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Background: Venous thromboembolism (VTE) is a common medical problem seen in primary care settings. The most common long-term adverse sequelae are recurrent thromboembolism and incomplete resolution of the embolic material, which may result in pulmonary hypertension after pulmonary embolism and post-thrombotic changes in the leg after deep vein thrombosis. Although there are detailed guidelines for diagnosing and treating acute VTE, there are few focused articles that provide recommendations for primary care physicians (PCPs) about how to manage VTE patients after completion of the initial period of anticoagulation treatment. Observations: In this article, we highlight several important clinical decisions that must be addressed after the first 3 months of anticoagulation treatment is complete, with a focus on particular management issues for PCPs. Conclusions: The 2 most important decisions the PCP must make are to determine, first, if symptoms of acute VTE have indeed resolved, and second, if they have resolved, to assess the long-term risk of recurrent VTE versus the risk of potential bleeding and decide if anticoagulation should be stopped, or if indefinite anticoagulation treatment is indicated. Among higher-risk patients who may benefit from indefinite anticoagulation, the PCP should discuss both the risks and benefits of anticoagulation treatment, empowering the patient to actively participate in this important shared decision-making process.

Background Single-center comparative effectiveness studies evaluating outcomes that can occur posthospitalization may become biased if outcomes diagnosed at other facilities are not ascertained. Administrative datasets that link patients' records across facilities may improve outcome ascertainment. Objective To determine whether use of linked administrative data significantly augments thromboembolic outcome ascertainment. Research design Retrospective cohort study. Subjects Patients with an acute isolated calf deep vein thrombosis (DVT) diagnosed at 1 Californian center during 2010-2013. Measures Proximal DVT or pulmonary embolism (PE) within 180 days. We ascertained outcomes from linked California hospitalization, emergency department, and ambulatory surgery data and compared this information to outcomes previously identified from review of the center's medical records. Results Among 384 patients with an isolated calf DVT, 333 could be linked to longitudinal administrative data records. Ten patients had a possible proximal DVT or PE (4 more clearly so) from administrative data; all were unknown from medical record review. Eleven patients with known outcomes from medical record review had no outcome from administrative data. The adjusted odds ratio of proximal DVT or PE with therapeutic anticoagulation attenuated from 0.33 [95% confidence interval (CI), 0.12-0.87] using only medical record review to 0.64 (95% CI, 0.29-1.40) using both medical record review and possible outcomes from administrative data. Restricting the outcome to diagnoses clearly involving proximal DVT or PE, the adjusted odds ratio was 0.46 (95% CI, 0.19-1.10). Conclusions Use of linked hospital administrative data augmented detection of outcomes but imperfect linkage, nonspecific diagnoses, and documentation/coding errors introduced uncertainty regarding the accuracy of outcome ascertainment.

Background Obesity is associated with a higher incidence of atrial fibrillation (AF). Weight reduction improves outcomes in patients known to have AF. Objective The purpose of this study was to compare the incidence of heart failure (HF) or first-time AF hospitalization in obese patients undergoing bariatric surgery (BAS) vs other abdominal surgeries. Methods A retrospective cohort study was conducted using linked hospital discharge records from 1994–2014. Obese patients without known AF or atrial flutter (AFL) who had undergone abdominal hernia or laparoscopic cholecystectomy surgery were identified for each case that underwent BAS (2:1). Clinical outcomes were HF, first-time hospitalization for AF, AFL, gastrointestinal bleeding (GIB), and ischemic or hemorrhagic stroke. Outcomes were analyzed using conditional proportional hazard modeling accounting for the competing risk of death, adjusting for demographics and comorbidities. Results There were 1581 BAS cases and 3162 controls (48% age, Graphical abstract

Prostate-specific antigen (PSA) levels are routinely surveilled after oncologic intervention in patients with prostate cancer. Occasionally, PSA levels are elevated because of factors unrelated to disease recurrence, such as herbal supplement use. False-positive PSA elevations may confound the clinical picture and subsequent decision-making processes, potentially leading to unnecessary diagnostic and therapeutic interventions. In this case report, a patient with low-risk prostate cancer who was treated with low-dose-rate interstitial brachytherapy presented several years after treatment with an erroneously elevated PSA level after taking an herbal supplement. This case highlights the importance of a holistic approach to patient care, whereby tactful assessment of the psychosocial and spiritual aspects of health led to the identification of an uncommon but potentially morbid entity.

The incidence of venous thromboembolism (VTE) is known to be higher in patients with malignancy as compared with the general population. It is important to understand and review the epidemiology of VTE in cancer patients because it has implications regarding treatment and prognosis. Multiple studies have shown that cancer patients who develop VTE are at higher risk for mortality. This article will focus on an update regarding the epidemiology of cancer-associated thrombosis (CT). The authors will describe factors associated with CT risk including cancer type and stage at the time of diagnosis, race and ethnicity, and cancer-directed therapy. In addition, recurrent thrombosis and the effect of thromboembolism on survival in cancer patients will also be addressed.

Glioblastoma (GBM) carries an abysmal prognosis. Current standard of care involves an aggressive multimodality approach including surgical resection followed by adjuvant chemoradiation. Despite this approach, overall survival remains poor and treatment approaches continue to evolve. Given the successes of immunotherapy in other disease sites, implementation in GBM management may improve outcomes. We conducted this retrospective National Cancer Database (NCDB) study to analyze treatment trends and outcomes from 2004-2015 regarding immunotherapy for GBM and queried for patients diagnosed between 2004-2015 with GBM and excluded patients treated without surgery, extracranial radiation, or chemotherapy as well as those lost to follow up. Of the 39,317 eligible patients in this study, 511 were treated with immunotherapy and 38,806 lack thereof. Median overall survival for all patients was 15 months with a 2 and 5 year survival rate of 29% and 8%, respectively. Factors positively influencing delivery of immunotherapy included younger age, higher income, facility location in a metropolitan location, greater distance to the treatment facility, treatment at an academic facility, treatment outside of the years 2007 to 2009, and Caucasian race. On propensity matched analysis, survival was 18 months and 17 months with and without immunotherapy, respectively (p=0.15). Higher comorbidity, lower income, and male gender predicted for worse survival. The results of the NCDB analysis showed an initial decrease and then increase in the use of immunotherapy in the management of GBM. Propensity-matched analyses did not show an overall survival benefit.

Introduction The risk of recurrent venous thromboembolism (VTE) after combined oral contraceptive (COC) use is variably reported. We assessed the long-term risk of recurrent VTE in women on COC at the time of a first VTE, in comparison to women without COC use. Our secondary aim assessed the impact of COC use on the recurrent VTE risk in high-risk and low-risk hyperpigmentation, edema, or redness in either leg; D-dimer level ≥250 μg/L; obesity with body mass index ≥30; or older age, ≥65 years (HERDOO2) subgroups. Methods The REVERSE cohort study derived the HERDOO2 clinical decision rule to predict recurrent VTE in patients who discontinued anticoagulation after 5-7 months for a first unprovoked VTE. Incidence rates of recurrent VTE among women with and without COC exposure were calculated as the number of recurrent VTE over the number of person-years of follow-up, and Cox proportional hazards model was used to compare risks between groups. Results The risk of recurrent VTE among COC users was 1.1% (95% confidence interval [CI] 0.3-2.9) per patient-year as compared with 3.2% per patient-year (95% CI 2.4-4.3) among nonusers (hazard ratio 0.37; 95% CI 0.1-1.0). Women who were COC users and high risk by HERDOO2 score had a recurrence rate of 3.5% (95% CI 0.4-12.5) compared with 6.1% (95% CI 4.3-8.5) among women who were non-COC users and at high risk by HERDOO2 score (HR 0.6, 95% CI 0.1-2.5). Conclusions Women who were COC users at the time of an otherwise unprovoked VTE event had a lower VTE recurrence rate during long-term follow-up, compared with nonusers. The use of HERDOO2 rule may help identify higher risk women with COC use.

Making a definitive diagnosis of heparin-induced thrombocytopenia (HIT) can be problematic. A prompt platelet rise following treatment has been proposed as a "post-test" criterion for diagnosis. However, the platelet response following discontinuation of heparin and initiation of a recommended alternative anticoagulant remains largely undefined and unstudied. This study aimed to characterize platelet response to initial treatment in patients with a low, intermediate, or high likelihood of having HIT. This was a multicenter retrospective cohort study. Patients were over 18 years in age, underwent serologic testing for HIT, and received alternative anticoagulation treatment for HIT. Classification of each patient's likelihood of having HIT was based on an empiric, pre-hoc combination of the 4T score and serology results. The primary outcome for this study was a platelet count response after initiation of direct thrombin inhibitor (DTI) or fondaparinux therapy within 48 h. 124 patients were analyzed. The sensitivity and specificity of having an immediate platelet rise of at least 10,000/µL by day 2 after starting treatment among high-likelihood for HIT patients were 0.71 (95% CI 0.55-0.84) and 0.64 (95% CI 0.5-0.76), respectively. The negative predictive value of no platelet rise was 75.5% (95% CI 0.61-0.86). A prompt platelet count rise may be appropriate to consider along with other known criteria for the clinical diagnosis of HIT. The rise should be immediate following discontinuation of heparin and initiation of recommended treatment, with an upward rise within 48 h.

Background For patients with symptomatic bilateral knee arthritis, it is unknown whether the risk of developing stiffness requiring manipulation under anesthesia postoperatively is higher or lower for those undergoing simultaneous bilateral total knee arthroplasty (TKA) compared with those having staged bilateral TKA. Therefore, we undertook this study to evaluate the risk of requiring manipulation under anesthesia in staged versus simultaneous bilateral TKA as well as patients undergoing unilateral TKA. Methods We utilized the California Patient Discharge Database, which is linked with the California Emergency Department, Ambulatory Surgery, and master death file databases. Using a literature-based estimate of the number of patients who failed to undergo the second stage of a staged bilateral TKA, replacement cases were randomly selected from patients who had unilateral TKA and were matched on 8 clinical characteristics of the patients who had staged bilateral TKA. Hierarchical multivariate logistic regression was performed to determine the risk-adjusted odds of manipulation in patients undergoing unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA using yearly hospital TKA volume as a random effect. Adjustment was made to allow fair comparison of the outcome at 90 and 180 days of follow-up after staged compared with simultaneous bilateral TKA. Results During the time period from 2005 through 2013, the cumulative incidence of manipulation within 90 days was 2.14% for unilateral TKA (4,398 events per 205,744 patients), 2.11% for staged bilateral TKA (724 events per 34,352 patients), and 1.62% for simultaneous bilateral TKA (195 events per 12,013 patients). At 180 days of complete follow-up, the cumulative incidence of manipulation was 3.07% after unilateral TKA (6,313 events per 205,649 patients), 2.89% after staged bilateral TKAs (957 events per 33,169 patients), and 2.29% after simultaneous bilateral TKA (267 events per 11,653 patients). With multivariate analyses used to adjust for relevant risk factors, the 90-day odds ratio (OR) of undergoing manipulation after simultaneous bilateral TKA was significantly lower than that for unilateral TKA (OR = 0.70; 95% confidence interval [CI], 0.57 to 0.86) and staged bilateral TKA (OR = 0.71; 95% CI, 0.57 to 0.90). Similarly, at 180 days, the odds of undergoing manipulation were significantly lower after simultaneous bilateral TKA than after both unilateral TKA (OR = 0.71; 95% CI, 0.59 to 0.84) and staged bilateral TKA (OR = 0.76; 95% CI, 0.63 to 0.93). The frequency of manipulation was significantly associated with younger age, fewer comorbidities, black race, and the absence of obesity. Conclusions Although the ORs were small (close to 1), simultaneous bilateral TKA had a significantly decreased rate of stiffness requiring manipulation under anesthesia at 90 days and 180 days after knee replacement compared with that after staged bilateral TKA and unilateral TKA. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Previous reports show increased incidence of venous thromboembolism [VTE, deep-vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients but did not account for frequency of hospitalization. We determined the incidence of VTE in a SCD cohort versus matched controls. For SCD patients, risk factors for incident VTE, recurrence and the impact on mortality were also determined. Among 6237 patients with SCD, 696 patients (11·2%) developed incident-VTE: 358 (51·6%) had PE (±DVT); 179 (25·7%) had lower-extremity DVT only and 158 (22·7%) had upper-extremity DVT. By 40 years of age, the cumulative incidence of VTE was 17·1% for severe SCD patients (hospitalized ≥3 times a year) versus 8·0% for the matched asthma controls. Amongst SCD patients, women (Hazard ratio [HR] = 1·22; 95% confidence interval [CI]: 1·05-1·43) and those with severe disease (HR = 2·86; 95% CI: 2·42-3·37) had an increased risk of VTE. Five-year recurrence was 36·8% in patients with severe SCD. VTE was associated with increased risk of death (HR = 2·88, 95% CI: 2·35-3·52). In this population-based study, the incidence of VTE was higher in SCD patients than matched controls and was associated with increased mortality. The high incidence of recurrent VTE in patients with severe SCD suggests that extended anticoagulation may be indicated.

Previous reports show increased incidence of venous thromboembolism [VTE, deep-vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients. The incidence, time course, and risk factors for VTE recurrence have been less well described. We determined the cumulative incidence of first VTE recurrence and bleeding in a cohort of SCD patients with incident VTE. Risk factors for recurrence and bleeding were also determined using multivariable Cox regression models, adjusting for gender, race/ethnicity, era of incident VTE, location and hospitalization-associated status of incident VTE, and SCD-related complications. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Among 877 SCD patients with an incident VTE, the 1-year and 5-year cumulative incidence of recurrence was 13.2% (95% CI 11.0%-15.5%) and 24.1% (95% CI 21.2%-27.1%). Risk factors for VTE recurrence included more severe SCD (HR = 2.41; CI: 1.67-3.47), lower extremity DVT as the incident event (HR = 1.64; CI: 1.17-2.30), and pneumonia/acute chest syndrome (HR = 1.68; CI: 1.15-2.45). The cumulative incidence of bleeding was 4.9% (CI 3.5%-6.4%) at 6 months and 7.9% (CI: 6.2%-9.8%) at 1 year. More severe SCD (HR = 1.61; CI: 1.11-2.35) was associated with bleeding. The high incidence of VTE recurrence in patients with SCD suggests that extended anticoagulation may be indicated; however, this must be weighed against a relatively high risk of bleeding. Prospective, randomized studies of anticoagulation in SCD patients with VTE are needed.

621 Background: Anal canal squamous cell carcinoma (SCC) is managed definitively with chemo and XRT, reserving surgery for salvage. Many different radiation dose schemes have been used, varying from 30 Gy to doses exceeding 60 Gy. RTOG 0529 established IMRT as a standard of care for anal canal SCC, using doses of 50.4-54 Gy. We used the National Cancer Database(NCDB) to examine trends in dose selection and radiation technique over time, as well as any potential effect on outcome. Methods: We queried the NCDB from 2004-2015 for cases of anal canal SCC stage 1-3, treated with definitive doses of XRT to the pelvis with chemo. Dose escalation was defined as > 54 Gy. Univariable and multivariable analyses were performed to identify factors predictive of increased dose and overall survival (OS). Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias. Results: We identified 7,792 patients meeting the eligibility criteria, with 4,269 treated to conventional doses and 3,163 treated to > 54 Gy. Patients that were older, had government or private insurance, were treated with IMRT, or at an academic center in a more recent year were less likely to get dose escalation. Increasing T and N stage were predictive of escalated dose. The use of dose escalation decreased over time, from 50% in 2005 to 30% in 2015. In contrast, IMRT use increased over that time from 2% to 63%. On multivariable analysis increasing age, higher comorbidity score, treatment at an academic center, and increasing stage corresponded to worse OS. Increased income, private insurance, IMRT use, increased distance to facility, and female gender all predicted improved OS. Multivariable analysis with propensity score included confirmed increased age, higher comorbidity score, income, distance, and gender as predictive of OS. In addition, escalated dose was found to have inferior outcome (OR: 1.10 95%CI: 1.01-1.20, p = 0.03). Conclusions: The results of this NCDB analysis show a steady increase in the use of IMRT over time, with a corresponding decrease in dose escalation. In this study, dose escalation was shown to have inferior outcomes, although that result is likely influenced by the increasing age, stage, and comorbidity scores in that group of patients.

Author(s): Ghazvinian, Roxanne; White, Richard H; Gage, Brian F; Fang, Margaret C; Saeed, Rabia; Khanna, Raman R

e16260 Background: Pancreatic ductal adenocarcinoma (PDAC) remains one of poor prognosis, portending a 5-year survival rate of 9% when considering all stages. Although the mainstay of treatment of PDAC remains cytotoxic chemotherapy in both the early and advanced stages, recent advances in tumor profiling and germline testing have allowed for the incorporation of poly-ADP-ribose polymerase (PARP) inhibitors, immune checkpoint inhibitors and targeted therapy to be utilized in the maintenance and subsequent-line settings for metastatic PDAC, respectively. We sought to identify our institutional compliance rate in germline testing and tumor profiling in all patients diagnosed with PDAC. Methods: A retrospective review was conducted of all patients diagnosed with PDAC from 2017-2019 at Allegheny General Hospital. Data analysis was completed using IBM SPSS v23. Summary statistics were presented using percentages for categorical variables and medians with interquartile ranges for continuous variables. Results: Out of 171 patients reviewed, 121 received and completed treatment in our institution, and were included in the analysis. Median age was 69 years. 55 patients (45%) were male and 66 (55%) were female. Germline testing was done in 28 patients (23%) and tumor molecular profiling was done in 25 patients (21%). Testing for microsatellite instability was performed in 28 patients (23%). Testing for programmed death-ligand (PD-L1) expression was done in 16 patients (13%). On univariate analysis, family history of malignancy was a predictor for germline testing (OR 5.3; 95% CI 1.4-2.01; p=0.01). No predictors were identified in association with tumor molecular profiling likely due to low sample size. Conclusions: Our analysis reveals an institutional compliance rate of 20-23% in adherence to national guidelines with respect to germline testing and tumor profiling in the management of PDAC. A family history of malignancy demonstrated predictive association with germline testing. Factors which may limit pathological evaluation of microsatellite stability status, assessment of PD-L1 expression and molecular profiling include lack of institutional protocol for reflex histological testing, financial or insurance constraints, and lack of adequate tissue. As part of our Quality improvement project, we identified that incorporation of reflex histological testing based on tumor-type, standardization of tissue biopsy to optimize yield, and utilization of support staff, such as Oncology Navigators, to facilitate scheduling for germline testing may increase compliance rates.

BACKGROUND Almost 700 patients suffered from hospital-associated venous thromboembolism (HA-VTE) across 5 University of California hospitals in calendar year 2011. OBJECTIVE Optimize venous thromboembolism (VTE) prophylaxis (VTEP) in adult medical/surgical inpatients and reduce HA-VTE by at least 20% within 3 years. DESIGN Prospective, unblinded, open-intervention study with historical controls. SETTING Five independent but cooperating academic hospitals. PATIENTS All adult medical and surgical inpatients with stays ≥3 days. The baseline year was 2011, 2012 to 2014 were intervention years, and year 2014 was the mature comparison period. VTEP adequacy was assessed with structured chart review of 45 patients per month at each site via random selection beginning partway through the study. HA-VTE was identified by discharge coding, capturing patients readmitted within 30 days of prior VTE-free admit and VTE occurring during index admission. Cases were stratified medical versus surgical and cancer or noncancer. INTERVENTIONS Interventions included structured order sets with “3-bucket” risk-assessment, measure-vention, techniques to improve reliable administration of VTEP, and education. RESULTS Adequate prophylaxis reached 89% by early 2014. The rate of HA-VTE fell from 0.90% in 2011 to 0.69% in 2014 (24% relative risk [RR] reduction; RR: 0.76, 95% confidence interval: 0.68-0.852), equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. VTE rates were highest in cancer and surgical patients. CONCLUSIONS Hospital systems can reduce HA-VTE by implementing a bundle of active interventions including structured VTEP orders with embedded risk assessment and measure-vention. Journal of Hospital Medicine 2016;11:S22–S28. © 2016 Society of Hospital Medicine

Municipal water restrictions across the southern and southwestern United States have created additional challenges for maintaining safe playing surfaces on recreational turf facilities. In recent years, many cities within these regions have begun to impose irrigation restrictions during winter months. Although winter overseeding has been regularly practiced in these areas, interest and use of colorants as an alternative to overseeding has grown due to decreasing water availability and budget concerns. Data on relative performance of colorant-treated vs. overseeded dormant turf would be of interest to turf managers, because colorants may be more cost-effective and require less water than winter overseeding. The objectives of this 2-year field study were to evaluate effects of winter treatments on performance (green cover, surface hardness, and soil moisture attributes), turfgrass injury resulting from simulated traffic, and spring transition of ‘Tifway’ bermudagrass (Cynodon dactylon L. × Cynodon transvaalensis Burtt-Davy) under a 1-day per week irrigation schedule. Treatments included 1) untreated bermudagrass, 2) fall colorant-treated bermudagrass, 3) perennial ryegrass (Lolium perenne L.) overseeded bermudagrass, and 4) turf-type annual ryegrass (Lolium multiflorum Lam.) overseeded bermudagrass. In both years, treatment differences were detected for percent green cover, soil volumetric water content (VWC), percent visual turfgrass injury, surface hardness, and percent bermudagrass transition. Percent green cover and visual turfgrass injury levels were similar between annual and perennial ryegrass in year 1, whereas loss of green cover and greater turfgrass injury were noted in annual ryegrass during the spring of year 2. Residual benefits of fall colorant applications extended into February of year 1, but dissipated by late December of year 2, likely due to higher rainfall and warmer temperatures, which prevented full bermudagrass shoot dormancy. Overseeding reduced bermudagrass spring transition by up to 50% compared with untreated and colorant-treated plots. Fall colorant treatments did not accelerate bermudagrass transition compared with untreated plots. Results of the study demonstrate that environmental differences from season to season can impact the relative benefits derived from colorant applications, as well as the performance of annual and perennial ryegrass.

© 2016 Elsevier Ltd. All rights reserved. Background Few studies have evaluated the use and outcomes of inferior vena cava filters (IVCF) insertion in cancer patients with deep venous thrombosis (DVT) or pulmonary embolism (PE). Methods Hospital records of patients with a principal diagnosis of lower extremity DVT and/or PE and cancer in California between January 1, 2005 and December 31, 2009 were analyzed. Multivariable logistic regression analysis was used to identify variables associated with IVCF use and propensity matched methodology was used to determine the effect of IVCF insertion on clinical outcomes. Results An IVCF was placed in 19.6% of 14,000 cancer patients and VTE. This varied widely across hospitals, from 0% to 52%, and by cancer type. The strongest predictors of IVCF use were a diagnosis of brain cancer (OR = 4.6, CI: 3.7-5.6), undergoing major surgery (OR = 4.9, CI: 3.9-6.1), and bleeding (OR = 2.7, CI: 2.0-3.5). Only 21% of patients with IVCF had a strong contraindication to anticoagulation (bleeding or major surgery). There was no benefit for 30-day mortality and no reduction in subsequent PE (+/- DVT). Additionally, there was 60% increased risk of recurrent DVT and 20% increased risk of subsequent bleeding when an IVCF was placed. Conclusions An IVCF was placed in approximately 20% of acute VTE patients with cancer and use varied widely between hospitals and cancer types. Most patients did not have a contraindication for anticoagulation. There was no benefit in short-term mortality or risk of PE; there was increased risk of DVT and subsequent bleeding.

Venous thromboembolism (VTE) is categorized by the U.S. Surgeon General as a major public health problem. VTE is relatively common and associated with reduced survival and substantial health-care costs, and recurs frequently. VTE is a complex (multifactorial) disease, involving interactions between acquired or inherited predispositions to thrombosis and VTE risk factors, including increasing patient age and obesity, hospitalization for surgery or acute illness, nursing-home confinement, active cancer, trauma or fracture, immobility or leg paresis, superficial vein thrombosis, and, in women, pregnancy and puerperium, oral contraception, and hormone therapy. Although independent VTE risk factors and predictors of VTE recurrence have been identified, and effective primary and secondary prophylaxis is available, the occurrence of VTE seems to be relatively constant, or even increasing.

SOURCE CITATION Haykal T, Zayed Y, Deliwala S, et al. Direct oral anticoagulant versus low-molecular-weight heparin for treatment of venous thromboembolism in cancer patients: an updated meta-analysis of randomized controlled trials. Thromb Res. 2020;194:57-65. 32788122.

Background Catheter ablation (ABL) for non-valvular (NV) atrial fibrillation (AF) improves rhythm control. Our aim was to compare re-hospitalization for heart failure (HF), acute coronary syndrome (ACS), or recurrent AF among patients with NVAF who underwent ABL versus controls. Methods From the Office of Statewide Planning and Development (OSHPD) database, we identified all patients who had at least one hospitalization for AF between 2005-2013. Patients who subsequently underwent ABL were compared to controls (up to fivematched controls by age, sex and duration of AF between diagnosis and time of ABL). Cases with valve disease, open maze, other arrhythmias, or implanted cardiac devices were excluded. Pre-specified clinical outcomes including readmission for HF, ACS, severe or simple AF (severe = with HF or ACS; simple= without HF or ACS)were assessed using a weighted proportional hazard model adjusting for number of hospital admissions with AF before the ABL, calendar year of ABL, and presence of chronic comorbidities. Results The study population constituted 8338 cases and controls, with mean 3.5+ 1 patient-year follow up. In the ABL cohort, there was lower risk of re-hospitalizations for HF, HR=0.55(95%CI: 0.43-0.69,); ACS,HR=0.5(95%CI: 0.35-0.72,); severe AF [HR=0.86 (CI:0.74-0.99), and higher for simple AF, HR=1.25 (CI:1.18-1.33). Conclusions In patients with NVAF,although ABL is associated with increased risk of re-hospitalization for simple AF, ABL was associated with a significant reduction in the risk of re-hospitalization for HF, ACS and severe AF. These findingsrequireconfirmation in a prospective clinical trial.

Background: Ablation for atrial fibrillation (AF) is superior to medical therapy for rhythm control. We compared stroke and mortality among patients undergoing ablation for AF to matched controls in a large multiethnic population. Methods: Using discharge and surgical records from California nonfederal hospitals, we identified patients who had ablation and principal diagnosis of AF with at least 1 prior hospitalization for AF. We excluded cases with valve disease, open maze, other arrhythmias, or implantable devices. Matched controls were selected based on years of AF diagnosis, age, sex, and being alive the same number of days from the initial AF encounter to the ablation date. Clinical outcomes, including mortality, ischemic stroke, or hemorrhagic stroke, were assessed using a weighted proportional hazard model, adjusting for demographics, prior admissions with AF before the ablation, calendar year, and presence of chronic comorbidities. Results: There were 4169 ablation cases and 4169 weighted-matched controls; 39% percent of the ablation group was >65 years, 72% men, 84% white; mean follow-up was up to 3.6±0.9 years. In adjusted models, ablation was associated with significantly lower mortality (per patient-years) 0.9% versus 1.9%, hazard ratio=0.59 ( P 30 days post-ablation ≤5 years), 0.37% versus 0.59%, hazard ratio=0.68 ( P =0.04; confidence interval: 0.47–0.97); hemorrhagic stroke 0.11% versus 0.35%, hazard ratio=0.36 ( P =0.001; confidence interval: 0.20–0.64) compared with controls. Conclusions: In this large population-based study of hospitalized patients with nonvalvular AF, ablation was associated with lower mortality, ischemic stroke, and hemorrhagic stroke compared with controls.

Background The optimal duration of oral anticoagulant therapy after a first, unprovoked venous thromboembolism is controversial due to tightly balanced risks and benefits of indefinite anticoagulation. Risk stratification tools may assist in decision making. Objectives We sought to determine the relationship between residual pulmonary embolism assessed by baseline ventilation-perfusion scan after completion of 5–7 months of oral anticoagulant therapy and the risk of recurrent venous thromboembolism in patients with the first episode of unprovoked pulmonary embolism. Methods We conducted a multicentre prospective cohort study of participants with a first, unprovoked venous thromboembolism enrolled after the completion of 5–7 months of oral anticoagulation therapy. The participants completed a mean 18-month follow-up. Participants with pulmonary embolism had baseline ventilation-perfusion scan before discontinuation of oral anticoagulant therapy and the percentage of vascular obstruction on baseline ventilation-perfusion scan was determined. During follow-up after discontinuation of oral anticoagulant therapy, all episodes of suspected recurrent venous thromboembolism were independently adjudicated with reference to baseline imaging. Measurements and main results During follow-up, 24 of 239 (10.0%) participants with an index event of isolated pulmonary embolism or pulmonary embolism associated with deep vein thrombosis and central assessment of percentage of vascular obstruction on baseline ventilation-perfusion scan had confirmed recurrent venous thromboembolism. As compared to participants with no residual pulmonary embolism on baseline ventilation-perfusion scan, the hazard ratio for recurrent venous thromboembolism was 2.0 (95% CI 0.5–7.3) for participants with percentage of vascular obstruction of 0.1%–4.9%, 2.1 (95% CI 0.5–7.8) for participants with percentage vascular obstruction of 5.0%–9.9% and 5.3 (95% CI 1.8–15.4) for participants with percentage vascular obstruction greater than or equal to 10%. Conclusions Residual pulmonary embolism assessed by pulmonary vascular obstruction on baseline ventilation-perfusion performed after 5–7 months of oral anticoagulant therapy for the first episode of unprovoked pulmonary embolism was associated with a statistically significant higher risk of subsequent recurrent venous thromboembolism. Percentage of pulmonary vascular obstruction assessment by ventilation-perfusion scans maybe a useful tool to help guide the duration of oral anticoagulant therapy after a first unprovoked pulmonary embolism. Trial registration Registered at www.clinicaltrials.gov identifier: NCT00261014 .

OBJECTIVE: Venous thromboembolism (VTE) is associated with almost 300,000 deaths per year in the United States. Novel oral anticoagulants (NOACs) offer an alternative to warfarin-based therapy without monitoring requirements and with fewer drug and food interactions. Edoxaban, a direct Xa inhibitor, is approved by the Food and Drug Administration (FDA), based upon results of the Hokusai-VTE Phase 3 trial. The trial demonstrated that edoxaban administered once daily after initial treatment with heparin was non-inferior in reducing the risk of VTE recurrence and caused significantly less major and clinically relevant non-major (CRNM) bleeding compared to warfarin. The objective of this study was to evaluate the cost-effectiveness of edoxaban versus warfarin for the treatment of adults with VTE.METHODS: A cost-effectiveness model was developed using patient-level data from the Hokusai-VTE trial, clinical event costs from real-world databases, and drug acquisition costs for warfarin of $0.36 and edoxaban of $9.24 per tablet.RESULTS: From a U.S. health-care delivery system perspective, the incremental cost-effectiveness ratio (ICER) was $22,057 per quality adjusted life year (QALY) gained. Probabilistic sensitivity analysis showed that edoxaban had an ICER

Concern exists over the potential loss of nitrogen (N) and phosphorus (P) in runoff from newly established and fertilized lawns. Nutrient losses can be higher from turf when shoot density and surface cover are low and root systems are not fully developed. This study was conducted to evaluate fertilizer source and timing effects on nutrient losses from newly sodded lawns of St. Augustinegrass [ (Walt.) Kuntze]. For each study, 12 33.6-m plots were established on an undisturbed Alfisol having a 3.7% slope. Each plot was equipped with a runoff collection system, instrumentation for runoff flow rate measurement, and automated samplers. A 28-d establishment study was initiated on 8 Aug. 2012 and repeated on 9 Sept. 2012. Treatments included unfertilized plots, fertilized plots receiving 4.88 g N m as urea 6 d after planting, fertilized plots receiving 4.88 g N m as sulfur-coated urea 6 d after planting, and fertilized plots receiving 4.88 g N m as urea 19 d after planting. Runoff events were created by irrigating with 17 mm of water over 27 min. Runoff water samples were collected after every 37.8 L and analyzed for NO-N, NH-N, dissolved organic N (DON), and PO-P. Increases of approximately 2 to 4 mg L NO-N and 8 to 12 mg L PO-P occurred in runoff 1 d after fertilization, which returned to background levels within 7 d. Total fertilizer N lost to runoff was 0.6 to 4.2% of that applied. Delaying fertilizer application until 19 d after planting provided no reduction in nutrient loss compared with a similar application 6 d after planting. Approximately 33% of the N lost in runoff was as DON. This large amount of DON suggests significant N loss from decomposing organic matter may occur during sod establishment.

As the need for landscape and golf course water conservation increases, use of low-quality irrigation water combined with deficit irrigation practices is becoming more common. Information is lacking concerning the effects of water quality on bermudagrass response to deficit irrigation, as well as the extent to which plant growth regulators may ameliorate or delay the negative effects of water stress on warm-season turfgrass. The objectives of this 10-week greenhouse study were to 1) characterize growth, quality, and evapotranspiration (ET) of ‘Tifway’ bermudagrass (Cynodon dactylon × C. traansvalensis Burt Davy) when irrigated at full (1.0 × ETa) or deficit (0.3 × ETa) levels of actual turfgrass evapotranspiration (ETa) using three irrigation water sources [reverse osmosis (RO), sodic potable, and saline] and 2) determine whether application of trinexapac-ethyl (TE) could mitigate turfgrass quality decline under deficit irrigation. Results indicated that turf irrigated with sodic irrigation water exhibited significantly elevated ETa and shoot growth compared with turf receiving RO or saline irrigation water in both studies. Irrigation water source affected turfgrass quality differently at each irrigation level. TE application improved turfgrass quality and/or delayed firing under soil moisture stress in both studies, with the greatest benefit noted under the less intense conditions of the spring experiment. Elevated canopy temperatures were observed within all deficit irrigation treatments, regardless of water chemistry. Results demonstrate that irrigation water quality may influence turfgrass ET rates. In addition, they suggest that trinexapac-ethyl may offer short-term mitigation of drought stress under deficit irrigation.

Phoma macrostoma is a bioherbicide being developed for selective weed control in turfgrass. The previous research with this product is limited to cool-season turfgrass systems with little information available on appropriate application rates or weed control spectrum for weeds common to warm-season turf. Studies were conducted to evaluate application rates and weed control spectrum of P. macrostoma on common dandelion (Taraxacum officinale G.H. Weber ex Wigg.), slender aster (Aster subulatus var. ligulatus Shinners), common mallow (Malva neglecta Wallr.), common purslane (Portulaca oleracea L.), California burclover (Medicago polymorpha L.), and annual sow thistle (Sonchus oleraceus L.). Although most weeds exhibited susceptibility to P. macrostoma, control differed by weed species and study. P. macrostoma had the greatest efficacy on dandelion, but provided little efficacy on common purslane and common mallow. Warm-season turfgrass tolerance was also evaluated across five commonly used warm-season turfgr...

DALBG 1201 (Reg. No. CV-101, PI 671854) is a turf-type interspecific F 1 hybrid derived from a cross between Texas bluegrass (Poa arachnifera Torr.) 20-11 (3-88) (PI 655088) as the female parent and a Kentucky bluegrass (P. pratensis L.) ecotype, CS#4, as the pollen parent. DALBG 1201 was evaluated under the designation 01-59-5 and TAES 5653. A total of 47 experimental hybrid bluegrass lines and three commercial checks, ‘Rebel Exeda’ tall fescue (Festuca arundinacea Schreb.) and ‘Reveille’ and ‘Thermal Blue Blaze’ hybrid bluegrass (P. arachnifera × P. pratensis) were evaluated at five locations (Auburn, AL, Starkville, MS, Raleigh, NC, Knoxville, TN, and Dallas, TX) from 2009 to 2012. DALBG 1201 was characterized by its superior turfgrass quality, darker green color, and higher shoot density than Reveille and Thermal Blue Blaze. Its leaf texture was finer than Rebel Exeda and similar to the hybrid bluegrass checks. Linear regression analysis for turfgrass quality indicated that DALBG 1201 was more stress tolerant compared with the three commercial checks and was highly stable across varying environmental conditions. Its superior performance over a wide range of southern test locations suggests that DALBG 1201 cool-season turf-type hybrid bluegrass is well-suited for use on lawns, landscapes, and other recreational sites across the southern United States.

Proper management of turfgrass systems is critical for reducing the risk of nutrient loss and protecting urban surface waters. In the southern United States, irrigation can be the most significant management practice regulating the biogeochemical and hydrological cycles of turfgrass systems. A turfgrass runoff research facility was used to assess the effects of deficit irrigation and fertilizer applications on turfgrass canopy cover and nitrate-N (NO₃–N) exports in runoff from St. Augustinegrass [Stenotaphrum secundatum (Walt.) Kuntze] turf over a 2-yr period. Treatments were arranged as a randomized complete block design having eight combinations of irrigation (100, 75, or 50% of estimated turfgrass water requirements) and fertility level (0, 88, and 176 kg N ha⁻¹ yr⁻¹). Runoff from 31 rainfall events and one irrigation excess event were used to estimate annual and seasonal NO₃–N exports. The majority of annual NO₃–N exports occurred during the late winter and spring. Deficit irrigation reduced summer and early autumn runoff volumes. Lower summer and autumn runoff volumes (from deficit irrigation) coincided with reduced NO₃–N exports from runoff during Year 1. Deficit irrigation combined with fertilizer applications increased runoff [NO₃–N] in Year 2, suggesting that the previous year’s export reduction contributed to higher N accumulation in the system and thus a higher N loss potential. These findings suggest that deficit irrigation can be a tool for reducing seasonal nutrient exports from St. Augustinegrass lawns so long as fertilizer inputs are moderate.

Background Catheter ablation (ABL) for non-valvular AF (NVAF) is recommended for symptomatic patients refractory to medical therapy and its success is related to the duration of the arrhythmia prior to intervention.Our aim was to assess the early utilization and the factors that prompted ABL in patients hospitalized for new onset NVAF. Methods Using de-identified administrative discharge records for hospitalizations and emergency department (ED) visits, we determined the patients who had a first-time (since 1991) health record diagnosis of AF between2005 - 2011. We linked ambulatory surgery encounters for ABL based on ICD 9 code occurring within two years of initial hospitalization. After excluding other cardiac arrhythmias, atrio-ventricular nodal ablation or pacemaker/defibrillator placement and cardiac valve disease, bivariate comparisons were made with those who did not undergo ABL. Results During the study period,3,440 of 424,592 patients (0.81%) hospitalized for new onset NVAF underwent ABL. Parameters significantly (p

BACKGROUND: Clinical trials evaluating the efficacy of dabigatran followed a very strict protocol, which included close monitoring and follow-up. Patients followed in this controlled environment had an average medication possession ratio (MPR) > 0.95. However, very few studies have evaluated patient adherence to dabigatran in a real-world setting. Other studies of chronic medications indicate patients are not reliably adherent to twice daily regimens. Adherence to therapy is particularly important for direct thrombin inhibitors because there may be a risk of increased thromboembolic events associated with poor adherence to these agents. OBJECTIVE: To identify the MPR for patients prescribed dabigatran at a large academic medical center and affiliated clinics. METHODS: This retrospective descriptive study evaluated the MPR for patients prescribed dabigatran between January 1, 2012, and December 31, 2012. Patients included in this study had to receive dabigatran for a minimum of 3 months, have a primary care physician or cardiologist at the medical center or affiliated clinics, and must not use a mail order pharmacy. Patient MPR was calculated based on prescriptions picked up from the patient. RESULTS: After screening 400 patients, 159 patients met eligibility criteria. The mean MPR for the patients in this study was 0.63. Overall, 43% of the patients had an MPR of < 0.80, and the mean MPR for this subgroup was 0.39 ± 0.27; 57% of the study population had an MPR of 0.80 or higher, with a mean MPR of 0.94 ± 0.08. There was a significantly higher proportion of men (67.7%, P = 0.0112) and a larger number of “as needed medications” prescribed (1.73 vs. 0.86, P = 0.0039) in patients with an MPR < 0.80. There were 5 patients hospitalized during the study period (3 for bleeding, 1 for confusion, and 1 death not related to dabigatran therapy). CONCLUSIONS: The relatively low mean MPR seen in this study may indicate that there is a need for improved anticoagulation services and followup for patients taking dabigatran.

Background Information regarding dosing of low-molecular-weight heparins (LMWH) for therapeutic anticoagulation in hemodialysis (HD) patients is limited. The aim of this study was to retrospectively compare the safety and efficacy of enoxaparin versus unfractionated heparin (UFH) for therapeutic anticoagulation in HD patients. Materials and Methods This retrospective chart review evaluated HD patients treated with subcutaneous enoxaparin that were matched based on the indication for anticoagulation with patients treated with intravenous UFH to achieve therapeutic anticoagulation. Primary outcome measures included 30-day incidence of thromboembolic events and major bleeding. Secondary outcomes included rehospitalization within 30 days, length of stay, and mortality. Results One hundred sixty-four patients were evaluated, 82 in each group. The average daily dose of enoxaparin used to target therapeutic levels was 0.7 ± 0.2 mg/kg/day (range = 0.4-1). Comparing enoxaparin to UFH, there was no significant difference in major bleeding (6.1% vs 11%, p = 0.4) or thromboembolism (0% vs 2.4%, p = 0.5). Hospital length of stay was shorter in the enoxaparin group (20 ± 53.8 vs 28.9 ± 44.5 days, p = 0.02); there was no significant difference between groups in mortality or readmission. Adjusting for risk factors for bleeding there was a slight but statistically non-significant difference between enoxaparin versus UFH (OR = 0.77, 95%CI: 0.2-3.5, p = 0.73). Conclusions These findings suggest that therapeutic dosing of enoxaparin, in doses that ranged from 0.4-1 mg/kg/day, was as safe as intravenous UFH in providing therapeutic anticoagulation in stable patients requiring chronic hemodialysis.

BACKGROUND Hospital-acquired venous thromboembolism (HA-VTE, VTE occurring during a hospitalization) codes in hospital billing data are often used as a surrogate for hospital-associated VTE events occurring during or up to 30 days after a hospitalization, which are more difficult to measure. OBJECTIVE Establish the incidence and composition of HA-VTE/superficial venous thrombosis (SVT) coded in a large cohort of medical patients. DESIGN Retrospective analysis of discharges. SETTING Eighty-three academic medical centers in UHC (formerly University HealthSystem Consortium). PATIENTS Patients with medical diagnoses hospitalized >2 days between October 1, 2009, and March 31, 2011. MEASUREMENTS Incidence and anatomic location of HA-VTE codes, defined as International Classification of Diseases, Ninth Revision, Clinical Modification codes for VTE coupled to a present-on-admission indicator flag set to “No.” RESULTS Among 2,525,068 medical hospitalizations, 12,847 (0.51%) cases had ≥1 thrombotic code; 2449 (19.1%) with pulmonary embolism (PE), and 3848 (30%) with lower-extremity deep venous thrombosis (LE-DVT) without PE. Upper-extremity DVT (2893; 22.5%) and SVT (3248; 25.3%) comprised the bulk of remaining cases. Among cases with HA-PE/LE-DVT, 34.3% had cancer, 47.8% received care in an intensive care unit, 78% had severe or extreme severity of illness, and 16.5% died in the hospital. Overall, 54.9% of the patients who developed a HA-PE/LE-DVT had been started on VTE pharmacoprophylaxis on hospital day 1 or 2. CONCLUSION At academic centers, HA-VTE/SVT is coded in 0.51% of medical inpatients, and HA-PE/LE-DVT is coded in half of those. Most patients with HA-PE/LE-DVT are severely ill and develop VTE despite receiving prophylaxis. Journal of Hospital Medicine 2014;9:221–225. © 2014 Society of Hospital Medicine

Mechanical ventilation (MV) is one of the most common, but difficult, costly and variably delivered therapies in intensive care. Model-based estimated patient-specific respiratory elastance can be used to guide clinical staff in selecting positive end-expiratory pressure (PEEP) for MV patients. The Clinical Utilisation of Respiratory Elastance (CURE) trial investigates the potential to optimise PEEP in MV patients. A software system, CURE Soft, capable of providing real-time patient-specific respiratory elastance was developed for the purpose of CURE clinical trial. CURE Soft uses airway pressure and flow data from the ventilator to calculate respiratory elastance using a time-varying elastance model. The CURE Soft graphical user interface (GUI) was developed to provide patient-specific respiratory elastance in real time, history and response during a recruitment manoeuvre both of which offer significant clinical insight. CURE Soft was extensively tested on a mechanical test lung to verify the model-based elastance estimation and its robustness. Model fitting errors are low across a range of ventilation modes, showing it can successfully identify respiratory elastance. Real-time monitoring of respiratory elastance enables new insights into patient-specific lung condition, with no added patient burden. The additional insight available to clinicians will provide the information necessary for improved decision-making and patient outcomes.

9024 Background: Immunotherapy has changed the face of treatment for stage IV non small cell lung cancer (NSCLC), quickly becoming the standard of care. The appropriate timing of immunotherapy in the setting of other ablative therapies, namely stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT), remains to be determined. We sought to use the National Cancer Database to examine trends in immunotherapy use as well as timing as it relates to SBRT/SRS in stage IV NSCLC patients. Methods: We queried the NCDB for patients with Stage IV NSCLC diagnosed between 2004-2015 that were treated with SRS or SBRT techniques (to any site) and had at least three months of follow up. Multivariable logistic regression was used to identify predictors of immunotherapy use. Receiver operator curve analysis was used to identify the optimal timepoint between SBRT and immunotherapy correlating with overall survival. Kaplan-meier curves were generated to determine overall survival. Multivariable cox regression was used to determine factors predictive of survival. A propensity score was generated and incorporated into Kaplan-meier and cox regressions to account for indication bias. Results: We identified 13,862 patients meeting the above eligibility criteria, 371 being treated with immunotherapy. The vast majority (75%) had chemotherapy as well. Patients with adenocarcinoma, treatment with chemotherapy, and more recent year of treatment were more likely to receive immunotherapy. Univariable Kaplan-meier analysis showed improved median survival with immunotherapy, 17 months vs. 13 months, p < 0.0001. On multivariable propensity-adjusted cox regression significant predictors for improved overall survival were younger age, lower comorbidity score, lower grade, private insurance, and female gender. Using a cutoff of 21 days after start of SBRT, patients treated thereafter were more likely to survive longer, median survival of 19 months vs 15 months, p = 0.0335. Conclusions: Immunotherapy use in Stage IV NSCLC after SBRT has increased over time, mostly in patients with adenocarcinoma and in the setting of chemotherapy. In this analysis, outcomes were improved when immunotherapy was given at least three weeks after start of SBRT.

e13500 Background: Glioblastoma (GBM) carries an abysmal prognosis. Current standard of care involves an aggressive multimodality approach including surgical resection followed by adjuvant chemoradiation. Despite this approach, overall survival remains poor and treatment approaches continue to evolve. Given the successes of immunotherapy in other disease sites, implementation in GBM management may improve outcomes. Methods: We conducted this NCDB-driven retrospective study to analyze treatment trends and outcomes from 2004-2015 with respect to GBM and immunotherapy. We queried the NCDB diagnosed between 2004-2015 with GBM and excluded patients treated without surgery, extracranial radiation, or chemotherapy as well as those lost to follow up. Results: Of the 39,317 eligible patients in this study, 511 were treated with immunotherapy and 38,806 lack thereof. Median overall survival for all patients was 15 months with a 2 and 5 year survival rate of 29% and 8%, respectively. Factors positively influencing delivery of immunotherapy included younger age, higher income, facility location in a metropolitan location, greater distance to the treatment facility, treatment at an academic facility, treatment outside of the years 2007 to 2009, and Caucasian race. On propensity matched analysis, survival was 18 months and 17 months with and without immunotherapy, respectively (p = 0.15). Higher comorbidity, lower income, and male gender predicted for worse survival. Conclusions: The results of the NCDB analysis showed an initial decrease and then increase in the use of immunotherapy in the management of GBM. Propensity-matched and –adjusted analyses did not show an overall survival benefit, consistent with data from randomized trials.

e17508 Background: Numerous trials are evaluating radiotherapy (RT) de-escalation for HPV-mediated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Herein, we evaluated the degree to which de-escalated RT is delivered in the United States, as well as, comparative outcomes with full-dose RT, as stratified for HPV status. Methods: We identified patients diagnosed with OPSCC in the National Cancer Database, excluding those with stage I/II disease, unknown HPV status, receiving surgery or not receiving EBRT to the primary site, receipt of radiation doses > 75 or < 54 Gy, radiation treatment course duration < 25 or > 75 days, and unknown or inadequate ( < 2 months) follow-up. Multivariable logistic regression analysis identified variables associated with delivery of de-escalated RT ( < 66 Gy). Overall survival of HPV+ and HPV- disease was compared between full-dose and de-escalated approaches. Results: Altogether, 617 and 551 patients were HPV+ and HPV-, respectively. De-escalated RT was delivered in 16.9% HPV+ and 15.2% of HPV- disease, respectively. Older patients and those not receiving systemic therapy were more likely to receive de-escalated RT. In HPV+ patients, 3- and 5-year survival rates were 83% and 80% in the de-escalated cohort versus 83% and 78% in the full-dose group (p = 0.83). In HPV- patients, corresponding 3- and 5-year survival rates were 29% and 23% versus 61% and 51% (p = 0.001). Conclusions: National utilization of de-escalated RT for OPSCC is low (15-20%), but does not seem to impact overall survival in HPV+ (but not HPV-) patients. The caveats of this heterogeneous, retrospective analysis require corroboration from a number of ongoing randomized trials.

e15791 Background: Pancreatic adenocarcinoma is an aggressive malignancy with a high propensity for distant spread. To date, surgery remains the only potentially curative treatment option; which has traditionally been followed by adjuvant chemotherapy. Past research from the pancreatic literature as well as other disease sites has shown conflicting outcomes as it relates to timely delivery of adjuvant chemotherapy. We thus used the National Cancer Database (NCDB) to evaluate time to initiation of chemotherapy following pancreatic resection and if there was any correlate with outcome. Methods: We identified patients diagnosed with stage 1-3 pancreatic adenocarcinoma in the NCDB, excluding those with stage IV disease, those treated nonoperatively, with adjuvant or neoadjuvant chemotherapy or radiotherapy and those with unknown or inadequate ( < 3 months) follow-up. Receiver operator curve analysis identified an interval of 66 days as associated with outcome. Multivariable logistic regression analysis identified variables associated with increased time to chemotherapy postoperatively ( > 66 days). Propensity matching was done to account for indication bias. Overall survival (OS) was compared between both propensity-matched groups receiving earlier and postponed chemotherapy post-resection, with an additional breakdown by stage. Results: In total, 6,873 and 3,348 patients received chemotherapy before and after the 66 day cutoff, respectively. Predictors of expedited chemotherapy included lower comorbidity, treatment outside a community program in an urban location, having insurance, Caucasian race and treatment after 2009. Median overall survival was 21.8 months for all patients and of these, 6462 were stage 1. 5-year OS was 20% in patients receiving chemotherapy within 66 days and 18% in those not (p = 0.0266). In stage 1 patients, 5-year OS was 23% versus 21% (p = 0.0116) in favor of expedited chemotherapy. In stage 2 patients, 5-year OS was 16% in both arms (p = 0.7231). Higher stage and comorbidity score, treatment at a community cancer program, lower salary, increased time from surgical resection to chemotherapy, higher grade, positive margins, and more distant year of treatment were associated with worse prognosis. Conclusions: The present propensity-matched analysis showed a significant benefit to earlier delivery of chemotherapy in the adjuvant setting, with the largest benefit seen in stage 1 patients.

Venous thromboembolism (VTE; deep venous thrombosis and pulmonary embolism) is associated with a poor prognosis in most malignancies and is a major cause of death among cancer patients. Universal anticoagulation for primary thromboprophylaxis in the outpatient setting is precluded by potential bleeding complications, especially without sufficient evidence that all patients would benefit from such prophylaxis. Therefore, appropriately targeting cancer patients for thromboprophylaxis is key to reducing morbidity and perhaps mortality. Predictive biomarkers could aid in identifying patients at high risk for VTE. Possible biomarkers for VTE include C-reactive protein, platelet and leukocyte counts, D-dimer and prothrombin fragment 1 + 2, procoagulant factor VIII, tissue factor, and soluble P-selectin. Evidence is emerging to support the use of risk assessment models in selecting appropriate candidates for primary thromboprophylaxis in the cancer setting. Further studies are needed to optimize these models and determine utility in reducing morbidity and mortality from cancer-associated thromboembolism.

Abstract 3284 Introduction: Splenectomy is efficacious for many patients with chronic immune thrombocytopenia (ITP) refractory to initial corticosteroid therapy. However, there are concerns about short and long term complications, especially venous thromboembolism (VTE) and sepsis. Information regarding the incidence and risk factors for these complications might inform therapeutic decisions. Methods: Using the California Office of Statewide Health Planning and Development Patient Discharge Dataset, we identified all the records of Californians discharged with a diagnosis of ITP from 1991–2009. Similarly, all records with a procedure code for splenectomy, or principal or secondary diagnosis of VTE or sepsis were identified. The resultant datasets were then merged with the ITP dataset so that incident splenectomy, VTE, and sepsis could be determined for the ITP cohort. Results: A total of 37,780 unique patients were initially identified with an ITP code, of which 13,798 were in the principal position. Records where the first ITP code was on the same date as a splenectomy were then excluded as we wished to study a cohort of ITP cases that warranted admission but may or may not have undergone splenectomy later. This resulted in 10,752 cases that constitute the ITP analysis cohort. This cohort was 60% female, 57% White, 23% Hispanic, 9% Asian, and 8% African-American with a median age of 54 years. One thousand nine hundred fifty-five ITP patients underwent splenectomy subsequent to their first ITP hospitalization; 8,797 did not. The cumulative incidences of VTE were 4.4% and 1.8%, and for sepsis were 7.9% and 6.7%, for patients who did and did not undergo splenectomy, respectively. Cox proportional hazard models for VTE and sepsis are given in the tables. Discussion: In this large cohort of cases with ITP, splenectomy was associated with hazard ratios (HR) of 2.6 to 4.8 for VTE and a HR of 8.2 in older patients for sepsis, confirming the results of smaller studies. Age and diagnosis of lupus also increased the risk of VTE. Asians had a lower risk of VTE, consistent with previous findings. The absolute risk of VTE was < 5% and would not seem to warrant long-term primary prophylaxis. Age, lupus, and co-morbidities also increased the risk of sepsis in patients with ITP. The increased risk of sepsis in Asians is unexplained. Of note, the cumulative incidence of sepsis in patients that did not undergo splenectomy was still considerable and may have reflected the use of immunosuppressive therapy. Disclosures: Wun: Glycomimetics, Inc.: Research Funding; Eli Lilly, Inc.: Research Funding.

As a result of increasing demand for potable water, local and national initiatives to conserve municipal water supplies have been implemented. Many of these initiatives focus on reducing irrigation of turfgrass in urban landscapes and may totally ban irrigation during periods of severe water shortage. Proper selection of adapted turfgrass species and cultivars is vital to long-term water conservation initiatives. Turfgrasses that can survive and recover from extended hot and dry periods under limited to no irrigation would best meet water conservation objectives. The present study was conducted to evaluate the recuperative potential of transplanted plugs of 24 commonly grown cultivars of three warm-season turfgrass species after incremental increases in water stress imposed by withholding all water for up to 60 days. A 2-year field study was conducted consisting of eight blocks containing 25 plots each. Each block was planted with one plot each of eight cultivars of bermudagrass (Cynodon dactylon sp.), seven cultivars of st. augustinegrass (Stenotaphrum secundatum sp.), and nine cultivars of zoysiagrass (five of Zoysia japonica sp. and four of Zoysia matrella sp.). Four blocks were planted on native soil with no restriction to rooting, whereas the other four had an effective root zone of only 10 cm of soil. Cup cutter plugs were collected at predetermined intervals, transported to College Station, TX, replanted, and grown under well-watered conditions. Measurements of the lateral spread of the plugs were taken every 10 to 14 days for the first 60 to 70 days after planting (DAP). The lateral spread of plugs collected after 0 days of summer dry-down (DSD) was greatest for bermudagrass, intermediate for st. augustinegrass, and lowest for zoysiagrass. In most cases there were no consistent differences between cultivars within a species. All species grown on the 10-cm deep root zone were unable to survive the 60-day period without water and died within the first 40 days. For each species, lateral spread was increasingly delayed or reduced with increasing DSD. Although all three species grown on native soil were able to survive and recover from a 60-day period without water, the bermudagrass cultivars had the most rapid recovery rates measured as lateral spread of transplanted plugs.

As the annual number of total knee arthroplasties has continued to increase, a concomitant increase in the number of bilateral total knee arthroplasties has occurred. Approximately 6% of primary total knee arthroplasties performed each year in the United States are performed on both knees as a single procedure with the patient under anesthesia (simultaneous bilateral total knee arthroplasty). This rate represents an almost twofold increase compared with the rate in the 1990s, when approximately 3.7% of all total knee arthroplasty operations were performed as a simultaneous bilateral total knee arthroplasty1. Because the fastest increase in total knee arthroplasty is occurring among younger people, a continued increase in the performance of simultaneous bilateral total knee arthroplasty is possible2. The identification of patients of all ages with symptomatic bilateral knee arthritis who are appropriate candidates for simultaneous bilateral total knee arthroplasty can be difficult. A major deficiency of the current orthopaedic literature is the absence of any adequately powered, prospective, controlled clinical trials that have directly compared simultaneous bilateral total knee arthroplasty with two total …

Background The assessment of patients with suspected deep vein thrombosis (DVT) remains challenging despite current diagnostic algorithms. 99m Tc-labelled DI-DD3B6/22-80B3 Fab´ fragments ( 99m Tc-DI-80B3, ThromboView®) is a novel diagnostic test that uses a radiolabelled humanized monoclonal antibody fragment specific for the D-dimer region of cross-linked fibrin to detect DVT. This test has an anatomic component to locate DVT and a functional component to differentiate acute (newly formed) thrombus from inactive (old) thrombus. Methods In a multi-centre prospective cohort trial we investigated the diagnostic accuracy and safety of 99m Tc-DI-80B3 in consecutive patients with suspected DVT who had the diagnosis confirmed or excluded by venography. Results We enrolled 94 patients with suspected DVT of whom 12 did not have 99m Tc-DI-80B3 imaging, leaving 82 patients for the safety analysis. Of these patients, there were 16 with non-evaluable imaging (11 venography, 7 99m Tc-DI-80B3, both in two patients) leaving 66 patients for the accuracy analysis. 99m Tc-DI-80B3 imaging was well-tolerated: 2 patients developed urticaria; none developed serious adverse events. For proximal DVT, the sensitivity (84.2%; 95% confidence interval [CI]: 62.4–94.5) and specificity (97.6%; CI: 83.3–99.4) were highest when the combined 0.25-hour and 3-hour 99m Tc-DI-80B3 images were used. The accuracy was lower for distal DVT, irrespective of the images used. There were insufficient patients to comment on the accuracy of 99m Tc-DI-80B3 imaging for suspected recurrent DVT. Conclusions 99m Tc-DI-80B3 (ThromboView®) is a novel diagnostic modality for patients with suspected DVT with a promising accuracy and safety profile that justifies additional clinical development in diagnostic accuracy and clinical management studies.

Background: It is unclear whether simultaneous-bilateral total knee arthroplasty is as safe as staged-bilateral arthroplasty is. We are aware of no randomized trials comparing the safety of these surgical strategies. The purpose of this study was to retrospectively compare these two strategies, with use of an intention-to-treat approach for the staged-bilateral arthroplasty cohort. Methods: We used linked hospital discharge data to compare the safety of simultaneous-bilateral and staged-bilateral knee arthroplasty procedures performed in California between 1997 and 2007. Estimates were generated to take into account patients who had planned to undergo staged-bilateral arthroplasty but never underwent the second procedure because of death, a major complication, or elective withdrawal. Hierarchical logistic regression modeling was used to adjust the comparisons for patient and hospital characteristics. The principal outcomes of interest were death, a major complication involving the cardiovascular system, and a periprosthetic knee infection or mechanical malfunction requiring revision surgery. Results: Records were available for 11,445 simultaneous-bilateral arthroplasty procedures and 23,715 staged-bilateral procedures. On the basis of an intermediate estimate of the number of complications that occurred after the first procedure in a staged-bilateral arthroplasty, patients who underwent simultaneous-bilateral arthroplasty had a significantly higher adjusted odds ratio (OR) of myocardial infarction (OR = 1.6, 95% confidence interval [CI] = 1.2 to 2.2) and of pulmonary embolism (OR = 1.4, 95% CI = 1.1 to 1.8), similar odds of death (OR = 1.3, 95% CI = 0.9 to 1.9) and of ischemic stroke (OR = 1.0, 95% CI = 0.6 to 1.6), and significantly lower odds of major joint infection (OR = 0.6, 95% CI = 0.5 to 0.7) and of major mechanical malfunction (OR = 0.7, 95% CI = 0.6 to 0.9) compared with patients who planned to undergo staged-bilateral arthroplasty. The unadjusted thirty-day incidence of death or a coronary event was 3.2 events per thousand patients higher after simultaneous-bilateral arthroplasty than after staged-bilateral arthroplasty, but the one-year incidence of major joint infection or major mechanical malfunction was 10.5 events per thousand lower after simultaneous-bilateral arthroplasty. Conclusions: Simultaneous-bilateral total knee arthroplasty was associated with a clinically important reduction in the incidence of periprosthetic joint infection and malfunction within one year after arthroplasty, but it was associated with a moderately higher risk of an adverse cardiovascular outcome within thirty days. If patients who are at higher risk for cardiovascular complications can be identified, simultaneous-bilateral knee arthroplasty may be the preferred surgical strategy for the remaining lower-risk patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.