Deciding between palliative and overly aggressive therapies for advanced cancer patients who present to the emergency department (ED) with acute issues requires a prediction of their short-term survival. Various scoring systems have previously been studied in hospices or intensive care units, though they are unsuitable for use in the ED. We aim to examine the use of a shock index (SI) in predicting the 60-day survival of advanced cancer patients presenting to the ED. Identified high-risk patients and their families can then be counseled accordingly. Three hundred and five advanced cancer patients who presented to the EDs of three tertiary hospitals were recruited, and their data retrospectively analyzed. Relevant data regarding medical history and clinical presentation were extracted, and respective shock indices calculated. Multivariate logistic regression analyses were performed. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of the SI. Nonsurvivors within 60 days had significantly lower body temperatures and blood pressure, as well as higher pulse rates, respiratory rates, and SI. Each 0.1 SI increment had an odds ratio of 1.39 with respect to 60-day mortality. The area under the ROC curve was 0.7511. At the optimal cut-off point of 0.94, the SI had 81.38% sensitivity and 73.11% accuracy. This makes the SI an ideal evaluation tool for rapidly predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. Identified patients can be counseled accordingly, and they can be assisted in making informed decisions on the appropriate treatment goals reflective of their prognoses.

Advanced cancer patients who are not expected to survive past the short term can benefit from early initiation of palliative care in the emergency department (ED). This discussion, however, requires accurate prognostication of their short-term survival. We previously found in our retrospective study that shock index (SI) is an ideal risk stratification tool in predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. This study is a follow-up prospective validation study conducted from January 2019 to April 2021. A total of 410 advanced cancer patients who presented to the ED of a medical centre and could be followed-up feasibly were recruited. Univariate and multivariable logistic regression analyses were performed with receiver operator calibrating (ROC) curve analysis. Non-survivors had significantly lower body temperatures, higher pulse rates, higher respiratory rates, lower blood pressures, and higher SI. Each 0.1 increment of SI increased the odds of 60-day mortality by 1.591. Area under ROC curve was 0.7819. At optimal cut-off of 0.94, SI had 66.10% accuracy. These results were similar to our previous study, thus validating the use of SI in predicting the 60-day mortality of advanced cancer patients presenting to the ED. Identified patients may be offered palliative care.

BackgroundThe OuTcomes Associated with taPering biologics among patiEnts with Rheumatoid arthritis (TAPER) is a retrospective chart review study to assess real-world implication of Taiwan policy on tapering/withdrawing biologics in stable rheumatoid arthritis (RA) patients.1ObjectivesTo assess RA flare rates before and after anti-TNF dose tapering and to identify predictors of flaring upon tapering.MethodsMedical chart data were collected from RA patients tapering adalimumab (ADA) or etanercept (ETN) (methods described elsewhere).1 RA flares were assessed for 6-month pre-tapering, and for short-term (6 months) and longer-term (12 to 18 months) post-tapering. Three alternative flare definitions were used: 1) TAPER: defined a priori the Institutional Review Board submission as a) increase in DAS28≥1.2, b) increase in number of swollen/tender joints, or c) use of injectable steroids during outpatient/ER visits; 2) OMERACT: a) increase in DAS28>1.2, or b) increase in DAS28>0.6 if prior DAS28≥3.2; and 3) Taiwan National Health Insurance Administration: a) increase in DAS28≥1.2 and b) erythrocyte sedimentation rate (ESR) >25mm/h and c) increase in ESR>25%. Logistic regression models were developed to identify factors significantly associated with post-tapering flare.ResultsData came from medical charts of 261 patients (ADA=40.6%; ETN=59.4%). More than half patients had a 12- to 18-month follow-up (58.6%: ADA=40.5%; ETN=59.5%). All three flare criteria showed that a greater proportion of patients had flare post-tapering (see table). During the short-term post-tapering, the risk factors of flaring included a longer disease duration (odds ratio=1.05, p=0.049) and having prior concomitant therapy on Cox-2 inhibitors (OR=2.61, p=0.003); being in remission (DAS28<2.6) prior to tapering was associated with a reduced risk (OR=0.41, p=0.037). Over a longer-term, a longer disease duration (OR=1.13, p=0.028) and having a flare within 6-month post-tapering were associated with an increased risk of flaring (OR=9.99, p<0.001).ConclusionsCareful considerations are needed when tapering a biologic in stable RA patients in order to avoid potentially increased risk of disease flaring. This could include assessing disease duration and remission status prior to tapering, and whether there is a flare within 6-month of tapering when considering for in long-term.ReferencesJ Rheum Dis 2015;18(Suppl1):22Disclosure of InterestC. Chang: None declared, K. Chen: None declared, Y. Chen: None declared, T. Cheng: None declared, P. Hsu: None declared, N. Lai: None declared, J. Lan: None declared, C. Lee: None declared, S. Lee: None declared, H. Lin: None declared, G. Tsay: None declared, J. Yen: None declared, C. Tsai Shareholder of: AbbVie, Employee of: AbbVie, V. Garg Shareholder of: AbbVie, Employee of: AbbVie, Y. Bao Shareholder of: AbbVie, Employee of: AbbVie, M. Yang Employee of: Analysis Group, E. Wu Employee of: Analysis Group

BackgroundThe OuTcomes Associated with taPering biologics among patiEnts with Rheumatoid arthritis (TAPER) study is a multicenter retrospective chart review to assess real-world implication of the Taiwan National Health Insurance Administration policy on tapering and withdrawing biologics in stable rheumatoid arthritis (RA) patients.ObjectivesTo assess the clinical and health resource utilization (HRU) outcomes associated with dose tapering and withdrawing of biologics among stable RA patients.MethodsMedical chart data were collected from RA patients tapering adalimumab (ADA) or etanercept (ETN) who had been on the treatment for ≥2 years prior to tapering. RA disease flares and HRU were assessed for the 6-month pre-tapering period, and for the 6-month short-term and up to 18-month longer-term post-tapering periods. A flare was defined a priori as any of the following: 1) an increase in DAS28 ≥1.2; 2) an increase in the number of swollen/tender joints; or 3) use of injectable steroids during outpatient or emergency room (ER) visits.ResultsData were collected from medical charts of 261 patients (ADA=106, 40.6%; ETN=155, 59.4%). The majority were female (76.2%), with a mean age of 57.2±13.0 years, and an average RA duration of 10.1±5.6 years. Hypertension (31.4%), osteoporosis (19.2%), other autoimmune diseases (16.9%), and dyslipidemia (14.2%) were the most common comorbidities. More than half of the patients had a longer-term follow-up between one year and18 months (58.6%: ADA=62, 40.5%; ETN=91, 59.5%). The majority of ADA patients were tapered to 40mg every three weeks (63.6%) or 40mg every four weeks (30.8%); most ETN patients were tapered to 25mg every 5 days (49.4%) or once a week (30.5%). Greater proportions of patients had an RA flare post-tapering (pre-tapering: 20.7%; post-tapering short-term: 44.1%; post-tapering longer-term: 73.9%). When compared to the pre-tapering period, the mean RA flare events per patient per year increased substantially post-tapering (pre-tapering: 0.5; post-tapering short-term: 1.2; post-tapering longer-term: 1.6, all p<0.001). Patients had increased office visits during the short-term (pre: 1.2 vs. post: 1.4 per patient per month, p<0.001).ConclusionsTapering biologic agents among stable RA patients may lead to an increase in RA flare and an increase in outpatient visits.Disclosure of InterestC. Chang: None declared, K. Chen: None declared, Y. Chen: None declared, T. Cheng: None declared, P. Hsu: None declared, N. Lai: None declared, J. Lan: None declared, C. Lee: None declared, S. Lee: None declared, H. Lin: None declared, G. Tsay: None declared, J. Yen: None declared, C. Tsai Shareholder of: AbbVie, Employee of: AbbVie, Y. Bao Shareholder of: AbbVie, Employee of: AbbVie, M. Skup Shareholder of: AbbVie, Employee of: AbbVie, M. Yang Employee of: Analysis Group, E. Wu Employee of: Analysis Group, V. Garg Shareholder of: AbbVie, Employee of: AbbVie

Point-of-care ultrasonography (POCUS) has become the most popular modality of testing for physicians in recent years and is used for improving the quality of care and increasing patient safety. However, POCUS is not always acceptable to all physicians. To address the benefits and importance of POCUS, numerous studies have examined the use of POCUS in clinical practice and even medical education. This article aims to highlight the effects of POCUS as an extension of the physical examination, and we present a case to address the reasons it should be performed. For a man experiencing abdominal pain immediately after his feeding jejunostomy tube was changed, there was high suspicion of small-bowel volvulus after a “whirlpool sign” was observed during the POCUS, whereby mesenteric vessels presented in a whirling or spiral shape. This impression was subsequently confirmed by computed tomography. Small-bowel volvulus is a rare complication of changing a feeding jejunostomy tube. The images submitted here add to the sparse evidence from the literature on the use of POCUS as an extension of the physical examination for evaluating abdominal pain. POCUS can be used after taking the patient’s history and conducting a physical examination. The observation of a whirlpool sign may indicate the presence of a volvulus that is life-threatening.