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Aim: Newborn babies who are released from the hospital at a younger postnatal age are more likely to be hospitalized to the nursery due to neonatal jaundice. This readmission is undoubtedly a significant source of strain in the nurseries, but it may be addressed by adequate assessment prior dismissing the newborn. The purpose of this study was to see if there was a link among cord blood bilirubin and vein bilirubin on the third day of life. Methods: On 120 healthy term newborns, a cross-sectional description research was conducted. Blood was drawn from the child's cord right after birth, whether vaginally or through caesarean surgery, for total serum bilirubin, unconjugated serum bilirubin levels, and conjugated serum bilirubin levels. On the third day (72 hours), a second serum blood sample is obtained from peripheral venous blood, and total serum bilirubin, unconjugated serum bilirubin, and conjugated serum bilirubin levels are measured again. The research was carried out over a one-year period, from March 2020 to February 2021. Results: The babies were divided into two groups: those with hyperbilirubinemia and those without. The findings acquired from aggregate and stratified samples demonstrate a significant association 0.542 and P-value 0.001 among serum cord blood bilirubin and peripheral venous blood bilirubin. Conclusion: There is a link among elevated bilirubin levels in normal infants born and serum cord blood bilirubin levels. The increase in serum cord blood bilirubin levels correlates with both the increase in peripheral venous blood bilirubin on the third day of life.

AimTo assess the effect of vasopressin, steroid and epinephrine (VSE) combination therapy on return of spontaneous circulation (ROSC) after in-hospital cardiac arrest (IHCA), and test the conclusiveness of evidence using trial sequential analysis (TSA).MethodsThe systematic search included PubMed, EMBASE, Scopus, and Cochrane Central Register of Controlled Trials. Randomized controlled trials that included adult patients with in-hospital cardiac arrest, with at least one group receiving combined vasopressin, epinephrine and steroid therapy were selected. Data was extracted independently by two reviewers. The main outcome of interest was ROSC. Other outcomes included survival to hospital discharge with good neurological outcomes and survival to 30 and 90 days with good neurological outcomes.ResultsWe included a total of three randomized controlled trials (n=869 patients). Results showed that Vasopressin, steroid and epinephrine combination therapy increased return of spontaneous circulation (risk ratio, 1.32; 95% CI, 1.18-1.47) as compared to placebo. Trial sequential analysis demonstrated that the existing evidence is conclusive. This was also validated by the alpha-spending adjusted relative risk (1.32 [1.16, 1.49], pConclusionsVSE combination therapy administered in cardiopulmonary resuscitation led to improved rates of return of spontaneous circulation. Future trials of vasopressin, steroid and epinephrine combination therapy should evaluate survival to hospital discharge, neurological function and long-term survival.

The Institute of Medicine defines quality in healthcare as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. This concept is highly relevant for cancer care that involves patients with complex diseases in the setting of rapidly evolving treatment landscape that requires provision of appropriate services in a patient-centric and technically competent manner. This chapter uses the Donabedian model to review the structural, process, and outcome-based quality domains that lay the foundation for a robust system to measure, monitor, and improve quality of care at cancer centers. The infrastructure and personnel, systems, and culture needed for ensuring provision of high-quality cancer care are reviewed.

e20012 Background: Multiple Myeloma (MM) accounts for approximately 10% of all hematological malignancies. MM patients have heterogeneous outcomes that depend on several demographic, genetic and clinical factors. Here, we report the demographics along with the short and long-term outcomes in a cohort of patients who underwent Autologous Stem Cell Transplant (ASCT) over a period of 5 years. Methods: In this retrospective cohort, we assessed all MM patients who underwent ASCT at the Cleveland Clinic during the period between January 1, 2016 and January 15, 2021. Demographic characteristics, ISS staging, Cytogenetic risk categorization, Pre-ASCT treatment, short-term in-hospital complications, response (defined per IMWG response criteria) before and up to12 months after ASCT, as well as maintenance therapy were collected by reviewing electronic health records. Continuous variables are presented as mean with standard deviation, while categorical variables are presented as percentages. Categorical variables are compared using the chi-squared test while continuous variables are compared using the ANOVA and t-tests. Results: 379 patients who underwent ASCT within the studied time period were identified (Table). Most common cytogenetic abnormalities were del(13) (RB) 25.07%, t(11;14) 17.94% and gain(1q) 16.62%. A Lenalidomide, Bortezomib and dexamethasone (RVd) regimen was the most common to elicit response pre-ASCT (59.05%). Complete response (CR) was achieved in 27.82%, very good partial response (VGPR) in 34.71% and partial response (PR) in 37.47% of all patients pre-ASCT as compared to CR in 43.05%, VGPR in 28.05%, PR in 24.73% and progressive disease (PD) in 4.17% 3 months post-ASCT. All patients received intermediate (140 mg/m2) or high-dose (200 mg/m2) Melphalan conditioning. Average length of hospital stay was 14.56 ± 2.11. Of all patients, thrombotic events were seen in 1.3%, bleeding in 1.8%, neuropathy in 5.34%, mucocutaneous toxicities in 47.99%, cytopenias in 98.39% and infections in 32.25%. RBC and platelet transfusions were required in 36.1% and 88.9% of patients, respectively. Progression-free survival (PFS) was 96.89% at 3 months, 93.77% at 6 months, 92.55% at 9 months, and 88.47% at 12 months post-ASCT. PFS up to 12 months was not statistically different across ISS stages (p = 0.881) or cytogenetic risk categories (p = 0.347). Most common cause of death was progressive MM (73.47%). Conclusions: Responses in MM are boosted by ASCT. Its most common complications are transfusion-dependent thrombocytopenia and infections. Most patients survive beyond 1 year with PD rate of only 11.53%. Advanced ISS stage and high-risk cytogenetics do not confer higher PD in the 1st 12 months post-ASCT.[Table: see text]

e20004 Background: Most Multiple Myeloma (MM) patients who respond to initial treatment ultimately progress. Data regarding 2nd line treatment remains scarce, but in general treatment relies on whether the disease is refractory to Lenalidomide (R) or not. Here, we report responses to 2nd line treatments of MM patients in with disease progression (PD) following Autologous Stem Cell Transplant (ASCT). Methods: We retrospectively reviewed MM patients with PD after ASCT at Cleveland Clinic during the period of April 1, 2016 till December 31, 2021. Baseline demographic, clinical and cytogenetic features were obtained from electronic records. Patients who had PD after ASCT, as defined by IMWG criteria, were divided into two smaller subcohorts: R-refractory and R-sensitive. Outcomes were compared among treatment groups within each subcohort. Continuous variables are reported as means with standard deviations, while categorical variables are presented as percentages. Categorical variables were compared using the chi-squared test while the t test and ANOVA were used for continuous variables. Results: 127 patients who had PD following ASCT were identified (Table). Most common cytogenetic aberrancies were del(13) (RB) 34.6%, t(11;14) 18.9% and gain(1q) 15%. Pre-PD maintenance included R 58.3%, Bortezomib (V) 7.1%, RV combination 8.7% and other R-based regimens 9.4%, with no difference in time to disease progression (TTPD) between them (p = 0.82), and an average of 15.5 months TTPD among all patients. ISS III patients were likely to progress earlier than ISS II or I (10.91 vs 14.56 vs 20.33 months; p = 0.008), while high and standard-risk cytogenetics did not predict TTPD (12.62 vs 16.85 months; p = 0.092). Patient who achieved CR either pre or post-ASCT were less likely to progress compared to others with weaker responses (p = 0.032; p = 0.002). Patients who did not achieve CR post-ASCT progressed earlier than those with CR (12.37 vs 16.53 months; p = 0.041). In R-sensitive patients (n = 25), PD was not significantly different in patients on 2nd line Daratumumab (D), R and dexamethasone (d) vs RVd (45.5% vs 60%; p = 0.505). In R-refractory patients (n = 57), PD was also not significantly different in DVd, Dd with Pomalidomide, or Carfilzomib (C)-based regimens (81.3% vs 68.2% vs 60%; p = 0.426). Time to 2nd PD was significantly longer in DRd vs RVd (12.4 vs 3 months; p = 0.026) but similar in DVd vs DPd vs C-based regimens (6.75 vs 8 vs 5.89 months; p = 0.711). Conclusions: TTPD in MM post-ASCT is determined by the ISS stage and achieving CR but not by cytogenetic risk or maintenance choice. Current regimens used as 2nd line in R-refractory patients are statistically indifferent, but DRd delays further PD compared to RVd in R-sensitive patients.[Table: see text]

Objective: To determine the 10-year Cardiovascular risk score with QRISK-2 and Framingham risk calculators in Rheumatoid Arthritis and Non Rheumatoid Arthritis subjects and asses the usefulness of QRISK-2 and Framingham calculators in both groups. Methods: During the study 106 RA and 106 Non RA patients age and sex matched participants were enrolled from outpatient department. Demographic data and questions regarding other study parameters were noted. After 14 hours of fasting 5 ml of venous blood was drawn for Cholesterol and HDL levels, laboratory tests were performed ON COBAS c III (ROCHE). QRISK-2 and Framingham risk calculators were used to get individual 10-year CVD risk score. Results: In this study the mean age of RA group was (45.1±9.5) for Non RA group (43.7±8.2), with female gender as common. The mean predicted 10-year score with QRISK-2 calculator in RA group (14.2±17.1%) and Non RA group was (13.2±19.0%) with (p-value 0.122). The 10-year score with Framingham risk score in RA group was (12.9±10.4%) and Non RA group was (8.9±8.7%) with (p-value 0.001). In RA group QRISK-2 (24.5%) and FRS (31.1%) cases with predicted score were in higher risk category. The maximum agreement scores between both calculators was observed in both groups (Kappa=0.618 RA Group; Kappa=0.671 Non RAGroup). Conclusion: QRISK-2 calculator is more appropriate as it takes RA, ethnicity, CKD, and Atrial fibrillation as factors in risk assessment score.

Objective: To record various clinicopathological characteristics of breast cancer (BC) in our population and to find an association between these characteristics and axillary nodal metastasis. Methods: This cross-sectional study included 150 BC patients from two tertiary care centers in Lahore from 15th February, 2016 to 31st March, 2018. Frequencies, percentages, and odds ratio were estimated to find out an association between various clinicopathological characteristics and lymph node status using SPSS version 20. Results: Approximately 75.4% patients had axillary lymph node metastasis (‘1-3’ LN = 34.4% and ‘>3’ LN = 44%). Menopausal status (p 3’ LN metastasis. Association of these variables with ‘1-3’ LN involvement was insignificant. Conclusion: Clinical spectrum of BC remains unchanged in 2016 with most of the patients presenting with high-grade, late-stage advanced disease. Moreover, clinicopathological variables, especially primary tumor size, tumor stage and lymphovascular invasion were significant predictors of >3 lymph node metastasis with high accuracy.

Melanoma is a highly aggressive disease with the risk of developing metastasis to virtually all organs including the heart, which can manifest as arrhythmia, right ventricular obstruction, heart failure, or pericardial effusion. Only a few reports are found in the literature of metastatic melanoma, causing ventricular arrhythmia. Prior to the advent of contemporary therapies, cardiac metastases implied a very poor prognosis. The use of immune checkpoint inhibitors and targeted therapy has greatly improved survival outcomes of metastatic melanoma. Aggressive therapy of cardiac metastasis including cardiac surgery can yield good outcomes. We present a case of a 57-year old gentleman with metastatic melanoma and cardiac involvement who initially presented as a ventricular arrhythmia and was successfully treated with immune checkpoint inhibitors and targeted therapy.

Introduction: Multiple myeloma accounts for 1% of all cancers and approximately 10% of all hematologic malignancies. With the advent of novel therapies for multiple myeloma and emerging data from randomized trials, there has been a substantial improvement and favorable outcomes in survival. Here, we report demographics and outcomes in a cohort of patients who underwent Autologous Stem Cell Transplant (ASCT) over the past year. Methods: In this retrospective, cohort study, we assessed all MM patients who received ASCT from January 1, 2020, to January 15, 2021, at Cleveland Clinic, and followed until July 31, 2021. Baseline demographics, ECOG performance status, ISS stage, cytogenetic risk category, therapy received before ASCT, maintenance therapy, time to first relapse/progression, time to next treatment (TTNT; 2nd line of treatment onwards) with treatment response (defined per IMWG response criteria) before and after ASCT were obtained by review of electronic medical records. All patients received HDCT Melphalan 140 mg/m2 or 200 mg/m2 prior to ASCT. Continuous variables were presented as median and interquartile range, while categorical variables were presented as numbers and percentages. Categorical variables were compared using the chi-square test. Results: Of 81 MM patients who underwent ASCT, 59% were males, 84% were white, with a median age of 62 (IQR: 57-67) at the time of diagnosis. 42 (52%) and 24 (30%) patients belonged to the standard and high-risk category. Amongst high-risk cytogenetic abnormalities, +1q was the most common (72%) followed by del(17p) (28%). Baseline characteristics of patients are included in Table 1.1. Lenalidomide, bortezomib, and dexamethasone (VRd) regimen was the most common (75%) first-line induction regimen used, followed by Daratumumab-based regimens (20%). 10 (12%) patients required second-line treatment, and 6 (7%) patients required more than 2 lines of treatments prior to transplant. The median time to transplant was 6.5 months. The overall response rate (ORR) prior to transplant was 99% (21% complete (CR), 40% very good partial (VGPR), and 38% partial (PR)). The ORR post-ASCT was 78% (CR 27%, VGPR 37%, PR 14%). There was no significant difference in response between risk categories after transplant (P=0.72). At 1-year follow-up, 10 (12%) patients had relapsed and 7 (9%) patients had progression of the disease. 3 (4%) patients died of progressive MM, one of which had progressed to plasma cell leukemia. Response to treatment before and after the ASCT are summarized in Table 1.2 and Figure 1. The time to second-line treatment among patients with relapse/progression was 7 months [IQR: 3.75-10.25]. Conclusion: Here we report the demographics and outcomes of patients with MM undergoing modern modality treatments and ASCT, at our center over the last year. The median time to transplant was 6.5 months after induction therapy, and the ORR post-ASCT was 78%. No significant difference in response was observed between high and standard risk categories. No transplant-related mortality was observed as well. Figure 1 Figure 1. Disclosures Anwer: Allogene Therapeutics: Research Funding; Janssen pharmaceutical: Honoraria, Research Funding; BMS / Celgene: Honoraria, Research Funding; GlaxoSmithKline: Research Funding.

OBJECTIVES:. Early palliative medicine consult in the ICU can significantly improve outcomes in high-risk patients. We describe a pilot study of including a recommendation for palliative medicine consult in the ICU morning huddle. DESIGN:. A prospective, observational, quality improvement study. PATIENTS AND SETTING:. Adult patients (age above 18 yr) admitted with cardiac arrest, stage IV cancer, admission from a long-term acute care facility, and circulatory shock on mechanical ventilation to the medical ICU. INTERVENTIONS:. We aim to assess the effect of an early palliative medicine consultation in selected high-risk patients on change in code status, referral to hospice, tracheostomy, and or percutaneous gastrostomy tube placement. MEASUREMENTS AND MAIN RESULTS:. There were 83 patients who triggered an early palliative medicine consult. Palliative medicine consultation occurred in 44 patients (53%); 23 patients (28%) had a palliative medicine consult within the first 48 hours, 21 (25%) had a palliative medicine consult afterwards. There was a significantly higher number of patients who de-escalated their code status in the palliative medicine consult group compared with the no palliative medicine consult group (63.6% vs 7.7%); however, the number was higher in the late palliative medicine consult group (71.4% vs 56.5%). There were more patients referred to hospice in the palliative medicine consult group. No difference in length of stay was observed. CONCLUSIONS:. Early palliative medicine consultation in the daily ICU morning huddle is achievable, can produce a palliative medicine consultation in most cases, and results in a significant change in code status toward less aggressive measures.

e15000 Background: Immune checkpoints inhibitors (ICIs) are associated with multiple side effects. Complications can affect any organ system including; endocrine, gastrointestinal, pulmonary, and less frequently hematological system.We evaluated the risk of bleeding and significant thrombocytopenia in cancer patients (pts) treated with ICIs. Methods: Cancer pts treated with ICIs between 01/2015 and 7/2019 at Cleveland Clinic Foundation were retrospectively reviewed. Platelets (plts) count and hemoglobin (hb) level at baseline, after one month and 3 months of treatment were reviewed. Thrombocytopenia was defined as plts count < 150,000. In pts with thrombocytopenia at baseline, more than 50% drop in the plts count was considered significant. Pts were followed-up for one year after ICIs treatment initiation for significant bleeding. Results: We identified 555 cancer pts treated with ICIs. Of these pts 65% were males. Among all included pts, 53% had lung cancer, 23% had genitourinary cancers, 17% had melanoma, 3% had gastrointestinal cancers, and 5% had other cancer types. Nivolumab, pembrolizumab, ipilimumab, and atezolizumab were used in 62%, 27%, 14%, and 12% respectively. Clinically significant bleeding, thrombocytopenia after one month and 3 months of treatment were identified in 21%, 6%, and 7% respectively. Of all pts who developed bleeding, 8% had gastrointestinal bleeding, 5% had intracerebral hemorrhage, and 3 % had hemoptysis. Only 23% of the pts who developed bleeding were receiving anticoagulation therapy. In multivariate analysis, breast cancer as primary malignancy (p = .03) and atezolizumab (p = 0.02) were predictors of clinically significant bleeding. Also, nivolumab was associated with increased risk of significant thrombocytopenia after one month of treatment (p = .02). There was no significant association between the use of specific medication and the development of significant anemia. Median overall survival time was not statistically different in patients who had bleeding compared to no bleeding group, 12.6 months (95% CI:10.8-14.5) and 12.4 months (95% CI:10.3-15) respectively (p = .21). Conclusions: In this cohort study, atezolizumab and breast cancer were significantly associated with increased risk of bleeding. The use of nivolumab was associated with a greater risk of thrombocytopenia after one month of treatment. Prospective studies are needed for better understanding of the hematological side effects of ICIs.

Left ventricle aneurysms (LVAs) are areas of thin and fibrotic myocardium leading to out pouching of the wall. Commonly seen as sequale of Myocardial infarction, they can lead to potentially devastating consequences. 57-year-old lady with a history of hypertension and dyslipidemia initially

e12515 Background: Women with stage IV HER2+ breast cancer typically have longer overall survival (OS) compared to other breast cancer subsets due to the effectiveness of dual anti HER-2 antibody therapy. The role of mastectomy remains controversial. Methods: We reviewed patients who were diagnosed with stage IV HER2+ breast cancer between 2/2015 and 12/2017 at Cleveland Clinic. Overall survival (OS) was estimated by the Kaplan-Meier method, and compared by the log-rank test. Univariable and multivariable analysis were performed using Cox regression to identify predictors of OS. Results: We identified 47 patients, with a median age of 58 (range: 22 – 87). Twenty-eight (60%) and 14 (30%) patients had ER+ and PR+ disease, respectively. Four patients had brain metastasis at time of stage IV diagnosis. All patients received systemic therapy. 17 (36%) patients underwent mastectomy after diagnosis of stage IV breast cancer,. Of the 30 (64%) patients who did not undergo mastectomy, 24 (80%), 2 (7%), and 4 (13%) were treated with both chemotherapy and HER2-directed therapy, chemotherapy alone, and HER2-directed therapy alone, respectively. Breast radiotherapy was performed on 9 (53%) and 8 (27%) patients in mastectomy and no mastectomy cohorts, respectively. Median follow-up time was 22 months . The two-year OS for mastectomy and no mastectomy cohorts were 94% (95% CI: 83 – 100) and 50% (95% CI: 33 – 76), respectively (p=0.009). On univariable analysis, only mastectomy vs no mastectomy (HR: 0.18, 95% CI: 0.04 – 0.80, p=0.025) predicted OS. On multivariable analysis, mastectomy vs no mastectomy has remained to be statistically significant predictor of OS (HR: 0.08, 95% CI: 0.01 – 0.66, p=0.019), whereas age, chemotherapy, HER2-directed therapy, and breast radiation were not independent predictors of improved OS (p>0.05). Conclusions: In our cohort, mastectomy was an independent predictor of longer OS in women with stage IV HER2+ breast cancer.

e14698 Background: Ovarian vein thrombosis (OVT) is a rare condition that is commonly associated with malignancy. Efficacy and safety profile of DOAC in OVT has not been compared with warfarin and low-molecular-weight-heparin in the literature. Methods: We reviewed patients who were diagnosed with OVT between 11/2012 and 1/2018 and had follow-up imaging with computed tomography to assess resolution of thrombus. The outcomes of interests were thrombus resolution, recurrent thromboembolic events, and 1-year cumulative incidence of clinically significant bleeding events. Cumulative incidence was calculated with death and discontinuation of therapeutic anticoagulation as competing risks. Results: We identified 36 patients, 17 (47%) had right, 14 (39%) had left, and 5 (14%) had bilateral OVT. Median age and body mass index at diagnosis were 47 (range: 25 - 86) and 28 (range: 19 – 43), respectively. At least one predisposing factor was identified for 32 (92%) patients, 16 (44%) had underlying active malignancy. Overall, 27 (75%) patients achieved complete or partial recanalization at follow up CT after median of 4 months (range: 1 – 13) from initiation of anticoagulation. Ten (28%) and 11 (31%) patients were treated with DOAC and warfarin after median of 3 and 2 days of anticoagulation with unfractionated heparin or enoxaparin, and follow up CT after median of 6 and 4 months showed complete/partial recanalization rates of 70% and 55%, respectively (p = 0.47). Whereas, 15 patients received enoxaparin and follow up CT after median of 3 months showed that 93% of patients achieved complete/partial recanalization (p = 0.12 between DOAC vs enoxaparin cohorts). Recurrent thromboembolic event has not occurred in any patient during median follow-up of 14 months (range: 3 – 71). One-year cumulative incidence of clinically significant any bleeding for DOAC cohort versus warfarin and enoxaparin cohorts was 10% (95% CI: 9 – 28) versus 18% (95% CI: 12 – 41), p = 0.64, and 25% (95% CI: 4 – 46), p = 0.42, respectively. Conclusions: Apixaban and rivaroxaban showed similar risk-benefit ratio as warfarin and enoxaparin, hence, they can be considered as alternatives for OVT patients.