Disparities Associated With Total Joint Arthroplasty Transfusion Rates.

BACKGROUND: Infections, readmissions, and mortalities after total joint arthroplasty (TJA) are serious complications, and transfusions have been associated with increased complication rates following TJA. Certain populations, including women, Black patients, patients who have public insurance and older adults have higher risks of transfusion. Recently, there has been a decline in transfusion rates and a greater emphasis on equity in medicine. This study examined whether disparities in transfusion rates still exist and what variables influence rates over time. METHODS: We used a health care system database to identify 5,435 total knee arthroplasty (TKA) and 2,105 total hip arthroplasty (THA) patients from 2013 to 2021. Transfusion rates were 2.9 and 3.1% in the TKA and THA arthroplasty groups, respectively. White race represented 67.1 and 69.8% of the TKA and THA groups, respectively. Fisher exact and Wilcoxon rank sum tests were used to compare categorical and continuous variables. Multivariable logistic regressions were performed to predict transfusion rates within 5 days of surgery and adjust for potential confounders. RESULTS: Transfusion rates declined over time. However, Black patients had a higher rate of transfusion than White patients despite similar hemoglobin levels, 5.1 versus 1.8% (P < .001) in the TKA group and 4.1 versus 2.7% (P = .103) in the THA group. Following adjustment, the biggest factor associated with a higher transfusion risk in the TKA group was being Black (adjusted odds ratio = 2.2, 95% confidence interval = 1.55 to 3.13). CONCLUSIONS: Transfusion rates for TJA patients are declining; however, Black patients continued to receive transfusions at higher rates in patients receiving TKA.

Preoperative frailty predicts postoperative falls in older patients with cancer.

INTRODUCTION: Patient falls in the hospital lead to adverse outcomes and impaired quality of life. Older adults with cancer who are frail may be at heightened risk of falls in the postoperative period. We sought to evaluate the association between degree of preoperative frailty and risk of inpatient postoperative falls and other outcomes among older adults with cancer. MATERIALS AND METHODS: We identified 7,661 patients aged 65 years or older who underwent elective cancer surgery from 2014 to 2020, had a hospital stay of ≥1 day, and had Memorial Sloan Kettering-Frailty Index (MSK-FI) data to allow assessment of frailty. Univariable logistic regression analysis was performed to evaluate the association between frailty and falls. Multivariable logistic regression analysis was performed to evaluate the composite outcome of 30-day readmission or 90-day death, with frailty, falls, and the interaction between frailty and falls as predictors; the analysis was adjusted for age, sex, race, and preoperative albumin level. RESULTS: In total, 7,661 patients were included in the analysis. Seventy-one (0.9%) had a fall, of whom eight (11%) were readmitted to the hospital within 30 days and seven (10%) died within 90 days. Higher MSK-FI score was associated with higher risk of falls (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.21-1.59]). The risk of falls for a patient with an MSK-FI score of 1 was 0.6%, compared with 1.7% for a patient with an MSK-FI score of 4. Poor outcome was associated with frailty (OR, 1.07 [95% CI, 1.02-1.13]) but not with falls (OR, 1.17 [95% CI, 0.57-2.22]). DISCUSSION: Preoperative frailty is associated with risk of inpatient postoperative falls and with other adverse outcomes after surgery among older adults with cancer. Screening for frailty in the preoperative setting would enable healthcare institutions to implement interventions aimed at reducing the incidence of inpatient postoperative falls to reduce fall-related adverse events.

The Amelioration of Grazing through Physiological Integration by a Clonal Dune Plant.

Rhizomatous growth and associated physiological integration can allow a clonal dune species to potentially compensate for the selective removal of leaves associated with herbivory. Hydrocotyle bonariensis is a rhizomatous clonal plant species that is abundant in the coastal dune environments of the southeastern United States that are inhabited by large feral horse populations. H. bonariensis has been shown to integrate resources among ramets within extensive clones as an adaptation to resource heterogeneity in sandy soils. In this study, we hypothesized that clonal integration is a mechanism that promotes H. bonariensis persistence in these communities, despite high levels of herbivory by feral horses. In a field experiment, we used exclosures to test for herbivory in H. bonariensis over a four-month period. We found that feral horses utilized H. bonariensis as a food species, and that while grazing will suppress clonal biomass, H. bonariensis is able to maintain populations in a high grazing regime with and without competition present. We then conducted an experiment in which portions of H. bonariensis clones were clipped to simulate different levels of grazing. Half of the clones were severed to eliminate the possibility of integration. We found that after 12 weeks, the mean number of leaves and ramets increased as the grazing level increased, for integrated clones. Integrated clones had significantly increased biomass production compared to the severed equivalents. Our research suggests that rhizomatous growth and physiological integration are traits that allow clonal plant species to maintain populations and to tolerate grazing in coastal dune environments.

Hypomethylating agent-based therapies in older adults with acute myeloid leukemia - A joint review by the Young International Society of Geriatric Oncology and European Society for Blood and Marrow Transplantation Trainee Committee.

Acute myeloid leukemia (AML) is associated with poor outcomes in older adults. A major goal of treatment is to balance quality of life and functional independence with disease control. With the approval of new, more tolerable regimens, more older adults are able to receive AML-directed therapy. Among these options are hypomethylating agents (HMAs), specifically azacitidine and decitabine. HMAs have become an integral part of AML therapy over the last two decades. These agents are used either as monotherapy or nowadays more commonly in combination with other agents such as the Bcl-2 inhibitor venetoclax. Biological AML characteristics, such as molecular and cytogenetic risk factors, play crucial roles in guiding treatment decisions. In patients with high-risk AML, HMAs are increasingly used rather than intensive chemotherapy, although further trials based on a risk-adapted approach using patient- and disease-related factors are needed. Here, we review trials and evidence for the use of HMA monotherapy and combination therapy in the management of older adults with AML. Furthermore, we discuss the use of HMAs and HMA combination therapies in AML, mechanisms of action, their incorporation into hematopoietic stem cell transplantation strategies, and their use in patients with comorbidities and reduced organ function.

Patterns of Care for Older Patients With Myelofibrosis: A Population-based Study.

BACKGROUND: Current treatments for myelofibrosis (MF) are largely palliative, with the JAK inhibitor ruxolitinib being the breakthrough approved for higher-risk patients by the United States Food and Drug Administration in November 2011. There are limited data on the "real-world" clinical experiences among patients with MF who are treated in the JAK inhibitor era. PATIENTS AND METHODS: We evaluated patterns of care for older patients with MF before and after ruxolitinib approval, using the Surveillance, Epidemiology, and End Results-Medicare database. Treatment patterns were assessed using Medicare part B and D claims. RESULTS: This study included 528 patients diagnosed during 2007 to 2015, with a median age at diagnosis of 76 years. Among 298 patients diagnosed in the ruxolitinib era (2012-2015), 113 (37.9%) were ruxolitinib users. Similar numbers of users started ruxolitinib at 5, 10, 15, or 20 milligrams twice a day (BID). Among 31 patients starting at 5 milligrams BID or less, 48.4% were unable to escalate the dose, and < 11 users could increase the dose to the maximum 25 mg BID. Approximately one-half of ruxolitinib users took hydroxyurea and/or prednisone simultaneously with ruxolitinib. The median time on ruxolitinib was 11.9 months (interquartile range, 4.2-21.7 months). CONCLUSION: It would be important to optimize the use of ruxolitinib and develop new drugs that may be administered together with or after ruxolitinib to accomplish better outcomes in older patients with MF.

Persistent leukocytosis in polycythemia vera is associated with disease evolution but not thrombosis.

There are unresolved questions regarding the association between persistent leukocytosis and risk of thrombosis and disease evolution in polycythemia vera (PV), as much of the published literature on the topic does not appropriately use repeated-measures data or time-dependent modeling to answer these questions. To address this knowledge gap, we analyzed a retrospective database of 520 PV patients seen at 10 academic institutions across the United States. Taking hematologic laboratory data at ∼3-month intervals (or as available) for all patients for duration of follow-up, we used group-based trajectory modeling to identify latent clusters of patients who follow distinct trajectories with regard to their leukocyte, hematocrit, and platelet counts over time. We then tested the association between trajectory membership and hazard of 2 major outcomes: thrombosis and disease evolution to myelofibrosis, myelodysplastic syndrome, or acute myeloid leukemia. Controlling for relevant covariates, we found that persistently elevated leukocyte trajectories were not associated with the hazard of a thrombotic event (P = .4163), but were significantly associated with increased hazard of disease evolution in an ascending stepwise manner (overall P = .0002). In addition, we found that neither hematocrit nor platelet count was significantly associated with the hazard of thrombosis or disease evolution.