Poor Functional Status Research Articles

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

ObjectiveWe conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. MethodsRecords from 2008 to 2018 for “laparoscopy, surgical; partial nephrectomy” for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. ResultsTotally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. ConclusionMultiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Ultrasound-guided cervical selective nerve block: A case series.

Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective. This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG). We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications. We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6. SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

Metaplastic Breast Cancer: Characteristics and Survival Outcomes.

ObjectivesMetaplastic breast cancer (MBC) is a rare neoplasm accounting for <1% of all breast cancer. We evaluated the clinical characteristics and survival outcomes of MBC.MethodsPatients diagnosed with pathologically proven MBC were reviewed from the institutional breast cancer database from 2000 to 2017.ResultsA total of 136 patients diagnosed with MBC were included in the study. The median age of the diagnosis was 60 years, and 60% of patients were stage II at diagnosis, and 22% were stage III. About two-thirds of the patients were triple-negative; 93% had nuclear grade III, and 25% had a lymphovascular invasion. Squamous differentiation (29%) was the most common histologic subtype, followed by the spindle subtype (21%). The most common distant metastases were lung (22%), followed by bone (13%). Moreover, 60% had a mastectomy, 19% had endocrine therapy, 58% had radiation, 51% received anthracycline-based chemotherapy, 26% had non-anthracycline chemotherapy, and 22% received no chemotherapy. In the entire cohort, the two-year overall survival (OS) and five-year OS were 79% and 69%, respectively, and the two-year progression-free survival (PFS) and five-year PFS were 72% and 61%, respectively. On multivariable analysis, the stage of MBC (stage III: hazard ratio (HR), 5.065 (95% confidence interval (CI), 1.02-25.27) (p=0.048)), poor functional status (Eastern Cooperative Oncology Group (ECOG) score, 2; HR, 24.736 (95% CI, 1.92-318.73) (p=0.014)), and distant metastasis to the brain (HR, 8.453 (95% CI, 1.88-38.04) (p=0.005)) and lung (HR, 42.102 (95% CI, 7.20-246.36) (p<0.001)) were significant predictors of decreased OS.ConclusionsMBC demonstrated early disease progression and poor overall survival. The stage of MBC, decreased performance status, and metastasis to the lung and brain were independent poor prognostic factors.

Polymorphisms in Cytokine Receptor and Regulator Genes are Associated with Levels of Exercise in Women Prior to Breast Cancer Surgery.

Background: Little is known about the genetic characteristics associated with exercise in women undergoing breast cancer surgery. Purpose: In a sample of women who were evaluated prior to breast cancer surgery (n = 310), we evaluated for differences in demographic and clinical characteristics between patients who did and did not exercise on a regular basis and evaluated for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators. Methods: Patients completed an investigator-developed exercise questionnaire. Based on the recommended level of exercise (≥150 minutes/week), survivors were classified into no exercise (NoEx), less exercise (LessEx), or recommended exercise (RecEx) groups. Candidate gene analyses were done to identify relationships between polymorphisms and exercise group membership (i.e., NoEx vs. RecEx). Only 23.5% of the total sample met the recommendations for regular exercise. Results: Compared to the RecEx group (n = 78), patients in the NoEx group (n = 120) had less education; were less likely to report being White or Asia/Pacific Islander; more likely to report a lower household income; had a higher body mass index (BMI), had a poorer functional status; had a higher comorbidity burden; were more likely to self-report high blood pressure; and were more likely to have received neoadjuvant chemotherapy. Polymorphisms in IFNGR1 and NFKB1 were associated with membership in the NoEx group. Conclusions: While they warrant replication, our findings suggest that variations in cytokine-related genes may play a role in exercise behavior, and that clinicians need to assess for barriers to regular exercise and educate patients on its benefits.

Evaluating Cancer Pain Characteristics and Treatment Factors in the Emergency Department: A Retrospective Cohort Study.

Objectives: To identify patient characteristics and treatment factors of patients presenting to the emergency department (ED) with cancer-related pain that may affect patient outcomes. Methods: We conducted a retrospective cohort study to evaluate adult patients with active cancer, who presented to the ED with a chief complaint of pain between June first, 2012 and January first, 2016. We utilized multivariable logistic regression to evaluate the association of several exposure variables, including disease and demographic characteristics, primary pain site, and treatment methods, on ED disposition and revisit rate. Results: We included 483 patients with active cancer with a chief complaint of pain. Patients with severe pain on arrival tended to be younger than those who did not present with severe pain (median: 58 vs 62 respectively, OR 8.0 p < 0.01). Patients with high ECOG scores (3-4) with severe pain on arrival (≥7 out of 10) had less improvement in their pain than the rest of our cohort (OR 8.4, p < 0.01). Also, those with musculoskeletal pain had significantly less improvement in reported pain than all other pain types (delta pain −2.1 vs −3.4, OR 2.3, p = 0.025) Long delays in initial analgesic administration were associated with increased rates of subsequent admission (OR 3.4) [p = 0.014]. Although opioid analgesics led to greater decreases in pain than non-opioid analgesics, patients treated with opioids were more likely to be admitted (43% vs 34.5% AOR 1.51, p = 0.048). Conclusion: Our study showed that delays in analgesic administration, poor functional status, and the presence of musculoskeletal (MSK) pain significantly influenced outcomes for this patient cohort. These findings suggest the development of specific protocols and tools to address cancer-related pain in the ED may be necessary.

TMEM106B Acts as a Modifier of Cognitive and Motor Functions in Amyotrophic Lateral Sclerosis.

The transmembrane protein 106B (TMEM106B) gene is a susceptibility factor and disease modifier of frontotemporal dementia, but few studies have investigated its role in amyotrophic lateral sclerosis. The aim of this work was to assess the impact of the TMEM106B rs1990622 (A–major risk allele; G–minor allele) on phenotypic variability of 865 patients with amyotrophic lateral sclerosis. Demographic and clinical features were compared according to genotypes by additive, dominant, and recessive genetic models. Bulbar onset was overrepresented among carriers of the AA risk genotype, together with enhanced upper motor neuron involvement and poorer functional status in patients harboring at least one major risk allele (A). In a subset of 195 patients, we found that the homozygotes for the minor allele (GG) showed lower scores at the Edinburgh Cognitive and Behavioral Amyotrophic Lateral Sclerosis Screen, indicating a more severe cognitive impairment, mainly involving the amyotrophic lateral sclerosis-specific cognitive functions and memory. Moreover, lower motor neuron burden predominated among patients with at least one minor allele (G). Overall, we found that TMEM106B is a disease modifier of amyotrophic lateral sclerosis, whose phenotypic effects encompass both sites of onset and functional status (major risk allele), motor functions (both major risk and minor alleles), and cognition (minor allele).

Postoperative Chemotherapy is Associated with Improved Survival in Patients with Node-Positive Pancreatic Ductal Adenocarcinoma After Neoadjuvant Therapy.

Postoperative chemotherapy following pancreatic cancer resection is the standard of care. The utility of postoperative chemotherapy for patients who receive neoadjuvant therapy (NAT) is unclear. Patients who underwent pancreatectomy after NAT with FOLFIRINOX or gemcitabine-based chemotherapy for non-metastatic pancreatic adenocarcinoma (2015-2019) were identified. Patients who received less than 2months of neoadjuvant chemotherapy or died within 90days from surgery were excluded. A total of 427 patients (resectable, 22.2%; borderline resectable, 37.9%; locally advanced, 39.8%) were identified with the majority (69.3%) receiving neoadjuvant FOLFIRINOX. Median duration of NAT was 4.1months. Following resection, postoperative chemotherapy was associated with an improved median overall survival (OS) (28.7 vs. 20.4months, P = 0.006). Risk-adjusted multivariable modeling showed negative nodal status (N0), favorable pathologic response (College of American Pathologists score 0 &amp; 1), and receipt of postoperative chemotherapy to be independent predictors of improved OS. Regimen, duration, and number of cycles of NAT were not significant predictors. Thirty-four percent (60/176) of node-positive and 50.1% (126/251) of node-negative patients did not receive postoperative chemotherapy due to poor functional status, postoperative complications, and patient preference. Among patients with node-positive disease, postoperative chemotherapy was associated with improved median OS (27.2 vs. 10.5months, P &lt; 0.001). Among node-negative patients, postoperative chemotherapy was not associated with a survival benefit (median OS, 30.9 vs. 36.9months; P = 0.406). Although there is no standard NAT regimen for patients with pancreatic cancer, postoperative chemotherapy following NAT and resection appears to be associated with improved OS for patients with node-positive disease.

The influence of tinnitus and hearing loss on the functional status of military Service members and Veterans

Objective This study evaluated the influence of tinnitus and hearing loss on the functional status of military Service members and Veterans. Design Participants completed audiologic testing and self-report instruments to assess tinnitus, hearing, and general functioning. We conducted multiple linear regression analyses using cross-sectional data with functional status as the dependent variable. The primary independent variables were tinnitus and average low-, high-, and extended high-frequency hearing thresholds. Secondary independent variables were subjective tinnitus severity and hearing difficulties. Each of the independent variables was modelled separately for Service members and Veterans; covariates for each multivariable model were identified a priori and, depending on the association being modelled, included age, gender, blast-wave exposure, and history of military traumatic brain injury. Study Sample Data were analysed from 283 Service members and 390 Veterans. Results After controlling for potential confounders, presence of tinnitus, tinnitus severity, average low-frequency hearing thresholds, and subjective hearing difficulties were significantly associated with functional status in Service members and Veterans. Conclusions These results suggest that tinnitus and poorer low-frequency hearing, and the perceived severity of tinnitus and hearing difficulties, may be associated with poorer functional status among Service members and Veterans.

Contemporary management of pain in cirrhosis: Toward precision therapy for pain.

Chronic pain is highly prevalent in patients with cirrhosis and is associated with poor health-related quality of life and poor functional status. However, there is limited guidance on appropriate pain management in this population, and pharmacologic treatment can be harmful, leading to adverse outcomes, such as gastrointestinal bleeding, renal injury, falls, and hepatic encephalopathy. Chronic pain can be categorized mechanistically into three pain types: nociceptive, neuropathic, and nociplastic, each responsive to different therapies. By discussing the identification, etiology, and treatment of these three mechanistic pain descriptors with a focus on specific challenges in patients with cirrhosis, we provide a framework for better tailoring treatments, including nonpharmacologic therapies, to patients' needs.

Correlations between paraspinal extensor muscle endurance and clinical outcomes in preoperative LSS patients and clinical value of an endurance classification.

BackgroundFew study has investigated how paraspinal muscle endurance deteriorates in lumbar spinal stenosis (LSS) patients. In addition, little information is available on the relationship between clinical outcomes and the endurance of paraspinal muscles.ObjectiveTo explore the correlation between paraspinal extensor muscle endurance, quality of life (QOL) and sagittal spinopelvic alignment. Besides, we attempted to propose a paraspinal extensor muscle endurance test (PEMET) classification for identifying the severity of clinical symptoms and sagittal imbalance in LSS patients.Methods171 hospitalized LSS patients and 100 healthy controls from the community were prospectively enrolled in this study. The paraspinal extensor endurance test was performed at baseline according to Ito test. The LSS patients were stratified into three groups based on the performance time of endurance test: grade I (<10s); grade II (10–60s); and grade III (>60s). Clinical measures of QOL included the visual analog scale scores (VAS) for back pain and leg pain and the Oswestry Disability Index (ODI). Sagittal alignment was analysed by standing posteroanterior and lateral whole spine X-ray in LSS patients.ResultsThe LSS group had a significantly shorter performance time of the endurance test than the control group. The paraspinal muscle endurance significantly correlated with VAS-back, VAS-leg, ODI, pelvic tilt, lumbar lordosis and sagittal vertical axis (SVA; all p < 0.05). In binary logistic regression, the performance time of the endurance test was an independent factor of both poor functional status (ODI >40; p = 0.005, OR = 0.985) and global sagittal imbalance (SVA >50 mm; p = 0.019, OR = 0.985). Based on PEMET classification, moving from the grade III group to the grade I group, there was progressive worsening in VAS-back and ODI (all adjusted p < 0.05). Moreover, the grade I group had significantly greater VAS- leg, less LL and greater SVA than the other two groups (all adjusted p < 0.05).ConclusionParaspinal muscle endurance was associated with QOL and sagittal spinopelvic alignment in LSS patients. A PEMET classification system has been constructed and has shown a correlation with QOL and sagittal imbalance.Translational potential statementThe PEMET classification system proposed in this study could be available for identifying the severity of clinical symptoms and sagittal imbalance during preoperative evaluation in LSS patients.

Managing patients with comorbidities: future models of care

One in four adults in the UK have two or more medical conditions. One in three adults admitted to hospital in the UK have five or more conditions. People with multimorbidity have poorer functional status, quality of life and health outcomes, and are higher users of ambulatory and inpatient care than those without multimorbidity. The entire healthcare system needs to change so that it can provide a better service for patients with multimorbidity. The system of healthcare professional education needs to change also. Clinical decision support has a clear role in the management of patients with multimorbidity. But, until now, clinical decision support tools have offered no support when dealing with patients with comorbidities; they have covered single conditions only. In light of this, BMJ Best Practice recently launched the Comorbidities Manager. This enables healthcare professionals to add a patient's comorbidities to an existing management plan and get a tailored plan instantly. This article outlines the importance of taking into account comorbidities when managing patients and the role that the BMJ Comorbidities Manager can play in this regard.

Factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients.

Inappropriate management of medications is a major threat to homebound patients with chronic conditions. Despite many efforts in improving medication reconciliation in ambulatory and inpatient settings, little research has focused on home care settings. In 2016, Taiwan initiated the Integrated Home Health Care programme, which was intended to reduce potentially inappropriate medication management and risks of uncontrolled polypharmacy through the integration of different medication sources for chronic conditions among homebound patients. This study investigated factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients. This retrospective cohort study enrolled 3142 community-dwelling homebound patients from Taipei City Hospital. Homebound patients' adherence to using home care physicians as an integrated source of chronic condition medications was defined as having all prescriptions for their chronic conditions prescribed by a single home care physician for at least 6 months. Both patient and home care physician characteristics were analysed. Multivariable logistic regression was applied. Of the 3142 patients with chronic conditions, 1002 (31.9%) had consistently obtained all medications for their chronic illnesses from their home care physicians for 6 months and 2140 (68.1%) had not. The most common chronic diseases among homebound patients were hypertension, diabetes mellitus, dementia, cerebrovascular disease and constipation. Oldest-old patients with poor functional status, fewer daily medications, no co-payment exemption and no recent inpatient experience were more likely to adhere to this medication integration system. In addition, patients whose outpatient physicians were also their home care physicians were more likely to adhere to the system. The finding suggests that building trust and enhancing communication among homebound patients, caregivers and home care physicians are critical. Patient and provider variations highlight the need for further improvement and policy modification for medication reconciliation and management in home care settings. The improvement in medication management and care integration in home care settings may reduce misuse and polypharmacy and improve homebound patients' safety.

P569: GILTERITINIB AND QUIZARTINIB IN RELAPSED/REFRACTORY (R/R) ACUTE MYELOBLASTIC LEUKEMIA (AML) WITH FLT3 MUTATIONS: A REAL-LIFE EFFECTIVENESS AND SAFETY STUDY

Background: Patients with R/R AML have poor prognosis. FLT3 mutations worsened the prognosis but offer a targeted therapy. FLT3 inhibitors have demonstrated efficacy as monotherapy in FLT3-positive R/R AML. Aims: The objective of the present study was to analyze the efficacy and safety of Gilteritinib and Quizartinib in R/R FLT3-mutated AML in real-life context. Methods: Between December 2016 and April 2021, 22 patients were treated with Gilteritinib and 5 patients with Quizartinib in 13 centers of the Spanish PETHEMA and CETLAM groups. Results: The median age was 62 years (range 25; 81) and 56% were women. Most patients presented ITD FLT3 (80%), 56% were refractory and 44% were relapsed (CR1 duration ≥6 months in 60%). The 1st line therapy was intensive chemotherapy (78%, 38% with midostaurin) or HMA (22%). A total of 13/27 patients (48%) had previously received a FLT3 inhibitor (midostaurin=6, sorafenib=2, quizartinib=2, midostaurin + crenolanib vs placebo=2 and midostaurin + quizartinib=1). Seventy percent of the patients received >1 line of treatment prior to Gilteritinib/Quizartinib (the most frequent was FLAG-IDA). Compared with diagnosis, patients in R/R had poorer functional status (ECOG<2 88% vs. 73%) but lower leukocyte counts, LDH level and FLT3 ITD ratio (21.5 x109/L vs 4.7x109/L, 563 U/L vs 330 U/L and 0.60 vs 0.42, respectively). Three patients displayed clonal evolution in R/R with acquisition of cytogenetic alterations in patients with altered karyotype at diagnosis and appearance of alterations in patients with normal karyotype. The ORR was 63% (21% CR, 21% CRi and 21% PR) and the median OS was 5.8 (95%CI, 3.8; 7.9) months. Time to achieve better response was 1.8 months (range 0.9;4.1). Eight patients received the FLT3 inhibitor as a bridge to SCT, and six of them were finally transplanted. Gilteritinib dose was 120mg/day, increasing to 200mg/d in 41% of patients (due to lack of response after 28 days). Toxicity was observed in 69% of patients (g3/4 in 30%). Febrile neutropenia was the most frequent toxicity (35%) followed by hepatotoxicity (28%) and QTc prolongation (16%). One patient died of toxicity attributed to Gilteritinib (febrile neutropenia). Summary/Conclusion: Treatment with Gilteritinib and Quizartinib as monotherapy is an effective and tolerable option for patients with R/R FLT3-mutated AML in real-life, with similar response rates and toxicity to those reported in Phase 3 trials, despite the fact that the study population from our series was more heterogeneous.

Determinants of Prolonged Length of Hospital Stay in Patients with Severe Acute Ischemic Stroke.

Objective: Long hospitalizations are associated with a high comorbidity and considerable hospital cost. Admissions of severe acute ischemic stroke are prone to longer hospitalizations. We aimed to explore the issue and method for improving the length of stay. Methods: From the prospective Stroke Registry between January 2019 and June 2020, acute ischemic strokes with an admission National Institutes of Health Stroke Scale ≥ 15 were identified. Prolonged length-of-stay was defined as in-hospital-stay ≥ 30 days. All clinical characteristics were collected, and all do-not-resuscitate documentations were categorized if the order had been written within 7 days of onset. Results: A total of 212 patients were eligible for severe stroke. Of these, 42 (19.8%) had prolonged length-of-stay and 170 had non-prolonged length-of-stay (median 43 vs. 13 days). The prolonged group was younger, mostly men, and was more likely to be in an independent state and more likely to receive reperfusion therapy, and there was a higher frequency of late do-not-resuscitate orders if signed. Although there was a lower in-hospital mortality rate in the prolonged group (12% vs. 23%), there was a higher proportion with a severe functional state (Modified Rankin Scale = 4–5) among the survivors (97% vs. 87%). Conclusions: Severe acute ischemic stroke patients with a prolonged length-of-stay were younger, mostly male, more likely to receive reperfusion therapy, less likely to have an early do-not-resuscitate order if signed, and more likely to have poor functional status at discharge, although there was a lower rate of in-hospital mortality.

Value of the Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Predicting CPET Performance in Patients with Stable CAD and Recent Elective PCI.

Background and Objectives: Functional capacity (FC) assessed via cardiopulmonary exercise testing (CPET) is a novel, independent prognostic marker for patients with coronary artery disease (CAD). Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are two readily available predictors of systemic inflammation and cardiovascular event risk, which could be used as cost-effective predictors of poor FC. The purpose of this study was to evaluate the utility of NLR and PLR in predicting poor FC in patients with CAD and recent elective percutaneous coronary intervention (PCI). Materials and Methods: Our cross-sectional retrospective analysis included 80 patients with stable CAD and recent elective PCI (mean age 55.51 ± 11.83 years, 71.3% male) who were referred to a cardiovascular rehabilitation center from January 2020 to June 2021. All patients underwent clinical examination, cardiopulmonary exercise testing on a cycle ergometer, transthoracic echocardiography and standard blood analysis. Results: Patients were classified according to percent predicted oxygen uptake (% VO2 max) in two groups—poor FC (≤70%, n = 35) and preserved FC (>70%, n = 45). There was no significant difference between groups regarding age, gender ratio, presence of associated comorbidities, left ventricular ejection fraction and NLR. PLR was higher in patients with poor FC (169.8 ± 59.3 vs. 137.4 ± 35.9, p = 0.003). A PLR cut-off point of 139 had 74% sensitivity and 60% specificity in predicting poor FC. After multivariate analysis, PLR remained a significant predictor of poor functional status. Conclusions: Although CPET is the gold standard test for assessing FC prior to cardiovascular rehabilitation, its availability remains limited. PLR, a cheap and simple test, could predict poor FC in patients with stable CAD and recent elective PCI and help prioritize referral for cardiovascular rehabilitation in high-risk patients.

Evaluation of inpatient chemotherapy among patients with cancer.

6566 Background: Administration of inpatient chemotherapy (IC) is associated with more aggressive end of life care, reduced use of palliative care (PC) and decreased quality of life (QOL). This study aims to identify risk factors associated with overutilization of IC. Methods: We conducted a retrospective chart review of all admissions where IC was administered at an academic center between January 2016 and December 2017. Patients (pts) were stratified by solid tumors (ST) versus hematologic malignancies (HM) and urgency for IC was assessed. We evaluated other variables which can impact patient care such as length of stay (LOS), reason for admission and for IC. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect taking into account correlations from multiple admissions per patient. All tests were two-sided and statistical significance was considered when p&lt;.05. Results: We analyzed 880 admissions (17% ST). Table 1 summarizes outcomes. HM pts required frequent direct admission for IC compared to ST. ST pts (p&lt;.0001), pts &gt;65 years (p=0.004) and pts with KPS ≤50% (p&lt;.0001) were most likely admitted for cancer complications rather than for IC. LOS (&gt;7 days) was significantly longer in HM admissions (p=0.0001), among pts with stage 4 cancer (p=0.014) and KPS ≤50% (p=0.0001). ST (p=0.006) and pts with KPS ≤50% (p=0.0001) received IC for a non-urgent indication significantly more often than HM. In 20% of ST admissions, pts received IC because the admission coincided with a non-urgent planned cycle compared to 3% of HM. In the adjusted analysis, tumor type was the most important factor correlated with urgency of IC (OR 0.42, 95% CI: 0.25-0.72; p=0.001). ST pts (p=0.0001), older pts (p=0.004) and pts with KPS ≤50% (p=0.0001) were less likely to respond to chemotherapy. Only 15% of HM admissions and 46% of ST admissions had a PC consult. 60-day mortality was significantly higher in ST pts than HM (p=0.002). Conclusions: IC is associated with poorer outcomes for pts with advanced stage ST, pts with poor functional status and pts admitted for acute indications. Additionally, ST pts have a higher mortality after IC compared to HM. Utilization of IC should be standardized to account for different patient characteristics and to reduce the incidence of non-urgent administration. Based on this data, we created a standardized protocol to better assess the appropriateness of IC to improve patient care, QOL, and reduce chemotherapy and healthcare utilization at the end of life. [Table: see text]

Impact of intensive multimodal treatment on the outcomes of patients with anaplastic thyroid cancer.

6082 Background: Anaplastic thyroid cancer (ATC) is a rare and aggressive type of thyroid malignancy with very poor prognosis and outcome despite therapy. The rarity of this disease and the poor functional status of ATC patients limit the ability to conduct clinical trials, thus there is a lack of large, controlled trials to guide treatment and evaluate the benefit of combined modality therapy. Methods: The National Cancer Database (NCDB) was queried for patients diagnosed with ATC at age 18 or older between 2004 and 2018. After excluding patients with unknown number of treatment modalities, Charlson-Deyo score of 3 or more and patients lost follow-up, we split the cohort into three groups according to the number of treatment modalities they received. Treatment modalities include surgery, radiation, and systemic therapy. Then, we evaluated the overall survival (OS) between the three groups. We studied the OS using Kaplan-Meier estimates and multivariate cox regression analyses to evaluate factors associated with OS. Additionally, propensity score matching (accounting for age, gender, race, Charlson-Deyo score, and clinical M stage) was used for more robust results. Results: A total of 3,460 patients with ATC were included in the analysis, of which 1,472 (42.5%) either received one type of therapy or did not receive any therapy (group1), 1,092 (31.6%) received bimodal therapy (group 2), and 896 (25.9%) received trimodal therapy (group 3). We found that group 3 had better OS compared to group 1 and group 2 (median OS 9.1 months vs 1.7 months and 4.9 months, respectively with P &lt; 0.001 for all). Propensity score matching yielded 896 patients in each group. We found that group 3 had better OS compared to group 1 and group 2 (median OS 9.1 months vs 1.9 months and 5.2 months, respectively with P &lt; 0.001 for all). Same trend was found in subgroup analysis when we split the cohort according to the metastatic status; in M0 group (median OS was 10.4 months vs 1.9 months and 6.1 months, respectively with P &lt; 0.001 for all), in M1 group (median OS was 5.9 months vs 1.4 months and 3.7 months, respectively with P &lt; 0.001 for all). On multivariate analysis, group 1 and group 2 were associated with worse OS compared to trimodal treatment (HR 2.721; 95% CI: 2.466 - 3.002 and HR 1.434; 95% CI: 1.299 - 1.582, P &lt; 0.001 for all). Conclusions: Patients with ATC who were treated with intensive trimodal therapy had statistically significant improvement in OS compared to patients who received less intense therapy. This survival benefit was observed in both metastatic and non-metastatic groups. While we acknowledge the limitations of this retrospective analysis, our results showed the critical role of intensive therapy approach in this aggressive malignancy.

Cerebrospinal fluid cystatin C levels in patients with anti-NMDAR encephalitis and other neurological diseases

BackgroundCystatin C has neuroprotective and immunomodulatory effects on the central nervous system. However, the role of cerebrospinal fluid (CSF) cystatin C in anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) remains unknown. MethodsIn this study, CSF levels of cystatin C were determined in 73 patients with anti-NMDARE; 496 patients with other neurological diseases, comprising 108 with neuromyelitis optica, 77 with multiple sclerosis, 71 with schizophrenia, 68 with cryptococcus meningitis or meningoencephalitis, 43 with tuberculous meningitis or meningoencephalitis, 43 with bacterial meningitis or meningoencephalitis (BM), 35 with Guillain–Barré syndrome, 23 with spinal cord injury (SCI), 14 with amyotrophic lateral sclerosis (ALS), and 14 with idiopathic epilepsy; and 136 control patients with non-inflammatory diseases. The associations of CSF cystatin C with anti-NMDARE and its clinical parameters were evaluated. ResultsCSF cystatin C levels were significantly lower in patients with anti-NMDARE than in patients with BM, SCI, and ALS, especially among those with poor functional status (modified Rankin Scale [mRS] ≥4). CSF cystatin C levels were also significantly lower in anti-NMDARE patients with poor functional status (mRS ≥4) than in those with good functional status (mRS <4). CSF cystatin C levels were significantly associated with mRS scores and CSF white blood cell counts in anti-NMDARE patients. ConclusionsCSF levels of cystatin C are decreased in anti-NMDARE patients and negatively associated with disease severity.

The relationship between nutritional status at the time of stroke on adverse outcomes: a systematic review and meta-analysis of prospective cohort studies.

The impact of existing malnutrition on stroke outcomes is poorly recognised and treated. Evidence was systematically reviewed and quantified by meta-analysis. MEDLINE, EMBASE and Web of Science were searched from inception to 11 January 2021 and updated in July. Prospective cohort studies, in English, evaluating anthropometric and biomarkers of nutrition on stroke outcomes were included. Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network checklist. Twenty-six studies (n = 156249) were eligible (follow-up: One month-14 years). Underweight patients had increased risk of long-term mortality (adjusted hazard ratio = 1.65,1.41-1.95), whilst overweight (0.80,0.74-0.86) and obese patients (0.80,0.75-0.85) had decreased risk compared to normal weight. Odds of mortality decreased in those with high serum albumin (odds ratio = 0.29,0.18-0.48) and increased with low serum albumin (odds ratio = 3.46,1.78-6.74) compared to normal serum albumin (30-35 g/L). Being malnourished compared to well-nourished, as assessed by the Subjective Global Assessment (SGA) or by a combination of anthropometric and biochemical markers increased all-cause mortality (odds ratio = 2.38,1.85-3.06) and poor functional status (adjusted odds ratio = 2.21,1.40-3.49). Nutritional status at the time of stroke predicts adverse stroke outcomes.

Psychological Outcome after Hemorrhagic Stroke is Related to Functional Status

BackgroundTo identify opportunities to improve morbidity after hemorrhagic stroke, it is imperative to understand factors that are related to psychological outcome. Design/MethodsWe prospectively identified patients with non-traumatic hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) between January 2015 and February 2021 who were alive 3-months after discharge and telephonically assessed 1) psychological outcome using the Quality of Life in Neurological Disorders anxiety, depression, emotional and behavioral dyscontrol, fatigue and sleep disturbance inventories and 2) functional outcome using the modified Rankin Scale (mRS) and Barthel Index. We also identified discharge destination for all patients. We then evaluated the relationship between abnormal psychological outcomes (T-score >50) and discharge destination other than home, poor 3-month mRS score defined as 3-5 and poor 3-month Barthel Index defined as <100. Results73 patients were included; 41 (56%) had an abnormal psychological outcome on at least one inventory. There were 41 (56%) patients discharged to a destination other than home, 44 (63%) with poor mRS score and 28 (39%) with poor Barthel Index. Anxiety, depression, emotional and behavioral dyscontrol and sleep disturbance were all associated with a destination other than home, poor mRS score, and poor Barthel Index (all p<0.05). Fatigue was related to poor mRS score and poor Barthel Index (p=0.005 and p=0.006, respectively). ConclusionMultiple psychological outcomes 3-months after hemorrhagic stroke are related to functional status. Interventions to improve psychological outcome and reduce morbidity in patients with poor functional status should be explored by the interdisciplinary team.