A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

Temporalis muscle thickness correlates with premorbid frailty in patients resuscitated from cardiac arrest

INTRODUCTION

Frailty is associated with mortality and functional outcome after cardiac arrest. Temporalis muscle thickness (TMT) is a measure of sarcopenia, which represents one dimension of frailty. We assessed the correlation between TMT, measured on head computed tomography (CT), and Clinical Frailty Scale (CFS) in patients resuscitated from cardiac arrest.

METHODS

We enrolled adults resuscitated from cardiac arrest who had a head CT obtained within 48 h of collapse. Study investigators prospectively obtained data to determine pre-arrest CFS and blinded investigators measured TMT. We calculated Spearman rank-order correlation to assess the relationship between TMT and CFS. We also performed multivariable regression adjusting for confounders of frailty and sarcopenia.

RESULTS

We enrolled 50 subjects with median CFS 4 [IQR 2-6] and median TMT 6.6 [IQR 5.0-8.9] mm. There was a moderate, negative correlation between TMT and CFS (ρ = -0.52 (p < 0.001)). In linear regression, TMT (R2 = 25%) explained more of the variance in CFS than age (R2 = 17%).

CONCLUSIONS

We found that TMT exhibits a moderate negative correlation with the CFS, supporting TMT as a tool to measure frailty. Measuring TMT in patients with early head CTs after resuscitation from cardiac arrest may allow for characterization of sarcopenia as a dimension of pre-arrest frailty.

Allogeneic stem cell transplantation for MDS-clinical issues, choosing preparative regimens and outcome

Despite the vast heterogeneity of myelodysplastic neoplasm (MDS), treatment options are limited and an allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative approach. While, subsequently, allo-HSCT is the treatment of choice in fit high-risk MDS patients younger than 70 years, it should only be considered in young and fit low-risk MDS patients who suffer from severe and life threatening cytopenias, and fail all available conservative treatment options. With the increasing use of mismatched or haploidentical donors, the majority of MDS patients will have a suitable donor available, however, matched donors should still be preferred if rapidly available. Strategies to prevent relapse after allo-HSCT are scarce, and include the use of donor lymphocytes or the experimental use of hypomethylating agents in patients with impeding relapse detected by MRD or chimerism evaluation. Here, we summarize current treatment options and factors to consider in the context of allo-HSCT in MDS.

Palliative care education as an integrated component of pulmonary rehabilitation: a real-world mixed-methods feasibility study

AIM

To explore the feasibility of integrating palliative care education in pulmonary rehabilitation (PR).

METHODS

A mixed-methods feasibility study was conducted in people with chronic respiratory diseases enrolled in 12-weeks outpatient hospital-based PR. A session about palliative care was integrated in the education content. Feasibility was assessed by attendance to the palliative care session, feasibility and acceptability of outcome assessment, acceptability of the intervention and undesirable effects. After PR, two focus groups were carried out. Descriptive and inductive thematic analyses were performed.

RESULTS

Out of 44 individuals referred to PR, 14 were excluded, six declined to participate and two were referred to another rehabilitation programme. Twenty-two people with chronic respiratory diseases started PR, however, six had discontinued the programme at the time of the palliative care session. Attendance to this session was 81% (n=13/16; 11 chronic obstructive pulmonary disease, 1 severe asthma and 1 interstitial lung disease; 77% men, 65±9 years-old, FEV1 41±21% of predicted). Outcome assessment was completed in 77% (n=10/13) of participants and lasted approximately 90 minutes. Three themes were identified from the focus groups: daily living with a chronic respiratory disease, meaningful care and demystifying misconceptions. Participants found the intervention and outcome assessment acceptable. An improvement in knowledge and change of attitude towards palliative care was considered a major effect of the palliative care session. No undesirable effects were reported.

DISCUSSION

Integrating an education session about palliative care in PR is feasible, meaningful for people with chronic respiratory diseases, and has no undesirable effects. A randomised controlled study is being prepared to strengthen these results.

Association of Rheumatoid Arthritis With Progression of Cognitive Impairment and Risk of Mortality in People With Dementia

BACKGROUND AND OBJECTIVES

Rheumatoid arthritis (RA) has been linked to an increased risk of dementia, yet little is known about how RA affects the progression of cognitive impairment and the risk of mortality in people with dementia. We aimed to investigate whether RA is linked to an accelerated cognitive decline and a higher risk of all-cause mortality in patients with dementia.

METHODS

We conducted a propensity score-matched register-based cohort study based on the Swedish Registry for Cognitive/Dementia Disorders-SveDem. Patients diagnosed with dementia and registered in SveDem between May 1, 2007, and October 16, 2018, were included. The main outcome for the study was cognitive decline, measured by Mini-Mental State Examination (MMSE) score changes over years. The secondary outcome was all-cause death. We used mixed-effects models to examine the association between RA and cognitive decline, and Cox proportional hazards models to investigate the risk of all-cause mortality. We also conducted subgroup analyses to explore the potential effects of sociodemographic, baseline MMSE, comorbidities, and the use of dementia medications on the association between RA and outcomes.

RESULTS

We included 1,685 dementia patients with RA (mean [SD] age, 79.9 [6.7] years; 73.4% were women) and 5,055 dementia patients with non-RA (80.1 [7.5] years; 73.1% were women). The median follow-up was 2.9 years (interquartile range, 1.5-4.6 years) for non-RA and 2.6 years (interquartile range, 1.4-4.2 years) for RA. In total, 111,266 MMSE measurements were available for analysis. Compared with non-RA patients, patients with RA presented faster cognitive decline (β = -0.24 points/y; 95% CI -0.38 to -0.10) and an increased risk of death (hazard ratio 1.15; 95% CI 1.06-1.24). In subgroup analysis, significant interactions were observed between RA and baseline MMSE scores as well as living conditions regarding cognitive decline (p for interaction <0.05).

DISCUSSION

We identified a worse cognitive function and an increased mortality risk in dementia patients with RA compared with non-RA. However, we lacked information on the duration of RA before the onset of dementia and on disease activity, which could influence our findings. Further studies are needed to validate these results in comparable populations.

Lisocabtagene maraleucel for relapsed/refractory large B-cell lymphoma: a cell therapy consortium real-world analysis

ABSTRACT

Lisocabtagene maraleucel (liso-cel) is an autologous CD19-directed chimeric antigen receptor T-cell therapy approved for the treatment of relapsed/refractory large B-cell lymphoma. We present a multicenter retrospective study evaluating safety, efficacy, and resource use of liso-cel in the standard-of-care setting. Patients received commercial liso-cel at 7 US medical centers, and patient selection, toxicity management, and disease assessment followed institutional practices. Among 101 patients who received infusion, the median age was 71 years (35% aged ≥75 years), 68% had a Charlson comorbidity index score of ≥3, and 10% had secondary central nervous system involvement. Median number of prior therapies was 3; and because of comorbidities, 33% would have been ineligible for the TRANSCEND study. Bridging therapy was used in 60% (43% received polatuzumab-based treatment). Any-grade cytokine-release syndrome occurred in 49% (3% grade ≥3) with any-grade immune effector cell-associated neurotoxicity syndrome occurring in 26% (10% grade ≥3). The overall response rate (ORR) to bridging therapy was 45%, with 18% achieving a complete response (CR). Following liso-cel infusion, the day 90 ORR was 66% (60% CR); and with a median follow-up of 15.5 months, 12-month progression-free survival (PFS) and overall survival (OS) were 55% and 68%, respectively. A normal lactate dehydrogenase level before lymphodepletion was associated with improved PFS and OS. These analyses confirm similar efficacy and safety of commercial liso-cel compared with pivotal trial results. Notably, these outcomes were achieved in patients predominantly of advanced age and with significant comorbidities. Results also likely reflect advancements in patient selection, toxicity management, and the use of novel bridging strategies.

Advancing drug development in myelodysplastic syndromes

ABSTRACT

Myelodysplastic syndromes/neoplasms (MDSs) are heterogeneous stem cell malignancies characterized by poor prognosis and no curative therapies outside of allogeneic hematopoietic stem cell transplantation. Despite some recent approvals by the US Food and Drug Administration, (eg, luspatercept, ivosidenib, decitabine/cedazuridine, and imetelstat), there has been little progress in the development of truly transformative therapies for the treatment of patients with MDS. Challenges to advancing drug development in MDS are multifold but may be grouped into specific categories, including criteria for risk stratification and eligibility, response definitions, time-to-event end points, transfusion end points, functional assessments, and biomarker development. Strategies to address these challenges and optimize future clinical trial design for patients with MDS are presented here.

Four decades of lung cancer: Trends in comorbidities and causes of death in a nationwide Danish cohort

BACKGROUND

Lung cancer remains the leading cause of cancer-related deaths globally, with gradual improvements in patient survival attributed to early detection through low-dose computed tomography screening and advances in oncological therapies. Despite these advancements, the management of comorbidities, particularly cardiovascular disease and chronic obstructive pulmonary disease, is critical due to their shared causal link with lung cancer - smoking. This study explores the prevalence of comorbidities among lung cancer patients in Denmark over four decades, using comprehensive national registry data.

METHODS

By examining the Danish National Patient Register and Danish Cancer Registry, we identified all Danish lung cancer cases diagnosed from 1980 to 2018, analyzing comorbidities and causes of death. A comparison cohort matched by age, sex, municipality, and marital status was also established.

FINDINGS

The findings reveal a significant increase in comorbidities among lung cancer patients over time, while this increase was less significant in the comparison cohort. Almost half of lung cancer patients had at least one comorbidity in the most recent period, 2008-2018. Cardiovascular disease, chronic obstructive pulmonary disease, diabetes, stroke, and peripheral atherosclerosis were the most prevalent comorbidities. Among patients diagnosed with lung cancer, it was the cause of death in 84 % of cases. The study also highlights a notable decrease in deaths from ischemic heart disease, with an increase in dementia-related deaths, suggesting an increasing burden of neurodegenerative diseases in aging populations.

INTERPRETATION

This longitudinal analysis highlights that as the burden of comorbidities increases, comprehensive management strategies become increasingly crucial. These strategies could include less invasive diagnostic approaches, such as endobronchial evaluation, as well as treatment options like segmental resection and stereotactic body radiation. Addressing comorbidities alongside cancer treatment may improve patient outcomes and overall quality of life in aging populations.

Cancer screening prevalence and preference among hospitalized women with and without diabetes mellitus

OBJECTIVE

To determine the prevalence of nonadherence to breast cancer and colorectal cancer screening, associated risk factors, and screening preference among hospitalized women with and without diabetes aged 50-75 years who were cancer-free at baseline.

METHODS

A prospective study compared women with and without diabetes who were cancer-free (except for skin cancer) at baseline and between 50 and 75 years of age, admitted to the general medical service at an academic center were approached for study participation from December 1, 2014, to May 31, 2017. The study evaluated breast and colorectal cancer screening nonadherence prevalence, preference for screening locale, sociodemographic and clinical variables associated with nonadherence using multivariable logistic regression model.

RESULTS

Of 510 women, 39% had a prior diagnosis of diabetes mellitus, and 36% were African American. Women with diabetes were more likely to have obesity, reliance on assistive devices for ambulation, inability to work (have a disability), and a greater average number of comorbidities compared to women without diabetes. Women with or without diabetes were equally nonadherent with BRC (28% vs 36%, p = 0.6) and CRC (25% vs 28%, p = 0.51) screening guidelines. After adjustment for sociodemographic and clinical risk factors, only high risk for CRC (OR = 3.20, 95%CI; 1.03-9.91) was an independent risk factor associated with nonadherence to BRC among hospitalized women with diabetes. Whereas after similar adjustment, age younger than 60 years (OR = 2.91, 95%CI; 1.15-7.35) and current or prior smoking (OR = 2.80, 95%CI; 1.14-6.86) were associated with nonadherence to CRC among women with diabetes. 46% of women with diabetes expressed a preference for in-hospital screening for BRC, while 45% expressed a similar preference for CRC.

CONCLUSION

Hospitalizations may offer additional screening opportunities as almost half of the women with diabetes preferred undergoing breast and colorectal cancer screening during a hospital stay.

Preparedness for care transitions to home and acute care use of skilled nursing facility patients

BACKGROUND

The purpose of this study was two-fold: (1) describe the relationship between patient or caregiver reported preparedness for care transitions, and acute care use in 30 days after discharge from a skilled nursing facility (SNF); and (2) explore how this relationship is influenced by patient, Charlson index, race and social determinants.

METHOD

The design was a secondary analysis of data collected as part of a cluster randomized trial of the Connect-Home transitional care intervention. The setting was 6 skilled nursing facilities located in the US state of North Carolina. The sample was 249 patient and caregiver dyads with acute care use data (i.e., emergency department or hospital readmission) in 30 days after transfers from SNFs to home. Preparedness for care transitions was measured with the Care Transitions Measure-15 (CTM-15), a 15 item Likert scaled measure with scores potentially ranging from 0 to 100, with higher scores indicating better preparedness. The association of preparedness and acute care use, in the overall study sample and within subgroups defined by five selected dyad background characteristics, was quantified as an incident rate ratio corresponding to the multiplicative change in the mean number of acute care use days for a 10 unit increase in CTM-15 score, using marginalized zero-inflated negative binomial regression.

RESULTS

Patients had a mean age of 76.4 years, 63.8% were female, and 73.6% were White. Caregivers were female (73.6%) and adult children (42.3%). The mean CTM-15 score was 72.9 and the mean days of acute care use in 30 days after SNF discharge was 0.62. For a 10 unit increase in preparedness score, among male patients the mean number of acute care use days decreased by 33% (IRR = 0.67; 95%CI: 0.44, 0.99); White patients had a 25% reduction (IRR = 0.75; 95%CI: 0.55, 1.02), patients with low area deprivation score (lower quartile, ADI = 54) had a 31% reduction in acute care use (IRR = 0.69; 95%CI: 0.47, 1.01), and patients with a high Charlson total score (upper quartile of 9) have a 22% reduction in acute care use (IRR = 0.78; 95%CI: 0.61, 1.02).

CONCLUSION

Preparedness of care transitions is an important outcome of high-quality SNF care and is associated with reduced use of further acute care. More research is necessary to evaluate the CTM-15 as an outcome measure among sociodemographic subgroups.

Association of socioeconomic status on return to work following primary total hip arthroplasty: a Danish population-based cohort study on 9,431 patients from 2008-2018

BACKGROUND AND PURPOSE

 Return to work (RTW) following primary total hip arthroplasty (THA) is important for patients and society. We aimed to investigate the association between markers of socioeconomic status (SES) and RTW after primary THA, and whether the association is influenced by sex, age, and comorbidity.

METHODS

 Using Danish population-based registries we included 9,431 patients aged 18 to 59 years, undergoing primary THA for osteoarthritis from 2008-2018. Exposure was individual-level data on SES markers (education, income, and cohabitation). Work status information before and after THA was obtained from the Danish Register for Evaluation of Marginalization. We computed cumulative incidence of RTW up to 24 months after THA. The association between SES and RTW was analyzed using Cox regression by hazard ratios with 95% confidence intervals (CI).

RESULTS

 The median time to RTW was 54 days. Cumulative incidence of RTW was 86% by 6 months and 93% by 24 months. The adjusted hazard ratio for RTW was 1.9 (CI 1.8-2.0) for high vs low education, 2.2 (CI 2.1-2.3) for high vs low income, and 1.3 (CI 1.3-1.4) for cohabiting vs living alone. Associations were stronger in male than female patients for all SES markers.

CONCLUSION

 Most patients returned to work within 24 months, with the largest proportion within 6 months. Markers of low SES were associated with delayed RTW, highlighting the importance of enhanced focus on THA patients in socially vulnerable positions to reduce health and financial implications of delayed RTW.

MicroRNA-143-3p and miR-452-5p: A Fingerprint for the Diagnosis of Aortic Stenosis in the Geriatric Population

Background/Objectives: Aortic stenosis (AS) is the most common valvular pathology in the geriatric population and is the primary cause of valve replacement. However, misdiagnoses and delays in treatment are common due to comorbidities, frailty, and sedentary lifestyles among elderly individuals. MicroRNAs (miRNAs) are highly conserved molecular regulators involved in various cellular processes and have gained recognition as reliable biomarkers in cardiovascular diseases. In the present study, we evaluated plasma miRNAs as potential biomarkers for the early diagnosis of AS in the geriatric population to identify early therapeutic strategies. Methods: This prospective, case-control study included 87 individuals over 75 years of age. The participants were divided into AS (n = 58) and control (n = 29) groups. Results: Fifty-four miRNAs were differentially expressed between patients with AS and controls. Among those genes, 29 were upregulated and 25 were downregulated in patients with AS relative to controls. We selected seven candidate genes (miR-185-5p, miR-143-3p, miR-370-3p, let-7d-3p, miR-452-5p, miR-6787-3p, and miR-21-3p) for experimental validation by qRT-PCR. Only miR-143-3p and miR-452-5p were significantly upregulated in the plasma of patients with AS compared with controls. We developed a multiparametric model by combining the two-miRNA signature with echocardiographic parameters (left ventricular ejection fraction, stroke volume, and global longitudinal strain) to increase diagnostic power; this model yielded sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) values of 78.2%, 70.7%, and 0.837, respectively. Conclusions: In clinical practice, the use of a multiparametric model involving this set of miRNAs combined with echocardiographic variables may improve the accuracy of AS diagnosis and risk stratification.

Impact of enhanced recovery after surgery on psychological outcomes in total hip arthroplasty

BACKGROUND

The occurrence of pain catastrophizing, depression, and anxiety is prevalent among patients undergoing primary total hip arthroplasty (THA). The Enhanced Recovery After Surgery protocol (ERAS-P) has demonstrated its efficacy in alleviating peri-operative stress responses in such patients. This study endeavors to explore the influence of ERAS-P on patient satisfaction, as well as the levels of pain catastrophizing, surgery-related anxiety, and depression following primary THA.

HYPOTHESIS

ERAS-P exerts a beneficial influence on patient satisfaction, mitigating pain catastrophizing, and reducing surgery-related anxiety and depression following primary THA.

PATIENTS AND METHODS

Data were retrospectively reviewed for patients who underwent primary THA between 2017 and 2020. Patients in the control group who received usual care were matched in a 1:1 ratio for baseline characteristics to patients in the ERAS-P group who followed ERAS-P. All patients were evaluated and analyzed for pain catastrophizing, depression and anxiety using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS) at postoperative 1 weeks, 6 weeks, 3 months, 6 months and 1 year.

RESULTS

182 patients in the ERAS-P group and 182 in the control group were analyzed using propensity score matching (PSM). Compared to the control group, ERAS-P patients showed significantly higher satisfaction levels (p = 0.002). They also experienced a notable reduction in pain catastrophizing at 1 week, 6 weeks, and 3 months postoperatively (p < 0.05 for all). Anxiety levels decreased markedly at 1 week and 6 weeks (p < 0.001 for both). Depression scores in the ERAS-P group declined significantly at these same time points up to 6 months (p < 0.05 for all). Remarkably, ERAS-P patients exhibited a greater decrease in peri-operative pain catastrophizing and anxiety, accompanied by a faster recovery. However, its effectiveness waned over time, with both groups reporting comparable outcomes within a few months.

DISCUSSION

Patients undergoing THA after adhering to the ERAS-P exhibit a more favorable outcome in improving peri-operative patient-reported depression, anxiety, and pain catastrophizing screenings compared to those following the traditional care scheme. Although these advantages gradually diminished over time, the outcomes for both groups converged to be similar within a few months. Nonetheless, ERAS-P retains its notable advantages for THA patients who grapple with psychological symptoms.

LEVEL OF EVIDENCE

III.

Kidney Transplant Fast Track and Likelihood of Waitlisting and Transplant: A Nonrandomized Clinical Trial

Importance

Kidney transplant (KT) is the optimal treatment for end-stage kidney disease (ESKD). The evaluation process for KT is lengthy, time-consuming, and burdensome, and racial and ethnic disparities persist.

Objective

To investigate the potential association of the Kidney Transplant Fast Track (KTFT) evaluation approach with the likelihood of waitlisting, KT, and associated disparities compared with standard care.

Design, Setting, and Participants

This nonrandomized clinical trial was a prospective comparative cohort trial with a historical control (HC) comparison and equal follow-up duration at a single urban transplant center. Study duration was 2015 to 2018 for KTFT, with follow-up through 2022, and 2010 to 2014 for HC, with follow-up through 2018. Adult, English-speaking patients with ESKD, no history of KT, and a scheduled KT evaluation appointment were included. Among 1472 eligible patients for the KTFT group, 1288 consented and completed the baseline interview and 170 were excluded for not attending an evaluation appointment; among 1337 patients eligible for the HC group, 1152 consented and completed the baseline interview and none were excluded. Data were analyzed from August 2023 through December 2024.

Exposure

Streamlined, patient-centered, coordinated-care KT evaluation process.

Main Outcomes and Measures

Time to waitlisting for KT and receipt of KT.

Results

The study included 1118 participants receiving KTFT (416 female [37.2%]; mean [SD] age, 57.2 [13.2] years; 245 non-Hispanic Black [21.9%], 790 non-Hispanic White [70.7%], and 83 other race or ethnicity [7.4%]) and 1152 participants in the HC group (447 female [38.8%]; mean [SD] age, 55.5 [13.2] years; 267 non-Hispanic Black [23.2%], 789 non-Hispanic White [68.5%], and 96 other race or ethnicity [8.3%]). After adjusting for demographic and clinical factors, the KTFT compared with the HC group had a higher likelihood of being placed on the active waitlist for KT (subdistribution hazard ratio [SHR], 1.40; 95% CI, 1.24-1.59). Among individuals who were waitlisted, patients in the KTFT vs HC group had a higher likelihood of receiving a KT (SHR, 1.21; 95% CI, 1.04-1.41). Black patients (SHR, 1.54; 95% CI, 1.11-2.14) and White patients (SHR, 1.38; 95% CI, 1.16-1.65) receiving KTFT were more likely to be waitlisted for KT than those in the HC group, but no such difference was found for patients with other race or ethnicity. Among Black patients, those with KTFT were more likely than those in the HC group to undergo KT (SHR, 1.52; 95% CI, 1.06-2.16), but no significant differences were found for White patients or those with other race or ethnicity.

Conclusions and Relevance

This study found that KTFT was associated with a higher likelihood of waitlisting and KT than standard care. Findings suggest that KTFT may be associated with reduced disparities in KT by race and ethnicity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02342119.

Comparative analysis of the risk of severe bacterial infection and septicemia in adolescents and young adults with treatment-resistant depression and treatment-responsive depression - a nationwide cohort study in Taiwan

Previous studies have shown an association between depression and increased susceptibility to infection in the general population. However, there has been no prior research specifically examining the relationship between treatment-resistant depression (TRD) and severe bacterial infections (SBI) in adolescents and young adults. This retrospective observational cohort study utilized the Taiwan National Health Insurance Research Database (NHIRD) from 2001 to 2010. It included adolescents (12-19 years of age) and young adults (20-29 years of age) diagnosed with major depressive disorder (MDD), comprising 6958 cases of TRD and 27,832 cases of antidepressant-responsive depression (ARPD). The TRD and ARPD groups were further matched (4:1) by chronological age, age at diagnosis of depression, sex, residence, and family income. The primary outcomes were severe bacterial infections (SBI) and septicemia. Cox regression analysis was conducted to identify the risk of hospitalization due to SBI or septicemia during the follow-up period. Compared with controls, the ARPD group had increased risks of SBI (hazard ratio [HR] with 95% confidence interval [CI]: 3.90, 2.73-5.57) and septicemia (HR, 95% CI: 2.56, 1.34-4.91). Notably, the risks of SBI and septicemia appeared to be further elevated in the TRD group. The TRD group exhibited higher incidences of SBI (HR, 95% CI: 6.99, 4.73-10.34) and septicemia (HR, 95% CI: 2.85, 1.28-6.36) than the control group. Adolescents and young adults with TRD had 6.99-fold and 3.90-fold increased risks of SBI and septicemia compared to individuals without MDD, respectively. Therefore, healthcare providers need to be vigilant when monitoring and implementing preventive measures in this population.

Influence of Frailty on Clinical and Radiological Outcomes in Patients Undergoing Transforaminal Lumbar Interbody Fusion-Analysis of a Controlled Cohort of 408 Patients

Background/Objectives: The concept of frailty has been recognized as an important issue which can influence postoperative outcomes. We aimed to investigate the influence of frailty on clinical and radiological outcomes in patients undergoing transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease. Methods: A single-center, retrospective cohort study was conducted involving 408 patients in whom 506 expandable interbody devices were implanted. The patients were grouped into vulnerable/frail versus well/fit according to the Canadian Frailty Index. Results: The frail patients were older and had a larger number of fused segments (3.0 vs. 2.4 segments, p = 0.009). In the univariate analysis, the frail patients were more likely to experience a postoperative adverse event (AE) until discharge (OR 1.89, 95% CI 1.22-2.92; p = 0.004), three (OR 1.57, 1.07-2.3; p = 0.021), and 12 months postoperatively (OR 3.77, 1.96-7.24; p < 0.001). Following the multivariable logistic regression analysis, frailty remained an independent risk factor for postoperative AEs at 12 months (OR 3.44, 95% CI 1.69-6.99; p = 0.001). Conclusions: Frailty negatively influenced the rate of AEs until 12 months, while the odds of having a favorable outcome at any time remained unaffected in patients undergoing posterior spinal fusion with TLIF. Future efforts are needed to evaluate whether preoperative medical optimization or prehabilitation may positively impact patient outcomes.

Screening to identify people with type 2 diabetes at risk of liver cancer in primary care: a randomised controlled trial protocol

INTRODUCTION

Hepatocellular carcinoma (HCC) is expected to become the third most common cause of cancer death worldwide by 2030. The increase in HCC is in large part due to the rising prevalence of risk factors such as type 2 diabetes mellitus (T2DM). Up to 1 in 20 people living with T2DM have liver cirrhosis, and they have a 1% to 2% incidence of HCC per year. Patients with cirrhosis enter surveillance for HCC to identify early-stage, curable tumours. A diagnosis of T2DM does not mandate testing to identify patients with cirrhosis, with testing restricted to those with additional risks. There has never been a trial and nested cost-effectiveness evaluation comparing screening all patients with T2DM for cirrhosis against usual care.

METHODS AND ANALYSIS

The study will use a multi-centre, unblinded individual randomised controlled trial design. The aim will be to determine the effectiveness and cost-effectiveness of screening all adults with T2DM to identify those at high risk of HCC. The recruitment strategy has been supported by patient and public involvement (PPI). Participants will be identified via an automated search of primary care records and invited to participate via text. 320 participants will be randomised for screening. The screening will include measurement of bio-markers for liver fibrosis (ELF and Fib-4) and vibration-controlled transient elastography. Another 320 participants will be randomised to standard care. Demographic and medical history data will be collected at baseline from all participants. Outcome data will be collected remotely from healthcare records. The primary outcome is the proportion of participants in each arm who are referred to HCC surveillance following testing for liver disease within 12 months of randomisation. The results will be used to calculate the incremental cost-effectiveness ratio of screening via a Markov model.

ETHICS AND DISSEMINATION

The results of this study will be presented directly to National Health Service England. Additional dissemination via conference proceedings and publication will be supported by our PPI team. Ethical approval was granted by the West of Scotland Research Ethics Service on 2 August 2023, REC reference 23/WS/0102.

TRIAL REGISTRATION NUMBER

ISRCTN17017677.

Real-world use and treatment outcomes of ceftazidime-avibactam in gram-negative bacterial infection in Taiwan: A multicenter retrospective study

OBJECTIVES

Ceftazidime-avibactam (CAZ-AVI) has been launched in Asian countries for five years, but local real-world data about patient characteristics, efficacy, and safety of CAZ-AVI is limited. We conducted a multicenter, retrospective study to investigate the clinical characteristics, microbiology, and outcomes of patients treated with CAZ-AVI for Gram-negative bacterial infection in Taiwan.

METHODS

This investigation was conducted as a multicenter retrospective cohort study involving five medical centers in Taiwan. Adult patients with documented/suspected Gram-negative bacterial infection and received ≥ 24 hours of CAZ-AVI were eligible for study cohort enrollment. In-hospital mortality was defined as the primary outcome, while symptom resolution or significant improvement, considered the secondary outcome, was defined as clinical success.

RESULTS

Among the 472 patients treated by CAZ-AVI, 46.2 % (218/472) had respiratory tract infections, 22.0 % (104/472) had complicated urinary tract infections, 14.0 % (66/472) had complicated intra-abdominal infections, and 10.0 % (47/472) had primary bacteremia. Most patients receiving ceftazidime/avibactam in Taiwan are old (mean: 70.6 years old), have a high SOFA score (mean 8.4), and have a high Charlson Comorbidity Index score (345/472, 73.1 % ≥ 4). 90 % of CAZ-AVI were used as targeted therapy for pathogens, including Klebsiella pneumoniae (64.4 %, 304/472), Pseudomonas aeruginosa (17.8 %, 84/472), Escherichia coli (8.3 %, 39/472), and Enterobacter spp. (2.3 %, 11/472). The overall clinical success rate is 58.1 % (274/472). The in-hospital mortality rate is 41.1 % (194/472).

CONCLUSIONS

Most patients receiving CAZ-AVI as targeted therapy in Taiwan with characteristics of older age, high SOFA scores, and high CCI scores. Receiving immunomodulators, higher SOFA score, and Enterobacter spp. infections were the significant factors associated with in-hospital mortality, whereas early initiating CAZ-AVI treatment and CAZ-AVI monotherapy are associated with better outcome.

Oral mucosal lesions in Polish patients with acute myeloid leukemia after allogeneic hematopoietic cell transplantation

The number of allogeneic hematopoietic cell transplantation constantly increases. Therefore, there is an urgent need to carefully analyze the general and oral health state of people with acute myeloid leukemia who underwent this procedure. This study aimed to investigate the type and frequency of oral mucosal lesions in patients with acute myeloid leukemia after allogeneic hematopoietic cell transplantation, depending on the intensity of the conditioning regimen. Eighty patients diagnosed with acute myeloid leukemia were assigned to two groups based on the conditioning used before transplantation. The dental team investigated the oral mucosa in all patients thrice during the treatment. The most common oral pathological lesion in the study group was mucositis, which developed in a significantly higher percentage of patients who underwent myeloablation therapy compared to reduced intensity conditioning (p = 0.0335). Other frequently found eruptions included massive coating on the dorsal tongue surface, petechiae, and exfoliating cheilitis. The type of conditioning did not significantly influence their frequency. A significant increase in post-transplant lesions was observed on the lips, sublingual area, and floor of the mouth. There were no statistically significant differences in the site of lesions depending on the type of conditioning. Oral mucosal pathological changes in the study group were frequent. The type of conditioning influenced the frequency of mucositis but did not affect the frequency and the location of other types of oral mucosal lesions. Providing the patients qualified for chemotherapy with professional dental support is important.

Lung Cancer Surveillance for Patients With Head and Neck Cancer

Importance

Patients with head and neck squamous cell cancer (HNSCC) are at a greater risk of developing pulmonary metastases and/or second primary lung cancer. However, it remains uncertain whether lung screening in these patients, when the initial staging studies are negative, confers any survival benefit.

Objective

To evaluate long-term cancer survival outcomes in patients with HNSCC undergoing chest radiography vs low-dose computed tomography screening for pulmonary metastasis and/or second primary lung cancer.

Design, Setting, and Participants

This randomized parallel trial was conducted at a large academic hospital in Canada enrolling treatment-naive patients with de novo HNSCC from September 2015 to December 2022. Eligible patients did not meet the criteria for lung screening established by the US National Comprehensive Cancer Network guidelines. Participants were randomized to chest radiography or low-dose computed tomography screening groups. Data were analyzed from March to August 2024.

Intervention or Exposure

Comparison of chest radiography vs low-dose computed tomography screening methods.

Main Outcomes and Measures

Primary outcomes were the lung cancer detection rate measured by comparing the sensitivity and specificity of low-dose computed tomography with chest radiography. Secondary outcomes were overall survival and disease-free survival.

Results

A total of 137 patients (mean [SD] age, 65.1 [14.1] years; 34 [24.8%] females and 103 [75.2%] males) were included and randomized, 68 (49.6%) to chest radiography and 69 (50.4%) to low-dose computed tomography. Nine of 137 patients (6.5%) developed a second primary lung cancer (6 patients) or lung metastases (3 patients). There were no clinically meaningful differences in survival outcomes between the 2 groups (hazard ratio, 1.2; 95% CI, 0.4-3.9). Chest radiography exhibited a relatively low sensitivity of 66.7% but a specificity of 100%. Low-dose computed tomography demonstrated both high sensitivity (100%) and specificity (100%), for an overall accuracy of 100%.

Conclusions and Relevance

The findings of this randomized parallel trial indicate that low-dose computed tomography exhibits statistically significant superior sensitivity compared with chest radiography for diagnosing lung metastases and second primary lung cancer. However, there were no important differences in survival rates. These results hold practical significance, offering valuable insights to clinicians who are guiding decisions regarding lung screening protocols.

Trial Registration

ISRCTN10954990.

Common Comorbidities and a Comparison of 4 Comorbidity Indices in Patients Undergoing Orthopaedic Oncology Surgery

BACKGROUND

Comorbidity indices are used to help to estimate patients' length of hospital stay, care costs, outcomes, and mortality. Increasingly, they are considered in reimbursement models. The applicability of comorbidity indices to patients undergoing orthopaedic oncology surgery has not been studied. The purpose of this study was to determine the predominant comorbidities in patients undergoing orthopaedic oncology surgery and to evaluate the predictive value of these indices.

METHODS

Patient demographic characteristics, diagnoses, and preoperative comorbidities were collected retrospectively on 300 patients undergoing orthopaedic oncology surgery between January 2014 and March 2023. In this study, 3 subsets of 100 patients each with malignant primary bone tumors, malignant primary soft-tissue tumors, or osseous metastatic disease were randomly selected. Comorbidities were tabulated and weighted according to the guidelines of the Charlson Comorbidity Index (CCI), the National Institute on Aging/National Cancer Institute (NIA/NCI) index, the van Walraven Index, and the Agency for Healthcare Research and Quality (AHRQ) Index. Two-tailed bivariate Pearson correlations were performed to assess the relationship between the indices and between each index and patient outcomes. Comorbidities in our patient population were compared with those published in other studies.

RESULTS

The predominant comorbidities in patients undergoing orthopaedic oncology surgery were hypertension, deficiency anemias, metastatic disease, recent unintended weight loss or being underweight, and fluid or electrolyte disorders. The percentage of patients with certain comorbidities exceeded those reported in other cancer, orthopaedic, and inpatient populations. The 4 comorbidity indices had variable correlation when assessing our patient population. The number of comorbidities and the weighted scores from all indices demonstrated little to no correlation with length of stay and survival in our patient sample.

CONCLUSIONS

The prevalence of many comorbidities in patients undergoing orthopaedic oncology surgery is greater than those reported in other patient populations. Commonly utilized indices demonstrate variable correlation with one another. With these tools, there was little to no correlation between comorbidities and patient outcomes in our patient population. The comorbidities deemed protective in these tools may underestimate the true assessment of the comorbidities in patients undergoing orthopaedic oncology surgery. This highlights the importance of developing tools to properly assess the comorbidities in defined patient populations, especially as these models are used to set benchmarks for measuring patient outcomes; assessing quality, efficiency, and safety; and determining reimbursement criteria.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Cancer Characteristics, Prognoses, and Mortality of Colorectal Cancer in Patients With Crohn's Disease-A Danish Nationwide Cohort Study, 2009-2019

BACKGROUND AND AIMS

The aim of this study was to investigate the impact of Crohn's disease (CD) on patient and cancer characteristics and mortality in patients with colorectal cancer (CRC).

METHODS

This was a nationwide cohort study of patients diagnosed with CRC in Denmark from 1 January, 2009 to 31 December, 2019. Cancer characteristics were retrieved from the Danish Colorectal Cancer Group registry and merged with a nationwide cohort for inflammatory bowel disease. The main outcome was all-cause mortality in CRC patients with and without CD, comparing CD patients with CRC with those in the general CRC population (non-CD CRC), evaluated by adjusted Cox regression analysis and propensity score matching.

RESULTS

Of 38 077 CRC patients, 245 (0.6%) had CD. The median age at cancer diagnosis was 69 years (interquartile range [IQR]: 60-76) for CD-CRC and 71 years (IQR: 64-78) for non-CD CRC (p < 0.001). Most cancers were located in the right colon in the CD-CRC group. CD was not associated with increased all-cause mortality in the cohort overall. CD patients with colon and rectal cancers and UICC Stage III tumors had a higher mortality rate in both multivariate {hazard ratio (HR) 1.60 (95% confidence interval [95% CI], 1.13-2.27), p = 0.008} and univariate analyses (HR 1.57 [95% CI, 1.11-2.22], p = 0.011). In the propensity score-matched analysis, CD was not associated with increased mortality for colon cancer (HR 1.06 [0.82-1.36], p = 0.7) or rectal cancer (HR 1.25 [0.79-1.98], p = 0.3).

CONCLUSIONS

This nationwide study identified distinct features of colon and rectal cancers in patients with CD that have implications for the timing of diagnoses, disease course, and mortality specifically in UICC Stage III disease.

Reporting of physical activity levels in intensive care unit survivors

The primary aim of this study was to report the physical activity profiles and the functional status of critically ill patients at one-month post-discharge using the 'Physical Activity Scale for the Elderly (PASE)' questionnaire. Study participants included were between 45 and 75 years of age, admitted to ICUs for a minimum of 24 h. Altogether, 110 study participants were included by consecutive sampling, from which six were lost to follow up. This prospective observational study was carried out in the ICU settings of Kasturba Hospital, Manipal. All the participants were assessed for ICU-acquired weakness at ICU discharge and were later followed up after one month for their physical activity level via telephonic follow-up. Participants' mean age was 57.5 ± 9.82 years, out of which 71% were female. The prevalence of ICU-acquired weakness was found to be 80% in these participants. The median PASE score was 5 (2-27) at one-month follow-up among the participants. Medical Research Council (MRC) sum score showed a statistically significant positive moderate association with PASE score ('r = 0.70, p < 0.05). The study showed that about 97.1% of ICU survivors lead a sedentary lifestyle and showed alarmingly high levels of physical inactivity at one month post-hospital discharge.

Patients with systemic autoimmune rheumatic diseases remain at risk for hospitalisation for COVID-19 infection in the Omicron era (2022-2024): a retrospective cohort study

OBJECTIVE

To investigate the risk factors for severe acute COVID-19 outcomes in the Omicron era among individuals with systemic autoimmune rheumatic diseases (SARDs).

METHODS

We identified patients with confirmed SARDs and COVID-19 (positive PCR and/or antigen test) from 1 September 2022 to 15 March 2024 in the Mass General Brigham healthcare system. We estimated the associations of baseline characteristics with the odds of hospitalisation due to COVID-19 infection, verified by medical record review, using multivariable logistic regression.

RESULTS

Of 2061 patients with SARDs and COVID-19 during the Omicron era (75% female, mean age 62.2 years), 134 (6.5%) were hospitalised due to COVID-19, mostly due to respiratory symptoms (84, 63%). Of those hospitalised, 11 (8%) required mechanical ventilation and 20 (15%) died. Older age (adjusted OR (aOR) 1.05 per year), Black race (vs White race, aOR 4.15), ever smoking (vs never, aOR 1.76), CD20 inhibitor use (vs antimalarial monotherapy, aOR 2.22) and glucocorticoid use (vs non-use, aOR 2.07) were significantly associated with higher odds of hospitalisation. Female sex (vs male, aOR 0.63), booster SARS-CoV-2 vaccination (vs initial series, aOR 0.49) and vaccination within either 3 months or 3-6 months prior to infection (aOR 0.41 and aOR 0.38, respectively, vs none within 12 months) were significantly associated with lower odds of hospitalisation.

CONCLUSIONS

Some patients with SARDs remain at higher risk of severe COVID-19 in the Omicron era. Patients who are older, Black, have more comorbidities, use CD20 inhibitors and/or glucocorticoids, or have not been vaccinated recently may benefit from risk-mitigating strategies, including booster vaccines and pre-exposure prophylaxis.

Dietary energy intake predicts mortality in Chinese patients with peritoneal dialysis: a single-center 18 years' follow-up study

BACKGROUND

Lower dietary energy intake (DEI) may be associated with increased mortality risk. This study aims to analyze the influence of baseline DEI, time average DEI, and other factors on survival in peritoneal dialysis (PD) patients.

METHOD

It was a single-center retrospective cohort study. Patients who started PD from January 2006 to June 2021 were included in this study and followed up until June 2023. Their baseline (six months after the beginning of PD) demographic, dietary intake, laboratory data, and time varying dietary intake data were collected and analyzed. The relationships between these data and survival were examined using Cox model to estimate death hazard ratios.

RESULT

A total of 794 patients were included in this study, 424 males and 370 females, with a mean age of 58.87 ± 16.02 years. Their mean normalize baseline dietary energy intake (nDEI) was 25.46 ± 6.72 kcal/kg/day, time average nDEI was 24.87 ± 4.74 kcal/kg/day. The median follow-up duration was 46.58 (27.38, 78.52) months in the overall cohort. Based on multivariate Cox proportional hazard analysis, age (HR = 1.056, 95% Cl = 1.047-1.065, p < 0.001), diabetes (HR = 1.364, 95% Cl = 1.114-1.671, p = 0.003), serum albumin (HR = 0.945, 95% Cl = 0.923-0.967, p < 0.001), blood sodium (HR = 0.973, 95% Cl = 0.954-0.992, p = 0.002), serum urea (HR = 0.974, 95% Cl = 0.953-0.994, p = 0.025), and baseline nDEI (HR = 0.980, 95% Cl = 0.964-0.996, p = 0.017) were significantly associated with mortality. Baseline DPI, BMI and time average nDEI were not related to PD patients' survival. When classified baseline nDEI into 4 groups (< 25 kcal/kg/day, 25-29.99 kcal/kg/day, 30-34.99 kcal/kg/day, and ≥ 35 kcal/kg/day), the univariate and multivariate Cox proportional hazard analysis showed that the patients with nDEI 30-34.99 kcal/kg/day had the lowest mortality risk (using the DEI < 25 kcal/kg/day group as reference, p < 0.05).

CONCLUSION

Our study revealed that DEI 30-34.99 kcal/kg/day might be beneficial to the long-term outcome for the Chinese PD population.

CLINICAL TRIAL NUMBER

Not applicable.

An Analysis of Costs in the Year Before and After Total Knee Arthroplasty

BACKGROUND

While insurance claims database studies have reported on costs before total knee arthroplasty (TKA), the cost-efficacy of nonoperative treatment remains unclear in patients who eventually undergo TKA. Furthermore, we hypothesized that patients undergoing primary TKA would have lower costs in the year following surgery than if patients continued nonoperative treatment. The purpose of this study was to determine the costs of various nonoperative treatment modalities in the year before and following primary TKA.

METHODS

We reviewed a consecutive series of 13,117 patients undergoing primary TKA from 2020 to 2022 at a single institution with claims data from Medicare and a single commercial payer. We recorded all office visits, intra-articular injections, bracing, physical therapy, and imaging in the 12 months before and immediately following the patient's primary TKA, analyzing costs by the payer. Patient-reported outcome scores, readmissions, and reoperations were also noted, and costs were included in the 12-month postoperative analysis.

RESULTS

There were 5,516 (42.1%) patients who were insured by Medicare, 5,044 (38.5%) commercially insured and 2,557 (19.4%) insured by Medicare Advantage The mean total cost in the year before and after TKA declined from $760 to $598 (commercial), $583 to $351 (Medicare Advantage), and $580 to $370 (Medicare). Medicare patients had the greatest number of nonoperative treatments (6.5 versus 5.3 versus 5.1, P < 0.001) in the year before TKA. Patients in all three groups achieved the minimum clinically important difference for the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement at similar rates (74.8 versus 75.6 versus 72.7%, P = 0.35).

CONCLUSIONS

Patients undergoing primary TKA had lower costs in the year following surgery than they did with trial nonoperative treatment in the year prior. Further studies are needed to evaluate the cost-efficacy of nonoperative treatment modalities.

Gut microbiome diversity is associated with muscle mass, strength and quality in post-stroke patients

BACKGROUND

The gut microbiome has emerged as a potential influencer of muscle health; however, its role in hospitalized patients remains unclear. This study aimed to investigate the association between gut microbiome diversity and skeletal muscle mass, strength, and quality in hospitalized post-stroke patients.

METHODS

We conducted a cross-sectional study of post-stroke patients admitted to a rehabilitation facility. Gut microbiome diversity was assessed using 16S ribosomal ribonucleic acid (rRNA) gene sequencing, calculating Operational Taxonomic Unit (OTU) Richness, Faith's Phylogenetic Diversity (PD), and Shannon index. Muscle health was evaluated using skeletal muscle index (SMI) for muscle mass, handgrip strength (HGS) for muscle strength, and bioimpedance analysis-derived phase angle (PhA) for muscle quality. Multiple linear regression analyses were performed, adjusting for potential confounders.

RESULTS

A total of 156 patients (mean age 78.4 years; 55.7 % male) were analyzed. OTU Richness showed significant positive associations with SMI (β = 0.197, p = 0.025), HGS (β = 0.180, p = 0.005), and PhA (β = 0.178, p = 0.022). The Shannon index was also positively associated with SMI (β = 0.120, p = 0.041), HGS (β = 0.140, p = 0.028), and PhA (β = 0.164, p = 0.032). Faith's PD did not demonstrate significant associations with muscle health parameters.

CONCLUSIONS

Higher gut microbiome diversity, assessed by OTU Richness and Shannon index, is associated with better muscle mass, strength, and quality in post-stroke patients. These findings suggest a potential role for gut microbiota in muscle health during stroke rehabilitation.

Evaluation of efficacy and tolerance of intravesical amphotericin B irrigation for the management of Candiduria

INTRODUCTION

Candiduria, is becoming increasingly common among hospitalized and immunocompromised patients. This infection poses a therapeutic challenge due to the rise in fluconazole resistance among Candida species. When fluconazole is unsuitable due to resistance or drug interactions, amphotericin B (AmB) is recommended. However, AmB's systemic use is limited by nephrotoxicity, which has led to interest in intravesical (bladder-administered) AmB.

METHODS

A retrospective study was conducted at Reims University Hospital on adult patients treated with intravesical AmB. Patient demographics, infection characteristics, and treatment details were extracted from medical records. Efficacy was determined by the absence of candiduria or rehospitalization, and renal safety was evaluated through serum creatinine and renal clearance before and after treatment. Adverse effects were graded by severity.

RESULTS

Sixteen patients were included (10 female patients (62.5%), mean age 69.8±15 years). Eight patients (50.0%) were admitted in urology department and diabetes mellitus was present in 9 patients (56.2%). Candida glabrata, resistant to fluconazole, was the most frequently isolated organism. Intravesical AmB was administered at a standard dose of 50mg diluted in 1 liter of sterile water, delivered over 24hours among almost all patients. Two patients were rehospitalized. Among patients with follow-up urine cultures, 66% (4 out of 6) achieved candiduria eradication. Two patients reported minor adverse effects, including mild catheter-related discomfort. No significant increase of serum creatinine level was observed after treatment.

DISCUSSION AND CONCLUSION

Intravesical AmB appear effective and safe for treating fluconazole-resistant candiduria, especially in high-risk, elderly patients. While promising, these findings are based on a small sample, highlighting the need for larger studies with prospective design to further elucidate the optimal management strategies for candiduria in vulnerable patients.

Health Care Use and Expenditures Associated With Cardiac Rehabilitation Among Eligible Medicare Fee-for-Service Beneficiaries

BACKGROUND

Cardiac rehabilitation (CR) can improve cardiovascular health. We identified whether CR participation was associated with fewer subsequent inpatient hospitalizations and emergency department visits and less Medicare and out-of-pocket expenditures, and whether outcomes varied by amount of participation.

METHODS

This retrospective study used Medicare fee-for-service claims data, including beneficiaries with a CR-qualifying event in 2016. Participants attended ≥2 sessions of CR within 365 days of the event. Propensity score matching was used to identify CR-eligible nonparticipants. Difference-in-differences analyses were used to compare differences in outcomes before (2014-2015) and after (2018-2019; 2-year CR period=2016-2017) the CR period between participants and nonparticipants.

RESULTS

We identified 57 668 CR-eligible beneficiaries after matching, with equal numbers of participants and nonparticipants. Nearly 65% of beneficiaries had a percutaneous coronary intervention, 33.5% had an acute myocardial infarction, 17.5% had a coronary artery bypass graft, and 16.8% had a heart valve repair/replacement. Compared with nonparticipants, participants had 47.6 fewer subsequent annual inpatient hospitalizations per 1000 beneficiaries (95% CI, -58.8 to -36.3) and $1005 lower subsequent annual Medicare expenditures per beneficiary (95% CI, -$1352 to -$659). Compared with no participation, medium participation (12-23 sessions), high participation (24-35 sessions), and CR completion (≥36 sessions) were associated with fewer inpatient hospitalizations and lower Medicare expenditures per year.

CONCLUSIONS

CR was associated with fewer subsequent annual inpatient hospitalizations and lower subsequent annual Medicare expenditures. A higher amount of participation was associated with a further reduction in hospitalizations and expenditures. These findings can inform programs and policies that encourage CR participation.

Is routine implant removal necessary after open reduction internal fixation of Lisfranc injuries? Comparing functional outcomes of routine and on-demand removal: A multicenter study

INTRODUCTION

Lisfranc joint injuries are a severe cause of disruption of foot stability and function, often requiring surgical intervention such as open reduction and internal fixation (ORIF). The necessity of routine implant removal after healing remains controversial. This study aimed to compare functional recovery and postoperative complications among patients undergoing routine, on-demand, or no implant removal following ORIF for Lisfranc fracture-dislocations.

MATERIALS AND METHODS

This multicenter retrospective study analyzed 188 patients treated with ORIF for Lisfranc fracture-dislocations. Patients were divided into three groups: routine removal (RR), on-demand removal (ODR), and no removal (NR). Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) midfoot score at the final follow-up. Complications were categorized as implant-related or post-removal. AOFAS midfoot scores and complication rates were compared between the three groups.

RESULTS

The median AOFAS midfoot scores at the final follow-up were 92 (IQR 83.00-95.00) in the RR group, 95 (IQR 85.00-95.00) in the ODR group, and 95 (IQR 82.00-95.00) in the NR group, with no significant differences among the three groups (p > 0.05). Implant-related complications were comparable across the groups, although irritation was significantly more frequent in the ODR group (42.9 %) than in the RR (24.4 %) and NR (11.9 %) groups (p = 0.013). Post-removal complications occurred in two cases in the RR group, including one case of loss of correction requiring reoperation.

CONCLUSION

Routine implant removal did not show superior outcomes in functional recovery or complication rates compared to selective removal or retention. Implant retention or selective removal based on individual needs minimizes complications and optimizes patient outcomes.

Trends in symptom severity and complexity in patients undergoing radiation therapy

Symptom severity and complexity have considerable impact on a patient's cancer care journey. This study describes symptom scores of radiotherapy patients across their radiotherapy care trajectory and factors associated with symptom complexity. Patients who received radiotherapy at a single tertiary cancer center, who also completed at least one symptom-reporting questionnaire, the Edmonton Symptom Assessment Scale- Revised (ESAS-r) between October 1, 2019 and April 1, 2020 were included in this retrospective analysis. Symptom assessment time points were pre-treatment, start and end of radiation treatment and post-treatment follow-up. Mean ESAS-r scores for individual symptoms were descriptively analyzed by assessment timing and tumour group. We calculated a symptom complexity score for each ESAS-r measurement, using a validated algorithm, and assigned overall symptom complexity as low, moderate or severe. We modelled the association between assessment timing, and tumor group, with symptom complexity using Generalized Estimating Equations (GEE). The study cohort consisted of 1,632 patients who completed 2,519 ESAS-r questionnaires. Patients with lung and H&N cancers reported higher mean symptom scores compared to other tumour groups. Patients at the start of treatment had significantly lower odds of having a more severe symptom complexity, compared with patients pre-treatment (OR = 0.77, 95% CI = 0.64-0.93). Patients with H&N and lung cancer and patients prior to starting radiation may benefit most from increased symptom support and management.

Factors associated with patient activation in people with heart failure based on the individual and family self-management theory: a cross-sectional study

AIMS

Patient activation (PA) is crucial for effective self-management of people with heart failure (HF). Clarifying factors associated with PA might be important to develop interventions to promote PA. This study aimed to explore context factors associated with PA in people with HF.

METHODS AND RESULTS

Two hundred and sixty-eight patients were enrolled in a cross-sectional study (median age = 65 years). We surveyed variables based on context factors of the individual and family self-management theory, including demographic and disease factors, quality of chronic care, family function, and depression. Correlation analysis was conducted for data analysis, and path analysis was used to verify our hypothesis model about context factors and PA. The median PA score was 51.10. Path analysis showed that age, educational level, living arrangement, device therapy, quality of chronic care, family function, and depression were directly or indirectly related to PA. The quality of chronic care mediated the associations between device therapy and educational level and PA. Age, educational level, living arrangement, and quality of chronic care affected family function and then affected activation. Depression mediated the relationships between the quality of chronic care, educational level, family function, and PA.

CONCLUSION

This study increased the understanding of factors associated with PA in the HF population. When assessing PA in people with HF, those who are older, have a low educational level, and living alone need more attention from healthcare professionals. Interventions focusing on improving the quality of chronic care, family function, and depression might help activate people to practice self-management.

Predictive validity of the sequential organ failure assessment score for mortality in patients with acute respiratory distress syndrome in Vietnam

Evaluating the prognosis of ARDS patients using grading systems can enhance treatment decisions. This retrospective observational study evaluated the predictive accuracy of the SOFA score, APACHE II score, SpO2/FiO2 ratio, and PaO2/FiO2 ratio for mortality in ARDS patients in Vietnam. The study included 335 adult ARDS patients admitted to a central hospital from August 2015 to August 2023. Among them, 66.9% were male, the median age was 55 years, and 61.5% died in the hospital. The SOFA (AUROC: 0.651) and APACHE II scores (AUROC: 0.693) showed poor discriminatory ability for hospital mortality. The SpO2/FiO2 (AUROC: 0.595) and PaO2/FiO2 ratios (AUROC: 0.595) also displayed poor discriminatory ability. In multivariable analyses, after adjusting for the same set of confounding variables, the APACHE II score (adjusted OR: 1.152), SpO2/FiO2 ratio (adjusted OR: 0.985), and PaO2/FiO2 ratio (adjusted OR: 0.989) were independently associated with hospital mortality. Although the SOFA score (adjusted OR: 1.132) indicated a potential association with hospital mortality, it did not reach statistical significance (p = 0.081). However, a SOFA score of ≥ 10 emerged as an independent predictor (adjusted OR: 3.398) of hospital mortality. These findings emphasize the need for further studies to develop more accurate scoring systems for predicting outcomes in ARDS patients.

Estimation of physiologic ability and surgical stress (E-PASS) predicts postoperative complications after adrenalectomy

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score, initially developed for gastrointestinal surgery, is a validated system used to predict postoperative complications by evaluating preoperative and intraoperative factors. This study aims to assess the effectiveness of the E-PASS score in predicting postoperative complications following adrenalectomy. In this single-center retrospective study, we analyzed data from 202 patients who underwent adrenalectomy by a single surgeon between January 2017 and March 2024. 182 patients with complete data and who met the study criteria were included in the study. Demographic, clinical, intraoperative, and postoperative data were collected and analyzed, including preoperative complaints, ASA classification, ECOG performance status, presence of systemic diseases, type of surgery, and intraoperative details, such as blood loss and complications. Postoperative complications were classified using the Clavien-Dindo Classification. The mean age of the patients was 48.7 ± 13.6 years. The mean BMI was 24.1 kg/m2. Postoperative complications were observed in 26.4% of patients, categorized as Grade 1 (54.1%), Grade 2 (25%), Grade 3 (16.7%), and Grade 4 (4.2%). Multivariate logistic regression identified higher BMI (OR = 1.394) and an E-PASS CRS score > - 0.0677 (OR = 6.17) as independent risk factors for complications. ROC curve analysis determined this CRS score cut-off with an AUC of 0.866 (CI 0.808-0.923; p < 0.001). The E-PASS scoring system effectively predicts postoperative complications in adrenalectomy. Its integration into clinical practice can enhance the identification of high-risk patients, optimize perioperative management, and potentially reduce adverse outcomes.

Developing a framework for estimating comorbidity burden of inpatient cancer patients based on a case study in China

Inpatient cancer patients often carry the dual burden of the cancer itself and comorbidities, which were recognized as one of the most urgent global public health issues to be addressed. Based on a case study conducted in a tertiary hospital in Shandong Province, this study developed a framework for the extraction of hospital information system data, identification of basic comorbidity characteristics, estimation of the comorbidity burden, and examination of the associations between comorbidity patterns and outcome measures. In the case study, demographic data, diagnostic data, medication data and cost data were extracted from the hospital information system under a stringent inclusion and exclusion process, and the diagnostic data were coded by trained coders with the 10th revision of the International Classification of Diseases (ICD-10). Comorbidities in this study was assessed using the NCI Comorbidity Index, which identifies multiple comorbidities. Rates, numbers, types and severity of comorbidity for inpatient cancer patients together form the characterization of comorbidities. All prevalent conditions in this cohort were included in the cluster analysis. Patient characteristics of each comorbidity cluster were described. Different comorbidity patterns of inpatient cancer patients were identified, and the associations between comorbidity patterns and outcome measures were examined. This framework can be adopted to guide the patient care, hospital administration and medical resource allocation, and has the potential to be applied in various healthcare settings at local, regional, national, and international levels to foster a healthcare environment that is more responsive to the complexities of cancer and its associated conditions. The application of this framework needs to be optimized to overcome a few limitations in data acquisition, data integration, treatment priorities that vary by stage, and ethics and privacy issues.

Ceftaroline versus vancomycin for methicillin-resistant Staphylococcus aureus bacteraemia, a matched cohort study

BACKGROUND

Vancomycin remains the treatment-of-choice in MRSA bacteraemia (MRSAB) despite significant limitations.

OBJECTIVE

To compare the effectiveness of ceftaroline and vancomycin monotherapy as the initial targeted therapy for MRSAB.

METHODS

We conducted a retrospective matched cohort study. Consecutive adult patients treated with ceftaroline in the years 2019-2021 were matched in a 1:2 ratio with patients who received vancomycin. Controls were matched for performance of trans-oesophageal echocardiography, Charlson comorbidity index and age. The primary outcome was a composite of treatment failure, defined as 90-day mortality or microbiological failure. Descriptive statistics were used to compare the ceftaroline and vancomycin-treated groups. Univariate and multivariable binary logistic regression models were created using ceftaroline treatment as the exposure variable.

RESULTS

Forty-five patients treated with ceftaroline for MRSAB were matched with 83 patients who received vancomycin. The groups were well balanced with regards to demographics and clinical characteristics. The primary outcome of treatment failure occurred at a similar rate in patients treated with ceftaroline or vancomycin (51.1%, 23/45% versus 57.8%, 48/83, respectively, P = 0.47). In the multivariable analysis, only age (aOR 1.06, 95% CI 1.01-1.1, P = 0.02) was associated with treatment failure. Acute kidney injury was more common among patients treated with ceftaroline (51.1%, 23/45% versus 18.1%, 15/83, P < 0.001).

CONCLUSIONS

Ceftaroline was not associated with improved outcomes compared to vancomycin when given as initial treatment for MRSAB, however, it appears to be a viable alternative to vancomycin. Larger studies are needed to provide definitive results and to elucidate the risk of nephrotoxicity.

Outpatient Physical Therapy Attendance by Older Adults After Emergency Department Discharge Was a Predictor for Lower 30-Day Revisits-But Demographic Factors Affected Attendance

OBJECTIVE

Given the high risk of functional loss and revisits among older adults presenting to the emergency department (ED), there is a need to understand how post-ED discharge outpatient physical therapy affects outcomes. This study sought to examine patient demographics and their association with outpatient physical therapy utilization after ED discharge and physical therapy attendance with 30-day ED revisits among older adults discharged to home.

METHODS

In this retrospective cohort study, we analyzed data from 1395 older adults (65 years old and older) who had a referral to outpatient physical therapy upon discharge from 15 EDs between January 2021 and December 2022. Descriptive statistics and multivariate logistic regression were used to evaluate the likelihood of attending outpatient physical therapy and the odds of a 30-day ED revisit.

RESULTS

Of the sample, 39.3% attended outpatient physical therapy. Older adults in the first and second neighborhood income quintile had a 51% lower odds of attending outpatient physical therapy than those in the fourth quintile. Patients with a diagnosis of vertigo had a 67% higher odds of attending outpatient physical therapy (OR = 1.67; 95% CI = 1.21-2.29) than those with back pain. Older adults who did not attend outpatient physical therapy within 30 days of ED visit had a 88% higher odds of returning to the ED than those who did attend (OR = 1.88; 95% CI = 1.34-2.64). Older adults in the first and second income quintile had a 66% higher odds of revisiting the ED than those in the fourth quintile.

CONCLUSION

Outpatient physical therapy attendance after ED discharge was a predictor of revisit within 30 days. Patient diagnosis of vertigo and higher median household income were predictors of higher outpatient physical therapy attendance. However, a diagnosis of falls or mobility concerns and a lower household income status were associated with lower attendance.

IMPACT

Physical therapy after ED discharge has the potential to reduce 30-day ED revisit but requires strategies to improve access equity across diagnostic groups and household income levels.

LAY SUMMARY

This study found that outpatient physical therapy attendance after discharge from the ED was a predictor of lower ED revisits within 30 days among older adults. However, factors such as socioeconomic status, age, and diagnosis negatively affected the ability to attend physical therapy.

Oropharyngeal Staphylococcus aureus is linked to higher mortality in long-term aged care residents

BACKGROUND

Biological ageing, healthcare interactions, and pharmaceutical and environmental exposures in later life alter the characteristics of the oropharyngeal (OP) microbiome. These changes, including an increased susceptibility to colonisation by pathobiont species, have been linked with diverse health outcomes.

OBJECTIVES

To investigate the relationship between OP microbiome characteristics and all-cause mortality in long-term aged care residents.

METHODS

OP swabs were collected from 190 residents of five aged care facilities in South Australia. Microbiota composition was assessed by shotgun metagenomics and related to health outcomes during a 12-month follow-up period. OP carriage of Staphylococcus aureus and methicillin resistance was confirmed by qPCR.

RESULTS

OP carriage of S. aureus was identified in 13 (6.8%) residents. Detection of S. aureus was significantly associated with an increased risk of mortality (adjusted HR [95% CI]: 9.7 [3.8-24.9], P < .0001), compared with non-carriers, independent of methicillin resistance. Staphylococcus aureus carriage demonstrated a stronger association with mortality risk than the total number of comorbidities at the univariate level (S. aureus HR [95% CI]: 7.2 [3.4-15.5], P < .0001 vs. comorbidity count HR [95% CI]: 1.1 [1.0-1.3], P = .03), and remained significant after multivariable adjustment. Staphylococcus aureus detection was significantly associated with total number of comorbidities (adjusted OR [95% CI]: 1.4 [1.0-2.0], P = .04).

CONCLUSION

OP S. aureus carriage predicts all-cause mortality in long-term aged care. We speculate that S. aureus carriage represents a marker of general health, including prior healthcare exposures. OP S. aureus carriage could contribute to estimations of general health in older individuals and thereby inform care strategies.

Bowel Disorder Incidence and Rectal Spacer Use in Patients With Prostate Cancer Undergoing Radiotherapy

Importance

The polyethylene glycol-based hydrogel spacer (PHS) system temporarily separates the rectum from the prostate in patients undergoing radiotherapy (RT) for prostate cancer (PCa).

Objective

To compare incidence of bowel disorders and related procedures in patients receiving RT with and without PHS.

Design, Setting, and Participants

This retrospective cohort study used 4 datasets: Medicare 5% Standard Analytic Files, Medicare 100% Standard Analytic Files, Merative MarketScan Commercial Database, and Premier Healthcare Database. Participants included adult patients with PCa undergoing RT from 2015 to 2021.

Exposure

Placement of PHS.

Main Outcomes

All-cause bowel disorders and related procedures, identified from diagnosis and procedure codes. Results were compared with age-matched male general population without PCa or RT.

Results

Of 261 906 patients with PCa included in the study, 25 167 (9.6%) received PHS (mean [SD] age, 70.7 [6.5] years) and 236 739 did not (mean [SD] age, 71.1 [7.5] years). One year prior to RT, patients who received PHS had a lower mean (SD) Charlson Comorbidity Index score than those who did not (2.48 [1.08] vs 3.14 [1.95]; P < .001). Stereotactic RT was more common in patients who received PHS (2743 [10.9%] vs 8810 [3.7%]; P < .001), while intensity-modulated RT was less common (12 755 [50.7%] vs 142 402 [60.2%]; P < .001). After 4 years post RT, patients who received PHS had a 25% lower hazard of bowel disorders (hazard ratio [HR], 0.75 [95% CI, 0.72-0.78]; P < .001) and a 46% lower hazard of related procedures (HR, 0.54 [95% CI, 0.47-0.62]; P < .001) than patients who did not receive PHS. Patients without PHS had higher hazard compared with an age-matched general population (disorders: 17.1% [95% CI, 17.3%-17.6%] vs 10.3% [95% CI, 10.1%-10.5%]; HR, 1.35 [95% CI, 1.32-1.37]; P < .001; procedures: 2.0% [95% CI, 1.9%-2.1%] vs 0.7% [95% CI, 0.7%-0.8%]; HR, 1.92 [95% CI, 1.79-2.06]; P < .001), while patients who received PHS did not (disorders: 12.4% vs 10.3%; HR, 1.00 [95% CI, 0.98-1.05]; P = .82; procedures: 1.1% [95% CI, 1.0%-1.3%] vs 0.7% [95% CI, 0.7%-0.8%]; HR, 1.11 [95% CI, 0.96-1.29]; P = .15). Common procedures included colonoscopy, sigmoidoscopy, and rectal resection.

Conclusions and Relevance

In this cohort study of patients with PCa receiving RT, those receiving a PHS had a significantly lower incidence of all-cause bowel disorders and related procedures compared with patients who did not receive a PHS over the 4-year follow-up. The incidence among patients with PHS was similar to the general population. These findings are consistent with prior phase 3 trial results, where patients receiving PHS experienced no decline in bowel quality of life.

Asthma exacerbation comorbidity index (AECI): Predicting in-hospital adverse outcomes

BACKGROUND

Despite optimal treatment, asthma exacerbations (AEs) can lead to severe adverse events, including mortality. Effective management of comorbidities is critical, as they are common in asthma patients and significantly impact quality of life, healthcare use, and treatment outcomes. Currently, no comprehensive clinical tool exists for assessing and managing these comorbidities during AE.

METHODS

We conducted a real-world study involving inpatients with AE. We assessed the risk of in-hospital composite outcome including death, intensive care unit admission, or invasive ventilation, associated with individual comorbidities, comorbidity systems, and the total number of comorbidities. We developed a predictive tool, the Asthma Exacerbation Comorbidity Index (AECI), which incorporates the major comorbidities identified. Patients were categorized into three risk groups based on their AECI scores.

RESULTS

Among the 43 comorbidities assessed, nine were significantly associated with the composite outcome. Each additional comorbidity increased the risk of the composite outcome by 25% (95% CI, 16.5%-34.1%; P < 0.001). The most prevalent comorbidity systems were the endocrine (51.7%), respiratory (50.9%), and cardiovascular (43.3%) systems, with 54.1% of patients exhibiting multiple comorbidity systems. The AECI exhibited an area under the curve (AUC) of 75.98%. A one-point increase in the AECI was associated with a 0.51-fold increase in the risk of composite outcome (95% CI, 0.41-0.62; P < 0.001).

CONCLUSION

The high prevalence of comorbidities among patients with AEs is associated with a poorer prognosis. The AECI proves to be a valuable tool to assess comorbidities, enabling clinicians to identify inpatients at higher risk of adverse in-hospital events and to make informed treatment decisions.

Unravelling the trajectory of frailty and its influencing factors in elderly patients with coronary heart disease after percutaneous coronary intervention: protocol for a cohort study in China

INTRODUCTION

Frailty is an important factor affecting the short-term and long-term outcomes of elderly patients with coronary heart disease (CHD) after surgery. Most previous studies only assessed frailty before surgery or at discharge, and there was limited tracking of the occurrence and progression of frailty during hospitalisation and after surgery. This paper describes the trends and influencing factors of frailty in elderly patients with CHD before and 6 months after percutaneous coronary intervention (PCI).

METHOD AND ANALYSIS

The frailty study is an observational, prospective cohort study aiming to recruit patients with CHD over 60 years of age who intend to undergo PCI. This study aims to investigate the evolving trends in frailty among elderly patients who have undergone PCI in the 6 months following hospital discharge. Additionally, the influence of cognitive, behavioural, psychosocial, physiological and biological factors on the trajectory of frailty changes in this population was explored based on the International Classification of Functioning, Disability and Health. There will be 11 data collection points, within 48 hours after admission, at hospital discharge and then monthly for the first 6 months, followed by assessments at 12, 24 and 36 months postdischarge. A general estimation equation will be used to analyse the overall trend of frailty. Growth mixture modelling and latent class growth modelling will both be used to identify distinct frailty trajectories. Univariate and logistic regression analyses will be used to identify predictors of trajectories. The Cox proportional hazard regression model will be employed to explore the relationship between the changing trend of different types of frailty within 6 months after discharge and survival status at 36 months.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of Guangzhou First People's Hospital (K-2023-136-01). All findings will be disseminated through publication in peer-reviewed scientific journals and presentation at conferences and stakeholder organisation events.

The relationship between hyponatremia and mortality in patients receiving nutrition support

BACKGROUND & AIMS

Hyponatremia is frequently seen in clinical practice, but most cases are mild and asymptomatic and therefore often go unmanaged. In recent years, it has been reported that the onset or improvement of hyponatremia, even in mild cases, has an impact on mortality and that hyponatremia is directly related to increased mortality. In addition, it has been reported that patients with Nutrition Support Team (NST) are more likely to develop hyponatremia than the general hospitalized population. This study aimed to determine the association between the development and amelioration of hyponatremia and mortality in patients with NST.

METHODS

A total of 1553 patients who underwent initial NST intervention from April 1, 2013 to March 31, 2017 were included. Hyponatremia was defined as hyponatremia <138 mEq/L and normal serum sodium level was defined as 138-145 mEq/L based on the laboratory reference values of our hospital. Hyponatremia was defined as L and normal sodium as N. Based on sodium levels at the start and end of the intervention, the population was classified into four groups, L-L, N-L, L-N, and N-N (sodium level at the start of intervention - sodium level at the end of intervention), and the 5-year survival rate curve and hazard ratio for death for each group were calculated. Multivariate analysis adjusted for age, sex, and body mass index.

RESULTS

Analysis revealed that the L-L group with persistent hyponatremia (hazard ratio (HR) = 3.47, vs N-N, p < 0.0001) had the highest risk of death, while the L-N group with improved hyponatremia (HR = 2.19, vs N-N, p < 0.0001) had a significantly lower risk than the L-L group. The risk of death was also increased in the L-N and N-L groups (HR = 1.97, vs. N-N, p << 0.0001) after even one episode of hyponatremia compared to the N-N group.

CONCLUSION

The results of this study indicate that hyponatremia is associated with poor survival in patients undergoing NST. Future randomized controlled trials are needed to determine whether correction of hyponatremia leads to improved survival in patients undergoing NST to clarify the need for prevention and management of hyponatremia.

Diabetes distress and depression in type 2 diabetes. A cross-sectional study in 18,000 individuals in the Central Denmark region

AIMS

Type 2 diabetes is linked to psychological distress and a doubled risk of depression. This study aims to characterize individuals with type 2 diabetes experiencing diabetes distress and/or depression in relation to lifestyle and metabolic outcomes.

METHODS

A population-based survey in 2020 targeted individuals with type 2 diabetes (aged 18-75 years) in the Central Denmark Region. This cross-sectional study assessed diabetes distress (using Problem-Area-in-Diabetes-scale) and depression (via hospital diagnosis and prescribed medication) as exposures. Logistic regression, adjusting for potential confounders, compared exposed and non-exposed groups on lifestyle habits, metabolic factors and medication usage related to cardio-metabolic risks.

RESULTS

Of 18,222 respondents with type 2 diabetes (46% response rate), 11% had depression, 14% had diabetes distress and 4% had both. Compared to those with neither condition, those with depression were more often smokers (OR: 2.0, 95% CI: 1.8; 2.3) and sedentary in leisure time (OR: 2.0, 95% CI: 1.8; 2.2). Diabetes distress was associated with elevated HbA1c (OR: 1.8, 95% CI: 1.5; 2.0) and treatment with insulin (OR: 1.8, 95% CI: 1.6; 2.0). Half with diabetes distress displayed stable blood glucose levels. Those with both conditions had a higher risk of sedentary behaviour (OR: 2.7, 95% CI: 2.3; 3.2), clinical insomnia (OR: 6.5, 95% CI: 5.5; 7.7) and low self-rated health (OR: 7.5, 95% CI: 6.3; 9.0) than those with either psychological condition in isolation.

CONCLUSIONS

This study emphasizes the importance of recognizing distinct features and risk factors associated with diabetes distress and depression in individuals with type 2 diabetes. Tailored care strategies for comorbid mental health issues are crucial for comprehensive management.

Proposal of "borderline resectable" colorectal liver metastases based on analysis of risk factors for early surgical failure

PURPOSE

We aimed to define borderline resectable colorectal liver metastases (CRLM) based on the analysis of risk factors for early surgical failure and investigate the efficacy of neoadjuvant chemotherapy in these patients.

METHODS

This was a retrospective analysis of a multi-institutional cohort of patients diagnosed with technically resectable CRLM. Early surgical failure within 6 months of liver surgery was defined as ESF6. We classified CRLM into three grades (A, B, and C) according to the definition of the Japanese Society for Cancer of the Colon and Rectum.

RESULTS

Among the 249 patients with technically resectable CRLM, 46 (18.5%) developed ESF6. The survival rate of these patients was significantly lower than that of the patients without ESF6. In the multivariate analysis of synchronous CRLM patients, no neoadjuvant chemotherapy, Grade B/C, and Charlson comorbidity index ≥ 3 were independent predictors of ESF6. Among patients with synchronous and Grade B/C CRLM, ESF6 rates, surgical failure-free survival, and overall survival in the neoadjuvant chemotherapy group were significantly better relative to the upfront surgery group.

CONCLUSIONS

Patients with synchronous and Grade B/C CRLM are at a high risk of early surgical failure, have a poor long-term prognosis, and can be defined as borderline resectable and good candidates for neoadjuvant chemotherapy.

Alcohol consumption has a J-shaped association with bacterial infection and death due to infection, a population-based cohort study

The aim of this study is to investigate the association between alcohol consumption and the risk of bacterial infection and its dose-response association. Participants in the Swedish Mammography Cohort and Cohort of Swedish Men answered lifestyle questionnaires in 1997 and have since been followed in national registers. The risks of acquiring infection, intensive care unit (ICU) admission and dying due to infection were assessed with Cox regression. Among 58,078 cohort participants followed for 23 years, 23,035 participants were diagnosed with an infection and 4,030 died from infection. Alcohol consumption exhibited a J-shaped association with the risk of acquiring infection and dying due to infection: compared to consuming 5-10 g of alcohol per day, consuming < 0.5 g/day and consuming > 30 g/day were both associated with higher risk of acquiring infection, ICU admission and dying due to infection, whereas alcohol consumption between 5 and 30 g/day was not associated with acquiring infection, ICU admission or death due to infection. In conclusion, moderate alcohol consumption was not associated with infection, but both very low and high levels of consumption were associated with acquiring infection, ICU admission and death. If replicated, this suggests that reduction of alcohol consumption might reduce mortality from bacterial infections.

Frequency and implications of malnutrition in systemic sclerosis

OBJECTIVES

To quantify the frequency and impact of malnutrition in systemic sclerosis (SSc), as diagnosed by the Global Leadership Initiative on Malnutrition (GLIM) criteria, based on weight loss, BMI and muscle atrophy.

METHODS

Australian Scleroderma Cohort Study participants meeting ACR/EULAR criteria for SSc with ≥1 concurrent weight and height measurement were included. The chi-squared test, two-sample t-test or Wilcoxon's rank-sum test was used for between-group comparison as appropriate. Multivariable logistic regression models were used to establish the determinants of malnutrition diagnosis. Kaplan-Meier and Cox proportional hazard models were used for survival analyses, based on malnutrition diagnosis, and individual GLIM criteria (percentage weight loss, BMI thresholds and presence of muscle atrophy).

RESULTS

In this study of 1903 participants, 43% were diagnosed with malnutrition according to GLIM criteria, of whom 33% had severe malnutrition. Participants diagnosed with malnutrition were older, and more likely to have diffuse cutaneous SSc (dcSSc), higher SSc severity scores and RNA polymerase-3 positivity. Gastrointestinal (GI) involvement, multimorbidity, cardiopulmonary disease, raised inflammatory markers, hypoalbuminaemia and anaemia were more common in malnourished participants (P < 0.01). Multimorbidity (odds ratio [OR] 1.6; 95% CI: 1.2, 2.0; P < 0.01), pulmonary arterial hypertension (OR 2.1; 95% CI: 1.4, 2.0; P < 0.01) and upper GI symptoms (OR 1.6; 95% CI: 1.3, 2.0; P < 0.01) were all associated with malnutrition. Health-related quality-of-life (HRQoL) and physical function were poorer in malnourished participants. Survival was worse in those with malnutrition after adjusting for age, sex and dcSSc (hazard ratio 1.4; 95% CI: 1.1, 1.7; P < 0.01).

CONCLUSION

Malnutrition is common in SSc and confers poorer survival, HRQoL and physical function.

Daily life mobility detects frailty, falls, and functioning in older prostate cancer survivors treated with androgen deprivation therapy

INTRODUCTION

Androgen deprivation therapy (ADT) increases the risk of frailty, falls, and poor physical functioning in older adults with prostate cancer. Detection of frailty is limited to self-report instruments and performance measures, so unbiased tools are needed. We investigated relationships between an unbiased measure - daily life mobility - and ADT history, frailty, fall history, and functioning in older prostate cancer survivors treated with ADT.

MATERIALS AND METHODS

This cross-sectional study recruited prostate cancer survivors with a history of ADT from an exercise clinical trial, an academic medical center, and the community. Participants completed performance measures and surveys to assess frailty, fall history, and physical functioning, then wore instrumented socks for up to seven days to continuously monitor daily life mobility. We performed a principal component analysis on daily life mobility metrics and used regression analyses to investigate relationships between domains of daily life mobility and frailty, fall history, and physical functioning.

RESULTS

Participants (N = 99) were aged 73.0 +/- 7.3 years, most were pre-frail or frail (75 %), and 35 % had fallen at least once in the last year. Daily life mobility metrics clustered into four domains: Gait Pace, Rhythm, Activity, and Balance. Worse scores on Rhythm and Activity were associated with increased odds of frailty (odds ratio [OR] 1.59, 95 % confidence interval [CI]: 1.04, 2.49 and OR 1.81, 95 % CI: 1.19, 2.83, respectively). A worse score on Rhythm was associated with increased odds of ≥1 falls in the previous year (OR 1.60, 95 % CI: 1.05, 2.47). Worse scores on Gait Pace, Rhythm, and Activity were associated with worse physical functioning. Mobility metrics were similar between current and past users of ADT.

DISCUSSION

Continuous passive monitoring of daily life mobility may identify prostate cancer survivors who have developed frailty, falls, and declines in physical functioning.

Race and ethnicity, not just insurance, is associated with biologics initiation in asthma and related conditions

BACKGROUND

There are pre-existing inequities in asthma care.

OBJECTIVES

We sought to evaluate effect modification by race of the effect of insurance on biologic therapy use in patients with asthma and related diseases.

METHODS

We conducted inverse probability weighted analyses using electronic health records data from 2011 to 2020 from a large health care system in Boston, Mass. We evaluated the odds of not initiating omalizumab or mepolizumab therapy within 1 year of prescription for an approved indication.

RESULTS

We identified 1132 individuals who met study criteria. Twenty-seven percent of these patients had public insurance and 12% belonged to a historically marginalized group (HMG). One-quarter of patients did not initiate the prescribed biologic. Among patients with asthma, individuals belonging to HMG had higher exacerbation rates in the period before initiation compared to non-HMG individuals, regardless of insurance type. Among HMG patients with asthma, those with private insurance were less likely to not initiate therapy compared to those with public insurance (odds ratio [OR]: 0.67, and 95% CI: 0.56-0.79). Among non-HMG with asthma, privately insured and publicly insured individuals had similar rates of not initiating the prescribed biologic (OR: 1.02; 95% CI: 0.95-1.09). Among those publicly insured with asthma, HMGs had higher odds of not initiating therapy compared to non-HMGs (OR: 1.16; 95% CI: 1.03-1.31), but privately insured HMG and non-HMG did not differ significantly (OR: 0.99; 95% CI: 0.91-1.07).

CONCLUSIONS

Publicly insured individuals belonging to HMG are less likely to initiate biologics when prescribed despite having more severe asthma, while there are no inequities by insurance in individuals belonging to other groups.

The inter-rater reliability of emergency department and paramedic frailty screening in older patients following a fall

BACKGROUND

Screening for frailty in the emergency setting may be useful in directing patients to appropriate management pathways. The main aim of this study was to assess the inter-rater reliability of the Clinical Frailty Scale between paramedics and emergency department staff (doctors and allied heath) for patients after a fall. Secondarily, to assess how these scores correlate with patient outcomes.

METHODS

A prospective study of older patients arriving by ambulance to a single hospital in Western Australia following a fall. The inter-rater reliability was assessed using a weighted Cohen's κ. The relationship between Clinical Frailty Scale and secondary outcomes were assessed using chi-squared and Kruskal-Wallis tests.

RESULTS

Data from 94 patients were included, the mean age was 82 years and 64 % were female. The inter-rater reliability between paramedics and emergency department staff using the Clinical Frailty Scale was moderate (κ 0.48 (95 % CI 0.36-0.59)).

CONCLUSIONS

There is only moderate agreement between emergency department staff and paramedics when screening for frailty in patients who present after a fall. The findings indicate the need to improve reliability as a pre-requisite to the use of frailty screening in emergency settings.

Outcomes for Patients with Obesity Undergoing Adrenalectomy for Pheochromocytoma: An International Multicenter Analysis

OBJECTIVE

The impact of obesity on outcomes after adrenalectomy for pheochromocytoma is unclear. This study aims to evaluate outcomes after minimally invasive and open adrenalectomy for pheochromocytoma in patients with obesity and to determine factors that may affect outcomes. Patients undergoing adrenalectomy for pheochromocytoma in 46 international centers between 2012 and 2022 were reviewed, analyzing baseline information, length of hospital stay (LOS), and postoperative complications.

PATIENTS AND METHODS

Obese (body mass index (BMI) ≥ 30 kg/m2) and nonobese patients were compared. Multivariable analysis was utilized to evaluate outcomes and risk factors for complications, LOS, and increased comprehensive complication index (CCI).

RESULTS

Of the 2016 patients, 639 (31.7%) had obesity. Operative time (110.0 versus 105.0 min; p = 0.467), conversion to open rate (3.1% versus 4.7%; p = 0.079), estimated blood loss (20.0 versus 20.0 ml, p = 0.088), rate of complications (19.3% versus 20.8%; p = 0.425), and CCI were similar. However, patients with obesity required a median of 1 day longer LOS (4.0 days versus 5.0 days; p < 0.001). On multivariable analysis, obesity was not significantly associated with complications or higher CCI. Analyzing solely obese patients, laparoscopic (OR 0.24; p < 0.001) and robotic (OR 0.22; p = 0.011) approaches were independently associated with less morbidity. Additionally, multivariable modeling demonstrated that a retroperitoneal approach in patients with BMI ≥ 30 kg/m2 was independently associated with reduced CCI (- 3.74; p = 0.017). Similar results were demonstrated when analyzing severe obesity (BMI ≥ 35).

CONCLUSIONS

Obesity does not increase complications or CCI following pheochromocytoma resection, but it does increase LOS. A retroperitoneal approach may uniquely benefit patients with obesity. In view of rising obesity rates, these results warrant further research to validate findings.

Severe hypoglycaemia and diabetic ketoacidosis in adults presenting to a hospital emergency department: Adverse prognostic markers for survival in type 2 diabetes and the role of SGLT2 inhibitors

AIMS

To determine the prognosis associated with severe hypoglycaemia (SH) and diabetic ketoacidosis (DKA) in adults presenting to a hospital emergency department (ED).

METHODS

Medical records of adults with type 1 (T1D) and type 2 (T2D) diabetes who attended the ED with SH and DKA between 1 January 2019 and 30 June 2023, were reviewed for comorbidities, long-term survival, mortality and causes of death.

RESULTS

A total of 429 episodes of DKA occurred in 293 people and 643 episodes of SH in 515 people. DKA predominated in T1D (77.6%) and SH in T2D (54.3%). In T2D, 32.3% of DKA events were associated with sodium-glucose cotransporter-2 inhibitor (SGLT2-i) medication. In both SH and DKA, patients with T2D were older and had more comorbidities than T1D, particularly cardiorenal disease, heart failure, cognitive impairment and cancer (all p < 0.005). Compared with T1D, mortality was higher in T2D after SH (48.4% vs. 19.9%, p < 0.005) and after DKA (30.8% vs. 13.4%, p = 0.001) with shorter median times to fatal outcome (SH: 134 vs. 511 days; DKA: 43 vs. 266 days, both p < 0.005). Long-term survival was lower (p < 0.005) and mortality risk was higher in T2D after index presentation with SH (HR 3.43 [95% CI: 2.43-4.84], p < 0.005) and DKA (HR 3.00 [95% CI: 1.77-5.10], p < 0.005). Irrespective of diabetes type, most causes of death in SH and DKA were non-cardiovascular.

CONCLUSIONS

SH and DKA events requiring hospital treatment herald a poor prognosis with greater mortality in T2D adults with multimorbidity. A significant number of DKA episodes in T2D occurred in people receiving SGLT2-i medication.