THU0286 THE SYSTEMIC LUPUS INTERNATIONAL COLLABORATING CLINICS (SLICC) FRAILTY INDEX (SLICC-FI) PREDICTS DAMAGE ACCRUAL IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS. DATA FROM A MULTI-ETHNIC, MULTI-CENTER US LUPUS COHORT

Background:

The Systemic Lupus International Collaborating Clinics (SLICC) Frailty Index (SLICC-FI) has been developed as a predictor of outcomes in SLE patients1-3. It combines disease activity, damage, comorbidities and health-related quality of life measures.

Objectives:

To evaluate the SLICC-FI as a predictor of damage accrual in systemic lupus erythematosus (SLE) patients.

Methods:

Patients from a multi-ethnic, multi-center US lupus cohort were included. Damage was ascertained with the SLICC/American College of Rheumatology (ACR) damage index (SDI) at last visit. The first visit in which the SLICC-FI could be derived was considered as the baseline visit. Univariable and multivariable Poisson regression models were performed to determine the association between the baseline SLICC-FI and last SDI, adjusted for sex, age at diagnosis, ethnicity, insurance, prednisone daily dose, antimalarial and immunosuppressive drug use at baseline. Age and gender were included a priori in the multivariable model, the other variables were included if they had a p<0.10 in the univariable models.

Results:

Of the 503 patients included, 454 (90.3%) were female with mean (SD) age 37.1 (12.5) years at diagnosis; 174 (34.6%) were African-American, 144 (28.6%) were Caucasians, 86 (17.1%) Hispanics (Texas), and 99 (19.7%) were Hispanics (Puerto Rico). The mean (SD) baseline SLICC-FI was 0.26 (0.06). The final mean (SD) SDI score was 1.9 (2.2). Higher SLICC-FI scores at baseline predicted greater damage accrual in the univariable analysis [Estimate=5.058, (SE=0.498); p<0.0001]. The SLICC-FI remained associated with damage accrual in the multivariable model, after adjustment for possible confounders [Estimate= 3.561 (SE=0.538); p<0.0001].

Conclusion:

The SLICC-FI predicts damage accrual in SLE patients from a multi-ethnic cohort, supporting the importance of this index in the evaluation of SLE patients, combining several aspects of the disease.

References:

[1]Legge A, Kirkland S, Rockwood K, et al. Construction of a Frailty Index as a Novel Health Measure in Systemic Lupus Erythematosus. J Rheumatol. 2020; 47: 72-81

[2]Legge A, Kirkland S, Rockwood K, et al. Evaluating the Properties of a Frailty Index and Its Association With Mortality Risk Among Patients With Systemic Lupus Erythematosus. Arthritis Rheumatol. 2019; 71: 1297-107

[3]Legge A, Kirkland S, Rockwood K, et al. Prediction of Damage Accrual in Systemic Lupus Erythematosus Using the Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI). Arthitis Rheumatol. Epub ahead of print 2019 Oct 21.

Disclosure of Interests:

Manuel F. Ugarte-Gil Grant/research support from: Jannsen, Pfizer, Jyoti Dubey: None declared, Gerald McGwin: None declared, Luis Vila: None declared, Graciela S Alarcon: None declared

Average area under the curve: An alternative method for quantifying the dental caries experience in longitudinal studies

OBJECTIVES

Field-traditional decayed, missing, filled surfaces (dmfs) increments require complete follow-up, only using initial and final visits. Repeated dmfs scores complicate sophisticated statistical models, limiting their utility. Elsewhere, area under the curve (AUC) uses all repeated measures to summarize data. This study applied AUC methodology to caries data, creating average AUCs for dmfs trajectories (dmfs^aAUC ) and comparing increments and dmfs^aAUC values.

METHODS

Longitudinal data were obtained from high-caries risk (i.e. poor, rural, African American community in Perry County, Alabama) infants, 8 to 18 months at baseline. Baseline and five annual visual oral examinations provided dmfs scores. Differences in baseline and final dmfs scores constituted increments. The trapezoidal rule was applied to dmfs trajectories to calculate AUC values which were adjusted for varying follow-up times, producing dmfs^aAUC values. Participants sharing incremental or dmfs^aAUC values had their trajectories and second caries measurements compared. Within-participant increment and dmfs^aAUC differences were evaluated (paired t test, α = 0.05). Comparative analyses required complete follow-up.

RESULTS

The dmfs^aAUC provided forty-eight additional person-years, increasing the potential sample size by 20% (N = 85). Sixty-six children, 5.7 to 6.3 year-olds at study's end, contributed 121 331 person-days to five-year increment and dmfs^aAUC calculations. Trajectories and dmfs^aAUC values varied for participants with equivalent increments; comparable trajectories and different increments resulted from participants with similar dmfs^aAUC values. Within-participant disease amounts were similar.

CONCLUSIONS

When desired, dmfs^aAUC can replace increments as a more data-inclusive summary of longitudinal caries burden, incorporating intermediate visits, incomplete follow-up and time.

Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries

Objective:

The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD).

Materials and Methods:

Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa.

Results:

Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62).

Conclusion:

The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.

Behind the Match Process: Is There Any Financial Difference Lurking below the Specialty of Choice?

The Match was developed in response to a chaotic residency selection process. While the match has remained relatively unchanged since it was introduced, the number of medical school graduates has increased at a rate outpacing the number of residency positions leading to a more competitive process for applicants. In May 2014, an 18-question mixed-response questionnaire was distributed to fourth year allopathic medical students via an E-mail distribution list for student affairs representatives. The individual surveys were accessible via SurveyMonkey and available for completion over the course of a 4-week period. Approximately 65.1 per cent of students performed at least one audition rotation and documented average expenditures of $2494 on housing, food, and transportation. The average applicant applied to 32 programs and attended 12 interviews while spending $4420 on the interview trail. Applicants for surgical programs applied to approximately 42 programs and attended 13 interviews compared with primary care applicants who averaged 23 programs ( P < 0.001) and attended 12 interviews ( P = 0.002). Surgical applicants averaged 20 days on the interview trail while spending $5500 ($423/interview) on housing, food, and transportation compared with primary care applicants averaged 19 days away from home ( P < 0.05) and spending $3400 ($283/interview) on these same items ( P < 0.001). The findings in our study indicate that the “Match process” contributes to the financial burden of graduating medical students and it is more expensive and time consuming for the candidates interested in surgical specialties.

Prospective Identification of Patients at Risk for Massive Transfusion: An Imprecise Endeavor

Most retrospective studies evaluating fresh-frozen plasma:packed red blood cell ratios in trauma patients requiring massive transfusion (MT) are limited by survival bias. As prospective resource-intensive studies are being designed to better evaluate resuscitation strategies, it is imperative that patients with a high likelihood of MT are identified early. The objective of this study was to develop a predictive model for MT in civilian trauma patients. Patients admitted to the University of Alabama at Birmingham Trauma Center from January 2005 to December 2007 were selected. Admission clinical measurements, including blood lactate 5 mMol/L or greater, heart rate greater than 105 beats/min, international normalized ratio greater than 1.5, hemoglobin 11g/dL or less, and systolic blood pressure less than 110 mmHg, were used to create a predictive model. Sensitivity (Sens), specificity (Spec), positive predictive value (PPV), and negative predictive value (NPV) were calculated for all possible combinations of clinical measurements as well as each measure individually. A total of 6638 patients were identified, of whom 158 (2.4%) received MT. The best-fit predictive model included three or more positive clinical measures (Sens: 53%, Spec: 98%, PPV: 33%, NPV: 99%). There was increased PPV when all clinical measurements were positive (Sens: 9%, Spec: 100%, PPV: 86%, NPV: 98%). All combinations or clinical measures alone yielded lower predictive probability. Using these emergency department clinical measures, a predictive model to successfully identify civilian trauma patients at risk for MT was not able to be constructed. Given prospective identification of patients at risk for MT remains an imprecise undertaking, appropriate resources to support these efforts will need to be allocated for the completion of these studies.

Trauma center resource consumption and mortality

Studies suggesting that increased trauma center (TC) patient volume leads to improved patient outcomes have produced inconsistent results. It is possible that the combination of TC patient volume and TC resources has a greater influence over outcomes than TC volume alone. Patients admitted to 131 TCs from 1994 to 2002 were included. TC density was calculated as the ratio of TC adult beds to patient volume and categorized into quartiles. Adjusted risk ratios (RRs) and 95 per cent confidence intervals (CIs) compared mortality of groups (Q1 [low density]-Q4 [high density]). Relative to Q4 TCs, for penetrating injuries with ISS < 15, elevated mortality was seen for Q2 (low-moderate density) TCs (RR 1.47, CI 1.09-1.99) and Q3 (high-moderate density) TCs (RR 1.81, CI 1.36-2.41); but for ISS > or = 15, mortality was lowest for Q1 (RR 0.78, CI 0.68-0.89). For blunt injury, mortality was similar for low- and high-density TCs but elevated for low-moderate- and high-moderate-density TCs. Mortality at low-density TCs was decreased overall and for penetrating injuries specifically but similar for blunt injuries when compared with high-density TCs. Enhanced resources measurements will clarify the relationship between patient volume, resources, and mortality.

Trauma Center Resource Consumption and Mortality

Studies suggesting that increased trauma center (TC) patient volume leads to improved patient outcomes have produced inconsistent results. It is possible that the combination of TC patient volume and TC resources has a greater influence over outcomes than TC volume alone. Patients admitted to 131 TCs from 1994 to 2002 were included. TC density was calculated as the ratio of TC adult beds to patient volume and categorized into quartiles. Adjusted risk ratios (RRs) and 95 per cent confidence intervals (CIs) compared mortality of groups (Q1 [low density]–Q4 [high density]). Relative to Q4 TCs, for penetrating injuries with ISS <15, elevated mortality was seen for Q2 (low-moderate density) TCs (RR 1.47, CI 1.09–1.99) and Q3 (high-moderate density) TCs (RR 1.81, CI 1.36–2.41); but for ISS ≥15, mortality was lowest for Q1 (RR 0.78, CI 0.68–0.89). For blunt injury, mortality was similar for low- and high-density TCs but elevated for low-moderate- and high-moderate-density TCs. Mortality at low-density TCs was decreased overall and for penetrating injuries specifically but similar for blunt injuries when compared with high-density TCs. Enhanced resources measurements will clarify the relationship between patient volume, resources, and mortality.

Early versus Delayed Fixation of Pelvic Ring Fractures

This retrospective study reports outcomes, after early and delayed surgical stabilization of fractures of the pelvic ring, in terms of pulmonary complications, length of hospital stay, and cost of hospitalization. The hospital course of 151 patients admitted to an academic teaching hospital who sustained acute fractures of the pelvic ring between June 1996 and December 2000 was reviewed. Patient demographics, Injury Severity Score (ISS), timing of operative fixation, and the incidence of pulmonary complications were analyzed. Radiographs were reviewed and fractures classified according to the modified Tile system. Tile fracture types B and C patients who underwent fixation within 1 week of injury (n = 71) were compared to those in whom surgery was delayed (n = 28). Adjusting for the ISS, early-repair patients had a lower risk of pulmonary complications (RR = 0.49, 95% CI = 0.25-0.96), a reduced length of hospital stay (12.2 vs. 20.5 days; P = 0.0005), and overall reduced cost of care ($57,084 vs. $158,625; P = 0.0317). Pelvic ring fixation within the first week of injury results in significantly reduced incidence of pulmonary complication, hospital stay, and cost of care regardless of injury severity. The coordinated team approach to insure prompt resuscitation, stabilization, and operative fixation results in more optimal patient outcomes.

Trauma-Specific Intensive Care Units Can be Cost Effective and Contribute to Reduced Hospital Length of Stay

Our hypothesis was that clinical outcomes are improved and cost and hospital length of stay (LOS) reduced as a result of the opening of a closed trauma intensive care unit (ICU). We conducted a cross-sectional study in a university-affiliated Level I trauma center. Our study population comprised trauma patients admitted to the ICU between June 1, 1996 and July 1, 1998 for at least 24 hours and with an Injury Severity Score (ISS) >16 (excluding those with severe brain injury). The main outcome measures were changes in LOS and number of ventilator days, prevalence of complications, changes in patient charges, and hospital costs. Two hundred four patients were included [trauma ICU (TICU) 60, surgical ICU 144]. The two groups were not statistically different in age, ISS, mechanism of injury, infection rate, and mortality; however, the TICU patients had a lower number of ventilator hours (83.1 vs 100.0; P = 0.007), lower ICU LOS (9.4 vs 12.1 days; P = 0.06), and lower total hospital LOS (15.6 vs 22.3 days; P = 0.01). Although this was not of statistical significance TICU patients had lower hospital charges ($125,383 vs $152,994; P = 0.06) and lower cost per case ($42,306 vs $47,548; P = 0.35) for a net savings of $314,520 during the first 6 months of operation of the TICU. This study suggests that improved clinical outcomes and decreases in cost and LOS are directly related to the opening of a closed trauma ICU.