Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures—Results from the Registry for Geriatric Trauma of the German Trauma Society

Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.

Functional outcome and health-related quality of life following ipsilateral femoral and acetabular fractures: a retrospective analysis

Introduction: The combination of ipsilateral femoral and acetabular fractures is known in the literature as the “Floating hip injury”. The primary aim of this study is to assess both generic and specific patient-reported outcomes and the factors affecting the quality of life in patients sustaining this injury, while the secondary aim was to assess the injury patterns and the associated complications. Methods: A retrospective study including 27 patients according to specific inclusion and exclusion criteria. EQ5D5L and Oxford hip score (OHS) were used. The mean age was 28 years (±10.1 SD) and 21 patients (77.8%) were males. The mean follow-up was 7 years (± 3.1 years SD). Results: Median OHS was 46.5 (IQR: 31.5–48). The median EQ5D score was 0.919 (95% CI: 0.601–1). The mean EQ5D index value was 0.679 ± 0.442 (95% CI: 0.492–0.865). In this young cohort of patients, this drop in the mean EQ5D index value has led to a loss of a mean of 2.2 Quality-adjusted Life Years (QALYs). Through multivariate analysis, we found that the quality of life was mainly affected by the occurrence of end-stage arthritis, the presence of non-recovered traumatic sciatic nerve injury, and the occurrence of infection. Conclusions: Our findings show that the quality of life of those patients was significantly affected. These findings can be beneficial in counselling patients sustaining this complex injury and could be helpful in the discussion of the prognosis and in planning postoperative rehabilitation and support.

Basal thumb osteoarthritis surgery improves health state utility irrespective of technique: a study of UK Hand Registry data

We used UK Hand Registry data to study two aspects of basal thumb osteoarthritis surgery: first, whether health-related quality of life improves after surgery. Second, whether results from trials comparing simple trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition are reproducible in routine clinical practice. Prospectively collected EQ5D index and Patient Evaluation Measure part 2 data were compared at baseline and at 3, 6, and 12 months postoperatively in 1456 patients (median age 67 years; 78% female). A mixed-effects regression model was also used to determine the postoperative trajectory of these variables. There was a significant improvement in the EQ5D index (median + 0.15; (interquartile range 0 to 0.40)) and Patient Evaluation Measure (–22; (–33 to –10)) by 1 year postoperatively and with no meaningful difference between the two techniques. This study demonstrates health state utility gains after basal thumb osteoarthritis surgery regardless of surgical techniques used. Level of evidence: III

Elevated Labile Plasma Iron (LPI) Levels in Patients with Lower-Risk Myelodysplastic Syndromes (MDS) Are Associated with Decreased Quality of Life and Reduced Survival

Background: Patients with lower-risk MDS (LR-MDS) are prone to iron toxicity due to long-term iron accumulation either caused by RBC transfusions or ineffective erythropoiesis. Nontransferrin bound iron (NTBI), including labile plasma iron (LPI), are toxic iron species that may mediate cellular damage via oxidative stress. The EUMDS registry collects prospective observational data on newly diagnosed LR-MDS patients from 145 centers in 17 countries since 2008. Methods: We analyzed serum from 247 LR-MDS patients collected at six-month intervals for ferritin, transferrin saturation (TSAT), hepcidin-25, soluble transferin receptor (sTfR) and toxic iron species (NTBI and LPI) in order to evaluate temporal changes in iron metabolism, the presence of potentially toxic forms of iron and their impact on survival, and quality of life. In addition, we measured the impact of iron chelation on the iron species levels and its impact on the outcome parameters. Results: The median age was 73 years (range: 37 to 95 years) and 66% were males. WHO2001 MDS-subtypes were RCMD (45%), RARS (22%), RA (18%), RAEB-1 (7%), 5q-syndrome (4%) and RCMD-RS (4%). The IPSS-R categories were: (very) low risk: 66%; intermediate risk: 11%; (very) high risk: 2% and unknown: 20%. The median EQ5D index score was 0.80 (p10 to p90: 0.52 to 1.00). The table shows iron parameters at registration, 1 and 2 years follow-up both in transfusion-dependent (TD) and transfusion-independent (TI) patients and according to: MDS-RS (RARS/RCMD-RS) or MDS Other (RA/RCMD/RAEB/5q-syndrome). Mean serum ferritin levels were increased in TD patients, compared to TI patients (Table). Increase of ferritin levels over time was high in both TD groups, but the increase was more pronounced in the RS subgroup. Elevated CRP levels (> 10mg/L) were observed in TD nonRS patients, especially during the first year after diagnosis. Markedly increased mean TSAT levels (>75%) occurred in the subgroup of TD-RS patients throughout the observation period. Hepcidin levels were most markedly elevated in TD nonRS patients at registration and remained elevated during follow-up (Table). Hepcidin levels were low in MDS-RS TI patients at all time points compared to nonRS MDS patients and decreased over time as a result of an increased (ineffective) erythropoiesis (Table). This is supported by the highest levels of STfR also noted in this patient category (data not shown). The highest NTBI and LPI levels were observed in TD-RS patients compared to the other 3 subgroups (Table). Both NTBI and LPI levels had a strong correlation (p <0.001) with TSAT. Elevated LPI levels in combination with high TSAT levels (>80%) occurred almost exclusively in patients with MDS-RS and/or previous transfusions. Both the EQ5D index score and EQ-VAS showed a negative correlation (r) with LPI levels with r = -0.09 (p = 0.028) and r = -0.07 (p=0.046) respectively. This negative effect of elevated LPI levels was most pronounced in the TD RS subgroup with a negative correlation of -0.17 for the EQ5D index score and -0.2 for the VAS score. In total 16 patients received iron chelation during the sample collection period (11 patients deferasirox, 4 patients desferioxamine and 1 patient unknown). LPI levels were normal in 14 out of the 17 samples collected during deferasirox treatment and in 2 out of 5 samples collected during desferoxamine treatment. The Kaplan-Meier curves (Figure) demonstrate the prognostic impact of elevated LPI levels by transfusion status as a time dependent variable; once a subject had an elevated LPI level, they remained in this group. Patients were censored at time of starting iron chelation (16 patients). In a multivariate analysis comparing elevated LPI levels and transfusion dependency to the control group with undetectable LPI and no transfusion showed a significantly decreased survival in all 3 risk groups after adjustment for age at diagnosis, baseline IPSS-R category and ESA treatment status; for details, see supplementary table. Conclusion: This study illustrates labile plasma iron species as a clinically relevant assay for identification of the toxic fraction of overt iron overload and its negative impact on HRQoL and overall survival in transfusion dependent and transfusion independent patients. Table. Table. Disclosures Culligan: Merck Sharp & Dohme (MSD): Honoraria; Abbvie: Other: Support to attend conferences; Takeda: Honoraria, Other: Support to attend conferences; Pfizer: Honoraria; Celgene: Other: Support to attend conferences; JAZZ: Honoraria; Daiichi-Sankyo: Other: Support to attend conferences. Garelius:novartis: Honoraria. de Witte:Celgene: Honoraria, Research Funding; Novartis: Research Funding; Amgen: Consultancy, Research Funding.

The role of pain in chronic pain patients’ perception of health-related quality of life: a cross-sectional SQRP study of 40,000 patients

Background and aims Health-related quality of life (Hr-QoL) reflects the burden of a condition on an overarching level. Pain intensity, disability and other factors influence how patients with chronic pain perceive their condition, e.g. Hr-QoL. However, the relative importance of these factors is unclear and there is an ongoing debate as to what importance pain measures have in this group. We investigated the importance of current pain level and mood on aspects of Hr-QoL in patients with chronic pain and investigated whether such relationships are influenced by demographics. Methods Data was obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP), between 2008 and 2016 on patients ≥18 years old who suffered from chronic pain and were referred to participating specialist clinics. Dependent variables were general Hr-QoL [using two scales from European Quality of Life instrument: EQ5D Index and the European Quality of Life instrument health scale (EQ thermometer)] and specific Hr-QoL [from the Short Form Health Survey (SF36) the physical component summary (SF36-PCS) and the mental (psychological) component summary (SF36-MCS)]. Independent variables were sociodemographic variables, pain variables, psychological distress and pain attitudes. Principal component analysis (PCA) was used for multivariate correlation analyses of all investigated variables and Orthogonal Partial Least Square Regression (OPLS) for multivariate regressions on health aspects. Results There was 40,518 patients (72% women). Pain intensity and interference showed the strongest multivariate correlations with EQ5D Index, EQ thermometer and SF36-PCS. Psychological distress variables displayed the strongest multivariate correlations with SF36-MCS. Demographic properties did not significantly influence variations in the investigated Hr-QoL variables. Conclusions Pain, mood and pain attitudes were significantly correlated with Hr-QoL variables, but these variables cannot explain most of variations in Hr-QoL variables. The results pinpoint that broad assessments (including pain intensity aspects) are needed to capture the clinical presentation of patients with complex chronic pain conditions.

Συμβιώνοντας με τον ασθενή με χρόνια νεφρική νόσο

Στόχος: Η διερεύνηση της ψυχικής και της σωματικής υγείας των συζύγων-φροντιστών ασθενών με χρόνια νεφρική νόσο (ΧΝΝ), ο προσδιορισμός των παραγόντων που αυξάνουν την αίσθηση της επιβάρυνσης τους και η σύγκριση τους με μια ομάδα συζύγων ατόμων χωρίς ΧΝΝ. Μέθοδος: Η παρούσα έρευνα πραγματοποιήθηκε στη Νεφρολογική Κλινική του Πανεπιστημιακού Νοσοκομείου Ιωαννίνων και συμμετείχαν 50 σύζυγοι - φροντιστές ασθενών με ΧΝΝ από όλα τα ειδικά ιατρεία της Νεφρολογικής Κλινικής. Οι σύζυγοι-φροντιστές χωρίστηκαν σε δύο υποομάδες, ανάλογα με το αν οι ασθενείς βρίσκονταν εντός νεφρικής κάθαρσης. Επίσης, συμπεριλήφθηκε μια ομάδα 50 συζύγων από το γενικό πληθυσμό ατόμων χωρίς ΧΝΝ. Τα κριτήρια ένταξης ήταν ίδια για τις δύο ομάδες και διέφεραν μόνο στην ύπαρξη ΧΝΝ. Οι παράγοντες που μελετήθηκαν ήταν η επιβάρυνση φροντιστή, η κατάθλιψη, το άγχος, η σχετιζόμενη με την υγεία ποιότητα ζωής, η ντροπή και σημαντικοί δημογραφικοί παράγοντες και χρησιμοποιήθηκαν τα εξής ερωτηματολόγια: PHQ-9, GAD-2, Zarit Burden Interview, EQ-5D- 3L, OAS, λίστα συμπτωμάτων υγείας και ερωτηματολόγιο δημογραφικών. Οι στατιστικές αναλύσεις έγιναν με τα προγράμματα Excel, SPSS και STATA.Αποτελέσματα: Η μέση επιβάρυνση στο σύνολο των συζύγων-φροντιστών ήταν 27.26 (SD, 18.33), δηλαδή ήπια - μέτρια επιβάρυνση. Η μέση τιμή κατάθλιψης ήταν 5.64 (SD, 4.80), δηλαδή ήπια κατάθλιψη. Αντίστοιχα, η μέση τιμή στο άγχος ήταν 1.90 (SD, 1.64). Τέλος, τα επίπεδα συνολικής εξωτερικής ντροπής (μ.ο. 10.98, SD 13.39) βρέθηκαν εντός των μέσων τιμών για τον ελληνικό πληθυσμό. Ο μέσος όρος του EQ5D index (0.747, SD 0.213) και η μέση τιμή του σκορ στην EQ5D VAS (70.86, SD 16.97) αναδεικνύουν καλή ποιότητα ζωής. Οι δυο υπο-ομάδες διέφεραν (P=0.031) στην αυτοαξιολόγηση του επιπέδου υγείας που ήταν υψηλότερη στους συζύγους των ασθενών εκτός νεφρικής κάθαρσης. Η κατάθλιψη και το μηνιαίο εισόδημα βρέθηκαν να επηρεάζουν στατιστικά πάρα πολύ σημαντικά την αίσθηση επιβάρυνσης (B = 2.57, P ≤ .001 και B = -5.95, P ≤ 0.050 αντίστοιχα). Βρέθηκαν ισχυρές συσχετίσεις μεταξύ της πλειοψηφίας των παραγόντων (p≤0.001). Στην ομάδα των συζύγων των υγιών τα επίπεδα ψυχικής και σωματικής υγείας ήταν παρόμοια καλά. Κατά τη σύγκριση των δύο ομάδων προέκυψαν στατιστικά σημαντικές διαφορές μόνο στην αξιολόγηση των παραγόντων που επιδρούν αρνητικά στη σχέση. Επίσης, οι σύζυγοι των ασθενών ανέφεραν υψηλότερη ικανοποίηση από το γάμο τους από ότι οι σύζυγοι των υγιών (P=0.015). Συμπεράσματα: Η ψυχική και σωματική υγεία των συζύγων – φροντιστών ασθενών με ΧΝΝ είναι σε καλά επίπεδα και δε διέφερε από τους συζύγους ατόμων χωρίς ΧΝΝ. Από την παρούσα έρευνα επιβεβαιώθηκε η ισχυρή επίδραση της κατάθλιψης στην αίσθηση επιβάρυνσης και η αρνητική σχέση της με το μηνιαίο εισόδημα, ανεξαρτήτως των υπολοίπων παραγόντων. Ο σχεδιασμός προγραμμάτων ψυχολογικής υποστήριξης και οικονομικής ενίσχυσης της οικογένειας των ασθενών αποτελεί μια απαραίτητη διάσταση της πρόληψης και της Πρωτοβάθμιας Φροντίδας Υγείας.

Abstract 224: Characterizing Quality of Life Responses and Physical Functioning Improvements to an Integrated Self-care Intervention for Persons With Co-morbid Heart Failure and Diabetes

Objectives: In the Quality HF-DM trial, which tested an integrated self-care intervention for persons with heart failure (HF) and diabetes (DM), improved perceived HF and general health-related quality of life (QOL) and physical functioning were observed, but not for DM QOL. However, some participants did improve. This analysis examined the demographic and clinical factors associated with positive and clinically meaningful change in outcomes in response to the intervention to help inform future improvement in targeted interventions. Methods: HF-DM participants (n=134), mean age 57.4 ± 11 years, 66% men, 69% African American, were randomized to usual care (UC) or intervention (INT) with assessments at baseline (BL), 1, 3 and 6 months (M). Intervention included education/counseling focused on HF-DM self-care. Variables (measures, clinically meaningful change between BL-6 M) were: HF QOL (MLHFQ &gt5), general QOL (EQ5D-index &gt0.1; EQ5D-VAS &gt10), DM QOL (ADDQOL, &gt1), physical function (6 Minute Walk Test [6MWT] &gt50 meters). Age, gender, race, education, living arrangements, NYHA class and time with HF and DM were evaluated after adjusting for the INT group using linear and logistic regression to assess for relationship to improvements in outcomes. Results: For general QOL EQ5D index scores, those with less education (high school or less) (p=.024); those with NYHA class 3 or 4 (p=.036); and those with DM longer (p=.011) improved more. For MLWHF scores, whites were more likely than African Americans to improve their MLWHF scores (p=.05). For DM QOL (ADDQOL), 35% of younger participants (&lt=58 yrs.) in the intervention group improved their ADDQOL scores by 1 or more points compared to only 10% of the older participants (&gt58 yrs.) (p=.039). For 6MWT distances, males in INT group more likely to achieve improvement (p=.014), and those with NYHA class 3 or 4 more likely to improve (p=.048). Conclusions: When considering QOL and physical function outcomes in response to an HF-DM self-care intervention, age, education, race, gender, NYHA class, and time with DM were important. The INT improved outcomes in vulnerable groups of lower education, greater HF severity, and longer times with DM. Effects differed by EQ5D, MLWHF and ADDQOL measures highlighting the importance of evaluating multiple general and disease specific QOL dimensions, and the need to consider demographic and clinical risk factors to tailor toward more precise interventions.

Abstract 188: Differences in Quality of Life Across Modified Rankin Scale Categories in IMS-3

Background: Modified Rankin Scale (mRS) score 0-2 is frequently used as a definition of good outcome in ischemic stroke trials. Patients with mRS 3 are frequently grouped with mRS 4-6 as having poor outcome yet there is limited data on health-related quality of life (QOL) across mRS scores. Objective: Determine QOL and levels of disability across mRS scores and to specifically compare mRS 2 and 3 outcome categories. Methods: A secondary analysis of the Interventional Management of Stroke 3 (IMS3) trial was performed. Patients with documented mRS, degree of disability assessed by Barthel Index (BI) and patient-completed EQ5D-3L quality of life questionnaires at 3 months after stroke were included. EQ5D index was calculated using utility weights published for the US population. Median and mean BI and EQ5D were compared across mRS categories. Multiple pairwise comparisons were performed and Bonferroni corrected p-values were used. No imputations were performed. Results: 423 patients were included (mean age 64±13 years, median ASPECTS 8 [IQR 6-10], median baseline NIHSS 16 [IQR 12-19], mean BI 84.1±25.3 and mean EQ5D index 0.727±0.24. Overall, there were inverse correlations between mRS and BI (Rho=-0.78, p<0.001) and between mRS and EQ5D (Rho=-0.69, p<0.001). While significant differences in BI were observed across several mRS categories including 1 vs 2, 2 vs 3 and 3 vs 4 (Fig A), there was no difference in QOL between mRS 2 (N=82) and 3 (N=88) categories (Fig B). Based on BI and EQ5D indices, mRS 3 had greater similarity to mRS 2 than to mRS 4 (Fig C). Conclusion: Health-related QOL is similar in patients who achieve mRS of 2 and 3 despite differences in degree of disability. If preservation of quality of life is the ultimate goal of acute stroke therapies, our results question the commonly used mRS 0-2 cut point used to dichotomize stroke outcomes.