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BACKGROUND: Frailty is a risk factor for presentation to the ED, in-hospital mortality, prolonged hospital stays and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty. The aim of this cross-sectional study was to establish the prevalence of frailty and co-morbidities among older adults in an acute hospital setting. METHODS: Data collection was undertaken by clinical research nurses and advanced nurse practitioners experienced in assessing older adults. All patients aged ≥ 65 years and admitted to a medical or surgical inpatient setting between 08:00 and 20:00 and who attended the ED over a 24-h period were screened using validated frailty and co-morbidity scales. Age and gender demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CCI) and admitting specialty (medical/surgical) were collected. Descriptive statistics were used to profile the cohort, and p values were calculated to ascertain the significance of results. RESULTS: Within a sample of 413 inpatients, 291 (70%) were ≥ 65 years and therefore were included in the study. 202 of these 291 older adults (70%) were ≥ 75 years. Frailty was investigated using validated clinical cut-offs on the CFS (not frail < 5; frail ≥ 5). Comorbidities were investigated using the Charlson Comorbidity Index (mild 1-2; moderate 3-4; severe ≥ 5). The median CFS was 6 indicating moderate frailty levels, and the median CCI score was 3 denoting moderate co-morbidity. In the inpatient cohort, 245 (84%) screened positive for frailty, while 223 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, severe ≥ 5). No significant differences were observed across genders for CFS and CCI. In the ED, 81 patients who attended the ED were ≥ 65 years. The median CFS was 6 (moderate frailty), and the median CCI was 5 (severe co-morbidity level). Seventy-four percent (60) of participants screened positively for frailty (CFS ≥ 5), and 31% (25) had a CFS of 7 or greater (severely frail). Ninety-six percent (78) of patients had a moderate-severe level of comorbidity. No significant associations were found between the CFS and CCI and ED participants age, gender, and medical/surgical speciality usage. CONCLUSION: There is a high prevalence of frailty and co-morbidity among older adults who present to the ED and require inpatient care. This may contribute to increased waiting times, lengths of stay, and the need for specialist intervention. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services, staff training in frailty care and multidisciplinary team resources across the hospital and community setting.

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Purpose: The aim of this study was to analyze hospital-discharged acute myocardial infarction (AMI) patients in Korea (2006-2020) to understand how pre-existing conditions affect mortality rates. Participants and Methods: This study utilized the 2006-2020 Korean National Hospital Discharge In-depth Injury Survey data. A weighted frequency analysis estimated discharged AMI patients and calculated age-standardized discharge and mortality rates, Charlson Comorbidity Index (CCI) score distribution, and general patient characteristics. Weighted logistic regression analysis examined influencing mortality factors. Results: There were 486,464 AMI patients (143,751 female), with AMI-related mortality rates at 7.5% (36,312): 5.7% for males (19,190) and 11.8% for females (17,122). The highest mortality rate was among individuals aged 70-79 years (25%). Factors influencing mortality included sex, insurance type, admission route, hospital bed count, region, operation status, and CCI score. Mortality risk at discharge was 1.151 times higher in females than males (95% CI: 1.002-1.322), 0.787 times lower among those with national health insurance than Medicaid recipients (95% CI 0.64-0.967), 2.182 times higher among those admitted via the emergency department than the outpatient department (95% CI 1.747-2.725), and 3.402 times higher in patients with a CCI score of 3 points than those with 0 points (95% CI 1.263-9.162). Conclusion: The number of discharged AMI patients and related mortality rates increased, underscoring the need for proactive management of chronic diseases, particularly for those with higher CCI scores.

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We lack knowledge about prognostic factors of resective epilepsy surgery (RES) in older adults (≥60 years), especially the role of comorbidities, which are a major consideration in managing the care of people with epilepsy (PWE). We analyzed a single-center cohort of 94 older adults (median age = 63.5 years, 52% females) who underwent RES between 2000 and 2021 with at least 6 months of postsurgical follow-up. Three fourths of the study cohort had lesional magnetic resonance imaging and underwent temporal lobectomy. Fifty-four (57%) PWE remained seizure-free during a median follow-up of 3.5 years. Cox proportional hazard multivariable analysis showed that aura (hazard ratio [HR] = .52, 95% confidence interval [CI] = .27-1.00), single ictal electroencephalographic pattern (HR = .33, 95% CI = .17-.660), and Elixhauser Comorbidity Index (HR = 1.05, 95% CI = 1.00-1.10) were independently associated with seizure recurrence at last follow-up. A sensitivity analysis using the Charlson Combined Score (HR = 1.38, 95% CI = 1.03-1.84, p = .027) confirmed the association of comorbidities with worse seizure outcome. Our findings provide a framework for a better informed discussion about RES prognosis in older adults. More extensive, multicenter cohort studies are needed to validate our findings and reduce hesitancy in pursuing RES in suitable older adults.

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Objective: This investigation examines burden of comorbidity measured by the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) among inpatients based on age, sex, and race. Methods: Cross-sectional analysis of 2012-2018 US NIS datasets. Participants were inpatients 55y+. ICD-9/10 codes for admitting diagnoses were used to calculate disease burden using the CCI and ECI. Unweighted mean CCI and ECI scores were compared across demographic variables. Results: An increase in mean CCI and ECI scores across age, sex, and races (p<.001) was identified. Compared to the youngest age group (55-59y), all age groups had higher mean CCI and ECI adjusting for time (p<.001). Increases were greatest in older age groups until age 80-84 for CCI and 85-89 for ECI. The female group had lower CCI adjusting for time (p<.001) compared to males. There was no difference between sex groups in mean ECI (p=.409). Compared with the White group, all other race groups had higher mean CCI adjusting for time (p<.001). Black inpatients had the highest CCI followed by Native American inpatients. Findings were similar for ECI, but with no difference between Hispanic and White groups (p=.434). Conclusions: Growing multimorbidity burden among adult inpatients across age, sex, and race supports the continued need for programs for preventing and reducing multimorbidity, especially among communities that experience health inequity including older, Black, and Native American patients.

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BACKGROUND: The National Early Warning Score 2 (NEWS2) standardizes assessment and response to acute illnesses using vital signs. Whether NEWS2 is useful in predicting the prognosis of candidemia remains to be determined. METHODS: Our study, conducted as a rigorous and retrospective analysis, examined patients with candidemia who were hospitalized between January 2014 and December 2023. We assessed candidemia severity using the Pitt Bacteremia Score (PBS) and NEWS2, while the Charlson Comorbidity Index (CCI) was used to assess underlying medical conditions. The endpoint was all-cause mortality within 30 days of candidemia onset, ensuring comprehensive evaluation of the patient's prognosis. RESULTS: Overall, 93 patients with candidemia were included. The 30-day all-cause mortality rate was 29.0 %. The area under the receiver operating characteristic curve (AUC) for CCI, PBS, and NEWS2 were 0.87 (95 % confidence interval [CI]: 0.80-0.95), 0.75 (95 % CI: 0.66-0.85), and 0.92 (95 % CI: 0.87-0.97), respectively, for predicting the 30-day mortality in patients with candidemia. The AUC values for CCI combined with PBS and NEWS2 were 0.89 (95 % CI: 0.83-0.96) and 0.96 (95 % CI: 0.93-1.00) for predicting the 30-day mortality in candidemia. Among the items that were significant in the univariate analysis, multivariate analysis showed that the combination of NEWS2 ≥ 10 and CCI ≥4 was the helpful prognostic factor for 30-day mortality. CONCLUSIONS: The combination of NEWS2 ≥ 10 and CCI ≥4 scores may be useful in predicting the risk of 30-day mortality in patients with candidemia.

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INTRODUCTION: Ewing sarcoma is an aggressive malignancy primarily affecting children and adolescents. Limited research is available on treatment practices, clinical course, and survival in adults. METHODS: A multi-institution retrospective cohort study of all adults (>18 years) and children (≤18 years) with Ewing sarcoma treated in British Columbia, Canada between January 01, 2000 and December 31, 2018. RESULTS: One-hundred seven individuals (66 adults, 41 children) were included in the analysis. 5-year OS was 58 % in adults and 75 % in children. For individuals with local disease, 5-year OS was 74 % in adults and 84 % in children. Adult status was associated with impaired PFS (HR, 1.8; 95 % CI, 1.0 - 3.1, p=0.04) and OS (HR, 1.8; 95 % CI, 0.9 - 3.5; p=0.088). A Charlson Comorbidity Index (CCI) ≥3 was associated with impaired survival in adults and children (HR, 3.9, 95 % CI, 2.0 - 7.5; p=<0.001); baseline CCIs were not significantly different between groups. Most adults (61/66; 92 %) and all children (41/41; 100 %) received systemic treatment with no significant difference in mean lines of therapy, treatment modalities or agents. Most children received interval-compressed chemotherapy (35/41; 85 %) compared to adults (19/61; 29 %; p=<0.001). Interval-compression was not significantly associated with improved survival in adults with local disease (HR, 0.51; 95 % CI 0.1 - 2.3; p=0.373). Children more often initiated treatment within 28 days of diagnosis (31/33; 94 %) compared to adults (41/64; 64 %, p=0.001). Treatment within 28 days was associated with improved survival in the entire cohort (HR, 2.04 95 % CI, 1.1 - 3.9; p = 0.03). This association was preserved in subanalysis of individuals with local disease (HR, 5.4; 95 % CI, 1.9 - 15; p = 0.001) and only adults (HR, 5.3, 95 % CI, 1.7 - 17; p = 0.005). DISCUSSION: Survival for adults with Ewing sarcoma is inferior to children despite similarities in presentation, tumour characteristics and treatments. Further studies on the value of interval-compression in adults are required. Timely initation of treatment should be a priority for this disease.

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BACKGROUND: Knowledge about impact of age and comorbidities on outcome in patients with leadless pacemakers (LPM) is limited. OBJECTIVES: To analyse outcome in LPM patients according to age and comorbidities. METHODS: This Swiss, multi-centre, retrospective analysis includes all patients with LPM implanted between 2015 and 2022. Charlson-Comorbidity-Index (CCI) was determined and patients were divided into a low- (CCI ≤ 5) and high-comorbidity (CCI > 5) group. Peri-procedural complications, in-hospital death, and all-cause mortalities were assessed. Finally, all-cause mortality according to three groups (CCI ≤ 3, 4-5, >5) was compared to age and sex-adjusted mortality in the general Swiss population. RESULTS: 863 patients (median age 81 years, 65% male, 42% with CCI > 5) were included. Peri-procedural/long-term complication rates did not differ between the low- vs. high-comorbidity groups (2.6% vs. 1.7%, p = 0.48 and 1.2% vs. 2.8%, p = 0.12, respectively). In-hospital (3.6% vs. 0.6%, p = 0.002) and all-cause mortality (HR 2.9, 95%CI 2.2-3.8, p < 0.001) were significantly higher in the high-comorbidity group resulting in a three-year mortality of 58% (95%CI 51-65%) vs. 22% (95%CI 17-27%) in the low-comorbidity group. In patients with a CCI ≤ 3, all-cause mortality was comparable to the age- and sex-adjusted mortality of the general Swiss population. CONCLUSIONS: In elderly patients with high comorbidity, LPM implantation was not associated with increased peri-procedural/long-term complications. All-cause mortality in LPM patients with a CCI ≤ 3 was comparable to age- and sex-adjusted mortality in the general Swiss population. Despite a relatively high three-year mortality due to competing risk factors, LPM implantation is safe, even in elderly patients with high comorbidity. CONDENSED ABSTRACT: In this Swiss, multi-centre, retrospective cohort analysis, 863 patients implanted with a leadless pacemaker were included and divided into a high-comorbidity (with a CCI > 5) and low-comorbidity (with a CCI ≤ 5) group. There was no between group difference in terms of implantation outcomes and peri-operative or long-term complications. Furthermore, all-cause mortality during follow-up in patients with a CCI ≤ 3 was comparable to age- and sex-adjusted mortality in the general Swiss population. These data indicate that LPM implantation is a safe procedure, even in elderly patients with high comorbidity.

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OBJECTIVES: The current knowledge about the role of comorbidities in systemic sclerosis (SSc) is limited. Therefore, the aim of this study was to evaluate the prevalence of comorbidities and their impact on disease activity and prognosis in the Systemic sclerosis PRogression INvestiGation (SPRING) registry. METHODS: SSc patients from the SPRING registry, fulfilling the ACR/EULAR 2013 classification criteria, with complete data on baseline comorbidities were enrolled. The Charlson comorbidity index (CCI) was used to quantify the overall comorbidity burden. The disease activity was calculated using the revised EUSTAR activity index (AI). The impact of SSc features on CCI, the effect of CCI on SSc disease activity and mortality were tested with multivariable regression models. RESULTS: Among 1910 SSc patients enrolled, 67.3 % had at least one comorbidity at baseline. The most frequent comorbidities were systemic arterial hypertension (23.7 %), osteoporosis (12.9 %) and dyslipidemia (11 %). The mean value of CCI score was 2.0 ± 1.8. When patients were grouped according to increasing levels of CCI, a clear separation in the distribution of SSc-related clinical features could be observed. Among over 900 patients with available follow-up, no association between baseline CCI and changes in disease activity was observed. Conversely, the risk of death over time was independently predicted by both CCI and AI. CONCLUSIONS: Comorbidities and disease activity independently impact on the prognosis of SSc patients. This suggests that the management of comorbidities, together with the reduction of disease activity, is fundamental to improve patient survival.

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Background: This study evaluated national trends in cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humerus fractures using a comprehensive national surgical database. This study aimed to compare RSA used in the treatment of proximal humerus fractures with the literature and to determine the country's trend. Methods: A cross-sectional study was conducted using the health records of individuals aged ≥ 18 years who underwent RSA for proximal humerus fractures between 2016 and 2022. Patients were divided into cemented and uncemented groups, and demographic data (age, sex), duration of hospital stay, transfusions, revisions, mortality, and Charlson Comorbidity Index (CCI) scores were analyzed. Results: A total of 618 cemented RSA and 1,364 uncemented RSA procedures were reviewed. Patients who underwent cemented RSA were significantly older than those who had uncemented RSA (p = 0.002). Transfusion rates were higher in the cemented RSA group (p = 0.006). The frequency of revision surgery was 6.1%. Younger age and male sex were associated with revision (p < 0.001). CCI scores were higher among transfused patients than non-transfused patients (p < 0.001). The incidence of cemented RSA was 11.7% and 49% in 2016 and 2022, respectively. Differences were found among hospital types and geographical regions. Conclusions: While cemented RSA has been gaining attention and increased application in recent years for proximal humerus fractures, uncemented RSA still predominates. The choice between these 2 methods is largely influenced by regional and hospital-level factors. The type of RSA and high CCI scores were found to have no significant impact on the risk of surgical revision.

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OBJECTIVES: Sublobar resections for lung cancer are increasing worldwide. However, the prognostic significance of weight loss after sublobar resection remains unclear. We aimed to investigate the prognostic significance of weight loss after sublobar resection for lung cancer. METHODS: Patients who underwent sublobar resection for non-small cell lung cancer between January 2016 and June 2021 were analysed. The percentage weight change at 3, 6, and 12 months postoperatively was determined based on the preoperative weight. Patients were divided into two groups: those with or without weight loss ≥ 5%, referring to the diagnostic criteria for frailty, to assess prognosis. Subsequently, the prognosis-related timing of weight loss ≥ 5% and its risk factors were analyzed. RESULTS: We reviewed 147 patients; 39 (26.5%) showed weight loss ≥ 5% within 1-year post-surgery. A total of 32 patients (21.8%) died, 13 from primary lung cancer and 19 from non-lung cancer causes. Cancer recurrence occurred in 22 patients (15.0%). Weight loss ≥ 5% within 1-year post-surgery was a poor prognostic factor for overall and recurrence-free survival (log-rank; p = 0.014 and 0.018, respectively). Additionally, weight loss ≥ 5% at 6-12 months postoperatively was associated with poor overall and recurrence-free survival (p < 0.05, both). In the multivariable analysis, an age-adjusted Charlson comorbidity index ≥ 4 was a predictive factor for weight loss ≥ 5% at 6-12 months postoperatively (odds ratio, 3.920; p = 0.023). CONCLUSIONS: Weight loss ≥ 5% at 6-12 months postoperatively was associated with poor prognosis. Long-term nutritional management is important in the treatment plan of sublobar resection in high-risk patients.

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INTRODUCTION: We evaluated the prognosis after endoscopic treatment for choledocholithiasis, particularly in patients with borderline tolerance to surgery. Stone removal and cholecystectomy are generally recommended for patients with choledocholithiasis combined with gallstones to prevent recurrent biliary events. However, the prognosis after choledocholithiasis treatment in patients with borderline tolerance to surgery, such as the elderly or those with many comorbidities, remains controversial. METHODS: We retrospectively analyzed data from patients with choledocholithiasis treated at our facility between January 2012 and December 2021. Patients who underwent endoscopic sphincterotomy were dichotomized into the cholecystectomy (CHOLE) and conservation (CONS) groups depending on whether cholecystectomy was performed, and their prognoses were subsequently compared. Furthermore, we performed a logistic regression analysis of the factors contributing to recurrent biliary events in patients with high age-adjusted Charlson Comorbidity Index (aCCI) scores. RESULTS: Of 169 participants, 110 had gallstones and were divided into the CHOLE (n = 56) and CONS (n = 54) groups. The CONS group was significantly ordered, had more comorbidities, and higher aCCI scores, whereas the CHOLE group had fewer recurrent biliary events, although not significant (p = 0.122). No difference was observed in the recurrent incidence of grade ≥2 biliary infections and mortality related to biliary events between the groups. In patients with aCCI scores ≥5, conservation without cholecystectomy was not an independent risk factor for recurrent biliary events. CONCLUSION: Cholecystectomy after choledocholithiasis treatment prevents recurrent biliary events, but conservation without cholecystectomy is a feasible option for patients with high aCCI scores.

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The current study planned to explore the correlation between an elevated Charlson Comorbidity Index score and post-operative complications following radical nephrectomy in patients with renal cell carcinoma. A total of 70 patients aged 30-80 years undergoing radical nephrectomy were categorised into low Charlson Comorbidity Index score <4 group A and high score >4 group B. Post-operatively, complications were noted in 21(30%) patients, with higher grades more prevalent in the group B patients (relative risk: 1.96, p=0.004). The finding underscored the importance of considering comorbidities in assessing the risk of complications following radical nephrectomy.

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OBJECTIVE: Femoral neck fractures (FNF) are known to have significant morbidity and mortality rates. Multiple chronic conditions (MCC) are defined as the presence of two or more chronic diseases that greatly affect the quality of life in older adults. The aim of this study is to explore the impact of MCC and Charlson comorbidity index (CCI) on surgical outcomes in patients with FNF. METHODS: Patients with FNF who underwent joint replacement surgery were selected for this study. Patients who had two or more diseases simultaneously were divided into two groups: the MCC group and the non-MCC (NMCC) group. The CCI was calculated to assess the severity of patients' comorbidities in the MCC group. Baseline data, surgical details, and prognosis-related indicators were analyzed and compared between the two patient groups. Spearman correlation analysis was performed to assess the relationship between CCI and length of hospital stay, Harris score, skeletal muscle index (SMI), and age. Univariate and multivariate logistic regression analysis was conducted to identify the risk factors for mortality in FNF patients at 1 and 5 years after surgery. RESULTS: A total of 103 patients were included in the MCC group, while the NMCC group consisted of 40 patients. However, the patients in the MCC group were found to be older, had a higher incidence of sarcopenia, and lower SMI values (p < 0.001). Patients in the MCC group had longer hospitalization times, lower Harris scores, higher intensive care unit (ICU) admission rates, and higher complication rates (p = 0.045, p = 0.035, p = 0.019, p = 0.010). Spearman correlation analysis revealed that CCI was positively correlated with hospitalization and age (p < 0.001, p < 0.001), while it was negatively correlated with Harris score and SMI value (p < 0.001, p < 0.001). Univariate and multivariate logistic regression analysis demonstrated that MCC patients had higher 1-year and 5-year mortality rates. Hospitalization time was identified as a risk factor for death in FNF patients 1 year after joint replacement (p < 0.001), whereas CCI and age were identified as risk factors for death 5 years after surgery (p < 0.001, p < 0.001). Kaplan-Meier survival analysis results showed that the difference in death time between the two groups of patients with MCC and NMCC was statistically significant (p < 0.001). Cox proportional hazard model analysis showed that CCI, age and SMI were risk factors affecting patient death. CONCLUSION: The surgical prognosis of patients with MCC, CCI and FNF is related. The higher the CCI, the worse the patient's function and the higher the long-term risk of death.

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OBJECTIVE: To evaluate predictive ability of a novel combined index, Charlson comorbidity index and C-reactive protein (CCI-CRP), for outcomes in renal cell carcinoma (RCC), and compare predictive outcomes with of CCI-CRP to its separate components and to the UCLA integrated staging system (UISS). PATIENTS AND METHODS: We retrospectively analyzed INMARC registry of RCC patients. Receiver Operator Characteristics (ROC) analysis was fitted to identify threshold defining low-CRP (LCRP) and high-CRP (HCRP). Patients were stratified according to CCI [low-CCI ≤ 3 (LCCI); intermediate-CCI 4-6 (ICCI); high-CCI > 6 (HCCI)] and CRP level. Kaplan-Meier analysis (KMA) was conducted for overall (OS) and cancer-specific survival (CSS). Based on survival analysis distribution we proposed a new stratification: CCI-CRP. Model performance was assessed with ROC/area under the curve (AUC) analysis and compared to CCI and CRP alone, and UISS. RESULTS: We analyzed 2,890 patients (median follow-up 30 months). ROC identified maximum product sensitivity and specificity for CRP at 3.5 mg/L. KMA revealed 5-year OS of 95.6% for LCRP/LCCI, 83% LCRP/ICCI, 73.3% LCRP/HCCI, 62.6% HCRP/LCCI, 51.6% HCRP/ICCI and 40.5% HCRP/HCCI (P < .001). From this distribution, new CCI-CRP is proposed: low CCI-CRP (LCRP/LCCI and LCRP/ICCI), intermediate CCI-CRP (LCRP/HCCI and HCRP/LCCI), and high CCI-CRP (HCRP/ICCI and HCRP/HCCI). AUC for CCI-CRP showed improved performance for predicting OS/CSS vs. CCI alone (0.73 vs. 0.63/0.77 vs. 0.60), CRP alone (0.73 vs. 0.71/0.77 vs. 0.74) and UISS (0.73 vs 0.67/0.77 vs 0.73). CONCLUSIONS: CCI-CRP, exhibits increased prognostic performance for survival outcomes in RCC compared to CCI and CRP alone, and UISS. Further investigation is requisite.

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INTRODUCTION: The Charlson Comorbidity Index (CCI) is widely utilized for risk stratification for non-cardiac surgical patients, yet it has not been broadly validated in patients undergoing cardiac surgery. We aim to assess its ability to predict early and late outcomes of concomitant mitral valve intervention with ascending aortic surgery. METHODS: Patients who underwent surgery between 1997 and 2022 were reviewed. Age-adjusted CCI scores were calculated based on clinical status at a time of index operation. The primary endpoint was all causes mortality while secondary outcomes were major adverse events (MAE) that included combined perioperative mortality, dialysis, myocardial infarction, and stroke in addition to the individual outcomes and take back for bleeding and tracheostomy. Chi-square test, Logistic and Cox regression analysis, and Kaplan-Meier curves were used. Maximally selected rank statistics were used to identify best cutoff of CCI for late mortality. RESULTS: 186 patients (median age 65 [interquartile range (IQR): 54-76] and 69% males) were included with a median CCI of 4 [IQR: 3-6]. Five and ten-years overall survival were 95.9% and 67.1% vs 59.7%, and 19.9% in CCI ≤ 5 vs >5 (P < 0.001). On multivariate Cox regression analysis, higher CCI (HR 1.60 [1.17;2.18], P = 0.00), and lower EF (HR 0.89 [0.83;0.96], P = 0.002) were associated with late mortality. There was a trend to lower mortality in recent surgery years (HR 0.91 [0.83;1.01], P = 0.070)). Perioperative MAE was higher in CCI >5 (11.0% vs 2.1%, P = 0.017), and postoperative need for tracheostomy and CVA had a trend to be higher in CCI > 5 (P = 0.055). Logistic regression revealed that higher CCI, as a continuous variable, was associated with significantly higher odds of MAE, postoperative dialysis, and need for tracheostomy. CONCLUSIONS: The CCI can be a helpful tool in predicting outcomes of patients undergoing concomitant mitral valve intervention with ascending aortic surgery.

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BACKGROUND & AIMS: Utility, a major principle for allocation in the context of transplantation, is questioned in patients with acute-on chronic liver failure grade 3 (ACLF-3) who undergo liver transplantation (LT). We aimed to explore long-term outcomes of patients included in a three-centre retrospective French study published in 2017. METHOD: All patients with ACLF-3 (n = 73), as well as their transplanted matched controls with ACLF-2 (n = 145), 1 (n = 119) and no ACLF (n = 292), who participated in the Princeps study published in 2017 were included. We explored 5- and 10-year patient and graft survival rates, causes of death and their predictive factors. RESULTS: Median follow-up of patients with ACLF-3 was 7.5 years. At LT, median MELD was 40. In patients with ACLF-3, 2, 1 and no ACLF, 5-year patient survival rates were 72.6% vs. 69.7% vs. 76.4% vs. 77.0%, respectively (p = 0.31). Ten-year patient survival for ACLF-3 was 56.8% and was not different to other groups (p = 0.37). Leading causes of death in patients with ACLF-3 were infections (33.3%) and cardiovascular events (23.3%). After exclusion of early death, UCLA futility risk score, age-adjusted Charlson comorbidity index and CLIF-C ACLF score were independently associated with 10-year patient survival. Long-term graft survival rates were not different across the groups. Clinical frailty scale and WHO performance status improved over time in patients alive after 5 years. CONCLUSION: 5- and 10-year patient and graft survival rates were not different in patients with ACLF-3 compared to matched controls. 5-year patient survival is higher than the 50%-70% threshold defining the utility of a liver graft. Efforts should focus on candidate selection based on comorbidities, as well as the prevention of infection and cardiovascular events. IMPACT AND IMPLICATIONS: While short-term outcomes following liver transplantation in the most severely ill patients with cirrhosis (acute-on-chronic liver failure grade 3 [ACLF-3]) are known, long-term data are limited, raising questions about the utility of graft allocation in the context of scarce medical resources. This study provides a favourable long-term update, confirming no differences in 5- and 10-year patient and graft survival following liver transplantation in patients with ACLF-3 compared to matched patients with ACLF-2, ACLF-1, and no-ACLF. The study highlights the risk of dying from infection and cardiovascular causes in the long-term and identifies scores including comorbidity evaluation, such as the age-adjusted Charlson comorbidity index, as independently associated with long-term survival. Therefore, physicians should consider the cumulative burden of comorbidities when deciding whether to transplant these patients. Additionally, after transplantation, the study encourages mitigating infectious risk with tailored immunosuppressive regimens and tightly managing cardiovascular risk over time.

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INTRODUCTION: The effect of polypharmacy on older patients with cancer is unclear. This study aimed to explore the effect of polypharmacy on the outcomes of treatment in older patients with advanced non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors. MATERIALS AND METHODS: We retrospectively reviewed the records of older patients (aged ≥65 years) with advanced NSCLC who received PD-1/PD-L1 inhibitors with or without platinum-based chemotherapy as first-line treatment from March 2016 to December 2020. Patients with driver oncogenes or Eastern Cooperative Oncology Group performance status (PS) ≥2 were excluded. Polypharmacy was defined as receiving five or more oral or inhaled medications at baseline. We compared the progression-free survival (PFS), overall survival (OS), and mean cumulative length of hospital stays between the polypharmacy and non-polypharmacy groups. RESULTS: A total of 122 patients, with a median age of 72 years (range, 65-89 years), were included in the analysis. Of the patients, 34 (27.8%) had a PS of 0 and 68 (55.7%) had a PD-L1 tumor proportion score (TPS) of ≥50%. The median number of oral or inhaled medications was 4 (range, 0-12), and 60 (49.1%) patients were taking ≥5 medications (polypharmacy). Age and Charlson Comorbidity Index score were significantly higher in the polypharmacy group (P = 0.01 and P < 0.001, respectively). Compared with the non-polypharmacy group, the polypharmacy group had a similar median PFS (6.7 vs. 8.5 months, P = 0.94) and a shorter median OS (17.3 vs. 26.0 months, P = 0.04). In the polypharmacy group, the adjusted hazard ratio for OS (adjusted for age, PS, and PD-L1 TPS) was 1.65 (95% confidence interval, 1.04-2.86, P = 0.03). Patients in the polypharmacy group had longer hospital stays (46.3 ± 7.5 vs. 27.7 ± 4.1 days/person, P < 0.05) and more emergency hospitalizations (1.6 ± 0.3 vs. 0.8 ± 0.1 times/person, P < 0.05) during the first year. DISCUSSION: Polypharmacy was associated with shorter survival time and longer hospitalization in older patients with advanced NSCLC receiving first-line immunotherapy with or without chemotherapy.

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BACKGROUND/AIM: With new therapies for metastatic prostate cancer, patients are living longer, increasing the need for better understanding of the impact of comorbid disease. Prescription medications may risk-stratify patients independent of established methods, such as the Charlson Comorbidity Index (CCI) and guide treatment selection. PATIENTS AND METHODS: In a nationwide retrospective study of US Veterans, we used multivariable logistic regression and Cox proportional hazard modeling to evaluate the association between number and class of prescription medications and overall survival (OS) with age, race, body-mass index, prostate specific antigen (PSA), and Charlson comorbidities as covariates in veterans treated for de novo metastatic hormone sensitive prostate cancer (mHSPC) between 2010-2021. RESULTS: Among 8,434 Veterans, a median of nine medications and five medication classes were filled in the year prior to initial treatment with abiraterone or enzalutamide for mHSPC. Veterans on 1-4 medications had an average survival of 38 months compared to 5-9 medicines (33 months), 10-14 medicines (27 months), and 15+ medicines (22 months) (p<0.001). After adjusting for age, race, body mass index (BMI), PSA, CCI, and year of diagnosis, both the number of medications and medication classes were associated with increased mortality. The adjusted hazard ratio (aHR) [95% confidence interval (CI)] was 1.03 (1.02-1.03) for the number of medications and 1.05 (1.04-1.07) for medication classes. Medications within ATC B (blood/blood forming organs), ATC C (cardiovascular), and ATC N (nervous) were associated with worse OS, with aHRs of 1.14 (1.07, 1.21), 1.14 (1.06, 1.22), and 1.12 (1.06, 1.19), respectively. CONCLUSION: The number and class of medications were independently associated with overall survival in patients undergoing treatment for mHSPC. With new therapies for advanced prostate cancer, patients are living longer, highlighting the need for a better understanding of the impact of comorbid diseases. Simple methods to assess disease burden and prognosticate survival have the potential to guide treatment decisions.

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Radical cystectomy (RC) remains a mainstay surgical treatment for non-metastatic muscle-invasive and BCG-unresponsive bladder cancer. Various perioperative scoring tools assess comorbidity burden, complication risks, and cancer-specific mortality (CSM) risk. We investigated the prognostic value of these scores in patients who underwent RC between 2015 and 2021. Cox proportional hazards were used in survival analyses. Risk models' accuracy was assessed with the concordance index (C-index) and area under the curve. Among 215 included RC patients, 63 (29.3%) died, including 53 (24.7%) cancer-specific deaths, with a median follow-up of 39 months. The AJCC system, COBRA score, and Charlson comorbidity index (CCI) predicted CSM with low accuracy (C-index: 0.66, 0.65; 0.59, respectively). Multivariable Cox regression identified the AJCC system and CCI > 5 as significant CSM predictors. Additional factors included the extent of lymph node dissection, histology, smoking, presence of concomitant CIS, and neutrophil-to-lymphocyte ratio, and model accuracy was high (C-index: 0.80). The internal validation of the model with bootstrap samples revealed its slight optimism of 0.06. In conclusion, the accuracy of the AJCC staging system in the prediction of CSM is low and can be improved with the inclusion of other pathological data, CCI, smoking history and inflammatory indices.