The Association of Body Mass Index with Surgical Time Is Mediated by Comorbidity in Patients Undergoing Total Hip Arthroplasty

Overweight represents a major issue in contemporary orthopaedic practice. A higher body mass index (BMI) is associated with an increase of perioperative complications following several orthopaedic procedures, in particular total hip arthroplasty (THA). However, the influence of overweight on THA surgical time is controversial. In this study, we investigated the association between BMI and surgical time analyzing the role of patients’ comorbidities. We conducted a retrospective study on 748 patients undergoing THA at our institutions between 2017 and 2018. Information regarding medical diseases was investigated and the burden of comorbidity was quantified using the Charlson score (CCI). Surgical time and blood loss were also recorded. Median surgical time was 76.5 min. Patients with surgical time above the median had both a higher BMI (28.3 vs. 27.1 kg/m2; p = 0.002); and CCI (1 vs. 0; p = 0.016). According to linear regression, surgical time was associated with BMI in the unadjusted model (p < 0.0001), after adjusting for age and sex (p < 0.0001), and in the multivariable model (p = 0.005). Furthermore, BMI was associated with increased surgical time only in patients with a Charlson score above the median, but not in others. Obesity is associated with increased surgical time during THA, especially in pluricomorbid patients, with a higher risk of perioperative complications.

36. Clinical Features of and Risk Factors for 30-day Readmission after an Initial Hospitalization with COVID-19

Background Little is known about risk factors for readmission after COVID-19 hospitalizations. Knowledge of these factors may help to identify patients at increased risk and may help to prevent these rehospitalizations. Methods This historical cohort study was conducted at a tertiary care academic medical center. We included COVID-19 cases diagnosed by reverse-transcriptase polymerase-chain-reaction (RT-PCR) assay between March 8th and June 14th, 2020. Patients readmitted within 30 days were identified. Using the electronic medical record, we collected data on demographic and clinical information. Data were analyzed using Student’s t-test, the chi-squared test and multivariable logistic regression. Results We included 391 patients who survived after the index hospitalization for COVID-19. The readmission rate was 13.3% (52/391). The mean time to readmission was 9.2 ± 7.9 days. The mean age (±SD) was 66.3 ± 18.6 years, 44.2% were male, and 78.8% were black/African-American. The most common presenting complaint was shortness of breath (50%). The most frequent diagnosis during the readmission was infectious process (57.7%). The mortality rate on readmission was 11.5%. Patients with a 30-day readmission were older than those not readmitted, mean age (±SD) 66.3 ± 18.6 vs. 61.0 ± 16.0, respectively (p=0.03). Readmitted patients also had a higher prevalence of heart failure and renal disease as comorbidities. Elevated alanine aminotransferase (AST) and low albumin level were also associated with readmission (Table 1). Intensive care unit (ICU) admission or mechanical ventilation during the index admission did not increase the risk of readmission. From multivariable analysis, independent predictors of 30-day readmission were higher Charlson score (p=0.004), higher creatinine on admission in the index hospitalization (p=0.009), and presence of rhabdomyolysis during the index hospitalization (p=0.039) (Table 2). Table 1. Univariable Analysis of Predictors for Readmission within 30 days from COVID-19 Infection Table 2. Multivariable Analysis of Predictors for Readmission within 30 days from COVID-19 Infection Conclusion In our cohort, infectious etiologies were common among those readmitted within 30 days of COVID-19. A higher Charlson score, acute renal failure, and rhabdomyolysis during the index admission were independent predictors of a 30-day readmission. Further studies are required to investigate these contributing factors. Disclosures All Authors: No reported disclosures

1438. Prevalence and Risk Factors for Extended Spectrum Betalactamases Among Hospitalized Patients with Community Acquired Pyelonephritis in Colombia

Background Urinary tract infections (UTI) are the most frequent bacterial infection in hospitalized patients. Extented spectrum betalactamases (ESBL) producing bacteria causing UTI have become more prevalent. Escherichia coli (E. coli) is the most frequent ESBL producing bacteria isolated in UTI. This drug resistant organisms are associated with poorer outcomes for patients. In low income countries, approaching to and treating ESBL E. coli, represent a major challenge for health care centers. Methods A retrospective cohort of adult patients with community acquired pyelonephritis caused by Escherichia coli was identified in a tertiary hospital in Colombia. Susceptibility was performed with Vitek (BioMerieux, France); extended spectrum beta lactamase (ESBL) production was defined phenotypically. Inclusion criteria were adult patients hospitalized with a positive urine culture for E. coli. Demographic and clinical characteristics were searched in electronic records. Risk factors associated with ESBL production were identified by using a multivariate logistic regression analysis. Results During 7 years 817 patients with pyelonephritis caused by E. coli were identified. 79 (9.7%) of them were caused by ESBL producers. Women were 66% and 408 (74.8% of them) had menopause. Mean age was 64.2 years (standard deviation of 19.1). Of the cohort, 481 (561.1%) had at least some comorbidity and was frequent to find diabetes (18.5%), immunosuppression due to oncologic disease or medications (18.4%), urolithiasis or previous surgical procedures (17%). After logistic regression, risk factors identified to predict ESBL production, were: being a man (aOR 5.4, 2.1-18.2), a woman with menopause (aOR 2.9, 1.3 -9.9), and the Charlson score (aOR 0.83, 0.73 – 0.96). Previous antibiotic use was not related to ESBL infection. Conclusion In this relatively large cohort of patients with pyelonephritis caused by E. coli, ESBL production risk factors were not clearly identified other than sex and menopause. Curiously, Charlson score predicted a lower risk of resistance. Other factors (food consumptions and others) might be driving the resistance in the community in E. coli. Disclosures Jorge Cortes, MD, Pfizer (Research Grant or Support)

Patterns of first-line systemic therapy delivery and adoption of bevacizumab in advanced ovarian cancer in Ontario, Canada.

292 Background: Initial treatment of epithelial ovarian cancer (EOC) consists of combination of cytoreductive surgery (CSR) and/or chemotherapy. Targeted therapies such as bevacizumab have shown to improve outcomes in a subset population with high-risk features. Real-world patterns of systemic therapy delivery in EOC in the modern era are not well understood. Our objective is to evaluate the patterns of first-line systemic treatment of advanced EOC in Ontario, focusing on adoption of bevacizumab, which was approved for use in 2016. Methods: We conducted a retrospective, population cohort study using administrative databases held at the ICES in Ontario, Canada. Patients diagnosed with non-mucinous EOC between 2014 and 2018 were identified from the Ontario Cancer Registry; early-stage disease was excluded. Information on systemic therapy was obtained from Activity Level Reporting and New Drug Funding Program databases. Provider of care (gynecologic oncologist vs medical oncologist) information was obtained from billing codes. Academic cancer centers were identified using validated systemic facility codes from Cancer Care Ontario. Statistical analyses include descriptive statistics, t-tests, and multivariable logistic regression using SAS. Results: Out of 4,680 cases diagnosed with EOC during the study period, 3,632 (77.6%) were considered advanced stage. Median age of cohort was between 65-70, and the majority had Charlson score of 1-2 (97%) and are urban (91.8%). A total of 3,181 (87.6%) patients underwent CRS and 2,722(74.9%) patients underwent chemotherapy. Of those who received chemotherapy, 1,259 (46.2%) received neoadjuvant chemotherapy, 1,012 (37.2%) received upfront CRS, and 451(16.5%) received chemotherapy only. The majority of chemotherapy was delivered by gynecologic oncologists (60.6%) and in academic cancer centres (61.7%). There was no significant difference in use of neoadjuvant chemotherapy between medical oncologists and gynecologic oncologists (p = 0.67). Only 53 chemotherapy patients (1.9%) received bevacizumab containing-regimen in the first-line setting. Medical oncologists were 4 times more likely to administer bevacizumab-containing regimen compared to gynecologic oncologists (OR 4.03, 95% CI.29 – 7.36) after adjusting for age, stage, Charlson score and rurality score on logistic regression. Delivery of bevacizumab is relatively higher in non-academic cancer centres (OR 2.61, 95% CI 2.32- 2.94) while 83% of intraperitoneal chemotherapy is delivered in academic cancer centres. Conclusions: Patterns of care of EOC in Ontario remain heterogenous between care providers and institutions, while uptake of bevacizumab for first-line treatment of EOC remains low. Factors leading to low uptake and real-world outcomes should be explored.

SP9.1.2 Sarcopenia and myosteatosis predict thirty-day emergency laparotomy mortality [The FrOGS study]

Aims Sarcopenia (low muscle mass - SM) and myosteatosis (low muscle quality - SM-RA) are associated with poor outcomes after elective cancer surgery. Body composition parameters have not been explored in emergency surgery and may offer additive value to risk prediction scores. This multicentre study assessed the association of body composition and survival after emergency laparotomy. Methods A retrospective longitudinal cohort of 674 patients, across 10 hospitals in southern England were recruited (NCT03534765). All patients underwent emergency laparotomy, fulfilling NELA criteria, between August 2016 and November 2017. Pre-operative CTs were blindly analysed using L3 slices, assessing SM and SM-RA. Regression analysis was used to assess associations of body composition and 30-day mortality. Results Six hundred and ten patients were included [283(46%) men, median(IQR) age 71 years (57-79)]. P-POSSUM and NELA predicted mortality was 7% and 4.5% respectively, with a length of stay of 15 days (9-24), 30-day mortality of 7.8% and 1-year mortality of 18.9%. Significant univariate associations between 30-day mortality and age (OR1.04 (1.02-1.07);p=0.001), Charlson score (OR 6.84 (1.64-28.55);p=0.008), P-POSSUM (OR 1.03 (1.02-1.05);p&lt;0.001, NELA mortality (OR 1.06 (1.04-1.08);p&lt;0.001), SM (OR 0.98 (0.97-0.99);p=0.003 and SM-RA (OR 0.93 (0.9-0.96);p&lt;0.001. Significant multivariate associations between 30-day mortality and NELA (OR 1.05 (1.03-1.07); p &lt; 0.001, P-POSSUM (OR 1.03 (1.01-1.04); p &lt; 0.001, SM-RA (OR 0.94 (0.9-0.97); p &lt; 0.001. Conclusions Sarcopenia and myosteatosis are associated with increased mortality in patients undergoing emergency surgery. Body composition should be considered as an objective adjunct to traditional risk assessments, further informing the shared-decision making process around emergency surgery.

Prognostic factors associated with upper gastrointestinal bleeding based on the French multicenter SANGHRIA trial

Background and study aims Prognostic and risk factors for upper gastrointestinal bleeding (UGIB) might have changed overtime because of the increased use of direct oral anticoagulants and improved gastroenterological care. This study was undertaken to assess the outcomes of UGIB in light of these new determinants by establishing a new national, multicenter cohort 10 years after the first. Methods Consecutive outpatients and inpatients with UGIB symptoms consulting at 46 French general hospitals were prospectively included between November 2017 and October 2018. They were followed for at least for 6 weeks to assess 6-week rebleeding and mortality rates and factors associated with each event. Results Among the 2498 enrolled patients (mean age 68.5 [16.3] years, 67.1 % men), 74.5 % were outpatients and 21 % had cirrhosis. Median Charlson score was 2 (IQR 1–4) and Rockall score was 5 (IQR 3–6). Within 24 hours, 83.4 % of the patients underwent endoscopy. The main causes of bleeding were peptic ulcers (44.9 %) and portal hypertension (18.9 %). The early in-hospital rebleeding rate was 10.5 %. The 6-week mortality rate was 12.5 %. Predictors significantly associated with 6-week mortality were initial transfusion (OR 1.54; 95 %CI 1.04–2.28), Charlson score > 4 (OR 1.80; 95 %CI 1.31–2.48), Rockall score > 5 (OR 1.98; 95 %CI 1.39–2.80), being an inpatient (OR 2.45; 95 %CI 1.76–3.41) and rebleeding (OR 2.6; 95 %CI 1.85–3.64). Anticoagulant therapy was not associated with dreaded outcomes. Conclusions The 6-week mortality rate remained high after UGIB, especially for inpatients. Predictors of mortality underlined the weight of comorbidities on outcomes.

Short-term outcome of Ivor Lewis esophagectomy following neoadjuvant chemoradiation versus perioperative chemotherapy in patients with locally advanced adenocarcinoma of the esophagus and gastroesophageal junction: a propensity score-matched analysis

Background Patients with locally advanced esophageal or gastroesophageal adenocarcinoma benefit from multimodal therapy concepts including neoadjuvant chemoradiation (nCRT), respectively, perioperative chemotherapy (pCT). However, it remains unclear which treatment is superior concerning postoperative morbidity. Methods In this study, we compared the postsurgical survival (30-day/90-day/1-year mortality) (primary endpoint), treatment response, and surgical complications (secondary endpoints) of patients who either received nCRT (CROSS protocol) or pCT (FLOT protocol) due to esophageal/gastroesophageal adenocarcinoma. Between January 2013 and December 2017, 873 patients underwent Ivor Lewis esophagectomy in our high-volume center. 339 patients received nCRT and 97 underwent pCT. After 1:1 propensity score matching (matching criteria: sex, age, BMI, ASA score, and Charlson score), 97 patients per subgroup were included for analysis. Results After matching, tumor response (ypT/ypN) did not differ significantly between nCRT and pCT (p = 0.118, respectively, p = 0.174). Residual nodal metastasis occurred more often after pCT (p = 0.001). Postsurgical mortality was comparable within both groups. No patient died within 30 or 90 days after surgery while the 1-year survival rate was 72.2% for nCRT and 68.0% for pCT (p = 0.47). Only grade 3a complications according to Clavien–Dindo were increased after pCT (p = 0.04). There was a trend towards a higher rate of pylorospasm within the pCT group (nCRT: 23.7% versus pCT: 37.1%) (p = 0.061). Multivariate analysis identified pCT, younger age, and Charlson score as independent variables for pylorospasm. Conclusion Both nCRT and pCT are safe and efficient within the multimodal treatment of esophageal/gastroesophageal adenocarcinoma. We did not observe differences in postoperative morbidity. However, functional aspects such as gastric emptying might be more frequent after pCT.

Management of Pseudomonas aeruginosa Bloodstream Infection and Impact on Health Outcomes

Background: Gram-negative bacteria cause a variety of hospital-associated infections (HAIs). Of concern is Pseudomonas aeruginosa, which is a leading cause of HAIs. Early and adequate therapy of P. aeruginosa blood stream infection (BSI) is associated with decreased mortality. Additionally, infectious disease consultation has also shown to improve health outcomes, streamline care, and decrease costs. Therefore, the goal of this study was to describe treatment of P. aeruginosa BSI and impact of infectious disease consultations on health outcomes. Methods: In this retrospective cohort study, we analyzed national VA medical, encounter, pharmacy, microbiology, and laboratory data from January 1, 2012 to December 31, 2018. The cohort included all hospitalized adult veterans (aged ≥18 years) who had a positive blood culture for P. aeruginosa. Only the first P. aeruginosa blood culture per patient was included, and duplicate cultures within 30 days were removed. Treatment was identified within −2 to +5 days of the culture date. Multidrug-resistant (MDR) cultures were identified based on resistance to at least 1 agent in at least 3 or more antimicrobial categories tested. Multivariable logistic regression models were fit to assess infectious disease consultations and adequate treatment on in-hospital mortality and 30-day mortality. Results: In total, 3,256 patients had a BSI with P. aeruginosa, of which 386 (11.5%) were MDR. Most of these patients were male (97.5%), >65 years of age (70.9%), and non-Hispanic white (63.8%). Also, 784 patients (23.3%) died during hospitalization and 870 (25.8%) died within 30 days of their culture. In multivariable regression models, infectious disease consultations were associated with decreased odds of in-hospital mortality (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53–0.77) and 30-day mortality (OR, 0.56, 95% CI, 0.48–0.67) even after adjusting for age, race, care setting, Charlson score, and prior healthcare exposures. Furthermore, inadequate definitive treatment was associated with increased odds of in-hospital mortality (OR, 2.77; 95% CI, 1.35–5.69) and 30-day mortality (OR, 2.37; 95% CI, 1.18–4.79), even after adjusting for age, Charlson score, care setting, and prior healthcare exposures. In addition, carbapenem treatment was associated with increased odds of in-hospital mortality (OR, 1.38; 95% CI, 1.12–1.70) and 30-day mortality (OR, 1.49; 95% CI, 1.22–1.81), whereas fluoroquinolone treatment was associated with lower odds of in-hospital mortality (OR, 0.49; 95% CI, 0.41–0.59) and 30-day mortality (OR, 0.60; 95% CI, 0.50–0.71). Finally, extended-spectrum cephalosporin was also associated with lower odds of in-hospital mortality (OR, 0.82; 95% CI, 0.68–0.98). Conclusions: Use of infectious disease consultations and any adequate definitive treatment for those with P. aeruginosa BSI lowered odds of in-hospital and 30-day mortality. Early consultation with infectious disease physicians regarding adequate treatment has direct positive impact on clinical outcomes for patients with P. aeruginosa BSI.Funding: NoDisclosures: None

Oncology consults in admitted cancer patients: The ways to reduce length of stay.

e13516 Background: The cancer patients, while being admitted to the hospital often have an oncologist consult (OC) through the admission. The goal of the study is to assess, whether OC impact the length of stay (LOS) and to define the group of cancer patients in whom omitting the OC can decrease LOS. Methods: We reviewed 415 admissions of cancer patients from 1/1/2018 to 11/30/2020 to the both campuses of Mercy Catholic Medical Center. We included patients who are 18 years or older with confirmed malignancy. We excluded COVID positive, patients who died during admission, were transferred to tertiary care institutions, or were recommended hospice care, but decided to continue treatment despite poor prognosis. Patient with hematologic disorders were excluded as well. The LOS of stay in cancer patients with and without OC will be compared using two tailed unpaired t-test and Mann-Whitney test ( < 20 admissions in each group, or one of the groups had a largely skewed data). Sub-analysis will be done accounting for Charlson score, spread of the disease and reason of admission (cancer vs non-cancer related). Statistical software Prism 9 will be used for analysis. Results: 290 admissions were selected using inclusion and exclusion criteria. Throughout all admission 234 admission had OC and mean LOS was 4.86 day compare to 4.23 in 56 patients, who did not have OC. Patients with non-cancer related (non-CR) admissions who had Charlson score ≤6 and no OC had shorter LOS (13 admission with median LOS 3 days) compared to those who had OC (11 admissions with LOS 7days), p 0.0462. Also, patient with non-CR admission and localized cancer tend have shorter LOS when no OC involved (15 admission with median LOS 6 days) compare to OC (16 admissions with median LOS 2.5 days), p 0.0365. No other significant difference in LOS were observed (Table). Conclusions: The cancer patients admitted for the reasons not related to their primary malignancy and who have either localized disease or Charlson score < 6 have shorter length of stay when OC not done. The limitation of the current study is the small number of patients in analysis subgroups, as well as fact that patients who had OC may have more severe disease during admission, despite the fact that patient had same extend of disease and comorbidities. Study with larger number of admissions may be necessary to confirm findings of this study.[Table: see text]

Underutilization of germline BRCA testing in commercially-insured women diagnosed with ovarian cancer.

5539 Background: Germline BRCA (gBRCA) testing has prognostic, therapeutic, and familial implications for patients with ovarian cancer. Since 2010, national guidelines have recommended universal genetic testing, but few data are available about rates and timeliness of testing or factors associated with testing. Methods: We examined rates of gBRCA testing and the time from index procedure to testing among commercially-insured women aged 18 to 64 with claims for ovarian, fallopian tube, or primary peritoneal cancers cancer who received cytoreductive surgery and chemotherapy between 2008-2018. We used logistic regression to assess patient-, clinician-, and practice-level characteristics associated with testing. Results: Overall, the rate of g BRCA testing was 33.9%, increasing from 14.7% in 2008 to 46.4% in 2018; the median time to testing decreased from 280.0 to 72.5 days. Patients who were tested were younger than those who were not (mean [SD] 54.7 [9.9] years vs. 58.1 [11.8] years, P<.001) and had fewer comorbidities (Charlson score ≥2: 3.7% vs. 9.5%, P=0.01). There were no differences in testing rates by US region, rurality of practice location, or medical vs. gynecologic oncology providers. However, testing rates were higher in academic and NCI-designated cancer centers (36.2% and 32.5%, respectively), compared with community practices (25.5%; P<0.001) (Table). In adjusted analyses, lower test rates were associated with older age (aOR=0.97, 95%CI=0.96-0.98), more medical comorbidities (Charlson score ≥2: aOR=0.77, 95%CI=0.61-0.97), and community practices vs. NCI cancer centers (aOR=0.64, 95%CI=0.46-0.88). Conclusions: While the rates and time to testing for gBRCA in patients with new diagnoses of ovarian cancer have improved over time, testing remains underutilized, even among well-insured populations. Future studies should examine barriers to timely genetic testing and identify scalable strategies for increasing testing in women with ovarian cancer, particularly for women treated in community practices.[Table: see text]