P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre

Background Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix. Methods TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO. Results Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p < 0.001) were independently associated with TO. Conclusions Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.

Role of comorbidity in assessment of long-term prognosis after myocardial infarction

The aim of the study. To compare different methods for assessing comorbidity in terms of its long-term predictive value after myocardial infarction (MI).Materials and methods. The analysis included 1176 patients with MI who were consecutively admitted to the hospital. The incidence of STsegment elevation MI was 60%; every second patient underwent endovascular intervention. All patients underwent an analysis of the severity of comorbidity according to the CIRS system (Cumulative lllness Rating Scale), according to the CCI (the Charlson’s comorbidity index), the CDS scale of chronic diseases (Chronic Disease Score), as well as according to their own model ‘K9’ (patent RU2734993C1 dated 10.27.2020) based on the summation of nine diseases: type 2 diabetes mellitus, chronic kidney disease, atrial fibrillation, anemia, stroke, arterial hypertension, obesity, peripheral atherosclerosis, thrombocytopenia.Results. Long-term mortality was 12.1 %. In Cox regression analysis of long-term survival after MI, the K9 model showed the best operational characteristics with a p < 0.00001 level. In multivariate analysis, when comorbidity data were added to GRACE, an increase in the χ2 value for GARCE + CCI and GRACE + K9 to 102.5 and 99.3, respectively, and the values of the area under the ROC curve to 0.78 (0.74–0, 82) and 0.77 (0.72–0.81), respectively. Regardless of the initial level of risk assessed by the GRACE scale, severe comorbidity (four or more diseases according to the K9) significantly increased the relative risk of mortality. In patients with severe comorbidity, the predictive value of the GRACE scale was the lowest.Conclusions. Among the analyzed methods of assessing comorbidity, only CCI and its own K9 scale have an acceptable predictive value, allowing better adaptation of the GRACE scale for stratification of the long-term risk of death after MI. At the same time ‘K9’, based on the summation of nine previously described diseases, is much more convenient than CCI in practical application

Empagliflozin in patient with heart failure and type 2 diabetes mellitus: new possibilities for drug therapy

The article demonstrates the practical experience of the effective use of inhibitor of sodium-glucose co-transporter 2 emplagliflozin as a part of optimal drug therapy in patients with decompensation of chronic heart failure with systolic dysfunction of ischemic genesis and type 2 diabetes mellitus. The place of this group of drugs in improving the quality of life and prognosis in patients with severe comorbidity has been indicated according to the data of evidence-based studies.

Prediction of post radical nephrectomy complications based on patient comorbidity preoperatively

Objectives: Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, using standardized systems to grade both comorbidity and severity of postoperative complications. Materials and methods: Clinicopathological data of 171 patients undergoing open radical nephrectomy for lesions suspected of RCC were prospectively recorded for a period of 3 years. Comorbidity was scored using the Charlson Comorbidity Index (CCI) while postoperative complications were graded according to the Clavien-Dindo system.Results: Patients were predominantly males (59.1%); their age ranged from 35 to 88 years (mean ± SD: 63.6 ± 11.9 yrs) with 50.8% of them being ≤ 65 yrs. CCI ranged from 0 to 8 with the majority (85.3%) scoring ≤ 2. The procedure was uncomplicated in 57.3% cases; 10 patients suffered major (grade III/IV) complications and 4 patients died within the 40 days postoperative period. CCI correlated with the manifestation of any postoperative complication, Clavien ≥ 1, OR (95% CI): 1.47 (1.09-1.96), p = 0.011 and the occurrence of severe complications, Clavien > 2. OR (95% CI): 1.29 (1.01-1.63), p = 0.038. Conclusions: The present prospective study showed that considerable complications occur in patients with major comorbidities. CCI is easily calculated and should be incorporated in preoperative consultation especially in cases of elder patients with severe comorbidity and favorable tumor characteristics where less invasive interventions or even active surveillance could be applied.

Temporal trend of comorbidity and increasing impacts on mortality, length of stay, and hospital costs of first stroke in Tianjin, North of China

Background Stroke patients have a high incidence of comorbidity. Previous studies have shown that comorbidity can impact on the short-term and long-term mortality after stroke. Methods Our study aimed to explore the trend of comorbidity among patients with first stroke from 2010 to 2020, and the influence of comorbidity on admission mortality, length of stay and hospitalization costs. 5988 eligible patients were enrolled in our study, and divided into 4 comorbidity burden groups according to Charlson comorbidity index (CCI): none, moderate, severe, very severe. Survival analysis was expressed by Kaplan–Meier curve. Cox regression model was used to analyze the effect of comorbidity on 7-day and in-hospital mortality. Generalized linear model (GLM) was used to analyze the association between comorbidity and hospitalization days and cost. Results Compared to patients without comorbidity, those with very severe comorbidity were more likely to be male (342, 57.7%), suffer from ischemic stroke (565, 95.3%), afford higher expense (Midian, 19339.3RMB, IQR13020.7–27485.9RMB), and have a higher in-hospital mortality (60, 10.1%). From 2010 to 2020, proportion of patients with severe and very severe comorbidity increased 12.9%. The heaviest comorbidity burden increased the risk of 7-day mortality (adjusted hazard ratio, 3.51, 95% CI 2.22–5.53) and in-hospital mortality (adjusted hazard ratio, 3.83, 95% CI 2.70–5.45). Patients with very severe comorbidity had a 12% longer LOS and extra 27% expense than those without comorbidity. Conclusions Comorbidity burden showed an increasing trend year in past eleven years. The heavy comorbidity burden increased in-hospital mortality, LOS, and hospitalization cost, especially in patients aged 55 years or more. The findings also provide some reference on improvement of health care reform policies and allocation of resources.

Importance of medication adherence in treatment needed diabetic retinopathy

We aim to investigate the role of medication adherence history in treatment needed diabetic retinopathy (TNDR). We conducted a retrospective nested case–control study using 3 population-based databases in Taiwan. The major one was the 2-million-sample longitudinal health and welfare population-based database from 1997 to 2017, a nationally representative random sample of National Health Insurance Administration enrolled beneficiaries in 2010 (LHID2010). The national death registry and national cancer registry were also checked to verify the information. The outcome was defined as the TNDR. The Medication possession ratio (MPR) was defined as the ratio of total days of diabetes mellitus (DM) medication supply divided by total observation days. MPR ≥ 80% was proposed as good medication adherence. The association of MPR and the TNDR was analyzed. Other potential confounders and MPR ratio were also evaluated. A total of (n = 44,628) patients were enrolled. Younger aged, male sex and patients with less chronic illness complexity or less diabetes complication severity tend to have poorer medication adherence. Those with severe comorbidity or participating pay-for-performance program (P4P) revealed better adherence. No matter what the characteristics are, patients with good MPR showed a significantly lower likelihood of leading to TNDR after adjustment with other factors. The protection effect was consistent for up to 5 years. Good medication adherence significantly prevents treatment needed diabetic retinopathy. Hence, it is important to promote DM medication adherence to prevent risks of diabetic retinopathy progression, especially those who opt to have low medication adherence.

Do age, fitness and concomitant medications influence management and outcomes of CLL patients treated with ibrutinib?

Functional reserve of organs and systems is known to be relevant in predicting immunochemotherapy tolerance. Age and comorbidities, assessed by the cumulative illness rating scale (CIRS), have been used to address chemotherapy intensity. In ibrutinib era it is still unclear whether age, CIRS and ECOG-PS retain their predictive role on treatment vulnerability. In this 712 CLL patients series treated with ibrutinib outside clinical trials, baseline ECOG-PS and neutropenia, resulted as the most accurate predictors of treatment feasibility and outcomes. Age did not independently influence survival and ibrutinib tolerance, indicating that not age per se, but age-related conditions may affect drug management. We confirmed the role of CIRS&gt;6 as a predictor of a poorer progression and event-free survival (PFS, EFS). The presence of a severe comorbidity was significantly associated with permanent dose reductions (PDR), not translating into worse outcomes. As expected, del(17p) and/or TP53mut and previous therapies affected PFS, EFS and overall survival. No study so far has analyzed the influence of concomitant medications and CYP3A-inhibitors with ibrutinib. In our series, these factors had no impact, though CYP3A4 inhibitors use correlated at Cox regression analysis, with an increased risk of PDR. Despite the limitation of its retrospective nature, this large study confirmed the role of ECOG-PS as the most accurate predictor of ibrutinib feasibility and outcomes and importantly neutropenia emerged as a relevant tool influencing patients vulnerability. Although CIRS&gt;6 retained a significant impact on PFS and EFS its value should be confirmed by prospective studies.

Temporal Trend of Comorbidity and Increasing Impacts on Mortality, Length of Stay, and Hospital Costs of First Stroke in Tianjin, North of China

Purpose: Stroke patients have a high incidence of comorbidity. Our study aimed to explore the trend of comorbidity among patients with first stroke from 2010 to 2020, and the influence of comorbidity on admission mortality, length of stay and hospitalization costs.5988 eligible patients were enrolled in our study, and divided into 4 comorbidity burden groups according to Charlson comorbidity index (CCI): none, moderate, severe, very severe. Survival analysis was expressed by Kaplan - Meier curve. Cox regression model was used to analyze the effect of comorbidity on 7-day and in-hospital mortality. Generalized linear model (GLM) was used to analyze the association between comorbidity and hospitalization days and cost. Results: Compared to patients without comorbidity, those with very severe comorbidity were more likely to be male (342, 57.7%), suffer from ischemic stroke (565, 95.3%), afford higher expense (Midian, 19339.3RMB, IQR13020.7-27485.9RMB), and have a higher in-hospital mortality (60, 10.1%). From 2010 to 2020, proportion of patients with severe and very severe comorbidity increased 12.9%. The heaviest comorbidity burden increased the risk of 7-day mortality (adjusted hazard ratio, 3.51, 95% CI, 2.22-5.53) and in-hospital mortality (adjusted hazard ratio, 3.83, 95% CI, 2.70-5.45). Patients with very severe comorbidity had a 12% longer LOS and extra 27% expense than those without comorbidity.Conclusion: Comorbidity burden showed an increasing trend year in past eleven years. The heavy comorbidity burden increased in-hospital mortality, LOS, and hospitalization cost, especially in patients aged 55 years or more.

A Clinical Case of Acute Polyarthritis Unmasking Severe Comorbidity

Acute polyarthritis requires a comprehensive differential diagnosis in order to establish its etiology. Moreover, sometimes it may unfold unexpected comorbidities, thus necessitating an individualized management approach. This article describes the case of an elderly patient whose initial presentation of acute polyarthritis was interpreted as crystal induced-arthritis demonstrated by the presence of calcium pyrophosphate and lipid crystals in the synovial fluid. The clinical deterioration of the patient along with the suspicion of a systemic infection required interdisciplinary collaboration and led to his transfer to the infectious diseases department where the diagnosis of sepsis from unknown origin was added. Further investigations unmasked a large complicated pancreatic pseudocyst that eventually ruptured into the peritoneal cavity and led to the patient's death.

Onset of Diabetes Pediatric Age and Comorbidly in the last 12 years and urgent Covid Vaccination in Sanitary Agency in Bergamo - Italy

Introduction Diabetes is a chronic disease as a result of absent or low intake in internal production of Insulin or glucose tolerance in a large diffusion population of 3.27 million people in Italy. 5,4 thousand of Italian people for ISTAT in a future prospective and there will be an increase in the next years for high increase risk of new cases every year until now. We have Diabetes typo II (T2DM, older in 90%), and Diabetes typo I (T1DM, younger in 10%), both are Prevent with Auxological Screening and early Intervention with Nutritional Applied Behavior Analysis (A.B.A.). An early diagnosis determines a survival of 5,000 patients for year. In our patients affects by T1DM, during pandemic of Coronavirus disease (SARS-CoV type 2 and variants), we have noted an increase of glycemia during respiratory infections with more comorbidities and complications for them. Clinical Study We study 181 patients who have accessed in Treviglio-Caravaggio Hospital in these years since 1/1/2009 to 1/6/2020. we have 181 records divided for sex: 104 males and 77 females. With follow-up for 55 patients with severe comorbidities and 4 were transferred to HUB Center for risk of coma in severe compliances and during Covid lock down 44 patients were suggested to take care in HUB center of Bergamo or Milan to prevent their hospitalizations in security environment. The children’s accesses affected by Diabetes type 1 was in our Emergency and Pediatric Department of Treviglio Hospital in the last 12 years, since 1 January 2009 to 1 June 2021, are 129 total patients and 52 new patients during Auxological-Nutritional Ambulatory for Pediatric T1DM outpatients before and during 2020-2021 controls of metabolic diet therapy in fellow-up, now, with cellphone and in Meet. Materials and Methods We have records data in excel and Pivot graphic and analysis in Anova Statics Program with follow-up of 181 patients divided in 2 period of age: preschooler 23, and scholar e adolescent 157. 125 patients are divided in 123 Diabetes Mellitus (with Italian code 775.1 e 250.1 national record), 2 MOBY cases and 57 patients with one or more comorbidly. From date of casehistory, we need now analysis 3 groups with outset of diabetes during 2 years of life of which 19.2% with comorbidity 21.6% with many comorbidities and cases of Insulin-dependent Diabetes after 2 years of life are 77,7%, with severe comorbidity in 24%. With comorbidity outset in the 39.2% and during follow-up in 42.4%. From report 21% patients have for the major part “Celiac Disease” and 6,4% other infections (Helicobacter Pylori and enteritis). Whereas 28% have metabolic-auxological endocrinological diseases (acute/chronic evolution during up-growth). Underweight young with T1DM (BMI < 15 Kg/m2) or obesity (BMI>35 Kg/m2) have a high risk to be infected and dead for COVID-19 owing to complications of their status of health. Conclusions Until 1/31/2018, we allow to do a distinction: the first since 2009-2014 within 20.6% early diagnosis and discovered in later age the second since 2014-2019 with more 38.4%. In the last years since 2019-2021 about, the early neonatal respect to mellitus DMT1 of last period, presents a predictive index of 55.5% with a better stature-ponderal development, neurological-behavior, and nutritional-compliance monitoring in 12 years of periodic controls. Since 11 March 2020 with WhatsApp, Hangouts and Meet or Skype, our data of SARS-CoV-19 infection in T1DM patients showed more than 65% positive patients by serological test after a period of suspect disease in 12 patients (6,6%) against a few symptoms in 107 patients (59,11%) with positive nasalpharyngeal test during quarantine or observation in a second lockdown, since September 2020 to May 2021.