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Study Design: Prospective observational study, level of evidence 1 for prognostic investigations. Objectives: To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database. Summary of Background Data: Sleep disturbances are a common yet understudied symptom in CSM. Materials and Methods: The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery. Results: Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias. Conclusion: The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.

Objectives: Administrative criteria are often used to define COVID-19 outcomes despite challenges in differentiating hospitalization “for” vs “with” COVID-19 and unknown reliability for identifying COVID-related cardiopulmonary complications. We implemented a protocol to adjudicate COVID-related events across 14 studies participating in C4R. Methods: C4R cohorts ascertained COVID-related hospitalizations and deaths via questionnaires or ongoing surveillance. Medical records were reviewed by C4R physicians using a standardized protocol to assign COVID-related diagnoses as definite or probable. C4R diagnoses were compared against ICD codes assigned to the events. This report includes data from events centrally adjudicated by C4R as of September 2022. Results: Among 144 events ascertained across 7 cohorts as potentially COVID-related, SARS-CoV-2 infection was confirmed in 107/117 (91%) non-fatal hospitalizations and 26/27 (96%) deaths. Of confirmed infections, COVID-19 illness was diagnosed as the cause of 101/107 (94%) hospitalizations and 24/26 (92%) deaths ( Table ). Of non-fatal hospitalizations with infection, 72% were diagnosed with severe or critical COVID-19, 78% with COVID-associated pneumonia, and 29% with renal failure; other complications were less common. C4R review did not validate diagnoses indicated by ICD codes for 1 COVID-19 infection, 5 pneumonias, 1 stroke, and 7 renal failure cases. C4R review did identify diagnoses that were not ICD-coded for 13 infections, 31 pneumonias, 6 myocardial infarctions, 5 venous thromboses, and 21 renal failure cases. Conclusions: Protocolized medical records review by C4R confirmed COVID-19 as the cause of hospitalization or death in 87% of events ascertained as potentially COVID-related and 94% of those in which SARS-CoV-2 infection was confirmed. Both false-positive and false-negative misclassification by ICD criteria was observed. Protocolized review may be useful to identify and validate COVID-related events for epidemiologic research.

Introduction Prioritization and acuity tools have been leveraged to facilitate targeted and efficient clinical pharmacist interventions. However, there is a lack of established pharmacy-specific acuity factors in the ambulatory hematology/oncology setting. Therefore, National Comprehensive Cancer Network's Pharmacy Directors Forum conducted a survey to establish consensus on acuity factors associated with hematology/oncology patients that are high priority for ambulatory clinical pharmacist review. Methods A three-round electronic Delphi survey was conducted. During the first round, respondents were asked an open-ended question to suggest acuity factors based on their expert opinion. Respondents were then asked in the second round to agree or disagree with the compiled acuity factors, in which those with ≥75% agreement were included in the third round. The final consensus was defined as a mean score ≥3.33 on a modified 4-point Likert scale (4 = strongly agree, 1 = strongly disagree) during the third round. Results A total of 124 hematology/oncology clinical pharmacists completed the first round of the Delphi survey (invitation response rate, 36.7%), of which 103 completed the second round (response rate, 83.1%) and 84 the third round (response rate, 67.7%). A final consensus was achieved for 18 acuity factors. Acuity factors were identified in the following themes: antineoplastic regimen characteristics, drug interactions, organ dysfunction, pharmacogenomics, recent discharge, laboratory parameters, and treatment-related toxicities. Conclusions This Delphi panel of 124 clinical pharmacists achieved consensus on 18 acuity factors that would identify a hematology/oncology patient as a high priority for ambulatory clinical pharmacist review. The research team envisions incorporating these acuity factors into a pharmacy-specific electronic scoring tool.

AbstractAimTo examine the impact of socioeconomic status (SES) and postacute care (PAC) locations on the association between hospital safety‐net status and 30‐day postdischarge outcomes (readmission, hospice use, or death).MethodMedicare Current Beneficiary Survey (MCBS) participants during 2006–2011 who were Medicare Fee‐for‐Service beneficiaries aged 65.5 years or older were included. The associations between hospital safety‐net status and 30‐day post‐discharge outcomes were evaluated by comparing the models with and without PAC and SES adjustments. Safety‐net hospital status was defined as being in the top 20% of hospitals ranked by hospital‐level percent of total Medicare patient days. SES was measured using individual‐level SES (dual eligibility, income, and education) and the Area Deprivation Index (ADI).ResultsThis study identified 13,173 index hospitalizations for 6,825 patients; 1,428 hospitalizations (11.8%) were in safety‐net hospitals. The average unadjusted 30‐day hospital readmission rate was 22.6% in safety‐net hospitals versus 18.8% in nonsafety‐net hospitals. Regardless of whether patient SES status was controlled or not, safety‐net hospitals had higher estimated probabilities of 30‐day readmission (ranging from 0.217 to 0.222 vs. 0.184 to 0.189), and lower probabilities for having neither readmission nor hospice/death (0.750–0.763 vs. 0.780–0.785); for models additionally adjusted for PAC types, safety‐net patients had lower rates of hospice use or death (0.019–0.027 vs. 0.030–0.031).ConclusionsThe results suggested that safety‐net hospitals had lower hospice/death rates but higher readmission rates relative to outcomes at nonsafety‐net hospitals. Readmission rate differences were similar regardless of patients' SES status. However, the rate of hospice referral or death rate was related to SES, which suggested that the outcomes were affected by SES and PAC types.

Abstract The field of transplant infectious diseases is rapidly evolving, presenting a challenge for clinical practice and trainee education. Here we describe the construction of transplantid.net, a free online library, crowdsourced and continuously updated for the dual purpose of point-of-care evidence-based management and teaching.

BACKGROUND: Changes in reimbursement policies have been demonstrated to correlate with clinical practice. OBJECTIVE: To investigate trends in physician reimbursement for anterior, posterior, and combined anterior/posterior (AP) lumbar arthrodesis and relative utilization of AP. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Project registry for anterior, posterior, and AP lumbar arthrodeses during 2010 and 2020. Work relative value units per operative hour (wRVUs/h) were calculated for each procedure. Trends in reimbursement and utilization of the AP approach were assessed with linear regression. Subgroup analyses of age and underlying pathology of AP arthrodesis were also performed. RESULTS: During 2010 and 2020, AP arthrodesis was associated with significantly higher average wRVUs/h compared with anterior and posterior arthrodesis (AP = 17.4, anterior = 12.4, posterior = 14.5). The AP approach had a significant yearly increase in wRVUs/h (coefficient = 0.48, P = .042), contrary to anterior (coefficient = −0.01, P = .308) and posterior (coefficient = −0.13, P = .006) approaches. Utilization of AP approaches over all arthrodeses increased from 7.5% in 2010 to 15.3% in 2020 (yearly average increase 0.79%, P < .001). AP fusions increased significantly among both degenerative and deformity cases (coefficients 0.88 and 1.43, respectively). The mean age of patients undergoing AP arthrodesis increased by almost 10 years from 2010 to 2020. Rates of major 30-day complications were 2.7%, 3.1%, and 3.5% for AP, anterior, and posterior arthrodesis, respectively. CONCLUSION: AP lumbar arthrodesis was associated with higher and increasing reimbursement (wRVUs/h) during the period 2010 to 2020. Reimbursement for anterior arthrodesis was relatively stable, while reimbursement for posterior arthrodesis decreased. The utilization of the combined AP approach relative to the other approaches increased significantly during the period of interest.

AbstractClinical trials of novel salvage therapies have encouraging outcomes for relapsed/refractory transplant‐eligible classic Hodgkin lymphoma (R/R cHL) but comparison with conventional chemotherapy is lacking. Herein, we report the final analysis of a multicenter retrospective cohort of R/R cHL assessing outcomes by type of salvage therapy before autologous stem cell transplant (ASCT). R/R cHL patients who underwent ASCT at 14 institutions across the United States were included. Outcomes were compared among patients receiving conventional chemotherapy, brentuximab vedotin (BV) + chemotherapy, BV alone, and a checkpoint inhibitor (CPI)‐based regimens before ASCT. Study endpoints included event‐free survival (EFS), progression‐free survival (PFS), and overall survival (OS). All endpoints are defined from relapse. Of 936 patients, 728 received conventional chemotherapy, 73 received BV + chemotherapy, 70 received BV alone, and 65 received CPI‐based regimens prior to ASCT. When adjusted for time to relapse, pre‐ASCT response and use of BV maintenance, patients receiving CPI‐based regimens had superior 2‐year EFS compared to conventional chemotherapy, BV + chemotherapy, and BV alone (79.7, 49.6, 62.3, and 36.9%, respectively, p < .0001). Among 649 patients transplanted after 1 line of salvage therapy, CPI‐based regimens were associated with superior 2‐year PFS compared to conventional chemotherapy (98% vs. 68.8%, hazard ratio: 0.1, 95% confidence interval: 0.03–0.5, p < .0001). OS did not differ by pre‐ASCT salvage regimen. In this large multicenter retrospective study, CPI‐based regimens improved EFS and PFS compared to other salvage regimens independent of pre‐ASCT response. These data support earlier sequencing of CPI‐based regimens in R/R cHL in the pre‐ASCT setting.

Abstract Previously we have reported the precise determination of the entire antigenic structure of sperm-whale myoglobin. This protein which is made up on a single polypeptide chain (153 residues, m.w. 17,816) has five antigenic sites located in exposed conformationally sensitive continuous portions of its polypeptide chain. The five antigenic sites occupy the following regions: Site 1: sequence 15–22; Site 2: sequence 56–62; Site 3: sequence 94–99; Site 4: sequence 113–119; Site 5: sequence 145–151. We investigated the genetic control of T lymphocyte proliferative response to myoglobin and its synthetic antigenic sites in mice (PETLES Assay). Two parts of the myoglobin molecule (sequences 1–6 and 121–127) that were not within antigenic sites were also synthesized and employed as controls. Also used as control was a synthetic ‘nonsense’ heptapeptide that did not resemble any part of myoglobin. Haplotypes H-2d, H-2f and H-2s gave substantial T lymphocyte proliferative response to whole myoglobin whereas haplotypes H-2d, H-2k, H-2p, H-2q and H-2r were low responders. Studies with the recombinant strains suggested that expression of a high responder allele in the I-A subregion was enough to give a good proliferative response. On the other hand expression of I-Cd gave a good response while I-Cs gave a poor response. In preliminary studies, mice were primed with whole myoglobin and then challenged in vitro with the synthetic peptides containing the antigenic sites. Among the high responder strains, H-2d haplotype responded to Sites 1, 2, 3 and 5, whereas H-2s and H-2f haplotypes responded only to Sites 1, 2 and 3. We were surprised to find that the low responder strains, haplotypes H-2b, H-2k and H-2r responded to Site 4 but failed to respond to Sites 1, 2, 3 and 5. Mice did not respond to the control peptides. Further studies are currently underway in recombinant strains and in F1 crosses and will be reported at the Ir Gene Workshop. We are also investigating the ability of synthetic antigenic sites in the priming process.

Abstract The genetic control of T lymphocyte proliferative response to the five synthetic antigenic sites of myoglobin, two synthetic nonantigenic control peptides, and one “nonsense” peptide was determined in independent and recombinant strains of mice. In all the strains examined, the nonantigenic control peptides and the “nonsense” peptide did not invoke a response in myoglobin-primed mice. Further, when mice were not primed with whole myoglobin, no response was obtained with any of the antigenic sites. Haplotypes H-2d, H-2f, and H-2s are higher responders to sites 1 and 2, whereas haplotypes H-2d and H-2s are high responders to site 5. Response to site 3 may be controlled by a non-H-2-linked gene. Site 4 can stimulate H-2b and H-2k haplotypes that are nonresponders to the whole myoglobin. Studies with the recombinant strains suggested that Ir genes to sites 1 and 2 map in the I-A subregion and I-C subregion and were designated Ir-Mb-1,2(A) and Ir-Mb-1,2(C). Ir genes to sites 4 and 5 mapped only in the I-A subregion and were designated Ir-Mb-4(A) and Ir-Mb-5(A). These studies suggest that individual antigenic sites in a molecule are controlled by unique Ir genes.