Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their interrelationship , modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.

Background and Objectives Atrial arrhythmias (AAs) are common after cardiac surgeries including pulmonary thromboendarterectomy (PTE). This study was done to identify patients at highest risk of developing post‐PTE AA and their length of stay (LOS). Methods We reviewed 521 consecutive patients referred to University of California San Diego (UCSD) for PTE and examined their demographics as well as their baseline pulmonary hemodynamics to determine risk factors for AA. Results Overall, 24.2% of patients developed an AA after PTE. Patients who developed AA had a significantly longer Intensive Care Unit (ICU) LOS (median: 5 vs 3 days, P < 0.001) and postoperative LOS (median: 14 vs 9 days; P < 0.001). Patients who developed AA were more frequently male (63.2% male, P = 0.003), older (mean age 60.8 vs 50.7 years, P < 0.001), had a prior history of atrial fibrillation (80.2% of those who developed AA) and were more likely to have undergone concomitant Coronary Artery Bypass Graft (12.7% vs 6.6%, P = 0.028). Compared to those who did not develop AA, the cardiopulmonary bypass time was longer among those who developed AA (261.6 vs 253.8 minutes, P = 0.027). In a multivariate logistic regression model, the preoperative variables that predicted AA were age (odds ratio [OR], 1.058 per year, 95% confidence interval [CI]: 1.038‐1.078), male sex (OR, 1.68, 95% CI: 1.06‐2.64), prior AA (OR, 2.52, 95% CI: 1.23‐5.15) and baseline right atrial pressure (OR, 1.039 per mm Hg, 95% CI: 1.000‐1.079). While mortality rates were similar, patients who developed AA had more bleeding complications and more postoperative delirium. Conclusions AA is common after PTE surgery. The strongest risk factors for AA after PTE included the previous history of AA, age and male sex. Development of AA was associated with longer lengths of stay and more postoperative complications.

No abstract

e16249 Background: Neuroendocrine tumors (NET) have an incidence of around 6.98/100k per year. Long-acting somatostatin receptor agonists (SSA) are first-line therapy for non-resectable disease. In January 2018, the United States FDA approved 177Lu-DOTATATE (PRRT) for second-line therapy in patients with somatostatin receptor-positive GEP-NETs based on the results from NETTER-1 randomized controlled trials. Those trials did not explore frequency of SSA dosing in relation to 177Lu-DOTATATE and its effects on mPFS. Methods: This is a retrospective observational analysis of the safety and efficacy of 177Lu-DOTATATE in treating NETs which progressed on SSA or other second-line therapy, as well as effects on PFS of differential dosing of SSA between PRRT treatments. Organizational IRB approval was obtained. All patients who received 177Lu-DOTATATE at Scripps MD Anderson Cancer Center from 1/2018 to 12/2022 were identified and relevant data were abstracted from the EHR. Patients received 200 mCi of PRRT followed by SSA every 8 weeks for 4 doses. Disease progression was defined as development of new metastases or growth in diameter of existing disease on imaging. Some patients chose to receive SSA between doses of PRRT for symptomatic control every 4 weeks, and these patients were stratified in analysis. For both groups, the mPFS was calculated and plotted on a Kaplan-Meier survival curve and p-values were calculated using the log-rank method. Results: Demographics: 34 patients completed the 4 PRRT doses at our institution. Demographically, our population was similar to NETTER-1 with regards to age (67 ± 12 years) and time since diagnosis (3 years). We included 5 patients with >5% Ki67 staining on pathology. The most common primary site was pancreas in our study compared to ileum in the RCT. Efficacy: The calculated mPFS in our population was 25.4 months (95% CI 11.6 – 43.4), versus in NETTER-1 mPFS had not been reached for the treatment group at 20 months. In our study there was no statistically significant difference in mPFS in patients who had received SSA every 4 weeks versus every 8 weeks (p=0.47). Safety: Symptom-focused side-effects of 177Lu-DOTATATE were not recorded at our center. Only 2 patients were incompletely treated due to measurable toxicities, including a grade 2 thrombocytopenia, and one patient with a grade 2 leukopenia with grade 3 neutropenia. Conclusions: Our population differed from NETTER-1 not only in size but by including patients with >5% Ki67 staining index which may indicate more aggressive disease. No difference was found in mPFS when dosing patients with SSA every 4 weeks compared to every 8, suggesting that interval SSA treatment for symptomatic control may not interfere with 177Lu-DOTATATE efficacy. Our analysis suggests that 177Lu-DOTATATE can be used safely as second-line therapy of NETs at a community-based institution with improved mPFS when compared to the control group studied in the larger NETTER-1 RCT.

Atrial fibrillation/flutter (AF/AFL) is a highly prevalent and important risk factor for stroke. Oral anticoagulation offers significant protection against AF/AFL-related thromboembolic events, but severe adverse events such as hemorrhagic stroke (i.e., subarachnoid and intracerebral hemorrhage) may complicate its use [1,2] . There is a paucity of recent data describing costs and consequences of such events. Thus, we sought to estimate in-hospital mortality, length of stay (LOS) and hospital treatment costs for hemorrhagic stroke admissions among United States (US) AF/AFL patients. Material and MethodsThis study used the Agency for Healthcare Research and Quality's (AHRQ's) National Inpatient Sample (NIS) database for the years 2008-2011. The NIS provides a nationally representative ~20% sample of US hospitals and their admissions [3] . We identified adult AF/AFL patients with an International Classification of Diseases, ninth-edition (ICD-9) code of 427.31 or 427.32 (any position) and a primary diagnosis code of 431 or 430 for subarachnoid or intracerebral hemorrhage, respectively. Patients not admitted through the emergency department or transfers from an outside facility were excluded. Endpoints of interest included in-hospital mortality, LOS and hospital treatment costs (in 2015 US dollars). Since all data were de-identified the study did not require institutional review board oversight.