Search

BACKGROUND: Early readmissions are important indicators of quality of care. No data exist describing hospital readmissions in Neutropenic fever. The aim of this study was to describe unplanned, 30-day readmissions among adult neutropenic fever patients and to assess readmission predictors. METHODS: We analyzed the 2013 and 2014 United States National Readmission Database and identified neutropenic fever admissions using ICD-9 CM administrative codes in patients older than 18 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations with readmissions adjusting for confounders. RESULTS: In the cohort of 52,017 hospitalizations with neutropenic fever, 7, 440 (14.3%) had at least one unplanned 30-day readmission. 50% of the readmissions occurred within the first two weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to disease of the white blood cells (32.5%), anemia and other deficiency (5.8%), complications related to implants, grafts or procedure during index admission (3.9%), recurrent fever (3.6%) and septicemia (3.2%). Neutropenic fever patients with readmissions were more likely to be older, males and have blood malignancy like acute leukemia along with comorbidities including chronic renal disease, hypertension, diabetes and chronic liver disease. Those with readmissions were sicker on index admissions with extreme likelihood of dying on the APR-DRG mortality scale, have non-elective admissions, CCI score of 3 and longer length of stay. Interestingly, index admissions with readmissions were more likely to have primary payer of Medicare and Medicaid insurance and less likely to have a routine discharge home. Admissions with readmissions had higher mean (±SE) cost on index admissions, $10,564 (±199) vs $12,057 (±388), P70 years. We also observed that the comorbidities with the higher aOR for readmissions were Diabetes Mellitus (aOR 1.2, 95% CI 1.04 - 1.4, p=0 P=0.01), Chronic liver disease (aOR 1.29, 95% CI 1.01 - 1.7, p=0 .05) as well as patient who received blood transfusion (aOR 1.22, 95% CI 1.1 - 1.4, p=0 .0001). Index admission characteristics associated with increased odds of readmission included elective admissions and higher APRDRG mortality scale scores. Within insurance categories, Medicaid insurance were more likely to have readmissions as compared to self-pay. With respect to hospital characteristics, patients getting discharged to home health care, larger bed size hospitals, teaching hospitals and metropolitan hospitals had significantly higher odds of readmission. CONCLUSIONS: On a national level, 1 in 7 hospitalizations for febrile neutropenia was followed by an unplanned readmission within 30 days with readmissions equally distributed over the 30 days. Multiple modifiable and non-modifiable factors influencing readmission rates were noted which should be targeted for further studies to examine if strategies that address these predictors can decrease readmissions. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Objectives - In current era of information technology, there is abundance of medical information for the patients and families. It is recommended that the online patient information (OPI) should be written no greater than sixth grade as per The National Institute of Health (NIH), American Medical Association, Department of Health & Human Services. We aim is to assess whether OPI on lymphoma from NCI-Designated Cancer Center (NCIDCC) and various cancer associations websites meet the current recommendations on a panel of readability indexes. Methods - OPI from patient only section of NCIDCC and cancer associations websites were collected. This text was analyzed by 7 commonly used readability tests - Flesch Reading Ease score(FRE), Gunning Fog(GF), Flesch-Kincaid Grade Level(FKGL), The Coleman-Liau Index(CLI), The Simple Measure of Gobbledygook (SMOG) Index, Automated Readability Index(ARI) and Linsear Write Formula(LWF). Text from each article was pasted into Microsoft Word and analyzed using the online software Readability formulas. Results - The mean FRE score is 55.4 (range 37.4-67.9) which corresponded to difficult level grade. The mean GF score is 12.9 (range 10.8-15.2) that comes between difficult and hard. The FKGL score is 9.9 (range 7.2-11.9) that corresponds to above the level of ninth grader.The mean CLI score is 11.09 (range 9-12) which represented text of twelfth grade. The mean SMOG index is 9.6 (range 8.1-11.1) which corresponded to greater than seventh grade level. While the mean ARI score was 10.5 (range 7.7-12.5) which represents readability suitable for people more than tenth grade. The mean LWF was 11.29 (range 7.8-14.4) that corresponds to tenth grade level of text. Conclusion - The currently available OPI on lymphoma did not met the set national recommendations level on seven different validated readability indexes. Currently, available literature is difficult to understand and comprehend for average patient and their kins. There is a dire need to revise the currently available material for easy comprehension and understanding by the general patient population. Disclosures No relevant conflicts of interest to declare.

Abstract 5065 Background Venous thromboembolism (VTE), a frequent complication in cancer and, occasionally, a harbinger of occult cancer, is one of the leading causes of death in cancer patients. VTE recurs with a three-fold greater frequency in cancer patients than in patients who do not have cancer, and requires long-term anticoagulation. There is a two-fold greater risk of bleeding complications in these patients compared to patients who do not have cancer. Because pulmonary embolism (PE) is a life-threatening sequel of VTE, we sought to evaluate the hypothesis that cancer patients suffer from extensive pulmonary embolism (involving central pulmonary artery or bilateral pulmonary arteries) and to determine if we could detect differences in two clinical outcomes, length of stay (LOS) and mortality. Patients and Methods This retrospective cohort of subjects with pulmonary embolism (PE) was developed using data beginning in January 2003 to December 2007 at a 680 bed, urban teaching hospital. The cohort of 118 patients with PE diagnosed with CT angiogram yielded 41 patients in cancer group (20 males and 21 females) and 47 (23 males and 24 females) patients in non cancer group. Other baseline characteristics gathered for the two groups included age, gender, race, co-morbidities, ambulatory status and therapeutic interventions. Criteria for being assigned to the “central PE” were a filling defect in the pulmonary arteries or the main stem. Patients who showed filling defects in both central and peripheral vessels were also assigned to the “central PE”. All other patients with filling defects in one or more peripheral vessels were assigned to the “peripheral PE” group. Results The baseline characteristics did not show significant differences between the groups. Our data demonstrated that central PE was strongly associated with the cancer group (26/41; 63.4%) compared with 15 of 47 (31.9%) in the non-cancer group (OR = 3.70; 95% CI: 1.53 to 8.95; p = 0.0051). The common cancers associated with VTE were genito–urinary (13) followed by gastro-intestinal (10), then lung and breast (6 in each group). LOS was significantly greater in the cancer group (median: 9d; IQR: 7-19d) compared to non-cancer group (median: 7d; IQR: 5-11d; p = 0.032. We detected no significant difference in overall mortality between the two groups (p = 0.11). Kaplan-Meier analysis of survival, similarly, demonstrated no significant difference (95% CI of HR: 0.62 to 3.18; p = 0.42) Conclusion Cancer patients appear to be at a higher risk for central PE and have longer stay in the hospital after diagnosis than patients without cancer. However, in this study we did not detect increased mortality over a twelve-month observation period. Disclosures No relevant conflicts of interest to declare.

Introduction: Different types of myeloma are classified by the type of immunoglobulin. From prior analysis, we know that IgG is the commonest class of myeloma and that this type seems to be the most benign. While IgA myeloma appear to be of intermediate outcome, IgD myeloma and lambda light-chain disease are the most aggressive types. Breakdown by immunoglobulin type reveals higher prevalence of IgG myeloma among Whites, compared to Blacks. This study examines the type of immunoglobulin and clinical implication in Hispanics compared to other ethnic groups. Methods: In a single inner city institution, we retrospectively examined patients diagnosed with multiple myeloma over a 5-year period. This investigation defined Hispanic patients as those of Latin American descent. We identified the M-component immunoglobulin type from immunoelectrophoresis as reported in medical records. New onset renal failure and disease related mortality are considered as adverse clinical outcomes. Various ethnic groups were compared between the type of immunoglobulin and adverse clinical outcomes using chi-square test. Results: A total of 203 patients were examined, of which 63 (30.9%) were Hispanics, 87 (42.9%) Caucasians and 53 (26.2%) African American, (104 males, 99 females, age range 34 – 93 yrs, mean age 67.45 ± sd 10.28 yrs). IgG and IgA M-components predominated among all ethnic groups respectively Hispanics 36 (57.9%), 6 (10.5%), Caucasians 51 (59%), 18 (22.7%) and African Americans 25 (50%), 20 (37.5%). A higher proportion of light-chain cases were seen among Hispanics since 21 (31.6%) had no peak on immunoelectrophoresis compared to Caucasians 31 (18.3%) and African Americans 8 (12.5%) (chi-square test, two-tailed p=0.426). Adverse clinical outcomes of new onset renal failure developed correspondingly in 20 (31.6%) Hispanics, 31 (36.3%) Caucasians and 15 (28.6%) African Americans while disease related mortality occurred in 20 (31.6%) Hispanics, 18 (21.4%) Caucasians and 9 (18.2%) African Americans (chi-square test, two-tailed p= 0.132). However, differences were not statistically significant. Conclusion: Although Hispanics exhibited more myeloma of light chain type and worse clinical outcomes compared to other ethnic groups, our study was unable to detect a statistical disparity. Further prospective large population based studies via the new light chain immunodiagnostic assay are warranted to define the epidemiology of this disease.

Background: Many studies have demonstrated a possible association between hepatitis C and a wide spectrum of lymphoproliferative malignancies. Increased hepatitis C virus (HCV) prevalence among patients with non-Hodgkin lymphoma (NHL), suggesting that HCV infection increases NHL risk through chronic immune stimulation. Most of the previous studies excluded patients with immunodeficiency. No study looked at the association between established chronic HCV infection and lymphoma in AIDS patients. However, previous studies found no relation between HCV infection and lymphoma in HIV patients. The aim of our study is to determine the correlation between chronic HCV infection and lymphoma in AIDS patients. Methods: A hospital based retrospective case control study was performed in a tertiary care center. The medical records of 603 AIDS patients were reviewed between January 2001 and December 2005. 284 patients with both AIDS and hepatitis C in the first group and 319 control patients with AIDS only in the second group. The diagnosis of hepatitis C and AIDS was determined retrospectively from the patients medical records. Only patients with AIDS were included in the study. AIDS was defined as CD4 < 200 or any AIDS defining illness. Results: Among the 284 patients with both AIDS and HCV infection 7 (2.4%) patients were found to have lymphoma at any stage of the disease. On the other hand, 8 (2.4%) patients were found in the control group. By using the Fisher Exact Probability Test there was no statistically significant increase in the incidence of lymphoma among AIDS patients with HCV infection compared to the control group (p=0.823063, and Odds Ratio =0.9824). The type of lymphoma was not determined giving the small number of cases and that the majority of lymphoma in AIDS are NHL cases. Conclusion: Our data showed that among AIDS patients, co infection with Hepatitis C virus doesn’t increase the incidence of lymphoma. Giving the fact that AIDS is a low immunity status, this conclusion supports the theory that chronic immune stimulation plays a role in the pathogenesis of lymphoma in HCV infection.

Introduction: Double minutes (dmin) are small chromatin particles that lack a centromere and represent a form of extrachromosomal gene amplification. They have been found in a variety of solid tumors but are rare in hematological malignancies. C-MYC and MLL are the most common genes amplified on the dmin in AML. Here we report a case of AML in which FISH did not demonstrate C-MYC or MLL gene amplification on the dmin. Case Report: A seventy-seven-year-old man was diagnosed with acute leukemia. Histology and flow cytometry (blasts positive for CD13, CD33, CD34, HLA-DR, CD15, CD117 and cytoplasmic MPO) were consistent with M2 AML. Chromosome analysis revealed abnormal karyotype with hypodiploidy 42–44 and loss of chromosome 5, 7,13,17,18, and Y. Structural rearrangements involving chromosomes 2,7,11,19 and 20 in addition to 2 marker chromosomes and dmin. FISH did not reveal C-MYC gene amplification. FISH did reveal MLL gene amplification, but not on the dmin. The patient received induction chemotherapy, and expired on day 14 due to cardiac complications. Discussion: Double minutes are a mechanism for upregulated oncogene expression. After the development of molecular technology, FISH, it became possible to identify the amplified gene. A previous review (Thomas et al. Double minute chromosomes in monoblastic (M5) and myeloblastic (M2) acute myeloid leukemia: two case reports and a review of literature. Am J Hematol 2004 Sep;77(1):55–61), found C-MYC to be amplified on the dmin in 25 cases, MLL was found to be amplified on the dmin in 5 cases, and only 3 cases in which neither gene was found to be amplified on the dmin. Double minutes are associated with advanced age at presentation, a more aggressive clinical course, poor outcome with therapy, and shortened survival. The survival in most cases is reported to be less than 12 months.

Introduction: Radiation recall dermatitis (RRD) is an inflammatory skin reaction at a site of previous radiation therapy after the administration of a medication, usually a chemotherapeutic agent. A radiation recall reaction has not been previously reported with bortezomib. Case Report: A seventy-year-old man with stage III IgD multiple myeloma was treated with bortezomib after previous treatments with pulse decadron and cyclophosphamide. The patient was treated ten years earlier for a chest wall sarcoma with a local resection and radiation therapy to the tumor bed. After receiving bortezomib therapy for multiple myeloma, the patient developed erythema, desquamation, and ulceration only at the site of radiation therapy ten years prior. The patient received a dose reduced second infusion, causing a similar reaction. Discussion: RRD is an inflammatory skin reaction that develops in a previously irradiated area after administration of certain promoting agents, most often with chemotherapy. Unlike radiation enhancement, there may be a long interval between the eruption and the administration of the causative agent. A number of drugs have been associated with this phenomenon, particularly the anthracyclines. Bortezomib has not been previously described as a causative agent for RRD. Erythema is the most common sign, which may be painful. Vesiculation, desquamation, and ulceration have also been reported. Histologically, the involved areas reveal epidermal dysplasia, necrotic keratinocytes, mixed inflammatory reaction, and sometimes psoriasiform dermatitis. Dose reduction, and the use of corticosteroids have been used to prevent recurrence of RRD, although rechallenge with the same agent may not lead to RRD again. The pathogenesis of this local phenomenon is not well understood, although an idiosyncratic drug hypersensitivity reaction has been proposed.

The major cause of non-relapse transplant related mortality (TRM) in UCBT continues to be infectious, with blood stream infections (BSI) constituting the majority of these events. However, CMV antigenemia and BK virus associated late onset hemorrhagic cystitis (LOHC) are increasingly important causes of morbidity and mortality. We review our single institution experience. We identified 13 patients with hematological malignancies in our database that had undergone UCBT in the period June 2002 - January 2005 and analyzed these data to document the incidence and patterns of infectious complications. The median age was 48 (range 19–62) years. All patients received infectious prophylaxis with Ciprofloxacin, Acyclovir, Voriconazole, Bactrim/nebulized Pentamidine. Eleven patients underwent conditioning with standardized Thiotepa/Busulfan/Cytoxan and GVHD prophylaxis with Tacrolimus/Mycphenalate Mofetil/ATG and the remaining 2 patients received TBI based conditioning. The median total nucleated cell (TNC) was 1.70E+07 and the median CD34 (+) cell count was 8.0E+04. The HLA matches were 4/6 in 9, 5/6 in 3 and 6/6 in 1 patient. All patients engrafted with a median time to neutrophil engraftment (TNE) of 25 (range 16–34) days. Twelve of thirteen patients achieved full donor chimerism at day 30 and 10 of 12 patients with full chimerism at day 100. Five patients developed grade II-IV acute GVHD requiring additional steroid therapy and 1 patient died of steroid refractory GVHD at day 50. Four patients had positive blood cultures at transplant. All patients developed documented bacterial infections: Gram positive in 12 (92%) (VRE in 23%, Steotrophomonas maltophilia in 31%); Gram negative in 8 (61%) (E. cloacae in 15%, Acinobacter spp. in 2 cases). Ten patients were CMV seropositive and 9 of these developed antigenemia requiring Gancyclovir/Foscarnet therapy. Nine patients had documented BK viruria with consequent late onset hemorrhagic cystitis (LOHC) and 5 patients developed BK viremia. There was 1 case of fungal BSI, while 8 patients had documented fungal tongue cultures. Four patients had positive bronchial washings (3 bacterial, 1 C. glabrata). Twelve (92%) patients were alive at day 100. Of note 62% of BSI and all cases of LOHC and CMV antigenemia developed after neutrophil engraftment. In our series of patients, viral infections (CMV, BK virus) were the most significant causes of morbidity. The high rate of BSI, especially after myeloid recovery, argues for a major influence of impaired immune recovery.