Primary Admission Research Articles

Valve unit instead of intensive care unit admission after transcatheter edge-to-edge tricuspid valve repair

Abstract Background Standardization of periprocedural pathways reduces the length of hospital stay and thus healthcare costs and increases patient safety. Post-procedure admission to the intensive care unit (ICU) after transcatheter edge-to-edge tricuspid valve repair (T-TEER) has been the standard of care. Due to the COVID-19 pandemic related decline in high-care hospital beds, our center established primary admission to a dedicated general cardiologic care ward, the valve unit (VU). Aim To assess benefits and risks of admission to the VU instead of ICU after T-TEER. Methods This retrospective observational study included 270 consecutive patients who underwent T-TEER between March 2017 and June 2023 at our university hospital. Patients were admitted to the ICU post-procedure up to April 9th 2020 as standard (ICU-group, n = 53). Subsequent patients were planned for admission to a dedicated VU (VU-group, n = 217). We compared the groups and assessed length of hospital stay and in-hospital complications. In the VU-group, we examined unplanned transfer to the ICU (cross-over) and its predictors. Results Monitoring at the VU included continuous telemetric ECG-recording, oxygen saturation assessment, periodical blood pressure measurements and 24-hours physician presence. In contrast to the ICU, only non-invasive blood pressure measurements, less frequent laboratory controls and less intense fluid monitoring took place. The postinterventional hospital stay of patients with planned VU admission was significantly shorter compared to patients with planned ICU admission (median 4 (interquartile range (IQR) 3 - 5) vs. 4 (IQR 4 - 5) days, p = 0.030). Remarkably, overall complication rates were low and cardiogenic shock, infections, bleeding, vascular complications, delirium and acute kidney injury requiring dialysis were similar in both groups. 37 patients that were planned for VU had to cross over to unplanned ICU admission (17.1 %). Patients that had crossed over to unplanned ICU treatment had significantly higher risk for acute kidney injury (20.0 vs. 10.0%, p = 0.039) and in-hospital mortality (5.6 vs. 0%, p = 0.045). Higher systolic pulmonary artery pressure (sPAP) (OR 1.048, 95 %-CI 1.015 – 1.082, p = 0.003), NYHA functional class >= III (OR 9.176, 95 % CI 1.141 – 74.396, p = 0.037), and pre-interventional tricuspid regurgitation (TR) grade V (OR 2.941, 95 % CI 1.089 – 7.970, p = 0.033) were found to independently predict cross-over to unplanned ICU treatment. Conclusion Postinterventional admission to the VU instead of ICU after T-TEER shortens postprocedural hospital stay. A small proportion of had an unplanned transfer to ICU, which was accompanied by slightly higher complication rates. This cross-over affects patients with more advanced disease indicated by high pulmonary pressures, NYHA class and TR grade. Thus, admission to a valve unit is favorable for most patients after T-TEER, but those with advanced disease should be monitored more closely.

Ability of Activated Clotting Time Measurements to Monitor Unfractionated Heparin Activity During NonCardiac Arterial Procedures

Activated clotting time (ACT) measurements are frequently used to monitor unfractionated heparin activity during non-cardiac arterial procedures (NCAP). Accuracy of ACT-guided heparinization is mandatory to prevent heparin under- and overdosing, thereby minimizing thrombo-embolic complications (TEC) and bleeding risk. The main objective of this study was to investigate accuracy of ACT to monitor heparin activity during NCAP using the Hemostasis Management System Plus with high-range cartridges. ACT values were compared with anti-Xa measurements, regarded as the standard test to measure active heparin. This was a single centre, prospective, observational cohort study. Perioperative blood samples of patients undergoing NCAP between December 2022 and September 2023 were used to perform bedside ACT measurements and anti-Xa assays in the clinical laboratory. Primary outcome was correlation between ACT and anti-Xa measurements. TEC, mortality and bleeding complications within 30 days postoperatively or during primary admission were also scored. 196 pairs of ACT and anti-Xa measurements were performed in 34 patients. Strong correlation was observed between anti-Xa and ACT measurements (Pearson correlation coefficient = 0.84, 95% CI = 0.79 - 0.87, p < 0.001). Apart from anti-Xa, no additional variables were associated with ACT in multivariate linear regression analyses (regression coefficient β = 36.7, 95% CI = 33.3 - 40.1, p < 0.001). Bleeding complications occurred in 29% of the patients, while both TEC and mortality were observed in one patient. strong correlation and an independent association were observed between heparin activity measured by anti-Xa and ACT using the Hemostasis Management System Plus.

Mental health of children with epilepsy compared to their peers: population-based cohort from linked primary and secondary healthcare record in England

BackgroundChildren with epilepsy have higher rates of internalising mental health (MH) conditions compared to their peers, although available evidence is limited by small and selective samples. We used linked primary care and hospital admission records covering approximately 4.42% of English population to describe incidence of mental health problems in children with epilepsy compared to their peers. MethodsWe developed a cohort of young people aged 7-17 years old between 2010-2019, with minimum 1 year of follow-up until death, 18th birthday or 2020 using linked data from the Clinical Practice Research Datalink and Hospital Episodes Statistics. Epilepsy (exposure), depression and anxiety (outcomes) were identified using a combination of diagnostic codes, and primary care prescribing records. We estimated incident rate ratios (IRR) for anxiety/depression/any MH condition for children with epilepsy compared to their peers using negative binomial regression adjusted for sex, age, and area-level deprivation. ResultsStudy cohort included 510,177 children and young people, of whom 3,011 (0.59%) had epilepsy. Children with epilepsy had higher incidence of any MH condition (IRR: 1.39, 95% CI: 1.11–1.73) and anxiety (IRR: 1.38, 95% CI: 1.06–1.77), with differences in depression being non-significant (IRR: 1.25, 95% CI: 0.92–1.66). DiscussionChildren with epilepsy have higher rates of MH problems than their peers. Further work will examine if this can be partially explained by increased opportunity for MH diagnosis due to more healthcare contacts. Our findings emphasise the importance of integrated care models that address both neurological and psychological aspects of epilepsy management.

WP3.16 - Comparing Outcomes in Acute Upper Gastrointestinal Bleeding: Initial Presentation versus In-hospital Incidence - A Single-Centre Investigation

Abstract Aims Acute upper gastrointestinal bleeding (AUGIB) is a gastrointestinal emergency with varied patient outcomes. We aimed to compare the outcomes of patients whose primary admission presentation was AUGIB versus inpatients who subsequently developed AUGIB as a complication. Methods This was a retrospective study of all adult patients receiving endoscopy for AUGIB in a single surgical unit from September 2021 to September 2022. Patient demographics, laboratory results, medical history and clinical progress, 30 and 90-day mortality were compared. Results 145 patients were identified, 75 (51.7%) were male and median age was 65 years (IQR 53-75). 117 presented to hospital with AUGIB (group 1) and 28 developed AUGIB as an inpatient (group 2). Median length-of-stay was 3.3 vs 10 days, respectively (p=0.014). Group 2 were more likely to present with symptomatic anaemia (p=0.001), higher National Early Warning System scores (p&amp;lt;0.001), shock (p&amp;lt;0.001), higher Glasgow-Blatchford score (p&amp;lt;0.001) and require blood transfusions (p&amp;lt;0.001). Group 2 had higher ASA Scores (p&amp;lt;0.001) and higher 30-day and 90-day all-cause mortality. No statistical correlations were noted regarding the distribution of endoscopic diagnoses obtained between both groups.Group 1(n=117)Group 2(n=28)P-Value30-Day all-cause Mortality4 (3.4%)4 (14.3%)0.02490-Day all-cause Mortality9 (7.7%)8 (28.6)0.002 Conclusion Our results echo previous studies that patients who develop AUGIB whilst an inpatient have significantly poorer outcomes. Causation is likely multifactorial and warrants further study. It remains important to closely apply the AUGIB care bundle and early critical care input to optimize outcome.

Implementation of a Speech-Language Pathologist–Led Tracheostomy Team in a Level 1 Trauma Hospital

Purpose: Cited benefits of a tracheostomy team include reduction in adverse events, length of stay (LOS), and hospital costs. However, there is a lack of research regarding the implementation and benefits of a speech-language pathologist (SLP)-led tracheostomy team. Our goal is to evaluate the effect of an SLP-led tracheostomy team in trauma patients. Method: An SLP-led tracheostomy team was implemented in the trauma service at Hospital Corporations of America Florida Kendall Hospital as a quality improvement project. Data were collected from January 1, 2021, to August 31, 2022. Patients were divided into a pre-tracheostomy team cohort, which served as a historical control, and a post-tracheostomy team cohort. SLP consult, days to SLP consult, Passy-Muir Valve (PMV) use, days to PMV, oral diet, days to start oral diet, downsizing the tracheostomy tube, days to downsize, decannulation, days to decannulation, and LOS were the outcome measures of interest. Pearson's chi-square and Mann–Whitney tests were used to evaluate for a significant difference ( p &lt; .05) between the pre-tracheostomy team cohort and the post-tracheostomy team cohort. Results: Ninety-one patients were included in the final analysis (36 pre-tracheostomy team cohort, 55 post-tracheostomy team cohort). Pre-tracheostomy team and post-tracheostomy team cohorts were grossly similar ( p &gt; .05) in age, sex, and primary admission diagnosis. We found an increase in SLP consultation (58.3%–89.1%, p &lt; .001), PMV utilization (44.4%–67.3%, p = .031), and decannulation (8.3%–30.9%, p = .011). Days to SLP consult decreased when comparing pre-tracheostomy team to post-tracheostomy team cohorts from 6 to 2, respectively ( p &lt; .001). Conclusions: Our approach of placing the SLP in the leading role is novel. After implementation of an SLP-led tracheostomy team, we saw improved outcomes of tracheostomy patients in the trauma population. SLPs should be included as integral members and potential leaders of tracheostomy teams based on their experience and expertise in tracheostomized patient care.

Prediction of primary admission total charges following cervical disc arthroplasty utilizing machine learning

BACKGROUND CONTEXTCervical disc arthroplasty (CDA) has become an increasingly popular alternative to anterior cervical discectomy and fusion, offering benefits such as motion preservation and reduced risk of adjacent segment disease. Despite its advantages, understanding the economic implications associated with varying patient and hospital factors remains critical. PURPOSETo evaluate how hospital size, geographic region, and patient-specific variables influence charges associated with the primary admission period following CDA. STUDY DESIGNA retrospective analysis using machine learning models to predict and analyze charge factors associated with CDA. PATIENT SAMPLEData from the National Inpatient Sample (NIS) database from 2016 to 2020 was used, focusing on patients undergoing CDA. OUTCOME MEASURESThe primary outcome was total charge associated with the primary admission for CDA, analyzed against patient demographics, hospital characteristics, and regional economic conditions. METHODSMultivariate linear regression and machine learning algorithms including logistic regression, random forest, and gradient boosting trees were employed to assess their predictive power on charge outcomes. Statistical significance was set at the 0.003 level after applying a Bonferroni correction. RESULTSThe analysis included 3,772 eligible CDA cases. Major predictors of charge identified were hospital size and ownership type, with large and privately owned hospitals associated with higher charges (p<.001). The Western region of the U.S. also showed significantly higher charges compared to the Northeast (p<.001). The gradient boosting trees model showed the highest accuracy (AUC=85.6%). Length of stay and wage index were significant charge drivers, with each additional inpatient day increasing charges significantly (p<.001) and higher wage index regions correlating with increased charges (p<.001). CONCLUSIONSHospital size, geographic region, and specific patient demographics significantly influence the charges of CDA. Machine learning models proved effective in predicting these charges, suggesting that they could be instrumental in guiding economic decision-making in spine surgery. Future efforts should aim to incorporate these models into broader clinical practice to optimize healthcare spending and enhance patient care outcomes.

Navigating complex care pathways-healthcare workers' perspectives on health system barriers for children with tuberculous meningitis in Cape Town, South Africa.

Tuberculous meningitis (TBM) occurs when tuberculosis (TB) bacilli disseminate and seed into the meninges, triggering a severe inflammatory response that often leads to brain infarction. It is the most severe and debilitating form of childhood TB with high mortality, and children who survive TBM often suffer lifelong physical and neuro-disability resulting in emotional, social, and economic burdens for families. In the early stages the symptoms may be non-specific and so the diagnosis is often made late when the patient already has significant brain injury. To facilitate earlier diagnosis, it is important to understand how patients are evaluated. This study aimed to chart health systems for paediatric TBM care at both primary healthcare (PHC) and hospital level in Cape Town, South Africa. We conducted fourteen in-depth interviews and eight days of semi-structured observations of patient flow across eight healthcare facilities. We found that children with TBM navigate multiple levels of care categorised into pre-admission and primary care, hospital admission and inpatient care, and post-discharge follow-up care. Healthcare workers identified the following health system barriers along the TBM care pathway for children: limited post-training and mentorship opportunities to manage TBM, overburdened facilities, time constraints, lack of recognition of TBM symptoms, delays in referral between PHC and hospital, lack of standardized diagnostic algorithms, limited diagnostic tests and a lack of child-friendly, easy-to-administer treatment. Regular and compulsory training on TB and TBM in children, including continuous mentoring and support to healthcare workers working in child health and TB services in high TB-burden settings, can facilitate early recognition of symptoms and rapid referral for diagnosis. Algorithms outlining referral criteria for patients with possible TBM at both PHC facilities and district level hospitals can guide healthcare providers and facilitate timely referral between different levels of healthcare services. An integrated data system and alert functions could flag multiple healthcare visits and improve communication between different healthcare facilities during diagnosis and treatment. Children and families affected by TBM are an especially vulnerable sub-population requiring high priority attention and support.

Association of accelerometer-derived “weekend warrior” moderate to vigorous physical activity, chronic kidney disease and acute kidney injury

ObjectiveTo examine the relationship between an accelerometer-derived “weekend warrior” pattern, characterized by achieving the most moderate to vigorous physical activity (MVPA) over 1–2 days, as opposed to more evenly distributed patterns, with risk of chronic kidney disease (CKD) and acute kidney injury (AKI). Methods77,977 participants without prior kidney diseases and with usable accelerometer data (collected between 2013 and 2015) were included from the UK Biobank. Three physical activity patterns were compared: active weekend warrior pattern (achieving ≥150 min MVPA per week and accumulating ≥50 % of total MVPA in 1–2 days), active regular pattern (achieving ≥150 min MVPA but not meeting active weekend warrior criteria per week), and inactive pattern (<150 min MVPA per week). The study outcomes included incident CKD and AKI, ascertained through self-report data and data linkage with primary care, hospital admissions, and death registry records. ResultsDuring a median follow-up of 6.8 years, 1324 participants developed CKD and 1515 developed AKI. In multivariable-adjusted models, when compared with inactive participants, individuals with active weekend warrior pattern (CKD: hazard ratio [HR], 0.79, 95 % confidence interval [CI], 0.69–0.89; AKI: HR, 0.70, 95 %CI, 0.62–0.79) and those with active regular pattern (CKD: HR, 0.81, 95 %CI, 0.69–0.95; AKI: HR, 0.79, 95 %CI, 0.68–0.91) exhibited a similar and significantly lower risk of incident CKD and AKI. Similar findings were observed at the median threshold of ≥230.4 min of MVPA per week. ConclusionConcentrated MVPA within 1 to 2 days is as effective as distributed ones in decreasing the risk of renal outcomes.

Time to Dementia Diagnosis Among Veterans with Comorbid Insomnia and Depressive Episodes.

Older adults with heart failure are at elevated risk of Alzheimer's disease and related dementias (AD/ADRD). Research suggests that insomnia and depressive episodes contribute somewhat dissociable impacts on risk for AD/ADRD in this patient population, although the temporal ordering of effects is unknown. This study examined time to dementia diagnosis among patients with comorbid insomnia and/or depressive episodes in an epidemiological sample. Secondary data analyses were conducted using a cohort study of 203,819 Veterans with a primary admission diagnosis of heart failure in 129 VA Medical Centers. Patients with diagnoses of both insomnia and depressive episodes had the shortest time to a dementia diagnosis at both 1-year (Hazard ratio = 1.43, 95% CI [1.36, 1.51]) and 3-year follow-up time points (Hazard ratio = 1.40, 95% CI [1.34, 1.47]) versus patients with one or neither comorbidity. Individuals with both comorbidities had the shortest time to dementia onset. Screening for these comorbidities may help to identify patients at elevated risk of dementia who could benefit from enhanced monitoring or early intervention strategies for more rapid detection and management of dementia symptoms.

Evaluating frailty using themodified frailty index for colonic diverticulardisease surgery: analysis of the national inpatient sample 2015-2019.

Frailty has been associated with increased postoperative mortality and morbidity; however, the use of themodified frailty index (mFI-11) to assess patients undergoing surgery for diverticular disease has not been widely assessed. This paper aims to examine frailty, evaluated by mFI-11, to assess postoperative morbidity and mortality among patients undergoing operative intervention for colonic diverticular disease. We used data from the Healthcare Cost and Utilization Project National Inpatient Sample (October 1, 2015-December 31, 2019). ICD-10-CM codes were utilized to identify a cohort of adult patients with a primary admission diagnosis of diverticulitis. mFI-11 items were adapted to correspond with ICD-10-CM codes. Patients were stratified into robust (mFI < 0.27) and frail (mFI ≥ 0.27) groups. Primary outcomes were in-hospital postoperative morbidity and mortality. Secondary outcomes included system-specific postoperative complications, length of stay (LOS), total admission cost, and discharge disposition. Multivariable regression models were fit. Of the 26,826 patients, there were 24,194 patients with mFI-11 < 0.27 (i.e., robust) and 2,632 patients with mFI-11 ≥ 0.27 (i.e., frail). Adjusted analysis showed significant increases in postoperative mortality (aOR 2.16, 95% CI 1.38-3.38, p = 0.001) and overall postoperative morbidity (aOR 1.84, 95% CI 1.65-2.06, p < 0.001). LOS was higher in the frail group (MD 1.78days, 95% CI 1.46-2.11, p < 0.001) as well as total cost (MD $25,495.19, 95% CI $19,851.63-$31,138.75, p < 0.001). In the elective setting, a high mFI-11 (i.e., presence of the variables comprising the index) could alert clinicians to the possibility of implementing preoperative optimization strategies. In the emergent setting, a high mFI-11 may help guide prognostication for these vulnerable patients.

Thiotepa/cyclophosphamide (TT/Cy) preparative regimen for patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic stem cell transplantation.

6556 Background: Total body irradiation (TBI)-based preparative regimens have been standard for patients with ALL undergoing allogeneic stem cell transplant (SCT). It is unclear if chemotherapy-only regimens are equally efficacious. Here, we present the largest reported experience with myeloablative TT/Cy in patients with ALL undergoing allogeneic SCT and compare outcomes with TBI-based regimens. Methods: Patients with ALL receiving myeloablative allogeneic SCT at Indiana University from 2007-2020 were included. TT/Cy consisted of TT 15 mg/kg and Cy 120 mg/kg. TBI/Cy consisted of 13.2 Gy in 8 fractions and Cy 3600 mg/m2 or etoposide 60 mg/kg. The primary endpoint was overall survival (OS). Secondary endpoints included relapse-free survival (RFS), engraftment, and toxicities within the first 100 days. Median follow up for surviving patients is 2,532 (range 599-4,762) days. Results: 80 patients with ALL of median age 40 (range 22-59 years) received conditioning with TT/Cy (n=25) versus TBI/Cy or TBI/etoposide (n=55). Baseline characteristics were similar. For patients receiving TT/Cy, the median OS was not reached, and the 4-year OS was 54.5% (95% confidence interval [CI], 34.3-74.7%), compared with a median OS of 1,491 days and a 4-year OS of 50.9% (95% CI, 37.8-64.2%) for those receiving TBI-based conditioning (p=.75). Similarly, for TT/Cy patients, the median RFS was 847 days and 4-year RFS was 43.2% (95% CI, 23.4-63%), not significantly different from median RFS of 1491 days and 4-year RFS 50.2% (95% CI 36.9-63.5; p=.232) for recipients of TBI regimens. On multivariable analysis, only a higher disease risk index was associated with significantly worse OS (p&lt;.001), while conditioning regimen was not predictive of OS. Similarly, there was no significant difference in RFS between TT/Cy and TBI-based regimens on either univariable or multivariable analysis. Secondary endpoints are summarized in the table. As shown, TT/Cy was associated with significantly lower incidence of mucositis, TPN usage, bacterial infection, sinusoidal obstruction syndrome (SOS), and longer length of stay of primary transplant admission. Conclusions: While there was no significant difference in OS or RFS for patients receiving either TT/Cy or TBI-based conditioning, TBI was associated with greater toxicity. Our data suggests that TT/Cy is an acceptable alternative to TBI-based conditioning for ALL patients undergoing myeloablative allogeneic SCT. [Table: see text]

Improved survival for myeloid malignancy patients receiving thiotepa/cyclophosphamide (TT/Cy) versus total body irradiation/cyclophosphamide (TBI/Cy) conditioning and allogeneic stem cell transplantation.

6555 Background: TBI/Cy is a commonly used conditioning regimen prior to allogeneic stem cell transplant (SCT). Chemotherapy only regimens, mostly containing busulfan, have been shown to be effective and less toxic in patients with myeloid malignancies. Here, we present the largest reported experience with a non-busulfan myeloablative chemotherapy regimen of TT/Cy in myeloid malignancy patients undergoing allogeneic SCT and compare outcomes with TBI/Cy. Methods: Patients with myeloid malignancies receiving allogeneic SCT at Indiana University from 2007-2020 were included. TT/Cy consisted of TT 15 mg/kg and Cy 120 mg/kg. TBI/Cy consisted of 13.2 Gy in 8 fractions and Cy 3600 mg/m2. The primary endpoint was overall survival (OS). Secondary endpoints included relapse-free survival (RFS), engraftment, and toxicities within the first 100 days. Median follow up for surviving patients is 2,046 (range 816-5,572) days. Results: 225 patients with AML (n=160), CML (n=45), and MDS (n=30) of median age 44 (range 19-59 years) received conditioning with TT/Cy (n=159) or TBI/Cy (n=66). Baseline characteristics were similar. For TT/Cy patients, the median OS was not reached, and 4-year OS was 57.2% (95% confidence interval [CI], 49.2-65.2%), which was significantly better than with TBI/Cy, with median OS 373 days and 4-year OS 33.9% (95% CI, 22.3-45.5%; p&lt;.001). Similarly, for TT/Cy patients, the median RFS was not reached and 4-year RFS was 59.2% (95% CI, 52-67.2%), significantly better than median RFS of 341 days and 4-year RFS 35.2% (95% CI, 23.7-46.9%; p&lt;.001) for recipients of TBI/Cy. On multivariable analysis adjusting for age, sex, diagnosis, disease risk, comorbidity index (HCI), and degree of stem cell source, TT/Cy had significantly lower risk of death (HR 0.44, 95% CI, 0.30-0.65; p&lt;.001) together with female sex (p=.03) and lower HCI (p=.046). As shown in the Table summarizing secondary endpoints, TBI/Cy was associated with significantly higher rates of mucositis, sinusoidal obstruction syndrome (SOS), TPN usage, multiorgan failure, and length of stay of primary admission. Conclusions: TT/Cy is an efficacious regimen for patients with myeloid malignancies undergoing myeloablative allogeneic SCT with less toxicity and improved RFS and OS compared with TBI/Cy. TT/Cy should be compared to other non-TBI containing busulfan-based regimens. [Table: see text]

A nationwide analysis of demographic and treatment patterns in admissions for malignant pleural effusions from 2016-2020.

1618 Background: Malignant pleural effusions are an indicator of metastatic malignancy, with poor survival and need for palliative procedures to alleviate symptoms. Our study aims to identify the disparities in the utilization of these procedures and their effects on hospitalization outcomes. Methods: The Nationwide Inpatient Sample (NIS) was used to identify all adult hospitalizations with malignant pleural effusion (MPL) between the years 2016-2020. We studied patient demographics and treatment modalities during admission. The study's primary outcome measure was to identify the difference in the total length of stay (LOS) and total healthcare cost (THC)incurred during admission. The secondary outcome was mortality rates among patients undergoing these procedures. Statistical analysis was done using multivariate linear and logistic regression models. Results: A total of 439,245 admissions for MPL were identified, constituting 0.2% of all U.S. admissions. Among these, 59.6% were females and mean age was 67.3 years. There were 68% Whites, 15% Blacks, 8% Hispanics, 4% Asians or Pacific Islanders, 0.4% Native Americans, and 2.9% others. About 61% had Medicare, 11.2% Medicaid, 25.7% Private insurance, and 1.9% Self-pay. Most admissions occurred in teaching hospitals (76.3%), urban settings (94.5%), and hospitals with larger bed strength (56.1%). The most common primary admission diagnosis was sepsis (8.3%). The most common primary malignancies were Lung (39.9%), breast (27.9%), gastrointestinal (9%), and hematopoietic malignancies (7.1%). We studied rates of thoracocentesis, Pleurodesis, Decortication, and intrapleural chemotherapy. The mean LOS and THC increased in admissions where procedures were performed, highest for decortication (12.1 days, p&lt;0.01). However, the odds of death in hospitals significantly reduced. When compared to primary lung cancer causing malignant effusions, primary G.I., renal, urinary, and upper aerodigestive malignancies with MPL had significantly higher mortality rates (p&lt;0.05). Disparities were observed in procedures performed, with women having 29% lower odds of undergoing decortication (p&lt;0.001). African Americans had lower odds of undergoing any procedures for MPL when adjusted for age, sex insurance status, compared to whites. Teaching hospitals had 10.9 times higher odds of performing thoracocentesis but lower odds of performing pleurodesis and decortication (p&lt;0.05). Conclusions: This investigation provides insights into the favorable impact of invasive procedures on in-hospital mortality for malignant pleural effusions, suggesting a possibility that patients with better performance status underwent such interventions. We also noted racial and sex-based disparities in the performance of these procedures. Further studies are essential to identify the reasons for this disparity to help promote equitable care.

Neutropenic Sepsis in the Intensive Care Unit: Differences in Clinical Profile and Outcomes According to the Cause of Neutropenia.

Neutropenic sepsis frequently requires admission to an intensive care unit (ICU). Differences between subgroups of patients with neutropenic sepsis are not well characterized. To investigate clinical outcomes among patients with neutropenic sepsis and hematological malignancy, metastatic solid cancer, or no cancer diagnosis. Retrospective cohort study of all patients admitted to ICU in Australia or New Zealand between January 2000 and December 2022 with a primary admission diagnosis of sepsis and total white cell count <1.0 × 109 cells/L. We identified 8617 ICU admissions with neutropenic sepsis (hematological malignancy n = 4660; metastatic solid cancer n = 1034; no cancer n = 2800). Patients with hematological malignancy were younger (median, 61.5 years) with low rates of chronic comorbidities (4.7%) and were usually admitted to ICU from the ward (67.4%). Mechanical ventilation rates were 20.2% and in-hospital mortality was 30.6%. Patients with metastatic solid cancers were older (median, 66.3 years), with higher rates of chronic comorbidities (9.9%), and were usually admitted to the ICU from the emergency department (50.8%). Mechanical ventilation rates were 16.9% and in-hospital mortality was 42.4%. Patients with no documented cancer had highest rates of mechanical ventilation (41.7%) and mortality (46.3%). Neutropenia was independently associated with mortality among patients with solid cancers or no cancer but did not confer increased risk among patients with hematological malignancy (odds ratio, 0.98; 95% confidence interval, .90-1.06; P = .60). Patients with neutropenic sepsis and hematological malignancy, metastatic solid cancer, or no cancer diagnosis constitute 3 distinct clinical groups. Management approaches should be tailored accordingly.

Sex and age significantly modulate cardiovascular disease presentation in type 2 diabetes: a large population-based cohort study.

We aimed to describe and compare the incidence of the first cardiovascular event and its major subtypes, coronary heart disease (CHD), cerebrovascular disease, heart failure (HF), or peripheral artery disease (PAD), according to age and sex in a population-based cohort of individuals with type 2 diabetes (T2D) from a Mediterranean region. We used linked primary care electronic medical reports, pharmacy-invoicing data, and hospital admission disease registry records from the SIDIAP database, which contains linked data for 74% of the Catalonian population. We selected individuals with T2D aged 30 to 89 years free of cardiovascular disease (CVD). The primary outcome was the first presentation of CVD. The study cohort included 247,751 individuals (48.6% women, 66.8 ± 11.9 years). During a 6.99-year follow-up, the cumulative incidence of the first cardiovascular event was 23.4%. Men were at higher risk for CVD (hazard ratio [HR]: 1.47 95%CI: 1.45-1.50), CHD (HR: 1.52 95%CI: 1.47-1.57), cerebrovascular disease (HR:1.07 95%CI: 1.03-1.10) and PAD (HR: 2.30 95%CI: 2.21-2.39) than women but at a lower risk for HF (HR:0.70 95%CI: 0.68-0.73). CHD and PAD were the most frequent CVD presentations among men (28.1% and 27.5%) and HF (40.1%) in women. CHD predominated among young participants of both sexes, while HF predominated among women older than 65 and men older than 75. In individuals with T2D, the overall risk and the type of first CVD manifestation largely varied by sex and age. This epidemiological evidence should be considered in clinical practice.

Assessment of Safe Early Fixation Strategies in a Cohort Polytraumatized Patients – How is the Surgical Treatment Influenced by the Injury Pattern?

Abstract Background While the inital assessment and the intial treatment of potentially life-threatening injuries is well-described, the surgical treatment strategy following initial resuscitation remains controversial. Timepoint of surgery and type of surgery still reamin topic of discussions. Various, different strategies for optimal timing of fracture fixation in polytrauma patients exist. Aims This study tests the hypothesis that a concept of clearing patients for early definitive surgery that relies on anatomical and physiologic parameters is influenced by the injury distribution. Methods Polytrauma patients treated at a Level 1 trauma center (01.01.2016 - 31.12.2018). Inclusion: primary admission, injury severity score (ISS) ≥16points, requirement of surgical fixation of major extremity or a truncal injury. Exclusion: death &amp;lt;72h after admission, severe traumatic brain injury (TBI). Stratification according to surgical fixation concept: Early total care (ETC, all surgeries &amp;lt;24 h), safe definitive surgery (SDS, staged surgeries &amp;lt;72h), and damage control orthopaedics (DCO, definitive care after stabilization). Endpoints: mortality, complication rates. Parameters of interest: Injury severity and distribution (ISS/AIS), pathophysiologic parameters of hemorrhagic shock, coagulopathy, hypothermia, soft tissue trauma. Results 527 patients, mean age 54.8 SD19.9 years, mean ISS 26.9 SD9.0 points, mortality 20.5%. Group ETC (n=21, 3.9%), Group SDS (n = 284, 53.9%), Group DCO (n = 222, 42.1%). Abdominal and spinal injuries associated with ETC (AIS Abdomen; OR 2.1, 95%CI 1.1 to 4.0, p = 0.026: AIS Spine OR 2.0, 95%CI 1.2 to 3.4, p = 0.007). Extremity and pelvic injuries associated with SDS (OR 1.8, 95%CI 1.1 to 2.8, p = 0.012 and OR 1.3, 95%CI 1.0 to 1.7, p = 0.036), head injuries associated with DCO (OR1.5, 95%CI 1.3 to 1.8, p &amp;lt;0.001). Head injuries were most relevant for mortality and were associated with patients undergoing DCO (29.7%) (ETC; 23.8%, SDS; 13.0%). Conclusion The concept of staged early fixation for major extremity and axial injuries (SDS) was successfully applied in the majority of patients. Predominant head and abdominal injuries were associated with ETC or DCO. The injury distribution influences decision making towards surgical management that is associated with a low complication rate.

In-Hospital Mortality in Patients with and without Dementia across Age Groups, Clinical Departments, and Primary Admission Diagnoses.

Studies have reported higher in-hospital mortality rates in patients living with dementia (PlwD) with limited evidence across age groups, clinical departments, and admission diagnoses. The aim of this study was to compare the in-hospital mortality rate of PlwD with patients without dementia across groups, clinical departments, and admission diagnoses. This case-control study included patients aged ≥ 60 years hospitalized in 1 of 14 German hospitals between January 2019 and July 2023. PlwD were matched to patients without dementia. The associations between dementia and in-hospital mortality across groups were assessed using univariable logistic regression analyses. 15,956 patients with and 15,956 without dementia were included (mean age: 83.9 years, 60.7% female). PlwD had a significantly higher in-hospital mortality rate (14.0% vs. 11.7%; OR 1.24, 95% CI: 1.16-1.32) than non-dementia controls. The highest excess mortality rate was observed in the youngest age group (60-70 years: 10.9% vs. 5.7%; OR: 2.05, 95% CI: 1.30-3.24), decreased with age, and became non-significant in the oldest age group (≥90 years: 16.2% vs. 17.3%; OR: 0.93, 95% CI: 0.80-1.08). Significant differences were found for digestive system disorders (OR: 1.59; 95% CI: 1.15-1.89), cardiovascular and cerebrovascular disorders (OR: 1.51; 95% CI: 1.30-1.75), endocrine, nutritional, and metabolic diseases (OR: 1.42; 95% CI: 1.06-1.90), and pneumonia (OR: 1.20; 95% CI: 1.04-1.37), as well as for all clinic departments except for geriatric departments. The excess mortality rate was highest in younger age groups, where the general mortality and complication rate is relatively low in the general population. Appropriate approaches are needed, especially in non-geriatric wards.

OA20 Serious infections hospital admissions and mortality in patients with early inflammatory arthritis: results from the National Early Inflammatory Arthritis Audit

Abstract Background/Aims To identify the risk of serious infections (SI) according to initial treatment strategy, using conventional synthetic disease modifying anti-rheumatic drugs (csDMARD) and corticosteroids, in patients recruited to the National Early Inflammatory Arthritis Audit (NEIAA). Methods An observational cohort study design was used. The population included adults in England with a new onset rheumatoid arthritis (RA), fulfilling ACR/EULAR 2010 criteria, between April 2018-March 2021. Outcomes studied were SI, defined by infections requiring hospitalisation (primary admission diagnosis/nosocomial acquisition) or death (SI stated on death certificate), identified using NHS Digital linkage. Patients' characteristics were tabulated by treatment strategies. Hazard ratios (HR) were calculated using single failure Cox proportional-hazards models, with confounders-adjusted models (age, gender, smoking status, comorbidities, social deprivation) and fully-adjusted models including disease factors (seropositivity, DAS28). Individuals were considered at risk from the date of RA diagnosis, and censored at SI event, death, or March 2021 (whichever was earliest). Results 20,060 patients with RA were included. Initial DMARD therapy was known for 19,572 patients, of whom 11,966 were on methotrexate/MTX based strategies (mono or combo), 5,059 on csDMARD combination strategies (other than MTX) and 2,547 on no DMARD strategy. 15,319 patients were on corticosteroids at baseline. Mean age 59.5 years (+/-15); 63% female; smoking status (20% current; 30% ex-smokers); comorbidities (21% hypertension; 10% diabetes; and 12% lung disease). Rheumatoid Factor/CCP antibodies were positive in 68%. At presentation, median disease scores were 5.1 (interquartile range [IQR]: 4.0-5.9) for DAS28, 1.1 (IQR: 0.6-1.7) for health assessment questionnaire (HAQ) and 24 (IQR: 16.0-33.0) for musculoskeletal health questionnaire (MSKHQ).There were 519 SI admissions and 17 SI deaths, corresponding to incidence rates per 100 person-years for admissions: 3.19 (95% CI: 2.93-3.48) and deaths: 0.10 (95% CI: 0.06-0.16). In fully-adjusted models, increasing age predicted both SI admissions and deaths. Being a smoker, having a comorbidity, higher disease activity (DAS28), symptom burden (MSKHQ) and disability (HAQ) at presentation associated with more SI admissions. For each 1 unit increase in DAS28, the risk of SI increased by 8% (HR 1.08 [95% CI:1.01-1.16]). Seropositivity did not associate with SI. MTX-based strategies 0.75 (95% CI:0.62-0.91) and csDMARD combination therapy 0.70 (95% CI:0.53-0.94) associated with fewer SI admissions compared to no DMARD. In unadjusted models, corticosteroid associated with more SI admissions 1.29 (95% CI:1.10 -1.62); however, in fully-adjusted models this association was no longer statistically significant. csDMARD strategies did not associated with SI deaths in any of the models. Conclusion Patient and disease factors at diagnosis appear to be important predictors of admissions and mortality for serious infections. Infection risk appears to be greatest in those with higher RA disease activity. An important limitation is that NEIAA does not capture data on treatment changes over time and steroid use beyond baseline. Disclosure M. Adas: None. K. Bechman: None. M. Russell: Honoraria; Lilly and Menarini. Other; upport for attending conferences from Lilly, Pfizer, Janssen, and UCB, and advisory board fees from Biogen.. I. Karafotias: None. D. Nagra: None. S. Patel: None. S. Gallagher: None. E. Price: None. M. Garton: None. A. Rutherford: None. A. Cope: None. S. Norton: None. J. Galloway: Honoraria; from Abbvie, Biovitrum, Bristol Myers Squib (BMS), Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi, and UCB.

Brief report: Effect of cardiac multi-morbidity on COVID hospitalization outcomes.

The COVID-19 pandemic has stretched healthcare resources thin and led to significant morbidity and mortality. There have been no studies utilizing national data to investigate the role of cardiac risk factors on outcomes of COVID hospitalizations. The aim of this study was to examine the effect of cardiac multimorbidity on healthcare utilization and outcomes among COVID hospitalizations during the first year of the pandemic. Using the national inpatient sample (NIS), we identified all adult hospital admissions with a primary diagnosis of COVID in 2020, using International Classification of Diseases, Tenth Revision, Clinical Modification codes (ICD010-CM). Coronary artery disease, diabetes mellitus, heart failure, peripheral vascular disease, previous stroke, and atrial fibrillation were then identified as cardiac comorbidities using ICD-10-CM codes. Multivariable logistic regression was used to evaluate the effect of cardiac multimorbidity on mortality and mechanical ventilation. We identified 1,005,040 primary COVID admissions in 2020. Of these admissions, 216,545 (20.6%) had CAD, 413,195 (39.4%) had DM, 176,780 (16.8%) had HF, 159,700 (15.2%) had AF, 30735 (2.9%) had PVD, and 25,155 (2.4%) had a previous stroke. When stratified by number of comorbidities, 428390 (40.8%) had 0 comorbidities, 354960 (33.8%) had 1, 161225 (15.4%) had 2, and 105465 (10.0%) had 3+ comorbidities. COVID hospitalizations with higher cardiac multimorbidity had higher mortality rates (p<0.001) higher MV rates (p<0.001). In our multivariable regression, these associations remained with increasing odds for mortality with each stepwise increase in cardiac multimorbidity (1: OR 1.48 (1.45-1.50); 2: OR 2.13 (2.09-2.17); 3+: OR 2.43 (2.38-2.48), p<0.001, all). Our study is the first national examination of the impact of cardiac comorbidities on COVID outcomes. A higher number of cardiac comorbidities was associated with significantly higher rates of MV and in-hospital mortality, independent of age. Future, more granular, and longitudinal studies are needed to further examine these associations.

P021 Uptake, safety, and effectiveness of pneumococcal vaccination in adults with immune mediated inflammatory diseases: a UK wide study using data from the Clinical Practice Research Datalink

Abstract Background/Aims The safety and effectiveness of pneumococcal vaccine in people with immune mediated inflammatory diseases (IMIDs) is not known, which may contribute to suboptimal uptake. We investigated UK wide pneumococcal vaccine uptake in adults with IMIDs, the association between pneumococcal vaccination and disease flares, and the effectiveness of pneumococcal vaccine in preventing pneumonia in this at-risk population. Methods Adults with incident rheumatoid arthritis (RA), inflammatory bowel disease (IBD), systemic lupus erythematosus (SLE) and spondyloarthritis (SpA) prior to 31st August 2018 in the Clinical Practice Research Datalink (CPRD) Gold were included. The study was approved by CPRD research data governance (Reference 21_000614). We calculated the proportion of patients vaccinated against pneumococcal pneumonia. To investigate the association between vaccination and IMID flare, we employed a self-controlled case series analysis, adjusted for season. The study period was up-to six-month before and six-month after the date of pneumococcal vaccination. This period was partitioned into induction (14 days pre-vaccination) and exposed periods (up-to 90 days post vaccination) with the remaining time considered unexposed. Incidence rate ratios (IRR) and 95% CI were calculated. We conducted a multivariable nested case-control study to assess vaccine effectiveness. Cases were patients hospitalised with pneumonia and were matched to up to ten controls for age and sex. Multivariable conditional logistic regression was used to calculate odds ratio (OR) and 95% CI. Results We included 32,277 IMID patients: 14,151 with RA, 13,631 with IBD, 3,804 with SpA and 691 with SLE. Overall uptake of pneumococcal vaccination was 50% (95% CI 49.4% -50.5%). Vaccination uptake was significantly lower in the under 45-year-olds, in patients with IBD and in those without additional indication for vaccination at 29.7%, 38.4%, 42.7% respectively. In the safety study, data for 1001, 854, 424 vaccinated patients with primary care consultations for joint pain, AIRD flare, and IBD flare respectively were included. Vaccination against pneumococcal pneumonia was not associated with AIRD flare (IRR (95% CI) 1.07 (0.93-1.22)), primary care consultations for joint pain (IRR (95% CI) 0.95 (0.83-1.10)), and IBD flare (IRR (95% CI) 0.82 (0.64-1.06)) in the 90-days post vaccination. The vaccine effectiveness study included 25,707 patients, either with (n = 2,771) or without (n = 22,936) a hospitalisation record for pneumonia after IMID diagnosis. Patients hospitalised for pneumonia compared with their matched controls, had higher odds of current smoking, deprivation, corticosteroid prescriptions, additional indication for vaccination, primary care consultations, hospital admissions and prescriptions. In the multivariable adjusted model, pneumococcal vaccination was associated with reduced odds of hospitalisation for pneumonia (OR (95% CI) 0.88 (0.78-0.98). Conclusion The uptake of pneumococcal vaccine is low in IMID patients. Pneumococcal vaccination is not associated with IMID flare and is protective against pneumonia. These findings call for promotion of pneumococcal vaccination in IMID by health professionals. Disclosure G. Nakafero: None. M.J. Grainge: None. C.D. Mallen: Grants/research support; NIHR, MRC, Versus Arthritis and BMS. T. Card: None. J.S. Nguyen Van-Tam: Consultancies; CSL Seqirus and Moderna. Royalties; AstraZeneca and Sanofi Pasteur. A. Abhishek: Consultancies; NGM Bio, Limbic and Inflazome.. Royalties; UpToDate, Springer, Cadilla Pharmaceuticals.. Grants/research support; AstraZeneca and Oxford Immunotech..