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Risk Stratification of Patients With Syncope  

Microsoft Academic Search

See related editorial p 540.Study objective: To develop and validate a risk classification system for patients presenting to emergency departments with syncope. Methods: Two prospective studies were carried out at a large urban teaching hospital ED. One cohort of 252 patients with syncope who reported to the ED was used to develop the risk classification system; a second cohort of

Thomas P Martin; Barbara H Hanusa; Wishwa N Kapoor



Risk stratification of rhabdomyosarcoma.  


Known prognostic factors for rhabdomyosarcoma include primary site, stage, group (amount of tumor remaining after initial surgery before chemotherapy), lymph node involvement, age, and histology. These factors are taken into account when determining risk stratification for treatment allocation, with some differences between the European and U.S. approaches. The relationship of fusion status for PAX-3 of PAX-7 FOXO1 to outcome has been analyzed by a number of groups, but many of the studies are troubled by problems inherent in the use of convenience cohorts and the fact that patients in the analyzed groups are not always treated in a uniform fashion. One recent study analyzed outcome of patients treated in a similar fashion on the same protocol and found that patients with alveolar histology who were fusion negative had an outcome similar to those with embryonal histology. This article reviews many of the studies surrounding fusion status and outcome, risk stratification issues, and outcome of risk groups. The time is rapidly approaching in which fusion status will be used to allocate therapy for rhabdomyosarcoma. PMID:23714563

Arndt, Carola A S



Lagged segmented Poincaré plot analysis for risk stratification in patients with dilated cardiomyopathy.  


The objectives of this study were to introduce a new type of heart-rate variability analysis improving risk stratification in patients with idiopathic dilated cardiomyopathy (DCM) and to provide additional information about impaired heart beat generation in these patients. Beat-to-beat intervals (BBI) of 30-min ECGs recorded from 91 DCM patients and 21 healthy subjects were analyzed applying the lagged segmented Poincaré plot analysis (LSPPA) method. LSPPA includes the Poincaré plot reconstruction with lags of 1-100, rotating the cloud of points, its normalized segmentation adapted to their standard deviations, and finally, a frequency-dependent clustering. The lags were combined into eight different clusters representing specific frequency bands within 0.012-1.153 Hz. Statistical differences between low- and high-risk DCM could be found within the clusters II-VIII (e.g., cluster IV: 0.033-0.038 Hz; p = 0.0002; sensitivity = 85.7 %; specificity = 71.4 %). The multivariate statistics led to a sensitivity of 92.9 %, specificity of 85.7 % and an area under the curve of 92.1 % discriminating these patient groups. We introduced the LSPPA method to investigate time correlations in BBI time series. We found that LSPPA contributes considerably to risk stratification in DCM and yields the highest discriminant power in the low and very low-frequency bands. PMID:22689265

Voss, Andreas; Fischer, Claudia; Schroeder, Rico; Figulla, Hans R; Goernig, Matthias



Value of planar 201Tl imaging in risk stratification of patients recovering from acute myocardial infarction  

SciTech Connect

Although exercise ECG testing has been shown to have important prognostic value after acute myocardial infarction, exercise 201Tl scintigraphy offers several potential advantages, including: (1) increased sensitivity for detecting residual myocardial ischemia; (2) the ability to localize ischemia to a specific area or areas subtended by a specific coronary artery; (3) the ability to identify exercise-induced left ventricular dysfunction, which is manifested by increased lung uptake or transient left ventricular dilation; and (4) more reliable risk stratification of individual patients. The more optimal prognostic efficiency of 201Tl scintigraphy partially results from the fact that the error rate in falsely classifying patients as low risk is significantly smaller with 201Tl scintigraphy than with stress ECG. Because of these substantial advantages, there seems to be adequate rationale for recommending exercise perfusion imaging rather than exercise ECG alone as the preferred method for evaluating mortality and morbidity risks after acute myocardial infarction.

Gibson, R.S.; Watson, D.D. (Medical Center, University of Virginia Health Sciences Center, Charlottesville (United States))



Risk Stratification of ICU Patients Using Topic Models Inferred from Unstructured Progress Notes  

PubMed Central

We propose a novel approach for ICU patient risk stratification by combining the learned “topic” structure of clinical concepts (represented by UMLS codes) extracted from the unstructured nursing notes with physiologic data (from SAPS-I) for hospital mortality prediction. We used Hierarchical Dirichlet Processes (HDP), a non-parametric topic modeling technique, to automatically discover “topics” as shared groups of co-occurring UMLS clinical concepts. We evaluated the potential utility of the inferred topic structure in predicting hospital mortality using the nursing notes of 14,739 adult ICU patients (mortality 14.6%) from the MIMIC II database. Our results indicate that learned topic structure from the first 24-hour ICU nursing notes significantly improved the performance of the SAPS-I algorithm for hospital mortality prediction. The AUC for predicting hospital mortality from the first 24 hours of physiologic data and nursing text notes was 0.82. Using the physiologic data alone with the SAPS-I algorithm, an AUC of 0.72 was achieved. Thus, the clinical topics that were extracted and used to augment the SAPS-I algorithm significantly improved the performance of the baseline algorithm.

Lehman, Li-wei; Saeed, Mohammed; Long, William; Lee, Joon; Mark, Roger



Risk stratification of patients with hypertension using exercise thallium-201 scintigraphy  

SciTech Connect

Hypertension (HT) is an important risk factor in coronary heart disease (CHD) and cardiac morbidity and mortality. This study examined the value of clinical, ECG, exercise (EX) and thallium-201 imaging descriptors that identify patients (pts) with HT at high risk. The 337 pts in the study underwent EX thallium-201 testing for evaluation of chest pain due to suspected or proven CHD. The mean age was 55 years, of whom 79% were still on active anti-HT therapy at the time of the study. The EX thallium scintigrams were evaluated qualitatively and quantitively using circumferential profile analysis. The scans were abnormal in 162 pts (48%) and reversible perfusion defects were present in 106 of the 162 pts (65%). At a folllowup fo up to 74 months, (15 +- 9 mean +- SD), 11 pts had hard cardiac events: 2 died of cardiac causes and 9 had non-fatal acute myocardial infractions. There were no significant differences between those with and without events in age, EX heart rate and double product, EX duration, blood pressure and EX ECG changes. Univariate and multivariate survival analysis (Cox regression model) of important clinical, ECG, EX and thallium variables, identified the presence of abnormal EX images as the only predictor of outcome. (X/sup 2/ = 5.4, p< 0.02). No other variable provided additional prognostic information. Actuarial life table analysis showed that pts with abnormal images had significantly more events than those with normal images (p = 0.008, Mantel-Cox). Thus, EX thallium imaging is useful in risk stratification in pts with HT. The presence of abnormal images identify a subgroup at high risk for future events.

Iskandrian, A.S.; Hakki, A.H.; Kane, S.



Risk Stratification by the \\  

Microsoft Academic Search

The identification of risks associated with sudden cardiac death requires further investigations. The question was addressed whether parameters can be established which not only de- scribe an increased risk for an enhanced electrical instability of the heart but also of inflammatory events underlying plaque rupture. Emphasis is placed on dose-dependent effects of the long-chain omega-(?-)3 fatty acids eicosapentaenoic acid (EPA)

Heinz Rupp; Daniela Wagner; Thomas Rupp; Lisa-Maria Schulte; Bernhard Maisch


Risk stratification models and mutational analysis: keys to optimising adjuvant therapy in patients with gastrointestinal stromal tumour.  


Imatinib is a standard of care in the adjuvant treatment of patients with resected gastrointestinal stromal tumour (GIST). Two important trials have shown a reduction in GIST recurrence rates for patients treated with imatinib 400 mg daily for 1 year; one of these trials also demonstrated a significant improvement in overall survival for patients with GIST at high risk of recurrence who were treated for 3 years. However, not all patients will benefit from adjuvant treatment. Considering the patient types in both trials, treatment decisions must take into account a number of factors including risk of recurrence and mutational status. Tumour characteristics including tumour size, location and mitotic index are the main prognostic factors of recurrence-free survival (RFS) after surgical resection of GISTs. Research, much of it in the advanced/metastatic setting, shows that mutational analysis is definitely predictive of treatment efficacy and probably prognostic of RFS. Patients on imatinib whose tumours harbour mutations in exon 11 of the KIT gene tend to have superior RFS compared with patients with exon 9 mutations. In contrast, patients with wild-type GIST often have disease that follows an indolent course and has limited sensitivity to imatinib in most cases. As such, increased use of existing risk-stratification schemes and mutational analysis will be essential for optimising tailored treatment approaches. In this review, the development and prognostic/predictive utility of key risk stratification tools and mutational analysis of GIST are discussed herein with the goal of facilitating adjuvant treatment decisions for patients with GIST. PMID:23206668

Gronchi, Alessandro



Risk stratification of acute pulmonary embolism.  


Acute pulmonary embolism (PE) is a potentially life-threatening condition, with an overall 3-month mortality rate of 15% and with right ventricular failure as the most common cause of early death. Risk stratification facilitates identification of high-risk patients and may be helpful in guiding the initial and long-term management. In patients with massive PE and hemodynamic instability, rapid risk assessment is paramount and bedside echocardiography and multislice chest computed tomography (CT) are useful for identifying patients who may benefit from thrombolysis or embolectomy. Cardiac biomarkers, including troponin and the natriuretic peptides, are sensitive markers of right ventricular function. Low levels of troponin, B-type natriuretic peptide (BNP), and NT-terminal proBNP are all highly sensitive assays for identifying patients with an uneventful clinical course. Multislice chest CT is not only useful to diagnose or exclude PE; it also is useful for risk assessment. A right-to-left ventricular dimension ratio > 0.9 on the reconstructed CT four-chamber view identifies patients at increased risk of early death. This article focuses on risk stratification tools, including the clinical examination, electrocardiography, echocardiography, cardiac biomarkers, and chest CT. PMID:17171598

Kucher, Nils; Goldhaber, Samuel Z



Current status of risk stratification methods in acute coronary syndromes  

Microsoft Academic Search

Distinguishing which patients with chest pain are at high risk versus which are at low risk remains an important clinical\\u000a problem despite modern risk stratification strategies. Current approaches often over-utilize hospital resources, yet still\\u000a miss a significant number of true acute coronary syndromes (ACS). This review focuses on important developments in risk stratification\\u000a in ACS from 2004 through 2005. Risk

Raphael See; James A. de Lemos



The risk stratification in atrial fibrillation.  


Atrial fibrillation (AF) is the most common rhythm disorder and represents a major public health problem because it carries an increased risk of arterial thromboembolism and ischemic stroke. Because the absolute benefit of antithrombotic therapy depends on the underlying risk of stroke, an accurate stratification of patients' risk is needed to choose the appropriate antithrombotic strategy. Over the years, several stroke risk stratification models (RSMs) were developed based on the 'classic' risk factors for stroke such as increasing age, hypertension, diabetes mellitus, and left ventricular dysfunction. Among all RSMs, the CHADS(2) score is the most popular and used one thanks to its simplicity and endorsement in several widely promulgated practice guidelines. Despite its validation in large datasets and specific population of AF patients, it has many limitations, especially due to the non-inclusion of several proven risk factors for stroke and to the classification of a large number of patients in the intermediate risk category, so creating ambiguity over the most appropriate antithrombotic therapy. Thus, the CHA(2)DS(2)-VASc score was introduced and was demonstrated to perform better than the CHADS(2), even in a "real world" population of elderly AF patients. Recently, in view of the availability of new oral anticoagulant drugs, that can overcome the limitations of warfarin and allow a more personalized therapy, many efforts are being made to identify other possibilities to assess the thromboembolic risk in AF patients. It has been demonstrated that an increase in C-reactive protein and interleukin-6 and the presence of G20210A factor II gene polymorphism and hyper-homocysteinemia are independent risk factors for ischemic complications in AF patients. Even the presence of chronic renal disease and the daily AF burden, registered with implantable monitors, are associated with an increase risk of stroke. Finally, the assessment of thromboembolic risk should go hand in hand with the consideration of the risk of bleeding. For this purpose, it has been recently developed a practical bleeding risk score, the HAS-BLED, which was included in the last ESC guidelines for the risk stratification of AF patients before starting anticoagulant therapy. PMID:23073863

Prisco, Domenico; Cenci, Caterina; Silvestri, Elena; Emmi, Giacomo; Barnini, Tommaso; Tamburini, Carlo



Linear and nonlinear heart rate variability risk stratification in heart failure patients  

Microsoft Academic Search

Chronic heart failure (CHF) is a major and growing public health concern (~23 million people worldwide) with five-year survival rates of 25% in men and 38% in women. Objective of this study was to investigate whether linear and nonlinear heart rate variability (HRV) indices enhance risk prediction in patients with CHF. To discriminate between low risk (stable condition, N =

A. Voss; R. Schroeder; M. Vallverdu; I. Cygankiewicz; R. Vazquez; A. Bayes de Luna; P. Caminal



Risk stratification theme for congenital heart surgery  

Microsoft Academic Search

Surgical practice is changing and auto-evaluation of quality of care, organized by scientific societies, is very likely to become an obligation during this new decade. This evaluation requires a common nomenclature, a registry, and risk stratification. The primary purpose of risk stratification is to offer the possibility of objective analysis of surgical outcomes according to the complexity of the pathology



Perioperative cardiovascular risk stratification of patients with diabetes who undergo elective major vascular surgery  

Microsoft Academic Search

Background: The importance of diabetes mellitus (DM) as an independent risk factor for perioperative cardiac morbidity after vascular surgery is controversial. This study examined the impact of DM on perioperative outcomes and length of stay in patients who underwent major vascular surgery. Methods: Patients who underwent elective aortic reconstruction (n = 2792), lower extremity bypass (n = 3838), carotid endarterectomy

David A. Axelrod; Gilbert R. Upchurch Jr; Sonya DeMonner; James C. Stanley; Shukri Khuri; Jennifer Daley; William G. Henderson; Rodney Hayward



Risk stratification after myocardial infarction. Clinical overview  

SciTech Connect

Many patients with an acute myocardial infarction can be stratified into subgroups that are at high risk for morbidity and mortality on the basis of clinical characteristics that indicate recurrent myocardial ischemia, persistent left ventricular dysfunction, and/or recurrent cardiac arrhythmias. In patients with uncomplicated myocardial infarction the assessment of symptoms, physical findings, and ECG changes during predischarge exercise testing often identifies patients at increased risk for further cardiac events. Because of the suboptimum sensitivity and specificity of the exercise ECG for detecting myocardial ischemia, myocardial perfusion imaging with 201Tl and/or assessment of global and segmental ventricular function by two-dimensional echocardiography or radionuclide cineangiography during or immediately after exercise are often added to the predischarge risk stratification.

O'Rourke, R.A. (Department of Medicine, University of Texas Health Science Center, San Antonio (United States))



Meta-analysis of optimal risk stratification in patients >65 years of age.  


This meta-analysis evaluated the optimal noninvasive strategy for cardiac risk assessment of patients >65 years of age with known or suspected coronary artery disease using the available literature. Patients >65 years of age constitute a growing proportion of the population and have higher cardiovascular morbidity and mortality, but an optimal strategy to predict the risk of cardiac events in this group is unknown. A systematic search of MEDLINE was performed for cohort studies of ?100 patients >65 years old with ?12 months of follow-up that reported cardiac death and/or nonfatal myocardial infarction after any of stress myocardial perfusion imaging (MPI), stress echocardiography, or exercise tolerance testing (ETT) for known or suspected coronary artery disease. Pooled annualized event rates were calculated for each technique. Summary odds ratios (ORs) between normal and abnormal test results were calculated using a random-effects model. Seventeen studies (MPI 7, stress echocardiography 7, ETT 3) in 13,304 patients (mean age 75.5 years) were included. Abnormal compared to normal stress MPI (OR 11.8, 95% confidence interval [CI] 7.5 to 18.7) and stress echocardiography (OR 3.2, 95% CI 2.6 to 3.9) accurately stratified risk in patients. However, patients with abnormal and normal ETT results had similar cardiac event rates (OR 3.1, 95% CI 0.8 to 11.5). In conclusion, stress imaging with MPI or stress echocardiography effectively stratified risk in patients, whereas ETT alone did not. PMID:22795509

Rai, Mridula; Baker, William Leslie; Parker, Matthew Wayne; Heller, Gary Vashon



Risk stratification and prognosis of patients treated with amiodarone for malignant ventricular tachyarrhythmias after myocardial infarction  

Microsoft Academic Search

Seventy-seven consecutive patients (mean age 62 years) with episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) after acute myocardial infarction (AMI) were evaluated to assess the long-term efficacy of first-line amiodarone treatment and to identify clinical and laboratory factors associated with a high risk of death or arrhythmia recurrence. The presenting arrhythmia was VT in 41 cases (53%)

Alessandro Proclemer; Domenico Facchin; Diego Vanuzzo; Giorgio Antonio Feruglio



Pulmonary embolism risk stratification: the intermediate-risk group.  


Despite all the advances on acute pulmonary embolism risk stratification, a grey area still justifies ongoing debate. Although growing scientific evidence has clarified the extremes of pulmonary embolism risk continuum and has given support to every day's clinical practice decisions, on who may be sent home or needs promptly aggressive measures, the intermediate-risk pulmonary embolism patients are still a challenging group. Moreover, recent studies reported most interesting findings, exposing weaknesses of traditional markers of pulmonary embolism prognosis (e.g. right-ventricular dysfunction), and shed some light on how we can potentially overcome the difficulties of risk assessment in these cases. Our intention is to briefly discuss the recent developments in pulmonary embolism risk stratification, aiming at clarifying their usefulness in current pulmonary embolism management. PMID:24176951

Paiva, Luis; Barra, Sérgio; Providência, Rui



Risk stratification and dental management of the patient with thyroid dysfunction.  


The thyroid gland produces hormones critical to the maintenance of the cellular metabolic rate. The actions of these hormones are far-reaching, affecting thermoregulation and calorigenesis; the metabolism of carbohydrates, fats, and proteins; and oxygen utilization. Thyroid hormones also appear to act synergistically with epinephrine and enhance tissue sensitivity to catecholamines. Signs and symptoms of hypothyroidism include listlessness, fatigue, cold intolerance, dry skin, hair loss, constipation, weight gain, muscle soreness, and slow heart rate. Signs and symptoms of hyperthyroidism include irritability, heat intolerance, tremors, increased sweating, frequent bowel movements, and quickened heart rate. The effect of inadequately treated or undiagnosed hyperthyroidism on the heart carries perioperative risks. To provide competent dental care to patients with thyroid dysfunction, clinicians must understand the disease, its treatment, and the impact the disease and its treatment may have on the patient's ability to undergo and respond to dental care. PMID:18560652

Huber, Michaell A; Terézhalmy, Géza T



Risk stratification in the hormonal treatment of patients with prostate cancer  

PubMed Central

Prostate cancer (PCa) is the most common type of cancer found in American men, other than skin cancer. The American Cancer Society estimates that there will be 186,320 new cases of prostate cancer in the United States in 2008. About 28,660 men will die of this disease this year and PCa remains the second-leading cause of cancer death in men. One in six men will get PCa during his lifetime and one in 35 will die of the disease. Today, more than 2 million men in the United States who have had PCa are still alive. The death rate for PCa continues to decline, chiefly due to early detection and treatment, and improved salvage therapy such as hormone therapy (HT). HT continues to be a mainstay for primary-recurrent PCa and locally-advanced PCa. However, HT is associated with many undesirable side effects including sexual dysfunction, osteoporosis and hot flashes, all of which can lead to decreased quality of life (QOL). These risks are seen in both long- and short-term HT regimens. Additionally, research in recent years has revealed trends related to clinico pathological variables and their predictive ability in HT outcomes. Awareness of the potential adverse effects, the risks associated with HT and the prognostic ability of clinical and pathological variables is important in determining optimal therapy for individual patients. A rigorous evaluation of the current scientific literature associated with HT was conducted with the goal of identifying the most favorable balance of benefits and risks associated with HT.

Uhlman, Matthew A.; Moul, Judd W.; Tang, Ping; Stackhouse, Danielle A.; Sun, Leon



Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis.  


Aims Abnormal exercise test defined as the occurrence of exercise limiting symptoms, fall in blood pressure below baseline, or complex ventricular arrhythmias is useful to predict clinical events in asymptomatic patients with aortic stenosis (AS). The purpose of this study was to determine whether exercise-stress echocardiography (ESE) adds any incremental prognostic value to resting echocardiography in patients with AS having a normal exercise response. Methods and results One hundred and eighty-six asymptomatic patients with at least moderate AS and preserved LV ejection fraction (>/=50%) were assessed by Doppler-echocardiography at rest and during a maximum ramp semi-supine bicycle exercise test. Fifty-one (27%) patients had an abnormal exercise test and were excluded from the present analysis. Among the 135 patients with normal exercise test, 67 had an event (aortic valve replacement motivated by symptoms or cardiovascular death) at a mean follow-up of 20 +/- 14 months. The variables independently associated with events were: age >/=65 years [hazard ratio (HR) = 1.96; 95% confidence interval (CI): 1.15-3.47; P = 0.01], diabetes, (HR = 3.20; 95% CI: 1.33-6.87; P = 0.01), LV hypertrophy (HR = 1.96; 95% CI: 1.17-3.27; P = 0.01), resting mean gradient >35 mmHg (HR = 3.60; 95% CI: 2.11-6.37; P < 0.0001), and exercise-induced increase in mean gradient >20 mmHg (HR = 3.83; 95% CI: 2.16-6.67; P < 0.0001). Conclusion The exercise-induced increase in transvalvular gradient may be helpful to improve risk stratification in asymptomatic AS patients with normal exercise response. These results thus suggest that ESE may provide additional prognostic information over that obtained from standard exercise testing and resting echocardiography. PMID:20308041

Maréchaux, Sylvestre; Hachicha, Zeineb; Bellouin, Annaïk; Dumesnil, Jean G; Meimoun, Patrick; Pasquet, Agnès; Bergeron, Sébastien; Arsenault, Marie; Le Tourneau, Thierry; Ennezat, Pierre Vladimir; Pibarot, Philippe



Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis  

PubMed Central

Aims Abnormal exercise test defined as the occurrence of exercise limiting symptoms, fall in blood pressure below baseline, or complex ventricular arrhythmias is useful to predict clinical events in asymptomatic patients with aortic stenosis (AS). The purpose of this study was to determine whether exercise-stress echocardiography (ESE) adds any incremental prognostic value to resting echocardiography in patients with AS having a normal exercise response. Methods and results One hundred and eighty-six asymptomatic patients with at least moderate AS and preserved LV ejection fraction (?50%) were assessed by Doppler-echocardiography at rest and during a maximum ramp semi-supine bicycle exercise test. Fifty-one (27%) patients had an abnormal exercise test and were excluded from the present analysis. Among the 135 patients with normal exercise test, 67 had an event (aortic valve replacement motivated by symptoms or cardiovascular death) at a mean follow-up of 20 ± 14 months. The variables independently associated with events were: age ?65 years [hazard ratio (HR) = 1.96; 95% confidence interval (CI): 1.15–3.47; P = 0.01], diabetes, (HR = 3.20; 95% CI: 1.33–6.87; P = 0.01), LV hypertrophy (HR = 1.96; 95% CI: 1.17–3.27; P = 0.01), resting mean gradient >35 mmHg (HR = 3.60; 95% CI: 2.11–6.37; P < 0.0001), and exercise-induced increase in mean gradient >20 mmHg (HR = 3.83; 95% CI: 2.16–6.67; P < 0.0001). Conclusion The exercise-induced increase in transvalvular gradient may be helpful to improve risk stratification in asymptomatic AS patients with normal exercise response. These results thus suggest that ESE may provide additional prognostic information over that obtained from standard exercise testing and resting echocardiography.

Marechaux, Sylvestre; Hachicha, Zeineb; Bellouin, Annaik; Dumesnil, Jean G.; Meimoun, Patrick; Pasquet, Agnes; Bergeron, Sebastien; Arsenault, Marie; Le Tourneau, Thierry; Ennezat, Pierre Vladimir; Pibarot, Philippe



Early risk stratification of patients with a first inferior wall acute myocardial infarction  

Microsoft Academic Search

A prognostic index based on admission characteristics of patients with inferior acute myocardial infarction was developed to predict mortality and other major complications during hospitalization. The study sample included 1841 consecutive patients with a first inferior wall acute myocardial infarction, hospitalized in 13 out of 21 operating coronary care units in Israel. Age, angina in the past, congestive heart failure

Micha S Feinberg; Valentina Boyko; Uri Goldbourt; Henrietta Reicher-Reiss; Lori Mandelzweig; Monty Zion; Elieser Kaplinsky; Solomon Behar



Assessment of noninvasive markers in identifying patients at risk in the brugada syndrome: insight into risk stratification  

Microsoft Academic Search

OBJECTIVESThe aim of this study was to compare the use of various noninvasive markers for detecting risk of life-threatening arrhythmic events in patients with Brugada syndrome.BACKGROUNDThe role of conduction disturbance in arrhythmogenesis of the syndrome is controversial, whereas it is well established that repolarization abnormalities are responsible for arrhythmias. The value of noninvasive markers reflecting conduction or repolarization abnormalities in

Takanori Ikeda; Harumizu Sakurada; Koichi Sakabe; Takao Sakata; Mitsuaki Takami; Naoki Tezuka; Takeshi Nakae; Mahito Noro; Yoshihisa Enjoji; Tamotsu Tejima; Kaoru Sugi; Tetsu Yamaguchi



Risk Stratification and Prevention of Sudden Death in Patients with Heart Failure  

Microsoft Academic Search

Opinion statement  For almost the past decade, recommendations for the use of implantable cardioverter defibrillators (ICDs) for primary prevention\\u000a of sudden cardiac death have been based upon the left ventricular ejection fraction (LVEF). Current guidelines recommend an\\u000a ICD for heart failure patients with LVEF ?35% and NYHA functional class of II or III; however, because the majority of heart\\u000a failure patients

Moustafa Banna; Julia H. Indik


Lipoprotein-associated phospholipase A 2 for early risk stratification in patients with suspected acute coronary syndrome: a multi-marker approach  

Microsoft Academic Search

Aims\\u000a   Numerous markers have been identified as useful predictors of major adverse cardiac events (MACE) in patients with suspected\\u000a acute coronary syndrome (ACS). However, only little is known about the relative benefit of the single markers in risk stratification\\u000a and the best combination for optimising prognostic power.\\u000a \\u000a The aim of the present study was to define the role of the

M. Möckel; Reinhold Müller; Jörn O. Vollert; Christian Müller; Oilver Danne; Ragnar Gareis; Thomas Störk; Rainer Dietz; Wolfgang Koenig



Cardiac risk stratification: Role of the coronary calcium score  

PubMed Central

Coronary artery calcium (CAC) is an integral part of atherosclerotic coronary heart disease (CHD). CHD is the leading cause of death in industrialized nations and there is a constant effort to develop preventative strategies. The emphasis is on risk stratification and primary risk prevention in asymptomatic patients to decrease cardiovascular mortality and morbidity. The Framingham Risk Score predicts CHD events only moderately well where family history is not included as a risk factor. There has been an exploration for new tests for better risk stratification and risk factor modification. While the Framingham Risk Score, European Systematic Coronary Risk Evaluation Project, and European Prospective Cardiovascular Munster study remain excellent tools for risk factor modification, the CAC score may have additional benefit in risk assessment. There have been several studies supporting the role of CAC score for prediction of myocardial infarction and cardiovascular mortality. It has been shown to have great scope in risk stratification of asymptomatic patients in the emergency room. Additionally, it may help in assessment of progression or regression of coronary artery disease. Furthermore, the CAC score may help differentiate ischemic from nonischemic cardiomyopathy.

Sharma, Rakesh K; Sharma, Rajiv K; Voelker, Donald J; Singh, Vibhuti N; Pahuja, Deepak; Nash, Teresa; Reddy, Hanumanth K



Carotid ultrasound is useful for the cardiovascular risk stratification of patients with rheumatoid arthritis: results of a population-based study.  


OBJECTIVE: To determine if the use of carotid ultrasonography (US) may improve the stratification of the cardiovascular (CV) risk in rheumatoid arthritis (RA). METHODS: A set of 370 consecutive patients without history of CV events were studied to assess carotid intima-media thickness (cIMT) and plaques. As previously proposed, CV risk was calculated according to the modified EULAR systematic coronary risk evaluation (mSCORE) for RA that was adapted by the application of a multiplier factor of 1.5 in those patients fulfilling ?2 of 3 specific criteria. RESULTS: The mean disease duration was 9.8 years, 250 (68%) had rheumatoid factor/anticyclic citrullinated peptide positivity and 61 (17%) extra-articular manifestations. 43 were excluded because they had type 2 diabetes mellitus or severe chronic kidney disease. CV risk was categorised in the remaining 327 RA patients according to the mSCORE: mild (96 cases; 29.3%), moderate (201; 61.5%) and high/very high risk (30; 9.2%). Only five patients were reclassified as having high/very high CV risk when the mSCORE was applied. Severe carotid US abnormalities (cIMT >0.90 mm and/or plaques) were uncommon in patients with low mSCORE (13%). Nevertheless, in patients with moderate mSCORE, severe carotid US abnormalities were observed in 63% of cases. A model that included a chart mSCORE risk ?5% plus the presence of severe carotid US findings in patients with moderate mSCORE risk (?1% and <5%) yielded high sensitivity for high/very high CV risk (93 (95% CI 88 to 96)). CONCLUSIONS: Our results support the use of carotid US in the assessment of CV risk in patients with RA. PMID:23505241

Corrales, Alfonso; González-Juanatey, Carlos; Peiró, María E; Blanco, Ricardo; Llorca, Javier; González-Gay, Miguel A



Influence of target organ lesion detection (assessment of microalbuminuria and echocardiogram) in cardiovascular risk stratification and treatment of untreated hypertensive patients.  


European guidelines indicate the importance of the evaluation of global cardiovascular risk (CVR) to determine the management of the hypertensive patients (EH). However, in primary care, the diagnostic work-up (PCD) only includes the metabolic risk factors. The aim of this study was to assess the importance of microalbuminuria (MA) and echocardiogram (ECHO) in the process of risk stratification, and the number of patients to be treated with drugs at diagnosis. In total, 155 nontreated EH were included in the study. Blood pressure, a lipid profile and plasma glucose (LG) were determined after an overnight fast. MA was evaluated with dipstick MICRALTEST, and in those patients with two positive results, it was measured again in two 24-h urine samples and was considered positive (MA+) if the average was >30 mg/24 h. Left ventricular mass index was calculated and values>125 g/m2 were considered as LV hypertrophy (LVH+). When the patients were stratified according to PCD, 22 had to be treated with drugs. When MA, ECHO and both tests used together were added to the risk evaluation, the number of patients to be treated were 42, 51 and 64, respectively (P<0.001 vs PCD). It is mainly in patients who have moderate cardiovascular risk that risk changes, whereas risk hardly changes in those having low and very high risk. In conclusion, in EH with moderate risk, measurement of MA, due to its easy availability and low cost, seems to be a cost effective screening test to avoid the underestimation of the CVR. PMID:16355120

Luque, M; de Rivas, B; Alvarez, B; Garcia, G; Fernandez, C; Martell, N



Impact of Early Risk Stratification on the Length of Hospitalization in Patients with Acute Q-Wave Myocardial Infarction  

Microsoft Academic Search

An assessment of individual risk factors may identify a subgroup of postinfarction patients at low risk, i.e. patients appropriate for early discharge. Using a large unselected population of the national registry, ‘The 60-Minutes Myocardial Infarction Project’, we (1) attempted to provide a retrospective analysis of clinical factors and in-hospital mortality in a population living on the 6th hospital day following

Stefan Schuster; Armin Koch; Rudolf Schiele; Udo Burczyk; Stefan Wagner; Ralf Zahn; Jörg Rustige; Peter Limbourg; Hartmut Gülker; Jochen Senges



Assessment of Holter ST monitoring for risk stratification in patients with acute myocardial infarction treated by thrombolysis  

Microsoft Academic Search

OBJECTIVES--To evaluate the role of Holter ST monitoring for identifying patients at risk of recurrent ischaemic events after acute myocardial infarction treated by thrombolysis. BACKGROUND--The natural history of myocardial infarction has changed with the introduction of thrombolytic treatment. There is now a lower mortality but a higher incidence of recurrent thrombotic events (reinfarction, unstable angina). Preliminary evidence indicates that Holter

R Stevenson; K Ranjadayalan; P Wilkinson; B Marchant; A D Timmis



Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Noninvasive Risk Stratification and a Conceptual Framework for the Selection of Noninvasive Imaging Tests in Patients with Known or Suspected Coronary Artery Disease*y  

Microsoft Academic Search

This review deals with noninvasive imaging for risk stratification and with a conceptual approach to the selection of noninvasive tests in patients with suspected or known chronic coronary ar- tery disease (CAD). Already widely acknowledged with SPECT, there is an increasing body of literature data demonstrating thatCTcoronarycalciumassessmentisalsoofprognosticvalue. The amount of coronary atherosclerosis, as can be extrapolated from CT coronary calcium

Daniel S. Berman; Rory Hachamovitch; Leslee J. Shaw; John D. Friedman; Sean W. Hayes; Louise E. J. Thomson; David S. Fieno; Guido Germano; Nathan D. Wong; Xingping Kang; Alan Rozanski


Recent advances in the management of chronic stable angina I: approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities.  


The potential importance of both prevention and personal responsibility in controlling heart disease, the leading cause of death in the USA and elsewhere, has attracted renewed attention. Coronary artery disease is preventable, using relatively simple and inexpensive lifestyle changes. The inexorable rise in the prevalence of obesity, diabetes, dyslipidemia, and hypertension, often in the risk cluster known as the metabolic syndrome, drives the ever-increasing incidence of heart disease. Population-wide improvements in personal health habits appear to be a fundamental, evidence based public health measure, yet numerous barriers prevent implementation. A common symptom in patients with coronary artery disease, classical angina refers to the typical chest pressure or discomfort that results when myocardial oxygen demand rises and coronary blood flow is reduced by fixed, atherosclerotic, obstructive lesions. Different forms of angina and diagnosis, with a short description of the significance of pain and silent ischemia, are discussed in this review. The well accepted concept of myocardial oxygen imbalance in the genesis of angina is presented with new data about clinical pathology of stable angina and acute coronary syndromes. The roles of stress electrocardiography and stress myocardial perfusion scintigraphic imaging are reviewed, along with the information these tests provide about risk and prognosis. Finally, the current status of gender disparities in heart disease is summarized. Enhanced risk stratification and identification of patients in whom procedures will meaningfully change management is an ongoing quest. Current guidelines emphasize efficient triage of patients with suspected coronary artery disease. Many experts believe the predictive value of current decision protocols for coronary artery disease still needs improvement in order to optimize outcomes, yet avoid unnecessary coronary angiograms and radiation exposure. Coronary angiography remains the gold standard in the diagnosis of coronary artery obstructive disease. Part II of this two part series will address anti-ischemic therapies, new agents, cardiovascular risk reduction, options to treat refractory angina, and revascularization. PMID:20730020

Kones, Richard



Patient and primary care provider experience using a family health history collection, risk stratification, and clinical decision support tool: a type 2 hybrid controlled implementation-effectiveness trial  

PubMed Central

Background Family health history (FHH) is the single strongest predictor of disease risk and yet is significantly underutilized in primary care. We developed a patient facing FHH collection tool, MeTree©, that uses risk stratification to generate clinical decision support for breast cancer, colorectal cancer, ovarian cancer, hereditary cancer syndromes, and thrombosis. Here we present data on the experience of patients and providers after integration of MeTree© into 2 primary care practices. Methods This was a Type 2 hybrid controlled implementation-effectiveness study in 3 community-based primary care clinics in Greensboro, NC. All non-adopted adult English speaking patients with upcoming routine appointments were invited. Patients were recruited from December 2009 to the present and followed for one year. Ease of integration of MeTree© into clinical practice at the two intervention clinics was evaluated through patient surveys after their appointment and at 3 months post-visit, and physician surveys 3 months after tool integration. Results Total enrollment =1,184. Average time to complete MeTree©?=?27 minutes. Patients found MeTree©: easy to use (93%), easy to understand (97%), useful (98%), raised awareness of disease risk (85%), and changed how they think about their health (86%). Of the 26% (N?=?311) asking for assistance to complete the tool, age (65 sd 9.4 vs. 57 sd 11.8, p-value?patients and providers and can be implemented without disruption to workflow.



[Ventricular preexcitation: is risk stratification feasible?].  


The Wolff-Parkinson-White syndrome is a current debated clinical issue. Although the anatomical characteristics, polymorphic electrocardiographic features, and electrophysiological mechanisms of arrhythmias and sudden cardiac death are well known, the identification of patients at risk of sudden cardiac death remains challenging. Owing to the lack of effective therapeutic strategies, in the pre-ablation era many studies have been conducted to define the prognostic value of clinical and instrumental tests, and to define the actual risk of sudden cardiac death in patients with ventricular preexcitation. Nowadays, radiofrequency transcatheter ablation of anomalous atrioventricular pathways is a strong therapeutic option for all patients, independent of the risk of sudden cardiac death. However, radiofrequency ablation is associated with serious complications, but many studies confirm an overall good prognosis for most of the patients with electrocardiographic pattern of ventricular preexcitation. The aim of this review is to assess the prognostic value of clinical and instrumental tests in patients with ventricular preexcitation, referring to the latest knowledge. PMID:20677574

De Rosa, Francesco; Mancuso, Paola; Chiatto, Mario; Calvelli, Antonio; De Donato, Vincenzo; Mazza, Salvatore; Spadafora, Gabriele



Standardized Reporting Guidelines for Emergency Department Syncope Risk Stratification Research  

PubMed Central

There is increasing research interest in the risk stratification of emergency department (ED) syncope patients. A major barrier to comparing and synthesizing existing research is wide variation in the conduct and reporting of studies. The authors wished to create standardized reporting guidelines for ED syncope risk stratification research using an expert consensus process. In that pursuit, a panel of syncope researchers was convened and a literature review was performed to identify candidate reporting guideline elements. Candidate elements were grouped into four sections: eligibility criteria, outcomes, electrocardiogram findings, and predictors. A two-round, modified Delphi consensus process was conducted using an internet-based survey application. In the first round, candidate elements were rated on a five-point Likert scale. In the second round, panelists re-rated items after receiving information about group ratings from the first round. Items that were rated by >80% of the panelists at the two highest levels of the Likert scale were included in the final guidelines. There were 24 panelists from eight countries who represented five clinical specialties. The panel identified an initial set of 183 candidate elements. After two survey rounds, the final reporting guidelines included 92 items that achieved >80% consensus. These included 10 items for study eligibility, 23 items for outcomes, 9 items for electrocardiogram abnormalities, and 50 items for candidate predictors. Adherence to these guidelines should facilitate comparison of future research in this area.

Sun, Benjamin C.; Thiruganasambandamoorthy, Venkatesh; Dela Cruz, Jeffrey



Natural history of Brugada Syndrome. Insights for risk stratification and management  

Microsoft Academic Search

Background—Treatment of patients with Brugada syndrome is complicated by the incomplete information on the natural history of the disease related to the small number of cases reported. Furthermore, the value of programmed electrical stimulation (PES) for risk stratification is highly debated. The objective of this study was to search for novel parameters to identify patients at risk of sudden death.

Silvia G. Priori; Carlo Napolitano; Maurizio Gasparini



La valutazione funzionale dopo rivascolarizzazione miocardica Risk stratification after myocardial revascularisation  

Microsoft Academic Search

Risk stratification after coronary revascular- ization. S. Pirelli, B.M. Fadin. Coronary angioplasty could be applied to broad groups of coronary patients with high rates of success and low rates of complication. Although multiple clinical, angiographic and procedural factors have beeen associated with an in- creased incidence of restenosis, the ability to predict the risk of restenosis in individual patients remains

Salvatore Pirelli; Bianca Maria Fadin


Gleason Pattern 5 Prostate Cancer: Further Stratification of Patients With High-Risk Disease and Implications for Future Randomized Trials  

SciTech Connect

Purpose: To compare prostate-specific antigen (PSA) outcomes in a cohort of men with high-risk prostate cancer based on the presence or absence of any Gleason Grade 5 component (primary, secondary, or tertiary). Methods and Materials: Our study cohort consisted of 312 men with T1c-T3N0M0 prostate cancer with Gleason Scores of 7 with tertiary Grade 5, 8, or 9-10 who underwent radical prostatectomy or external beam radiotherapy with or without androgen suppression therapy. Cox regression multivariable analysis was used to assess whether a difference existed in risk of PSA recurrence in men with Gleason Score of 9-10 compared with those with Gleason Score of 8 and 7 with tertiary Grade 5, adjusting for treatment, age, and known prostate cancer prognostic factors. Results: After a median follow-up of 5.7 years, men with a Gleason Score of 8 had a lower risk of PSA recurrence than those with a Gleason Score of 9-10 (hazard ratio, 0.74; 95% confidence interval, 0.52-1.05; p = 0.09). Conversely, men with a Gleason Score of 7 with tertiary Grade 5 had a similar risk of PSA recurrence compared with men with a Gleason Score of 9-10 (hazard ratio, 1.08; 95% confidence interval, 0.60-1.94; p = 0.81). Median times to PSA failure for men with Gleason Scores of 9-10, 7 with tertiary Grade 5, and 8 were 4.5, 5.0, and 5.4 years, respectively. Conclusions: Our results highlight the importance of further substratification of the high-risk Gleason Score category of 8-10 into 8 vs. 9, 10, and 7 with tertiary Grade 5.

Nanda, Akash [Harvard Radiation Oncology Program, Boston, MA (United States)], E-mail:; Chen, M.-H. [Department of Statistics, University of Connecticut, Storrs, CT (United States); Renshaw, Andrew A. [Department of Pathology, Baptist Hospital of Miami, Miami, FL (United States); D'Amico, Anthony V. [Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA (United States)



Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection  

Microsoft Academic Search

Objective: In many centers, carbon monoxide lung diffusion capacity (DLCO) is still not routinely measured in all patients but only in patients with airflow limitation. The objective of the study was to assess the degree of correlation between forced expiratory volume in 1s (FEV1) and DLCO, and verify whether a low predicted postoperative DLCO (ppoDLCO) could have a role in

Alessandro Brunelli; Majed Al Refai; Michele Salati; Armando Sabbatini; Nicholas J. Morgan-Hughes; Gaetano Rocco



[Acute kidney injury--prevention, risk stratification and biomarkers].  


Acute kidney injury influences negatively morbidity and mortality of the critically ill patient and causes increased costs by prolonged length of stay in the intensive care unit. At present the diagnosis and classification of acute kidney injury is derived from the RIFLE and AKIN criteria based on serum creatinine and urine output. The possible pre-, intra- and postrenal causes of acute kidney injury are the starting points of preventive therapy and risk stratification.Because of the unreliability of serum creatinine in critically ill patients the development of new biomarkers raises hope. But none of the promising candidates is used in clinical routine up to now. For evaluation of clinical benefit the results of large prospective multicenter studies have to be awaited. PMID:23504469

Bläser, Daniel; Weiler, Norbert



Risk stratification in the elderly patient after coronary artery bypass grafting: The prognostic value of radionuclide cineangiography  

Microsoft Academic Search

Background  Recent data have shown that assessment of left ventricular function by radionuclide cineangiography (RNCA) predicts survival\\u000a and cardiac events among non-age-selected patients who have previously undergone coronary artery bypass grafting (CABG). However,\\u000a the prognostic value of this noninvasive approach is not known for elderly patients who now undergo CABG with progressively\\u000a increasing frequency and who survive longer because of operation.

Phyllis G. Supino; James B. Wallis; Gregory Chlouverakis; Jeffrey S. Borer



Prognostic value of troponin i in cardiac risk stratification of cancer patients undergoing high-dose chemotherap  

Microsoft Academic Search

Background—In patients with aggressive malignancies who are undergoing high-dose chemotherapy, even minimal elevation of troponin I (TnI) is associated with late left ventricular dysfunction. The time course of the subclinical myocardial damage and its impact on the clinical outcome have never been investigated previously. Methods and Results—In 703 cancer patients, we measured TnI soon after chemotherapy (early TnI) and 1

Daniela Cardinale; Maria T. Sandri; Alessandro Colombo



Oncological results, functional outcomes and health-related quality-of-life in men who received a radical prostatectomy or external beam radiation therapy for localized prostate cancer: a study on long-term patient outcome with risk stratification  

Microsoft Academic Search

Health-related quality-of-life (HRQOL) after a radical prostatectomy (RP) or external beam radiation therapy (EBRT) has not been studied in conjunction with oncological outcomes in relation to disease risk stratification. Moreover, the long-term outcomes of these treatment approaches have not been studied. We retrospectively analyzed oncological outcomes between consecutive patients receiving RP (n = 86) and EBRT (n = 76) for

Itsuhiro Takizawa; Noboru Hara; Tsutomu Nishiyama; Masaaki Kaneko; Tatsuhiko Hoshii; Emiko Tsuchida; Kota Takahashi



Genetics can contribute to the prognosis of Brugada syndrome: a pilot model for risk stratification.  


Brugada syndrome is an inherited arrhythmogenic disorder leading to sudden death predominantly in the 3-4 decade. To date the only reliable treatment is the implantation of a cardioverter defibrillator; however, better criteria for risk stratification are needed, especially for asymptomatic subjects. Brugada syndrome genetic bases have been only partially understood, accounting for <30% of patients, and have been poorly correlated with prognosis, preventing inclusion of genetic data in current guidelines. We designed an observational study to identify genetic markers for risk stratification of Brugada patients by exploratory statistical analysis. The presence of genetic variants, identified by SCN5A gene analysis and genotyping of 73 candidate polymorphisms, was correlated with the occurrence of major arrhythmic events in a cohort of 92 Brugada patients by allelic association and survival analysis. In all, 18 mutations were identified in the SCN5A gene, including 5 novel, and statistical analysis indicated that mutation carriers had a significantly increased risk of major arrhythmic events (P=0.024). In addition, we established association of five polymorphisms with major arrhythmic events occurrence and consequently elaborated a pilot risk stratification algorithm by calculating a weighted genetic risk score, including the associated polymorphisms and the presence of SCN5A mutation as function of their odds ratio. This study correlates for the first time the presence of genetic variants with increased arrhythmic risk in Brugada patients, representing a first step towards the design of a new risk stratification model. PMID:23321620

Sommariva, Elena; Pappone, Carlo; Martinelli Boneschi, Filippo; Di Resta, Chiara; Rosaria Carbone, Maria; Salvi, Erika; Vergara, Pasquale; Sala, Simone; Cusi, Daniele; Ferrari, Maurizio; Benedetti, Sara



Dickkopf-1 as a Novel Predictor Is Associated with Risk Stratification by GRACE Risk Scores for Predictive Value in Patients with Acute Coronary Syndrome: A Retrospective Research  

PubMed Central

Objective Dickkopf-1 (DKK-1), a major regulator of the Wnt pathway, plays an important role in cardiovascular disease. However, no study has evaluated the association of DKK-1 and acute coronary syndrome (ACS). We investigated this association and whether the Global Registry of Acute Coronary Events (GRACE) hospital-discharge risk score predicting major adverse cardiac events (MACE) can be improved by adding the DKK-1 value. Methods We enrolled 291 patients (46 with ST-segment elevation myocardial infarction [STEMI] and 245 with non-ST elevated ACS [NSTE-ACS]) who were divided into groups by tertiles of baseline plasma DKK-1 level measured by ELISA. The GRACE risk score was calculated and predictive value alone and together with DKK-1 and/or high-sensitivity C-reactive protein (hs-CRP) level were assessed, respectively. Results Compared with patients with NSTE-ACS, those with STEMI had higher plasma DKK-1 level at baseline (P?=?0.006). Plasma DKK-1 level was correlated with hs-CRP level (r?=?0.295, P<0.001) and was greater with high than intermediate or low GRACE scores (P?=?0.002 and P<0.001, respectively). We found 44 (15.1%) MACEs during a median 2-year follow-up. DKK-1 levels were higher for patients with than without events (P<0.001). The rate of MACE increased with increasing DKK-1 level (P<0.001). The area under the receiver operating characteristic curve for GRACE score with MACE was 0.524 and improved to 0.791 with the addition of hs-CRP level, 0.775 with the addition of DKK-1 level and 0.847 with both values added. Conclusions DKK-1 is an independent predictor of long-term MACE of patients with ACS. The long-term predictive ability of post-discharge GRACE score may be enhanced by adding DKK-1 level.

Wang, Lin; Hu, Xiao Bo; Zhang, Wei; Wu, Lin Di; Liu, Yu Sheng; Hu, Bo; Bi, Cheng Long; Chen, Yi Fei; Liu, Xin Xin; Ge, Cheng; Zhang, Yun; Zhang, Mei



Natural history and risk stratification of arrhythmogenic right ventricular dysplasia\\/cardiomyopathy  

Microsoft Academic Search

Background—Management of patients with arrhythmogenic right ventricular dysplasia\\/cardiomyopathy (ARVD\\/C) is complicated by the incomplete information on the natural history of the disease and by the lack of risk stratification for cardiovascular death. The aim of the study was the identification of risk factors related to long-term prognosis. Methods and Results—Data were collected from 130 patients (100 men; age at onset

Jean-Sébastien Hulot; Xavier Jouven; Jean-Philippe Empana; Robert Frank; Guy Fontaine



Diagnosis and Risk Stratification of Acute Pancreatitis  

Microsoft Academic Search

Patients with acute pancreatitis (AP) usually present with sudden onset of abdominal pain, nausea, and vomiting. Approximately\\u000a 80% of patients have interstitial pancreatitis with mild-to-moderate symptoms, and 20% have life-threatening necrotizing disease.\\u000a Careful clinical assessment and the judicial use of biochemical tests and radiological imaging enables the practitioner to\\u000a differentiate AP from other causes of acute abdomen and to assess

Frank R. Burton


Risk stratification and epidemiology of sudden death  

Microsoft Academic Search

Recent data from the Centers for Disease Control and Prevention show that sudden cardiac death accounts for approximately\\u000a 400,000 deaths annually in this country. The survival rate for these patients is dismal. Because of the low probability of\\u000a survival from a cardiac arrest, there has been an increasing focus on primary prevention. The implantable cardioverter defibrillator\\u000a (ICD) is a highly

Sri Sundaram; Jeffrey J. Goldberger



Patient stratification for preventive care in dentistry.  


Prevention reduces tooth loss, but little evidence supports biannual preventive care for all adults. We used risk-based approaches to test tooth loss association with 1 vs. 2 annual preventive visits in high-risk (HiR) and low-risk (LoR) patients. Insurance claims for 16 years for 5,117 adults were evaluated retrospectively for tooth extraction events. Patients were classified as HiR for progressive periodontitis if they had ? 1 of the risk factors (RFs) smoking, diabetes, interleukin-1 genotype; or as LoR if no RFs. LoR event rates were 13.8% and 16.4% for 2 or 1 annual preventive visits (absolute risk reduction, 2.6%; 95%CI, 0.5% to 5.8%; p = .092). HiR event rates were 16.9% and 22.1% for 2 and 1 preventive visits (absolute risk reduction, 5.2%; 95%CI, 1.8% to 8.4%; p = .002). Increasing RFs increased events (p < .001). Oral health care costs were not increased by any single RF, regardless of prevention frequency (p > .41), but multiple RFs increased costs vs. no (p < .001) or 1 RF (p = .001). For LoR individuals, the association between preventive dental visits and tooth loss was not significantly different whether the frequency was once or twice annually. A personalized medicine approach combining gene biomarkers with conventional risk factors to stratify populations may be useful in resource allocation for preventive dentistry (, NCT01584479). PMID:23752171

Giannobile, W V; Braun, T M; Caplis, A K; Doucette-Stamm, L; Duff, G W; Kornman, K S



Risk Stratification: History, Physical, and EKG  

Microsoft Academic Search

\\u000a Chest pain annually accounts for over 5% of more than 110 million emergency department (ED) visits nationwide (PHS, PHS 2004;1250).\\u000a Of these patients, approximately one-third will be diagnosed with acute coronary syndrome (ACS) (Storrow and Gibler, Ann Emerg\\u000a Med 2000;35(5):449–61). ACS describes a continuum of conditions that ranges from unstable angina (UA) and non-ST-segment elevation\\u000a myocardial infarction (NSTEMI) to ST-segment

Alan B. Storrow; Ian McClure; Elizabeth Harbison


Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule  

Microsoft Academic Search

INTRODUCTION: To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3. METHODS: Using the original data from four North American and European prospective multicentre cohort studies of patients with CAP,

Bertrand Renaud; José Labarère; Eva Coma; Aline Santin; Jan Hayon; Mercé Gurgui; Nicolas Camus; Eric Roupie; François Hémery; Jérôme Hervé; Mirna Salloum; Michael J Fine; Christian Brun-Buisson



High-Sensitivity C-Reactive Protein and Soluble CD40 Ligand as Indices of Inflammation and Platelet Activation in 880 Patients With Nonvalvular Atrial Fibrillation Relationship to Stroke Risk Factors, Stroke Risk Stratification Schema, and Prognosis  

Microsoft Academic Search

Background and Purpose—There is now considerable evidence that atrial fibrillation is associated with an inflammatory state. We tested the hypothesis that plasma levels of C-reactive protein (CRP; an index of inflammation) and soluble CD40 ligand (an index of platelet activation, with links to inflammation) could be related to 3 established stroke risk stratification schema (SPAF, CHADS2, and NICE), recognized stroke

Gregory Y. H. Lip; Jeetesh V. Patel; Elizabeth Hughes; Robert G. Hart



Novel biomarkers for risk stratification and identification of life-threatening cardiovascular disease: troponin and beyond.  


Chest pain and other symptoms that may represent acute coronary syndromes (ACS) are common reasons for emergency department (ED) presentations, accounting for over six million visits annually in the United States [1]. Chest pain is the second most common ED presentation in the United States. Delays in diagnosis and inaccurate risk stratification of chest pain can result in serious morbidity and mortality from ACS, pulmonary embolism (PE), aortic dissection and other serious pathology. Because of the high morbidity, mortality, and liability issues associated with both recognized and unrecognized cardiovascular pathology, an aggressive approach to the evaluation of this patient group has become the standard of care. Clinical history, physical examination and electrocardiography have a limited diagnostic and prognostic role in the evaluation of possible ACS, PE, and aortic dissection, so clinicians continue to seek more accurate means of risk stratification. Recent advances in diagnostic imaging techniques particularly computed-tomography of the coronary arteries and aorta, have significantly improved our ability to diagnose life-threatening cardiovascular disease. In an era where health care utilization and cost are major considerations in how disease is managed, it is crucial to risk-stratify patients quickly and efficiently. Historically, biomarkers have played a significant role in the diagnosis and risk stratification of several cardiovascular disease states including myocardial infarction, congestive heart failure, and pulmonary embolus. Multiple biomarkers have shown early promise in answering questions of risk stratification and early diagnosis of cardiovascular pathology however many do not yet have wide clinical availability. The goal of this review will be to discuss these novel biomarkers and describe their potential role in direct patient care. PMID:22708908

Razzouk, Louai; Fusaro, Mario; Esquitin, Ricardo



Novel Biomarkers for Risk Stratification and Identification of Life-threatening Cardiovascular Disease: Troponin and Beyond  

PubMed Central

Chest pain and other symptoms that may represent acute coronary syndromes (ACS) are common reasons for emergency department (ED) presentations, accounting for over six million visits annually in the United States [1]. Chest pain is the second most common ED presentation in the United States. Delays in diagnosis and inaccurate risk stratification of chest pain can result in serious morbidity and mortality from ACS, pulmonary embolism (PE), aortic dissection and other serious pathology. Because of the high morbidity, mortality, and liability issues associated with both recognized and unrecognized cardiovascular pathology, an aggressive approach to the evaluation of this patient group has become the standard of care. Clinical history, physical examination and electrocardiography have a limited diagnostic and prognostic role in the evaluation of possible ACS, PE, and aortic dissection, so clinicians continue to seek more accurate means of risk stratification. Recent advances in diagnostic imaging techniques particularly computed-tomography of the coronary arteries and aorta, have significantly improved our ability to diagnose life-threatening cardiovascular disease. In an era where health care utilization and cost are major considerations in how disease is managed, it is crucial to risk-stratify patients quickly and efficiently. Historically, biomarkers have played a significant role in the diagnosis and risk stratification of several cardiovascular disease states including myocardial infarction, congestive heart failure, and pulmonary embolus. Multiple biomarkers have shown early promise in answering questions of risk stratification and early diagnosis of cardiovascular pathology however many do not yet have wide clinical availability. The goal of this review will be to discuss these novel biomarkers and describe their potential role in direct patient care.

Razzouk, Louai; Fusaro, Mario; Esquitin, Ricardo



Circulating Progenitor Cell Count for Cardiovascular Risk Stratification: A Pooled Analysis  

Microsoft Academic Search

BackgroundCirculating progenitor cells (CPC) contribute to the homeostasis of the vessel wall, and a reduced CPC count predicts cardiovascular morbidity and mortality. We tested the hypothesis that CPC count improves cardiovascular risk stratification and that this is modulated by low-grade inflammation.Methodology\\/Principal FindingsWe pooled data from 4 longitudinal studies, including a total of 1,057 patients having CPC determined and major adverse

Gian Paolo Fadini; Shoichi Maruyama; Takenori Ozaki; Akihiko Taguchi; James Meigs; Stefanie Dimmeler; Andreas M. Zeiher; Saula de Kreutzenberg; Angelo Avogaro; Georg Nickenig; Caroline Schmidt-Lucke; Nikos Werner; Stefan Kiechl



N-Terminal pro-B-Type Natriuretic Peptide in Risk Stratification after Acute Myocardial Infarction in Patients on Long-Term Beta-Adrenergic Receptor Blocker Therapy  

Microsoft Academic Search

Background: N-terminal pro-B-type natriuretic peptide (NT-proBNP) appears to be a strong risk marker of mortality in patients with acute coronary syndrome. However, little information is available on NT-proBNP as a predictor of long-term serious cardiovascular events beyond that of left ventricular ejection fraction in patients with acute myocardial infarction (AMI), most of them treated with an early invasive strategy and

Gisli Jonsson; Michael Abdelnoor; Sverre Landaas; Carl Müller; Sverre Erik Kjeldsen; Ingrid Os; Arne Westheim



RR-QT interval trend covariability for sudden cardiac death risk stratification.  


This paper examines the feasibility of the trend covariability between QT and RR Intervals (QTIs and RRIs) be a novel mean of the sudden cardiac death (SCD) risk stratification. Twenty four hour beat to beat QTIs and RRIs are measured from Holter ECG recordings of 25 normal control subjects (SCD-C), 14 low SCD risk patients (SCD-L) with high blood pressure or light cardiac arrhythmia and 11 SCD high risk patients (SCD-H) with heart attack history. The Kalman filtering technique has been applied to decompose 24 hour short term mean QTIs and RRIs sequences into trend components and additive random variations. The correlation coefficients (TC-QT/RR) and cross entropies (TE-QT/RR) between the QT and RR trend signals are estimated. Cross entropy TE-QT/RR achieved the best stratification of subject groups. TE-QT/RR distribution for SCD-C, -L -H subject groups were 1.697 ± 0.058, 1.160 ± 0.099, 0.920 ± 0.067. The differences in entropy values are statistically significant for all classes pairs (SCD-H and -C (p<0.00001); -L and -C (p<0.001); -H and -L (p<0.05) The result indicates that the TE-QT/RR could be a novel index for the SCD risk stratification. PMID:23366875

Nishibe, Toshihiro; Sato, Kei; Yoshino, Kunihiro; Seki, Ryota; Yana, Kazuo; Ono, Takuya





ABSTRACT BACKGROUND In hemodynamically stable patients with acute pulmonary embolism risk stratification is essential to drive clinical management. In these patients, risk stratification for in-hospital adverse outcome based on markers of right ventricle dysfunction and injury has been proposed. METHODS The aim of this study was to validate a model based on the incremental prognostic value of right ventricle dysfunction and injury in hemodynamically stable patients with acute pulmonary embolism. Patients from the prospective Italian Pulmonary Embolism Registry (IPER) were included in the study. Study outcomes were in-hospital death and the composite of in-hospital death or clinical deterioration. RESULTS Among 1515 hemodynamically stable patients, 869 had both echocardiography and troponin assessments. The risk for in-hospital death or clinical deterioration was higher in patients with right ventricle dysfunction and elevated troponin (8.8%; HR 14.2; 95% CI 1.94-104.16; p< 0.01) and with either right ventricle dysfunction or elevated troponin (4.7%; HR 7.9; 95% CI 1.1-59.9; p< 0.05) compared to patients without dysfunction and normal troponin. The negative predictive value of the model was 100% for in-hospital death and 99% for death or clinical deterioration. c-statistics showed an improvement of the discriminatory power for in-hospital death or clinical deterioration by using the overall model (0.66; 95% CI 0.60-0.73) over either echocardiography (0.59, 95% CI 0.53-0.67) or troponin (0.61, 95% CI 0.53-0.69) alone. CONCLUSIONS A model including both right ventricle dysfunction and injury has an incremental prognostic value for risk stratification in hemodynamically stable patients with acute pulmonary embolism. Patients with no dysfunction or injury have a favourable outcome. ( NCT01604538). PMID:23764909

Becattini, Cecilia; Casazza, Franco; Forgione, Chiara; Porro, Fernando; Fadin, Bianca Maria; Stucchi, Alessandra; Lignani, Alessandra; Conte, Luca; Imperadore, Ferdinando; Bongarzoni, Amedeo; Agnelli, Giancarlo



Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule  

PubMed Central

Introduction To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3. Methods Using the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support). Results A total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population. Conclusions The REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.

Renaud, Bertrand; Labarere, Jose; Coma, Eva; Santin, Aline; Hayon, Jan; Gurgui, Merce; Camus, Nicolas; Roupie, Eric; Hemery, Francois; Herve, Jerome; Salloum, Mirna; Fine, Michael J; Brun-Buisson, Christian



Risk stratification in heart surgery: comparison of six score systemsq  

Microsoft Academic Search

Objective: Risk scores have become an important tool in patient assessment, as age, severity of heart disease, and comorbidity in patients undergoing heart surgery have considerably increased. Various risk scores have been developed to predict mortality after heart surgery. However, there are significant differences between scores with regard to score design and the initial patient population on which score development

Hans J. Geissler; Philipp Holzl; Sascha Marohl; Uwe Mehlhorn; Michael Sudkamp; E. Rainer de Vivie



Risk stratification in heart surgery: comparison of six score systems  

Microsoft Academic Search

Objective: Risk scores have become an important tool in patient assessment, as age, severity of heart disease, and comorbidity in patients undergoing heart surgery have considerably increased. Various risk scores have been developed to predict mortality after heart surgery. However, there are significant differences between scores with regard to score design and the initial patient population on which score development

Hans J Geissler; Philipp Hölzl; Sascha Marohl; Ferdinand Kuhn-Régnier; Uwe Mehlhorn; Michael Südkamp; E. Rainer de Vivie



Influence of different echocardiographic criteria for detection of left ventricular hypertrophy on cardiovascular risk stratification in recently diagnosed essential hypertensives  

Microsoft Academic Search

Background: Hypertensive patients with left ventricular hypertrophy (LVH) need a prompter and more intensive pharmacological treatment than subjects without evidence of cardiac involvement. So the detection of LVH plays an important role for decision-making in hypertensives.Objective: To evaluate the impact of different echocardiographic criteria to define LVH in a more precise stratification of absolute cardiovascular risk in hypertensives without target

C Cuspidi; G Macca; L Sampieri; I Michev; V Fusi; M Salerno; B Severgnini; C Corti; F Magrini; A Zanchetti



Pre-admission NT-proBNP improves diagnostic yield and risk stratification - the NT-proBNP for EValuation of dyspnoeic patients in the Emergency Room and hospital (BNP4EVER) study  

PubMed Central

Background: Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) level is useful to diagnose or exclude acutely decompensated heart failure (ADHF) in dyspnoeic patients presenting to the emergency department (ED). Aim: To evaluate the impact of ED NT-proBNP testing on admission, length of stay (LOS), discharge diagnosis and long-term outcome. Methods: Dyspnoeic patients were randomized in the ED to NT-proBNP testing. Admission and discharge diagnoses, and outcomes were examined. Results: During 17 months, 470 patients were enrolled and followed for 2.0±1.3 years. ADHF likelihood, determined at study conclusion by validated criteria, established ADHF diagnosis as unlikely in 86 (17%), possible in 120 (24%), and likely in 293 (59%) patients. The respective admission rates in these subgroups were 80, 91, and 96%, regardless of blinding, and 61.9% of blinded vs. 74.5% of unblinded ADHF-likely patients were correctly diagnosed at discharge (p=0.029), with similar LOS. 2-year mortality within subgroups was unaffected by test, but was lower in ADHF-likely patients with NT-proBNP levels below median (5000 pg/ml) compared with those above median (p=0.002). Incidence of recurrent cardiac events tracked NT-proBNP levels. Conclusion: ED NT-proBNP testing did not affect admission, LOS, 2-year survival, or recurrent cardiac events among study patients but improved diagnosis at discharge, and allowed risk stratification even within the ADHF-likely group. (

Januzzi, James L; Medvedovski, Margarita; Sharist, Moshe; Shochat, Michael; Ashkar, Jalal; Peschansky, Pavel; Haim, Shmuel Bar; Blondheim, David S; Glikson, Michael; Shotan, Avraham



CHADS2 versus CHA2DS2-VASc score in assessing the stroke and thromboembolism risk stratification in patients with atrial fibrillation: a systematic review and meta-analysis  

PubMed Central

Objective To perform a systematic review and meta-analysis of the predictive abilities of CHADS2 and CHA2DS2-VASc in stroke and thromboembolism risk stratification of atrial fibrillation (AF) patients. Methods We searched PubMed and EMBASE for English-language literature on comparisons of the diagnostic performance between CHADS2 and CHA2DS2-VASc in predicting stroke, or systemic embolism, in AF. We then assessed the quality of the included studies and pooled the C-statistics and 95% confidence intervals (95% CI). Results Eight studies were included. It was unsuitable to perform a direct meta-analysis because of high heterogeneity. When analyzed as a continuous variable, the C-statistic ranged from 0.60 to 0.80 (median 0.683) for CHADS2 and 0.64–0.79 (median 0.673) for CHA2DS2-VASc. When analyzed as a continuous variable in anticoagulation patients, the subgroup analysis showed that the pooled C-statistic (95% CI) was 0.660 (0.655–0.665) for CHADS2 and 0.667 (0.651–0.683) for CHA2DS2-VASc (no significant difference). For non-anticoagulation patients, the pooled C-statistic (95% CI) was 0.685 (0.666–0.705) for CHADS2 and 0.675 (0.656–0.694) for CHA2DS2-VASc (no significant difference). The average ratio of endpoint events in the low-risk group of CHA2DS2-VASc was less than CHADS2 (0.41% vs. 0.94%, P < 0.05). The average proportion of the moderate-risk group of CHA2DS2-VASc was lower than CHADS2 (11.12% vs. 30.75%, P < 0.05). Conclusions The C-statistic suggests a similar clinical utility of the CHADS2 and CHA2DS2-VASc scores in predicting stroke and thromboembolism, but CHA2DS2- VASc has the important advantage of identifying extremely low-risk patients with atrial fibrillation, as well as classifying a lower proportion of patients as moderate risk.

Chen, Jia-Yuan; Zhang, Ai-Dong; Lu, Hong-Yan; Guo, Jun; Wang, Fei-Fei; Li, Zi-Cheng



Noninvasive Risk Stratification of Sudden Death: T-Wave Alternans  

Microsoft Academic Search

year in the USA and remains a health problem of epidemic proportions. Most SCDs are caused by fatal ventricular arrhythmias, i.e., ventricular tachycardia (VT) and ventricular fibrillation (VF), in patients with and without known structural heart diseases [1, 2]. Identifying patients at risk for these arrhythmias remains a major challenge since < 2% of patients who have sudden cardiac arrest

Roberto Pedretti; Simona Braga; Raffaella Vaninetti; Antonio Laporta; Sergio Masnaghetti; Rossella Raimondo; Mario Salerno; Francesco Santoro


Transcriptional Instability during Evolving Sepsis May Limit Biomarker Based Risk Stratification  

PubMed Central

Background Sepsis causes extensive morbidity and mortality in children worldwide. Prompt recognition and timely treatment of sepsis is critical in reducing morbidity and mortality. Genomic approaches are used to discover novel pathways, therapeutic targets and biomarkers. These may facilitate diagnosis and risk stratification to tailor treatment strategies. Objective To investigate the temporal gene expression during the evolution of sepsis induced multi-organ failure in response to a single organism, Neisseria meningitidis, in previously healthy children. Method RNA was extracted from serial blood samples (6 time points over 48 hours from presentation) from five critically ill children with meningococcal sepsis. Extracted RNA was hybridized to Affymetrix arrays. The RNA underwent strict quality control and standardized quantitation. Gene expression results were analyzed using GeneSpring software and Ingenuity Pathway Analysis. Result A marked variability in differential gene expression was observed between time points and between patients revealing dynamic expression changes during the evolution of sepsis. While there was evidence of time-dependent changes in expected gene networks including those involving immune responses and inflammatory pathways, temporal variation was also evident in specific “biomarkers” that have been proposed for diagnostic and risk stratification functions. The extent and nature of this variability was not readily explained by clinical phenotype. Conclusion This is the first study of its kind detailing extensive expression changes in children during the evolution of sepsis. This highlights a limitation of static or single time point biomarker estimation. Serial estimations or more comprehensive network approaches may be required to optimize risk stratification in complex, time-critical conditions such as evolving sepsis.

Kwan, Antonia; Hubank, Mike; Rashid, Asrar; Klein, Nigel; Peters, Mark J.



Use of risk stratification to target therapies in patients with recent onset arthritis; design of a prospective randomized multicenter controlled trial  

PubMed Central

Background Early and intensive treatment is important to inducing remission and preventing joint damage in patients with rheumatoid arthritis. While intensive combination therapy (Disease Modifying Anti-rheumatic Drugs and/or biologicals) is the most effective, rheumatologists in daily clinical practice prefer to start with monotherapy methotrexate and bridging corticosteroids. Intensive treatment should be started as soon as the first symptoms manifest, but at this early stage, ACR criteria may not be fulfilled, and there is a danger of over-treatment. We will therefore determine which induction therapy is most effective in the very early stage of persistent arthritis. To overcome over-treatment and under-treatment, the intensity of induction therapy will be based on a prediction model that predicts patients' propensity for persistent arthritis. Methods A multicenter stratified randomized single-blind controlled trial is currently being performed in patients 18 years or older with recent-onset arthritis. Eight hundred ten patients are being stratified according to the likelihood of their developing persistent arthritis. In patients with a high probability of persistent arthritis, we will study combination Disease Modifying Antirheumatic Drug therapy compared to monotherapy methotrexate. In patients with an intermediate probability of persistent arthritis, we will study Disease Modifying Antirheumatic Drug of various intensities. In patients with a low probability, we will study non-steroidal anti-inflammatory drugs, hydroxychloroquine and a single dose of corticosteroids. If disease activity is not sufficiently reduced, treatment will be adjusted according to a step-up protocol. If remission is achieved for at least six months, medication will be tapered off. Patients will be followed up every three months over two years. Discussion This is the first rheumatological study to base treatment in early arthritis on a prediction rule. Treatment will be stratified according to the probability of persistent arthritis, and different combinations of treatment per stratum will be evaluated. Treatment will be started early, and patients will not need to meet the ACR-criteria for rheumatoid arthritis. Trial registration This trial has been registered in Current Controlled Trials with the ISRCTN26791028.

Claessen, Susanne JJ; Hazes, Johanna MW; Huisman, Margriet AM; van Zeben, Derkjen; Luime, Jolanda J; Weel, Angelique EAM



N-terminal pro brain natriuretic peptide on admission for early risk stratification of patients with chest pain and no ST-segment elevation  

Microsoft Academic Search

ObjectivesThe study evaluated the prognostic value of single measurement of N-terminal pro brain natriuretic peptide (NT-proBNP) obtained on admission in patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation.

Tomas Jernberg; Mats Stridsberg; Per Venge; Bertil Lindahl



Very Early Risk Stratification Using Combined ECG and Biochemical Assessment in Patients With Unstable Coronary Artery Disease (A Thrombin Inhibition in Myocardial Ischemia (TRIM) Substudy)  

Microsoft Academic Search

Background—The diagnostic capability of troponin T (TnT), troponin I (TnI), myoglobin, and creatine kinase (CK)-MB mass for detection of myocardial injury seems evident. Newer studies have found these sensitive markers to carry independent prognostic information in patients with unstable coronary artery disease as well. ST-segment depression in the admission ECG is known to be an important indicator of poor outcome

Lene Holmvang; Michael S. Luscher; Peter Clemmensen; Kristian Thygesen; Peer Grande


Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: results from the DOPPS.  


Benefits and risks of antithrombotic agents remain unclear in the hemodialysis population. To help clarify this we determined variation in antithrombotic agent use, rates of major bleeding events, and factors predictive of stroke and bleeding in 48,144 patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases I-IV. Antithrombotic agents including oral anticoagulants (OACs), aspirin (ASA), and anti-platelet agents (APAs) were recorded along with comorbidities at study entry, and clinical events including hospitalization due to bleeding were then collected every 4 months. There was wide variation in OAC (0.3-18%), APA (3-25%), and ASA use (8-36%), and major bleeding rates (0.05-0.22 events/year) among countries. All-cause mortality, cardiovascular mortality, and bleeding events requiring hospitalization were elevated in patients prescribed OACs across adjusted models. The CHADS2 score predicted the risk of stroke in atrial fibrillation patients. Gastrointestinal bleeding in the past 12 months was highly predictive of major bleeding events; for patients with previous gastrointestinal bleeding, the rate of bleeding exceeded the rate of stroke by at least twofold across all categories of CHADS2 score, including patients at high stroke risk. Appropriate risk stratification and a cautious approach should be considered before OAC use in the dialysis population. PMID:23677245

Sood, Manish M; Larkina, Maria; Thumma, Jyothi R; Tentori, Francesca; Gillespie, Brenda W; Fukuhara, Shunichi; Mendelssohn, David C; Chan, Kevin; de Sequera, Patricia; Komenda, Paul; Rigatto, Claudio; Robinson, Bruce M



Risk stratification to predict pain during unsedated colonoscopy: results of a multicenter cohort study.  


Background and study aims: Colonoscopy without sedation has several advantages over sedated colonoscopy, but a considerable proportion of patients experience pain. The aim of this study was to develop a risk stratification model of pre-examination risk factors to enable targeted sedation during colonoscopy. Patients and methods: Between October 2011 and January 2012, consecutive outpatients who were willing to start colonoscopy without sedation at 11 Norwegian centers were prospectively recruited. Patients recorded pain on a validated 4-point scale (none, slight, moderate, or severe pain). Potential risk factors for a painful procedure (defined as moderate or severe pain) were evaluated using multivariate logistic regression analyses, and the area under the receiver operating characteristics curve (AUROC) was calculated to assess the discriminatory ability of the derived model. Results: A total of 1198 patients (635 men and 563 women) were included. Seven independent, pre-procedural risk factors for patient pain were identified: female sex, age < 40 years, previous abdominal surgery, abdominal pain as indication for colonoscopy, anticipation of pain, previous painful colonoscopy, and a history of diverticulitis. In patients with 0, 1, 2, or ? 3 risk factors, a painful colonoscopy was experienced by 35 %, 43 %, 52 %, and 63 % of women and 18 %, 24 %, 35 %, and 63 % of men, respectively. The model showed modest discrimination abilities (AUROC = 0.69).Conclusion: Female sex was a strong risk factor for pain during colonoscopy, and sedation or analgesia should be considered for all women prior to colonoscopy. For male patients, the presence of multiple risk factors should encourage the endoscopist to offer sedation. PMID:23884794

Holme, Oyvind; Bretthauer, Michael; de Lange, Thomas; Seip, Birgitte; Huppertz-Hauss, Gert; Høie, Ole; Sandvei, Per; Ystrøm, Carl Magnus; Hoff, Geir



Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model  

Microsoft Academic Search

Objective: Our purpose was to compare the performance of risk stratification model between Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patient database. Methods: From August 1994 to December 2000, 803 consecutive patients have undergone heart and thoracic aorta surgery using cardiopulmonary bypass and scored according to Parsonnet and EuroSCORE algorithm. The population was divided into

Yoshito Kawachi; Atsuhiro Nakashima; Yoshihiro Toshima; Kouich Arinaga; Hiroshi Kawano



One-year Risk of Advanced Colorectal Neoplasia: United States vs. United Kingdom Risk-stratification Guidelines  

PubMed Central

Background United Kingdom (U.K.) and United States (U.S.) guidelines for risk stratification after polypectomy differ, as do recommended surveillance intervals. Objective To compare risk of advanced colorectal neoplasia at one-year colonoscopy among patients cross-classified by U.S. and U.K. surveillance guidelines. Design Pooled analysis of four prospective studies, 1984-1998. Setting Academic and private clinics in the U.S. Patients 3226 post-polypectomy patients with 6-18 month follow-up colonoscopy. Measurements Rates of advanced neoplasia (adenoma ? 1cm, high-grade dysplasia, >25% villous histology, or invasive cancer) at one year, compared across U.S. and U.K. risk categories. Results Advanced neoplasia (95% CI) was detected one year post-polypectomy in 3.8% (2.7%-4.9%) of lower-risk and 11.2% (9.8%-12.6%) of higher-risk patients, by U.S. criteria. Using U.K. criteria, 4.4% (3.3%-5.4%), 9.9% (8.3%-11.5%), and 18.7% (14.8%-22.5%) of low-, intermediate-, and high-risk patients, respectively, presented with advanced neoplasia; U.K. high-risk patients comprised 12% of all patients. All U.S. lower-risk patients were low-risk by U.K. criteria; however, since the U.K. guidelines do not consider histological features, more patients are classified as low-risk. U.S. higher-risk patients distributed across the three U.K. categories. Considering all patients with advanced neoplasia, 26.3% were reclassified by the U.K criteria to a higher and 7.0% to a lower risk category, with a net 19% benefiting from two-year earlier detection. Overall, substitution of U.K. for U.S. guidelines resulted in an estimated 0.03 additional colonoscopies per five years per patient. Limitations Patients were enrolled 15-20 years ago; colonoscopy quality measures were unavailable. Patients lacking follow-up colonoscopy or with surveillance colonoscopy after 6-18 months, and those with cancer or insufficient baseline adenoma characteristics were excluded (2076/5302). Conclusions Application of the U.K. guidelines in the U.S. could identify a subset of patients whose high risk may warrant a one-year clearing colonoscopy, without substantially increasing colonoscopy rates.

Martinez, Maria Elena; Thompson, Patricia; Messer, Karen; Ashbeck, Erin L.; Lieberman, David A.; Baron, John A.; Ahnen, Dennis J.; Robertson, Douglas J.; Jacobs, Elizabeth T.; Greenberg, E. Robert; Cross, Amanda J.; Atkin, Wendy



Risk stratification for implantable cardioverter defibrillator therapy: the role of the wearable cardioverter-defibrillator.  


The benefit of implantable cardioverter-defibrillator (ICD) therapy depends upon appropriate evaluation of a persisting risk of sudden death and estimation of the patient's overall survival. Assessment of a stable and unchangeable arrhythmogenic substrate is often difficult. Structural abnormality and ventricular dysfunction, the two major risk parameters, may recover, and heart failure symptoms can improve so that ICD therapy may not be indicated. Risk stratification can take time while the patient continues to be at high risk of arrhythmic death, and patients may need temporary bridging by a defibrillator in cases of interrupted ICD therapy. The wearable cardioverter-defibrillator (WCD) combines a long-term electrocardiogram (ECG)-monitoring system with an external automatic defibrillator. The LIfeVest® (ZOLL, Pittsburgh, PA, USA) is composed of a garment, containing two defibrillation patch electrodes on the back, and an elastic belt with a front-defibrillation patch electrode and four non-adhesive ECG electrodes, connected to a monitoring and defibrillation unit. The WCD is a safe and effective tool to terminate ventricular tachycardia/ventricular fibrillation events, unless a conscious patient withholds shock delivery. It may be used in patients in the early phase after acute myocardial infarction with poor left ventricular function, after acute coronary revascularization procedures (percutaneous coronary intervention or coronary artery bypass grafting) and reduced left ventricular ejection fraction (?35%), in patients with acute heart failure in non-ischaemic cardiomyopathy of uncertain aetiology and prognosis. The WCD may be helpful in subjects with syncope of assumed tachyarrhythmia origin or in patients with inherited arrhythmia syndromes. The WCD may replace ICD implantation in patients waiting for heart transplantation or who need a ventricular-assist device. This review describes the technical details and characteristics of the WCD, discusses its various potential applications, and reports the currently available experience with the wearable defibrillator. PMID:23729691

Klein, Helmut U; Goldenberg, Ilan; Moss, Arthur J



Prognostic factors and risk stratification in early mycosis fungoides.  


Available demographic, clinical, histologic, immunohistochemical and laboratory findings, including serum cytokine/cytokine receptor levels, obtained at initial evaluation in a cohort of 33 patients with mycosis fungoides (MF) at stages I-IIA who had subsequent progression of disease were compared against 70 stage-matched cases of MF without observed progression. Significant factors that correlated with both disease progression and overall survival were: (1) presence of large Pautrier microabscesses (10 or more atypical lymphocytes), (2) presence of atypical lymphocytes with hyperchromatic or vesicular nuclei in the dermal infiltrate, (3) less than 20% CD8 + cells in the dermal infiltrate and (4) above normal (> 122 U/mL) serum immunoglobulin E (IgE) level. Combination of these factors was used to construct prognostic groupings which, if validated, might be useful to identify patients with clinically early MF at highest risk for disease progression and poor outcome. PMID:23547839

Vonderheid, Eric C; Pavlov, Igor; Delgado, Julio C; Martins, Thomas B; Telang, Gladys H; Hess, Allan D; Kadin, Marshall E



Use of risk stratification to guide ambulatory management of neutropenic fever. Australian Consensus Guidelines 2011 Steering Committee.  


Utilization of risk-stratification tools in the setting of neutropenic fever is currently limited by inadequate knowledge and lack of awareness. Within this context, the approach to management of low-risk patients with neutropenic fever is inconsistent with the available evidence across many Australian treating centres. These clinical guidelines define and clarify an accepted standard of care for this patient group given the current evidence base. The Multinational Association for Supportive Care in Cancer risk index is presented as the preferred risk assessment tool for determining patient risk. Suitability of ambulatory care within specific patient populations is discussed, with defined eligibility criteria provided to guide clinical decision-making. Detailed recommendations for implementing appropriate ambulatory strategies, such as early discharge and outpatient antibiotic therapy, are also provided. Due consideration is given to infrastructural requirements and other supportive measures at a resourcing and operational level. An analysis of the relevant health economics is also presented. PMID:21272172

Worth, L J; Lingaratnam, S; Taylor, A; Hayward, A M; Morrissey, S; Cooney, J; Bastick, P A; Eek, R W; Wei, A; Thursky, K A



Application of Multivariate Probabilistic (Bayesian) Networks to Substance Use Disorder Risk Stratification and Cost Estimation  

PubMed Central

Introduction: This paper explores the use of machine learning and Bayesian classification models to develop broadly applicable risk stratification models to guide disease management of health plan enrollees with substance use disorder (SUD). While the high costs and morbidities associated with SUD are understood by payers, who manage it through utilization review, acute interventions, coverage and cost limitations, and disease management, the literature shows mixed results for these modalities in improving patient outcomes and controlling cost. Our objective is to evaluate the potential of data mining methods to identify novel risk factors for chronic disease and stratification of enrollee utilization, which can be used to develop new methods for targeting disease management services to maximize benefits to both enrollees and payers. Methods: For our evaluation, we used DecisionQ machine learning algorithms to build Bayesian network models of a representative sample of data licensed from Thomson-Reuters' MarketScan consisting of 185,322 enrollees with three full-year claim records. Data sets were prepared, and a stepwise learning process was used to train a series of Bayesian belief networks (BBNs). The BBNs were validated using a 10 percent holdout set. Results: The networks were highly predictive, with the risk-stratification BBNs producing area under the curve (AUC) for SUD positive of 0.948 (95 percent confidence interval [CI], 0.944–0.951) and 0.736 (95 percent CI, 0.721–0.752), respectively, and SUD negative of 0.951 (95 percent CI, 0.947–0.954) and 0.738 (95 percent CI, 0.727–0.750), respectively. The cost estimation models produced area under the curve ranging from 0.72 (95 percent CI, 0.708–0.731) to 0.961 (95 percent CI, 0.95–0.971) Conclusion: We were able to successfully model a large, heterogeneous population of commercial enrollees, applying state-of-the-art machine learning technology to develop complex and accurate multivariate models that support near-real-time scoring of novel payer populations based on historic claims and diagnostic data. Initial validation results indicate that we can stratify enrollees with SUD diagnoses into different cost categories with a high degree of sensitivity and specificity, and the most challenging issue becomes one of policy. Due to the social stigma associated with the disease and ethical issues pertaining to access to care and individual versus societal benefit, a thoughtful dialogue needs to occur about the appropriate way to implement these technologies.

Weinstein, Lawrence; Radano, Todd A; Jack, Timothy; Kalina, Philip; Eberhardt, John S



Diagnostic accuracy of dual-source CT angiography and coronary risk stratification  

PubMed Central

Purpose The aim of this study was to evaluate the diagnostic accuracy of dual-source computed tomography (DSCT) in coronary artery disease, and to test the possibility of using this technique for coronary risk stratification. Background With the advent of DSCT, it is possible to image coronary plaque noninvasively. However, the accuracy of this method in terms of sensitivity and specificity has not been determined. Furthermore, noninvasive determination of plaque composition and plaque burden may be important for improving coronary risk stratification. Methods Forty-six patients with known coronary artery disease underwent DSCT quantitative coronary angiography (QCA), and intravascular ultrasound (IVUS) were included in the study. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DSCT was calculated against QCA and IVUS. Plaque analysis software in a DSCT workstation was used to detect plaque characteristics associated with the Hounsfield unit (Hu) value compared with IVUS. Coronary artery plaques were classified into three types of lesions based on DSCT, and the relationship between different coronary lesions and clinical diagnosis was determined. Results DSCT angiography was performed in 46 patients, and a diagnostic-quality CT image was obtained in 44 patients. Coronary angiography was performed in 138 vessels and IVUS in 102 vessels of all 46 patients. Sensitivity, specificity, PPV, and NPV of DSCT compared with QCA was 100%, 98%, 92%, and 100%, respectively. The same corresponding index of DSCT compared with IVUS was 100%, 99%, 95%, and 100%, respectively. Quantitative coronary stenosis analysis revealed a good correlation between DSCT and QCA (r = 0.85, P < 0.05, 95% confidence interval [CI] 0.60–0.87). There was also a good correlation between DSCT and IVUS (r = 0.81, P < 0.05, 95% CI 0.56–0.82). In comparison with IVUS, DSCT predicted plaque characteristics more accurately. The coefficient correlation (r) of luminal cross-sectional area and external elastic membrane cross-sectional area between DSCT and IVUS was 0.82 (P < 0.01, CI 0.67–0.89) and 0.78 (P < 0.01, CI 0.67–0.86), respectively. Three different types of plaque were identified on IVUS. Fatty plaque had a 45 ± 14 Hu value, fibrous plaque 90 ± 20, and calcified plaque 530 ± 185, respectively, on DSCT. The relationship between clinical diagnosis and coronary plaque on DSCT indicated that lesions in patients with unstable angina pectoris or ST elevation myocardial infarction were mainly discrete soft plaques, but there was no significant difference in the distributive characteristics of the lesions in patients with non-ST elevation myocardial infarction and stable angina pectoris patients. Conclusions DSCT is a noninvasive tool that allows accurate evaluation of plaque characteristics, diagnosis of coronary artery disease, and stratification of coronary risk according to different coronary plaque type.

Yang, Xia; Gai, Lu-yue; Li, Ping; Chen, Yun-dai; Li, Tao; Yang, Li



Comparison of cardiac troponin T versus creatine kinase-MB for risk stratification in a chest pain evaluation unit.  


We evaluated cardiac troponin T (cTnT) and creatine kinase-MB (CK-MB) for risk stratification of chest pain unit (CPU) patients. We studied 383 consecutive patients with chest pain assigned to our CPU by emergency department physicians. At baseline all had normal or nondiagnostic electrocardiograms, no high-risk clinical features, and negative CK/CK-MB. CK-MB and electrocardiograms were taken at 0, 4, 8, and 12 hours and cTnT at 0, 4, and 8 hours. Eight patients (2.1%) were CK-MB positive and 39 (10.2%) were cTnT positive, including all but 1 CK-MB-positive patient. All marker-positive patients were detected by 8 hours. Seven cTnT-positive patients and 1 cTnT-negative patient had myocardial infarction (p <0.0001). cTnT-positive patients were older, less likely to be women or smokers, and more often had diabetes mellitus or known coronary disease (CAD). Seventy-one percent of patients underwent diagnostic testing. cTnT-positive patients more often underwent angiography (46% vs 20%) and underwent stress testing less often (28% vs 57%) than cTnT-negative patients. When performed, their stress tests were more often positive (46% vs 14%) and they more often had angiographically significant lesions (89% vs 49%) and multivessel disease (67% vs 29%). There were no short-term deaths. Long-term mortality was higher in cTnT-positive patients (27% vs 7%, p <0.0001). Thus, cTnT identified more CPU patients with myocardial necrosis and multivessel CAD than CK-MB and a population with high long-term mortality risk. Routine use of cTnT in CPUs could facilitate risk stratification and management. PMID:10758916

Newby, L K; Kaplan, A L; Granger, B B; Sedor, F; Califf, R M; Ohman, E M



Is Risk Stratification for Breast Cancer Screening Methodologically Feasible?  

Microsoft Academic Search

Background: In 2004 the Institute of Medicine of the U.S. National Academies published a report, Saving Women's Lives - Strategies for Improving Breast Cancer Detection and Diagnosis. A major recommendation was to develop tools to identify women who would benefit most from breast cancer screening, based on individually tailored risk prediction techniques. This talk examines what is known about risk

Fletcher SW


Evidence-based Guidelines for Precision Risk Stratification-Based Screening (PRSBS) for Colorectal Cancer: Lessons learned from the US Armed Forces: Consensus and Future Directions.  


Colorectal cancer (CRC) is the third most common cause of cancer-related death in the United States (U.S.), with estimates of 143,460 new cases and 51,690 deaths for the year 2012. Numerous organizations have published guidelines for CRC screening; however, these numerical estimates of incidence and disease-specific mortality have remained stable from years prior. Technological, genetic profiling, molecular and surgical advances in our modern era should allow us to improve risk stratification of patients with CRC and identify those who may benefit from preventive measures, early aggressive treatment, alternative treatment strategies, and/or frequent surveillance for the early detection of disease recurrence. To better negotiate future economic constraints and enhance patient outcomes, ultimately, we propose to apply the principals of personalized and precise cancer care to risk-stratify patients for CRC screening (Precision Risk Stratification-Based Screening, PRSBS). We believe that genetic, molecular, ethnic and socioeconomic disparities impact oncological outcomes in general, those related to CRC, in particular. This document highlights evidence-based screening recommendations and risk stratification methods in response to our CRC working group private-public consensus meeting held in March 2012. Our aim was to address how we could improve CRC risk stratification-based screening, and to provide a vision for the future to achieving superior survival rates for patients diagnosed with CRC. PMID:23459409

Avital, Itzhak; Langan, Russell C; Summers, Thomas A; Steele, Scott R; Waldman, Scott A; Backman, Vadim; Yee, Judy; Nissan, Aviram; Young, Patrick; Womeldorph, Craig; Mancusco, Paul; Mueller, Renee; Noto, Khristian; Grundfest, Warren; Bilchik, Anton J; Protic, Mladjan; Daumer, Martin; Eberhardt, John; Man, Yan Gao; Brücher, Björn Ldm; Stojadinovic, Alexander



Fetal and neonatal alloimmune thrombocytopenia: a management algorithm based on risk stratification.  


Fetal and neonatal alloimmune thrombocytopenia constitutes the most common cause of severe thrombocytopenia in fetuses and neonates and of intracranial hemorrhage among term newborns. The cornerstone of therapy involves the use of steroids and intravenous immunoglobulins. Despite the risk of potentially devastating consequences to the fetus, fetal blood sampling has typically been used to document response to therapy. We propose a therapeutic algorithm based on risk stratification with individualized treatment optimization without the use of fetal blood sampling. PMID:22015886

Pacheco, Luis D; Berkowitz, Richard L; Moise, Kenneth J; Bussel, James B; McFarland, Janice G; Saade, George R



[The importance of cardiac bio-marker assay for the stratification and monitoring of AL amyloidosis patients -? single center experience].  


Introduction: Cardiac involvement is a dominant prognostic factor in AL amyloidosis patients. A detailed assessment of the presence and degree of cardiac involvement utilizes an array of noninvasive investigation methods, particularly echocardiography and MRI; laboratory parameters include troponins and natriuretic peptides. Cardiac involvement detection aside, cardiac bio-markers are used as a relatively strong stratification and prognostic factor. Objective: The presentation of cardiac bio-markers assay applications in AL amyloidosis patients at an individual treatment center.Patients and methods: The monitored patient set consisted of 22 patients with histologically confirmed AL amyloidosis, of whom 18 met the criteria for cardiac involvement. Levels of cardiac bio-markers troponin T (TnT) and Nterminal probrain natriuretic peptide (NT?ProBNP) were determined in all patients. Risk stratification of the patients utilized the Mayo staging system which is based on both bio-markers assays; Log Rank Test was applied to survival evaluation. Results: Median survival of patients with cardiac involvement stigmata was 10 months vs 60 months survival of patients without signs of cardiac involvement (p = 0.133). Of the 4 patients without cardiac involvement, 1 has shown positive levels of TnT and 2 positive levels of NT?ProBNP. All cardiac involvement patients exhibited abnormal levels of NT?ProBNP (median 4,752 ng/?l; 415.7-?35,000) as well as positive levels of TnT (median 0.0815 ?g/?l; 0.02-?0.986). The application of the Mayo stratification system to the set had determined 2 patients at stage I, 5 patients at stage II and 15 patients at stage III. The median survival of the Mayo I + II group vs the Mayo III group was 60 vs 6 months (p = 0.015), revealing extremely limited survival of stage III patients. Assessment of TnT and NT?ProBNP levels relative to treatment response shows that the degree of decrease in both markers depends on maximum treatment response -? respectively the attainment of a complete hematological remission. Conclusion: The results, although obtained from a limited set of patients, confirm a definitive benefit of the application of cardiac bio-markers assay in the dia-gnostic and therapeutic algorithm of AL amyloidosis patients. The Mayo stratification system utilizing the cardiac indicator values represents a robust tool for risk stratification of AL amyloidosis patients. Key words: AL amyloidosis -? cardiac involvement -? troponin -? natriuretic peptides. PMID:24073949

Pika, T; Lochman, P; Vym?tal, J; Metelka, R; Flodr, P; Mina?ík, J; Látalová, P; Zapletalová, J; Ba?ovský, J; S?udla, V



Sudden cardiac death in non-ischemic dilated cardiomyopathy: a critical appraisal of existing and potential risk stratification tools.  


Non ischemic dilated cardiomyopathy poses a significant risk of malignant ventricular arrhythmias and subsequent sudden cardiac death. The pathologic and electrophysiological substrate implicated to arrhythmogenesis has been quite adequately defined over the last decades and multiple forms of myocardial fibrosis - diffuse, patchy or gross scarring - are being studied regarding their arrhythmogenic potential. Moreover, the recent demonstration and continuous expansion of knowledge regarding causative genes in dilated cardiomyopathy open a new chapter in the field of diagnosis and prognosis of these patients. Numerous noninvasive and invasive methods have been used to stratify patients according to sudden cardiac death level of risk. Severely reduced left ventricular systolic myocardial function, expressed mostly by left ventricular ejection function, NYHA functional class, syncope and invasive electrophysiological study with programmed electrical stimulation have been incorporated into international guidelines, though leaving significant proportions of primary prevention patients out of stratification schemes. Electrocardiographic markers, signal-averaged ECG, heart rate variability, heart rate turbulence, baroreflex sensitivity, heart rate recovery and T-wave alternans have given conflicting results in non ischemic dilated cardiomyopathy. During the last decade, cardiac magnetic resonance, especially with gadolinium enhancement, has made a step forward in defining the fibrotic substrate of such patients. Prospective studies have given promising results, demonstrating correlation between late gadolinium enhancement and ventricular arrhythmogenesis. Identification of patients with genetically caused dilated cardiomyopathy prone to sudden cardiac death and large prospective trials investigating cardiac magnetic resonance and its prognostic potential may be able to establish a new era in stratification schemes. PMID:22889703

Koutalas, Emmanuel; Kanoupakis, Emmanuel; Vardas, Panos



Risk Stratification After Acute Myocardial Infarction by Heart Rate Turbulence  

Microsoft Academic Search

Background—Retrospective postinfarction studies revealed that decreased heart rate turbulence (HRT) indicates increased risk for subsequent death. This is the first prospective study to validate HRT in a large cohort of the reperfusion era. Methods and Results—One thousand four hundred fifty-five survivors of an acute myocardial infarction (age 76 years) in sinus rhythm were enrolled. HRT onset (TO) and slope (TS)

Petra Barthel; Raphael Schneider; Axel Bauer; Kurt Ulm; Claus Schmitt; Albert Schömig; Georg Schmidt



Systemic mastocytosis in adults: 2013 update on diagnosis, risk stratification, and management.  


DISEASE OVERVIEW: Systemic mastocytosis (SM) results from a clonal proliferation of abnormal mast cells (MC) in one or more extracutaneous organs. DIAGNOSIS: The major criterion is presence of multifocal clusters of morphologically abnormal MC in the bone marrow. Minor diagnostic criteria include elevated serum tryptase level, abnormal MC expression of CD25 and/or CD2, and presence of KITD816V. RISK STRATIFICATION: The 2008 World Health Organization (WHO) classification of SM has been shown to be prognostically relevant. Classification of SM patients into indolent (SM), aggressive SM (ASM), SM associated with a clonal non-MC lineage disease (SM-AHNMD) and mast cell leukemia (MCL) subgroups is a useful first step in establishing prognosis. MANAGEMENT: SM treatment is generally palliative. ISM patients have a normal life expectancy and receive symptom-directed therapy; infrequently, cytoreductive therapy may be indicated for refractory symptoms. ASM patients have disease-related organ dysfunction; interferon-? (±corticosteroids) can control dermatological, hematological, gastrointestinal, skeletal, and mediator-release symptoms, but is hampered by poor tolerability. Similarly, cladribine has broad therapeutic activity, with particular utility when rapid MC debulking is indicated; the main toxicity is myelosuppression. Imatinib has a therapeutic role in the presence of an imatinib-sensitive KIT mutation or in KITD816-unmutated patients. Treatment of SM-AHNMD is governed primarily by the non-MC neoplasm; hydroxyurea has modest utility in this setting. INVESTIGATIONAL DRUGS: Dasatinib's in vitro anti- KITD816V activity has not translated into significant therapeutic activity in most SM patients. In contrast, recently updated data confirms Midostaurin's significant anti-MC activity in patients with advanced SM. Am. J. Hematol. 00:000-000, 2013. © 2013 Wiley Periodicals, Inc. PMID:23720340

Pardanani, Animesh



Plasma IL-8 is not an effective risk stratification tool for adults with vasopressor-dependent septic shock  

PubMed Central

Objective Plasma interleukin-8 (IL-8) levels of < 220 pg/ml have an excellent negative predictive value (94–95%) for death at 28 days in children with septic shock and thus may be useful for risk stratification in clinical trial enrollment in this population. Whether plasma IL-8 would have similar utility in adults with septic shock is unknown. Design, Setting, and Patients Analysis of plasma IL-8 levels in 192 adults with vasopressor-dependent septic shock enrolled in clinical trials of acute lung injury conducted by the Acute Respiratory Distress Syndrome Network Measurements and Main Results Plasma IL-8 levels ? 220 pg/ml were significantly associated with death at 28 days in this cohort (odds ratio 2.92, 95% CI 1.42–5.99; p=0.001). However, in contrast to the findings in pediatric septic shock, a plasma IL-8 cutoff below 220 pg/ml had a negative predictive value for death of only 74% (95% CI 66–81%) in adults with septic shock. Receiver-operating characteristic analysis found an area under the curve of 0.59 for plasma IL-8, indicating that plasma IL-8 is a poor predictor of mortality in this group. In adults under age 40, a plasma IL-8 cutoff < 220 pg/ml had a negative predictive value of 92%. Conclusions In contrast to similar pediatric patients, plasma IL-8 levels are not an effective risk stratification tool in older adults with septic shock. Future studies of biomarkers for risk stratification in critically ill subjects will need to be replicated in multiple different populations before being applied in screening for clinical trials.

Calfee, Carolyn S.; Thompson, B. Taylor; Parsons, Polly E.; Ware, Lorraine B.; Matthay, Michael A.; Wong, Hector R.



Baseline Risk of Major Bleeding in Non-ST-Segment-Elevation Myocardial Infarction: The CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC\\/AHA guidelines) Bleeding Score  

Microsoft Academic Search

Background—Treatments for non-ST-segment-elevation myocardial infarction (NSTEMI) reduce ischemic events but increase bleeding. Baseline prediction of bleeding risk can complement ischemic risk prediction for optimization of NSTEMI care; however, existing models are not well suited for this purpose. Methods and Results—We developed (n71 277) and validated (n17 857) a model that identifies 8 independent baseline predictors of in-hospital major bleeding among

Sumeet Subherwal; Richard G. Bach; Anita Y. Chen; Brian F. Gage; Sunil V. Rao; L. Kristin Newby; Tracy Y. Wang; W. Brian Gibler; E. Magnus Ohman; Matthew T. Roe; Charles V. Pollack; Eric D. Peterson; Karen P. Alexander



Prediction of Failure in Vancomycin-Treated Methicillin-Resistant Staphylococcus aureus Bloodstream Infection: a Clinically Useful Risk Stratification Tool?†  

PubMed Central

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of bloodstream infection (BSI) and is often associated with invasive infections and high rates of mortality. Vancomycin has remained the mainstay of therapy for serious Gram-positive infections, particularly MRSA BSI; however, therapeutic failures with vancomycin have been increasingly reported. We conducted a comprehensive evaluation of the factors (patient, strain, infection, and treatment) involved in the etiology and management of MRSA BSI to create a risk stratification tool for clinicians. This study included consecutive patients with MRSA BSI treated with vancomycin over 2 years in an inner-city hospital in Detroit, MI. Classification and regression tree analysis (CART) was used to develop a risk prediction model that characterized vancomycin-treated patients at high risk of clinical failure. Of all factors, the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, with a cutoff point of 14, was found to be the strongest predictor of failure and was used to split the population into two groups. Forty-seven percent of the population had an APACHE-II score < 14, a value that was associated with low rates of clinical failure (11%) and mortality (4%). Fifty-four percent of the population had an APACHE-II score ? 14, which was associated with high rates of clinical failure (35%) and mortality (23%). The risk stratification model identified the interplay of three other predictors of failure, including the vancomycin MIC as determined by Vitek 2 analysis, the risk level of the source of BSI, and the USA300 strain type. This model can be a useful tool for clinicians to predict the likelihood of success or failure in vancomycin-treated patients with MRSA bloodstream infection.

Moore, Carol L.; Lu, Mei; Cheema, Faiqa; Osaki-Kiyan, Paola; Perri, Mary Beth; Donabedian, Susan; Haque, Nadia Z.; Zervos, Marcus J.



Incurring Greater Health Care Costs: Risk Stratification of Employees With Bipolar Disorder  

PubMed Central

Purpose: To compare the costs of employees with bipolar disorder with other employee cohorts and to assess cost differences among employees with bipolar disorder of varying severity. Methods: Retrospective data analysis comparing employees with bipolar disorder (cohort 1) with employees without bipolar disorder (cohort 2), employees with other mental disorders (cohort 3), and employees with no mental disorders (cohort 4). Sick leave, short-term disability, long-term disability, and workers' compensation data were used to compare annual lost time and work-absence costs from January 1, 2001, through December 31, 2002. For bipolar disorder severity and risk stratification, quintiles were identified based on total medical and prescription drug costs and analyzed for many health benefits cost categories. Results: Cohort 1 was the most costly in nearly every health benefits cost category. All comparisons between cohort 1 and cohorts 2, 3, and 4 yielded significant (p ? .05) differences except for sick leave costs in cohorts 1 and 3. The aggregate health benefits costs for the highest-cost cohort 1 quintile were $70,616, or 21 times greater than the health benefits costs for the lowest-cost quintile ($3385). Medical comorbidity costs accounted for most of this difference ($51,495; p ? .05). Conclusion: Employees with bipolar disorder are the most costly in nearly every health benefits category, with a small minority (2.4%) accounting for 20% of the costs. Employers need to identify and target high-risk (“high cost”) employees with bipolar disorder and coexisting conditions that use resources more frequently for appropriate interventions that may include early screening and diagnosis, appropriate treatment, and/or behavioral strategies for improved adherence. These strategies have the potential to improve quality of patient care and reduce costs.

Brook, Richard A.; Rajagopalan, Krithika; Kleinman, Nathan L.; Smeeding, James E.; Brizee, Truman J.; Gardner, Harold H.



Prognostic stratification of patients with advanced renal cell carcinoma treated with sunitinib: comparison with the Memorial Sloan-Kettering prognostic factors model  

Microsoft Academic Search

BACKGROUND: The treatment paradigm in advanced renal cell carcinoma (RCC) has changed in the recent years. Sunitinib has been established as a new standard for first-line therapy. We studied the prognostic significance of baseline characteristics and we compared the risk stratification with the established Memorial Sloan Kettering Cancer Center (MSKCC) model. METHODS: This is a retrospective analysis of patients treated

Aristotelis Bamias; Alexandra Karadimou; Sofia Lampaki; George Lainakis; Lia Malettou; Eleni Timotheadou; Kostas Papazisis; Charalambos Andreadis; Loukas Kontovinis; Ioannis Anastasiou; Kostas Stravodimos; Ioannis Xanthakis; Andreas Skolarikos; Christos Christodoulou; Kostas Syrigos; Christos Papandreou; Evangelia Razi; Urania Dafni; George Fountzilas; Meletios A Dimopoulos



Limited Value of Cystatin-C over Estimated Glomerular Filtration Rate for Heart Failure Risk Stratification  

PubMed Central

Background To compare the prognostic value of estimated glomerular filtration rate, cystatin-C, an alternative renal biomarker, and their combination, in an outpatient population with heart failure.Estimated glomerular filtration rate is routinely used to assess renal function in heart failure patients. We recently demonstrated that the Cockroft-Gault formula is the best among the most commonly used estimated glomerular filtration rate formulas for predicting heart failure prognosis. Methodology/Principal Findings A total of 879 consecutive patients (72% men, age 70.4 years [P25–75 60.5–77.2]) were studied. The etiology of heart failure was mainly ischemic heart disease (52.7%). The left ventricular ejection fraction was 34% (P25–75 26–43%). Most patients were New York Heart Association class II (65.8%) or III (25.9%). During a median follow-up of 3.46 years (P25–75 1.85–5.05), 312 deaths were recorded. In an adjusted model, estimated glomerular filtration rate and cystatin-C showed similar prognostic value according to the area under the curve (0.763 and 0.765, respectively). In Cox regression, the multivariable analysis hazard ratios were 0.99 (95% CI: 0.98–1, P?=?0.006) and 1.14 (95% CI: 1.02–1.28, P?=?0.02) for estimated glomerular filtration rate and cystatin-C, respectively. Reclassification, assessed by the integration discrimination improvement and the net reclassification improvement indices, was poorer with cystatin-C (?0.5 [?1.0;?0.1], P?=?0.024 and ?4.9 [?8.8;?1.0], P?=?0.013, respectively). The value of cystatin-C over estimated glomerular filtration rate for risk-stratification only emerged in patients with moderate renal dysfunction (eGFR 30–60 ml/min/1.73 m2, chi-square 12.9, P<0.001). Conclusions/Significance Taken together, the results indicate that estimated glomerular filtration rate and cystatin-C have similar long-term predictive values in a real-life ambulatory heart failure population. Cystatin-C seems to offer improved prognostication in heart failure patients with moderate renal dysfunction.

Zamora, Elisabet; Lupon, Josep; de Antonio, Marta; Vila, Joan; Galan, Amparo; Gastelurrutia, Paloma; Urrutia, Agustin; Bayes-Genis, Antoni



Diagnostic evaluation of people with hypertension in low income country: cohort study of "essential" method of risk stratification  

PubMed Central

Objectives To explore the predictive power of a risk stratification method for people with hypertension based on “essential” procedures (that is, available in economically less developed areas of the world), comparing it in the same population with the results given by the method suggested by the 1999 World Health Organization-International Society of Hypertension (WHO-ISH) guidelines. Design Prospective cohort study of outcomes according to cardiovascular risk profile at baseline. Setting Primary care in a poor rural area of the Ecuadorian forest. Participants 504 people with hypertension prospectively monitored for a mean of 6.7 (SD 2.3) years. Interventions Essential data included blood pressure, medical history, smoking, age, sex, and diagnosis of diabetes; the WHO-ISH methods additionally included measurement of fasting blood glucose, total cholesterol, and creatinine, urinalysis, and electrocardiography. Main outcome measures Cardiovascular events and total deaths. Results With both methods there was a highly significant association between the level of predicted risk and the incidence of cardiovascular events and of total deaths: up to three quarters of all cardiovascular events and two thirds of all deaths were reported among people classified as at high or very high risk with either method. The predictive discrimination of the essential method is comparable with the WHO-ISH with C statistics (95% confidence interval) of 0.788 (0.721 to 0.855) and 0.744 (0.673 to 0.815), respectively, for cardiovascular events and 0.747 (0.678 to 0.816) and 0.705 (0.632 to 0.778) for total mortality. Conclusions The risk stratification of patients with hypertension with an essential package of variables (that is, available and practicable even in the economically less developed areas of the world) serves at least as well as the more comprehensive method proposed by WHO-ISH.



New directions in cardiovascular risk assessment: the role of secondary risk stratification markers.  


Cardiovascular disease (CVD) risk screening is performed by multivariate methods relying on calculators derived from the Framingham study, other epidemiological studies or primary care records. However, it only identifies 70% of individuals at risk for CVD events and there has been interest in adding other risk factors to improve its predictive capacity. The addition of a family history of premature CVD is well established and there is evidence for adding lipoprotein (a) in some populations and possibly C-reactive protein may be suitable for general use in CVD risk assessment. Most new biochemical and imaging markers have been assessed in the context of improving risk classification in intermediate-risk groups rather than in the general population. There is evidence that N-terminal pro-B-type natriuretic peptide and coronary artery calcium score add significantly to risk prediction. The data for carotid intima-media thickness, ankle-brachial index are less strong and high sensitivity troponins look promising, but have had only limited data to date. Large scale meta-analyses ideally of pooled primary patient data will be required to determine the best additional markers to add to conventional risk prediction and in what groups to apply them. PMID:22698414

Wierzbicki, A S



[Risk stratification of asymptomatic subjects using resting ECG and stress ECG].  


The resting electrocardiogram (ECG) and stress ECG are established tests in the array of cardiovascular diagnostic modalities. In addition to their diagnostic value for structural heart disease and rhythm disorders, ECGs at rest or during stress also contain prognostically relevant information. Several ECG abnormalities, e.g., left ventricular hypertrophy (LVH), Q waves, ST segment changes, left bundle branch block, atrial fibrillation or QT interval prolongation, were shown to be associated with cardiovascular events. Differences in study design, the cohorts of investigation and morphological definitions of ECG abnormalities may in part be responsible for the abnormalities not being implemented in risk stratification algorithms. The non-ST-segment-related variables in stress testing, e.g., functional capacity, chronotropic (in)competence, heart rate (HR) recovery, and the HR/ST index and slope, could be identified as prognostically relevant markers in population-based studies. For many of these resting and stress ECG-based abnormalities, associations with the extent of subclinical atherosclerosis in persons without established coronary heart disease were observed, indicating a preclinical relationship between epicardial atherosclerosis and myocardial pathology. The resting and the stress ECG provide a number of prognostically relevant indices that can easily be obtained in routine clinical practice, but have thus far found little acceptance for risk stratification of asymptomatic individuals. PMID:17687525

Möhlenkamp, Stefan; Wieneke, Heinrich; Sack, Stefan; Erbel, Raimund



Incremental Prognostic Value of Myocardial Perfusion Single Photon Emission Computed Tomography for the Prediction of Cardiac Death Differential Stratification for Risk of Cardiac Death and Myocardial Infarction  

Microsoft Academic Search

Background—The incremental prognostic value of stress single photon emission computed tomography (SPECT) for the prediction of cardiac death as an individual end point and the implications for risk stratification are undefined. Methods and Results—We identified 5183 consecutive patients who underwent stress\\/rest SPECT and were followed up for the occurrence of cardiac death or myocardial infarction. Over a mean follow up

Rory Hachamovitch; Daniel S. Berman; Leslee J. Shaw; Hosen Kiat; Ishac Cohen; J. Arthur Cabico; John Friedman; George A. Diamond



PubMed Central

Background Quality and benchmarking initiatives highlight the need for accurate stratified risk adjustment. The stratification of trauma patients has relied on scores specific to trauma populations. While the Acute Physiologic and Chronic Health Evaluation (APACHE) II score has been considered "invalid" in the trauma population, we hypothesized that APAHCE II would more accurately predict outcomes in critically injured patients in whom commonly used trauma scores have inherent limitations. Methods A prospective cohort of critically injured patients was enrolled. Severity scores and their sub-components were collected, and in-hospital mortality was assessed. The area under the receiver operating characteristic (AUROC) curve was used to determine the predictive value of each score. Logistic regression estimated the odds of death associated with incremental changes in severity scores and their subcomponents. Results 1,019 patients were available for analysis. APACHE II was the best predictor of mortality (AUROC 0.77 versus AUROC 0.54 for ISS and 0.64 for TRISS). A unit increase in APACHE II was associated with an OR of death of 1.18 (95% CI 1.14 – 1.22). The components of APACHE II that contributed the most to its accuracy included temperature, serum creatinine and the Glasgow Coma Scale (GCS). Conclusion Critically injured patients have physiologic derangements not accurately accounted for by commonly used trauma scores. In this subset a more general ICU scoring system is useful for risk adjustment for research, administrative and quality improvement purposes.

Dossett, Lesly A; Redhage, Leigh Anne; Sawyer, Robert G; May, Addison K



Usefulness of semiquantitative analysis of dipyridamole-thallium-201 redistribution for improving risk stratification before vascular surgery  

SciTech Connect

Preoperative dipyridamole-thallium-201 scanning is sensitive in identifying patients prone to ischemic cardiac complications after vascular surgery, but most patients with redistribution do not have an event after surgery. Therefore, its positive predictive value is limited. To determine which patients with thallium redistribution are at highest risk, dipyridamole-thallium-201 images were interpreted semiquantitatively. Sixty-two consecutive patients with redistribution on preoperative dipyridamole-thallium-201 planar imaging studies were identified. Each thallium scan was then analyzed independently by 2 observers for the number of myocardial segments out of 15, the number of thallium views out of 3 and the number of coronary artery territories with redistribution. Seventeen patients (27%) had postoperative ischemic events, including unstable angina pectoris, ischemic pulmonary edema, myocardial infarction and cardiac death. Thallium predictors of ischemic operative complications included thallium redistribution greater than or equal to 4 myocardial segments (p = 0.03), greater than or equal to 2 of the 3 planar views (p = 0.005) and greater than or equal to 2 coronary territories (p = 0.007). No patient with redistribution in only 1 view had an ischemic event (0 of 15). Thus, determining the extent of redistribution by dipyridamole-thallium-201 scanning improves risk stratification before vascular surgery. Patients with greater numbers of myocardial segments and greater numbers of coronary territories showing thallium-201 redistribution are at higher risk for ischemic cardiac complications. In contrast, when the extent of thallium redistribution is limited, there is a lower risk despite the presence of redistribution.

Levinson, J.R.; Boucher, C.A.; Coley, C.M.; Guiney, T.E.; Strauss, H.W.; Eagle, K.A. (Harvard Univ. School of Medicine, Boston, MA (USA))



Genomic biomarkers for patient selection and stratification: the cancer paradigm.  


The revolution in disease diagnosis and treatment promised on the completion of the human genome project over a decade ago has materialized in the form of unified drug and biomarker discovery and development pipelines. This strategic shift has been principally catalyzed through success stories in the field of oncology, ushering in the era of personalized medicine. Thus, a number of molecular targets have also been demonstrated to be reliable markers for selecting patients wherein treatment can be efficacious. Perhaps more importantly, however, the late adoption of biomarker strategies has also rescued drug candidates from complete late-stage failure. This review examines the historical lessons of key challenges in translating biomarker assay information into strategic and clinically actionable decisions and assesses the impact of personalized genome sequencing in the future of companion diagnostic development and commercialization. PMID:23157358

Moschos, Sterghios Athanasios



Predictive power of increased heart rate versus depressed left ventricular ejection fraction and heart rate variability for risk stratification after myocardial infarction  

Microsoft Academic Search

Objectives. The aim of this study was to compare the predictive value of mean RR interval assessed from predischarge Holter recordings with that of heart rate variability and left ventricular ejection fraction for risk stratification after myocardial infarction.Background. Heart rate variability is a powerful tool for risk stratification after myocardial infarction. Although heart rate variability is related to heart rate,

Xavier Copie; Katerina Hnatkova; Anne Staunton; Lü Fei; A. John Camm; Marek Malik



Estimated Glomerular Filtration Rate in Short-Risk Stratification in Acute Myocardial Infarction  

Microsoft Academic Search

Background\\/Aims: Renal dysfunction is associated with a higher risk of cardiovascular disease in patients with acute myocardial infarction (AMI). The aim of this study was to investigate the independent prognostic value of renal dysfunction and its incremental predictability risk after adjusting for well-known clinical factors in patients with AMI. Methods: 751 consecutive patients with AMI admitted to the Coronary Care

Luisa Blasco; Rafael Sanjuan; Nieves Carbonell; Miguel A. Solís; María J. Puchades; Isidro Torregrosa; Juan A. Miguel



A clinical study of ischaemic strokes with micro-albuminuria for risk stratification, short-term predictive value and outcome.  


Stroke results more than 4.3 million deaths worldwide per annum and 85% of all strokes are ischaemic in nature. Besides numerous modifiable and non-modifiable known risk factors, microalbuminuria is thought to be an important marker of global endothelial dysfunction and associated with cardiovascular disease including stroke. Fifty ischaemic stroke cases and 50 (age, sex matched) control subjects were subjected to study to compare and evaluate risk stratification of micro-albuminuria, its predictive value and outcome on day 1 and day 7 among admitted ischaemic stroke cases.The result was found that micro-albuminuria was present in 66% of ischaemic stroke cases compared to only 8% of control group (p < 0.001). Most validated National Institute of Health Stroke Scale (NIHSS) score was used for evaluation and calculation of predictive value and outcome of micro-albuminuria positive patient where higher value indicates poor prognosis, and the result was mean NIHSS score 29.12 versus 18.88 between two groups of strokes ie, with and without micro-albuminuria. Out of 50 ischaemic stroke patients 33 (66%) had micro-albuminuria. Among 11 patients who died, 10 (90.9%) had micro-albuminuria and NIHSS score was 33.64 and 25.0 on day 1 and day 7. Among 39 patients who were discharged, 23 patients (58.97%) were MA positive and NIHSS score was much less than death group ie, 23.38 and 16.38 on day 1 and day 7 respectively. So this study reveals micro-albuminuria itself results higher risk for ischaemic stroke compared to control group and it shows good predictive value for early assessment of clinical severity and subsequent fatal outcome. This is also simple, cost effective and affordable. PMID:23936957

Das, Sukdeb; Yadav, Ujjal; Ghosh, Kartik Chandra; Panchadhyayee, Sujoy; Kundu, Shib Shankar; Ganguly, Prasanta Kumar



Risk Stratification of Coronary Heart Disease in Greece: Final Results from the CARDIO2000 Epidemiological Study  

Microsoft Academic Search

Background. In past years several risk factors have been associated with the incidence of coronary heart disease. The aim of this study was to investigate the associations between the risk of developing acute coronary syndromes and several risk factors in Greece.Methods. During 2000–2002, 700 male (59 ± 10 years old) and 148 female (65 ± 9 years old) patients with

Demosthenes B Panagiotakos; Christos Pitsavos; Christine Chrysohoou; Christodoulos Stefanadis; Pavlos Toutouzas



Urinary Proteomic Biomarkers for Diagnosis and Risk Stratification of Autosomal Dominant Polycystic Kidney Disease: A Multicentric Study  

PubMed Central

Treatment options for autosomal dominant polycystic kidney disease (ADPKD) will likely become available in the near future, hence reliable diagnostic and prognostic biomarkers for the disease are strongly needed. Here, we aimed to define urinary proteomic patterns in ADPKD patients, which aid diagnosis and risk stratification. By capillary electrophoresis online coupled to mass spectrometry (CE-MS), we compared the urinary peptidome of 41 ADPKD patients to 189 healthy controls and identified 657 peptides with significantly altered excretion, of which 209 could be sequenced using tandem mass spectrometry. A support-vector-machine based diagnostic biomarker model based on the 142 most consistent peptide markers achieved a diagnostic sensitivity of 84.5% and specificity of 94.2% in an independent validation cohort, consisting of 251 ADPKD patients from five different centers and 86 healthy controls. The proteomic alterations in ADPKD included, but were not limited to markers previously associated with acute kidney injury (AKI). The diagnostic biomarker model was highly specific for ADPKD when tested in a cohort consisting of 481 patients with a variety of renal and extrarenal diseases, including AKI. Similar to ultrasound, sensitivity and specificity of the diagnostic score depended on patient age and genotype. We were furthermore able to identify biomarkers for disease severity and progression. A proteomic severity score was developed to predict height adjusted total kidney volume (htTKV) based on proteomic analysis of 134 ADPKD patients and showed a correlation of r?=?0.415 (p<0.0001) with htTKV in an independent validation cohort consisting of 158 ADPKD patients. In conclusion, the performance of peptidomic biomarker scores is superior to any other biochemical markers of ADPKD and the proteomic biomarker patterns are a promising tool for prognostic evaluation of ADPKD.

Kistler, Andreas D.; Serra, Andreas L.; Siwy, Justyna; Poster, Diane; Krauer, Fabienne; Torres, Vicente E.; Mrug, Michal; Grantham, Jared J.; Bae, Kyongtae T.; Bost, James E.; Mullen, William; Wuthrich, Rudolf P.; Mischak, Harald; Chapman, Arlene B.



Prediction of Emergent Heart Failure Death by Semi-Quantitative Triage Risk Stratification  

Microsoft Academic Search

ObjectivesGeneric triage risk assessments are widely used in the emergency department (ED), but have not been validated for prediction of short-term risk among patients with acute heart failure (HF). Our objective was to evaluate the Canadian Triage Acuity Scale (CTAS) for prediction of early death among HF patients.MethodsWe included patients presenting with HF to an ED in Ontario from Apr

Harriette G. C. Van Spall; Clare Atzema; Michael J. Schull; Gary E. Newton; Susanna Mak; Alice Chong; Jack V. Tu; Thérèse A. Stukel; Douglas S. Lee



Psychiatric patient stratification using biosignatures based on cerebrospinal fluid protein expression clusters.  


Psychiatric disorders are caused by perturbed molecular pathways that affect brain circuitries. The identification of specific biosignatures that are the result of altered pathway activities in major depression, bipolar disorder and schizophrenia can contribute to a better understanding of disease etiology and aid in the implementation of diagnostic assays. In the present study we identified disease-specific protein biosignatures in cerebrospinal fluid of depressed (n: 36), bipolar (n: 27) and schizophrenic (n: 35) patients using the Reverse Phase Protein Microarray technology. These biosignatures were able to stratify patient groups in an objective manner according to cerebrospinal fluid protein expression patterns. Correct classification rates were over 90%. At the same time several protein sets that play a role in neuronal growth, proliferation and differentiation (NEGR1, NPDC1), neurotransmission (SEZ6) and protection from oxidative damage (GPX3) were able to distinguish diseased from healthy individuals (n: 35) indicating a molecular signature overlap for the different psychiatric phenotypes. Our study is a first step toward implementing a psychiatric patient stratification system based on molecular biosignatures. Protein signatures may eventually be of use as specific and sensitive biomarkers in clinical trials not only for patient diagnostic and subgroup stratification but also to follow treatment response. PMID:23962679

Maccarrone, Giuseppina; Ditzen, Claudia; Yassouridis, Alexander; Rewerts, Christiane; Uhr, Manfred; Uhlen, Mathias; Holsboer, Florian; Turck, Christoph W



The incremental value of brachial flow-mediated dilation measurements in risk stratification for incident cardiovascular events: a systematic review.  


Abstract Adequate risk assessment for cardiovascular disease (CVD) is essential as a guide to initiate drug treatment. Current methods based on traditional risk factors could be improved considerably. Although brachial flow-mediated dilation (FMD) predicts subsequent cardiovascular events, its predictive value on top of traditional risk factors is unknown. We performed a systematic review to evaluate the incremental predictive value of FMD on top of traditional risk factors in asymptomatic individuals. Using PubMed and reference tracking, three studies were identified that reported on the incremental value of FMD using change in the area under the curve (AUC). Two large cohort studies found no improvement in AUC when FMD was added to traditional risk prediction models, whereas one small case-control study found an improvement. One study used the net reclassification improvement (NRI) to assess whether FMD measurement leads to correct risk stratification in risk categories. Although this study did not find an improvement in AUC, the NRI was statistically significant. Based on the reclassification results of this study, FMD measurement might be helpful in risk prediction. Evidence supporting the use of FMD measurement in clinical practice for risk stratification for CVD on top of traditional risk factors is limited, and future studies are needed. PMID:21585249

Peters, Sanne A E; den Ruijter, Hester M; Bots, Michiel L



Electrocardiologic and related methods of non-invasive detection and risk stratification in myocardial ischemia: state of the art and perspectives  

PubMed Central

Background: Electrocardiographic methods still provide the bulk of cardiovascular diagnostics. Cardiac ischemia is associated with typical alterations in cardiac biosignals that have to be measured, analyzed by mathematical algorithms and allegorized for further clinical diagnostics. The fast growing fields of biomedical engineering and applied sciences are intensely focused on generating new approaches to cardiac biosignal analysis for diagnosis and risk stratification in myocardial ischemia. Objectives: To present and review the state of the art in and new approaches to electrocardiologic methods for non-invasive detection and risk stratification in coronary artery disease (CAD) and myocardial ischemia; secondarily, to explore the future perspectives of these methods. Methods: In follow-up to the Expert Discussion at the 2008 Workshop on "Biosignal Analysis" of the German Society of Biomedical Engineering in Potsdam, Germany, we comprehensively searched the pertinent literature and databases and compiled the results into this review. Then, we categorized the state-of-the-art methods and selected new approaches based on their applications in detection and risk stratification of myocardial ischemia. Finally, we compared the pros and cons of the methods and explored their future potentials for cardiology. Results: Resting ECG, particularly suited for detecting ST-elevation myocardial infarctions, and exercise ECG, for the diagnosis of stable CAD, are state-of-the-art methods. New exercise-free methods for detecting stable CAD include cardiogoniometry (CGM); methods for detecting acute coronary syndrome without ST elevation are Body Surface Potential Mapping, functional imaging and CGM. Heart rate variability and blood pressure variability analyses, microvolt T-wave alternans and signal-averaged ECG mainly serve in detecting and stratifying the risk for lethal arrythmias in patients with myocardial ischemia or previous myocardial infarctions. Telemedicine and ambient-assisted living support the electrocardiological monitoring of at-risk patients. Conclusions: There are many promising methods for the exercise-free, non-invasive detection of CAD and myocardial ischemia in the stable and acute phases. In the coming years, these new methods will help enhance state-of-the-art procedures in routine diagnostics. The future can expect that equally novel methods for risk stratification and telemedicine will transition into clinical routine.

Huebner, Thomas; Goernig, Matthias; Schuepbach, Michael; Sanz, Ernst; Pilgram, Roland; Seeck, Andrea; Voss, Andreas



Derivation and validation of a disease-specific risk score for cardiac risk stratification in chronic kidney disease  

Microsoft Academic Search

Objective. Cardiac events (CE; cardiac death, non- fatal myocardial infarction and acute coronary syn- drome) are the principal causes of death in patients with chronic kidney disease (CKD). We sought to devise and validate a cardiac risk score to risk-stratify patients with CKD. Methods. Clinical history and biochemical data were obtained in 167 CKD patients. CE were recorded over a

Kirsten A. Armstrong; Dhrubo J. Rakhit; Colin Case; David W. Johnson; Nicole M. Isbel; Thomas H. Marwick



Impact of Primary Gleason Grade on Risk Stratification for Gleason Score 7 Prostate Cancers  

SciTech Connect

Purpose: To evaluate the primary Gleason grade (GG) in Gleason score (GS) 7 prostate cancers for risk of non-organ-confined disease with the goal of optimizing radiotherapy treatment option counseling. Methods: One thousand three hundred thirty-three patients with pathologic GS7 were identified in the Duke Prostate Center research database. Clinical factors including age, race, clinical stage, prostate-specific antigen at diagnosis, and pathologic stage were obtained. Data were stratified by prostate-specific antigen and clinical stage at diagnosis into adapted D'Amico risk groups. Univariate and multivariate analyses were performed evaluating for association of primary GG with pathologic outcome. Results: Nine hundred seventy-nine patients had primary GG3 and 354 had GG4. On univariate analyses, GG4 was associated with an increased risk of non-organ-confined disease. On multivariate analysis, GG4 was independently associated with seminal vesicle invasion (SVI) but not extracapsular extension. Patients with otherwise low-risk disease and primary GG3 had a very low risk of SVI (4%). Conclusions: Primary GG4 in GS7 cancers is associated with increased risk of SVI compared with primary GG3. Otherwise low-risk patients with GS 3+4 have a very low risk of SVI and may be candidates for prostate-only radiotherapy modalities.

Koontz, Bridget F., E-mail: [Department of Radiation Oncology, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States); Tsivian, Matvey [Division of Urology, Department of Surgery, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States); Mouraviev, Vladimir [Department of Radiation Oncology, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States); Sun, Leon [Division of Urology, Department of Surgery, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States); Vujaskovic, Zeljko [Department of Radiation Oncology, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States); Moul, Judd [Division of Urology, Department of Surgery, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States); Lee, W. Robert [Department of Radiation Oncology, Duke Prostate Center, Duke University Medical Center, Durham, NC (United States)



Does chronic kidney disease improve the predictive value of the CHADS2 and CHA2DS2-VASc stroke stratification risk scores for atrial fibrillation?  


Chronic Kidney Disease (CKD) constitutes an adverse risk factor in chronic anticoagulated atrial fibrillation (AF) patients, being related to adverse cardiovascular events, mortality and major bleeds. It is unclear if CKD adds independent prognostic information to stroke risk stratification schemes, as the risk factor components of the CHADS2 and CHA2DS2-VASc scores are themselves related to renal dysfunction. The aim of our study was to determine if CKD independently improves the predictive value of the CHADS2 and CHA2DS2-VASc stroke stratification scores in AF. We recruited consecutive patients (n=978) patients (49% male; median age 76) with permanent or paroxysmal AF on oral anticoagulants with acenocoumarol, from our out-patient anticoagulation clinic. After a median follow-up of 875 (IQR 706-1059) days, we recorded stroke/transient ischaemic attack (TIA), peripheral embolism, vascular events (acute coronary syndrome, acute heart failure and cardiac death) and all-cause mortality. During follow-up, 113 patients (4.82%/year) experienced an adverse cardiovascular event, of which 39 (1.66%/year) were strokes, 43 (1.83%/year) had an acute coronary syndrome and 32 (1.37%/year) had acute heart failure. Also, 102 patients (4.35%/year) died during the following up, 31 of them (1.32%/year) as a result of a thrombotic event. Based on c-statistics and the integrated discrimination improvement (IDI), CKD did not improve the prediction for stroke/systemic embolism, thrombotic events and all-cause mortality using the CHADS2 and CHA2DS2-VASc scores. In conclusion, evaluating renal function in AF patients is important as CKD would confer a poor overall prognosis in terms of thromboembolic events and all-cause mortality. Adding CKD to the CHADS2 and CHA2DS2-VASc stroke risk scores did not independently add predictive information. PMID:23572113

Roldán, V; Marín, F; Manzano-Fernandez, S; Fernández, H; Gallego, P; Valdés, M; Vicente, V; Lip, G Y H



Improving Breast Cancer Risk Stratification Using Resonance-Frequency Electrical Impedance Spectroscopy Through Fusion of Multiple Classifiers  

Microsoft Academic Search

This study aims to improve breast cancer risk stratification. A seven-probe resonance-frequency-based electrical impedance\\u000a spectroscopy (REIS) system was designed, assembled, and utilized to establish a data set of examinations from 174 women. Three\\u000a classifiers, including artificial neural network (ANN), support vector machine (SVM), and Gaussian mixture model (GMM), were\\u000a independently developed to predict the likelihood of each woman to be

Dror Lederman; Bin Zheng; Xingwei Wang; Xiao Hui Wang; David Gur



Myocardial Perfusion Imaging for Risk Stratification in Suspected or Known Coronary Artery Disease: Current Status and Limitations  

Microsoft Academic Search

Coronary artery disease (CAD) remains the leading cause of morbidity and mortality in the western world. Early detection and\\u000a risk stratification of underlying (CHD) is a major step in clinical decision-making. As discussed in the other chapters, myocardial\\u000a perfusion imaging (MPI) using thallium-201(Tl-201) or technetium- 99m (Tc-99m) sestamibi or tetrofosmin, is used in various\\u000a clinical settings to provide invaluable information

Firas A. Ghanem; Assad Movahed


Optimal Timing of Intervention in Non-ST-Segment Elevation Acute Coronary Syndromes Insights From the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC\\/AHA guidelines) Registry  

Microsoft Academic Search

Background—Recent studies indicate that a routine invasive approach for patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) yields improved outcomes compared with a conservative approach, but the optimal timing of this approach remains open to debate. Methods and Results—We used day of hospital presentation as an instrumental variable to study the impact of timing of cardiac catheterization

Jason W. Ryan; Eric D. Peterson; Anita Y. Chen; Matthew T. Roe; E. Magnus Ohman; Christopher P. Cannon; Peter B. Berger; Jorge F. Saucedo; Elizabeth R. DeLong; Sharon-Lise Normand; Charles V. Pollack; David J. Cohen


Autonomic nervous system in the genesis of arrhythmias in chronic heart failure: implication for risk stratification.  


Sudden cardiac death (SCD) is one of a major cause of morbidity and mortality in patients with chronic heart failure (CHF). There is a circadian variation of the frequency of SCD. Beta-blocker therapy significantly reduces the incidence of SCD. These clinical observations suggest a close association between ventricular arrhythmia and sympathetic activity. The identification of patients at risk is a major clinical problem not only for the unpredictability of the event, but also for the continuous growth of patients'number. The implantable cardioverter-defibrillator (ICD) is highly effective at terminating life threatening ventricular tachyarrhythmia At present, 1-2% of the population has heart failure and numbers continue to increase, but the ICD remains expensive. The challenge lies in identifying patients with heart failure who are at significant risk of arrhythmia and who would benefit from an ICD in addition to other anti-arrhythmic strategies. Our power of identifying heart failure patients at risk for arrhythmic death is far from being satisfactory. Heart rate variability and baroreflex sensitivity analysis has been largely utilized to obtain information on autonomic modulation of sinus node as well as to identify patients at risk. It is possible that the combination of results of multiple noninvasive tests such as reduction in ejection fraction and positivity for T wave alternans may not only provide general prognostic information but also facilitate the appropriate identification of patients at risk who may benefit from antiarrhythmic therapy. PMID:17534251

Piepoli, M F; Capucci, A



Risk stratification after acute myocardial infarction by Doppler stroke distance measurement  

Microsoft Academic Search

OBJECTIVETo establish the value of Doppler stroke distance measurement as a predictor of mortality risk following acute myocardial infarction.DESIGNFollow up study.SETTINGCoronary care unit of a teaching and district general hospital.SUBJECTS378 patients (mean age 61 years) with acute myocardial infarction followed up for a mean of five years (range 2–7 years); 299 (79%) patients received thrombolysis.MAIN OUTCOME MEASURESStroke distance (the systolic

R J Trent; J M Rawles



Minimal screening analysis based algorithm for diagnosis and clinical stratification of patients with acute myeloid leukaemia (AML): single centre experience.  


(Full text is available at In this paper we present our results from a study designed in order to establish and standardize a diagnostic algorithm for acute myeloid leukaemia (AML) in the Republic of Macedonia. A total of 146 consecutive adult patients (> 15 years) were enrolled in the study. First, we determined the correct lineage assignment of the blast cells and evaluated the incidence of the favourable PML/RAR?, AML1/ETO, CBF?/MYH11 genetic markers among the AML cases. Additionally, the obtained results were correlated with patients' age, comorbidities, and performance status, and each single AML patient was stratified to effective treatment strategy. Our results showed that morphology and cytochemistry established a lineage in 132 (89.1%) of the patients, but not in 16 cases that presented as acute leukaemia, of which 7 were assigned as myeloid, and in two a non-haematopoietic malignancy was indicated with immunophenotyping. Mulitparameter flow cytometry immunophenotyping also changed the assigned lineage based on morphology and cytochemistry in 5 (3.3%) of the patients from lymphoid to myeloid and improved diagnosis in 21 (14.1%) cases. By using a reverse transcriptase-polymerase chain reaction (RT-PCR) essay 28 (23.1%) patients were classified in the prognostically favourable AML genetic group; 8 patients expressed the fusion transcript PML/RAR? AML1/ETO and 15 CBF?/MYH11. Moreover, analyses of the age, performance status and comorbidities further strtified an additional 12.5% of the patients to a different risk-adapted therapy. The applied minimal screening-analysis-based diagnostic algorithm enabled improved and more precise diagnosis and clinical stratification in 37.2 % of AML patients from our study group. Key words: AML, prognosis, diagnostic algorithm, genetic markers, flow citometry. PMID:22952097

Panovska-Stavridis, I; Trajkova, S; Ivanovski, M; Hadzi-Pecova, L; Dukovski, D; Popova-Simjanovska, M; Cevreska, L



Biomarker Discovery for Risk Stratification of Cardiovascular Events using an Improved Genetic Algorithm  

Microsoft Academic Search

Detection of an optimal panel of biomarkers capable of predicting a patient's risk of major adverse cardiac events (MACE) is of clinical significance. Due to the high dynamic range of the protein concentration in human blood, applying proteomics techniques for protein profiling can generate large arrays of data for development of optimized clinical biomarker panels. The objective of this study

Xiaobo Zhou; Honghui Wang; Jun Wang; Gerard Hoehn; Joseph Azok; Marie-Luise Brennan; Stanley L. Hazen; King Li; Stephen T. C. Wong



Microdetermination of fatty acids by gas chromatography and cardiovascular risk stratification by the "EPA+DHA level".  


The therapeutic options for interfering with the electrical instability of a pathologically remodeled or ischaemic heart remain limited. Of increasing importance become interventions which target the fatty acid composition of blood and membrane lipids. In particular, the long-chain omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) provide parameters for stratification of risks associated with severe arrhythmia disorders and sudden cardiac death. Since EPA and DHA appear to have their anti-arrhythmogenic actions when present as free fatty acids, the parameters which determine a critical free fatty acid concentration are of great interest. In the present study, conclusions on EPA and DHA incorporation in blood lipids are derived from the administration of Omacor which contains highly purified (84%) EPA and DHA ethyl esters and reduced the risk of sudden cardiac death by 45% in post-myocardial infarction patients (GISSI-Prevention study). The "EPA+DHA level" is described as risk identifying parameter for severe arrhythmia disorders, particularly if they are associated with myocardial ischaemia. It appears essential not only to build up body stores for release of EPA and DHA but to provide also a sustained uptake of EPA and DHA in the form of ethyl esters. In contrast to more rapidly absorbed triacylglycerols from fish, ethyl esters are taken up slowly within 24 h. For the administration of 1 g/day Omacor to healthy volunteers, it is shown that in whole blood EPA is increased from 0.6% to 1.4% within 10 days while DHA is increased from 2.9% to 4.3%. After withdrawal, the EPA and DHA levels approach baseline values within 10 days. A gas chromatographic procedure was established which requires only 10 microl of whole blood for the identification of more than 30 fatty acids. Evidence is summarized strengthening the concept that a low "EPA+DHA level" presents a risk for severe arrhythmia disorders and sudden cardiac death. The administration of 840 mg/day of EPA and DHA ethyl esters raises the "EPA+DHA level" to approximately 6% that is associated with protection from sudden cardiac death. The pharmacological effects of ethyl esters are compared with the naturally occurring EPA and DHA triacylglycerols present in fish or fish oils which are of interest in primary prevention of cardiovascular disorders. PMID:17575804

Rupp, Heinz; Rupp, Thomas P; Wagner, Daniela; Alter, Peter; Maisch, Bernhard



Risk-benefit stratification as a guide to lidocaine prophylaxis of primary ventricular fibrillation in acute myocardial infarction: an analytic review.  

PubMed Central

Early investigators suggested that ventricular fibrillation without heart failure in acute myocardial infarction was reliably preceded by warning arrhythmias, and that suppression of such arrhythmias with intravenous lidocaine could avoid the need for resuscitation. While the efficacy and safety of lidocaine have been substantiated, the reliability of warning arrhythmias as predictors for primary ventricular fibrillation has not. We present data showing that the risk of primary ventricular fibrillation is most dependent on the patient's age and the interval since the onset of his symptoms, rather than on the presence of warning arrhythmias. We have estimated that lidocaine prophylaxis would have to be given to about 12 patients in the highest risk group (patients under age 50 and within six hours of the onset of symptoms), compared to about 400 patients in the lowest risk group (patients above age 70 and more than 24 hours since the onset of symptoms), to prevent one episode of primary ventricular fibrillation in each group. We propose that these risk stratifications, as adapted to the conditions in specific hospitals, provide the most rational approach to lidocaine prophylaxis of primary ventricular fibrillation.

Goldman, L.; Batsford, W. P.



[Trauma-associated bleeding in the severely injured. Relevance, risk stratification and current therapy approaches].  


Of all trauma-related deaths 40% are due to exsanguination. The causes for acute, hemorrhaging are uncontrolled bleeding sources and the development of acute posttraumatic coagulopathy. Clinical observations and recent research results emphasize the key role of this disorder in acute trauma care. The present synopsis summarizes the results from different analyses based on datasets from severely injured patients derived from the Trauma Register of the German Trauma Society (DGU) on frequency, potential triggers and strategies to manage acute posttraumatic coagulopathy. In an extension to this work a clinical scoring system for early identification of patients at high risk for ongoing bleeding is presented. High risk patients seem to benefit from a more balanced transfusion regimen. PMID:21161153

Peiniger, S; Maegele, M



Genetic factors associated with drug-resistance of epilepsy: relevance of stratification by patient age and aetiology of epilepsy.  


Epilepsy drug-resistance may depend on the metabolism of antiepileptic drugs (AEDs), transport to the epileptic focus and/or target sensitivity. Furthermore, drug response depends on multiple characteristics of the patient, the epilepsy, and the antiepileptic drugs used. We have investigated the association between polymorphisms related to antiepileptic drug metabolism (CYP2C9, CYP2C19, and UGT), transport (ABCB1), and targets (SCN1A) both in a crude analysis and after adjusting by clinical factors associated with drug-resistance, and stratifying by patient age or aetiology of epilepsy. Caucasian outpatients (N=289), children (N=80) and adolescent-adults (N=209), with idiopathic (N=69), cryptogenic (N=97) or symptomatic epilepsies (N=123) were selected when they had either drug-resistance (with at least four seizures over the previous year after treatment with more than three appropriate AEDs at appropriate doses) or drug responsiveness (without seizures for at least a year). Samples were genotyped by allelic discrimination using TaqMan probes. No significant association between polymorphisms and drug-resistance was found either in the crude analysis or in the adjusted analysis. However, adults with the ABCB1_3435TT or 2677TT genotypes had a lower risk of drug-resistance than those with the CC or the GG genotypes. Furthermore, patients with symptomatic epilepsies with the ABCB1_3435CT or TT genotypes had a lower risk of drug-resistance than those with the CC genotype. An opposite but insignificant tendency was found in children and in idiopathic epilepsies. Although replication studies will be needed to confirm our results, they suggest that stratification by patient age and by the aetiology of epilepsy could contribute to unmask the association between ABCB1 polymorphisms and drug-resistance of epilepsy. PMID:20064729

Sánchez, M Blanca; Herranz, José L; Leno, Carlos; Arteaga, Rosa; Oterino, Agustín; Valdizán, Elsa M; Nicolás, José M; Adín, Javier; Armijo, Juan A



The expression of KIT receptor dimers in gastrointestinal stromal tumors independent of c-kit mutation and SCF expression is associated with high-risk stratification.  


Although the dimerization of KIT, a receptor tyrosine kinase, plays a major role in a number of tumors, correlations between the clinicopathological parameters and KIT receptor dimers have not been identified. In the current study, a method for the detection of KIT receptor dimer expression was described and correlations between the clinicopathological parameters and KIT receptor dimers were analyzed. A single center cohort study of 49 patients with gastrointestinal stromal tumors (GISTs) was conducted to analyze the expression of KIT receptor dimers by SDS-PAGE, Native-PAGE and modified Native-PAGE. Immunohistochemistry was used to examine the expression of ki-67, c-kit and stem cell factor (SCF). Mutations of the c-kit gene were examined in 48 GISTs according to the polymerase chain reaction (PCR) and direct sequencing methods. Based on the data, a signal for the KIT receptor monomer was obtained by SDS-PAGE. Faint bands were observed on the nitrocellulose membrane by Native-PAGE, while clear bands were identified for KIT receptor dimers and monomers using modified Native-PAGE (15 out of 49 cases). The tumor size was larger in KIT receptor dimer-positive cases compared with that in KIT receptor dimer-negative cases. Analysis of KIT receptor dimer expression levels and risk stratification demonstrated that KIT receptor dimer-positive cases belonged to the higher risk classification. In addition, there was no significant correlation between the existence of KIT receptor dimers and c-kit gene mutations, including SCF expression. In conclusion, this study established a method for the detection of the existence of KIT receptor dimers in tissues and confirmed that KIT receptor dimers were correlated with risk stratification. Data also indicated that ligand-dependent SCF/KIT dimerization is an independent crucial mechanism in GIST cell proliferation and increases the risk of GIST. Therefore, blocking KIT dimerization may prove to be an effective approach for the treatment of GISTs. PMID:23205104

Qiu, Cen; Liu, Xiaohong; Bai, Chenguang; Ma, DA Lie



The long-term impact of in vitro drug sensitivity on risk stratification and treatment outcome in acute lymphoblastic leukemia of childhood (CoALL 06-97)  

PubMed Central

Background In a study of childhood acute lymphoblastic leukemia (CoALL 06-97 study), the in vitro sensitivity of the patients’ cells to prednisolone, vincristine and asparaginase was introduced as a new additional risk parameter for treatment stratification. In parallel in vivo treatment response was assessed by determining the presence and extent of minimal residual disease in a subset of patients (n=224). Here we report the long-term impact of in vitro sensitivity-based risk stratification according to survival and compare the results of in vitro sensitivity with in vivo response. Design and Methods Patients with a sensitive in vitro profile were treated with a reduced intensity protocol (n=167) whereas patients defined as low risk according to conventional parameters but with a resistant in vitro profile were given intensified therapy (n=47). Results At a median follow-up of 6.8 years event-free survival was 0.80±0.03 for patients with a sensitive profile, 0.73±0.03 for those with an intermediate profile and 0.67±0.08 for those with a resistant profile (P=0.015). Overall, the treatment results of the cases stratified according to in vitro sensitivity were similar to those of the historical control group stratified based on conventional risk factors. Minimal residual disease at the end of induction was a strong predictor of outcome in B-precursor and T-cell acute lymphoblastic leukemia. There was no correlation between in vitro and in vivo treatment response in B-precursor leukemia (Spearman’s r=0.13; P=0.15) in contrast to T-cell acute lymphoblastic leukemia (Spearman’s r=0.63; P<0.001) Conclusions A moderate reduction in treatment intensity for patients with a sensitive in vitro profile was possible without jeopardizing treatment outcome. However, in vitro drug testing was affected by a decrease in risk predictive power over time and was not correlated with in vivo assessment of minimal residual disease in B-precursor acute lymphoblastic leukemia. It was, therefore, abandoned in favor of the assessment of in vivo response in subsequent CoALL trials.

Escherich, Gabriele; Troger, Anja; Gobel, Ulrich; Graubner, Ulrike; Pekrun, Arnulf; Jorch, Norbert; Kaspers, Gjl; Zimmermann, Martin; zur Stadt, Udo; Kazemier, Karin; Pieters, Rob; Den Boer, Monique L.; Horstmann, Martin; Janka, Gritta E.



The inclusion of stroke in risk stratification for primary prevention of vascular events: the Northern Manhattan Study  

PubMed Central

Background and Purpose The Framingham coronary heart disease (CHD) risk score (FRS) estimates 10-year risk of myocardial infarction (MI) and CHD death. Since preventive approaches to CHD and stroke are similar, a composite outcome may be more appropriate. We compared 10-year risk of 1) MI or CHD death, and 2) stroke, MI, or CHD death, among individuals free of vascular disease. Methods The Northern Manhattan Study contains a prospective, population-based study of stroke- and CHD-free individuals ?40 years of age, followed for a median of 10 years for vascular events. FRS was calculated for each individual, and for each category of predicted risk, Kaplan-Meier observed 10-year cumulative probabilities were calculated for 1) MI or CHD death and 2) stroke, MI, or CHD death. The cumulative probability of (1) was subtracted from (2), and 95% confidence intervals (CI) for the difference were obtained with 1000 bootstrap samples. Using stratified analyses by race-ethnicity, we compared risk differences between race-ethnic groups. Results Among 2613 participants (53% Hispanic, 25% non-Hispanic black and 20% non-Hispanic white), observed 10-year risk of MI or CHD death was 14.20%. With stroke in the outcome, observed risk was 21.98% (absolute risk difference 7.78%, 95% CI 5.86-9.75%). The absolute risk difference among blacks was significantly larger than among whites (p=0.01). Conclusions In this multi-ethnic urban population, adding stroke to the risk stratification outcome cluster resulted in a 55% relative increase in estimated risk, and crossing of the absolute risk threshold (>20% over 10 years) considered for preventive treatments such as statins.

Dhamoon, Mandip S.; Moon, Yeseon Park; Paik, Myunghee C.; Sacco, Ralph L.; Elkind, Mitchell S. V.



Incidence, risk stratification, antibiogram of pathogens isolated and clinical outcome of ventilator associated pneumonia  

PubMed Central

Background: The initial empirical therapy of Ventilator Associated Pneumonia (VAP) modified based on the knowledge of local microbiological data is associated with decreased morbidity and mortality. The objective was to find the incidence and risk factors associated with VAP, the implicated pathogens and their susceptibility pattern as well as to assess the final clinical outcome in VAP. Materials and Methods: This was a prospective cohort study of 107 patients taken on ventilatory support for two or more days and those not suffering from pneumonia prior were to be taken on ventilator. The study was done over a period of one year. VAP was diagnosed using clinical pulmonary infection score of >6. The mortality, incidence of VAP, frequency of different pathogens isolated, their antibiotic sensitivity pattern, duration of mechanical ventilation and duration of hospital stay were assessed. Statistical Analysis: Univariate analysis, ?2 test and paired t-test. Results: The incidence of VAP was 28.04%. Mortality in VAP group was 46.67%, while in the non-VAP group was 27.28%. High APACHE II score was associated with a high mortality rate as well as increased incidence of VAP. The most common organisms isolated from endotracheal aspirate of patients who developed VAP were Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter baumannii. Most strains of Pseudomonas (55.56%) were resistant to commonly used beta-lactam antibiotics known to be effective against Pseudomonas. All strains of Staphylococcus aureus were MRSA and most isolates of K. pneumoniae (85.71%) were extended-spectrum beta-lactamase producing. About 50% isolates of Acinetobacter were resistant to carbapenems. Mortality was highest for infections caused by A. baumannii (83.33%) and K. pneumoniae (71.42%). Conclusions: APACHE II score can be used to stratify the risk of development of VAP and overall risk of mortality. Drug-resistant strains of various organisms are an important cause of VAP in our setting.

Gupta, Alok; Agrawal, Avinash; Mehrotra, Sanjay; Singh, Abhishek; Malik, Shruti; Khanna, Arjun



Prediction of Emergent Heart Failure Death by Semi-Quantitative Triage Risk Stratification  

PubMed Central

Objectives Generic triage risk assessments are widely used in the emergency department (ED), but have not been validated for prediction of short-term risk among patients with acute heart failure (HF). Our objective was to evaluate the Canadian Triage Acuity Scale (CTAS) for prediction of early death among HF patients. Methods We included patients presenting with HF to an ED in Ontario from Apr 2003 to Mar 2007. We used the National Ambulatory Care Reporting System and vital statistics databases to examine care and outcomes. Results Among 68,380 patients (76±12 years, 49.4% men), early mortality was stratified with death rates of 9.9%, 1.9%, 0.9%, and 0.5% at 1-day, and 17.2%, 5.9%, 3.8%, and 2.5% at 7-days, for CTAS 1, 2, 3, and 4–5, respectively. Compared to lower acuity (CTAS 4–5) patients, adjusted odds ratios (aOR) for 1-day death were 1.32 (95%CI; 0.93–1.88; p?=?0.12) for CTAS 3, 2.41 (95%CI; 1.71–3.40; p<0.001) for CTAS 2, and highest for CTAS 1: 9.06 (95%CI; 6.28–13.06; p<0.001). Predictors of triage-critical (CTAS 1) status included oxygen saturation <90% (aOR 5.92, 95%CI; 3.09–11.81; p<0.001), respiratory rate >24 breaths/minute (aOR 1.96, 95%CI; 1.05–3.67; p?=?0.034), and arrival by paramedic (aOR 3.52, 95%CI; 1.70–8.02; p?=?0.001). While age/sex-adjusted CTAS score provided good discrimination for ED (c-statistic?=?0.817) and 1-day (c-statistic?=?0.724) death, mortality prediction was improved further after accounting for cardiac and non-cardiac co-morbidities (c-statistics 0.882 and 0.810, respectively; both p<0.001). Conclusions A semi-quantitative triage acuity scale assigned at ED presentation and based largely on respiratory factors predicted emergent death among HF patients.

Van Spall, Harriette G. C.; Atzema, Clare; Schull, Michael J.; Newton, Gary E.; Mak, Susanna; Chong, Alice; Tu, Jack V.; Stukel, Therese A.; Lee, Douglas S.



Atherosclerotic risk stratification strategy for carotid arteries using texture-based features.  


Plaques in the carotid artery result in stenosis, which is one of the main causes for stroke. Patients have to be carefully selected for stenosis treatments as they carry some risk. Since patients with symptomatic plaques have greater risk for strokes, an objective classification technique that classifies the plaques into symptomatic and asymptomatic classes is needed. We present a computer aided diagnostic (CAD) based ultrasound characterization methodology (a class of Atheromatic systems) that classifies the patient into symptomatic and asymptomatic classes using two kinds of datasets: (1) plaque regions in ultrasound carotids segmented semi-automatically and (2) far wall gray-scale intima-media thickness (IMT) regions along the common carotid artery segmented automatically. For both kinds of datasets, the protocol consists of estimating texture-based features in frameworks of local binary patterns (LBP) and Law's texture energy (LTE) and applying these features for obtaining the training parameters, which are then used for classification. Our database consists of 150 asymptomatic and 196 symptomatic plaque regions and 342 IMT wall regions. When using the Atheromatic-based system on semiautomatically determined plaque regions, support vector machine (SVM) classifier was adapted with highest accuracy of 83%. The accuracy registered was 89.5% on the far wall gray-scale IMT regions when using SVM, K-nearest neighbor (KNN) or radial basis probabilistic neural network (RBPNN) classifiers. LBP/LTE-based techniques on both kinds of carotid datasets are noninvasive, fast, objective and cost-effective for plaque characterization and, hence, will add more value to the existing carotid plaque diagnostics protocol. We have also proposed an index for each type of datasets: AtheromaticPi, for carotid plaque region, and AtheromaticWi, for IMT carotid wall region, based on the combination of the respective significant features. These indices show a separation between symptomatic and asymptomatic by 4.53 units and 4.42 units, respectively, thereby supporting the texture hypothesis classification. PMID:22502883

Acharya, U Rajendra; Sree, S Vinitha; Krishnan, M Muthu Rama; Molinari, Filippo; Saba, Luca; Ho, Sin Yee Stella; Ahuja, Anil T; Ho, Suzanne C; Nicolaides, Andrew; Suri, Jasjit S



Development of a Bayesian Classifier for Breast Cancer Risk Stratification: A Feasibility Study.  

National Technical Information Service (NTIS)

Background: Lifetime risk assessment tools are relatively limited in identifying breast cancer risk in younger women. The predictive value of mathematical models to estimate risk varies according to age, menopausal status, race/ethnicity, and family histo...

A. Stojadinovic C. Eberhardt E. A. Elster J. Eberhardt L. Henry



Improving breast cancer risk stratification using resonance-frequency electrical impedance spectroscopy through fusion of multiple classifiers.  


This study aims to improve breast cancer risk stratification. A seven-probe resonance-frequency-based electrical impedance spectroscopy (REIS) system was designed, assembled, and utilized to establish a data set of examinations from 174 women. Three classifiers, including artificial neural network (ANN), support vector machine (SVM), and Gaussian mixture model (GMM), were independently developed to predict the likelihood of each woman to be recommended for biopsy. The performances of these classifiers were compared, and seven fusion methods for integrating these classifiers were investigated. The results showed that among the three classifiers, the ANN yielded the highest performance with an area under the curve (AUC) of 0.81 for the receiver operating characteristic (ROC), while SVM and GMM achieved AUCs of 0.80 and 0.78, respectively. Improvements of up to 3% were obtained using fusion of the three classifiers, with the largest improvement obtained using either a "minimum score" rule or a "weighted sum" rule. Comparing different combinations of two out of the three classifiers, the weighted sum rule provided the most robust and consistent results, with AUCs of 0.81, 0.83, and 0.82 for the different combinations of ANN and SVM, ANN and GMM, and SVM and GMM, respectively. Furthermore, at 90% specificity, the ANN, the weighted sum- and min rule-based classifiers, all detected 67% of the verified cancer cases as compared with 50, 50, and 60% detection of the high risk cases, respectively. The study demonstrated that REIS examinations provide relevant information for developing breast cancer risk stratification tools and that using fusion of several not-fully-correlated classifiers can improve classification performance. PMID:21116847

Lederman, Dror; Zheng, Bin; Wang, Xingwei; Wang, Xiao Hui; Gur, David



Integrated e-Health approach based on vascular ultrasound and pulse wave analysis for asymptomatic atherosclerosis detection and cardiovascular risk stratification in the community.  


New strategies are urgently needed to identify subjects at increased risk of atherosclerotic cardiovascular disease (ACVD) development or complications. A National Public University Center (CUiiDARTE) was created in Uruguay, based on six main pillars: 1) integration of experts in different disciplines and creation of multidisciplinary teams, 2) incidence in public and professional education programs to give training in the use of new technologies and to shift the focus from ACVD treatment to disease prevention, 3) implementation of free vascular studies in the community (distributed rather than centralized healthcare), 4) innovation and application of e-Health and noninvasive technology and approaches, 5) design and development of a biomedical approach to determine the target population and patient workflow, and 6) improvement in individual risk estimation and differentiation between aging and ACVD-related arterial changes using population-based epidemiological and statistical patient-specific models. This work describes main features of CUiiDARTE project implementation, the scientific and technological steps and innovations done for individual risk stratification, and sub-clinical ACVD diagnosis. PMID:22271835

Santana, Daniel Bia; Zócalo, Yanina A; Armentano, Ricardo L



Noninvasive cardiac risk stratification of diabetic and nondiabetic uremic renal allograft candidates using dipyridamole-thallium-201 imaging and radionuclide ventriculography  

SciTech Connect

The ability of noninvasive risk stratification using dipyridamole-thallium-201 (Tl-201) imaging and radionuclide ventriculography to predict perioperative and long-term cardiac events (myocardial infarction or cardiac death) was evaluated in 36 uremic diabetic and 29 nondiabetic candidates for renal allograft surgery. Of the 35 patients who underwent renal allograft surgery 8 +/- 7 months after the study, none had transient Tl-201 defects (although 13 had depressed left ventricular ejection fraction) and none developed perioperative cardiac events. During a mean follow-up of 23 +/- 11 months, 6 (9%) patients developed cardiac events. Logistic regression analysis was used to compare the predictive value of clinical data (including age, sex, diabetes, chest pain history, allograft recipient) and radionuclide data. Presence of transient Tl-201 defect and left ventricular ejection fraction were the only significant predictors of future cardiac events (p less than 0.01). No other patient variables, including diabetes or receiving a renal allograft, had either univariate or multivariate predictive value. All 3 patients with transient Tl-201 defects had cardiac events compared with only 3 of 62 (5%) patients without transient Tl-201 defect (p less than 0.0001). Mean left ventricular ejection fraction was lower in patients with cardiac events (44 +/- 13%) compared with patients without cardiac events (57 +/- 9%, p less than 0.005). Overall, 5 of 6 patients with cardiac events had either transient Tl-201 defects or depressed left ventricular ejection fraction. Dipyridamole-Tl-201 imaging and radionuclide ventriculography may be helpful in identifying uremic candidates for renal allograft surgery who are at low risk for perioperative and long-term cardiac events.

Brown, K.A.; Rimmer, J.; Haisch, C. (Univ. of Vermont College of Medicine, Burlington (USA))



I-CLIP: Improved Stratification of Advanced Hepatocellular Carcinoma Patients by Integrating Plasma IGF-1 into CLIP Score  

PubMed Central

Objective Improving the prognostic stratification of unresectable hepatocellular carcinoma (HCC) patients is critically needed. Since patients’ survival is closely linked to the severity of the underlying liver disease, and insulin-like growth factor-1 (IGF-1) is produced predominantly in the liver, we hypothesized that IGF-1 may correlate with patients’ survival and hence improve the prognostic ability of the Cancer of the Liver Italian Program (CLIP) score. Methods Baseline plasma IGF-1 and clinicopathologic parameters were available from 288 patients. Multivariate Cox regression models, Kaplan-Meier curves, and the log-rank test were applied. Recursive partitioning was used to determine the optimal cut point for IGF-1 using training/validation samples. Prognostic ability of the I-CLIP (I = IGF) was compared to CLIP using C-index. Results IGF-1 significantly correlated with the clinicopathologic features. With an optimal IGF-1 cut point of 26 ng/ml, the overall survival of patients with IGF-1 >26 was 17.7 months (95% CI 13.6–22.8), and with IGF-1 ?26 was 5.8 months (95% CI 4.0–12.5), p < 0.0001. The concordance probabilities for CLIP and I-CLIP were 0.7037 and 0.7096, respectively (p < 0.0001). Conclusions Our preliminary results indicate that I-CLIP significantly improved prognostic stratification of patients with advanced HCC. However, independent validation of our study is warranted.

Kaseb, Ahmed O.; Abbruzzese, James L.; Vauthey, Jean-Nicolas; Aloia, Thomas A.; Abdalla, Eddie K.; Hassan, Manal M.; Lin, E.; Xiao, Lianchun; El-Deeb, Adel S.; Rashid, Asif; Morris, Jeffrey S.



Risk Stratification of Coronary Heart Disease Through Established and Emerging Lifestyle Factors in a Mediterranean Population: CARDIO2000 Epidemiological Study  

Microsoft Academic Search

Background In recent decades various lifestyle factors have been associated with the increasing risk of coronary heart disease. The aim of this study is to assess coronary risk, based on established and emerging lifestyle risk factors such as smoking habit, physical activity, alcohol consumption and depression in a Mediterranean population.Methods During 2000–2001, 535 male and 126 female patients with a

Demosthenes B Panagiotakos; Christos Pitsavos; Christine Chrysohoou; Christodoulos Stefanadis; Pavlos Toutouzas



Public health implications from COGS and potential for risk stratification and screening.  


The PHG Foundation led a multidisciplinary program, which used results from COGS research identifying genetic variants associated with breast, ovarian and prostate cancers to model risk-stratified prevention for breast and prostate cancers. Implementing such strategies would require attention to the use and storage of genetic information, the development of risk assessment tools, new protocols for consent and programs of professional education and public engagement. PMID:23535723

Burton, Hilary; Chowdhury, Susmita; Dent, Tom; Hall, Alison; Pashayan, Nora; Pharoah, Paul



Risk stratification and heparin prophylaxis to prevent venous thromboembolism in pregnant women.  


Women with a history of venous thromboembolism (VTE), thrombophilia or both may be at increased risk of thrombosis during pregnancy, but the optimal management strategy is not well defined in clinical guidelines because of limited trial data. A strategy of risk assessment and heparin prophylaxis was evaluated in pregnant women at increased risk of VTE. In a prospective trial (Efficacy of Thromboprophylaxis as an Intervention during. Gravidity [EThIG]), 810 pregnant women were assigned to one of three management strategies according to pre-defined risk factors related to history of VTE and thrombophilic profile. Low-risk women (group I), received 50-100 IU dalteparin/kg body weight/day for 14 days postpartum, or earlier when additional risk factors occurred. Women at high (group II) or very high risk (group III) received dalteparin from enrollment until six weeks postpartum (50-100 IU and 100-200 IU/kg/day, respectively). Objectively confirmed, symptomatic VTE occurred in 5/810 women (0.6%; 95% confidence interval [CI], 0.2 to 1.5%) (group I, 0 of 225; II, 3/469; III, 2/116). The rate of serious bleeding was 3.0% (95 % CI, 1.9 to 4.4%); 1.1% (95 % CI, 0.5 to 2.2%) was possibly dalteparin-related. There was no evidence of heparin-induced thrombocytopenia, one case of osteoporosis, and rates of miscarriage and stillbirth were similar to previous, retrospective studies. Risk-stratified heparin prophylaxis was associated with a low incidence of symptomaticVTE and few clinically important adverse events. Antepartum heparin prophylaxis is, therefore, warranted in pregnant women with idiopathic thrombosis or symptomatic thrombophilia. PMID:18064320

Bauersachs, Rupert M; Dudenhausen, Joachim; Faridi, Andree; Fischer, Thorsten; Fung, Samson; Geisen, Ulrich; Harenberg, Job; Herchenhan, Eberhard; Keller, Franz; Kemkes-Matthes, Bettina; Schinzel, Helmut; Spannagl, Michael; Thaler, Christian J



Risk Stratification by the “EPA+DHA Level” and the “EPA\\/AA Ratio”  

Microsoft Academic Search

The identification of risks associated with sudden cardiac death requires further investigations. The question was addressed whether parameters can be established which not only describe an increased risk for an enhanced electrical instability of the heart but also of inflammatory events underlying plaque rupture. Emphasis is placed on dose-dependent effects of the long-chain omega-(?-)3 fatty acids eicosapentaenoic acid (EPA) and

Heinz Rupp; Daniela Wagner; Thomas Rupp; Lisa-Maria Schulte; Bernhard Maisch



Risk Stratification after Biochemical Failure following Curative Treatment of Locally Advanced Prostate Cancer: Data from the TROG 96.01 Trial  

PubMed Central

Purpose. Survival following biochemical failure is highly variable. Using a randomized trial dataset, we sought to define a risk stratification scheme in men with locally advanced prostate cancer (LAPC). Methods. The TROG 96.01 trial randomized 802 men with LAPC to radiation?±?neoadjuvant androgen suppression therapy (AST) between 1996 and 2000. Ten-year follow-up data was used to develop three-tier post-biochemical failure risk stratification schemes based on cutpoints of time to biochemical failure (TTBF) and PSA doubling time (PSADT). Schemes were evaluated in univariable, competing risk models for prostate cancer-specific mortality. The performance was assessed by c-indices and internally validated by the simple bootstrap method. Performance rankings were compared in sensitivity analyses using multivariable models and variations in PSADT calculation. Results. 485 men developed biochemical failure. c-indices ranged between 0.630 and 0.730. The most discriminatory scheme had a high risk category defined by PSADT?risk category by PSADT?>?9 months or TTBF?>?3 years. Conclusion. TTBF and PSADT can be combined to define risk stratification schemes after biochemical failure in men with LAPC treated with short-term AST and radiotherapy. External validation, particularly in long-term AST and radiotherapy datasets, is necessary.

Steigler, Allison; Denham, James W.; Lamb, David S.; Spry, Nigel A.; Joseph, David; Matthews, John; Atkinson, Chris; Turner, Sandra; North, John; Christie, David; Tai, Keen-Hun; Wynne, Chris



Risk Stratification after Biochemical Failure following Curative Treatment of Locally Advanced Prostate Cancer: Data from the TROG 96.01 Trial.  


Purpose. Survival following biochemical failure is highly variable. Using a randomized trial dataset, we sought to define a risk stratification scheme in men with locally advanced prostate cancer (LAPC). Methods. The TROG 96.01 trial randomized 802 men with LAPC to radiation?±?neoadjuvant androgen suppression therapy (AST) between 1996 and 2000. Ten-year follow-up data was used to develop three-tier post-biochemical failure risk stratification schemes based on cutpoints of time to biochemical failure (TTBF) and PSA doubling time (PSADT). Schemes were evaluated in univariable, competing risk models for prostate cancer-specific mortality. The performance was assessed by c-indices and internally validated by the simple bootstrap method. Performance rankings were compared in sensitivity analyses using multivariable models and variations in PSADT calculation. Results. 485 men developed biochemical failure. c-indices ranged between 0.630 and 0.730. The most discriminatory scheme had a high risk category defined by PSADT?risk category by PSADT?>?9 months or TTBF?>?3 years. Conclusion. TTBF and PSADT can be combined to define risk stratification schemes after biochemical failure in men with LAPC treated with short-term AST and radiotherapy. External validation, particularly in long-term AST and radiotherapy datasets, is necessary. PMID:23320177

Steigler, Allison; Denham, James W; Lamb, David S; Spry, Nigel A; Joseph, David; Matthews, John; Atkinson, Chris; Turner, Sandra; North, John; Christie, David; Tai, Keen-Hun; Wynne, Chris



Chronic heart failure in the elderly: value of cardiopulmonary exercise testing in risk stratification  

Microsoft Academic Search

OBJECTIVETo assess the value of cardiopulmonary exercise testing in predicting prognosis in a cohort of elderly patients with chronic heart failure (CHF).DESIGNA retrospective cohort study of all patients with CHF over the age of 70 years assessed between January 1992 and May 1997.SETTINGTertiary centre.PATIENTS50 patients (mean (SD) age 75.9 (4.5) years, 8 women) with CHF New York Heart Association (NYHA)

L C Davies; D P Francis; M Piepoli; A C Scott; P Ponikowski; A J S Coats



Emergency department admissions to inpatient cardiac telemetry beds: a prospective cohort study of risk stratification and outcomes  

Microsoft Academic Search

Purpose: Little is known about physicians’ use of inpatient cardiac telemetry units among emergency department patients at risk for cardiac complications. We therefore studied the outcomes of patients admitted to inpatient telemetry beds to identify a subset of patients from whom cardiac monitoring could be withheld safely.Subjects and Methods: We conducted a prospective cohort study of 1,033 consecutive adult patients

Lakshmi Durairaj; Brendan Reilly; Krishna Das; Christopher Smith; Christine Acob; Shahid Husain; Mohammed Saquib; Pamela Ganschow; Arthur Evans; Robert McNutt



Cardiac testing to manage cardiovascular risk in cancer patients.  


Cardiovascular toxicity is one of the most feared complications of cancer treatment. Recent advances in oncologic therapies have resulted in improved cancer outcomes but also a new set of cardiovascular adverse effects. Common toxicities include left ventricular dysfunction/heart failure, hypertension, and myocardial ischemia. Accurate risk stratification allows avoidance of potentially harmful treatments in those patients at greatest risk while maintaining the ability to deliver high doses of effective therapies to the lower-risk population. Cardiac investigations, including echocardiography, nuclear imaging, magnetic resonance imaging, biomarker measurement, blood pressure monitoring, electrocardiography, stress testing, and invasive angiography, can help to risk-stratify selected patients. In this review, common complications are discussed in terms of the factors used to identify patients with elevated risk, the monitoring strategies available, and selected interventions that have been used to modify outcomes in patients identified as being at high risk for cardiac complications of cancer treatment. PMID:23540740

Davis, Margot; Witteles, Ronald M



Identifying patient risk: The basis for rational discharge planning after acute myocardial infarction  

Microsoft Academic Search

Variations in the management of patients with chest pain and acute myocardial infarction (MI) can significantly affect hospital length of stay and cost. Risk stratification of such patients, combined with data about effective therapies, provides the basis for developing rational guide-lines for patient care that can improve efficiency while maintaining quality of care. Such standardized management approaches are often referred

L. Kristin Newby; Robert M. Califf



Advances in Biophotonics Detection of Field Carcinogenesis for Colon Cancer Risk Stratification  

PubMed Central

The process of neoplastic transformation of the colon involves a progression through hyperproliferative epithelium through the aberrant crypt foci?small adenoma?large adenoma?invasive cancer?metastatic disease. These are orchestrated by sequential genetic and epigenetic events which provide the underpinnings of cellular alterations such as early induction in proliferation/suppression of apoptosis, along with the late stage increase in invasiveness. Colorectal cancer (CRC) averages 49-111 mutations per tumor encompassing 10-15 critical signaling pathways[1]. Accumulating such a high number of mutations requires a fertile mutational field, which is the hallmark of colon carcinogenesis. While genetic susceptibility to colorectal cancer is well-known, at least half of the risk is believed to be due to exogeneous factors (e.g., obesity, diet, exercise). Understanding these risk factors represents a promising mode of tailoring screening modality and intensity. However, previous attempts using these factors (i.e., NCI risk calculator) have only been modestly successful with an area under receiver operating characteristics (ROC) curve (AUC) of just 0.61. One of the most important concepts is that risk is the interaction between these genetic and environmental components and is driven by the variety of polymorphisms. Thus, predicting risk is difficult given the complexity. On the other hand, the colonic mucosa represents the end product of the complex interplay between these multiple factors. The power of field carcinogenesis is that it reflects this interplay between genetics and environment.

Backman, Vadim; Roy, Hemant K.



Cardiovascular High-Risk Patients - Treat to Protect, But Whom?  

PubMed Central

Current guidelines for the prevention of coronary heart disease emphasize the importance of global cardiovascular risk, which requires the evaluation and treatment of multiple risk factors. Cardiovascular risk can be stratified with the Framingham algorithm, which produces a numerical score related to the presence of risk factors, such as hypertension, dyslipidemia, and smoking. However, this algorithm is not generally applicable to European countries, particularly for those countries where the risk for cardiovascular disease is low. The SCORE (Systematic COronary Risk Evaluation) project has produced risk charts that are based on cholesterol, blood pressure, and age for low-risk European countries (Belgium, France, Greece, Italy, Luxembourg, Spain, and Switzerland) and high-risk countries. Assessments of end-organ damage can provide further prognostic information, particularly in intermediate-risk patients, but the value of including additional biomarkers in risk stratification remains to be confirmed. Risk for coronary heart disease is high or very high in more than 50% of hypertensive patients. Risk appears to be underestimated in clinical practice, particularly in those patients at highest risk. Major intervention trials with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have shown that these agents reduce the risk for cardiovascular events in patients at all levels of risk, with the greatest benefits seen in those at highest risk.

Zannad, Faiez



Risk Stratification by 24-Hour Ambulatory Blood Pressure and Estimated Glomerular Filtration Rate in 5322 Subjects From 11 Populations  

PubMed Central

No previous study addressed whether in the general population estimated glomerular filtration rate (eGFR [Chronic Kidney Disease Epidemiology Collaboration formula]) adds to the prediction of cardiovascular outcome over and beyond ambulatory blood pressure. We recorded health outcomes in 5322 subjects (median age, 51.8 years; 43.1% women) randomly recruited from 11 populations, who had baseline measurements of 24-hour ambulatory blood pressure (ABP24) and eGFR. We computed hazard ratios using multivariable-adjusted Cox regression. Median follow-up was 9.3 years. In fully adjusted models, which included both ABP24 and eGFR, ABP24 predicted (P?0.008) both total (513 deaths) and cardiovascular (206) mortality; eGFR only predicted cardiovascular mortality (P=0.012). Furthermore, ABP24 predicted (P?0.0056) fatal combined with nonfatal events as a result of all cardiovascular causes (555 events), cardiac disease (335 events), or stroke (218 events), whereas eGFR only predicted the composite cardiovascular end point and stroke (P?0.035). The interaction terms between ABP24 and eGFR were all nonsignificant (P?0.082). For cardiovascular mortality, the composite cardiovascular end point, and stroke, ABP24 added 0.35%, 1.17%, and 1.00% to the risk already explained by cohort, sex, age, body mass index, smoking and drinking, previous cardiovascular disease, diabetes mellitus, and antihypertensive drug treatment. Adding eGFR explained an additional 0.13%, 0.09%, and 0.14%, respectively. Sensitivity analyses stratified for ethnicity, sex, and the presence of hypertension or chronic kidney disease (eGFR <60 mL/min per 1.73 m2) were confirmatory. In conclusion, in the general population, eGFR predicts fewer end points than ABP24. Relative to ABP24, eGFR is as an additive, not a multiplicative, risk factor and refines risk stratification 2- to 14-fold less.

Boggia, Jose; Thijs, Lutgarde; Li, Yan; Hansen, Tine W.; Kikuya, Masahiro; Bjorklund-Bodegard, Kristina; Ohkubo, Takayoshi; Jeppesen, J?rgen; Torp-Pedersen, Christian; Dolan, Eamon; Kuznetsova, Tatiana; Stolarz-Skrzypek, Katarzyna; Tikhonoff, Valerie; Malyutina, Sofia; Casiglia, Edoardo; Nikitin, Yuri; Lind, Lars; Schwedt, Emma; Sandoya, Edgardo; Kawecka-Jaszcz, Kalina; Filipovsky, Jan; Imai, Yutaka; Wang, Jiguang; Ibsen, Hans; O'Brien, Eoin; Staessen, Jan A.



Arrhythmia Phenotype During Fetal Life Suggests Long-QT Syndrome Genotype: Risk Stratification of Perinatal Long-QT Syndrome.  


Background- Fetal arrhythmias characteristic of long QT syndrome (LQTS) include torsades de pointes (TdP) and/or 2° atrioventricular block, but sinus bradycardia, defined as fetal heart rate <3% for gestational age, is most common. We hypothesized that prenatal rhythm phenotype might predict LQTS genotype and facilitate improved risk stratification and management. Method and Results- Records of subjects exhibiting fetal LQTS arrhythmias were reviewed. Fetal echocardiograms, neonatal ECG, and genetic testing were evaluated. We studied 43 subjects exhibiting fetal LQTS arrhythmias: TdP±2° atrioventricular block (group 1, n=7), isolated 2° atrioventricular block (group 2, n=4), and sinus bradycardia (group 3, n=32). Mutations in known LQTS genes were found in 95% of subjects tested. SCN5A mutations occurred in 71% of group 1, whereas 91% of subjects with KCNQ1 mutations were in group 3. Small numbers of subjects with KCNH2 mutations (n=4) were scattered in all 3 groups. Age at presentation did not differ among groups, and most subjects (n=42) were live-born with gestational ages of 37.5±2.8 weeks (mean±SD). However, those with TdP were typically delivered earlier. Prenatal treatment in group 1 terminated (n=2) or improved (n=4) TdP. The neonatal heart rate-corrected QT interval (mean±SE) of group 1 (664.7±24.9) was longer than neonatal heart rate-corrected QT interval in both group 2 (491.2±27.6; P=0.004) and group 3 (483.1±13.7; P<0.001). Despite medical and pacemaker therapy, postnatal cardiac arrest (n=4) or sudden death (n=1) was common among subjects with fetal/neonatal TdP. Conclusions- Rhythm phenotypes of fetal LQTS have genotype-suggestive features that, along with heart rate-corrected QT interval duration, may risk stratify perinatal management. PMID:23995044

Cuneo, Bettina F; Etheridge, Susan P; Horigome, Hitoshi; Sallee, Denver; Moon-Grady, Anita; Weng, Hsin-Yi; Ackerman, Michael J; Benson, D Woodrow



Galectin 3 complements BNP in risk stratification in acute heart failure  

PubMed Central

Background Galectin 3 (G3) is a mediator of fibrosis and remodeling in heart failure. Methods Patients diagnosed with and treated for Acute Heart Failure Syndromes were prospectively enrolled in the Decision Making in Acute Decompensated Heart Failure multicenter trial. Results Patients with a higher G3 had a history of renal disease, a lower heart rate and acute kidney injury. They also tended to have a history of HF and 30-day adverse events compared with B-type natriuretic peptide. Conclusion In Acute Heart Failure Syndromes, G3 levels do not provide prognostic value, but when used complementary to B-type natriuretic peptide, G3 is associated with renal dysfunction and may predict 30-day events.

Fermann, Gregory J.; Lindsell, Christopher J.; Storrow, Alan B.; Hart, Kimberly; Sperling, Matthew; Roll, Susan; Weintraub, Neal L.; Miller, Karen F.; Maron, David J.; Naftilan, Allen J.; Mcpherson, John A.; Sawyer, Douglas B.; Christenson, Robert; Collins, Sean P.



[Risk stratification for sudden cardiac death: from the electrophysiological study to T-wave alternans].  


T-wave alternans is a change, in the microvolt range, of T-wave amplitude on an ABABAB sequence. At present, various groups of patients have been evaluated, including those with myocardial infarction, congestive heart failure, implantable cardioverter-defibrillators and a clinical indication for programmed ventricular stimulation. In all clinical conditions analyzed, T-wave alternans analysis demonstrated a good diagnostic accuracy, suggesting a possible clinical use of the test in these settings. PMID:19195304

Pedretti, Roberto F E; Sarzi Braga, Simona; Vaninetti, Raffaella; Laporta, Antonio; Masnaghetti, Sergio; Raimondo, Rosa; Rubin, Debora; Santoro, Francesco; Salerno, Mario



Risk Stratification of Latent Tuberculosis Defined by Combined Interferon Gamma Release Assays  

PubMed Central

Background Most individuals infected with Mycobacterium tuberculosis develop latent tuberculosis infection (LTBI). Some may progress to active disease and would benefit from preventive treatment yet no means currently exists to predict who will reactivate. Here, we provide an approach to stratify LTBI based on IFN-? responses to two antigens, the recombinant Early-Secreted Antigen Target-6 (rESAT-6) and the latency antigen Heparin-Binding Haemagglutinin (HBHA). Methods We retrospectively analyzed results from in-house IFN-?-release assays with HBHA (HBHA-IGRA) and rESAT-6 (rESAT-6-IGRA) performed during a 12-year period on serial blood samples (3 to 9) collected from 23 LTBI subjects in a low-TB incidence country. Both the kinetics of the absolute IFN-? concentrations secreted in response to each antigen and the dynamics of HBHA/rESAT-6-induced IFN-? concentrations ratios were examined. Results This analysis allowed the identification among the LTBI subjects of three major groups. Group A featured stable HBHA and rESAT-6-IGRA profiles with an HBHA/rESAT-6 ratio persistently higher than 1, and with high HBHA- and usually negative rESAT-6-IGRA responses throughout the study. Group B had changing HBHA/rESAT-6 ratios fluctuating from 0.0001 to 10,000, with both HBHA and rESAT-6 responses varying over time at least once during the follow-up. Group C was characterized by a progressive disappearance of all responses. Conclusions By combining the measures of IFN-? concentrations secreted in response to an early and a latency antigens, LTBI subjects can be stratified into different risk groups. We propose that disappearing responses indicate cure, that persistent responses to HBHA with HBHA/rESAT-6 ratios ?1 represent stable LTBI subjects, whereas subjects with ratios varying from >1 to <1 should be closely monitored as they may represent the highest-risk group, as illustrated by a case report, and should therefore be prioritized for preventive treatment.

Corbiere, Veronique; Pottier, Gaelle; Bonkain, Florence; Schepers, Kinda; Verscheure, Virginie; Lecher, Sophie; Doherty, T. Mark; Locht, Camille; Mascart, Francoise



A GMM-based breast cancer risk stratification using a resonance-frequency electrical impedance spectroscopy  

PubMed Central

Purpose: The authors developed and tested a multiprobe-based resonance-frequency-based electrical impedance spectroscopy (REIS) system. The purpose of this study was to preliminarily assess the performance of this system in classifying younger women into two groups, those ultimately recommended for biopsy during imaging-based diagnostic workups that followed screening and those rated as negative during mammography. Methods: A seven probe-based REIS system was designed, assembled, and is currently being tested in the breast imaging facility. During an examination, contact is made with the nipple and six concentric points on the breast skin. For each measurement channel between the center probe and one of the six external probes, a set of electrical impedance spectroscopy (EIS) signal sweeps is performed and signal outputs ranging from 200 to 800 kHz at 5 kHz interval are recorded. An initial subset of 174 examinations from an ongoing prospective clinical study was selected for this preliminary analysis. An initial set of 35 features, 33 of which represented the corresponding EIS signal differences between the left and right breasts, was established. A Gaussian mixture model (GMM) classifier was developed to differentiate between “positive” (biopsy recommended) cases and “negative” (nonbiopsy) cases. Selecting an optimal feature set was performed using genetic algorithms with an area under a receiver operating characteristic curve (AUC) as the fitness criterion. Results: The recorded EIS signal sweeps showed that, in general, negative (nonbiopsy) examinations have a higher level of electrical impedance symmetry between the two breasts than positive (biopsy) examinations. Fourteen features were selected by genetic algorithm and used in the optimized GMM classifier. Using a leave-one-case-out test, the GMM classifier yielded a performance level of AUC=0.78, which compared favorably to other three widely used classifiers including support vector machine, classification tree, and linear discriminant analysis. These results also suggest that the REIS signal based GMM classifier could be used as a prescreening tool to correctly identify a fraction of younger women at higher risk of developing breast cancer (i.e., 47% sensitivity at 90% specificity). Conclusions: The study confirms that asymmetry in electrical impedance characteristics between two breasts provides valuable information regarding the presence of a developing breast abnormality; hence, REIS data may be useful in classifying younger women into two groups of “average” and “significantly higher than average” risk of having or developing a breast abnormality that would ultimately result in a later imaging-based recommendation for biopsy.

Lederman, Dror; Zheng, Bin; Wang, Xingwei; Sumkin, Jules H.; Gur, David



When is risk stratification by race or ethnicity justified in medical care?  


Issues of race and ethnicity have been controversial in both clinical care and medical education. In daily practice, many physicians struggle to be culturally competent and avoid racial stereotyping. One educational development that makes this goal more complex is the rise of clinical epidemiology and Bayesian thinking. These population-based, probabilistic approaches to medicine help guide the diagnostic and therapeutic pathways for patients, and are foundations of the evidence-based medicine movement. Can Bayesian thinking be applied effectively to issues of race and ethnicity in medical care, or are the dangers of prejudicial stereotyping too great? The authors draw upon lessons from recent cases of racial profiling, and develop a conceptual framework for thinking about ethnicity as a clinical tool. In their typology of ethnicity as a proxy, they argue that the costs of using ethnicity as a proxy for socioeconomic status and behavior are too high, but that ethnicity may appropriately be used as an initial proxy for history, language, culture, and health beliefs. They discuss their approach within the context of new curricula in cultural competence, and argue that viewing the patient within a wider cultural setting can help guide the initial clinical approach, but individualized care is mandatory. Also, physicians must remain sensitive to the changing nature of cultural norms; thus lifelong learning and flexibility are necessary. PMID:11891155

Chin, Marshall H; Humikowski, Catherine A



Coronary bypass in vascular patients: A relatively high-risk procedure  

Microsoft Academic Search

A premise of cardiac risk stratification is that the added risk of coronary artery bypass grafting (CABG) is offset by the\\u000a improved safety of subsequent vascular reconstruction (VR). We questioned if elective CABG is patients with severe peripheral\\u000a vascular disease (PVD) is a relatively high-risk procedure. A cohort study of 680 elective CABG patients from January 1993\\u000a to December 1994

Charles L. Mesh; Brian L. Cmolik; Daniel W. Van Heekeren; Jai H. Lee; Dianna Whittlesey; Linda M. Graham; Alexander S. Geha; Steven J. Bowlin



Biology, Risk Stratification, and Therapy of Pediatric Acute Leukemias: An Update  

PubMed Central

Purpose We review recent advances in the biologic understanding and treatment of childhood acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML), identify therapeutically challenging subgroups, and suggest future directions of research. Methods A review of English literature on childhood acute leukemias from the past 5 years was performed. Results Contemporary treatments have resulted in 5-year event-free survival rates of approximately 80% for childhood ALL and almost 60% for pediatric AML. The advent of high-resolution genome-wide analyses has provided new insights into leukemogenesis and identified many novel subtypes of leukemia. Virtually all ALL and the vast majority of AML cases can be classified according to specific genetic abnormalities. Cooperative mutations involved in cell differentiation, cell cycle regulation, tumor suppression, drug responsiveness, and apoptosis have also been identified in many cases. The development of new formulations of existing drugs, molecularly targeted therapy, and immunotherapies promises to further advance the cure rates and improve quality of life of patients. Conclusion The application of new high-throughput sequencing techniques to define the complete DNA sequence of leukemia and host normal cells and the development of new agents targeted to leukemogenic pathways promise to further improve outcome in the coming decade.

Pui, Ching-Hon; Carroll, William L.; Meshinchi, Soheil; Arceci, Robert J.



Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: Implementation and validation of a medical risk factor model  

Microsoft Academic Search

OBJECTIVES: To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model. DESIGN: Prospective cohort study. SETTING: Medical school-affiliated general hospital in Alkmaar, the Netherlands. PARTICIPANTS: Six hundred three hip-surgery patients aged 70 and older screened for risk factors for postoperative delirium. MEASUREMENTS: Predefined risk factors for delirium were

Kees J. Kalisvaart; Ralph Vreeswijk; Jonghe de J. F. M; Ploeg van der T; Gool van W. A; P. Eikelenboom



Very early assessment of risk for in-hospital death among 11,483 patients with acute myocardial infarction  

Microsoft Academic Search

Background The efficacy of reperfusion therapy after acute myocardial infarction is time dependent. The risk profile of every patient should be available as soon as possible. Our aim was to determine whether collection of simple clinical markers at hospital admission might allow reliable risk stratification for in-hospital mortality. Methods The subjects were 11,483 patients with acute myocardial infarction from the

C. Fresco; F. Carinci; A. P. Maggioni; A. Ciampi; A. Nicolucci; E. Santoro; L. Tavazzi; G. Tognonia



Exercise Single-Photon Emission Computed Tomography Provides Effective Risk Stratification of Elderly Men and Elderly Women  

Microsoft Academic Search

Background—In a recent study, we reported that the Duke treadmill score was unable to effectively stratify elderly patients according to risk. The purpose of this study was to evaluate the prognostic value of exercise single-photon emission computed tomography (SPECT) in this same population and to examine results by gender. Methods and Results—A cohort of 247 elderly (age 75 years) patients

Uma S. Valeti; Todd D. Miller; David O. Hodge; Raymond J. Gibbons



Combined assessment of sex- and mutation-specific information for risk stratification in type 1 long QT syndrome  

PubMed Central

BACKGROUND Men and women with type 1 long QT syndrome (LQT1) exhibit time-dependent differences in the risk for cardiac events. OBJECTIVE We hypothesized that sex-specific risk for LQT1 is related to the location and function of the disease-causing mutation in the KCNQ1 gene. METHODS The risk for life-threatening cardiac events (comprising aborted cardiac arrest [ACA] or sudden cardiac death [SCD]) from birth through age 40 years was assessed among 1051 individuals with LQT1 (450 men and 601 women) by the location and function of the LQT1-causing mutation (prespecified as mutations in the intracellular domains linking the membrane-spanning segments [ie, S2–S3 and S4–S5 cytoplasmic loops] involved in adrenergic channel regulation vs other mutations). RESULTS Multivariate analysis showed that during childhood (age group: 0–13 years) men had >2-fold (P < .003) increased risk for ACA/SCD than did women, whereas after the onset of adolescence the risk for ACA/SCD was similar between men and women (hazard ratio = 0.89 [P = .64]). The presence of cytoplasmic-loop mutations was associated with a 2.7-fold (P < .001) increased risk for ACA/SCD among women, but it did not affect the risk among men (hazard ratio 1.37; P = .26). Time-dependent syncope was associated with a more pronounced risk-increase among men than among women (hazard ratio 4.73 [P < .001] and 2.43 [P = .02], respectively), whereas a prolonged corrected QT interval (?500 ms) was associated with a higher risk among women than among men. CONCLUSION Our findings suggest that the combined assessment of clinical and mutation location/functional data can be used to identify sex-specific risk factors for life-threatening events for patients with LQT1.

Costa, Jason; Lopes, Coeli M.; Barsheshet, Alon; Moss, Arthur J.; Migdalovich, Dmitriy; Ouellet, Gregory; McNitt, Scott; Polonsky, Slava; Robinson, Jennifer L.; Zareba, Wojciech; Ackerman, Michael J.; Benhorin, Jesaia; Kaufman, Elizabeth S.; Platonov, Pyotr G.; Shimizu, Wataru; Towbin, Jeffrey A.; Vincent, G. Michael; Wilde, Arthur A.M.; Goldenberg, Ilan



The promise of pharmacogenetics: assessing the prospects for disease and patient stratification.  


Pharmacogenetics is an emerging biotechnology concerned with understanding the genetic basis of drug response, and promises to transform the development, marketing and prescription of medicines. This paper is concerned with analysing the move towards segmented drug markets, which is implicit in the commercial development of pharmacogenetics. It is claimed that in future who gets a particular drug will be determined by their genetic make up. Drawing on ideas from the sociology of expectations we examine how pharmaceutical and biotechnology companies are constructing, responding to and realising particular 'visions' or expectations of pharmacogenetics and market stratification. We argue that the process of market segmentation remains uncertain, but that the outcome will be fashioned according to the convergence and divergence of the interests of key commercial actors. Qualitative data based both on interviews with industry executives and company documentation will be used to explore how different groups of companies are developing pharmacogenetics in distinct ways, and what consequences these different pathways might have for both clinical practice and health policy. In particular, the analysis will show a convergence of interests between biotechnology and pharmaceutical companies for creating segmented markets for new drugs, but a divergence of interest in segmenting established markets. Whilst biotechnology firms have a strong incentive to innovate, the pharmaceutical industry has no commercial interest in segmenting markets for existing products. This has important implications, as many of the claimed public health benefits of pharmacogenetics will derive from changing the prescribing of existing medicines. One significant implication of this is that biotechnology companies who wish to apply pharmacogenetics to existing medicines will have to explore an alternative convergence of interests with healthcare payers and providers (health insurers, HMOs, MCOs and national health systems). Healthcare providers may have a strong incentive to use pharmacogenetics to make the prescribing of existing medicine more cost-effective. However, we conclude by suggesting that a question mark hangs over their ability to provide the necessary economic and structural resources to bring such a vision to fruition. PMID:16980196

Smart, Andrew; Martin, Paul



Atlas stratification ?  

PubMed Central

The process of constructing an atlas typically involves selecting one individual from a sample on which to base or root the atlas. If the individual selected is far from the population mean, then the resulting atlas is biased towards this individual. This, in turn, may bias any inferences made with the atlas. Unbiased atlas construction addresses this issue by either basing the atlas on the individual which is the median of the sample or by an iterative technique whereby the atlas converges to the unknown population mean. In this paper, we explore the question of whether a single atlas is appropriate for a given sample or whether there is sufficient image based evidence from which we can infer multiple atlases, each constructed from a subset of the data. We refer to this process as atlas stratification. Essentially, we determine whether the sample, and hence the population, is multi-modal and is best represented by an atlas per mode. In this preliminary work, we use the mean shift algorithm to identify the modes of the sample and multidimensional scaling to visualize the clustering process on clinical MRI neurological image datasets.

Blezek, Daniel J.; Miller, James V.



Stroke Prevention in the High-risk Atrial Fibrillation Patient: Medical Management  

Microsoft Academic Search

Medical management of patients with atrial fibrillation (AF) at high risk for stroke is limited by problems of imperfect tools\\u000a for assessment of thromboembolism and bleeding risks. Improved instruments, such as the CHA2DS2VASc and HAS-BLED risk stratification scores, have been incorporated into European practice guidelines. Until recently, the\\u000a most effective therapy for stroke prevention has been anticoagulation with a vitamin

Michael Broukhim; Jonathan L. Halperin



High risk plaque, high risk patient or high risk procedure?  


SAPPHIRE, a randomised trial of endarterectomy versus angioplasty in 'high-risk' patients, concluded that angioplasty was 'not inferior' to surgery. This has subsequently been translated to mean that angioplasty was 'preferable' or 'advisable' in patients considered high-risk for surgery, with no further discrimination between symptomatic and asymptomatic individuals. Moreover, there have been suggestions that the accepted procedural risks may have to be increased in these patients. In fact, 71% of patients in SAPPHIRE were asymptomatic in whom there was an average 6% 30-day death/stroke rate. At this level of risk, neither surgery nor angioplasty could ever prevent long-term stroke. The concept of identifying high-risk patients is laudable, but they should be high risk for stroke (i.e. symptomatic). There is currently little systematic evidence to include asymptomatic patients within this definition. PMID:16870479

Naylor, A R; Golledge, J



Postoperative transarterial chemoembolization benefits patients with high ?-glutamyl transferase levels after curative hepatectomy for hepatocellular carcinoma: a survival stratification analysis.  


Hepatocellular carcinoma (HCC) is the most common liver tumor in Asian countries, and hepatectomy is currently regarded as the optimal curative treatment for HCC; however, the postoperative outcome remains unsatisfactory. Aiming at further clarification of prognostic factors after hepatectomy, we adopted a detailed stratification on survival periods. A total of 428 HCC patients undergoing curative hepatectomy were firstly divided into two groups using 2-year survival as cutoff point. Multivariate analysis showed that tumor-related factors, including vascular invasion (P < 0.001), high Edmondson grade (P < 0.001), large tumor size (P < 0.001) and high serum alpha-fetoprotein level (P = 0.001), were significant determinants for early death within 2 years, while postoperative transarterial chemoembolization (TACE) was demonstrated a protective factor (P = 0.013). Then the 281 patients with survival > 2 years were divided into two subgroups according to survival or death during follow-up to examine the late death related factors. We found that high serum ?-glutamyl transpeptidase (GGT), indicating severity of underlying liver disease, was significantly linked to death in this stage (P = 0.006). In further comparison of survival rates between subgroups stratified by early- and late-death indictors, we found the long-term outcomes of patients with high serum GGT were poor, regardless of the factors related with primary tumor. Furthermore, postoperative TACE decreased late death rate of patients with high GGT levels. In conclusion, despite the overwhelmed effects of primary tumor in the early stage after hepatectomy, postoperative TACE is beneficial for HCC patients with poor liver status. PMID:22820835

Liu, Hansheng; Zhang, Aiqun; Qian, Niansong; Gao, Lijie; Xu, Lining; Zhang, Wenzhi; Jiang, Kai; Cai, Shouwang; Huang, Zhiqiang; Dong, Jiahong



Premature Ventricular Contractions and Non-sustained Ventricular Tachycardia: Association with Sudden Cardiac Death, Risk Stratification, and Management Strategies  

PubMed Central

Premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (NSVT) are frequently encountered and a marker of electrocardiomyopathy. In some instances, they increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death. While often associated with a primary cardiomyopathy, they have also been known to cause tachycardia-induced cardiomyopathy in patients without preceding structural heart disease. Medical therapy including beta-blockers and class III anti-arrhythmic agents can be effective while implantable cardiac defibrillators (ICD) are indicated in certain patients. Radiofrequency ablation (RFA) is the preferred, definitive treatment in those patients that improve with anti-arrhythmic therapy, have tachycardia-induced cardiomyopathy, or have certain subtypes of PVCs/NSVT. We present a review of PVCs and NSVT coupled with case presentations on RFA of fascicular ventricular tachycardia, left-ventricular outflow tract ventricular tachycardia, and Purkinje arrhythmia leading to polymorphic ventricular tachycardia.

Sheldon, Seth H; Gard, Joseph J; Asirvatham, Samuel J



Improving the Identification of High Risk Precursor B Acute Lymphoblastic Leukemia Patients with Earlier Quantification of Minimal Residual Disease  

PubMed Central

The stratification of patients with acute lymphoblastic leukemia (ALL) into treatment risk groups based on quantification of minimal residual disease (MRD) after induction therapy is now well accepted but the relapse rate of about 20% in intermediate risk patients remains a challenge. The purpose of this study was to further improve stratification by MRD measurement at an earlier stage. MRD was measured in stored day 15 bone marrow samples for pediatric patients enrolled on ANZCHOG ALL8 using Real-time Quantitative PCR to detect immunoglobulin and T-cell receptor gene rearrangements with the same assays used at day 33 and day 79 in the original MRD stratification. MRD levels in bone marrow at day 15 and 33 were highly predictive of outcome in 223 precursor B-ALL patients (log rank Mantel-Cox tests both P<0.001) and identified patients with poor, intermediate and very good outcomes. The combined use of MRD at day 15 (?1×10?2) and day 33 (?5×1?5) identified a subgroup of medium risk precursor B-ALL patients as poor MRD responders with 5 year relapse-free survival of 55% compared to 84% for other medium risk patients (log rank Mantel-Cox test, P?=?0.0005). Risk stratification of precursor B-ALL but not T-ALL could be improved by using MRD measurement at day 15 and day 33 instead of day 33 and day 79 in similar BFM-based protocols for children with this disease.

Karsa, Mawar; Dalla Pozza, Luciano; Venn, Nicola C.; Law, Tamara; Shi, Rachael; Giles, Jodie E.; Bahar, Anita Y.; Cross, Shamira; Catchpoole, Daniel; Haber, Michelle; Marshall, Glenn M.; Norris, Murray D.; Sutton, Rosemary



Traditional Chinese Medicine ZHENG Identification Provides a Novel Stratification Approach in Patients with Allergic Rhinitis  

PubMed Central

Background. We aimed to apply the ZHENG identification to provide an easy and useful tool to stratify the patients with allergic rhinitis (AR) through exploring the correlation between the quantified scores of AR symptoms and the TCM ZHENGs. Methods. A total of 114 AR patients were enrolled in this observational study. All participants received the examinations of anterior rhinoscopy and acoustic rhinometry. Their blood samples were collected for measurement of total serum immunoglobulin E (IgE), blood eosinophil count (Eos), and serum eosinophil cationic protein (ECP). They also received two questionnaire to assess the severity scores of AR symptoms and quantified TCM ZHENG scores. Multiple linear regression analysis was used to determine explanatory factors for the score of AR manifestations. Results. IgE and ECP level, duration of AR, the 2 derived TCMZHENG scores of “Yin-Xu ? Yang-Xu”, and “Qi-Xu + Blood-Xu” were 5 explanatory variables to predict the severity scores of AR symptoms. The patients who had higher scores of “Yin-Xu ? Yang-Xu” or “Qi-Xu + Blood-Xu” tended to manifest as “sneezer and runner” or “blockers,” respectively. Conclusions. The TCM ZHENG scores correlated with the severity scores of AR symptoms and provided an easy and useful tool to stratify the AR patients.

Liang, Kai-Li; Jiang, Rong-San; Lee, Chia-Lin; Chiang, Pei-Jung; Lin, Jui-Shan; Su, Yi-Chang



Cardiac computed tomography and myocardial perfusion scintigraphy for risk stratification in asymptomatic individuals without known cardiovascular disease: a position statement of the Working Group on Nuclear Cardiology and Cardiac CT of the European Society of Cardiology.  


Cardiovascular events remain one of the most frequent causes of mortality and morbidity worldwide. The majority of cardiac events occur in individuals without known coronary artery disease (CAD) and in low- to intermediate-risk subjects. Thus, the development of improved preventive strategies may substantially benefit from the identification, among apparently intermediate-risk subjects, of those who have a high probability for developing future cardiac events. Cardiac computed tomography and myocardial perfusion scintigraphy (MPS) by single photon emission computed tomography may play a role in this setting. In fact, absence of coronary calcium in cardiac computed tomography and inducible ischaemia in MPS are associated with a very low rate of major cardiac events in the next 3-5 years. Based on current evidence, the evaluation of coronary calcium in primary prevention subjects should be considered in patients classified as intermediate-risk based on traditional risk factors, since high calcium scores identify subjects at high-risk who may benefit from aggressive secondary prevention strategies. In addition, calcium scoring should be considered for asymptomatic type 2 diabetic patients without known CAD to select those in whom further functional testing by MPS or other stress imaging techniques may be considered to identify patients with significant inducible ischaemia. From available data, the use of MPS as first line testing modality for risk stratification is not recommended in any category of primary prevention subjects with the possible exception of first-degree relatives of patients with premature CAD in whom MPS may be considered. However, the Working Group recognizes that neither the use of computed tomography for calcium imaging nor of MPS have been proven to significantly improve clinical outcomes of primary prevention subjects in prospective controlled studies. This information would be crucial to adequately define the role of imaging approaches in cardiovascular preventive strategies. PMID:20630895

Perrone-Filardi, Pasquale; Achenbach, Stephan; Möhlenkamp, Stefan; Reiner, Zeljko; Sambuceti, Gianmario; Schuijf, Joanne D; Van der Wall, Ernst; Kaufmann, Philip A; Knuuti, Juhani; Schroeder, Stephen; Zellweger, Michael J



TMA Navigator: Network inference, patient stratification and survival analysis with tissue microarray data.  


Tissue microarrays (TMAs) allow multiplexed analysis of tissue samples and are frequently used to estimate biomarker protein expression in tumour biopsies. TMA Navigator ( is an open access web application for analysis of TMA data and related information, accommodating categorical, semi-continuous and continuous expression scores. Non-biological variation, or batch effects, can hinder data analysis and may be mitigated using the ComBat algorithm, which is incorporated with enhancements for automated application to TMA data. Unsupervised grouping of samples (patients) is provided according to Gaussian mixture modelling of marker scores, with cardinality selected by Bayesian information criterion regularization. Kaplan-Meier survival analysis is available, including comparison of groups identified by mixture modelling using the Mantel-Cox log-rank test. TMA Navigator also supports network inference approaches useful for TMA datasets, which often constitute comparatively few markers. Tissue and cell-type specific networks derived from TMA expression data offer insights into the molecular logic underlying pathophenotypes, towards more effective and personalized medicine. Output is interactive, and results may be exported for use with external programs. Private anonymous access is available, and user accounts may be generated for easier data management. PMID:23761446

Lubbock, Alexander L R; Katz, Elad; Harrison, David J; Overton, Ian M



Wdr66 is a novel marker for risk stratification and involved in epithelial-mesenchymal transition of esophageal squamous cell carcinoma  

PubMed Central

Background We attempted to identify novel biomarkers and therapeutic targets for esophageal squamous cell carcinoma by gene expression profiling of frozen esophageal squamous carcinoma specimens and examined the functional relevance of a newly discovered marker gene, WDR66. Methods Laser capture microdissection technique was applied to collect the cells from well-defined tumor areas in collaboration with an experienced pathologist. Whole human gene expression profiling of frozen esophageal squamous carcinoma specimens (n?=?10) and normal esophageal squamous tissue (n?=?18) was performed using microarray technology. A gene encoding WDR66, WD repeat-containing protein 66 was significantly highly expressed in esophageal squamous carcinoma specimens. Microarray results were validated by quantitative real-time polymerase chain reaction (qRT-PCR) in a second and independent cohort (n?=?71) consisting of esophageal squamous cell carcinoma (n?=?25), normal esophagus (n?=?11), esophageal adenocarcinoma (n?=?13), gastric adenocarcinoma (n?=?15) and colorectal cancers (n?=?7). In order to understand WDR66’s functional relevance siRNA-mediated knockdown was performed in a human esophageal squamous cell carcinoma cell line, KYSE520 and the effects of this treatment were then checked by another microarray analysis. Results High WDR66 expression was significantly associated with poor overall survival (P?=?0.031) of patients suffering from esophageal squamous carcinomas. Multivariate Cox regression analysis revealed that WDR66 expression remained an independent prognostic factor (P?=?0.042). WDR66 knockdown by RNA interference resulted particularly in changes of the expression of membrane components. Expression of vimentin was down regulated in WDR66 knockdown cells while that of the tight junction protein occludin was markedly up regulated. Furthermore, siRNA-mediated knockdown of WDR66 resulted in suppression of cell growth and reduced cell motility. Conclusions WDR66 might be a useful biomarker for risk stratification of esophageal squamous carcinomas. WDR66 expression is likely to play an important role in esophageal squamous cell carcinoma growth and invasion as a positive modulator of epithelial-mesenchymal transition. Furthermore, due to its high expression and possible functional relevance, WDR66 might be a novel drug target for the treatment of squamous carcinoma.



Which Is the Optimal Risk Stratification System for Surgically Treated Localized Primary GIST? Comparison of Three Contemporary Prognostic Criteria in 171 Tumors and a Proposal for a Modified Armed Forces Institute of Pathology Risk Criteria  

Microsoft Academic Search

Background  This study aims to validate and compare the performance of the National Institute of Health (NIH) criteria, Huang modified\\u000a NIH criteria, and Armed Forces Institute of Pathology (AFIP) risk criteria for gastrointestinal stromal tumors (GISTs) in\\u000a a large series of localized primary GISTs surgically treated at a single institution to determine the ideal risk stratification\\u000a system for GIST.\\u000a \\u000a \\u000a \\u000a Methods  The clinicopathological

Brian K. P. Goh; Pierce K. H. Chow; Wai-Ming Yap; Sittampalam M. Kesavan; In-Chin Song; Pradeep G. Paul; Boon-Swee Ooi; Yaw-Fui A. Chung; Wai-Keong Wong



Opioid misuse and abuse: risk assessment and management in patients with cancer pain.  


The FDA's 2012 risk evaluation and mitigation strategy is a major step toward systematically reducing the inherent risks of chronic opioid therapy for pain, but does not distinguish between risks related to sources of pain. This article discusses the effect of risk mitigation in the treatment of cancer pain, with a focus on pretreatment screening and ongoing monitoring in this patient population that often requires pain management at some time during cancer treatment. Experience with screening, risk stratification, and interventions at one cancer center is shared, along with some recommendations for practice. A new screening checklist is proposed that summarizes known risk factors. Patients with cancer are not protected from the problems of opioid abuse/misuse, and the multidisciplinary cancer treatment team should coordinate an evaluation of risk and the monitoring of aberrant behaviors as part of the comprehensive care plan. PMID:23946178

Anghelescu, Doralina L; Ehrentraut, Jennifer Harman; Faughnan, Lane G



Lake Layers: Stratification.  

ERIC Educational Resources Information Center

This teacher guide and student workbook set contains two learning activities, designed for fifth through ninth grade students, that concentrate on lake stratification and water quality. In the activities students model the seasonal temperature changes that occur in temperate lakes and observe the resulting stratification of lake waters. Students…

Brothers, Chris; And Others


Evaluation of Clinical Outcomes in Patients with Bloodstream Infections Due to Gram-Negative Bacteria According to Carbapenem MIC Stratification  

PubMed Central

Predictive modeling suggests that actual carbapenem MIC results are more predictive of clinical patient outcomes than categorical classification of the MIC as susceptible, intermediate, or resistant. Some have speculated that current CLSI guidelines' suggested thresholds are too high and that clinical success is more likely if the MIC value is ?1 mg/liter for certain organisms. Patients treated with carbapenems and with positive blood cultures for Pseudomonas aeruginosa, Acinetobacter baumannii, or extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria were considered for evaluation in this clinical retrospective cohort study. Relevant patient demographics and microbiologic variables were collected, including carbapenem MIC. The primary objective was to define a risk-adjusted all-cause hospital mortality breakpoint for carbapenem MICs. Secondarily, we sought to determine if a similar breakpoint existed for indirect outcomes (e.g., time to mortality and length of stay [LOS] postinfection for survivors). Seventy-one patients met the criteria for study inclusion. Overall, 52 patients survived, and 19 died. Classification and regression tree (CART) analysis determined a split of organism MIC between 2 and 4 mg/liter and predicted differences in mortality (16.1% versus 76.9%; P < 0.01). Logistic regression controlling for confounders identified each imipenem MIC doubling dilution as increasing the probability of death 2-fold (adjusted odds ratio [aOR] 2.0; 95% confidence interval [CI], 1.3 to 3.2). Secondary outcomes were similar between groups. This study revealed that patients with organisms that had a MIC of ?4 mg/liter had worse outcomes than patients whose isolates had a MIC of ?2 mg/liter, even after adjustment for confounding variables. We recommend additional clinical studies to better understand the susceptibility breakpoint for carbapenems.

Esterly, John S.; Wagner, Jamie; McLaughlin, Milena M.; Postelnick, Michael J.; Qi, Chao



Combining Exercise with Pharmacologic Stress to Optimize the Accuracy and Risk Stratification of SPECT Myocardial Perfusion Imaging: A Systematic Review  

Microsoft Academic Search

Coronary artery disease (CAD) remains the leading cause of death in the United States. Due to the substantial morbidity and\\u000a mortality related to CAD, stress single photon emission CT (SPECT) myocardial perfusion imaging has emerged as an important\\u000a noninvasive means of evaluating patients with suspected and known CAD. The preferred stress modality is exercise. However,\\u000a many patients require pharmacologic stress

Steven M. Borer; Gary V. Heller



Stratification of foot risk predicts the incidence of new foot disease, but do we yet know that the adoption of routine screening reduces it?  

Microsoft Academic Search

The evidence to justify classifications of foot risk is derived from a number of large cross-sectional and prospective studies,\\u000a and is very strong: it is possible to identify clinical features of the individual patient that are linked to the relative\\u000a risk of future ulceration. The presence of peripheral arterial disease, neuropathy or deformity will increase the risk modestly,\\u000a while any

W. J. Jeffcoate



Role of Coronary Artery Calcium Score and Coronary CT Angiography in the Diagnosis and Risk Stratification of Individuals with Suspected Coronary Artery Disease  

Microsoft Academic Search

Coronary heart disease is the leading cause of death worldwide, and has traditionally been assessed through a patient’s cardiovascular\\u000a risk profile that is comprised of a combination of genetic, social, physiologic, and environmental factors. A growing discordance\\u000a is being recognized in the ability of current risk estimation tools to predict outcomes versus that of actual measured outcomes.\\u000a Exciting new improvements

Sean R. Wilson; Fay Y. Lin; James K. Min


Erythroid-predominant myelodysplastic syndromes: enumeration of blasts from nonerythroid rather than total marrow cells provides superior risk stratification  

Microsoft Academic Search

In the FAB (French–American–British) and WHO (World Heath Organization) classifications, the blasts in erythroleukemia (M6a) are enumerated from the marrow nonerythroid rather than the total-nucleated cells. However, the method for blast calculation in erythroid-predominant myelodysplastic syndrome (erythroblasts?50%) is not specified either in the FAB or WHO classifications. We retrieved the files of 74 erythroid-predominant myelodysplastic syndrome patients (17% of all

Sa A Wang; Guilin Tang; Oluwole Fadare; Suyang Hao; Azra Raza; Bruce A Woda; Robert P Hasserjian



Post-myocardial infarction risk stratification with stress nuclear myocardial perfusion imaging versus echocardiography: Separate but not equal  

Microsoft Academic Search

The unique contribution of the study by Candell-Riera et al in this issue of the Journal is the evaluation of the prognostic\\u000a value of stress nuclear MPI and stress echocardiography in the same post-MI cohort. Importantly, it confirms the valuable\\u000a information that stress nuclear MPI has to offer for management of post-MI patients and simultaneously underscores the limitations\\u000a of stress

Kenneth A. Brown



Improving the identification of high risk precursor B acute lymphoblastic leukemia patients with earlier quantification of minimal residual disease.  


The stratification of patients with acute lymphoblastic leukemia (ALL) into treatment risk groups based on quantification of minimal residual disease (MRD) after induction therapy is now well accepted but the relapse rate of about 20% in intermediate risk patients remains a challenge. The purpose of this study was to further improve stratification by MRD measurement at an earlier stage. MRD was measured in stored day 15 bone marrow samples for pediatric patients enrolled on ANZCHOG ALL8 using Real-time Quantitative PCR to detect immunoglobulin and T-cell receptor gene rearrangements with the same assays used at day 33 and day 79 in the original MRD stratification. MRD levels in bone marrow at day 15 and 33 were highly predictive of outcome in 223 precursor B-ALL patients (log rank Mantel-Cox tests both P<0.001) and identified patients with poor, intermediate and very good outcomes. The combined use of MRD at day 15 (?1×10(-2)) and day 33 (?5×1(-5)) identified a subgroup of medium risk precursor B-ALL patients as poor MRD responders with 5 year relapse-free survival of 55% compared to 84% for other medium risk patients (log rank Mantel-Cox test, P?=?0.0005). Risk stratification of precursor B-ALL but not T-ALL could be improved by using MRD measurement at day 15 and day 33 instead of day 33 and day 79 in similar BFM-based protocols for children with this disease. PMID:24146872

Karsa, Mawar; Dalla Pozza, Luciano; Venn, Nicola C; Law, Tamara; Shi, Rachael; Giles, Jodie E; Bahar, Anita Y; Cross, Shamira; Catchpoole, Daniel; Haber, Michelle; Marshall, Glenn M; Norris, Murray D; Sutton, Rosemary



The Burden of Hard Atherosclerotic Plaques Does Not Promote Endoleak Development After Endovascular Aortic Aneurysm Repair: A Risk Stratification  

Microsoft Academic Search

Purpose  To objectify the influence of the atherosclerotic burden in the proximal landing zone on the development of endoleaks after\\u000a endovascular abdominal aortic aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) using objective aortic calcium scoring (ACS).\\u000a \\u000a \\u000a \\u000a \\u000a Materials and Methods  This retrospective observation study included 267 patients who received an aortic endograft between 1997 and 2010 and for\\u000a whom preoperative computed

Johannes Petersen; Bernhard Glodny


Stratification of risk in thin cap fibroatheromas using peak plaque stress estimates from idealized finite element models.  


Thin cap fibroatheroma (TCFA) in coronary arteries is believed to be associated with plaque rupture leading to cardiovascular death and non-fatal myocardial infarction. Catheter-based imaging platforms can identify TCFAs but detection algorithms lack specificity. Here we report results of an exploratory study of the variability in TCFA plaque attributes and effects on peak von Mises stress of TCFA using idealized finite element models. A total of 1272 idealized TCFA finite element models were developed by strategically varying attribute dimensions - external elastic membrane diameter, lumen diameter, necrotic core thickness, fibrous cap thickness, and necrotic core angle - obtained from a global registry of subjects undergoing percutaneous coronary intervention with Virtual Histology intravascular ultrasound. Peak stress exhibited parabolic or higher order proportionality with lumen diameter, sigmoidal proportionality with necrotic core thickness, inverse hyperbolic proportionality with fibrous cap thickness, and skewed sinusoidal proportionality with necrotic core angle. Each of these relationships was governed by highly sensitive, complex, and interdependent influences of various attributes on plaque stress. An over 7-fold increase in peak stress from 101 to 788kPa was observed in models of coronary dimensions commonly encountered in clinical practice. Peak stress of intramural TCFA within this common coronary artery subset did not exceed 300kPa for fibrous cap thickness greater than 100?m and necrotic core angle outside 90-120° range, indicating low risk of rupture. This exploratory study demonstrated the complex and interdependent influence of plaque attributes on the peak stress of TCFA. PMID:22342558

Dolla, William Jacob S; House, John A; Marso, Steven P



Income Stratification and Income Inequality  

Microsoft Academic Search

This paper develops a new index of stratification that highlights the distinction between inequality and stratification. The stratification index captures the extent to which population subgroups occupy disctinct strata within an overall distribution. The indices are group specific and control for group size. A weighted sum of group stratification indices is the third term that, together with between-group inequality and

Shlomo Yitzhaki; Robert I. Lerman



Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery  

Microsoft Academic Search

The use of cardiopulmonary exercise testing (CPET) as a preoperative risk stratification tool for a range of non-cardiopulmonary surgery is increasing. The utility of CPET in this role is dependent on the technology being able to identify accurately and reliably those patients at increased risk of perioperative events when compared with existing risk stratification tools. This article identifies and reviews

Philip J Hennis; Paula M Meale; Michael P W Grocott



Venous thromboembolism in cancer patients - risk scores and recent randomised controlled trials.  


Cancer patients are at increased risk of developing venous thromboembolism (VTE). Guidelines recommend routine thromboprophylaxis in hospitalised acutely ill cancer patients and in myeloma patients receiving combination treatments including thalidomide or lenalidomide. Currently, thromboprophylaxis is not recommended in cancer outpatients. It is the aim of this review to give an overview of studies that applied scores for the risk assessment of cancer-related VTE. We will also discuss randomised controlled trials (RCTs) that investigated primary thromboprophylaxis in cancer patients. Recently, Khorana et al. published a practical and reproducible risk assessment score that includes clinical and laboratory parameters for the stratification of cancer patients according to their propensity to develop VTE. Patients assigned to the high-risk group are likely to benefit most from primary thromboprophylaxis. This score was validated in prospective and retrospective observational studies. In the Vienna Cancer and Thrombosis Study (CATS) the score was expanded by adding two biomarkers, and the prediction of VTE was considerably improved. In recent RCTs including cancer patients with different malignancies it was shown that thromboprophylaxis is safe and effective. However, VTE incidence rates were low. To date, no data is available from interventional studies applying thromboprophylaxis in cancer patients categorised into high-risk groups on the basis of risk assessment with scores. From the available literature we conclude that risk assessment for VTE is feasible in cancer patients; however, interventional studies to investigate the safety and efficacy of thromboprophylaxis in a high risk cancer population have yet to be performed. PMID:22836491

Thaler, Johannes; Ay, Cihan; Pabinger, Ingrid



The high-risk patient with heart failure with reduced ejection fraction: treatment options and challenges.  


An estimated 5.1 million Americans aged 20 years and older have heart failure.(1) With therapies ranging from medication and physical therapy to implantable defibrillators and circulatory support, and possibly transplantation, accurate risk stratification of patient with heart failure and delivery of therapies appropriate to the level of their disease severity is becoming increasingly important. Determination of risk and associated treatment strategies is the subject of this brief review.Clinical Pharmacology & Therapeutics (2013); 94 4, 509-518. doi:10.1038/clpt.2013.137. PMID:23852394

Bartos, J A; Francis, G S



Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department  

PubMed Central

Chest pain is a common reason for presentation to the emergency department (ED). Absolute criteria for Acute Coronary Syndrome without ST elevation (NSTE-ACS) are lacking. An acute coronary syndrome (ACS) needs to be distinguished from a variety of other cardiac and non-cardiac diseases that may cause chest pain. For patients with confirmed ACS, several scoring methods can be applied in order to distinguish patients in the coronary care unit who may benefit most from therapies. The PURSUIT, TIMI, GRACE and FRISC risk scores are well validated with this respect. However, none of these risk scores has been used in the identification of an ACS in the emergency setting. The vast majority of patients with chest pain due to causes other than ACS were not evaluated in these trials. An evidence-based systematic stratification and policy for these patients does not currently exist. The more recently developed HEART score is specifically designed to stratify all chest pain patients in the ED. The HEART score was validated in a retrospective multicenter study and proved to be a strong predictor of event free survival on one hand and potentially life threatening cardiac events on the other hand. The HEART score facilitates risk stratification of chest pain patients in the ED.

Backus, B.E; Six, A.J; Kelder, J.H; Gibler, W.B; Moll, F.L; Doevendans, P.A



Dipyridamole-thallium scanning in patients undergoing vascular surgery. Optimizing preoperative evaluation of cardiac risk  

SciTech Connect

Dipyridamole-thallium imaging has been suggested as a method of preoperatively assessing cardiac risk in patients undergoing major surgery. To define more clearly its proper role in preoperative assessment, we prospectively evaluated 111 patients undergoing vascular surgery. In the first set of 61 patients, our data confirmed the value of preoperative dipyridamole-thallium scanning in identifying the patients who suffered postoperative ischemic events. Events occurred in eight of 18 patients with reversible defects on preoperative imaging, compared with no events in 43 patients with no thallium redistribution (confidence interval for the risk difference: 0.624, 0.256). The results also suggested that clinical factors might allow identification of a low-risk subset of patients. To test the hypothesis that patients with no evidence of congestive heart failure, angina, prior myocardial infarction, or diabetes do not require further preoperative testing, we evaluated an additional 50 patients having vascular procedures. None of the 23 without the clinical markers had untoward outcomes, while ten of 27 patients with one or more of these clinical markers suffered postoperative ischemic events (confidence interval for the risk difference: 0.592, 0.148). In the clinical high-risk subset, further risk stratification is achieved with dipyridamole-thallium scanning.

Eagle, K.A.; Singer, D.E.; Brewster, D.C.; Darling, R.C.; Mulley, A.G.; Boucher, C.A.



Predictive factor analysis as the basis for the clinical utility of percent positive prostate biopsies in patients with intermediate-risk prostate cancer  

Microsoft Academic Search

Objectives. To define the clinical reason for the further refinement of stratification of prostate-specific antigen (PSA) outcome using percent positive prostate biopsies in intermediate-risk patients.Methods. A chi-square metric was used to compare the distribution of pretreatment clinical and post-treatment pathologic factors for patients with intermediate-risk prostate cancer with 50% or less versus greater than 50% positive prostate biopsies. The PSA

Jeong H Yoon; Ming-Hui Chen; Andrew A Renshaw; Jerome P Richie; Anthony V D’Amico



Social Change and Stratification  

Microsoft Academic Search

Korean society has changed a great deal in the wake of rapid economic development and industrialization that began in the early 1960s. This article examines social change in Korea in terms of shifts in its occupational structure and class stratification. For the past four decades, industrialization has steadily reduced the agricultural labour force and significantly expanded the urban labour force

Doo-Seung Hong



Stratification of Bastar Tribes  

Microsoft Academic Search

Caste system, ethnic formation and other religion-based communities speak of plurality in India, depicts a variety of cultural variations. Concerning Indian society the saying of 'unity in diversity', it is revealed that the diversity is not only distinctive feature of caste but it goes beyond, providing a typical stratification in the social order; while the world of Indian tribes, is

Amitabha Sarkar; Samira Dasgupta



Managing pain in high-risk patients within a patient-centered medical home.  


Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the "true" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid. PMID:24073097

Cheatle, Martin D; Klocek, John W; McLellan, A Thomas



Defining patient outcomes in stage IV colorectal cancer: a prospective study with baseline stratification according to disease resectability status  

Microsoft Academic Search

Background:Stage IV colorectal cancer encompasses a broad patient population in which both curative and palliative management strategies may be used. In a phase II study primarily designed to assess the efficacy of capecitabine and oxaliplatin, we were able to prospectively examine the outcomes of patients with stage IV colorectal cancer according to the baseline resectability status.Methods:At enrolment, patients were stratified

D J Watkins; I Chau; D Cunningham; S S Mudan; N Karanjia; G Brown; S Ashley; A R Norman; A Gillbanks



Stratification of the phase clouds and statistical effects of the non-Markovity in chaotic time series of human gait for healthy people and Parkinson patients  

NASA Astrophysics Data System (ADS)

In this work we develop a new method of diagnosing the nervous system diseases and a new approach in studying human gait dynamics with the help of the theory of discrete non-Markov random processes (Phys. Rev. E 62 (5) (2000) 6178, Phys. Rev. E 64 (2001) 066132, Phys. Rev. E 65 (2002) 046107, Physica A 303 (2002) 427). The stratification of the phase clouds and the statistical non-Markov effects in the time series of the dynamics of human gait are considered. We carried out the comparative analysis of the data of four age groups of healthy people: children (from 3 to 10 year olds), teenagers (from 11 to 14 year olds), young people (from 21 up to 29 year olds), elderly persons (from 71 to 77 year olds) and Parkinson patients. The full data set are analyzed with the help of the phase portraits of the four dynamic variables, the power spectra of the initial time correlation function and the memory functions of junior orders, the three first points in the spectra of the statistical non-Markov parameter. The received results allow to define the predisposition of the probationers to deflections in the central nervous system caused by Parkinson's disease. We have found out distinct differences between the five submitted groups. On this basis we offer a new method of diagnostics and forecasting Parkinson's disease.

Yulmetyev, Renat; Demin, Sergey; Emelyanova, Natalya; Gafarov, Fail; Hänggi, Peter



Prognostic gene signatures for patient stratification in breast cancer - accuracy, stability and interpretability of gene selection approaches using prior knowledge on protein-protein interactions  

PubMed Central

Background Stratification of patients according to their clinical prognosis is a desirable goal in cancer treatment in order to achieve a better personalized medicine. Reliable predictions on the basis of gene signatures could support medical doctors on selecting the right therapeutic strategy. However, during the last years the low reproducibility of many published gene signatures has been criticized. It has been suggested that incorporation of network or pathway information into prognostic biomarker discovery could improve prediction performance. In the meanwhile a large number of different approaches have been suggested for the same purpose. Methods We found that on average incorporation of pathway information or protein interaction data did not significantly enhance prediction performance, but indeed greatly interpretability of gene signatures. Some methods (specifically network-based SVMs) could greatly enhance gene selection stability, but revealed only a comparably low prediction accuracy, whereas Reweighted Recursive Feature Elimination (RRFE) and average pathway expression led to very clearly interpretable signatures. In addition, average pathway expression, together with elastic net SVMs, showed the highest prediction performance here. Results The results indicated that no single algorithm to perform best with respect to all three categories in our study. Incorporating network of prior knowledge into gene selection methods in general did not significantly improve classification accuracy, but greatly interpretability of gene signatures compared to classical algorithms.



Progression in Acute Stroke Value of the Initial NIH Stroke Scale Score on Patient Stratification in Future Trials  

Microsoft Academic Search

Background and Purpose—The objective was to determine the occurrence of neurological changes during the first 48 hours after acute stroke as it relates to initial stroke severity. Methods—The National Institutes of Health Stroke Scale (NIHSS) was performed serially for the first 48 hours on 127 consecutive ischemic stroke patients (129 strokes) admitted to the neuroscience intensive care unit. Incidence of

Thomas J. DeGraba; John M. Hallenbeck; Karen D. Pettigrew; Andrew J. Dutka; Brian J. Kelly


Cerebrospinal A?11-x and 17-x levels as indicators of mild cognitive impairment and patients' stratification in Alzheimer's disease  

PubMed Central

In the present work, the concentrations of A?11-x and A?17-x peptides (x=40 or 42), which result from the combined cleavages of ?-amyloid precursor protein (A?PP) by ?'/? or ?/?-secretases, respectively, were assessed in cerebrospinal fluid (CSF) samples from patients with Alzheimer's disease (AD) or mild cognitive impairment (MCI). Specific multiplexed assays were set up using new anti-40 and anti-42 monoclonal antibodies (mAbs) for the capture of these N-truncated A? peptides and anti-11 or anti-17 mAbs for their detection. The specificity, sensitivity and reproducibility of such assays were assessed using synthetic peptides and human cell models. A?11-x and A?17-x were then measured in CSF samples from patients with AD (n=23), MCI (n=23) and controls with normal cognition (n=21). A?11-x levels were significantly lower in patients with MCI than in controls. Compared with the combined quantification of A?1-42, total Tau (T-Tau) and phosphorylated Tau (P-Tau; AlzBio3, Innogenetics), the association of A?11-40, A?17-40 and T-Tau improved the discrimination between MCI and controls. Furthermore, when patients with MCI were classified into two subgroups (MCI ?1.5 or ?2 based on their CDR-SB (Cognitive Dementia Rating–Sum of Boxes) score), the CSF A?17-40/A?11-40 ratio was significantly higher in patients with CDR-SB ?1.5 than in controls, whereas neither A?1-42, T-Tau nor P-Tau allowed the detection of this subpopulation. These results need to be confirmed in a larger clinical prospective cohort.

Abraham, J-D; Prome, S; Salvetat, N; Rubrecht, L; Cobo, S; du Paty, E; Galea, P; Mathieu-Dupas, E; Ranaldi, S; Caillava, C; Cremer, G-A; Rieunier, F; Robert, P; Molina, F; Laune, D; Checler, F; Fareh, J



Childhood medulloblastoma: the paradigm shift in molecular stratification and treatment profile.  


Medulloblastoma is the most common malignant brain tumor of childhood, accounting for nearly 25% to 30% of primary central nervous system tumors in children younger than 18 years of age. Risk stratification into low and high risk categories has been based on age of clinical presentation, extent of postsurgical residual tumor, and disease dissemination. The World Health Organization (WHO) in 2007 recognized 5 histological subtypes as classic, anaplastic, large cell, desmoplastic/nodular, and medulloblastoma with extensive nodularity. Recent work with gene expression profiling along with histological classification has generated a novel combined histopathological and molecular stratification scheme into 4 subgroups (Wnt, Shh, group 3, and group 4). This could now help to identify patients who might benefit from dose escalation and de-escalation of therapy. Restratification brings optimism in treating these patients as scholars now have the ability to profile a more targeted therapy approach. This review discusses the literature regarding this new research endeavor. PMID:22826514

Sadighi, Zsila; Vats, Tribhawan; Khatua, Soumen



Statin use in rheumatoid arthritis in relation to actual cardiovascular risk: evidence for substantial undertreatment of lipid-associated cardiovascular risk?  

Microsoft Academic Search

BackgroundCardiovascular disease (CVD) is partially attributed to traditional cardiovascular risk factors, which can be identified and managed based on risk stratification algorithms (Framingham Risk Score, National Cholesterol Education Program, Systematic Cardiovascular Risk Evaluation and Reynolds Risk Score). We aimed to (a) identify the proportion of at risk patients with rheumatoid arthritis (RA) requiring statin therapy identified by conventional risk calculators,

Tracey E Toms; Vasileios F Panoulas; Karen M J Douglas; Helen Griffiths; Naveed Sattar; Jaqueline P Smith; Deborah P M Symmons; Peter Nightingale; George S Metsios; George D Kitas



Reducing Vascular Events Risk in Patients with Dyslipidaemia: An Update for Clinicians  

PubMed Central

Reducing the risk of vascular events in patients with dyslipidaemia requires cardiovascular disease risk stratification and lifestyle/pharmacological intervention on modifiable risk factors. Reduction of low-density lipoprotein cholesterol (LDL-C) with statins is highly effective in reducing cardiovascular disease in patients with and without diabetes, but leaves unaddressed a sizeable residual vascular risk (RvR), which is rarely quantified in routine clinical practice. Such RvR may relate to lack of strict target attainment for all atherogenic variables [LDL-C, non-high-density lipoprotein cholesterol (HDL-C) and/or apolipoprotein B100]. Another substantial lipid-related and modifiable RvR component is related to atherogenic dyslipidaemia, especially as global rates of obesity, type 2 diabetes and metabolic syndrome are increasing. Atherogenic dyslipidaemia is associated with insulin-stimulated very-low-density lipoprotein overproduction and reduced reverse cholesterol transport. The hallmark of atherogenic dyslipidaemia is the coexistence of low HDL-C and elevated triglycerides. Therapeutic lifestyle changes and combination lipid-lowering therapy with drugs targeting atherogenic dyslipidaemia (such as fibrates or innovative drugs targeting atherogenic dyslipidaemia and/or apolipoprotein B100 metabolism) on top of background statins, have a potential to reduce RvR in high-risk groups, as shown in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, in which combination therapy with simvastatin plus fenofibrate decreased macrovascular risk in patients with diabetes and atherogenic dyslipidaemia, and retinopathy risk irrespective of baseline lipids.

Hermans, Michel P.; Fruchart, Jean-Charles



Contrast Material-induced Nephrotoxicity and Intravenous Low-Osmolality Iodinated Contrast Material: Risk Stratification by Using Estimated Glomerular Filtration Rate.  


Purpose: To determine the effect of intravenous (IV) low-osmolality iodinated contrast material (LOCM) on the development of post-computed tomography (CT) acute kidney injury (AKI), stratified by pre-CT estimated glomerular filtration rate (eGFR), in patients with stable renal function. Materials and Methods: Institutional review board approval was obtained and patient consent waived for this HIPAA-compliant, retrospective study. CT examinations performed over a 10-year period on unique adult inpatients with sufficient serum creatinine (SCr) data and stable renal function (difference between baseline and pre-CT SCr within 0.3 mg/dL and 50% of baseline) were identified. A 1:1 propensity score matched cohort analysis with multivariate analysis of effects was performed with post-CT AKI as the primary outcome measure (8826 nonenhanced and 8826 IV contrast agent-enhanced CT studies in 17 652 patients). Propensity matching was performed with respect to likelihood of receiving IV contrast material (19 tested covariates). Post-CT AKI with Acute Kidney Injury Network SCr criteria was the primary endpoint. A stepwise multivariate conditional logistic regression model was performed to identify the effect of IV LOCM on post-CT AKI. Results: After 1:1 propensity matching, IV LOCM had a significant effect on the development of post-CT AKI (P = .04). This risk increased with decreases in pre-CT eGFR (?60 mL/min/1.73 m(2): odds ratio, 1.00; 95% confidence interval: 0.86, 1.16; 45-59 mL/min/1.73 m(2): odds ratio, 1.06; 95% confidence interval: 0.82, 1.38; 30-44 mL/min/1.73 m(2): odds ratio, 1.40; 95% confidence interval: 1.00, 1.97; <30 mL/min/1.73 m(2): odds ratio, 2.96; 95% confidence interval: 1.22, 7.17). Conclusion: IV LOCM is a nephrotoxic risk factor in patients with a stable eGFR less than 30 mL/min/1.73 m(2), with a trend toward significance at 30-44 mL/min/1.73 m(2). IV LOCM does not appear to be a nephrotoxic risk factor in patients with a pre-CT eGFR of 45 mL/min/1.73 m(2) or greater. © RSNA, 2013. PMID:23579046

Davenport, Matthew S; Khalatbari, Shokoufeh; Cohan, Richard H; Dillman, Jonathan R; Myles, James D; Ellis, James H



Cardiac risk telemonitoring  

Microsoft Academic Search

Utilization of advanced information, telecommunication and implant technology for cardiac risk stratification and management is one of the greatest challenges for modern health care provision. Sudden cardiac death is the major contributor to overall cardiovascular mortality with approximately 60% of all coronary heart disease fatalities occurring annually. Although some high-risk patient groups have been identified with reasonable sensitivity and specificity

H. Hutten; M. Hribernigg; G. Rauchegger



Cardiovascular risk in the peritoneal dialysis patient  

Microsoft Academic Search

Cardiovascular death is the most frequent cause of death in patients on peritoneal dialysis. Risk factors for cardiovascular death in these patients include those that affect the general population as well as those related to end-stage renal disease (ESRD) and those that are specific to peritoneal dialysis. The development of overhydration after loss of residual renal function is probably the

Olga Balafa; Raymond T. Krediet



Network-based stratification of tumor mutations.  


Many forms of cancer have multiple subtypes with different causes and clinical outcomes. Somatic tumor genome sequences provide a rich new source of data for uncovering these subtypes but have proven difficult to compare, as two tumors rarely share the same mutations. Here we introduce network-based stratification (NBS), a method to integrate somatic tumor genomes with gene networks. This approach allows for stratification of cancer into informative subtypes by clustering together patients with mutations in similar network regions. We demonstrate NBS in ovarian, uterine and lung cancer cohorts from The Cancer Genome Atlas. For each tissue, NBS identifies subtypes that are predictive of clinical outcomes such as patient survival, response to therapy or tumor histology. We identify network regions characteristic of each subtype and show how mutation-derived subtypes can be used to train an mRNA expression signature, which provides similar information in the absence of DNA sequence. PMID:24037242

Hofree, Matan; Shen, John P; Carter, Hannah; Gross, Andrew; Ideker, Trey



Cardiovascular risk in the peritoneal dialysis patient.  


Cardiovascular death is the most frequent cause of death in patients on peritoneal dialysis. Risk factors for cardiovascular death in these patients include those that affect the general population as well as those related to end-stage renal disease (ESRD) and those that are specific to peritoneal dialysis. The development of overhydration after loss of residual renal function is probably the most important cardiovascular risk factor specific to peritoneal dialysis. The high glucose load associated with peritoneal dialysis may lead to insulin resistance and to the development of an atherogenic lipid profile. The presence of glucose degradation products in conventional dialysis solutions, which leads to the local formation of advanced glycation end products, is also specific to peritoneal dialysis. Other risk factors that are not specific to peritoneal dialysis but are related to ESRD include calcifications and protein-energy wasting. When present together with inflammation and atherosclerosis, protein-energy wasting is associated with a marked increase in the risk of cardiovascular death. Obesity is not associated with increased cardiovascular risk in patients on any form of dialysis. Left ventricular hypertrophy and increased arterial stiffness are the most important risk factors for cardiovascular events in the general population. PMID:20567248

Krediet, Raymond T; Balafa, Olga



Prognostic value of dobutamine stress echocardiography in patients with diabetes  

Microsoft Academic Search

OBJECTIVE: The aim of this study was to assess the incremental value of\\u000a dobutamine stress echocardiography (DSE) for the risk stratification of\\u000a diabetic patients who are unable to perform an adequate exercise stress\\u000a test. Exercise capacity is frequently impaired in patients with diabetes.\\u000a The role of pharmacologic stress echocardiography in the risk\\u000a stratification of diabetic patients has not been well

FABIOLA B. SOZZI; ABDOU ELHENDY; A. F. Schinkel; E. C. Vourvouri; J. J. Bax; Sutter de J; A. Borghetti; D. Poldermans; J. R. T. C. Roelandt; Domburg van R. T



Risk factors for thrombosis in lupus patients.  

PubMed Central

Lupus anticoagulant, concentrations of anticardiolipin antibodies, antithrombin III, plasminogen, (free) protein S, protein C, prothrombin, platelet counts, and bleeding times were determined in 74 lupus patients (58 with systemic lupus erythematosus; 16 with lupus-like disease) to establish the presence of risk factors for thrombosis in these patients. Of the variables evaluated, lupus anticoagulant had the strongest association with a history of thrombosis. Both positive anticardiolipin antibody concentrations and the presence of (mild) thrombocytopenia were significantly associated with a history of thrombosis and the presence of lupus anticoagulant. Reduced concentrations of antithrombin III, plasminogen, (free) protein S, and protein C were found in some patients but were not associated with either thrombosis or lupus anticoagulant. Mean concentrations of total protein S were significantly lower in patients with thrombosis than in those without and in patients with lupus anticoagulant than in those without. The antigenic concentration of prothrombin was reduced in 3/74 (4%) lupus patients. These three patients had lupus anticoagulant but no history of thrombosis, which suggests that a low prothrombin concentration protects patients with lupus anticoagulant from the development of thrombosis. A prolonged bleeding time was associated with the presence of lupus anticoagulant but not with a history of thrombosis. Analysis by stepwise logistic regression did not disclose additional risk factors for thrombosis in lupus patients with lupus anticoagulant. Increased antithrombin III concentrations and decreased free protein S concentrations are often found in lupus patients, unrelated to lupus anticoagulant or thrombosis.

Hasselaar, P; Derksen, R H; Blokzijl, L; Hessing, M; Nieuwenhuis, H K; Bouma, B N; De Groot, P G



Laser recanalization in high risk patients.  


Laser recanalization was attempted in 13 patients in whom the risk of surgical therapy was increased by severe angina, infection, absent venous conduit, or recent deep venous thrombosis, and in 4 patients at high risk for limb loss due to severe infrapopliteal arterial occlusive disease. Total occlusions of the superficial femoral, tibial, or peroneal arteries were treated. Recanalization was accomplished using Argon laser power and a Spectraprobe-PLR. Two patients also required common femoral artery endarterectomy to improve inflow. Laser recanalization was successful in 9 patients (53%), and 8 (47%) had relief symptoms. None of the 4 patients with tibial and peroneal artery occlusion had successful recanalization or limb salvage. Restenosis or reocclusion developed in 4 patients during the first year after successful recanalization, but only 1 had recurrent symptoms. Limb salvage was initially achieved in 5 of 8 recanalization failures by surgical reconstruction but 3 developed graft infections requiring graft removal in 2 and amputation in 1. Thus, laser recanalization can accomplish limb salvage in selected patients whose medical or surgical risks complicate arterial bypass surgery. PMID:2139708

Seeger, J M; Kaelin, L D; Barbeau, G; Abela, G S



Factors affecting relevance of tele-ECG systems application to high risk for future ischemic heart disease events patients group.  


Telecardiology can identify patients with urgent problems requiring rapid assessment at the hospital or even emergency admission. Telemedicine applications in cardiology must identify factors that make the service most beneficial to the patients. The aim of the study was to analyze factors affecting relevance and benefits of telephonic electrocardiography (ECG) consultations. A transnational telephonic ECG system was established between Lithuania and Germany. Using a follow-up study design, clinical performance and beneficial factors for telecardiology were assessed. According to inclusion and exclusion criteria, 34 patients sent 329 ECGs with 14 ECG showing important clinical changes. Of the 329 ECGs only 263 (80%) ECGs were of acceptable quality for clinical interpretation. Most important factors associated with benefits from tele-ECG service were gender, Thrombolysis in Myocardial Infarction (TIMI), Systematic Coronary Risk Evaluation (SCORE) risk stratification, and chest pain in previous month. Tele-ECG service of routine ECGs can be useful in recognition of silent ischemia or arrhythmias, and facilitating diagnosis. However, other factors such as chest pain in the previous month, gender, TIMI, and SCORE risk stratifications are important in planning tele-ECG services. PMID:18570563

Vanagas, Giedrius; Zali?nas, Remigijus; Benetis, Rimantas; Slapikas, Rimvydas



Anesthesia for the High-Risk Patient  

Microsoft Academic Search

In fewer than 300 pages, this book covers the complex topic of anesthesia for the high-risk patient in a comprehensive and complete way. Each chapter covers the most up-to-date literature, providing a summary of evidence as well as practical advice on how to approach and tackle the multitude of diff erent problems of highrisk patients. Th is book describes anesthesia

Maurizio Cecconi; Andrew Rhodes



Lymphoma Risk Varies for Celiac Disease Patients  


... page, please enable JavaScript. Lymphoma Risk Varies for Celiac Disease Patients Blood cancer more common for those with ... Preidt Monday, August 5, 2013 Related MedlinePlus Pages Celiac Disease Diets Lymphoma MONDAY, Aug. 5 (HealthDay News) -- Celiac ...


Cancer risk among patients with condylomata acuminata.  


Condylomata acuminata have been shown to increase the risk of anogenital cancers. However, previous studies have been of limited sample size and/or short follow-up duration, which prevent precise estimates of long-term excess risk, especially for specific cancer sites. We estimated the risk of specific cancers in a large cohort of hospitalized patients with condylomata acuminata, as recorded in the Swedish Inpatient Register between 1965 and 1999. Altogether, 10,971 patients (1,685 men and 9,286 women) were followed through 1999 for a median of 13 years. The standardized incidence ratio (SIR)--the ratio of the observed number of cancers to the number expected on the basis of the incidence in the Swedish population at large--was used as a measure of relative risk. After excluding the first-year of follow-up, we observed 43 cases of anogenital cancer in women, and 7 cases in men. Risks were elevated for cancers of the vulva (N = 13, SIR = 10.2, 95% confidence interval (CI) = 5.4-17.4), vagina (N = 4, SIR = 12.0, 95% CI = 3.3-30.7) and penis (N = 5, SIR = 21.9, 95% CI = 7.1-51.2). There was a moderate excess risk of cervical cancer in situ (N = 259, SIR = 1.9, 95% CI = 1.7-2.1), but not invasive cervical cancer. Excess risks of esophageal, buccal cavity, nonmelanoma skin, lung and bladder cancers, and Hodgkin and non-Hodgkin lymphoma, were also observed in both men and women. In conclusion, condylomata acuminata are strongly associated with increased risk of cancers of the vulva, vagina, penis and anus, as well as some nonanogenital malignancies, but not invasive cervical cancer. PMID:16557590

Nordenvall, Caroline; Chang, Ellen T; Adami, Hans-Olov; Ye, Weimin



Further stratification of patients with multiple myeloma by International Staging System in combination with ratio of serum free ? to ? light chains.  


The serum free light chain (sFlc) levels were measured for 122 Chinese patients with newly diagnosed symptomatic multiple myeloma (NDSMM), and ?/? ratios (rFlc) were calculated. The data were analyzed for the roles of sFlc and rFlc in the diagnosis and prognosis of MM. Abnormal sFlc and/or rFlc were detected in 99.2% of patients, demonstrating that the FLC assay is much more sensitive than the commonly used methods. Baseline sFlc and rFlc successfully predicted the overall survival (OS). The median OS was not reached (NR) versus 23 months for the low sFLC group (sFLC-? < 180 mg/L or sFLC-? < 592.5 mg/L) and high sFLC group (sFLC-? ? 180 mg/L or sFLC-? ? 592.5 mg/L) (p = 0.001), and NR versus 21 months for the low rFLC group (0.04 ? rFLC ? 25) and high rFLC group (p < 0.001), respectively. Interestingly, the significant differences in OS between the low and high rFLC groups were not changed by bortezomib chemotherapy. In addition, patients were further stratified by three novel poor-prognosis factors (?(2)-microglobulin [?2-MG] > 3.5 mg/L, albumin [ALB] < 35 g/L, rFLC > 25 or rFLC < 0.04) that were developed from combination of the rFlc with the International Staging System (ISS): the low risk group (no factor), the low-intermediate risk group (one factor), the high-intermediate risk group (two factors) and the high risk group (three factors). The median OS for those groups was NR, NR, 24 months and 13 months, respectively (p < 0.05). In conclusion, the sFLC assay was highly sensitive in the diagnosis of MM in Chinese patients. The prognostic potential of the ISS may be improved with the addition of rFLC. PMID:22712834

Xu, Yan; Sui, Weiwei; Deng, Shuhui; An, Gang; Wang, Yafei; Xie, Zhenqing; Yao, Hongjing; Zhu, Guoqing; Zou, Dehui; Qi, Junyuan; Hao, Mu; Zhao, Yaozhong; Wang, Jianxiang; Chen, Tao; Qiu, Lugui



Heterogeneity in cost-effectiveness of lifestyle counseling for metabolic syndrome risk groups -primary care patients in Sweden  

PubMed Central

Background Clinical trials have indicated that lifestyle interventions for patients with lifestyle-related cardiovascular and diabetes risk factors (the metabolic syndrome) are cost-effective. However, patient characteristics in primary care practice vary considerably, i.e. they exhibit heterogeneity in risk factors. The cost-effectiveness of lifestyle interventions is likely to differ over heterogeneous patient groups. Methods Patients (62 men, 80 women) in the Kalmar Metabolic Syndrome Program (KMSP) in primary care (Kalmar regional healthcare area, Sweden) were divided into three groups reflecting different profiles of metabolic risk factors (low, middle and high risk) and gender. A Markov model was used to predict future cardiovascular disease and diabetes, including complications (until age 85 years or death), with health effects measured as QALYs and costs from a societal perspective in Euro (EUR) 2012, discounted 3%. Simulations with risk factor levels at start and at 12 months follow-up were performed for each group, with an assumed 4-year sustainability of intervention effects. Results The program was estimated cost-saving for middle and high risk men, while the incremental cost vs. do-nothing varied between EUR 3,500 – 18,000 per QALY for other groups. There is heterogeneity in the cost-effectiveness over the risk groups but this does not affect the overall conclusion on the cost-effectiveness of the KMSP. Even the highest ICER (for high risk women) is considered moderately cost-effective in Sweden. The base case result was not sensitive to alternative data and methodology but considerably affected by sustainability assumptions. Alternative risk stratifications did not change the overall conclusion that KMSP is cost-effective. However, simple grouping with average risk factor levels over gender groups overestimate the cost-effectiveness. Conclusions Lifestyle counseling to prevent metabolic diseases is cost-effective in Swedish standard primary care settings. The use of risk stratification in the cost-effectiveness analysis established that the program was cost-effective for all patient groups, even for those with very high levels of lifestyle-related risk factors for the metabolic syndrome diseases. Heterogeneity in the cost-effectiveness of lifestyle interventions in primary care patients is expected, and should be considered in health policy decisions.



[Mechanism and risk factors of cardiogenic thromboembolism in patients with atrial fibrillation].  


Atrial fibrillation (AF) is well known as one of the cardiogenic causes for thromboembolism. Here, the role of 3 important components as known Virchow's triad, blood coagulability, abnormalities in the blood flow, and the endocardial function of the atria, in thrombus formation in the fibrillating atria are discussed. In the experimental model, rapid atrial pacing acutely downregulated the gene expression of thrombomodulin(TM) and tissue factor pathway inhibitor (TFPI) in the atrial endocardium. In the clinical practice, CHADS2 score had been used for the risk stratification of thromboembolism in patients with AF. High CHADS2 score might be associated with abnormalities of left atrial blood flow or progression of fibrosis in the left atrial wall. PMID:23631169

Otsuka, Takayuki



Genome-wide genotype-based risk model for survival in acute myeloid leukaemia patients with normal karyotype.  


Single nucleotide polymorphisms (SNP) are inter-individual genetic variations that could explain inter-individual differences of response/survival to chemotherapy. The present study was performed to build up a risk model for survival in 247 patients with acute myeloid leukaemia (AML) with normal karyotype (AML-NK). Genome-wide Affymetrix SNP array 6.0 was used for genotyping in discovery set (n = 118). After identifying significant SNPs for overall survival (OS) in single SNP analysis, a risk model was constructed. Out of 632 957 autosomal SNPs analysed, finally four SNPs (rs2826063, rs12791420, rs11623492 and rs2575369) were introduced into the risk model. The model could stratify the patients according to their OS in discovery set (P = 1·053656 × 10?4). Replication was performed using Sequenom platform for genotyping in the validation cohort (n = 129). The model incorporated with clinical and four SNP risk score was successfully replicated in a validation set (P = 5·38206 × 10?3). The integration of four SNPs and clinical factors into the risk model showed higher area under the curve (AUC) reults than in the model incorporating only clinical or only four SNPs, suggesting improved prognostic stratification power by combination of four SNPs and clinical factors. In conclusion, a genome-wide SNP-based risk model in 247 patients with AML-NK can identify a group of high risk patients with poor survival. PMID:24159609

Choi, Hangseok; Jung, Chulwon; Sohn, Sang Kyun; Kim, Seonwoo; Kim, Hyeoung-Joon; Kim, Yeo-Kyeoung; Kim, TaeHyung; Zhang, Zhaolei; Shin, Eun-Soon; Lee, Jong-Eun; Moon, Joon Ho; Kim, Sung Hyun; Kim, Kyoung Ha; Mun, Yeung-Chul; Kim, Hawk; Park, Jinny; Kim, Jhingook; Kim, Dennis



Risk Stratification in Elderly Coronary Artery Disease Patients: Can We Predict Which Seniors Benefit Most from Revascularization Options?  

Microsoft Academic Search

With the increased global burden of an aging population manifesting cardiovascular disease, the decision process for use of\\u000a coronary revascularization options in older adults has gained attention. Assessment of physiologic status has greater bearing\\u000a than chronologic age; items that have proven of particular merit in evaluating comorbidities as they relate to treatment prognosis\\u000a for both PCI and CABG in older

James B. McClurken; Raphael Rosenhek; T. Sloane Guy; Daniel E. Forman


Cardiovascular risk assessment in patients with retinal vein occlusion  

Microsoft Academic Search

Aim: Patients with retinal vein occlusions (RVO) are at increased risk of cardiovascular disease (CVD). The risk of future CVD was determined using the Framingham algorithm and this risk estimate was used to guide decisions about preventative treatment for CVD in RVO patients.Methods: 107 unselected RVO patients were studied. After excluding 18 patients because of age, missing data, or pre-existing

S C Martin; A Butcher; N Martin; J Farmer; P M Dobson; W A Bartlett; A F Jones



Approaches to risk-stratifying cancer patients for venous thromboembolism  

Microsoft Academic Search

Cancer patients are clearly at increased risk for venous thromboembolism (VTE). However, the risk is not equal for all cancer patients or even in the same patient over the course of the natural history of cancer. VTE prophylaxis has been shown to be beneficial in certain high-risk populations such as post-surgical or hospitalized cancer patients but data in the ambulatory

Alok A. Khorana; Maithili V. Rao



Chemosensitivity and Stratification by a Five Monoclonal Antibody Immunohistochemistry Test in the NSABP B-14 and B-20 Trials  

PubMed Central

Purpose To test the association between risk stratification and outcome in a prospectively designed, blinded retrospective study using tissue arrays of available paraffin blocks from the estrogen receptor - expressing, node-negative samples from the National Surgical Adjuvant Breast and Bowel Project B-14 and B-20 tamoxifen and chemotherapy trials. Experimental Design Tissue arrays were stained by immunohistochemistry targeting p53, NDRG1, SLC7A5, CEACAM5, and HTF9C. Risk stratification was done using predefined scoring rules, algorithm for combining scores, and cutoff points for low-risk, moderate-risk, and high-risk patient strata. Results In a univariate Cox model, this test was significantly associated with recurrence-free interval [HR, 1.3 (95% confidence interval, 1.1-1.6); P = 0.006]. In a multivariate model it contributed information independent of age, tumor size, and menopausal status (P = 0.007).The Kaplan-Meier estimates of the proportion of recurrence-free after 10 years were 73%, 86%, and 85% for the high-risk, moderate-risk, and low-risk groups (P = 0.001). The Kaplan-Meier estimates of the breast-cancer-specific-death rate were 23%, 10%, and 9% (P < 0.0001). Exploratory analysis in patients ?60 years old showed Kaplan-Meier estimates of the proportion of recurrence-free of 78%, 89%, and 92%. Both high-risk and low-risk groups showed significant improvement on treatment with cytotoxic chemotherapy. Conclusions Immunohistochemistry using five monoclonal antibodies assigns breast cancer patients to a risk index that was significantly associated with clinical outcome among the estrogen receptor - expressing, node-negative tamoxifen-treated patients. It seems that the test may be able to identify patients who have greater absolute benefit from adjuvant chemotherapy compared with unstratified patient populations. Exploratory analysis suggests that this test will be most useful in clinical decision making for postmenopausal patients.

Kim, Chung-yeul; Tang, Gong; Bohn, Olga L.; Beck, Rodney A.; Ring, Brian Z.; Seitz, Robert S.; Paik, Soonmyung; Costantino, Joseph P.; Wolmark, Norman



Risk-Based Patient Safety Metrics  

Microsoft Academic Search

Patient safety programs require meaningful metrics. Dominant frameworks are based on two safety metrics: one that seeks to identify, measure, and eliminate error and one that seeks to identify, measure, and eliminate injuries. However, non-health care safety programs suggest a third framework, hazard- or risk-based measurement. Error measurement has many limitations, including the issues of error identification, hindsight bias, outcome-based

Matthew C. Scanlon; Ben-Tzion Karsh; Kelly A. Saran


An operational research approach to identify cardiac surgery patients at risk of severe post-operative bleeding.  


Severe post-operative bleeding can lead to adverse outcomes for cardiac surgery patients and is a relatively common complication of cardiac surgery. One of the most effective drugs to prevent such bleeding, aprotinin, has been withdrawn from the market due to concerns over its safety. Alternative prophylactic drugs which can be given to patients to prevent bleeding can result in significant side effects and are expensive. For this reason it is difficult to make a clinical or economic case for administering these drugs to all cardiac surgery patients, and the prevailing view is that their use should be targeted at patients considered to be at relatively high risk of post-operative bleeding. However, there is currently no objective method for identifying such patients. Over the past 7 years, a team of clinicians and researchers at Papworth Hospital has collected data concerning post-operative blood loss for each cardiac surgery patient, totalling 11,592 consecutive records. They approached a team of operational researchers (MU, ACP, BR) with extensive experience of developing clinical risk models with the aim of devising a risk stratification scheme that could potentially be used to identify a cohort of higher risk patients. Such patients could be treated with the available prophylactic drugs or recruited to studies to evaluate new interventions. This paper is intended to describe the Operational Research process adopted in the development of this scheme. A concise description of the scheme and its clinical interpretation is published elsewhere. PMID:21404116

Reddy, Brian; Pagel, Christina; Vuylsteke, Alain; Gerrard, Caroline; Nashef, Sam; Utley, Martin



Patient repositioning and pressure ulcer risk--monitoring interface pressures of at-risk patients.  


Repositioning patients regularly to prevent pressure ulcers and reduce interface pressures is the standard of care, yet prior work has found that standard repositioning does not relieve all areas of at-risk tissue in nondisabled subjects. To determine whether this holds true for high-risk patients, we assessed the effectiveness of routine repositioning in relieving at-risk tissue of the perisacral area using interface pressure mapping. Bedridden patients at risk for pressure ulcer formation (n = 23, Braden score <18) had their perisacral skin-bed interface pressures recorded every 30 s while they received routine repositioning care for 4-6 h. All participants had specific skin areas (206 +/- 182 cm(2)) that exceeded elevated pressure thresholds for >95% of the observation period. Thirteen participants were observed in three distinct positions (supine, turned left, turned right), and all had specific skin areas (166 +/- 184 cm(2)) that exceeded pressure thresholds for >95% of the observation period. At-risk patients have skin areas that are likely always at risk throughout their hospital stay despite repositioning. Healthcare providers are unaware of the actual tissue-relieving effectiveness (or lack thereof) of their repositioning interventions, which may partially explain why pressure ulcer mitigation strategies are not always successful. Relieving at-risk tissue is a necessary part of pressure ulcer prevention, but the repositioning practice itself needs improvement. PMID:23934869

Peterson, Matthew J; Gravenstein, Nikolaus; Schwab, Wilhelm K; van Oostrom, Johannes H; Caruso, Lawrence J



Population Stratification in Epidemiologic Studies of Common Genetic Variants and Cancer: Quantification of Bias  

Microsoft Academic Search

Background: Some critics argue that bias from population stratification (the mixture of individuals from heterogeneous genetic backgrounds) undermines the credibility of epide- miologic studies designed to estimate the association between a genotype and the risk of disease. We investigated the de- gree of bias likely from population stratification in U.S. stud- ies of cancer among non-Hispanic Caucasians of European origin.

Sholom Wacholder; Nathaniel Rothman; Neil Caporaso



Bedside multimarker testing for risk-stratification in chest pain units: the chest pain evaluation by creatine Kinase-MB, myoglobin, and Troponin-I (CHECKMATE) study  

Microsoft Academic Search

Background—Earlier, rapid evaluation in chest pain units may make patient care more efficient. A multimarker strategy (MMS) testing for several markers of myocardial necrosis with different time-to-positivity profiles also may offer clinical advantages. Methods and Results—We prospectively compared bedside quantitative multimarker testing versus local laboratory results (LL) in 1005 patients in 6 chest pain units. Myoglobin, creatine kinase-MB, and troponin

L. Kristin Newby; Alan B. Storrow; W. Brian Gibler



The Effect of a Provider-Enhanced Clinical Decision Support Tool for Guiding Venous Thromboembolism Pharmacoprophylaxis in "Low-Risk" Patients  

PubMed Central

Background Computer-based tools to assess venous thromboembolism (VTE) risk have been shown to increase VTE pharmacoprophylaxis rates and decrease VTE incidence in high-risk hospitalized patients. However, VTE risk may be underestimated using computer-based tools alone. We tested the effect of a provider-enhanced clinical decision support (CDS) tool on VTE pharmacoprophylaxis and VTE incidence in patients who would have been deemed “low-risk” using a computer-based risk assessment tool alone. Methods The study sample was adult patients hospitalized during a 13-month period who were determined to be “low-risk” for VTE with a computer-based risk assessment tool. The provider-enhanced CDS tool was implemented 4 months into the study period that required providers to stratify patients as high, moderate, or low-risk for VTE. We compared rates of VTE pharmacoprophylaxis and VTE incidence before and after implementation of the provider-enhanced CDS tool. Results There were 1,322 patients in the 4-month pre-implementation period and 3,347 patients in the 9-month post-implementation period who were deemed “low-risk” for VTE based on a computer-based risk assessment tool. Using the provider-enhanced CDS tool, providers stratified 31% of these computer-assigned “low-riskpatients as moderate-risk and 7% as high-risk for VTE. The rate of VTE pharmacoprophylaxis increased (27% to 34%, p<0.01). VTE rate decreased from 0.98% to 0.42% after implementation of the provider-enhanced CDS tool (p<0.02). Conclusions Patients identified as “low-risk” for VTE solely by computer-based algorithms may include patients that providers determine to be at risk for VTE. Provider-enhanced CDS tools may outperform computer-based VTE risk stratification algorithms.

MaCauley, Michael J.; Showalter, John W.; Beck, Michael J.; Chuang, Cynthia H.



Automated detection of dual p16/Ki67 nuclear immunoreactivity in liquid-based Pap tests for improved cervical cancer risk stratification  

PubMed Central

The Papanicolau (Pap) test is a routine cytological procedure for early detection of dysplastic lesions in cervical epithelium. A reliable screening method is crucial for triage of women at risk; however manual screening and interpretation are associated with relatively low sensitivity and substantial interobserver diagnostic variability. P16 and Ki67 biomarkers have been recently proposed as adjunctive tools in the diagnosis of high-risk human papillomavirus (hrHPV) associated dysplasias to supplement the morphological characteristics of cells by additional colorimetric features. In this study, an automated technique for the evaluation of dual p16/Ki67 immunoreactivity in cervical cell nuclei is introduced. Smears stained with p16 and Ki67 antibodies were digitized, and analyzed by algorithms we developed. Gradient-based radial symmetry operator and adaptive processing of symmetry image were employed to obtain the nuclear mask. This step was followed by the extraction of features including pixel data and immunoreactivity signature from each nucleus. The features were analyzed by two support vector machine classifiers to assign a nucleus into one of four types of immunoreactivity: p16 positive (p16+/Ki67-), Ki67 positive (p16-/Ki67+), dual p16/Ki67 positive (p16+/Ki67+) and negative (p16-/Ki67-) respectively. Results obtained by our method correlated well with readings by two cytopathologists (n=18068 cells); p16+/Ki67+ nuclei were classified with respective precisions of 77.1% and 82.6%. Specificity in identification of p16-/Ki67- nuclei was better than 99.5%, and the sensitivity in detection of all immunopositive nuclei was 86.3% and 89.4% respectively. We found that the quantitative characterization of immunoreactivity provided by the additional highlighting of classified nuclei can positively impact the efficacy and screening outcome of the Pap test.

Gertych, Arkadiusz; Joseph, Anika O.; Walts, Ann E.; Bose, Shikha



MRI plaque imaging reveals high-risk carotid plaques especially in diabetic patients irrespective of the degree of stenosis  

PubMed Central

Background Plaque imaging based on magnetic resonance imaging (MRI) represents a new modality for risk assessment in atherosclerosis. It allows classification of carotid plaques in high-risk and low-risk lesion types (I-VIII). Type 2 diabetes mellitus (DM 2) represents a known risk factor for atherosclerosis, but its specific influence on plaque vulnerability is not fully understood. This study investigates whether MRI-plaque imaging can reveal differences in carotid plaque features of diabetic patients compared to nondiabetics. Methods 191 patients with moderate to high-grade carotid artery stenosis were enrolled after written informed consent was obtained. Each patient underwent MRI-plaque imaging using a 1.5-T scanner with phased-array carotid coils. The carotid plaques were classified as lesion types I-VIII according to the MRI-modified AHA criteria. For 36 patients histology data was available. Results Eleven patients were excluded because of insufficient MR-image quality. DM 2 was diagnosed in 51 patients (28.3%). Concordance between histology and MRI-classification was 91.7% (33/36) and showed a Cohen's kappa value of 0.81 with a 95% CI of 0.98-1.15. MRI-defined high-risk lesion types were overrepresented in diabetic patients (n = 29; 56.8%). Multiple logistic regression analysis revealed association between DM 2 and MRI-defined high-risk lesion types (OR 2.59; 95% CI [1.15-5.81]), independent of the degree of stenosis. Conclusion DM 2 seems to represent a predictor for the development of vulnerable carotid plaques irrespective of the degree of stenosis and other risk factors. MRI-plaque imaging represents a new tool for risk stratification of diabetic patients. See Commentary:



A risk stratification by hormonal receptors (ER, PgR) and HER2 status in small (?1 cm) invasive breast cancer: who might be possible candidates for adjuvant treatment?  

Microsoft Academic Search

As the use of screening mammography expands, the proportion of invasive breast cancer ?1 cm is increasing. The aims of this\\u000a study were: (1) to identify risk factors for systemic metastases in patients with ?1 cm invasive breast cancer and (2) to\\u000a investigate the patient groups at the greatest risk for metastases with such small tumors. Data were collected retrospectively\\u000a from the

Yeon Hee Park; Seung Tae Kim; Eun Yoon Cho; Yoon La Choi; Oh-Nam Ok; Hae Jin Baek; Jeong Eon Lee; Seok Jin Nam; Jung-Hyun Yang; Won Park; Doo Ho Choi; Seung Jae Huh; Jin Seok Ahn; Young-Hyuck Im



A comparison between B-type natriuretic peptide, Global Registry of Acute Coronary Events (GRACE) score and their combination in ACS risk stratification  

Microsoft Academic Search

Background:In acute coronary syndrome (ACS), both the Global Registry of Acute Coronary Events (GRACE) score and B-type natriuretic peptide (BNP) predict cardiovascular events. However, it is unknown how BNP compares with GRACE and how their combination performs in ACS.Methods:The authors recruited 449 consecutive ACS patients and measured admission GRACE score and bedside BNP levels. The main outcome measure was all-cause

D S C Ang; L Wei; M P C Kao; C C Lang; A D Struthers



Age Stratification and Value Orientations.  

ERIC Educational Resources Information Center

Value orientations of members of younger and older age strata in 2 subcultural systems--one urban and one rural--are examined. The author looks at age stratification in a vertical sense (i.e., assessing differences existing between members of younger and older age strata), as well as in a horizontal sense (i.e., comparing the value orientations of…

Youmans, E. Grant


Association of lipoprotein subfractions and coronary artery calcium in patient at intermediate cardiovascular risk.  


More precise estimation of the atherogenic lipid parameters could improve identification of residual risk beyond what is possible using traditional lipid risk factors. The aim of the present study was to explore the association between advanced analysis of lipoprotein subfractions and the prevalence of coronary artery calcium. Consecutive participants at intermediate cardiovascular risk who were undergoing computed tomographic assessment of coronary calcium (calcium score) were included. Using a validated ultracentrifugation method (the vertical autoprofile II test), cholesterol in eluting lipoprotein subfractions [i.e., low- (LDL), very-low-, intermediate-, and high-density lipoprotein subclasses, lipoprotein (a), and predominant LDL distribution] was directly quantified. A total of 410 patients were included (29% women, mean age 57 years), of whom 297 (72.4%) had coronary artery calcium. LDL pattern B (predominance of small dense particles) emerged as an independent predictor of coronary calcium after adjustment for traditional risk factors (odds ratio 4.46, 95% confidence interval 1.19 to 16.7). However, after additional stratification for dyslipidemia, as defined by conventional lipid profiling, a statistically significant prediction was only retained for high-density lipoprotein subfraction 2 (odds ratio 3.45, 95% confidence interval 2.03 to 50.1) and "real" LDL (odds ratio 6.10, 95% confidence interval 1.26 to 23.41) in the normolipidemia group and for lipoprotein (a) (odds ratio 7.81, 95% confidence interval 1.41 to 43.5) in the dyslipidemic group. In conclusion, advanced assessment of the lipoprotein subfractions [i.e., LDL pattern B, high-density lipoprotein subfraction 2, "real" LDL, and lipoprotein (a)] using the vertical autoprofile II test provided additional information to that of conventional risk factors on the prevalence of coronary artery calcium in patients at intermediate cardiovascular risk. PMID:23141758

Jug, Borut; Papazian, Jenny; Lee, Robert; Budoff, Matthew J



Social Stratification and its Indices: A Critique  

Microsoft Academic Search

Social stratification, which is an aspect of social inequality, has persisted as an important social issue. Indeed, according to Miller, ‘Nearly 30 percent of all research articles in major sociological journals [were] devoted to social stratification in 1990.’1 Usually, social stratification is used as an independent and explanatory variable in empirical research. Yet, despite its theoretical and methodological merits, sociologists

Hooshang Nayebi; Hamid Abdollahyan



Burn Injury in the Aged or High-Risk Patient.  

National Technical Information Service (NTIS)

Every patient with a burn of more than 40 percent of the total body surface should be considered a high-risk patient, since anticipated mortality in such patients is 30 percent or greater. The aged patient is at an even greater risk of fatal outcome from ...

B. A. Pruitt A. D. Mason J. L. Hunt



Alternative Therapies for High-Risk Elderly Rheumatic Patients  

Microsoft Academic Search

The main high-risk conditions among elderly rheumatic patients are peptic ulcer, renal or hepatic insufficiencies, and bleeding problems (either spontaneous or iatrogenic). Because the incidence of these conditions is significant, elderly patients should be monitored for them regularly. Although nonsteroidal antiinfiammatory drugs (NSAIDs) generally are avoided, these agents can be used in selected patients. High-risk elderly rheumatoid arthritis patients can

Michel Lequesne



Ontological Stratification in an Ecology of Infohabitants  

NASA Astrophysics Data System (ADS)

This paper reports progress from the EEII research project where ontological stratification is applied in the study of openness. We explain a stratification approach to reduce the overall complexity of conceptual models, and to enhance their modularity. A distinction is made between ontological and epistemological stratification. The application of the stratification approach to agent system design is explained and illustrated. A preliminary characterization of the relevant strata is given. The wider relevance of this result for information infrastructure design is addressed: ontological stratification will be key to the model management and semantic interoperability in a ubiquitous and model driven information infrastructure.

Abramov, V. A.; Goossenaerts, J. B. M.; de Wilde, P.; Correia, L.


Treatment options for hypertension in high-risk patients  

PubMed Central

Patients are considered to be at high risk of cardiovascular events if they have diabetes, chronic kidney disease, stroke, established coronary artery disease, or a coronary artery disease equivalent. Blood pressure-lowering therapy has been shown to reduce cardiovascular events in these patients significantly. Identification of high-risk patients by global risk evaluation is recommended for every hypertensive patient. Treatment of hypertension in high-risk patients with an angiotensin-converting enzyme inhibitor or an angiotensin receptor antagonist, with or without addition of a dihydropyridine calcium channel antagonist, is a reasonable approach based on current clinical trials.

Tsai, Wei-Chuan



Rapid cholesterol measurement: patient classification in heart risk evaluation clinics.  


Plasma cholesterol levels of patients attending a heart risk evaluation clinic were measured both in the clinic at the time of attendance, and later in a reference laboratory. The workflow of evaluation clinics may be improved, and patient satisfaction enhanced, by in situ measurement, since more than 60% of patients can be given a complete risk score at the time of attendance. PMID:470690

Fraser, C G; Peake, M J; Calvert, G D



Collectives of diagnostic biomarkers identify high-risk subpopulations of hematuria patients: exploiting heterogeneity in large-scale biomarker data  

PubMed Central

Background Ineffective risk stratification can delay diagnosis of serious disease in patients with hematuria. We applied a systems biology approach to analyze clinical, demographic and biomarker measurements (n = 29) collected from 157 hematuric patients: 80 urothelial cancer (UC) and 77 controls with confounding pathologies. Methods On the basis of biomarkers, we conducted agglomerative hierarchical clustering to identify patient and biomarker clusters. We then explored the relationship between the patient clusters and clinical characteristics using Chi-square analyses. We determined classification errors and areas under the receiver operating curve of Random Forest Classifiers (RFC) for patient subpopulations using the biomarker clusters to reduce the dimensionality of the data. Results Agglomerative clustering identified five patient clusters and seven biomarker clusters. Final diagnoses categories were non-randomly distributed across the five patient clusters. In addition, two of the patient clusters were enriched with patients with 'low cancer-risk' characteristics. The biomarkers which contributed to the diagnostic classifiers for these two patient clusters were similar. In contrast, three of the patient clusters were significantly enriched with patients harboring 'high cancer-risk" characteristics including proteinuria, aggressive pathological stage and grade, and malignant cytology. Patients in these three clusters included controls, that is, patients with other serious disease and patients with cancers other than UC. Biomarkers which contributed to the diagnostic classifiers for the largest 'high cancer- risk' cluster were different than those contributing to the classifiers for the 'low cancer-risk' clusters. Biomarkers which contributed to subpopulations that were split according to smoking status, gender and medication were different. Conclusions The systems biology approach applied in this study allowed the hematuric patients to cluster naturally on the basis of the heterogeneity within their biomarker data, into five distinct risk subpopulations. Our findings highlight an approach with the promise to unlock the potential of biomarkers. This will be especially valuable in the field of diagnostic bladder cancer where biomarkers are urgently required. Clinicians could interpret risk classification scores in the context of clinical parameters at the time of triage. This could reduce cystoscopies and enable priority diagnosis of aggressive diseases, leading to improved patient outcomes at reduced costs.



Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients  

Microsoft Academic Search

Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients.BackgroundCardiovascular diseases are the most common causes of death among chronic hemodialysis patients, yet the risk factors for these events have not been well established.MethodsIn this cross-sectional study, we examined the relationship between several traditional cardiovascular disease risk factors and the presence or history of cardiovascular events in 936 hemodialysis patients enrolled in

Alfred K. Cheung; Mark J. Sarnak; Guofen Yan; Johanna T. Dwyer; Robert J. Heyka; Michael V. Rocco; Brendan P. Teehan; Andrew S. Levey



Risk of malignancy in patients with celiac disease  

Microsoft Academic Search

PurposeStudies from Europe have demonstrated an increased risk of malignancy, especially non-Hodgkin’s lymphoma, in patients with celiac disease. However, there are no data on the risk for similar patients in the United States. Our aim was to estimate the risk of malignancy in a cohort of patients with celiac disease compared with the general U.S. population and to determine if

Peter H. R Green; Aaron T Fleischauer; Govind Bhagat; Rishi Goyal; Bana Jabri; Alfred I Neugut



A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery  

Microsoft Academic Search

OBJECTIVE: To evaluate the discriminatory value and compare the predictive\\u000a performance of six non-invasive tests used for perioperative cardiac risk\\u000a stratification in patients undergoing major vascular surgery. DESIGN:\\u000a Meta-analysis of published reports. METHODS: Eight studies on ambulatory\\u000a electrocardiography, seven on exercise electrocardiography, eight on\\u000a radionuclide ventriculography, 23 on myocardial perfusion scintigraphy,\\u000a eight on dobutamine stress echocardiography, and four on dipyridamole

M. D. Kertai; J. J. Bax; M. H. Heijenbrok-Kal; M. G. M. Hunink; Italien L' G. J; Urk van H; D. Poldermans; J. R. T. C. Roelandt; H. Boersma



Uremia-related cardiovascular risk factors in chronic kidney disease  

Microsoft Academic Search

Cardiovascular disease is the leading cause of mortality in the dialysis population and a major cause of morbidity and mortality in patients with chronic renal failure. The conventional Framingham cardiovascular (CV) risk factors (ie, hypertension, smoking, age, hyper- cholesterolemia, and a family history of CV disease) have typically been the focus of risk stratification and subse- quent primary and\\/or secondary

Caroline E. Stigant


Therapy Insight: managing cardiovascular risk in patients with rheumatoid arthritis  

Microsoft Academic Search

Chronic low-grade inflammation was recognized during the past decade as an important risk factor for the development of atherosclerosis and, more recently, for the development of heart failure. Patients with rheumatoid arthritis (RA) are at increased risk of morbidity and mortality from ischemic cardiovascular events and heart failure. Epidemiologic and clinical studies indicate that RA is an independent risk factor

Jon T Giles; Wendy Post; Roger S Blumenthal; Joan M Bathon



Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients  

Microsoft Academic Search

Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients. Conventional risk factors of cardiovascular disease and mortality in the general population such as body mass, serum cholesterol, and blood pressure are also found to relate to outcome in maintenance dialysis patients, but often in an opposite direction. Obesity, hypercholesterolemia, and hypertension appear to be protective features that are associated

Kamyar Kalantar-Zadeh; Gladys Block; Michael H. Humphreys; Joel D. Kopple



Knowledge of Risk Factors and Stroke Symptoms among Nonstroke Patients  

Microsoft Academic Search

Background and Purpose: This study aimed to evaluate knowledge of stroke warning signs, risk factors, treatment and prevention among patients not suffering from stroke. Methods: Patients admitted to one of five Neurology Departments in Poland for diseases other than stroke were asked to answer a questionnaire regarding awareness of cerebrovascular risk factors and stroke. The study was performed between November

Ma?gorzata Wiszniewska; Marcin G?uszkiewicz; Adam Kobayashi; Agata W?odek; Agnieszka Jezierska-Ostapczuk; Waldemar Fryze; Anna Cz?onkowska



Risks of Percutaneous Transhepatic Drainage in Patients with Cholangitis  

Microsoft Academic Search

Percutaneous transhepatic biliary drainage (PTD) has been advocated as a method of achieving biliary decompression in patients with cholangitis. However, the risk of PTD in these patients has not been determined. Therefore, we reviewed the records of 95 consecutive PTD patients, 30 (32%) of whom had cholangitis. Forty-four (46%) of the 95 patients underwent PTD as a preoperative measure; the

Juan F. Lois; Antoinette S. Gomes; Pierce A. Grace; Larry-Stuart Deutsch; Henry A. Pitt


Risk of thromboembolic events in patients with atrial flutter  

Microsoft Academic Search

Based on multiple studies, clear, guided anticoagulation therapy is recommended for patients with atrial fibrillation. The value of anticoagulation therapy in patients with atrial flutter, however, is less well established. Little is known about the incidence of thromboembolism in patients with atrial flutter. We evaluated the risk of thromboembolism in 191 consecutive unselected patients referred for treatment of atrial flutter.

Karlheinz Seidl; Bernd Hauer; Nicola G Schwick; Dietmar Zellner; Ralf Zahn; Jochen Senges



Modifiable Risk Factors for Cardiovascular Disease in CKD Patients  

Microsoft Academic Search

Risk factors for cardiovascular disease (CVD) have been studied extensively in CKD patients. It can be differentiated between modifiable, potentially-modifiable and non-modifiable risk factors. Nonetheless, even for easily modifiable risk factors there is still a lack of data demonstrating the benefit of common interventions, such as statin treatment for dyslipidemia, improvement of HbA1c levels in diabetic patients, implementation of physical

E. Seibert; M. Kuhlmann; N. Levin



An Assessment of Risk Understanding in Hispanic Genetic Counseling Patients  

Microsoft Academic Search

This study sought to identify if differences existed in risk comprehension and risk format understanding between genetic counseling\\u000a patients of Hispanic and Caucasian ethnicity. A total of 107 questionnaires were collected, 56 from Hispanic patients, and\\u000a 51 from Caucasian controls. Of the total population 41.1% (44\\/107) could not demonstrate sufficient risk understanding, which\\u000a was 71.4% (40\\/56) of Hispanics and 7.8%

Jennifer N. Eichmeyer; Hope Northrup; Michael A. Assel; Thomas J. Goka; Dennis A. Johnston; Aimee Tucker Williams



Screening for fall risk in patients with haemophilia.  


Many risk factors for falls identified in the general population are found in patients with haemophilia. Furthermore, fall risk increases with age and patients with haemophilia are increasingly entering the over 65 age group. After a fall occurs, there are often behavioural changes that have significant health consequences and further increase fall risk. Fall risk can be quickly assessed in the clinical setting with specific questions in the medical history and by a variety of performance-based screening tools. Identification of fall risk enables early intervention, thereby preventing injury and fear of physical activity, both of which have been associated with falling and may carry an increased risk in patients with haemophilia. Review of the existing literature on assessment of fall risk reveals the importance of screening in the clinical setting, which is commonly done via a fall history and performance-based assessment tools. Selecting appropriate fall risk screening tools is an important step in identifying and providing optimal interventions for those at risk. Assessments of fall history, fear of falling, gait velocity, gait variability and vestibular dysfunction are suggested as screening tools for patients with haemophilia. Additional research is needed to determine the optimal screening, evaluation and treatment techniques for these patients. The longitudinal physical therapy care provided by Haemophilia Treatment Centres presents a unique opportunity for instituting measures that will reduce the incidence of falling in patients with haemophilia. PMID:23216824

Flaherty, L M; Josephson, N C



Risks related to patient bed safety.  


There is heightened public awareness of the inherent risks of hospitalization. The hospital bed itself, however, is often not where jeopardy is expected. This article examines 3 chief contributors to hazards associated with hospital bed systems: fire, entrapment, and pressure ulcers. Strategies to assess beds for safety risks are discussed. PMID:22796733

Sharkey, Jeannine E; Van Leuven, Karen; Radovich, Patti


The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism.  


Objective: Wider application of CT angiography (CTA) improves the diagnosis of acute pulmonary embolism (PE). It also permits the visualisation of saddle embolism (SE), namely thrombi, which are located at the bifurcation of the main pulmonary artery. The aim of this study was to assess the prevalence of SE and whether SE predicts a complicated clinical course in patients with non-high-risk PE. Methods: In total, 297 consecutive patients with non-high-risk PE confirmed using CTA in the emergency department were studied. The presence of SE and its ability to predict the occurrence of major adverse events (MAEs) within 1 month were determined. Results: Of the 297 patients, 27 (9.1%) had an SE. The overall mortality at 1 month was 12.5%; no significant difference was observed between the SE and non-SE groups (18.5% vs 11.9%, p=0.32). However, patients with SE were more likely to receive thrombolytic therapy (29.6% vs 8.1%, p<0.01) and had significantly more MAEs (59.3% vs 25.6%, p<0.01). Conclusion: At the time of diagnosis, SE, as determined using CTA, is associated with the development of MAE within 1 month. It may be a simple method for risk stratification of patients with non-high-risk PE. Advances in knowledge: The prognosis of patients with SE, especially those who are haemodynamically stable, is unclear. This study shows that patients with SE, determined with CTA, is associated with the development of MAE. PMID:24058095

Kwak, M K; Kim, W Y; Lee, C W; Seo, D W; Sohn, C H; Ahn, S; Lim, K S; Donnino, M W



A combined index of cardiac biomarkers as a risk factor for early cardiovascular mortality in hemodialysis patients.  


Abstract Background: Cardiac biomarkers, including cardiac troponin-I (cTn-I) and N-terminal pro brain natriuretic peptide (NT-proBNP) have been associated with poor outcome in hemodialysis (HD) patients. The present study was designed to evaluate these biomarkers as biological risk factors for early and late mortality in HD patients. In addition, a multimarker approach including inflammatory index was performed in order to improve the cardiovascular risk assessment of these patients. Methods: cTnI, NT-proBNP and C-reactive protein (CRP) were measured at baseline (October through November 2002) in 130 HD patients [median age 69.0 (23.4-87.7) years old, 76 females, 54 males]. Patients were followed during 8 years. Adjusted hazard ratios (HRs) of death and 95% confidence intervals (CIs) were estimated using Cox proportional hazard models. Results: During the follow-up, 82 patients died, mainly from cardiac cause (63.4%). Elevated cTnI, NT-proBNP or CRP were all associated with increased early (death within 2 years of follow-up) but not late mortality. Moreover, the combination of all parameters (CRP ?10.51 mg/L and cTnI ?0.037 µg/L and NT-proBNP ?10,204 pg/mL) dramatically increased the short-term mortality especially the cardiovascular mortality (HR 8.58, 95% CI 1.59-46.2; p=0.0007). Conclusions: A combined index of cardiovascular risk factors could provide supplementary risk stratification in HD patients for early cardiovascular mortality, strongly supporting the annual routine determination of these biomarkers. PMID:23399590

Bargnoux, Anne-Sophie; Morena, Marion; Jaussent, Isabelle; Maurice, Francois; Chalabi, Lotfi; Leray-Moragues, Hélène; Terrier, Nathalie; Dupuy, Anne-Marie; Badiou, Stéphanie; Canaud, Bernard; Cristol, Jean-Paul



Principal Stratification -- a Goal or a Tool?  

PubMed Central

Principal stratification has recently become a popular tool to address certain causal inference questions, particularly in dealing with post-randomization factors in randomized trials. Here, we analyze the conceptual basis for this framework and invite response to clarify the value of principal stratification in estimating causal effects of interest.

Pearl, Judea



Stratification dynamics in wastewater stabilization ponds  

Microsoft Academic Search

Measurements show that wastewater stabilization ponds although often only 1–2 m deep stratify and destratify intermittently depending primarily on weather. Stratification can be observed in vertical profiles of water temperature, dissolved oxygen, pH and other water quality parameters. In three stabilization ponds of a small Minnesota town, stratification develops primarily by differential heating of the pondwater through its surface and,

Ruochuan Gu; Heinz G. Stefan




Microsoft Academic Search

While early stratification students were deeply categorical in their theory and methods, concerning themselves with discrete categories or “bins” such as status, strata, classes, layers and such, Haller already conceived of stratification as a continuous, comparative process. While older theory held that each individual occupied a discrete status to which were attached role expectations which guided the individual’s behavior, Haller

Joseph Woelfel; Monica Murero



High-risk patients with hypertension: Are we doing enough?  


Despite the increasing risk of cardiovascular disease, especially in patients with multiple risk factors, blood pressure (BP) control remains suboptimal. This study investigated real-world BP goal attainment and prescribing patterns for high-risk patients. A retrospective chart review study was conducted in patients treated by eight large primary care physician group practices between December 2003 and May 2006. A total of 1,917 hypertensive patients were identified with >/=1 risk factors: African-American ethnicity (634); diabetes (851); advanced age (1,123); body mass index (BMI) 25 kg/m(2) (1,614). BP control rate was 46% overall, and similar in the advanced age and overweight/obese subpopulations, but substantially lower (28%) in the diabetic subpopulation. Systolic blood pressure >/=20 mm Hg above the Joint National Committee on Prevention, Detection, Evaluation, and Treatment Report recommendation was found in 13% of the overall, advanced age and overweight/obese subpopulations, and in 20% of diabetics and 18% of African-Americans. Overall, 62% of patients received >/=2 antihypertensive while 36% of diabetics, 31% of African-Americans, 28% of advanced age, and 26% of overweight/obese patients received >/=3 antihypertensive classes. Despite availability of multiple antihypertensive classes, BP control rates were still suboptimal in this study's high-risk patients. There is a need for awareness and more aggressive treatment in high-risk patients given their increased risk of poor outcomes. PMID:20409920

Chiao, Evelyn; Sobolski, John; Krienke, Russ; Wong, Ken S; Dastani, Homa B; Nightengale, Brian



Patient risk factors' influence on survival of posterior composites.  


This practice-based retrospective study evaluated the survival of resin composite restorations in posterior teeth, focusing on the influence of potential patient risk factors. In total, 306 posterior composite restorations placed in 44 adult patients were investigated after 10 to 18 yrs. The history of each restoration was extracted from the dental records, and a clinical evaluation was performed with those still in situ. The patient risk status was assessed for caries and "occlusal-stress" (bruxism-related). Statistical analysis was performed by the Kaplan-Meier method and Cox-regression multivariate analysis. In total, 30% of the restorations failed, of which 82% were found in patients with 1 or 2 risk factors. Secondary caries was the main reason of failure within caries-risk patients, whereas fracture was the main reason in "occlusal-stress-risk" patients. The patient variables gender and age did not significantly affect survival, but risk did (p < .001). Tooth type (p < .001), arch (p = .013), and pulpal vitality (p = .003) significantly affected restoration survival. Within the limits of this retrospective evaluation, the survival of restorations is affected by patient risk factors, which should be included in survival analyses of restorations. PMID:23690354

van de Sande, F H; Opdam, N J; Rodolpho, P A Da Rosa; Correa, M B; Demarco, F F; Cenci, M S



Risk prediction and risk reduction in patients with manifest arterial disease  

Microsoft Academic Search

Risicovoorspelling en risicoverlaging bij patienten met manifest vaatlijden Engelstalig abstract The number of patients with clinical manifest arterial disease is increasing because of the aging of the population. Patients with manifest arterial disease have an increased risk of a new vascular event in the same or different arterial bed. Medical treatment of vascular risk factors (hypertension, hyperlipidemia, diabetes mellitus) and

B. M. B. Goessens



Thermal stratification in storage tanks  

NASA Astrophysics Data System (ADS)

The future of solar energy as a commerical source of energy critically depends on cost reduction and/or improvement in the performance of solar systems. Use of a properly designed thermocline storage tank is one factor in reducing overall solar system costs. Thermal stratification of a fluid in storage tank is a natural process that takes place due to the decreased density of the fluid at higher temperature. This natural process creates a transition zone temperature gradient between cold and hot fluid zones, called the thermocline. The percentage of recoverable heat (PHR), and thickness of the thermocline (d) are defined and theoretical relationships are found between PHR, d and different design parameters such as length of tank, radius of tank, insulation thickness, time, and initial temperature difference between cold and hot water.

Abdoly, M. A.


Anomalous Subjective Experience and Psychosis Risk in Young Depressed Patients  

Microsoft Academic Search

Background: Help-seeking young people often display depressive symptoms. In some patients, these symptoms may co-exist with clinically high-risk mental states for psychosis. The aim of this study was to determine differences in subjective experience and social perception in young depressed patients with and without psychosis risk. Methods: Participants were 68 young persons with major depressive disorder. Twenty-six patients also met

Erika Szily; Szabolcs Kéri



Effects of stratification in spherical shell convection  

NASA Astrophysics Data System (ADS)

We report on simulations of mildly turbulent convection in spherical wedge geometry with varying density stratification. We vary the density contrast within the convection zone by a factor of 20 and study the influence of rotation on the solutions. We demonstrate that the size of convective cells decreases and the anisotropy of turbulence increases as the stratification is increased. Differential rotation is found to change from anti-solar (slow equator) to solar-like (fast equator) at roughly the same Coriolis number for all stratifications. The largest stratification runs, however, are sensitive to changes of the Reynolds number. Evidence for a near-surface shear layer is found in runs with strong stratification and large Reynolds numbers.

Käpylä, P. J.; Mantere, M. J.; Brandenburg, A.



Preoperative cardiac risk assessment for noncardiac surgery: defining costs and risks.  


Cardiac risk stratification before noncardiac surgery remains important. Two major areas have been emphaized, namely, cost-effective risk stratification and enhanced identification of high risk populations. Recent studies have highlighted the lack of quality and affordable medical consultation. The indications for resting preoperative echocardiography merit streamlining, given recent data that failed to demonstrate tangible benefit. Further more, noninvasive cardiac stress testing is expensive and unnecessary in low risk patients. Perioperative troponin determination significantly improves the detection of myocardial infarction, facilitating its early management. The revised cardiac risk index is a standard tool for risk stratification, despite multiple limitations. The first approach has been tore calibrate the traditional risk index to specific high-risk surgical subgroups. The second approach has been to develop new cardiac risk models with more power. Both approaches have yielded risk calculators that out perform the traditional risk model. Furthermore, this latest generation of risk models is available as online calculators that can be accessed at the bedside. Further clinical trials are indicated to test the validity, clinical utility, and cost-effectiveness of these novel risk calculators. It is likely that these powerful instruments will refine the indications for specialized cardiac testing, offering multiple opportunities to reduce perioperative risk and cost simultaneously. PMID:23620898

Augoustides, John G T; Neuman, Mark D; Al-Ghofaily, Lourdes; Silvay, George



Venous thromboembolism risk assessment in hospitalised patients: A new proposal  

PubMed Central

OBJECTIVE: Cross-sectional studies have been conducted to evaluate the adequacy of prophylaxis for venous thromboembolism. However, these studies often evaluate prophylaxis on the data collection day, without analysing the prophylactic dose or duration and without reference to inappropriate use in patients without risk. A prospective, observational study was performed to assess the adequacy of prophylaxis in a general medicine ward of a university hospital. METHOD: In the analysis, the use of the proper prophylactic dose at the correct time, the use in patients with contraindications, and the misuse in patients without risk of venous thromboembolism were considered. RESULTS: A total of 245 patients were evaluated. Of these patients, 104 (42.4%) were considered to be at risk, and 82.7% either received adequate prophylaxis (i.e., the correct dose at the right time) or did not receive prophylaxis because it was contraindicated. Among the 141 patients who were not at risk, 81 (57.4%) incorrectly received prophylaxis, the majority (61/81) of whom presented with risk factors but did not demonstrate reduced mobility. Among the entire group, only 59.6% of patients were properly treated. CONCLUSIONS: The evaluation of prophylaxis adequacy should consider not only whether the correct dose is administered at the correct time but also whether it is used in patients with contraindications and whether it is inappropriately administered to patients who are not at risk.

Alckmin, Carolina Alves Vono; Garcia, Mariana Dionisia; de Carvalho Bricola, Solange Aparecida Petilo; de Arruda Martins, Milton; Lichtenstein, Arnaldo; de Paiva, Edison Ferreira



Psoriasis and Cardiovascular Risk: Assessment by CUORE Project Risk Score in Italian Patients  

PubMed Central

Background. Psoriasis is a common inflammatory and immune-mediated skin disease. There is growing controversy as to whether cardiovascular risk is elevated in psoriasis. A number of studies suggest a high prevalence of cardiovascular risk factors as well as cardiovascular diseases in psoriasis patients. Objective. The objective of this study was to estimate cardiovascular risk score in psoriasis patients and the relation between cardiovascular risk and psoriasis features. Cardiovascular risk was assessed by CUORE project risk score built within the longitudinal study of the Italian CUORE project and suited to populations with a low rate of coronary heart disease. Results. A case-control study in 210 psoriasis outpatients and 111 controls with skin diseases other than psoriasis was performed. CUORE project risk score was higher in patients than controls (6.80 ± 6.34 versus 4.48 ± 4.38, P < 0.001). Compared to controls, psoriasis patients have higher risk of developing major cardiovascular events. Cardiovascular risk was not related to psoriasis characteristics. Conclusion. Increased focus on identifying cardiovascular risk factors and initiation of preventive lifestyle changes or therapeutic interventions in patients with psoriasis is warranted.

Caputo, Valentina; Bongiorno, Maria Rita



Communicating the risk of side effects to rheumatic patients.  


When proposing a new therapy, rheumatologists must inform patients of a range of therapeutic options and support them towards making an informed decision. This article introduces definitions of equipoise and a good decision, contrasts persuasion from informed patient choice, and discussed the effects of patient characteristics including cognition on decision making. It also describes and offers examples of techniques and visual formats utilized in patient decision aids to present risk estimates to reduce cognitive bias and maximize patient comprehension. PMID:23137575

Martin, Richard W



Risk stratification in stable coronary artery disease is possible at cardiac troponin levels below conventional detection and is improved by use of N-terminal pro-B-type natriuretic peptide.  


AIMS: Low prevalence of detectable cardiac troponin in healthy people and low-risk patients previously curtailed its use. With a new high-sensitive cardiac troponin assay (hs-cTnT), concentrations below conventional detection may have prognostic value, notably in combination with N-terminal pro-B-type natriuretic peptide (NT-pro-BNP). METHODS AND RESULTS: Biomarker concentrations were determined from serum obtained at enrolment in the CLARICOR trial involving 4197 patients with stable coronary artery disease (CAD) followed for 2.6 years. Serum hs-cTnT was detectable (above 3?ng/l) in 78% and above the conventional 99th percentile (13.5?ng/l) in 23%. Across all levels of hs-cTnT there was a graded increase in the risk of cardiovascular death after adjustment for known prognostic indicators: hazard ratio (HR) per unit increase in the natural logarithm of the hs-cTnT level, 1.49; 95% confidence interval (CI), 1.23-1.81; similarly for all-cause mortality (HR 1.48, 95% CI 1.29-1.70) and myocardial infarction (HR 1.37, 95% CI 1.13-1.67). Increasing values of hs-cTnT were associated with increased mortality across all values of NT-pro-BNP, but this was particularly prominent when NT-pro-BNP >400?ng/l. CONCLUSIONS: In patients with stable CAD, any detectable hs-cTnT level is significantly associated with all-cause mortality, cardiovascular death, and myocardial infarction after adjustment for traditional risk factors and NT-pro-BNP. Excess mortality is particularly pronounced in patients with NT-pro-BNP >400?ng/l. PMID:23723326

Lyngbæk, Stig; Winkel, Per; Gøtze, Jens P; Kastrup, Jens; Gluud, Christian; Kolmos, Hans Jørn; Kjøller, Erik; Jensen, Gorm Boje; Hansen, Jørgen Fischer; Hildebrandt, Per; Hilden, Jørgen



Helping Patients Decide: Ten Steps to Better Risk Communication  

PubMed Central

With increasing frequency, patients are being asked to make complex decisions about cancer screening, prevention, and treatment. These decisions are fraught with emotion and cognitive difficulty simultaneously. Many Americans have low numeracy skills making the cognitive demands even greater whenever, as is often the case, patients are presented with risk statistics and asked to make comparisons between the risks and benefits of multiple options and to make informed medical decisions. In this commentary, we highlight 10 methods that have been empirically shown to improve patients’ understanding of risk and benefit information and/or their decision making. The methods range from presenting absolute risks using frequencies (rather than presenting relative risks) to using a risk format that clarifies how treatment changes risks from preexisting baseline levels to using plain language. We then provide recommendations for how health-care providers and health educators can best to communicate this complex medical information to patients, including using plain language, pictographs, and absolute risks instead of relative risks.

Zikmund-Fisher, Brian J.; Ubel, Peter A.



Risk of Retinal Detachment in Patients with Lattice Degeneration  

Microsoft Academic Search

To determine the risk of retinal detachment in patients with lattice degeneration of the retina, we statistically analyzed the incidence of retinal detachment in these patients. The data of hospital patients with retinal detachment associated with lattice degeneration in Kumamoto Prefecture, Japan, in 1990 were collected. The prevalence of lattice degeneration in Kumamoto was reported to be 9.5% in 1980.

Kiwamu Sasaki; Hidenao Ideta; Junichi Yonemoto; Sumiyoshi Tanaka; Akira Hirose; Chitoshi Oka



Patient-centered computing: can it curb malpractice risk?  

PubMed Central

The threat of a medical malpractice suit represents a major cause of career dissatisfaction for American physicians. Patient-centered computing may improve physician-patient communications, thereby reducing liability risk. This review describes programs that have sought to enhance patient education and involvement pertaining to 5 major categories of malpractice lawsuits: Diagnosis, medications, obstetrics, surgery, and treatment errors.

Bartlett, E. E.



Postoperative constipation risk assessment in Turkish orthopedic patients.  


This descriptive, correlational study was conducted to describe constipation risk assessment and the affecting factors of constipation risk of patients who have undergone major orthopedic surgery. Data were collected using a patient information form and the Constipation Risk Assessment Scale (CRAS) on the second postoperative day. Data were analyzed using the SPSS version 11.5 for Windows. The mean age of the 83 patients studied was 53.75 ± 21.29 years. Subjects were hospitalized in the orthopedic wards for 14.39 ± 15.17 days, and their current bowel habit was 2.18 ± 1.80 stools per week. Of the sample, 63.9% were female, 69.9% of the patients had a history of previous surgery, 45.8% had hip/knee arthroplasty surgery, and 55.4% had bowel problems during the hospitalization period. Patients had a medium risk for constipation according to the CRAS subscale (gender, mobility, and pharmacological agents). Total CRAS score was 12.73 ± 4.75 (medium risk) on the second postoperative day. In addition, age, marital status, educational level, having a history of surgery, and bowel elimination problems did have a significant effect on constipation risk. On the basis of the findings from this study, nurses must learn the postoperative constipation risk of orthopedic patients to implement safe and effective interventions. PMID:22472670

?endir, Merdiye; Büyük?ylmaz, Funda; A?t?, Türkinaz; Gürp?nar, ?engül; Yazgan, ?lknur


Potential health risks of complementary alternative medicines in cancer patients.  


Many cancer patients use complementary alternative medicines (CAMs) but may not be aware of the potential risks. There are no studies quantifying such risks, but there is some evidence of patient risk from case reports in the literature. A cross-sectional survey of patients attending the outpatient department at a specialist cancer centre was carried out to establish a pattern of herbal remedy or supplement use and to identify potential adverse side effects or drug interactions with conventional medicines. If potential risks were identified, a health warning was issued by a pharmacist. A total of 318 patients participated in the study. Of these, 164 (51.6%) took CAMs, and 133 different combinations were recorded. Of these, 10.4% only took herbal remedies, 42.1% only supplements and 47.6% a combination of both. In all, 18 (11.0%) reported supplements in higher than recommended doses. Health warnings were issued to 20 (12.2%) patients. Most warnings concerned echinacea in patients with lymphoma. Further warnings were issued for cod liver/fish oil, evening primrose oil, gingko, garlic, ginseng, kava kava and beta-carotene. In conclusion, medical practitioners need to be able to identify the potential risks of CAMs. Equally, patients should be encouraged to disclose their use. Also, more research is needed to quantify the actual health risks. PMID:14735185

Werneke, U; Earl, J; Seydel, C; Horn, O; Crichton, P; Fannon, D



Are Adult Patients More Tolerant of Treatment Risks Than Parents of Juvenile Patients?  

PubMed Central

Understanding patient-specific differences in risk tolerance for new treatments that offer improved efficacy can assist in making difficult regulatory and clinical decisions for new treatments that offer both the potential for greater effectiveness in relieving disease symptoms, but also risks of disabling or fatal side effects. The aim of this study is to elicit benefit-risk trade-off preferences for hypothetical treatments with varying efficacy and risk levels using a stated-choice (SC) survey. We derive estimates of “maximum acceptable risk” (MAR) that can help decisionmakers identify welfare-enhancing alternatives. In the case of children, parent caregivers are responsible for treatment decisions and their risk tolerance may be quite different than adult patients' own tolerance for treatment-related risks. We estimated and compared the willingness of Crohn's disease (CD) patients and parents of juvenile CD patients to accept serious adverse event (SAE) risks in exchange for symptom relief. The analyzed data were from 345 patients over the age of 18 and 150 parents of children under the age of 18. The estimation results provide strong evidence that adult patients and parents of juvenile patients are willing to accept tradeoffs between treatment efficacy and risks of SAEs. Parents of juvenile CD patients are about as risk tolerant for their children as adult CD patients are for themselves for improved treatment efficacy. SC surveys provide a systematic method for eliciting preferences for benefit-risk tradeoffs. Understanding patients' own risk perceptions and their willingness to accept risks in return for treatment benefits can help inform risk management decision making.

Johnson, F. Reed; Ozdemir, Semra; Mansfield, Carol; Hass, Steven; Siegel, Corey A.; Sands, Bruce E.



Radiation risks for patients having X rays  

Microsoft Academic Search

In addition to radiation from naturally occurring radioactive materials and cosmic rays, individuals in developed countries receive radiation doses to bone marrow and gonads from the medical diagnostic use of X rays. A brief discussion of radiation epidemiology shows that deleterious effects are low even when doses are high. The concept of acceptable risk is introduced to help evaluate the

John Hale; John W. Thomas



Patients at risk of suicide and overdose  

Microsoft Academic Search

Suicide is a complex and confusing subject. Although social factors may be important a clear relationship has been established between suicide and some medical conditions, notably depression, schizophrenia and alcohol dependence. Primary care physicians are in the “front line” as far as the recognition of suicidal risk is concerned. There is good evidence that many individuals who commit suicide have

G. Beaumont; W. Hetzel



JAMA Patient Page: Coronary Heart Disease Risk Factors  


... the American Medical Association JAMA PATIENT PAGE Coronary Heart Disease Risk Factors H eart disease is the leading ... common type of heart disease is called coronary heart disease , sometimes referred to as coronary artery disease. The ...


Treating Patients with High-Risk Smoldering Myeloma

In this phase III clinical trial, patients with smoldering myeloma classified as high risk for progression will be randomly assigned to undergo standard observation or six 4-week courses of treatment with the drug lenalidomide.


Anemia for risk assessment of patients with acute coronary syndromes.  


In patients admitted with acute coronary syndromes, those with anemia are at higher risk. However, current risk score systems do not take into account the presence of anemia. The impact of anemia on mortality was studied, and its incremental predictive value was evaluated. Demographic, clinical, and biologic characteristics at admission, as well as treatments and mortality, were recorded for 1,410 consecutive patients with acute coronary syndromes. The incremental value of adding anemia information to risk score evaluation was determined using changes in the appropriateness of Cox models when anemia was added. Anemia was detected in 381 patients (27%). They were older, had more co-morbidities, had higher Global Registry of Acute Coronary Events (GRACE) risk scores, received fewer guideline-recommended treatments, and, as a result, had 4-fold higher mortality. When included in a prediction model based on the GRACE risk score, anemia remained an independent predictor of mortality. The addition of anemia improved both the discriminatory capacity and calibration of the models. According to the GRACE risk score, the population was divided into 4 groups of different risk levels of <1%, 1% to <5%, 5% to <10%, and > or =10%. The addition of anemia to the model made it possible to reclassify 9%, 43%, 47%, and 23% of patients into the different risk categories, respectively. In conclusion, our data confirmed that anemia was an independent predictive factor of mortality and had incremental predictive value to the GRACE score system for early clinical outcomes. PMID:19195499

Meneveau, Nicolas; Schiele, François; Seronde, Marie-France; Descotes-Genon, Vincent; Oettinger, Joanna; Chopard, Romain; Ecarnot, Fiona; Bassand, Jean-Pierre



Identification of older hospitalized patients at risk for functional decline  

Microsoft Academic Search

Between 30% and 60% of older patients experience functional decline after hospitalization, resulting in a decline in health-related quality of life and autonomy. This is associated with increased risk of readmission, nursing home placement and mortality, increased length of hospital stay and increased need for health care at home. A decreased functional status is a risk factor for the development

J. G. Hoogerduijn



Behavioral Risk Assessment of the Guarded Suicidal Patient  

ERIC Educational Resources Information Center

|Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time-limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assist…

Simon, Robert I.




Microsoft Academic Search

Patients on peritoneal dialysis (PD) are at high cardio- vascular risk. Although some risk factors are unmodifiable (for example, age, sex, genetics), others are exacerbated in the unfriendly uremic milieu (inflammation, oxidative stress, mineral disturbances) or contribute per se to kid- ney disease and cardiovascular progression (diabetes mel- litus, hypertension). Moreover, several factors associated with PD therapy may both increase

Elvia García-López; Juan J. Carrero; Mohamed E. Suliman; Bengt Lindholm; Peter Stenvinkel


Management of Secondary Risk Factors in Patients with Intermittent Claudication  

Microsoft Academic Search

Objectives: the first line management of patients with intermittent claudication is “best medical therapy” i.e., smoking cessation, exercise, antiplatelet therapy and risk factors modification. The aim of this study was to assess the current management of risk factors in primary care and to compare General Practitioner (GP) attitudes and actual management.Design and Methods: postal questionnaire of all 336 GPs in

K. Cassar; R. Coull; P. Bachoo; E. Macaulay; J. Brittenden



Predicting Stroke Risk in Hypertensive Patients With Coronary Artery Disease  

PubMed Central

Background and Purpose Our understanding of factors influencing stroke risk among patients with coronary artery disease is incomplete. Accordingly, factors predicting stroke risk in hypertensive, clinically stable coronary artery disease patients were determined with data from the INternational VErapamil SR-trandolapril STudy (INVEST). Methods The effect of baseline characteristics and on-treatment blood pressure (BP) were analyzed to determine the risk of stroke (fatal or nonfatal) among the 22 576 patients enrolled. Cox proportional-hazards models (unadjusted, adjusted, and time dependent) were used to identify predictors of stroke among subgroups with these characteristics present at entry and on-treatment BP. Results Excellent BP control (at 24 months, >70% <140/90 mm Hg) was achieved during 61 835 patient-years of follow-up, as 377 patients had a stroke (6.1 strokes/1000 patient-years) and 28% of those patients had a fatal stroke. Increased age, black race, US residency, and history of prior myocardial infarction, smoking, stroke/transient ischemic attack, arrhythmia, diabetes, and coronary bypass surgery were associated with an increased risk of stroke. Achieving a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg was associated with a decreased risk of stroke. There was no statistically significant difference in stroke risk comparing the verapamil SR–based with the atenolol-based treatment strategy (adjusted hazard ratio=0.87; 95% CI, 0.71 to 1.06; P=0.17). Conclusions Among hypertensive patients with chronic coronary artery disease, stroke was an important complication associated with significant mortality. Black race, US residency, and conditions associated with increased vascular disease severity and arrhythmia predicted increased stroke risk, whereas achieving a BP <140/90 mm Hg on treatment predicted a reduced stroke risk.

Coca, Antonio; Messerli, Franz H.; Benetos, Athanase; Zhou, Qian; Champion, Annette; Cooper-DeHoff, Rhonda M.; Pepine, Carl J.



Evaluation of risk factors for advanced glaucoma in Ghanaian patients  

Microsoft Academic Search

PurposeThis study was to determine factors associated with individuals presenting late with advanced glaucomatous optic nerve damage.MethodsA case–control study recruiting 123 patients with early features of primary open angle glaucoma (control) and 93 patients with advanced glaucoma (cases) was carried out for risk-factor analysis. Exposures of interest included those already established as major risk factors for glaucoma. These were initial

C T Ntim-Amponsah; W M K Amoaku; R K Ewusi; R Idirisuriya-Khair; E Nyatepe-Coo; S Ofosu-Amaah; WMK Amoaku



Risk of Connective Tissue Disorders among Breast Implant Patients  

Microsoft Academic Search

In a US retrospective cohort study (1960-1996), 351 (4.8%) of 7,234 patients with breast implants and 62 (2.9%) of 2,138 patients who had undergone other types of plastic surgery reported subsequent rheumatoid arthritis (RA), scleroderma, systemic lupus erythematosus, or Sjögren's syndrome (relative risk = 2.0, 95% confidence interval (CI): 1.5, 2.8). Risks of RA, scleroderma, and Sjögren's syndrome were elevated

Louise A. Brinton; Lenore M. Buckley; Olga Dvorkina; Jay H. Lubin; Theodore Colton; Mary Cay Murray; Robert N. Hoover


Inflammation enhances cardiovascular risk and mortality in hemodialysis patients  

Microsoft Academic Search

Inflammation enhances cardiovascular risk and mortality in hemodialysis patients.BackgroundAtherosclerosis, a major problem in patients on chronic hemodialysis, has been characterized as an inflammatory disease. C-reactive protein (CRP), the prototypical acute phase protein in humans, is a predictor of cardiovascular mortality in the general population. We hypothesize that several of the classic, as well as nontraditional, cardiovascular risk factors may respond




Stratification, superfluidity and magnetar QPOs  

NASA Astrophysics Data System (ADS)

The violent giant flares of magnetars excite quasi-periodic oscillations (QPOs) which persist for hundreds of seconds, as seen in the X-ray tail following the initial burst. Recent studies, based on single-fluid barotropic magnetar models, have suggested that the lower frequency QPOs correspond to magneto-elastic oscillations of the star. The higher frequencies, however - in particular the strong 625 Hz peak - have proved harder to explain, except as high-mode multipoles. In this work we study the time evolutions of non-axisymmetric oscillations of two-fluid Newtonian magnetars with no crust. We consider models with superfluid neutrons and normal protons, and poloidal and toroidal background field configurations. We show that multifluid physics (composition-gradient stratification, entrainment) tends to increase Alfvén mode frequencies significantly from their values in a single-fluid barotropic model. The higher frequency magnetar QPOs may then be naturally interpreted as Alfvén oscillations of the multifluid stellar core. The lower frequency QPOs are less easily explained within our purely fluid core model, but we discuss the possibility that these are crustal modes.

Passamonti, A.; Lander, S. K.



Pure variation and organic stratification.  


The fundamental problem posed by Darwin distinguishes his theory from any transformism of the past as well as any evolutionism to come: since variation is inherent to the living, it is a question of explaining, not at all why the living varies, but instead why the living does not vary in all directions to the point of constituting a continuum of forms varying ad infinitum. What limits and stabilizes this intrinsically unlimited variation, allowing certain forms to subsist and multiply to the detriment of others, is natural selection. This double principle of intrinsic variation/extrinsic selection constitutes a vector for the unification of reality that underlies Jean-Jacques Kupiec's ontophylogenesis as well as Deleuze and Guattari's global philosophy of Nature. Therefore, everything would potentially tend to incessantly vary. The work of Kupiec and others identifies an intrinsic random variation within ontogenesis itself. For Deleuze and Guattari, it is nothing but the figure, already selected by the organic stratum, of a more fundamental or pure variation. But, in fact, nothing really varies incessantly: everything undergoes a selective pressure according to which nothing subsists as such except what manages to endure through invariance (physical stratum) or reproduction (organic stratum). Thus, organic stratification only retains from variation what ensures and augments this reproduction. In this sense, every organism stratifies, i.e. submits to its imperative of subsistence and reproduction, a body without organs that varies in itself and always tends to escape the organism, for better (intensifications of life) or worse (cancerous pathologies). PMID:22884711

Rosanvallon, Jérôme



MDCT in Early Triage of Patients with Acute Chest Pain  

Microsoft Academic Search

OBJECTIVE. Current risk stratification of patients with acute chest pain but normal initial cardiac enzymes and nondiagnostic ECG is inefficient. We sought to determine whether con- trast-enhanced MDCT-based detection of stenosis is feasible and improves early and accurate triage of patients with acute chest pain. SUBJECTS AND METHODS. We studied 40 patients (53% men; mean age, 57 ± 13 years)

Udo Hoffmann; Antonio J. Pena; Fabian Moselewski; Maros Ferencik; Suhny Abbara; Ricardo C. Cury; Claudia U. Chae; John T. Nagurney


Sleep Apnea: Is Your Patient at Risk.  

National Technical Information Service (NTIS)

Sleep apnea is a serious, potentially life-threatening condition. It is a breathing disorder characterized by repeated collapse of the upper airway during sleep, with consequent cessation of breathing. Virtually all sleep apnea patients have a history of ...



Increased liver stiffness denotes hepatic dysfunction and mortality risk in critically ill non-cirrhotic patients at a medical ICU  

PubMed Central

Introduction Hepatic dysfunction is a common finding in critically ill patients on the ICU and directly influences survival. Liver stiffness can be measured by the novel method of transient elastography (fibroscan) and is closely associated with hepatic fibrosis in patients with chronic liver disease, but also is increased in patients with acute hepatitis, acute liver failure and cholestasis. We investigated liver stiffness as a potentially useful tool for early detection of patients with hepatic deterioration and risk stratification with respect to short- and long-term mortality. Methods We prospectively evaluated 108 consecutive critically ill patients at our medical intensive care unit (ICU) with subsequent longitudinal liver stiffness measurements (admission, Day 3, Day 7 and weekly thereafter) during the course of ICU treatment. Outcome was followed after discharge (median observation time 237 days). Results Liver stiffness could be reliably measured in 71% of ICU patients at admission (65% at Day 3, 63% at Day 7). Critically ill patients (n = 108) had significantly increased liver stiffness compared to sex- and age-matched standard care patients (n = 25). ICU patients with decompensated cirrhosis showed highest liver stiffness, whereas other critical diseases (for example, sepsis) and comorbidities (for example, diabetes, obesity) did not impact stiffness values. At admission to the ICU, liver stiffness is closely related to hepatic damage (liver synthesis, cholestasis, fibrosis markers). During the course of ICU treatment, fluid overload (renal failure, volume therapy) and increased central venous pressure (mechanical ventilation, heart failure) were major factors determining liver stiffness. Liver stiffness values > 18 kilopascal (kPa) at ICU admission were associated with increased ICU and long-term mortality, even in non-cirrhotic patients. Conclusions Considering that liver stiffness cannot be validly measured in about 30% of ICU patients, transient elastography performed at ICU admission might be a useful tool to early identify liver dysfunction and predict mortality in critically ill patients at a medical ICU.



Thermal Stratification Enhancement for Solar Energy Applications.  

National Technical Information Service (NTIS)

A study is presented that shows methods to enhance stratification in liquid storage tanks. The report focusses on the development of a passive inlet distributor which minimizes mixing between incoming and stored fluids at unlike temperatures. Theoretical ...

H. N. Gari M. K. Sharp R. D. Haberstroh R. I. Loehrke



Curriculum Placement and Educational Stratification in France.  

ERIC Educational Resources Information Center

Maintains that curriculum differentiation in France is the keystone of educational, and, consequently, social stratification. Factors which influence curriculum differentiation include father's occupation, academic performance, parents' expectations, and teachers' expectations. (DB)

Hout, Michael; Garnier, Maurice A.



Cardiovascular risk and dyslipidemia management in HIV-infected patients.  


HIV infection and antiretroviral therapy each appear to increase cardiovascular disease risk. Increased risk may be attributable to the inflammatory effects of HIV infection and dyslipidemia associated with some antiretroviral agents. The prevalence of cardiovascular disease is increasing as patients live longer, age, and acquire traditional coronary heart disease (CHD) risk factors. In general, any additional cardiovascular risk posed by HIV infection or antiretroviral therapy is of potential concern for patients who are already at moderate or high risk for CHD. Long-term and well-designed studies are needed to more accurately ascertain to what degree HIV infection and antiretroviral therapy affect long-term cardiovascular disease risk. Management of dyslipidemia to reduce CHD risk in HIV-infected patients is much the same as in the general population, with the cornerstone consisting of statin therapy and lifestyle interventions. Smoking cessation is a major step in reducing CHD risk in those who smoke. This article summarizes a presentation by James H. Stein, MD, at the IAS-USA live continuing medical education activity held in New York City in March 2012. PMID:23154252

Stein, James H


Recommendations for management of dyslipidemia in high cardiovascular risk patients  

PubMed Central

Overwhelming evidence supports a causal relationship between elevated levels of plasma cholesterol, particularly low-density lipoprotein cholesterol, and increased risk of coronary artery disease, which remains the leading cause of death and morbidity worldwide. Low-density lipoprotein cholesterol lowering has been the main goal of therapy, and clinical trial results from recently published studies of intensive statin therapy confirm the benefits of more aggressive lipid-lowering targets, particularly in subjects at high risk for cardiovascular events. This management update will focus on the implications of risk reduction in patients at high cardiovascular risk, and will provide practical steps to help further risk stratify these patients and help them reach their target goals.

Braga, Manoela B; Langer, Anatoly; Leiter, Lawrence A



Some Effects of Stratification on Rotating Fluids  

Microsoft Academic Search

A simple example of the steady motion of a rotating, stratified fluid is studied. The solution which is uniformly valid for all values of the stratification, s = vgDT\\/(f2L2), is presented. The transitions in the dynamics from the homogeneous limit to strong stratification are illustrated in detail. The motion is driven by a stress. Consequently, Ekman suction is weaker than

Ants Leetmaa



Brain Natriuretic Peptide Levels Predict Perioperative Events in Cardiac Patients Undergoing Noncardiac Surgery: A Prospective Study  

Microsoft Academic Search

Objectives: Brain natriuretic peptide (BNP) levels correlate with prognosis in patients with cardiac disease and may be useful in the risk stratification of cardiac patients undergoing noncardiac surgery (NCS). The objective of this study was to examine whether BNP levels predict perioperative events in cardiac patients undergoing NCS. Methods: Patients undergoing NCS with at least 1 of the following criteria

David Leibowitz; David Planer; David Rott; Yair Elitzur; Tova Chajek-Shaul; A. Teddy Weiss



Elderly patients undergoing major vascular surgery: Risk factors and medication associated with risk reduction  

Microsoft Academic Search

This study assesses risk factors in elderly vascular surgery patients and to evaluate whether perioperative cardiac medication can reduce postoperative mortality rate. In a cohort study, 1693 consecutive patients ?65 years undergoing major non-cardiac vascular surgery were preoperatively screened for cardiac risk factors and medication. During follow-up (median: 8.2 years), mortality was noted. Hospital mortality occurred in 8.1% and long-term

Harm H. H. Feringa; Jeroen J. Bax; Stefanos E. Karagiannis; Peter Noordzij; Ron van Domburg; Jan Klein; Don Poldermans



Early Identification of Patients at Risk of Acute Lung Injury  

PubMed Central

Rationale: Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. Objectives: To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). Methods: In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. Measurements and Main Results: Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1–4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78–0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9–5.7). Conclusions: ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with (NCT00889772).

Gajic, Ognjen; Dabbagh, Ousama; Park, Pauline K.; Adesanya, Adebola; Chang, Steven Y.; Hou, Peter; Anderson, Harry; Hoth, J. Jason; Mikkelsen, Mark E.; Gentile, Nina T.; Gong, Michelle N.; Talmor, Daniel; Bajwa, Ednan; Watkins, Timothy R.; Festic, Emir; Yilmaz, Murat; Iscimen, Remzi; Kaufman, David A.; Esper, Annette M.; Sadikot, Ruxana; Douglas, Ivor; Sevransky, Jonathan



Identification of patients at risk for diabetic foot  

Microsoft Academic Search

The aim of the study was the comparison of a simple standardized noninvasive examination of neuropathy and angiopathy with routine diagnostic practice in community diabetes clinics for the identification of patients at risk of foot ulceration. Consecutive patients (n=322), aged 30 years and more, with a diabetes duration of more than 5 years, were examined by trained podiatric nurses in

Alexandra Jirkovská; Petr Bou?ek; Veronika Wosková; Vladim??r Bartoš; Jelena Skibová



Mortality risk factors in chronic haemodialysis patients with infective endocarditis  

Microsoft Academic Search

Background. It is well documented that infective endocarditis (IE) is strongly associated with morbidity and mortality in haemodialysis (HD) patients. Less clear are the mortality risk factors for IE, particularly in an urban African-American dialysis population. Methods. IE patients were identified from the medical records for the period from January 1999 to February 2004 and confirmed by Duke criteria. The

Uday S. Nori; Anup Manoharan; John I. Thornby; Jerry Yee; Ravi Parasuraman; Venkataraman Ramanathan



Epidemiology of cardiovascular risk in patients with chronic kidney disease  

Microsoft Academic Search

Background. Chronic kidney disease (CKD) patients are highly prone to cardiovascular disease for a number of reasons. At the time of starting renal replacement treatment, their cardiovascular condition is already severely compromised, suggesting that cardiovascular risk factors begin to operate very early in the progression of CKD. Moreover, those patients reaching end-stage renal disease without cardiovascular abnormalities have a high

Francesco Locatelli; Pietro Pozzoni; Francesca Tentori; Lucia Del Vecchio



Gun Safety Management with Patients at Risk for Suicide  

ERIC Educational Resources Information Center

Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated person…

Simon, Robert I.



Risk of Disease in Siblings of Patients with Hereditary Hemochromatosis  

Microsoft Academic Search

Background: Parents of hereditary hemochromatosis (HH) homozygote patients, who are predominantly HH heterozygotes, have been found to have an increased risk of colonic neoplasia, diabetes, stroke death, stomach cancer and leukemia. The health histories of siblings of HH patients are reported. Methods: Individuals homozygous for HH were mailed questionnaires concerning the health histories of their siblings. Spouses of the HH

Richard L. Nelson; Victoria Persky; Faith Davis; Eugene Becker



Gun Safety Management with Patients at Risk for Suicide  

ERIC Educational Resources Information Center

|Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated person…

Simon, Robert I.



Predictors of high-risk angiographic findings in patients with non-ST-segment elevation acute coronary syndrome.  


Background: Current risk assessment of patients with non ST-elevation acute coronary syndrome (NSTE-ACS) may fail to identify some patients with severe coronary artery disease (CAD). We aimed to identify predictors of the angiographic extent and severity of CAD in patients with NSTE-ACS undergoing early angiography and evaluating its impact on prognosis. Methods: We evaluated 923 patients with NSTE-ACS who underwent coronary angiography. High-risk coronary anatomy (HRCA) was defined as either: left main disease >50%; proximal LAD lesion >70%; or 2-3 vessel disease involving the LAD. Clinical characteristics, in-hospital, and 30-day outcome and 1-year mortality were compared between the high-risk (N=370) and the low-risk groups (N=553). Results: Proportion of patients with elevated cardiac biomarkers was similar in both groups. The presence of peripheral vascular disease (OR 1.88, 95%CI1.62-5.80, p<0.001) and a GRACE score>140 (OR 1.88, 95%CI1.29-2.75, p<0.001) were the strongest predictors of HRCA. Patients with HRCA were prone to more complication during hospitalization and at 30 days (11.9% vs. 6%, p<0.01) and increased 1-year mortality (6.7% vs. 0.9%, p<0.001). HRCA was the strongest predictor for 30-day MACCE (OR 2.32, 95%CI1.42-3.79, p<0.001). HRCA (OR 8.36, 95%CI1.01-69.4, p=0.049; OR 3.64 95%CI1.2-11.07, p=0.02) and GRACE score>140 (OR 6.86, 95%CI1.68-27.9, p=0.007; OR 4.84 95%CI1.74-13.5, p=0.002) were significant predictors of 30-day and 1-year mortality, respectively. Conclusions: HRCA is predicted by clinical parameters and was not associated with elevated cardiac biomarkers. These patients fared worse compared to those with low risk anatomy. We suggest that HRCA predictors should be included in the risk stratification of patients with NSTE-ACS. © 2013 Wiley Periodicals, Inc. PMID:23784997

Beigel, Roy; Matetzky, Shlomi; Gavrielov-Yusim, Natalie; Fefer, Paul; Gottlieb, Shmuel; Zahger, Doron; Atar, Shaul; Finkelstein, Ariel; Roguin, Ariel; Goldenberg, Ilan; Kornowski, Ran; Segev, Amit



Neural network diagnostic system for dengue patients risk classification.  


With the dramatic increase of the worldwide threat of dengue disease, it has been very crucial to correctly diagnose the dengue patients in order to decrease the disease severity. However, it has been a great challenge for the physicians to identify the level of risk in dengue patients due to overlapping of the medical classification criteria. Therefore, this study aims to construct a noninvasive diagnostic system to assist the physicians for classifying the risk in dengue patients. Systematic producers have been followed to develop the system. Firstly, the assessment of the significant predictors associated with the level of risk in dengue patients was carried out utilizing the statistical analyses technique. Secondly, Multilayer perceptron neural network models trained via Levenberg-Marquardt and Scaled Conjugate Gradient algorithms was employed for constructing the diagnostic system. Finally, precise tuning for the models' parameters was conducted in order to achieve the optimal performance. As a result, 9 noninvasive predictors were found to be significantly associated with the level of risk in dengue patients. By employing those predictors, 75% prediction accuracy has been achieved for classifying the risk in dengue patients using Scaled Conjugate Gradient algorithm while 70.7% prediction accuracy were achieved by using Levenberg-Marquardt algorithm. PMID:20703665

Faisal, Tarig; Taib, Mohd Nasir; Ibrahim, Fatimah



Risk factors in patients with type 2 diabetes mellitus.  


This study was carried out to evaluate the risk factors of type 2 diabetic patients through sociodemographic data, habits of health, anthropometric and biochemist profiles, assisted at a basic public health care unit in Maringá, Paraná. Sixty-six patients, 56 women aged over than 50 years-old were interviewed. High prevalence factors for cardiovascular risk were observed, such as: overweight and obesity, hypertension, dyslipidemia, sedentariness and inadequate diet. Data suggested the need for multidisciplinary intervention programs in health care units associated to educative programs, adjusted diet intake and regular physical activity for these diabetic patients. PMID:18506342

Carolino, Idalina Diair Regla; Molena-Fernandes, Carlos Alexandre; Tasca, Raquel Soares; Marcon, Sonia Silva; Cuman, Roberto Kenji Nakamura


Risk factors for recurrence amongst high intermediate risk patients with endometrioid adenocarcinoma  

PubMed Central

Objective To determine risk factors associated with recurrence in patients with high intermediate risk (HIR) endometrioid adenocarcinoma. Methods A retrospective analysis of patients with HIR endometrioid adenocarcinoma who underwent hysterectomy, bilateral salpingo-oophorectomy, with or without pelvic/para-aortic lymphadenectomy at the University of Pennsylvania between 1990 and 2009 was performed. Results A total of 103 women with HIR endometrial cancer were identified. Multivariable analysis revealed that ?2/3 myometrial invasion (HR, 4.79; p=0.010) and grade 3 disease (HR, 3.04; p=0.045) were independently predictive of distant metastases. The 5-year distant metastases free survival (DMFS) for patients with neither or one of these risk factors was 89%, and the 5-year DMFS for patients with both risk factors was 48% (p<0.001). Conclusion Patients with both grade 3 disease and deep third myometrial invasion have a high risk of distant metastases. Identifying these patients may be important in rationally selecting patients for systemic therapy.

Bahng, Agnes Y.; Chu, Christina; Wileyto, Paul; Rubin, Stephen



A prognostic score for patients with lower risk myelodysplastic syndrome  

Microsoft Academic Search

Current prognostic models for myelodysplastic syndromes (MDS) do not allow the identification of patients with lower risk disease and poor prognosis that may benefit from early therapeutic intervention. We evaluated the characteristics of 856 patients with low or intermediate-1 disease by the International Prognostic Scoring System. Mean follow-up was 19.6 months (range 1–262). Of these patients, 87 (10%) transformed to

G Garcia-Manero; J Shan; S Faderl; J Cortes; F Ravandi; G Borthakur; W G Wierda; S Pierce; E Estey; J Liu; X Huang; H Kantarjian



Risk factors, quality of care and prognosis in South Asian, East Asian and White patients with stroke  

PubMed Central

Background Stroke has emerged as a significant and escalating health problem for Asian populations. We compared risk factors, quality of care and risk of death or recurrent stroke in South Asian, East Asian and White patients with acute ischemic and hemorrhagic stroke. Methods Retrospective analysis was performed on consecutive patients with ischemic stroke or intracerebral hemorrhage admitted to 12 stroke centers in Ontario, Canada (July 2003-March 2008) and included in the Registry of the Canadian Stroke Network database. The database was linked to population-based administrative databases to determine one-year risk of death or recurrent stroke. Results The study included 253 South Asian, 513 East Asian and 8231 White patients. East Asian patients were more likely to present with intracerebral hemorrhage (30%) compared to South Asian (17%) or White patients (15%) (p<0.001). Time from stroke to hospital arrival was similarly poor with delays >2 hours for more than two thirds of patients in all ethnic groups. Processes of stroke care, including thrombolysis, diagnostic imaging, antithrombotic medications, and rehabilitation services were similar among ethnic groups. Risk of death or recurrent stroke at one year after ischemic stroke was similar for patients who were White (27.6%), East Asian (24.7%, aHR 0.97, 95% CI 0.78-1.21 vs. White), or South Asian (21.9%, aHR 0.91, 95% CI 0.67-1.24 vs. White). Although risk of death or recurrent stroke at one year after intracerebral hemorrhage was higher in East Asian (35.5%) and White patients (47.9%) compared to South Asian patients (30.2%) (p=0.002), these differences disappeared after adjustment for age, sex, stroke severity and comorbid conditions (aHR 0.89 [0.67-1.19] for East Asian vs White and 0.99 [0.54-1.81] for South Asian vs. White). Conclusion After stratification by stroke type, stroke care and outcomes are similar across ethnic groups in Ontario. Enhanced health promotion is needed to reduce delays to hospital for all ethnic groups.



Redo surgery risk in patients with cardiac prosthetic valve dysfunction  

PubMed Central

Introduction The aim of the study was to analyse the risk factors of early and late mortality in patients undergoing the first reoperation for prosthetic valve dysfunction. Material and methods A retrospective observational study was performed in 194 consecutive patients (M = 75, F = 119; mean age 53.2 ±11 years) with a mechanical prosthetic valve (n = 103 cases; 53%) or bioprosthesis (91; 47%). Univariate and multivariate Cox statistical analysis was performed to determine risk factors of early and late mortality. Results The overall early mortality was 18.6%: 31.4% in patients with symptoms of NYHA functional class III-IV and 3.4% in pts in NYHA class I-II. Multivariate analysis identified symptoms of NYHA class III-IV and endocarditis as independent predictors of early mortality. The overall late mortality (> 30 days) was 8.2% (0.62% year/patient). Multivariate analysis identified age at the time of reoperation as a strong independent predictor of late mortality. Conclusions Reoperation in patients with prosthetic valves, performed urgently, especially in patients with symptoms of NYHA class III-IV or in the case of endocarditis, bears a high mortality rate. Risk of planned reoperation, mostly in patients with symptoms of NYHA class I-II, does not differ from the risk of the first operation.

Maciejewski, Marek; Piestrzeniewicz, Katarzyna; Bielecka-Dabrowa, Agata; Piechowiak, Monika; Jaszewski, Ryszard



Screening of risk from patient manual handling with MAPO method.  


International standards highlight the steps required by risk assessment and involving first hazard identification, then risk evaluation and finally, if necessary, risk assessment. To check approach appropriateness to "risk evaluation" from manual patient handling through MAPO, a cross study was carried out in view of checking relationship between this new risk assessment model and occurrence of acute low back pain. After proper training the MAPO screening method was assessed in 31 wards, 411 exposed subjects of geriatric hospitals. At the same time health data were collected on occurrence of low back pain episodes during the last year both in the exposed subjects' group and the external reference group (n?237). Risk and clinical assessment data were tutored and checked by EPM research unit. The logistic analysis was used as a method to evaluate the relationship between risk index and acute low back pain. Investigating relationship between acute low back pain episodes and levels of MAPO screening index, carried out only with the people exposed who claimed to work for at least 30 hours per week (n = 178), showed definitely positive trends. The study results indicate that MAPO screening may represent a useful tool to estimate the risk from manual handling patients. PMID:22316996

Battevi, Natale; Menoni, Olga



Prediction of cardiac risk in patients undergoing vascular surgery  

SciTech Connect

In an attempt to determine whether noninvasive cardiac testing could be used to assess cardiac risk in patients undergoing surgery for vascular disease, the authors studied 96 patients. Seventy-seven patients eventually underwent major vascular surgery with 11 (14%) experiencing a significant cardiac complication. Thallium imaging was much more likely to be positive (p less than 0.01) in patients with a cardiac complication; however, there was a significant number of patients with cardiac complications who had a positive history or electrocardiogram for myocardial infarction. When grouped by complication and history of infarction, thallium imaging, if negative, correctly predicted low cardiac risk in the group with a history of infarction. Thallium imaging, however, did not provide a clear separation of risk in those without a history of infarction. Age and coronary angiography, on the other hand, did reveal significant differences within the group without a history of infarction. The resting radionuclide ejection fraction followed a similar pattern to thallium imaging. It is concluded that a positive history of myocardial infarction at any time in the past is the strongest risk predictor in this population and that the predictive value of noninvasive testing is dependent on this factor. Considering these findings, a proposed scheme for assessing risk that will require further validation is presented.

Morise, A.P.; McDowell, D.E.; Savrin, R.A.; Goodwin, C.A.; Gabrielle, O.F.; Oliver, F.N.; Nullet, F.R.; Bekheit, S.; Jain, A.C.



Awareness of vitamin D deficiency among at-risk patients  

PubMed Central

Background Vitamin D deficiency is a significant problem for a growing proportion of the UK population. Individuals with dark or covered skin are at particularly high risk due to ethno-cultural, environmental and genetic factors. We assessed the level of awareness of vitamin D deficiency among at-risk patients in order to identify groups most in need of education. Findings A cross-sectional survey using a piloted questionnaire was conducted among consecutive at-risk patients without a diagnosis of Vitamin D deficiency arriving at a large inner city general practice in the North West of England over a five day period. The survey was completed by 221 patients. The mean age was 35 years. 28% of them (n = 61) had never heard about vitamin D. Older patients (p = 0.003) were less likely to have heard about vitamin D. 54% of participants were unaware of the commonest symptoms of vitamin D deficiency. 34% did not expose their skin other than their face in the last one year, and 11% did not include vitamin D rich foods in their diet. Conclusion The majority of at-risk patients are aware of vitamin D; nevertheless, there is a significant lack of knowledge among older people, who have higher morbidity. A programme of targeted education of the at-risk population is recommended.



Risk Factors for Falls among Hospitalized Trauma Patients.  


Inpatient falls lead to an injury in 30 per cent of cases and serious injury in 5 per cent. Increasing staffing and implementing fall prevention programs can be expensive and require a significant use of resources. We hypothesized that trauma patients have unique risk factors to sustain a fall while hospitalized. This is a retrospective cohort study from 2005 to 2010 of all trauma patients admitted to an urban Level I trauma center. Patients who fell while hospitalized were compared with patients who did not fall to identify risk factors for sustaining an inpatient fall. There were 16,540 trauma patients admitted during the study period and 128 (0.8%) fell while hospitalized. Independent risk factors for a trauma patient to fall while hospitalized included older age (odds ratio [OR], 1.02 [1.01 to 1.03], P < 0.001), male gender (OR, 1.6 [1.0 to 2.4], P = 0.03), blunt mechanism (OR, 5.1 [1.6 to 16.3], P = 0.006), Glasgow Coma Score at admission (OR, 0.59 [0.35 to 0.97], P = 0.04), intensive care unit admission (OR, 2.3 [1.4 to 3.7], P = 0.001), and need for mechanical ventilation (OR, 2.2 [1.2 to 3.9], P = 0.01). Trauma patients who fell while hospitalized sustained an injury in 17 per cent of cases and a serious injury in 5 per cent. Inpatient falls in hospitalized trauma patients are uncommon. Risk factors include older age, male gender, blunt mechanism, lower Glasgow Coma Score, and the need for intensive care unit admission or mechanical ventilation. Trauma patients with these risk factors may require higher staffing ratios and should be enrolled in a formal fall prevention program. PMID:23635580

Brown, Carlos V R; Ali, Sadia; Fairley, Romeo; Lai, Bryan K; Arthrell, Justin; Walker, Melinda; Tips, Gaylen



Effectiveness of guidelines implementation for the control of multiple cardiovascular risk factors in high-risk patients in practice  

Microsoft Academic Search

For the effective cardiovascular protection current guidelines recommend multifactorial intervention on cardiovascular risk factors. This study assessed the efficiency of the combined implementation of guidelines for the control of major modifiable cardiovascular risk factors in high-risk patients.Study participants were consecutive patients attending an Outpatients Cardiovascular Risk Factor Clinic. Current guidelines were simultaneously implemented by trained physicians aiming to reach the

George Stergiou; Nikos Baibas; Irini Skeva; George Damianidis; P. Douitsis; I. Terzi; A. Sidiropoulos; N. Kakavas; N. Liakopoulos



Risk of falling in patients with a recent fracture  

PubMed Central

Background Patients with a history of a fracture have an increased risk for future fractures, even in short term. The aim of this study was to assess the number of patients with falls and to identify fall risk factors that predict the risk of falling in the first three months after a clinical fracture. Methods Prospective observational study with 3 months of follow-up in a large European academic and regional hospital. In 277 consenting women and men aged ? 50 years and with no dementia and not receiving treatment for osteoporosis who presented to hospital with a clinical fracture, fall risk factors were assessed according to the guidelines on fall prevention in the Netherlands. Follow-up information on falls and fractures was collected by monthly telephone interview. Incidence of falls and odds ratio's (OR, with 95% confidence intervals) were calculated. Results 512 consecutive patients with a fracture were regarded for analysis, 87 were not eligible for inclusion and 137 patients were excluded. No follow-up data were available for 11 patients. Therefore full analysis was possible in 277 patients. A new fall incident was reported by 42 patients (15%), of whom five had a fracture. Of the 42 fallers, 32 had one new fall and 10 had two or more. Multivariate analysis in the total group with sex, age, ADL difficulties, urine incontinence and polypharmacy showed that sex and ADL were significant fall risk factors. Women had an OR of 3.02 (95% CI 1.13–8.06) and patients with ADL-difficulties had an OR of 2.50 (95% CI 1.27–4.93). Multivariate analysis in the female group with age, ADL difficulties, polypharmacy and presence of orthostatic hypotension indicated that polypharmacy was the predominant risk factor (OR 2.51; 95% CI: 1.19 – 5.28). The incidence of falls was 35% in women with low ADL score and polypharmacy compared to 15% in women without these risk factors (OR 3.56: CI 1.47 – 8.67). Conclusion 15% of patients reported a new fall and 5 patients suffered a new fracture within 3 months. Female sex and low ADL score were the major risk factors and, in addition, polypharmacy in women.

van Helden, Svenhjalmar; Wyers, Caroline E; Dagnelie, Pieter C; van Dongen, Martien C; Willems, Gittie; Brink, Peter RG; Geusens, Piet P



Risks and risk-analysis for the development of pressure ulcers in surgical patients  

Microsoft Academic Search

With prevalence figures of 13% for university hospitals and 23% for general hospitals, pressure ulcers are a major health care issue in The Netherlands. Pressure ulcers in surgical patients are frequently encountered, as is illustrated by reported incidence rates up to 66%. The number of patients at risk will probably also grow, due to an ageing population. In an extensive

Bastiaan Paul Johan Aart Keller



Risk of surgical site infection in patients undergoing orthopedic surgery.  


This study aimed to identify risk factors associated with surgical site infections in orthopedic surgical patients at a public hospital in Minas Gerais, Brazil, between 2005 and 2007. A historical cohort of 3,543 patients submitted to orthopedic surgical procedures. A descriptive analysis was conducted and surgical site infection incidence rates were estimated. To verify the association between infection and risk factors, the Chi-square Test was used. The strength of association of the event with the independent variables was estimated using Relative Risk, with a 95% confidence interval and p<0.05. The incidence of surgical site infection was 1.8%. Potential surgical wound contamination, clinical conditions, time and type of surgical procedure were statistically associated with infection. Identifying the association between surgical site infection and these risk factors is important and contributes to nurses' clinical practice. PMID:22249670

Ercole, Flávia Falci; Franco, Lúcia Maciel Castro; Macieira, Tamara Gonçalves Rezende; Wenceslau, Luísa Cristina Crespo; de Resende, Helena Isabel Nascimento; Chianca, Tânia Couto Machado


Residual risk of cardiovascular mortality in patients with coronary heart disease: The EUROASPIRE Risk Categories.  


BACKGROUND: The EUROASPIRE I, II and III surveys revealed high prevalences of modifiable risk factors in the high priority group of coronary patients all over Europe. The potential to further reduce coronary heart disease (CHD) morbidity and mortality rates is still considerable. We report here on the relative risk of cardiovascular disease (CVD) death associated with common modifiable risk factor levels based on the mortality follow-up of patients participating in the first two EUROASPIRE surveys. We also present a novel simple risk classification system (ERC) that can be used in the management of patients with existing CHD. METHODS: The study cohort consisted of a consecutive sample of CHD patients aged ?70years from 12 European countries. Baseline data gathered in 1995-2000 through standardized methods, were linked to cardiovascular mortality in 5216 patients according to an accelerated failure time model. RESULTS: During 28,143person-years of follow-up, 332 patients died from cardiovascular disease denoting a CVD mortality risk of 12.3 per 1000person-years in men and 10.2 per 1000person-years in women. In multivariate analysis, fasting glucose, total cholesterol and smoking emerged as the strongest independent modifiable predictors of cardiovascular mortality. CONCLUSIONS: The results of the mortality follow-up of the EUROASPIRE I and II CHD patients emphasize the continuing risk from elevated glucose and total cholesterol levels and underline the importance of smoking cessation in secondary prevention. The ERC risk tool that we developed may prove helpful to obtain these goals in the setting of secondary prevention. PMID:23157810

De Bacquer, Dirk; Dallongeville, Jean; Kotseva, Kornelia; Cooney, Marie Therese; Pajak, Andrzej; Deckers, Jaap W; Mayer, Otto; Vanuzzo, Diego; Lehto, Seppo; Fras, Zlatko; Ostor, Erika; Ambrosio, Giovanni B; De Backer, Guy; Wood, David; Keil, Ulrich; Sans, Susana; Graham, Ian; Pyörälä, Kalevi



Risk factors of Parkinson's disease in Indian patients  

Microsoft Academic Search

Epidemiological data on risk factors of Parkinson's disease (PD) are not available from India. In a case control study, we investigated environmental and genetic risk factors in the etiology of idiopathic Parkinson's disease. Three hundred seventy-seven patients of Parkinson disease (301 men, 76 women, mean±SD age 56.78±11.08 years) and equal number of age matched (±3 years) neurological controls (271 men,

M Behari; Achal K Srivastava; Radhika R Das; R. M Pandey



The effect of visual impairment on patients' falls risk.  


When older people fall it can result in injuries and adversely affect quality of life. People with visual impairment are at greater risk of falling. This article explores the risk of falling and preventive assessment in patients with visual impairment, whether they are in long-term care settings or living in their own homes. Five types of visual impairment common to older people are discussed. The importance of assessment for falls prevention and suggestions for practice are highlighted. PMID:24067043

Newton, Mel; Sanderson, Allyson



Atherosclerotic risk factors in patients with ischemic cerebrovascular disease  

Microsoft Academic Search

Opinion statement  Aggressive treatment of atherosclerotic risk factors can substantially reduce stroke risk in patients with a history of stroke\\u000a or transient ischemic attack. Data from several recent large clinical trials provide convincing evidence of benefit for a\\u000a number of specific therapies directed at this population. The authors recommend treatment with ramipril alone or perindopril\\u000a plus indapamide regardless of blood pressure,

Brett L. Cucchiara; Scott E. Kasner



Risk factors of patients with and without postoperative nausea (PON).  


This purpose of this analysis was to study risk factors of postoperative nausea (PON) and their strength. Data were obtained during the screening phase of a controlled clinical trial of aromatherapy for PON. In a sample of 1151 postsurgical subjects, 301 (26.2%) reported PON. Significant risk factors identified in the order of odds ratios for nausea were female gender, gastrointestinal surgery, use of volatile anesthesia gases, history of PON, history of motion sickness, and use of opioids after surgery. Although still over 1.0, the risk factors of length of surgery over 1 hour and gynecologic surgery had the lowest odds ratios. Likelihood of nausea increased significantly with the number of significant risk factors (P<.0001). Administration of preventive antiemetic medication also increased with the number of significant risk factors (P<.0001). Among 301 subjects reporting nausea, 49 (16.28%) received preventive medication. Despite prevention efforts, PON remains a substantial side effect for many surgical patients. PMID:22828021

Dienemann, Jacqueline; Hudgens, Amanda N; Martin, Dana; Jones, Holly; Hunt, Ronald; Blackwell, Richard; Norton, H James; Divine, George



[Cinacalcet therapy and cardiovascular risk in hemodialysis patients].  


 Patients with end-stage kidney disease are at high cardiovascular risk due to accelerated atherosclerosis development. Important factors that accelerate the development of atherosclerosis in this group are calcium-phosphorus disturbances causing vascular calcification. Therefore, slowing the development and progression of vascular calcification is a novel therapeutic target in the treatment of calcium and phosphorus disturbances associated with chronic kidney disease. It seems that cinacalcet, a calcimimetic of the second generation, used in patients with refractory secondary hyperparathyroidism can slow the progression of vascular calcification and potentially reduce the cardiovascular risk. This paper reviews the current literature on the pathogenesis of vascular calcification and the potential impact of cinacalcet to reduce cardiovascular risk in patients with end-stage kidney disease. PMID:23175326

Zela?nicka, Marzena; Koce?ak, Piotr; Olszanecka Glinianowicz, Magdalena; Chudek, Jerzy



Evaluation of Operative Risk in Elderly Patients Undergoing Aortic Valve Replacement: The Predictive Value of Operative Risk Scores  

Microsoft Academic Search

Objectives: An increasing number of elderly patients develop aortic valve disease requiring surgery. Operative risk scores are currently used to identify patients at high operative risk who may benefit from interventional treatment options. The aim of this study was to analyze the predictive value of these risk scores in geriatric patients undergoing aortic valve replacement. Methods: We reviewed data of

Birgit Frilling; Wolfgang von Renteln-Kruse; Friedrich-Christian Rie?



Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores in STEMI undergoing primary PCI: insights from a cohort of 1391 patients  

PubMed Central

Aims: To compare the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION risk models in the ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods: We studied all consecutive patients with STEMI who underwent PPCI at our institution between 2006 and 2010 (n=1391). The CRUSADE, ACUITY-HORIZONS, and ACTION risk scores were calculated based on the patients’ clinical characteristics. The occurrence of in-hospital major bleeding (defined as the composite of intracranial or intraocular bleeding, access site haemorrhage requiring intervention, reduction in haemoglobin ?4 g/dl without or ?3g/dl with overt bleeding source, reoperation for bleeding, or blood transfusion) reached 9.8%. Calibration and discrimination of the three risk models were evaluated by the Hosmer?Lemeshow test and the C-statistic, respectively. We compared the predictive accuracy of the risk scores by the DeLong non-parametric test. Results: Calibration of the three risk scores was adequate, given the non-significant results of Hosmer?Lemeshow test for the three risk models. Discrimination of CRUSADE, ACUITY-HORIZONS, and ACTION models was good (C-statistic 0.77, 0.70, and 0.78, respectively). The CRUSADE and ACTION risk scores had a greater predictive accuracy than the ACUITY-HORIZONS risk model (z=3.89, p-value=0.0001 and z=3.51, p-value=0.0004, respectively). There was no significant difference between the CRUSADE and ACTION models (z=0.63, p=0.531). Conclusions: The CRUSADE, ACUITY-HORIZONS, and ACTION scores are useful tools for the risk stratification of bleeding in STEMI treated by PPCI. Our findings favour the CRUSADE and ACTION risk models over the ACUITY-HORIZONS risk score.

Couto-Mallon, D; Rodriguez-Garrido, J; Garcia-Guimaraes, M; Gargallo-Fernandez, P; Pinon-Esteban, P; Aldama-Lopez, G; Salgado-Fernandez, J; Calvino-Santos, R; Vazquez-Gonzalez, N; Castro-Beiras, A



A prospective study on incidence and risk factors of arteriovenous fistulae following transfemoral cardiac catheterization  

Microsoft Academic Search

Background: A potentially harmful complication of cardiac catheterization is the arteriovenous fistula. Precise knowledge of possible factors predisposing for acquisition of iatrogenic AV-fistulae could enable cardiologists to perform a risk stratification for cardiac patients prior to catheterization. Methods: Over a period of 2 years, 10?271 consecutive patients who underwent cardiac catheterization were included in this study. Auscultation of a new

Stefan Martin Perings; Malte Kelm; Thomas Jax; Bodo Eckehard Strauer



Obesity and Mortality Risk among Younger Dialysis Patients  

PubMed Central

Summary Background and objectives Many studies show that obesity in dialysis patients is not strongly associated with mortality but not whether this modest association is constant over age. This study investigated the extent to which the relation of body mass index (BMI) and mortality differs between younger and older dialysis patients. Design, setting, participants, & measurements Adult dialysis patients were prospectively followed from their first dialysis treatment for 7 years or until death or transplantation. Patients were stratified by age (<65 or ?65 years) and baseline BMI (<20, 20–24 [reference], 25–29, and ?30 kg/m2). Results The study sample included 984 patients younger than 65 years and 765 patients 65 years or older; cumulative survival proportions at end of follow-up were 50% and 16%. Age-standardized mortality rate was 1.7 times higher in obese younger patients than those with normal BMI, corresponding to an excess rate of 5.2 deaths/100 patient-years. Mortality rates were almost equal between obese older patients and those with normal BMI. Excess rates of younger and older patients with low compared with normal BMI were 8.7 and 1.1 deaths/100 patient-years. After adjustment for age, sex, smoking, comorbidity, and treatment modality, hazard ratios by increasing BMI were 2.00, 1, 0.95, and 1.57 for younger patients and 1.07, 1, 0.88, and 0.91 for older patients, implying that obesity is a 1.7-fold (95% confidence interval, 1.1- to 2.9-fold) stronger risk factor in younger than older patients. Conclusions In contrast to older dialysis patients, younger patients with low or very high BMI had a substantially elevated risk for death.

Hoogeveen, Ellen K.; Halbesma, Nynke; Rothman, Kenneth J.; Stijnen, Theo; van Dijk, Sandra; Dekker, Friedo W.; Boeschoten, Elisabeth W.; de Mutsert, Renee



Minimally invasive tricuspid valve surgery in patients at high risk.  


OBJECTIVE: Reports of minimally invasive tricuspid valve operations are rare, and results are often contradictory. This study analyzes our 5-year experience with minimally invasive tricuspid valve operations in high-risk patients. METHODS: Between November 2005 and December 2011, tricuspid valve surgery using a nonsternotomy minimally invasive technique was performed in 64 patients (19 male, 45 female; mean age, 63.2 ± 12.8 years). Mean preoperative European System for Cardiac Operative Risk Evaluation was 7.3 ± 2.9, and predicted mortality was 11.6% ± 11.7%. Tricuspid valve regurgitation cause was functional in 36 patients (56.2%), endocarditis in 2 patients (3.1%), and rheumatic in 24 patients (37.5%). Two patients (3.1%) showed prosthesis dysfunction. Forty patients (62.5%) had undergone previous cardiac surgery. RESULTS: Tricuspid valve repair was performed in 35 patients (54.7%). Tricuspid valve replacement with bioprosthesis was performed in 27 patients (42.2%), and the remaining 2 patients (3.1%) underwent bioprosthetic replacement. Concomitant procedures (48) included mitral valve surgery (42 patients), atrial septal defect closure (5 patients), and myxoma exeresis (1 patient). Conversion to sternotomy occurred in 1 patient (1.6%). Overall hospital mortality was 7.9%. Stroke occurred in 1 patient (1.6%), and 5 patients underwent reoperation for bleeding (7.8%). Mean follow-up time was 21 ± 16 months (range, 1-59 months) and 100% completed. Cumulative Kaplan-Meier estimated 5-year survival was 81.3%, and 5-year freedom from reoperation was 100%. CONCLUSIONS: The heart-port-based minimally invasive approach seems to be safe, feasible, and reproducible in case of tricuspid valve operations. It ensures low perioperative morbidity, moderate to low rates of tricuspid regurgitation recurrence, and low late mortality. It also seems to have an added value in case of reoperative procedures. PMID:23623618

Ricci, Davide; Boffini, Massimo; Barbero, Cristina; El Qarra, Suad; Marchetto, Giovanni; Rinaldi, Mauro



Patients with Celiac Disease Have an Increased Risk for Pancreatitis  

PubMed Central

BACKGROUND & AIMS Patients with celiac disease have been reported to be at increased risk for pancreatitis and pancreatic insufficiency, but the risk might have been overestimated because of patient selection and limited numbers of patients for analysis. Furthermore, no distinction has been made between patients with gallstone-related and non gallstone-related pancreatitis. We performed a nationwide study to determine the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease. METHODS We analyzed data from patients in Sweden with celiac disease (n=28,908), identified based on small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008 and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified based on diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis. RESULTS We identified 406 individuals with celiac disease who were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR=2.85; 95% confidence interval [CI], 2.53–3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06–2.40), for non-gallstone-related acute pancreatitis was 1.86 (1.52–2.26), for chronic pancreatitis was 3.33 (95% CI, 2.33–4.76), and for supplementation with pancreatic enzymes was 5.34 (95% CI, 2.99–9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36–3.22). CONCLUSIONS Based on an analysis of medical records in Sweden, patients with celiac disease were at an almost 3-fold increase in risk of developing pancreatitis.

Sadr-Azodi, Omid; Sanders, David S.; Murray, Joseph A; Ludvigsson, Jonas F



Model Formulation: A Risk Analysis Method to Evaluate the Impact of a Computerized Provider Order Entry System on Patient Safety  

Microsoft Academic Search

ObjectivesQuantitative evaluation of safety after the implementation of a computerized provider order entry (CPOE) system, stratification of residual risks to drive future developments.DesignComparative risk analysis of the drug prescription process before and after the implementation of CPOE system, according to the Failure Modes, Effects and Criticality Analysis (FMECA) method.MeasurementsThe failure modes were defined and their criticality indices calculated on the

Pascal Bonnabry; Christelle Despont-Gros; Damien Grauser; Pierre Casez; Magali Despond; Deborah Pugin; Claire Rivara-Mangeat; Magali Koch; Martine Vial; Anne Iten; Christian Lovis



HbA1c and Lower-Extremity Amputation Risk in Low-Income Patients With Diabetes.  


OBJECTIVE Diabetes confers a very high risk of lower-extremity amputation (LEA); however, few studies have assessed whether blood glucose control can reduce LEA risk among patients with diabetes, especially in practice settings where low-income patients predominate. RESEARCH DESIGN AND METHODS We performed a prospective cohort study (2000-2009) on patients with diabetes that included 19,808 African Americans and 15,560 whites. The cohort was followed though 31 May 2012. Cox proportional hazards regression models were used to estimate the association of HbA1c with LEA risk. RESULTS During a mean follow-up of 6.83 years, 578 LEA incident cases were identified. The multivariable-adjusted hazard ratios of LEA associated with different levels of HbA1c at baseline (<6.0% [reference group], 6.0-6.9, 7.0-7.9, 8.0-8.9, 9.0-9.9, and ?10.0%) were 1.00, 1.73 (95% CI 1.07-2.80), 1.65 (0.99-2.77), 1.96 (1.14-3.36), 3.02 (1.81-5.04), and 3.30 (2.10-5.20) (P trend <0.001) for African American patients with diabetes and 1.00, 1.16 (0.66-2.02), 2.28 (1.35-3.85), 2.38 (1.36-4.18), 2.99 (1.71-5.22), and 3.25 (1.98-5.33) (P trend <0.001) for white patients with diabetes, respectively. The graded positive association of HbA1c during follow-up with LEA risk was observed among both African American and white patients with diabetes (all P trend <0.001). With stratification by sex, age, smoking status, blood pressure, LDL cholesterol, BMI, use of glucose-lowering agents, and income, this graded association of HbA1c with LEA was still present. CONCLUSIONS The current study conducted in a low-income population suggests a graded association between HbA1c and the risk of LEA among both African American and white patients with type 2 diabetes. PMID:24062322

Zhao, Wenhui; Katzmarzyk, Peter T; Horswell, Ronald; Wang, Yujie; Johnson, Jolene; Heymsfield, Steven B; Cefalu, William T; Ryan, Donna H; Hu, Gang



Molecular Reclassification of Crohn's Disease: A Cautionary Note on Population Stratification  

PubMed Central

Complex human diseases commonly differ in their phenotypic characteristics, e.g., Crohn’s disease (CD) patients are heterogeneous with regard to disease location and disease extent. The genetic susceptibility to Crohn’s disease is widely acknowledged and has been demonstrated by identification of over 100 CD associated genetic loci. However, relating CD subphenotypes to disease susceptible loci has proven to be a difficult task. In this paper we discuss the use of cluster analysis on genetic markers to identify genetic-based subgroups while taking into account possible confounding by population stratification. We show that it is highly relevant to consider the confounding nature of population stratification in order to avoid that detected clusters are strongly related to population groups instead of disease-specific groups. Therefore, we explain the use of principal components to correct for population stratification while clustering affected individuals into genetic-based subgroups. The principal components are obtained using 30 ancestry informative markers (AIM), and the first two PCs are determined to discriminate between continental origins of the affected individuals. Genotypes on 51 CD associated single nucleotide polymorphisms (SNPs) are used to perform latent class analysis, hierarchical and Partitioning Around Medoids (PAM) cluster analysis within a sample of affected individuals with and without the use of principal components to adjust for population stratification. It is seen that without correction for population stratification clusters seem to be influenced by population stratification while with correction clusters are unrelated to continental origin of individuals.

Maus, Barbel; Jung, Camille; Mahachie John, Jestinah M.; Hugot, Jean-Pierre; Genin, Emmanuelle; Van Steen, Kristel



Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments.  


This column is the second in a series presenting a model for therapeutic risk management of the suicidal patient. As discussed in the first part of the series, the model involves several elements including augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. This column explores in more detail how to augment clinical risk assessment with structured instruments. Unstructured clinical interviews have the potential to miss important aspects of suicide risk assessment. By augmenting the free-form clinical interview with structured instruments that demonstrate reliability and validity, a more nuanced and multifaceted approach to suicide risk assessment is achieved. Incorporating structured instruments into practice also serves a medicolegal function, since these instruments may become a living part of the medical record, establishing baseline levels of suicidal thoughts and behaviors and facilitating future clinical determinations regarding safety needs. We describe several instruments used in a multidisciplinary suicide consultation service, each of which has demonstrated relevance to suicide risk assessment and screening, ease of administration, and strong psychometric properties. In addition, we emphasize the importance of viewing suicide risk assessment as an ongoing process rather than as a singular event. Finally, we discuss special considerations in the evolving practice of risk assessment. (Journal of Psychiatric Practice 2013;19:406-409). PMID:24042246

Homaifar, Beeta; Matarazzo, Bridget; Wortzel, Hal S



Prognostic value of exercise echocardiography in diabetic patients  

Microsoft Academic Search

BACKGROUND: Coronary artery disease (CAD) is the leading cause of death in diabetic patients. Although exercise echocardiography (EE) is established as a useful method for diagnosis and stratification of risk for CAD in the general population, there are few studies on its value as a prognostic tool in diabetic patients. The purpose of this investigation was to evaluate the value

Joselina LM Oliveira; José AS Barreto-Filho; Carla RP Oliveira; Thaiana A Santana; Fernando D Anjos-Andrade; Érica O Alves; Adão C Nascimento-Junior; Thiago JS Góes; Nathalie O Santana; Francis L Vasconcelos; Martha A Barreto; Argemiro D'Oliveira Junior; Roberto Salvatori; Manuel H Aguiar-Oliveira; Antônio CS Sousa



Cardiovascular risk factors in patients with chronic kidney disease  

Microsoft Academic Search

Patients with chronic kidney disease have a higher burden of cardiovascular disease, which increases in a dose-dependent fashion with worsening kidney function. Traditional cardiovascular risk factors, including advanced age, diabetes mellitus, hypertension and dyslipidemia, have an important role in the progression of cardiovascular disease in patients who have a reduced glomerular filtration rate, especially in those with mild-to-moderate kidney disease.

Sarina van der Zee; Usman Baber; Sammy Elmariah; Jonathan Winston; Valentin Fuster



Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care  

Microsoft Academic Search

Paroxysmal supraventricular tachycardia (PSVT), a common dysrhythmia seen in the emergency department (ED), is usually managed without difficulty and with a favorable prognosis. Serum cardiac troponin I (cTnI) testing provides important risk stratification information in certain patients; its use in PSVT patients, however, has not been explored. A retrospective review of consecutive adult ED PSVT patients seen for 21 months

David J. Carlberg; Sarah Tsuchitani; Kevin S. Barlotta; William J. Brady



The cardiovascular polypill in high-risk patients.  


Atherosclerotic cardiovascular diseases remain the leading cause of morbidity and mortality in both developed and developing countries. Adequate treatment of vascular risk factors, such as low-density lipoprotein cholesterol and systolic blood pressure are known to reduce the future risk of cardiovascular disease in these patients. However currently, large treatment gaps exist among high-risk individuals, in whom the guidelines recommend concomitant treatment with aspirin, statin, and blood-pressure lowering agents. Combining aspirin, cholesterol, and blood-pressure lowering agents into a single pill called the cardiovascular polypill has been proposed as complementary care in the prevention of cardiovascular diseases in both intermediate- and high-risk patient populations. It is now a decade since the first recommendations to develop and trial cardiovascular polypills. The major scientific debate has been about the appropriate initial target population. This review article focuses on the potential role of fixed-dose combination therapy in different patient populations, outlines the pros and cons of combination therapy, and emphasizes the rationale for trialing their use. Current and planned future cardiovascular polypill trials are summarized and the pre-requisites for implementation of the polypill strategy in both primary and secondary prevention are described. The recent development of combination pills containing off-patent medications holds promise for highly affordable and effective treatment and evidence is emerging on the use of this strategy in high-risk populations. PMID:22019908

Lafeber, Melvin; Spiering, Wilko; Singh, Kavita; Guggilla, Rama K; Patil, Vinodvenkatesh; Webster, Ruth



Effect of oncologist-based counseling on patient-perceived breast cancer risk and psychological distress  

Microsoft Academic Search

Women often seek reassurance from oncologists regarding their risk of developing breast cancer. Patient-perceived risk frequently is higher than calculated estimates of risk. We assessed perceived breast cancer risk, perceived BRCA1\\/2 mutation carriage risk, and anxiety measured by the Brief Symptom Inventory-18 in 81 high-risk clinic patients before and immediately after risk counseling by an oncologist. Pre-counseling risk perceptions were

Wilson C. Mertens; Deborah Katz; Marlene Quinlan; Ruth Barham; Sandra Hubbard; Pamela Hyder; Mary Jean Pineau; Grace Makari-Judson


Prevalence Of Validated Risk Factors For Developing Atrial Fibrillation - Can We Identify High Risk ED Patients?  

PubMed Central

Objective Investigate whether emergency department (ED) patients who were newly diagnosed with atrial fibrillation (AF) displayed risk factors for incident AF on prior ED visits. Methods This was a secondary analysis of a retrospective cohort study of ED patients with symptomatic AF at a tertiary referral center. We selected patients who were newly diagnosed with AF between 7/1/05 and 8/31/08 and had at least one ED visit prior to their diagnosis. We calculated the Framingham Heart Study AF risk score for each visit by documenting the presence of the risk factors (age, sex, body-mass index, systolic blood pressure, hypertension treatment, PR interval, and ages of clinically significant cardiac murmur and heart failure diagnosis). Results Of the 296 patients newly diagnosed with AF, 115 (39%) had at least one prior ED visit resulting in 454 ED visits for analysis. The median time from first to last visit was 4 years (IQR 2.1, 5.9). The median age was 66 (IQR: 49 to 79). Home medications included antihypertensives in 81% of visits and 60% of visits with available electrocardiograms had a PR interval ? 160 msec. Heart failure history was reported in 23% of visits. The median AF risk score was 8 (IQR 4, 10) corresponding to a 16% 10-year predicted risk. Conclusions Nearly 40% of patients diagnosed with new AF had previous ED visits and displayed validated risk factors for incident AF. The ED provides an opportunity to identify and educate these patients, as well as refer them for primary prevention interventions.

Barrett, Tyler W.; Couch, Stephanie A.; Jenkins, Cathy A.; Storrow, Alan B.



Risk stratification by the "EPA+DHA level" and the "EPA/AA ratio" focus on anti-inflammatory and antiarrhythmogenic effects of long-chain omega-3 fatty acids.  


The identification of risks associated with sudden cardiac death requires further investigations. The question was addressed whether parameters can be established which not only describe an increased risk for an enhanced electrical instability of the heart but also of inflammatory events underlying plaque rupture. Emphasis is placed on dose-dependent effects of the long-chain omega-(omega-)3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Since free acids of EPA and DHA are required for most of their biological effects, it appears essential not only to build up stores in the body for release of these fatty acids, but also to provide a sustained uptake of EPA and DHA in the form of ethyl esters. In contrast to rapidly absorbed triacylglycerols from fish, ethyl esters are taken up more slowly within 24 h. For the administration of 1 g/day highly purified EPA+DHA ethyl esters (Omacor) to healthy volunteers, it is shown that EPA is increased from 0.6% to 1.4% within 10 days, while DHA is increased from 2.9% to 4.3%. After withdrawal, EPA and DHA approach baseline values within 10 days. A gas chromatographic procedure was established which requires only 10 microl of whole blood for the identification of more than 35 fatty acids. Evidence is summarized strengthening the concept that a low "EPA+DHA level" presents a risk for sudden cardiac death and that the administration of 840 mg/day of EPA+DHA ethyl esters raises the "EPA+DHA level" to approximately 6% that is associated with a marked protection from sudden cardiac death. For reducing pro-inflammatory eicosanoids and cytokines, a higher "EPA+DHA level" is required which can be achieved with an intake of 2-4 g/day of 84% EPA+DHA ethyl esters. For assessing influences from pro-inflammatory eicosanoids and cytokines, the EPA/arachidonic acid ratio ("EPA/AA ratio") was identified as diagnostic parameter. To assess the dietary EPA+DHA intake, fatty acids were determined in fish dishes of the cafeteria of the Philipps University Hospital Marburg, Germany. The EPA+DHA content of the popular Alaska Pollock was 125 +/- 70 mg/100 g. A once daily fish dish can thus not provide the 840 mg/day EPA+DHA administered in the GISSI Prevention Study in the form of ethyl ester which markedly reduced the risk of sudden cardiac death in postmyocardial infarction patients. Nonetheless, at least two preferably oily fish meals per week should be consumed as preventive measure by persons without coronary artery disease. With documented coronary heart disease, it was advised to consume approximately 1 g/day of EPA+DHA. PMID:15580322

Rupp, Heinz; Wagner, Daniela; Rupp, Thomas; Schulte, Lisa-Maria; Maisch, Bernhard



Impulsivity, Aggression and Suicide Risk among Male Schizophrenia Patients  

Microsoft Academic Search

Introduction: Impulsivity has been shown to be a major variable in the etiology of suicide and aggression, but has not been researched as much in the schizophrenic population, which is characterized by serious suicide and aggression risks. Methods: 68 male schizophrenia patients responded to a battery of measures including the Positive and Negative Syndrome Scale (PANSS), the impulsivity control scale

Iulian Iancu; Ehud Bodner; Suzana Roitman; Anna Piccone Sapir; Amir Poreh; Moshe Kotler



Risk assessment in the management of patients with ocular hypertension  

Microsoft Academic Search

PurposeTo develop a model for estimating the global risk of disease progression in patients with ocular hypertension and to calculate the “number-needed-to-treat” (NNT) to prevent progression to blindness as an aid to practitioners in clinical decision making.

Robert N. Weinreb; David S. Friedman; Robert D. Fechtner; George A. Cioffi; Anne L. Coleman; Christopher A. Girkin; Jeffrey M. Liebmann; Kuldev Singh; M. Roy Wilson; Richard Wilson; William B. Kannel



Cured meat consumption increases risk of readmission in COPD patients.  


Recent studies have shown that a high dietary intake of cured meat increases the risk of chronic obstructive pulmonary disease (COPD) development. However, its potential effects on COPD evolution have not been tested. We aimed to assess the association between dietary intake of cured meat and risk of COPD readmission in COPD patients. 274 COPD patients were recruited during their first COPD admission between 2004 and 2006, provided information on dietary intake of cured meat during the previous 2 yrs, and were followed until December 31, 2007 (median follow-up 2.6 yrs). Associations between cured meat intake and COPD admissions were assessed using parametric regression survival-time models. Mean ± SD age was 68 ± 8 yrs, 93% of patients were male, 42% were current smokers, mean post-bronchodilator forced expiratory volume in 1 s (FEV(1)) was 53 ± 16% predicted, and median cured meat intake was 23 g · day(-1). After adjusting for age, FEV(1), and total caloric intake, high cured meat intake (more than median value) increased the risk of COPD readmission (adjusted HR 2.02, 95% CI 1.31-3.12; p=0.001). High cured meat consumption increases the risk of COPD readmission in COPD patients. The assessment of the effectiveness of healthy diet advice should be considered in the future. PMID:22408205

de Batlle, Jordi; Mendez, Michelle; Romieu, Isabelle; Balcells, Eva; Benet, Marta; Donaire-Gonzalez, David; Ferrer, Jaume J; Orozco-Levi, Mauricio; Antó, Josep M; Garcia-Aymerich, Judith



Radiation risk to patients from nuclear Medicine in Poland (1981)  

Microsoft Academic Search

This paper presents the method and results of an estimation of radiation risk to the patients subjected to in vivo diagnostic radio-isotopic procedures in Poland in 1981. The qualitative and quantitative structure of these examinations is also presented. The estimation of an expected number of the stochastic effects caused by the internal exposure to ionizing radiation from the administered radionuclides

M. A. Staniszewska



Mortality Risk Factors in Patients Treated by Chronic Hemodialysis  

Microsoft Academic Search

A survival analysis was applied to 1,453 patients treated between 1972 and 1978 in 33 French dialysis centers and prospectively followed up in the computerized Diaphane Dialysis Registry. 198 deaths (overall mortality = OM) were registered, of which 87 (43%) were secondary to cardiovascular complications (cardiovascular mortality = CVM). Risk factors for OM and CVM (p values < 0.05) were

Patrice Degoulet; Marcel Legrain; Isabelle Réach; Françoise Aimé; Claude Devriès; Patricio Rojas; Claude Jacobs



Ethics, risk, and patient-centered care: how collaboration between clinical ethicists and risk management leads to respectful patient care.  


Patient-centered care is driven in part by the ethical principle of autonomy and considers patients' cultural traditions, personal preferences, values, family situations, and lifestyles. Patient decision-making capacity, surrogate decision making with or in the absence of a patient's advance directive, and the right to refuse treatment are three patient-care issues that are central to the work done by both the risk manager and the clinical ethicist that have strong relevance to patient-centered care. This article discusses these three issues briefly and offers two challenging case studies involving patient-centered care that illustrate how a clinical ethics consultation may help to avert the escalation that can lead to a tort claim. PMID:21793115

Sine, David M; Sharpe, Virginia A



Predictors of appropriate implantable cardioverter-defibrillator therapy in patients with idiopathic dilated cardiomyopathy  

Microsoft Academic Search

Evaluating predictors of appropriate implantable cardioverter-defibrillator (ICD) therapy in patients with idiopathic dilated cardiomyopathy (IDC) may be helpful in developing risk stratification strategies for these patients. Fifty-four patients with IDC underwent ICD implantation and were followed up. Twenty-three patients (42%) had a class I indication for ICD implantation; the remaining patients underwent implantation for multiple risk factors for sudden death

Vladimir Rankovic; Juhana Karha; Rod Passman; Alan H Kadish; Jeffrey J Goldberger



Medical application of engineering risk analysis and anesthesia patient risk illustration.  


The engineering risk analysis method can be extended to include some human and organizational factors and can be used in the medical domain; this transfer is illustrated by a description of a study of anesthesia patient risk. This study involves first a dynamic analysis of accident risks. The model is then extended by relating the basic events of accident scenarios to the state of the practitioner described by the probability of personal problems that may affect his or her level of competence and alertness. These potential problems, in turn, are linked (by probabilistic relations) to the way the system is managed. This extension of the analytical framework allows assessment of the effect of particular types of practitioner problems and therefore of corresponding risk mitigation measures on the probability of the different accident scenarios. The risk analysis model can then be used as a management tool that permits setting priorities among patient safety measures, based either on the sole benefits of the corresponding decrease of patient risk or on a cost-to-benefit ratio. This probabilistic approach constitutes a departure from the classic risk studies exclusively based on statistical frequencies because it involves both available statistics and expert opinions. It is commonly used in engineering for systems for which there is not enough information at the time when decisions need to be made. I show here how the probabilistic model can be used in the medical field to support patient safety decisions before complete data sets can be gathered or in cases in which some key factors are not directly observable. PMID:11329106

Paté-Cornell, E



Predictors of Risk Tolerance Among Oral Surgery Patients  

PubMed Central

Purpose This study attempts to provide insight on how the treatment preference for a mandible fracture and treatment received and its consequences, are related to the patient’s risk tolerance, as measured by the Standard Gamble(SG). Patients and Methods Data from a prospective cohort study of 203 subjects receiving treatment at the former King/Drew Medical Center (KDMC) in Los Angeles for either a mandible fracture(n=98) or third-molar removal (n=105) are examined. Subjects were interviewed at four time points; upon admission to the medical center, and at three monthly follow-up visits. Risk tolerance for hypothetical treatment scenarios is measured using the SG, a health-value utility measure assessing the tradeoff between good outcomes and serious complications associated with treatment. Separate regression analyses with subsets of predictors (sociodemographic, psychosocial health, and clinical characteristics) were conducted and then synthesized using the significant predictors in separate analyses. Results For fracture subjects, there is a noticeable rise in the SG reports from admission to the one-month follow-up. Their greater risk tolerance was associated with being older, receiving surgery, having a lower PTSD score, and having a swollen jaw or face. For third-molar subjects, SG does not change substantively over the course of the study. Predictors of greater risk tolerance for third molar subjects include the jaw or face being swollen and having to use less pain medication. Conclusions Findings from this study demonstrate a preference for less invasive treatment, with the majority of both groups preferring wiring and support the theory that treatment choices differ between subjects with different health states. Factors associated with risk tolerance include the patient’s age, treatment received, psychosocial health state, experience with prior treatment, and value for oral health quality of life.

Atchison, Kathryn A.; Der-Martirosian, Claudia; Belin, Thomas R.; Black, Edward E.; Gironda, Melanie W.



Risk factors for unplanned hospital readmission in otolaryngology patients.  


Objective Identify the risk factors that predict 30-day unplanned readmission in hospitalized otolaryngology patients. Study Design Retrospective cohort study. Setting Single academic hospital. Subjects and Methods All otolaryngology admissions for the 1-year period between January 1, 2011, and December 31, 2011, at an academic hospital were reviewed. Univariate logistic regression and multivariate logistic regression, employing a backward elimination stepwise approach, were performed to identify risk factors for unplanned readmission to the hospital within 30 days of discharge from the otolaryngology service. Results There were 1058 patients that accounted for 1271 hospital admissions. The 30-day unplanned readmission rate for patients discharged from the otolaryngology service was 7.3% (93/1271). Significant predictors identified on univariate analysis were used to build a multivariable logistic regression model of risk factors for unplanned readmission. These risk factors included presence of a complication (odds ratio [OR] = 11.60, 95% confidence interval [CI], 7.11-18.93), new total laryngectomy (OR = 4.72, 95% CI, 1.58-14.10), discharge destination of skilled nursing facility (OR = 2.70, 95% CI, 1.21-6.02), severe coronary artery disease or chronic lung disease (OR = 2.33, 95% CI, 1.38-3.93), and current illicit drug use (OR = 2.60, 95% CI, 1.27-5.34). The discriminative ability of the multivariate regression model to predict unplanned readmissions, as measured by the c-statistic, was 0.85. Conclusion Otolaryngology patients have unique risk factors that predict unplanned readmission within 30 days of discharge. These data identify specific patient characteristics and care processes that can be targeted with quality improvement interventions to decrease unplanned readmissions. PMID:24042556

Graboyes, Evan M; Liou, Tzyy-Nong; Kallogjeri, Dorina; Nussenbaum, Brian; Diaz, Jason A



Factors Related to Morbidity and Mortality in Patients with Chronic Heart Failure with Systolic Dysfunction: The HF-ACTION Predictive Risk Score Model  

PubMed Central

Background We aimed to develop a multivariable statistical model for risk stratification in patients with chronic heart failure (HF) with systolic dysfunction, using patient data that are routinely collected and easily obtained at the time of initial presentation. Methods and Results In a cohort of 2331 patients enrolled in the HF-ACTION study (New York Heart Association [NYHA] class II-IV, left ventricular ejection fraction [LVEF] ?0.35, randomized to exercise training and usual care vs. usual care alone, median follow-up 2.5 years), we performed risk modeling using Cox proportional hazards models and analyzed the relationship between baseline clinical factors and the primary composite endpoint of death or all-cause hospitalization and the secondary endpoint of all-cause death alone. Prognostic relationships for continuous variables were examined using restricted cubic spline functions, and key predictors were identified using a backward variable selection process and bootstrapping methods. For ease of use in clinical practice, point-based risk scores were developed from the risk models. Exercise duration on the baseline cardiopulmonary exercise (CPX) test was the most important predictor of both the primary endpoint and all-cause death. Additional important predictors for the primary endpoint risk model (in descending strength) were Kansas City Cardiomyopathy Questionnaire (KCCQ) symptom stability score, higher blood urea nitrogen (BUN), and male sex (all P <0.0001). Important additional predictors for the mortality risk model were higher BUN, male sex, and lower body mass index (BMI) (all P <0.0001). Conclusions Risk models using simple, readily obtainable clinical characteristics can provide important prognostic information in ambulatory patients with chronic HF with systolic dysfunction. Clinical Trial Registration URL: http:/// Unique identifier: NCT00047437.

O'Connor, Christopher M.; Whellan, David J.; Wojdyla, Daniel; Leifer, Eric; Clare, Robert M.; Ellis, Stephen J.; Fine, Lawrence J.; Fleg, Jerome L.; Zannad, Faiez; Keteyian, Steven J.; Kitzman, Dalane W.; Kraus, William E.; Rendall, David; Pina, Ileana L.; Cooper, Lawton S.; Fiuzat, Mona; Lee, Kerry L.



Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke  

Microsoft Academic Search

BACKGROUND: Previous studies have demonstrated poor knowledge of stroke among patients with established risk factors. This study aims to assess the baseline knowledge, among patients with increased risk for stroke in Oman, of warning symptoms of stroke, impending risk factors, treatment, and sources of information. METHODS: In April 2005, trained family practice residents at Sultan Qaboos University Hospital Clinics (cardiology,

Mohammed A Al Shafaee; Shyam S Ganguly; Abdullah R Al Asmi



Fertility risk discussions in young patients diagnosed with colorectal cancer  

PubMed Central

Purpose In 2006, the American Society of Clinical Oncology established guidelines on fertility preservation in cancer patients, but recent data suggest that the guidelines are not widely followed. To identify the frequency of fertility discussions and the characteristics that influence the rate of discussion, we performed a retrospective chart review for patients less than 40 years of age with newly diagnosed colorectal cancer (crc). Methods Charts of patients aged 18–40 years with newly diagnosed crc presenting to the Juravinski Cancer Centre from 2000 to 2009 were reviewed for documentation of discussions regarding fertility risks with treatment and reproductive options available. The influences of sex, age, year of diagnosis, stage of cancer, and type of treatment on the frequency of discussions were explored. Results The review located 59 patients (mean age: 35 years) who met the criteria for inclusion. A fertility discussion was documented in 20 of those patients [33.9%; 95% confidence interval (ci): 22.1% to 47.4%]. In the multivariate analysis, the odds of fertility being addressed was higher for patients receiving radiation [odds ratio (or): 9.31; 95% ci: 2.49 to 34.77, p < 0.001) and lower by age (or: 0.86; 95% ci: 0.74 to 0.99; p = 0.040). Of patients less than 35 years of age undergoing radiation treatment, 85% had a documented fertility discussion. We observed no significant difference in the frequency of discussions after 2006, when the American Society of Clinical Oncology guidelines were published (31.4% for 2000–2006 vs. 37.5% for 2007–2009, p = 0.63). Conclusions Discussions about fertility risks associated with crc treatment occur infrequently among young adults with newly diagnosed crc. However, discussions occur more frequently in younger patients and in those undergoing radiation. Further investigations assessing barriers and physician attitudes to fertility risk discussion and reproductive options are planned.

Kumar, A.; Merali, A.; Pond, G.R.; Zbuk, K.



Stratification and isotope separation in CP stars  

Microsoft Academic Search

We investigate the elemental and isotopic stratification in the atmospheres of selected chemically peculiar (CP) stars of the upper main sequence. Reconfiguration of the UV-Visual Echelle Spectrograph in 2004 has made it possible to examine all three lines of the CaII infrared (IR) triplet. Much of the material analysed was obtained in 2008. We support the claim of Ryabchikova, Kochukhov

C. R. Cowley; S. Hubrig; J. F. González



Stratification of Women's Sport in Contemporary China  

Microsoft Academic Search

Since economic reform in the 1980s, Chinese sport has undergone an extraordinary transformation. The most distinguishing phenomenon is the rapid growth of mass sport at the grassroots level with increasing demands for physical activities in women's daily lives. The rapid growth of women's sports participation at the grassroots is deeply embedded in the process of social stratification as a result

Huan Xiong



Clinical Symptoms and Risk Factors in Cerebral Microangiopathy Patients  

PubMed Central

Objective Although the clinical manifestation and risk factors of cerebral microangiopathy (CM) remain unclear, the number of diagnoses is increasing. Hence, patterns of association among lesion topography and severity, clinical symptoms and demographic and disease risk factors were investigated retrospectively in a cohort of CM patients. Methods Patients treated at the Department of Neurology, University of Bonn for CM (n?=?223; 98m, 125f; aged 77.32±9.09) from 2005 to 2010 were retrospectively enrolled. Clinical symptoms, blood chemistry, potential risk factors, demographic data and ratings of vascular pathology in the brain based on the Wahlund scale were analyzed using Pearson's chi square test and one-way ANOVA. Results Progressive cognitive decline (38.1%), gait apraxia (27.8%), stroke-related symptoms and seizures (24.2%), TIA-symptoms (22%) and vertigo (17%) were frequent symptoms within the study population. Frontal lobe WMLs/lacunar infarcts led to more frequent presentation of progressive cognitive decline, seizures, gait apraxia, stroke-related symptoms, TIA, vertigo and incontinence. Parietooccipital WMLs/lacunar infarcts were related to higher frequencies of TIA, seizures and incontinence. Basal ganglia WMLs/lacunar infarcts were seen in patients with more complaints of gait apraxia, vertigo and incontinence. Age (p?=?.012), arterial hypertension (p<.000), obesity (p<.000) and cerebral macroangiopathy (p?=?.018) were positively related to cerebral lesion load. For increased glucose level, homocysteine, CRP and D-Dimers there was no association. Conclusion This underlines the association of CM with neurological symptoms upon admission in a topographical manner. Seizures and vertigo are symptoms of CM which may have been missed in previous studies. In addition to confirming known risk factors such as aging and arterial hypertension, obesity appears to increase the risk as well. Since the incidence of CM is increasing, future studies should focus on the importance of prevention of vascular risk factors on its pathogenesis.

Okroglic, Sandra; Widmann, Catherine N.; Urbach, Horst; Scheltens, Philip; Heneka, Michael T.



Risk and potential risk reduction in diabetes type 2 patients in Germany  

Microsoft Academic Search

Avoiding serious complications such as stroke, myocardial infarction, and amputations in diabetes patients is the main interest of long-term treatment. Given the considerable prevalence of diabetes type 2 in industrialized countries this is a major public health concern as well as a burden to health care systems. The present study estimated the current risk of major complications occurring in the

Bertram Häussler; Ursula Berger; Oliver Mast; Wolfgang Thefeld



Identification of Patients at Risk for Hereditary Colorectal Cancer  

PubMed Central

Diagnosis of hereditary colorectal cancer syndromes requires clinical suspicion and knowledge of such syndromes. Lynch syndrome is the most common cause of hereditary colorectal cancer. Other less common causes include familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome (PJS), juvenile polyposis syndrome, and others. There have been a growing number of clinical and molecular tools used to screen and test at risk individuals. Screening tools include diagnostic clinical criteria, family history, genetic prediction models, and tumor testing. Patients who are high risk based on screening should be referred for genetic testing.

Mishra, Nitin; Hall, Jason



Cardiovascular risk factors in hemodialysis and peritoneal dialysis patients.  


Cardiovascular diseases are a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The aim of our investigation was the evaluation of an extensive cardiovascular profile in hemodialysis (HD) and peritoneal dialysis (PD) patients. We studied 74 patients with ESRD (38 males, 36 females), maintained either on chronic HD (n= 50) or chronic PD (n= 24) and age and sex matched 20 healthy subjects as controls. The lipid profile, homocysteine (Hcy) and C reactive protein (CRP) were measured. When compared to a healthy population, HD patients displayed a marked atherogenic profile, as attested by increased levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein-cholesterol (LDL-C), apolipoprotein A (Apo A), CRP, Hcy and lower concentrations of high-density lipoprotein-cholesterol (HDL-C), Apo B, albumin (ALB). A significant difference was noted concerning the rates of Apo B, HDL-C, TC, ALB and Hcy. Same biological disorders that those found at HD patients were noted in these PD patients. One also noted lower concentration in Apo A. there were a significant difference with the reference group concerning the rates of albumin, Apo A, HDL-Cl and Hcy. When compared to PD patients, HD patients had significantly decreased concentration of LDL-C. The peculiar metabolic changes observed in the present study confirm the marked tendency of patients with impaired renal function for developing cardiovascular diseases, irrespectively of the type of dialysis. We suggest including uremia-related risk factors in the panel for evaluation of cardiovascular risk in dialysis patients. PMID:20061694

Helal, Imed; Smaoui, Wided; Hamida, Fethi Ben; Ouniss, Monder; Aderrahim, Ezzeddine; Hedri, Hafedh; Elyounsi, Fethi; Maiz, Hedi Ben; Abdallah, Taieb Ben; Kheder, Adel



The risk of reoperation in patients with bioprosthetic valves.  


The risk of operative mortality in patients undergoing a first reoperation for bioprosthetic failure was assessed in a series of patients reoperated upon during the last two decades (1970-1990). A total of 330 such patients underwent replacement of 351 bioprostheses: 88 had aortic; 221 mitral; and 21 mitral and aortic bioprosthetic replacement. Indication for reoperation was in most cases structural valve deterioration (87%), followed by periprosthetic leak (7%) and endocarditis (6%). The operative mortality was significantly higher in patients who preoperatively were in New York Heart Association Functional Class IV or had a lower left ventricular function, in those reoperated because of prosthetic infection, and in those reoperated on an emergency basis. Structural valve deterioration was associated to a substantially low risk; operative mortality has improved in recent years, regardless of the indication for reoperation, partly due to the increasing experience and improved surgical techniques. Our results indicate that in recipients of bioprosthetic valves, careful follow-up with closer surveillance of valve and cardiac function and earlier prosthetic replacement might contribute to reducing the risk of reoperation. PMID:1810560

Bortolotti, U; Milano, A; Mossuto, E; Guerra, F; Rubino, M; Rizzoli, G; Mazzucco, A; Gallucci, V



Stratification on the Eastern Bering Sea shelf revisited  

NASA Astrophysics Data System (ADS)

The timing and magnitude of stratification can have profound influences on the marine ecosystem. On the Eastern Bering Sea shelf, in the absence of strong wind mixing, stratification can be initiated by the melting of seasonal sea ice or by springtime warming of the surface. Temperature and salinity both influence the stratification of the Eastern Bering Sea shelf with their relative importance varying spatially and temporally. In the northern middle shelf domain (north of ?60°N), salinity stratification is often as important as temperature stratification. On the southern middle shelf, while the influence of temperature on stratification dominates during summer, the influence of salinity stratification plays a role in the interannual variability. Mooring 2 (M2; 56.9°N, 164.1°W) has been deployed at ?70 m depth in the southern middle shelf domain since 1995. Data from this mooring show that stratification typically begins to set up in May and to break down in September/October, but these dates can vary by >30 d. While no trend is found in the timing of the spring setup, the fall stratification breakdown exhibited a trend toward later breakdown (?2 d later per year from 1996 to 2009). Results suggest that it may be difficult to forecast stratification on the Eastern Bering Sea shelf from climate models as simple indices of wind mixing or heat fluxes are not correlated with stratification. Contrary to intuition, the strength of summer stratification is not correlated with depth averaged temperature. Warm years such as 2000 and 2001 can have low stratification and cold years such as 2007 can have very high stratification. This decoupling of stratification and temperature has implications for forecasting the ecosystem in the face of climate change, as we cannot assume that projections of a warmer climate simply imply higher stratification in the future.

Ladd, Carol; Stabeno, Phyllis J.



Effect of sample stratification on dairy GWAS results  

Technology Transfer Automated Retrieval System (TEKTRAN)

Background Artificial insemination and genetic selection are major factors contributing to population stratification in dairy cattle. In this study, we analyzed the effect of sample stratification and the effect of stratification correction on results of a dairy genome-wide association study (GWAS)....


Cardiovascular risk factor treatment targets and renal complications in high risk vascular patients: a cohort study  

PubMed Central

Background To determine if recommended treatment targets, as specified in clinical practice guidelines for the management of cardiovascular disease, reduces the risk of renal complications in high risk patient populations. Methods This was a cohort study. Participants in Utrecht, The Netherlands either at risk of, or had cardiovascular disease were recruited. Cardiovascular treatment targets were achievement of control in systolic and diastolic blood pressure, total and low-density cholesterol, and treatment of albuminuria. Outcome measures were time to development of end stage renal failure or symptomatic renal atherosclerotic disease requiring intervention. Results The cohort consisted of 7,208 participants; 1,759 diabetics and 4,859 with clinically manifest vascular disease. The median age was 57 years and 67% were male. Overall, 29% of the cohort achieved the treatment target for systolic blood pressure, 39% for diastolic blood pressure, 28% for total cholesterol, 31% for LDL cholesterol and 78% for albuminuria. The incidence rate for end stage renal failure and renal atherosclerotic disease reduced linearly with each additional treatment target achieved (p value less than 0.001). Achievement of any two treatment targets reduced the risk of renal complications, hazard ratio 0.46 (95% CI 0.26-0.82). For patients with clinically manifest vascular disease and diabetes, the hazard ratios were 0.56 (95% CI 0.28 - 1.12) and 0.28 (95%CI 0.10 - 0.79) respectively. Conclusion Clinical guidelines for cardiovascular disease management do reduce risk of renal complications in high risk patients. Benefits are seen with attainment of any two treatment targets.



Safety of Discontinuation of Anticoagulation in Patients With Intracranial Hemorrhage at High Thromboembolic Risk  

Microsoft Academic Search

Background: Limited data are available to guide the management of anticoagulation in patients with intra- cranial hemorrhage (ICH) at high thromboembolic risk. Objective: To review the management of anticoagula- tion in patients with ICH at high thromboembolic risk. Patients and Methods: We reviewed the manage- ment of anticoagulation in 141 patients who have a high risk of ischemic stroke and

Thanh G. Phan; Merian Koh; Eelco F. M. Wijdicks



Clinical Utility of Microvolt T-wave Alternans Testing In Identifying Patients at High or Low Risk of Sudden Cardiac Death  

PubMed Central

Background Previous studies have demonstrated that microvolt T-wave alternans (MTWA) testing is a robust predictor of ventricular tachyarrhythmias and sudden cardiac death (SCD) in at-risk patients. However, recent studies have suggested that MTWA testing is not as good a predictor of “appropriate” implantable cardioverter-defibrillator (ICD) therapy as it is a predictor of SCD in patients without ICDs. Objective We sought to evaluate the utility of MTWA testing for SCD risk stratification in patients without ICDs. Methods Patient-level data were obtained from five prospective studies of MTWA testing in patients with no history of ventricular arrhythmia or SCD. In these studies, ICDs were implanted in only a minority of patients and patients with ICDs were excluded from the analysis. We conducted a pooled analysis and examined the 2-year risk for SCD based on MTWA test result. Results The pooled cohort included 2883 patients. MTWA testing was positive in 856 (30%), negative in 1627 (56%) and indeterminate in 400 (14%) patients. Among patients with LVEF ? 35%, annual SCD event rates were 4.0%, 0.9% and 4.6% among the MTWA positive, negative and indeterminate groups. The SCD rate was significantly lower among patients with a negative MTWA test compared to either the positive or the indeterminate groups (p<0.001 for both comparisons). In patients with LVEF > 35%, annual SCD event rates were 3.0%, 0.3% and 0.3% among the MTWA positive, negative and indeterminate groups. The SCD rate associated with a positive test was significantly higher than either the negative (p<0.001) or the indeterminate groups (p=0.003). Conclusions In patients without ICDs, MTWA testing is a powerful predictor of SCD. Among patients with LVEF ? 35%, a negative MTWA test is associated with a low risk for SCD. Conversely, among patients with LVEF > 35%, a positive MTWA test identifies patients at significantly heightened SCD risk. These findings may have important implications for refining primary prevention ICD treatment algorithms.

Merchant, Faisal M.; Ikeda, Takanori; Pedretti, Roberto F.E.; Salerno-Uriarte, Jorge A.; Chow, Theodore; Chan, Paul S.; Bartone, Cheryl; Hohnloser, Stefan H.; Cohen, Richard J.; Armoundas, Antonis A.



Risk of subsequent primary tumor development in melanoma patients.  


Incidence of subsequent malignant tumor development in 740 patients with primary cutaneous melanoma verified between 2006 and 2010 at the Semmelweis University was studied retrospectively and was compared to data of sex and age matched Hungarian population. The follow-up period was 1499 person-years for the whole group from the diagnosis of index melanoma with an average of 2 years. Standardized incidence rate (SIR) was established as the ratio of observed and expected values. The risk of all subsequent malignancies was 15- and 10-fold higher in males (SIR: 15.42) and in females (SIR: 10.55) with melanoma, than in the general population. The increased cancer risk resulted mainly from the significantly higher skin tumor development: SIR values were 160.39 and 92.64 for additional invasive melanoma and 342.28 and 77.04 for subsequent in situ melanoma in males and females, respectively. Non-melanoma skin cancers also notably contributed to the higher risk, the SIR was elevated in both genders to the same extent (males: 17.12, females: 17.55). The risk was also significantly higher for extracutaneous tumor development like chronic lymphocytic leukemia, colon and kidney cancer (both genders), non-Hodgkin's lymphoma, cervical cancer (females), and bladder carcinoma (males). These data underline the importance of patient education and the necessity of frequent medical follow up, including a close-up dermatological screening of melanoma survivors for further malignancies. PMID:23681370

Tóth, Veronika; Hatvani, Zsófia; Somlai, Beáta; Hársing, Judit; László, János F; Kárpáti, Sarolta



Partner Dependence and Sexual Risk Behavior Among STI Clinic Patients  

PubMed Central

Objectives To investigate the relation between partner dependence and sexual risk behavior in the context of the information-motivation-behavioral skills (IMB) model. Methods STI clinic patients (n = 1432) completed a computerized interview assessing partner dependence, condom use, and IMB variables. Results Men had higher partner-dependence scores than women did. Patients reporting greater dependence reported less condom use. Gender did not moderate the partner dependence-condom-use relationship. Partner dependence did not moderate the relation between IMB constructs and condom use. Conclusions Further research is needed to determine how partner dependence can be incorporated into conceptual models of safer sex behaviors.

Senn, Theresa E.; Carey, Michael P.; Vanable, Peter A.; Coury-Doniger, Patricia



Attitudes toward Risk Factor Behavior of Relatives of Cancer Patients  

Microsoft Academic Search

Background.Targeted health promotion requires an identifiable subpopulation which is accessible, at increased risk, receptive to input, and receptive to change. Relatives of recently diagnosed cancer patients may meet these criteria and have not previously been investigated as recipients of preventive education regarding smoking and diet.Methods.This study investigates these factors, beliefs regarding perceived susceptibility to cancer, and attitudes toward behavior change

Jean L. Kristeller; James Hebert; Kathryn Edmiston; Marcia Liepman; Michael Wertheimer; Allen Ward; Rose Luippold



Risk Factors in Patients with Hereditary Gallstones in Chinese Pedigrees  

Microsoft Academic Search

Objective: We aimed to define the risk factors and to evaluate the impact of family background on the prevalence of gallstones in China. Subjects and Methods: Thirty-eight gallstone pedigrees were collected and a case-control study was conducted. This study consisted of 272 first-degree relatives and 201 non-first-degree relatives of index patients. The participants completed a questionnaire and underwent physical and

Yunfeng Cui; Zhonglian Li; Erpeng Zhao; Naiqiang Cui



Geographic Tongue and Associated Risk Factors among Iranian Dental Patients  

PubMed Central

Background Geographic Tongue is a benign disorder involving the dorsal surface of the tongue characterized by depapillated areas with leading and folded edges in yellowish or grayish white color and sometimes with unclear borders. Many studies have reported a relationship between such condition and different risk factors. This study aimed to investigate the prevalence rate and the risk factors of geographic tongue in the patients referring to the Department of Oral Medicine of Zahedan Dental School, in 2012. Methods: Using Poisson regression model, 2000 patients referred to the Department were selected for this cross-sectional study. Data collection method included an investigation into the medical history as well as doing intraoral examinations. Using SPSS 17 software and Chi-square statistical test, the collected data were analyzed. Result: Among the 2000 patients selected, 7.8% (156 persons) suffered from geographic tongue. The results of our study show that there is a significant relationship between the occurrence of geographic tongue and a history of allergy and fissured tongue (P<0.001). There was no significant statistical relationship between the occurrence of geographic tongue and gender, smoking and medication. Conclusion: The geographic tongue is more frequently in the patients suffering from atopy or allergy as well as the patients with fissured tongue.




Cumulative genetic risk and prefrontal activity in patients with schizophrenia.  


The lack of consistency of genetic associations in highly heritable mental illnesses, such as schizophrenia, remains a challenge in molecular psychiatry. Because clinical phenotypes for psychiatric disorders are often ill defined, considerable effort has been made to relate genetic polymorphisms to underlying physiological aspects of schizophrenia (so called intermediate phenotypes), that may be more reliable. Given the polygenic etiology of schizophrenia, the aim of this work was to form a measure of cumulative genetic risk and study its effect on neural activity during working memory (WM) using functional magnetic resonance imaging. Neural activity during the Sternberg Item Recognition Paradigm was measured in 79 schizophrenia patients and 99 healthy controls. Participants were genotyped, and a genetic risk score (GRS), which combined the additive effects of 41 single-nucleotide polymorphisms (SNPs) from 34 risk genes for schizophrenia, was calculated. These risk SNPs were chosen according to the continuously updated meta-analysis of genetic studies on schizophrenia available at We found a positive relationship between GRS and left dorsolateral prefrontal cortex inefficiency during WM processing. GRS was not correlated with age, performance, intelligence, or medication effects and did not differ between acquisition sites, gender, or diagnostic groups. Our study suggests that cumulative genetic risk, combining the impact of many genes with small effects, is associated with a known brain-based intermediate phenotype for schizophrenia. The GRS approach could provide an advantage over studying single genes in studies focusing on the genetic basis of polygenic conditions such as neuropsychiatric disorders. PMID:22267534

Walton, Esther; Turner, Jessica; Gollub, Randy L; Manoach, Dara S; Yendiki, Anastasia; Ho, Beng-Choon; Sponheim, Scott R; Calhoun, Vince D; Ehrlich, Stefan



Hereditary breast cancer. Risk assessment of patients with a family history of breast cancer.  

PubMed Central

OBJECTIVES: To assist family physicians in stratifying women with a family history of breast cancer as being at low, moderate, or high risk of hereditary breast cancer (HBC). To present guidelines for managing each of these risk groups. QUALITY OF EVIDENCE: A MEDLINE search was conducted from January 1976 to December 1997 using key words related to breast cancer risk factors, risk assessment, prevention, and screening. Risk stratification criteria were derived empirically and assessed using retrospective chart review. MAIN FINDINGS: Although up to 20% of women in the general population have a family history of breast cancer, less than 5% are at high risk for HBC. Certain features in a family history suggest increased risk. Women with none of these features are at low risk for HBC and should have annual clinical breast examinations and mammography at least every 2 years starting at age 50. Women with one or more features of increased risk who do not meet criteria for referral to a familial cancer clinic are at moderate risk for HBC and should begin annual mammography and clinical breast examination at age 40. Women who meet referral criteria are at high risk for HBC and should be counseled regarding referral to a familial cancer clinic for more detailed risk assessment and consideration for genetic testing. All women should be taught proper breast self-examination technique and encouraged but not pressured to practise it monthly for life. CONCLUSION: A simple algorithm can assist physicians in stratifying women into low, moderate, and high HBC risk groups. Management strategies for each group are given in this article and the two following (Heisey et al page 114 and Carroll et al page 126).

Warner, E.; Heisey, R. E.; Goel, V.; Carroll, J. C.; McCready, D. R.



Communicating non-steroidal anti-inflammatory drug risks: Verbal counseling, written medicine information, and patientsrisk awareness  

Microsoft Academic Search

ObjectiveTo assess potential associations among physician counseling, pharmacist counseling, written medicine information (WMI) and patient awareness of non-steroidal anti-inflammatory drug (NSAID) risks.

Michael R. Schmitt; Michael J. Miller; Donald L. Harrison; Kevin C. Farmer; Jeroan J. Allison; Daniel J. Cobaugh; Kenneth G. Saag



Socioeconomic status in HCV infected patients - risk and prognosis  

PubMed Central

Background and aims It is unknown whether socioeconomic status (SES) is a risk factor for hepatitis C virus (HCV) infection or a prognostic factor following infection. Methods From Danish nationwide registries, we obtained information on three markers of SES: employment, income, and education. In a case control design, we examined HCV infected patients and controls; conditional logistic regression was employed to obtain odds ratios (ORs) for HCV infection for each of the three SES markers, adjusting for the other two SES markers, comorbidity, and substance abuse. In a cohort design, we used Cox regression analysis to compute mortality rate ratios (MRRs) for each of the three SES markers, adjusting for the other two SES markers, comorbidity level, age, substance abuse, and gender. Results When compared to employed persons, ORs for HCV infection were 2.71 (95% confidence interval [CI]: 2.24–3.26) for disability pensioners and 2.24 (95% CI: 1.83–2.72) for the unemployed. When compared to persons with a high income, ORs were 1.64 (95% CI: 1.34–2.01) for low income persons and 1.19 (95% CI: 1.02–1.40) for medium income persons. The OR was 1.35 (95% CI: 1.20–1.52) for low education (no more than basic schooling). When compared to employed patients, MRRs were 1.71 (95% CI: 1.22–2.40) for unemployed patients and 2.24 (95% CI: 1.63–3.08) for disability pensioners. When compared to high income patients, MRRs were 1.47 (95% CI: 1.05–2.05) for medium income patients and 1.64 (95% CI: 1.13–2.34) for low income patients. Educational status was not associated with mortality. Conclusion Low SES was associated with an increased risk of HCV infection and with poor prognosis in HCV infected patients.

Omland, Lars Haukali; Osler, Merete; Jepsen, Peter; Krarup, Henrik; Weis, Nina; Christensen, Peer Brehm; Roed, Casper; S?rensen, Henrik Toft; Obel, Niels



Patient-specific radiation dose and cancer risk estimation in CT: Part II. Application to patients  

SciTech Connect

Purpose: Current methods for estimating and reporting radiation dose from CT examinations are largely patient-generic; the body size and hence dose variation from patient to patient is not reflected. Furthermore, the current protocol designs rely on dose as a surrogate for the risk of cancer incidence, neglecting the strong dependence of risk on age and gender. The purpose of this study was to develop a method for estimating patient-specific radiation dose and cancer risk from CT examinations. Methods: The study included two patients (a 5-week-old female patient and a 12-year-old male patient), who underwent 64-slice CT examinations (LightSpeed VCT, GE Healthcare) of the chest, abdomen, and pelvis at our institution in 2006. For each patient, a nonuniform rational B-spine (NURBS) based full-body computer model was created based on the patient's clinical CT data. Large organs and structures inside the image volume were individually segmented and modeled. Other organs were created by transforming an existing adult male or female full-body computer model (developed from visible human data) to match the framework defined by the segmented organs, referencing the organ volume and anthropometry data in ICRP Publication 89. A Monte Carlo program previously developed and validated for dose simulation on the LightSpeed VCT scanner was used to estimate patient-specific organ dose, from which effective dose and risks of cancer incidence were derived. Patient-specific organ dose and effective dose were compared with patient-generic CT dose quantities in current clinical use: the volume-weighted CT dose index (CTDI{sub vol}) and the effective dose derived from the dose-length product (DLP). Results: The effective dose for the CT examination of the newborn patient (5.7 mSv) was higher but comparable to that for the CT examination of the teenager patient (4.9 mSv) due to the size-based clinical CT protocols at our institution, which employ lower scan techniques for smaller patients. However, the overall risk of cancer incidence attributable to the CT examination was much higher for the newborn (2.4 in 1000) than for the teenager (0.7 in 1000). For the two pediatric-aged patients in our study, CTDI{sub vol} underestimated dose to large organs in the scan coverage by 30%-48%. The effective dose derived from DLP using published conversion coefficients differed from that calculated using patient-specific organ dose values by -57% to 13%, when the tissue weighting factors of ICRP 60 were used, and by -63% to 28%, when the tissue weighting factors of ICRP 103 were used. Conclusions: It is possible to estimate patient-specific radiation dose and cancer risk from CT examinations by combining a validated Monte Carlo program with patient-specific anatomical models that are derived from the patients' clinical CT data and supplemented by transformed models of reference adults. With the construction of a large library of patient-specific computer models encompassing patients of all ages and weight percentiles, dose and risk can be estimated for any patient prior to or after a CT examination. Such information may aid in decisions for image utilization and can further guide the design and optimization of CT technologies and scan protocols.

Li Xiang; Samei, Ehsan; Segars, W. Paul; Sturgeon, Gregory M.; Colsher, James G.; Toncheva, Greta; Yoshizumi, Terry T.; Frush, Donald P. [Medical Physics Graduate Program, Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States); Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Medical Physics Graduate Program, Department of Physics, and Department of Biomedical Engineering, Duke University Medical Center, Durham, North Carolina 27705 (United States); Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Medical Physics Graduate Program, Duke University Medical Center, Durham, North Carolina 27705 (United States); Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 and Department of Biomedical Engineering, University of North Carolina, Chapel Hill, North Carolina 27599 (United States); Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States); Duke Radiation Dosimetry Laboratory, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States); Duke Radiation Dosimetry Laboratory, Department of Radiology, Medical Physics Graduate Program, Duke University Medical Center, Durham, North Carolina 27705 (United States); Division of Pediatric Radiology, Department of Radiology, Medical Physics Graduate Program, Duke University Medical Center, Durham, North Carolina 27710 (United States)



Prospective evaluation of pneumonia severity index in hospitalised patients with community-acquired pneumonia  

Microsoft Academic Search

The aim of the present study was to investigate whether the pneumonia severity index (PSI) could adequately predict the severity of community-acquired pneumonia (CAP) and could be used as a severity of illness classification system. Furthermore, reasons that may influence the decision to admit low risk patients were analysed.In a prospective study 260 patients with CAP were included. Stratification in

M. M van der Eerden; C. S de Graaff; W. Bronsveld; H. M. Jansen; W. G. Boersma



The SYNTAX score and SYNTAX-based clinical risk scores.  


Risk stratification is an important and essential component in appropriately informing patients electing to undergo coronary artery bypass graft or percutaneous coronary intervention. This process is an integral part of the SYNTAX pioneered Heart Team approach in selecting the most appropriate revascularization modality in patients with complex coronary artery disease. The SYNTAX score was pioneered as an anatomical-based risk score that aided in this decision-making process. The purpose of this review is to examine the SYNTAX score and subsequent risk models that have been developed on the basis of this landmark anatomical-based risk score. PMID:22041038

Farooq, Vasim; Brugaletta, Salvatore; Serruys, Patrick W



Stratification and Isotope Separation in CP Stars  

Microsoft Academic Search

We investigate the elemental and isotopic stratification in the atmospheres\\u000aof selected chemically peculiar (CP) stars of the upper main sequence.\\u000aReconfiguration of the UVES spectrograph in 2004 has made it possible to\\u000aexamine all three lines of the Ca II infrared triplet. Much of the material\\u000aanalyzed was obtained in 2008.\\u000a We support the claim of Ryabchikova, Kochukhov &

C. R. Cowley; S. Hubrig; J. F. González



Stratification in college entry and completion  

Microsoft Academic Search

This paper examines stratification of opportunities in college access and completion. Using propensity score methods, we investigate two comparisons: (1) four- versus two-year public colleges and (2) private versus public two-year colleges. While previous research finds lower degree completion in two-year than in four-year public colleges, the comparability of students is doubtful. This paper re-considers the public four-year college effect,

Jennifer L. Stephan; James E. Rosenbaum; Ann E. Person



Cardiometabolic risk factors among HIV patients on antiretroviral therapy  

PubMed Central

Background HIV and combination antiretroviral therapy (cART) may increase cardiovascular disease (CVD) risk. We assessed the early effects of cART on CVD risk markers in a population with presumed low CVD risk. Methods Adult patients (n=118) in Lusaka, Zambia were recruited at the time of initiation of cART for HIV/AIDS. Cardiometabolic risk factors were measured before and 90?days after starting cART. Participants were grouped according to cART regimens: Zidovudine + Lamivudine + Nevirapine (n=58); Stavudine + Lamivudine + Nevirapine (n=43); and ‘other’ (Zidovudine + Lamivudine + Efavirenz, Stavudine + Lamivudine + Efavirenz, Tenofovir + Emtricitabine + Efavirenz or Tenofovir + Emtricitabine + Nevirapine, n=17). ANOVA was used to test whether changes in cardiometabolic risk markers varied by cART regimen. Results From baseline to 90?days after initiation of cART, the prevalence of low levels of high-density lipoprotein cholesterol (<1.04?mmol/L for men and <1.30?mmol/L for women) significantly decreased (78.8% vs. 34.8%, P<0.001) while elevated total cholesterol (TC ?5.18?mmol/L, 5.1% vs. 11.9%, P=0.03) and the homeostasis model assessment of insulin resistance ?3.0 (1.7% vs. 17.0%, P<0.001) significantly increased. The prevalence of TC:HDL-c ratio ?5.0 significantly decreased (44.9% vs. 6.8%, P<0.001). These changes in cardiometabolic risk markers were independent of the cART regimen. Conclusion Our results suggest that short-term cART is associated with a cardioprotective lipid profile in Zambia and a tendency towards insulin resistance regardless of the cART regimen.



From guidelines to clinical practice: cardiovascular risk management in inflammatory arthritis patients.  


There exists significant evidence of increased risk of cardiovascular (CV) disease in rheumatoid arthritis (RA) patients in comparison with the general population. This finding has been supported by a number of guidelines recommending screening for CV disease risk in patients with the disease. However, the opportunity to identify and manage those patients at risk has been missed in both primary and secondary care. The success of CV risk management in diabetes patients provides a clear incentive to identify and actively manage CV risk in all RA patients as part of routine practice. This article provides an approach that shows how to assess for CV risk in standard clinical practice. PMID:24005485

Palmer, Deborah; El Miedany, Yasser



Gun safety management with patients at risk for suicide.  


Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated person responsible for removing guns from the home. A call-back to the clinician from the designated person is required confirming that guns have been removed and secured according to plan. The principle of gun safety management applies to outpatients, inpatients, and emergency patients, although its implementation varies according to the clinical setting. PMID:17967118

Simon, Robert I



Fabric stratification manifolds for solar water heating  

SciTech Connect

The level of thermal stratification that can be maintained in forced-flow, direct solar water-heating systems using a fabric manifold is studied in a 372-liter tank with an inlet flow rate of 0.07 l/s. A rib-knit, lightweight, spun-orlon acrylic is the most effective manifold material in a comparative study of 13 synthetic and natural fabrics. Thermal stratification (or more appropriately mixing) in the tank equipped with this acrylic manifold is compared to the level of stratification achieved using a rigid, porous manifold and a conventional drop-tube inlet. Initial tank temperature profile, temperature of the water entering the tank, and test duration are varied in three testing schemes. Comparison of vertical temperature profiles and height-weighted energy stored in the tank indicate that under realistic operating conditions, the fabric manifold is 4 percent more effective than the rigid manifold, and 48 percent more effective than the conventional drop-tube inlet.

Davidson, J.H. (Univ. of Minnesota, Minneapolis, MN (United States). Mechanical Engineering Dept.); Adams, D.A. (Colorado State Univ., Fort Collins, CO (United States). Solar Energy Applications Lab.)



Risk Management for Gastrointestinal Endoscopy in Elderly Patients: Questionnaire for Patients Undergoing Gastrointestinal Endoscopy  

PubMed Central

More elderly patients now undergo gastrointestinal endoscopy following recent advances in endoscopic techniques. In this study, we conducted a high-risk survey of endoscopies in Japan, using a questionnaire administered prior to upper gastrointestinal tract endoscopy (UGITE), and identified anticholinergic agents and glucagon preparations as high-risk premedication. We also evaluated the cardiovascular effects of anticholinergic agents and glucagon through measurements of plasma levels of human atrial natriuretic peptide (hANP) and human brain natriuretic peptide (hBNP). The subjects were 1480 patients who underwent UGITE. Nurses administered a pre-endoscopy questionnaire, questioning subjects regarding heart disease, hypertension, glaucoma, and urinary difficulties as risk factors for anticholinergic agents, and Diabetes mellitus as a risk factor for glucagon preparations. Evaluation of subjects divided into under 65 and over 65 age groups revealed that in subjects aged 65 and over, risk factors for anticholinergic agents were significantly more high than those for glucagon. Analysis of the cardiovascular effects of anticholinergic agents and glucagon, in the elderly patients showed that hANP levels were significantly higher following administration of anticholinergic agents, but the change was not significant for glucagon premedication. Taking a detailed history before UGITE with the aid of a questionnaire at the same time as informed consent is obtained, is extremely useful in terms of risk management and selection of the appropriate premedication.

Umegaki, Eiji; Abe, Shinya; Tokioka, Satoshi; Takeuchi, Nozomi; Takeuchi, Toshihisa; Yoda, Yukiko; Murano, Mitsuyuki; Higuchi, Kazuhide



Perceived and objective risk in children of patients with peripheral arterial disease  

Microsoft Academic Search

This study examined perceived and objective health risks, health promotive behavior, risk perception, and knowledge of risk factors for peripheral arterial disease (PAD) in children of patients with PAD. Children of patients who had lower extremity distal arterial reconstructive surgery or amputation for complications of PAD completed an investigator-developed questionnaire. Risk factor and behavioral measures were self-reported. Data were collected

Karen A. Hayden



Thyroid Cancer Risk Is Not Increased in Diabetic Patients  

PubMed Central

Objective This study evaluated thyroid cancer risk with regards to diabetes status and diabetes duration, and with the use of anti-diabetic drugs inclu