Management of Adults with Newly Diagnosed Atrial Fibrillation with and without CKD.

BACKGROUND: Atrial fibrillation (AF) is highly prevalent in CKD and is associated with worse cardiovascular and kidney outcomes. Limited data exist on use of AF pharmacotherapies and AF-related procedures by CKD status. We examined a large "real-world" contemporary population with incident AF to study the association of CKD with management of AF. METHODS: We identified patients with newly diagnosed AF between 2010 and 2017 from two large, integrated health care delivery systems. eGFR (≥60, 45-59, 30-44, 15-29, <15 ml/min per 1.73 m2) was calculated from a minimum of two ambulatory serum creatinine measures separated by ≥90 days. AF medications and procedures were identified from electronic health records. We performed multivariable Fine-Gray subdistribution hazards regression to test the association of CKD severity with receipt of targeted AF therapies. RESULTS: Among 115,564 patients with incident AF, 34% had baseline CKD. In multivariable models, compared with those with eGFR >60 ml/min per 1.73 m2, patients with eGFR 30-44 (adjusted hazard ratio [aHR] 0.91; 95% CI, 0.99 to 0.93), 15-29 (aHR, 0.78; 95% CI, 0.75 to 0.82), and <15 ml/min per 1.73 m2 (aHR, 0.64; 95% CI, 0.58-0.70) had lower use of any AF therapy. Patients with eGFR 15-29 ml/min per 1.73 m2 had lower adjusted use of rate control agents (aHR, 0.61; 95% CI, 0.56 to 0.67), warfarin (aHR, 0.89; 95% CI, 0.84 to 0.94), and DOACs (aHR, 0.23; 95% CI, 0.19 to 0.27) compared with patients with eGFR >60 ml/min per 1.73 m2. These associations were even stronger for eGFR <15 ml/min per 1.73 m2. There was also a graded association between CKD severity and receipt of AF-related procedures (vs eGFR >60 ml/min per 1.73 m2): eGFR 30-44 ml/min per 1.73 (aHR, 0.78; 95% CI, 0.70 to 0.87), eGFR 15-29 ml/min per 1.73 m2 (aHR, 0.73; 95% CI, 0.61 to 0.88), and eGFR <15 ml/min per 1.73 m2 (aHR, 0.48; 95% CI, 0.31 to 0.74). CONCLUSIONS: In adults with newly diagnosed AF, CKD severity was associated with lower receipt of rate control agents, anticoagulation, and AF procedures. Additional data on efficacy and safety of AF therapies in CKD populations are needed to inform management strategies.

Utilization of the healthcare system by gynecologic oncology patients during the SARS-CoV-2 pandemic surge in New York City

COVID-19 is characterized by rapid human-to-human transmission via contaminated respiratory droplets and therefore presents unique challenges in all aspects of healthcare delivery. This is especially true for patients with conditions, such as gynecologic cancer, which require frequent interface with healthcare centers. To further decrease the risk of exposure to these patients, alternate models of care delivery have been implemented and quickly adopted by medical centers. We sought to report the impact of modifications to traditional gynecologic cancer care at our institution. We identified women with suspected or confirmed gynecologic malignancy, age 18 or older, who received care at Montefiore Medical Center between March 16, 2020 and June 7, 2020;these dates reflect a series of executive orders issued by the governor of New York allowing the State Commissioner of Health to cancel elective procedures at hospitals, ambulatory surgery centers, and in the outpatient setting. Clinical data was abstracted from each patient's chart. Patients with incomplete treatment records were excluded. A total of 111 women were identified to be undergoing active treatment and were included in our analysis, representing a total of 703 virtual or in-person patient encounters. More televisit encounters were performed compared to in-person encounters (209 vs 153). The average number of televisits per patient was significantly greater than the average number of in-person outpatient visits per patient (1.88±0.28 vs 1.38±0.42, p=0.047). Other encounters included 173 outpatient laboratory encounters, 112 outpatient radiology encounters, 30 emergency department encounters, 23 hospitalizations, and 3 ambulatory surgeries. Per patient, the median number of interactions was 5 (interquartile range 3-10). Patients with endometrial cancer (n=38) were more likely to be seen in person at least once in an outpatient visit than those with ovarian cancer (n=57) (OR 3.56, 95% CI 1.50-8.43). No significant difference between endometrial and ovarian cancer was seen in other types of encounters, including televisits (OR 0.94, 95% CI 0.32-2.74), inpatient admissions (OR 0.60, 95% CI 0.22-1.70), emergency room encounters (OR 0.77, 95% CI 0.28-2.09), ambulatory radiology encounters (OR 0.67, 95% CI 0.30-1.55), or ambulatory laboratory encounters (OR 0.96, 95% CI 0.42-2.24). The majority of patient encounters for gynecologic cancer at our institution during the SARS-COV-2 pandemic surge were conducted by telemedicine. Prior to the pandemic, telemedicine was not an active method of cancer care delivery within our institution. We predict that gynecologic oncology practice patterns will shift to include telemedicine as an integral part of patient care, even after SARS-COV-2 is no longer prevalent in the community. [ABSTRACT FROM AUTHOR] Copyright of Gynecologic Oncology is the property of Academic Press Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The impact of the SARS-COV2 pandemic on the delivery of chemotherapy for gynecologic cancer at a tertiary care institution in the United States epicenter

In New York City, the SARS-CoV2 pandemic epicenter of the United States, the surge of cases predated much of the country by several weeks, leading to changes in practice patterns that have informed decisions made by other medical institutions. As the SARS-CoV2 pandemic unfolded, many professional subspecialty organizations released practice guidelines in order to minimize transmission of COVID-19 and protect vulnerable populations. The impact of modifications to traditional gynecologic cancer treatment is not known. Here, we describe the impact of the SARS-COV2 pandemic on chemotherapy practices for gynecologic cancer during the pandemic surge. We identified patients age 18 or older at Montefiore Medical Center who had a confirmed or suspected diagnosis of gynecologic cancer and received care between March 16, 2020 and June 7, 2020;these dates reflect a series of executive orders issued by the Governor of New York allowing the State Commissioner of Health to cancel elective procedures at hospitals and ambulatory surgery centers. Clinical data were abstracted from patients' charts. Patients with incomplete treatment records were excluded. A total of 146 women who were included to whom 169 cycles of cytotoxic chemotherapy were delivered during the study period and 68 women (46.6%) received at least one cycle of chemotherapy. Nine patients screened positive for symptoms of COVID or active infection during the study period. Among patients receiving chemotherapy, 52.9% (n=36) had modifications to traditional cancer treatment as a result of state and institutional regulations. Dose reduction was the leading pandemic-related treatment modification and occurred in 69.4% of patients (n=25). Other treatment modifications included prophylactic use of pegfilgrastim (n=1), and treatment deferral or delay (n=7). Women receiving a platinum-based doublet (n=36) during the study period were more likely to sustain dose reduction in chemotherapy (25%) compared to patients undergoing other regimens (0%). A total of 111 women received at least one dose of disease-modifying therapy during the cohort period including chemotherapy, immunotherapy, anti-angiogenesis agents, hormonal therapy, PARP inhibitors, or investigational agents. Treatments were most often discontinued due to completion of adjuvant therapy (n=5), progression of disease (n=4), or toxicity (n=5). Notably 5 patients chose to defer therapy in the setting of the pandemic surge. Only one patient was identified as receiving neoadjuvant chemotherapy specifically due to COVID pandemic-related restrictions. The SARS-COV2 pandemic has led to modification of current standard chemotherapy delivery for gynecologic malignancies with the shared goal of protecting the most vulnerable populations from COVID infection. The impact of these modifications on cancer specific outcomes is not yet known. Future investigation will focus on identifying whether treatment modification to circumvent iatrogenic immunosuppression compromises oncologic outcomes. [ABSTRACT FROM AUTHOR] Copyright of Gynecologic Oncology is the property of Academic Press Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)