.9%. Patients who required revascularisation were not statistically significantly more at risk for limb loss at 5 years [13.6% vs. 6.6%; P=0.08]. Limb salvage at 1 year was not different between groups revascularized before and after amputation [89.5% vs. 90.9%; P=0.70]. Over all 5-year mortality rate was 50%. In the diabetic subset, those who had revascularisation after minor amputation had a greater 5-year mortality [67.9% vs. 50%; P=0.03]. A scoring system based on risk factors was developed but was not reliable based on the study data. The data from this study suggest that patients with diabetes who undergo revascularisation after minor amputation have worse outcomes than those revascularised prior to minor amputation. A predictive model applied at presentation could help detect high-risk patients but requires further work.

Functional status in rural and urban adults: The Canadian Longitudinal Study on Aging.

To document the prevalence of functional impairment in middle-aged and older adults from rural regions and to determine urban-rural differences. We have conducted a secondary analysis using data from an ongoing population-based cohort study, the Canadian Longitudinal Study on Aging (CLSA). We used a cross-sectional sample from the baseline wave of the "tracking cohort." The definition of rurality was the same as the one used in the CLSA sampling frame and based on the 2006 census. This definition includes rural areas, defined as all territory lying outside of population centers, and population centers, which collectively cover all of Canada. We grouped these into "Urban," "Peri-urban," "Mixed" (areas with both rural and urban areas), and "Rural," and compared functional status across these groups. Functional status was measured using the Older Americans Resource Survey (OARS) and categorized as not impaired versus having any functional impairment. Logistic regression models were constructed for the outcome of functional status and adjusted for covariates. No differences were found in functional status between those living in rural, mixed, peri-urban, and urban areas in unadjusted analyses and in analyses adjusting for sociodemographic and health-related factors. There were no rural-urban differences in any of the individual items on the OARS scales. We found no rural-urban differences in functional status.

Frailty as a predictor of outcomes for patients undergoing carotid artery stenting

ObjectiveThe concept of frailty has been proposed to capture the vulnerability resulting from aging and has been implemented for the prediction of perioperative outcomes. Carotid artery stenting (CAS) is considered an appropriate minimally invasive procedure for patients considered to high risk to undergo carotid endarterectomy. Recently, the predictive accuracy for perioperative outcomes using the five-item modified frailty index (5mFI) has been reported to be relatively poor for cardiovascular surgery compared with other surgeries. The effects of functional status and the 5mFI on the outcomes after CAS remain unknown. Thus, in the present study, we investigated the relationship between 5mFI, functional status, and perioperative outcomes. MethodsAll the patients who had undergone CAS in the Vascular Quality Initiative from November 15, 2016 to December 31, 2018 were included. Good functional status was defined as the ability to perform all predisease activities without restriction using a new variable added to the Vascular Quality Initiative from November 15, 2016 onward. The 5mFI was calculated using functional status and a history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The perioperative outcomes included in-hospital stroke or death within 30 days after CAS, a prolonged postoperative stay (≥2 days), and nonhome discharge. The associations between functional status, 5mFI, and perioperative outcomes were examined using univariate and multivariable logistic regression, adjusting for sex, age, race, degree of stenosis, symptomatic status, and the usage of preoperative medications. An analysis stratified by functional status was also performed. ResultsOf the 7836 patients, 188 (2.4%) had experienced perioperative stroke or death, 765 (9.8%) had required a nonhome discharge, and 2584 (33.0%) had required a prolonged postoperative stay. A higher (≥0.6 vs <0.6) 5mFI score was associated with greater odds of perioperative stroke or death (adjusted odds ratio [aOR], 2.75; 95% confidence interval [CI], 1.42-5.28; P = .003), non–home discharge (aOR, 2.70; 95% CI, 1.89-3.85; P < .001), and a prolonged postoperative length of stay (aOR, 1.96; 95% CI, 1.56-2.46; P < .001). For the predictive accuracy of the perioperative outcomes, the 5mFI model had an area under the curve for in-hospital stroke or death, nonhome discharge, and prolonged postoperative length of stay of 0.714, 0.767, and 0.668, respectively. The functional status model was not inferior to the 5mFI model for any of these outcomes. In the subgroup analysis, of the asymptomatic patients, a higher 5mFI score was associated with greater odds of perioperative stroke or death (aOR, 7.08; 95% CI, 2.02-24.48; P = .002), nonhome discharge (aOR, 5.87; 95% CI, 2.45-13.90; P < .001), and a prolonged postoperative stay (aOR, 2.60; 95% CI, 1.82-3.71; P < .001). ConclusionsFrailty, as measured using the 5mFI, and functional status were independent predictors of perioperative stroke or death, nonhome discharge, and an increased length of stay for patients undergoing CAS. These results were greatly pronounced in asymptomatic patients. The results from the present study, thus, caution against the use of CAS for asymptomatic frail patients.

Acupuncture for acute low back pain: a systematic review and meta-analysis.

Acupuncture has been widely used for acute low back pain (LBP), yet there remains continued controversy regarding its efficacy. Therefore, we aimed to critically evaluate the evidence for acupuncture as an effective treatment for acute LBP. English and Chinese databases were searched for randomized controlled trials (RCTs) that involved acupuncture for acute LBP published up to May 2020. Data on the outcomes of pain intensity, functional status, and analgesic use were extracted. The meta-analysis was performed using the Cochrane Collaboration's RevMan 5.3, and pooled data were expressed as mean differences (MD) with 95% confidence intervals (CIs). Of the 13 eligible RCTs identified, 11 RCTs (involving 707 patients) provided moderate-quality evidence that acupuncture has a statistically significant association with improvements in VAS (visual analog scale) score [MD: -1.75 (95% CI: -2.39, -1.12)]. Two studies indicated that acupuncture did not influence the RMDQ (Roland-Morris Disability Questionnaire) scores more than the control treatment [MD: -2.34 (95% CI: -5.34, 0.67)]. Three studies suggested that acupuncture influenced the ODI (Oswestry Disability Index) scores more than the control treatment [MD: -12.84 (95% CI: -23.94, -1.74)]. Two studies suggested that acupuncture influenced the number of pills more than the control treatment [MD: -3.19 (95% CI: -3.45, -2.92)]. Acupuncture treatment of acute LBP was associated with modest improvements in the VAS score, ODI score, and the number of pills, but not the RMDQ score. Our findings should be considered with caution due to the low power original studies. High-quality trials are needed to assess further the role of acupuncture in the treatment of acute LBP.

Predicting Discharge Destination of Critically Ill Patients Using Machine Learning.

Decision making about discharge destination for critically ill patients is a highly subjective and multidisciplinary process, heavily reliant on the ICU care team, patients and their caregivers' preferences, resource demand, staffing, and bed capacity. Timely identification of discharge disposition can be useful in care planning, and as a surrogate for functional status outcomes following critical illness. Although prior research has proposed methods to predict discharge destination in a critical care setting, they are limited in scope and in the generalizability of their findings. We proposed and implemented different machine learning architectures to determine the efficacy of the Acute Physiology and Chronic Health Evaluation (APACHE) IV score as well as the patient characteristics that comprise it to predict the discharge destination for critically ill patients within 24 hours of ICU admission. We conducted a retrospective study of ICU admissions within the eICU Collaborative Research Database (eICU-CRD) populated with de-identified clinical data from adult patients admitted to an ICU between 2014 and 2015. Machine learning models were developed to predict four discharge categories: death, home, nursing facility, and rehabilitation. These models were trained and tested on 115,248 unique ICU admissions. To mitigate class imbalance, we used synthetic minority over-sampling techniques. Hierarchical and ensemble classifiers were used to further study the impact of imbalanced testing set on the performance of our predictive models. Amongst all of the tested models, XGBoost provided the best discrimination performance with an area under the receiver operating characteristic curve of 90% (recall: 71%, F1: 70%). Our findings indicate that the variables used in the APACHE IV model for estimating patient severity of illness are better predictors of hospital discharge destination than the APACHE IV score alone. Incorporating these models into clinical decision support systems may assist patients, caregivers, and the ICU team to begin disposition planning as early as possible during the hospitalization.

Support for osteopathic manipulative treatment inclusion in chronic pain management guidelines: a narrative review.

Osteopathic manipulative treatment (OMT) is used to treat chronic pain conditions. However, few guidelines focusing on chronic pain management include recommendations for OMT. To evaluate previous literature on the use of OMT for improving chronic pain. A literature search was conducted on MEDLINE/PubMed and ScienceDirect on August 26-27, 2019, using theterms "osteopathic," "chronic," and "pain," yielding a total of 312 MEDLINE/PubMed articles and 515 ScienceDirect articles. Eligibility criteria required that studies investigate pain, functional status, or medication usage through an experimental design, focusing on human subjects with chronic pain who had various forms of OMTadministered by osteopathically trained individuals in which the comparator group received no intervention, asham or placebo, or conventional care. Three authors independently performed literature searches and methodically settled disagreements over article selection. In the 22 articles included in our study that examined OMT use in chronic pain conditions, we evaluated primary outcomes of pain (22; 100%) and functional status (20; 90.9%), and the secondary outcome of medication usage (3; 13.6%). The majority of articles showed that OMTresulted in a significant decrease in pain levels as compared to baseline pain levels or the control group (20;90.9%) and that OMT resulted in an improvement in functional status (17; 77.3%). In articles that did not find a significant difference in pain (2; 9.1%) or functional status (3;13.6%), there were overall outcomes improvements noted. All articles that investigated medication usage (3;13.6%) showed that OMT was effective in decreasing patients' medication usage. Our study was limited by its small sample size and multimodal comparator group exclusion. OMT provides an evidence-based management option to reduce pain levels, improve functional status, and decrease medication usage in chronic pain conditions, especially low back pain (LBP). Pain management guidelines should include OMT as a resource to alleviate chronic pain.

The association of malnutrition and sarcopenia with geriatric assessment impairment and outcomes in patients with bladder cancer undergoing cystectomy.

423 Background: Malnutrition and sarcopenia are linked to decreased functional status in older adults with malignancy, but their effect on geriatric assessment (GA) impairment in patients with bladder cancer (BC) undergoing radical cystectomy (RC) is unknown. We investigated the association between malnutrition and sarcopenia with GA impairment and postoperative outcomes. Methods: Patients with BC undergoing RC between 2012 – 2019 were enrolled in a prospective cohort study of GA before RC. Malnutrition was evaluated by a dietitian pre-RC per the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition diagnostic criteria. Sarcopenia, defined by a skeletal muscle index of &lt; 52.4 cm2/m2 in males and &lt; 38.5 cm2/m2 in females, was determined using SliceOmatic software to analyze pre-RC CT images at the L3 vertebra. Patients with vs without malnutrition and those with vs without sarcopenia were compared using Fisher’s exact and Wilcoxon rank sum tests. Results: Of 73 patients, 59 had GA + nutrition evaluation and 51 had GA + sarcopenia assessment (overall median age 68 [IQR 62-74], 76% male). The prevalence of malnutrition was 7% and sarcopenia was 63%. A numerically greater proportion of patients with malnutrition or sarcopenia were impaired on ≥ 1 GA measure compared to those without malnutrition (100% vs 78%, p=0.57) or sarcopenia (78% vs 68%, p=0.52), although this was not statistically significant (Table). Median hospital length of stay (LOS) was increased for patients with vs without sarcopenia (4 vs 5 days, p=0.005). Post-RC complication rate was similar for patients with vs without malnutrition (100% vs 75%, p=0.56) and patients with vs without sarcopenia (81% vs 74%, p=0.73), but malnourished patients were more likely to have Clavien-Dindo grade 3+ complications than those without malnutrition (100% vs 27%, p = 0.009). Conclusions: In our cohort of patients with BC undergoing RC, those with malnutrition or sarcopenia may have an increased rate of impairment on GA compared to those without malnutrition or sarcopenia. Sarcopenia was associated with increased LOS while malnutrition was associated with increased major complications. Our results are limited by small sample size, and future work is needed to elucidate whether addressing these modifiable factors improves functional status and postoperative outcomes. Research Sponsor: U.S. National Institutes of Health[Table: see text]

Symptom burden, functional status, and clinical outcomes of hospitalized patients with advanced genitourinary cancers.

42 Background: Patients with advanced genitourinary (GU) cancers are often hospitalized for complications of their cancer and symptom management. Yet, little is known about the symptom burden, functional status, and health care utilization of these patients. Methods: We prospectively enrolled patients with advanced cancer who experienced unplanned hospitalizations at an academic medical center. Upon admission, we asked patients to self-report their physical (Edmonton Symptom Assessment Scale-revised [ESAS-r]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We also collected data from nursing assessments about impairments in activities of daily living (ADLs). We compared symptoms, functional impairment, readmissions, and overall survival (OS) between cancer types (dichotomizing GU cancers vs other cancer types) and within GU cancers (dichotomizing prostate cancer vs kidney/bladder/adrenal cancer) using univariate and multivariable regression analyses adjusted for age, sex, education, comorbidities, and time since advanced cancer diagnosis. Results: Among 971 patients enrolled, 106 (10.9%) had advanced GU cancers (39.6% prostate cancer, 32.1% kidney cancer, 25.5% bladder cancer, and 2.8% adrenal cancer). Compared to patients with other cancer types, patients with GU cancers were older (median: 69.0 vs 64.0 years, p &lt; 0.001) and had more time since advanced cancer diagnosis (median: 14.0 vs 7.0 months, p &lt; 0.001). In univariate analyses, a greater proportion of patients with GU cancers had an ADL impairment (57.5% vs 38.0%, p &lt; 0.001) compared to other cancer types but the groups did not differ in their physical (Mean = 33.3 vs 32.6, p = 0.61) or depression (Mean = 4.1 vs 3.3, p = 0.05) symptoms. In multivariable models, patients with GU cancers had similar risk of readmission in 90 days (HR 1.31, p = 0.077), but worse survival (median OS: 102.0 days vs 133.5 days, p &lt; 0.001; HR 1.27, p = 0.046). Within GU cancers, patients with kidney/bladder/adrenal cancer (vs. prostate cancer) were younger (median: 66.0 vs 74.0, p &lt; 0.001) with less time since advanced cancer diagnosis (median: 9.0 vs 23.0 months, p = 0.012) but had no difference in symptoms or functional impairment. They were more likely to be admitted for symptom management (66% vs. 39% for prostate cancer, p = 0.026). Patients with kidney/bladder/adrenal cancer also had higher risk of readmission (HR 2.04, p = 0.043) but no difference in OS, compared to patients with prostate cancer. Conclusions: We found that hospitalized patients with advanced GU cancers had significantly greater functional impairment and worse survival compared to those with other cancer types, and those with kidney/bladder/adrenal cancer had significantly higher readmission risk compared to those with prostate cancer. These findings support the need to develop tailored supportive care for hospitalized patients with GU cancers.