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Sample records for patient risk stratification

  1. Risk Stratification of Patients Presenting with Transient Loss of Consciousness.

    PubMed

    Puppala, Venkata Krishna; Akkaya, Mehmet; Dickinson, Oana; Benditt, David G

    2015-08-01

    Important goals in the initial evaluation of patients with transient loss of consciousness include determining whether the episode was syncope and choosing the venue for subsequent care. Patients who have high short-term risk of adverse outcomes need prompt hospitalization for diagnosis and/or treatment, whereas others may be safely referred for outpatient evaluation. This article summarizes the most important available risk assessment studies and points out key differences among the existing recommendations. Current risk stratification methods cannot replace critical assessment by an experienced physician, but they do provide much needed guidance and offer direction for future risk stratification consensus development. PMID:26115825

  2. Risk stratification of patients with acute symptomatic pulmonary embolism.

    PubMed

    Jimnez, David; Lobo, Jose Luis; Barrios, Deisy; Prandoni, Paolo; Yusen, Roger D

    2016-02-01

    Patients with acute symptomatic pulmonary embolism (PE) who present with arterial hypotension or shock have a high risk of death (high-risk PE), and treatment guidelines recommend strong consideration of thrombolysis in this setting. For normotensive patients diagnosed with PE, risk stratification should aim to differentiate the group of patients deemed as having a low risk for early complications (all-cause mortality, recurrent venous thromboembolism, and major bleeding) (low-risk PE) from the group of patients at higher risk for PE-related complications (intermediate-high risk PE), so low-risk patients could undergo consideration of early outpatient treatment of PE and intermediate-high risk patients would undergo close observation and consideration of thrombolysis. Clinicians should also use risk stratification and eligibility criteria to identify a third group of patients that should not undergo escalated or home therapy (intermediate-low risk PE). Such patients should initiate standard therapy of PE while in the hospital. Clinical models [e.g., Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI)] may accurately identify those at low risk of dying shortly after the diagnosis of PE. For identification of intermediate-high risk patients with acute PE, studies have validated predictive models that use a combination of clinical, laboratory and imaging variables. PMID:26768476

  3. Heart rate variability in risk stratification of cardiac patients.

    PubMed

    Huikuri, Heikki V; Stein, Phyllis K

    2013-01-01

    Heart rate (HR) variability has been extensively studied in cardiac patients, especially in patients surviving an acute myocardial infarction (AMI) and also in patients with congestive heart failure (CHF) or left ventricular (LV) dysfunction. The majority of studies have shown that patients with reduced or abnormal HR variability have an increased risk of mortality within a few years after an AMI or after a diagnosis of CHF/LV dysfunction. Various measures of HR dynamics, such as time-domain, spectral, and non-linear measures of HR variability have been used in risk stratification. The prognostic power of various measures, except of those reflecting rapid R-R interval oscillations, has been almost identical, albeit some non-linear HR variability measures, such as short-term fractal scaling exponent have provided somewhat better prognostic information than the others. Abnormal HR variability predicts both sudden and non-sudden cardiac death. Because of remodeling of the arrhythmia substrate after AMI, early measurement of HR variability to identify those at high risk should likely be repeated later in order to assess the risk of fatal arrhythmia events. Future randomized trials using HR variability/turbulence as one of the pre-defined inclusion criteria will show whether routine measurement of HR variability/turbulence will become a routine clinical tool for risk stratification of cardiac patients. PMID:24215747

  4. Molecular risk stratification in advanced heart failure patients.

    PubMed

    Lamirault, Guillaume; Meur, Nolwenn Le; Roussel, Jean-Christian; Cunff, Marie-France Le; Baron, Daniel; Bihoue, Audrey; Guisle, Isabelle; Raharijaona, Mahatsangy; Ramstein, Grard; Teusan, Raluca; Chevalier, Catherine; Gueffet, Jean-Pierre; Trochu, Jean-Nol; Lger, Jean J; Houlgatte, Rmi; Steenman, Marja

    2010-06-01

    Risk stratification in advanced heart failure (HF) is crucial for the individualization of therapeutic strategy, in particular for heart transplantation and ventricular assist device implantation. We tested the hypothesis that cardiac gene expression profiling can distinguish between HF patients with different disease severity. We obtained tissue samples from both left (LV) and right (RV) ventricle of explanted hearts of 44 patients undergoing cardiac transplantation or ventricular assist device placement. Gene expression profiles were obtained using an in-house microarray containing 4217 muscular organ-relevant genes. Based on their clinical status, patients were classified into three HF-severity groups: deteriorating (n= 12), intermediate (n= 19) and stable (n= 13). Two-class statistical analysis of gene expression profiles of deteriorating and stable patients identified a 170-gene and a 129-gene predictor for LV and RV samples, respectively. The LV molecular predictor identified patients with stable and deteriorating status with a sensitivity of 88% and 92%, and a specificity of 100% and 96%, respectively. The RV molecular predictor identified patients with stable and deteriorating status with a sensitivity of 100% and 96%, and a specificity of 100% and 100%, respectively. The molecular prediction was reproducible across biological replicates in LV and RV samples. Gene expression profiling has the potential to reproducibly detect HF patients with highest HF severity with high sensitivity and specificity. In addition, not only LV but also RV samples could be used for molecular risk stratification with similar predictive power. PMID:19793385

  5. Risk stratification of patients with atrial fibrillation: Biomarkers and other future perspectives

    PubMed Central

    Providência, Rui; Paiva, Luís; Barra, Sérgio

    2012-01-01

    Risk stratification of atrial fibrillation (AF) and adequate thromboembolism prophylaxis is the cornerstone of treatment in patients with AF. Current risk stratification schemes such as the CHADS2 and CHA2DS2-VASc scores are based on clinical risk factors and suboptimally weight the risk/benefit of anticoagulation. Recently, the potential of biomarkers (troponin and NT-proBNP) in the RE-LY biomarker sub-analysis has been demonstrated. Echocardiography is also being evaluated as a possible approach to improve risk score performance. The authors present an overview on AF risk stratification and discuss future potential developments that may be introduced into our current risk stratification schemes. PMID:22761972

  6. Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints

    PubMed Central

    Nickel, Christian Hans; Messmer, Anna Sarah; Ghanim, Leyla; Ilsemann-Karakoumis, Julia; Giersdorf, Sven; Hertel, Sabine; Ernst, Susanne; Geigy, Nicolas; Bingisser, Roland

    2016-01-01

    Abstract Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting. Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission. The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected. Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change. ClinicalTrials. gov Identifier: NCT00920491 PMID:26735540

  7. Cardiac risk stratification in patients undergoing endovascular aortic repair.

    PubMed

    Biagi, Paolo; de Donato, Gianmarco; Setacci, Carlo

    2016-04-01

    Endovascular aortic repair (EVAR) for abdominal aortic aneurysms (AAA) is the preferred first treatment option in case of patients with advanced age and/or fit anatomy owing to shorter length of in hospital staying, less complications or laparotomy-related re-interventions, and lower initial costs. Although it is a less-invasive intervention, EVAR entails a risk similar to that of open aortic procedures for medical comorbidities, and a perioperative clinical evaluation is mandatory to minimize the early and late cardiovascular risk. In this brief review the determinants of cardiac risk (functional capacity, cardiac evaluation, non-invasive tests, bio markers and "specialist" cardiac tests) as well the most widely used predictive risk scores were analyzed. Taking into account that a preoperative cardiovascular assessment is conditioned by the urgency of the repair, in everyday practice rarely the patient undergoes over a complete and exhaustive cardiac assessment with the exclusion of few selected cases that do not represent the rule. Moreover most of models focused on perioperative mortality, tailored for open repair and then adjusted to EVAR or specifically retailed for this procedure show both differences and remarkable similarities. None defines the patient's cardiac risk "alone" (angina, recent myocardial infarction, chronic heart failure, arrhythmias). Actually they measure a "global" medical risk for they take into account of various comorbidities, such as previous stroke, kidney failure, including dialysis, diabetes, COPD, etc. that contribute to intra and perioperative mortality/morbidity and that may be heavier for prognosis. PMID:26474370

  8. Risk stratification for venous thromboembolism in hospitalized patients in a developing country: a prospective study.

    PubMed

    Awidi, Abdallah; Obeidat, Nathir; Magablah, Ahmad; Bsoul, Nazzal

    2009-10-01

    Venous Thrombo-Embolism (VTE) is a serious complication in hospitalized patients but can be preventable. This prospective study addresses risk factors assessment and the use of heparin in this population. About 2,496 non pediatric patients were admitted to Jordan University Hospital between June 12, 2007 and July 19, 2007. A random sample of 624 patients consisting of every fourth admission was chosen. The stratification of risk factors was assessed using Caprini model and the ACCP score. The mean age of the patients (229 males and 395 females) was 45.34 +/- 18.3 years. More than 80% of the admitted patients were considered at high risk for VTE but heparin was used in only 26% of the patients. The majority of our patients constitute a high-risk population. Implementation of strategies including educational sessions and risk stratification guidelines can reduce the incidence, morbidity, and mortality of VTE especially in developing countries. PMID:19023522

  9. [Immunophenotype characteristics of patients with multiple myeloma in different risk stratification].

    PubMed

    Hu, Kai; Wang, Jing; Zhu, Ming-Xia; Wang, Yan-Fang; Ke, Xiao-Yan

    2014-12-01

    This study assessed the immunophenotype characteristics of newly diagosised patients with multiple myeloma (MM) in different risk stratification in order to find the relationship between the immunophenotype and prognosis of MM. The expressions of CD45, CD38, CD138, CD56, CD19, CD117, CD13, CD20, CD22, CD34, Kappa, Lambda in bone marrow samples from 62 newly diagnosed MM patients were detected by using flow cytometric multiparametric direct immunofluorescence technique, CD45/SSC and CD38/SSC combination gating, then the immumophemotypic characteristics of patients in different risk stratification groups were analyzed and compared. The new risk stratification of all patients was carried out according to ISS stages (Interuational Staging System) and cytogenetic characteristics. The results indicated that all the malignant plasma cells commonly expressed CD38 (100%) and CD138 (100%); CD19? (6.5%) ,CD45? (22.6%), CD56? (59.6%) and monoclonal light chain (82%); but the expressions of CD117? (27.4%) , CD13? (17.7%) , CD20? (16.1%) were diverse. According to risk stratification, it is found that the standard-risk and high-risk groups had lower expression of CD56 (P = 0.022) and higher expression of CD117 (P = 0.011), compared with the low-risk group. It is concluded that the immunophenotype of MM is heterogeneity, the lower expression of CD56 and higher expression of CD117 may be associate with poor prognosis. PMID:25543486

  10. Sudden cardiac death risk stratification.

    PubMed

    Deyell, Marc W; Krahn, Andrew D; Goldberger, Jeffrey J

    2015-06-01

    Arrhythmic sudden cardiac death (SCD) may be caused by ventricular tachycardia/fibrillation or pulseless electric activity/asystole. Effective risk stratification to identify patients at risk of arrhythmic SCD is essential for targeting our healthcare and research resources to tackle this important public health issue. Although our understanding of SCD because of pulseless electric activity/asystole is growing, the overwhelming majority of research in risk stratification has focused on SCD-ventricular tachycardia/ventricular fibrillation. This review focuses on existing and novel risk stratification tools for SCD-ventricular tachycardia/ventricular fibrillation. For patients with left ventricular dysfunction or myocardial infarction, advances in imaging, measures of cardiac autonomic function, and measures of repolarization have shown considerable promise in refining risk. Yet the majority of SCD-ventricular tachycardia/ventricular fibrillation occurs in patients without known cardiac disease. Biomarkers and novel imaging techniques may provide further risk stratification in the general population beyond traditional risk stratification for coronary artery disease alone. Despite these advances, significant challenges in risk stratification remain that must be overcome before a meaningful impact on SCD can be realized. PMID:26044247

  11. Midregional Proadrenomedullin Improves Risk Stratification beyond Surgical Risk Scores in Patients Undergoing Transcatheter Aortic Valve Replacement

    PubMed Central

    Schuetz, Philipp; Huber, Andreas; Mller, Beat; Maisano, Francesco; Taramasso, Maurizio; Moarof, Igal; Obeid, Slayman; Sthli, Barbara E.; Cahenzly, Martin; Binder, Ronald K.; Liebetrau, Christoph; Mllmann, Helge; Kim, Won-Keun; Hamm, Christian; Lscher, Thomas F.

    2015-01-01

    Background Conventional surgical risk scores lack accuracy in risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR). Elevated levels of midregional proadrenomedullin (MR-proADM) levels are associated with adverse outcome not only in patients with manifest chronic disease states, but also in the general population. Objectives We investigated the predictive value of MR-proADM for mortality in an unselected contemporary TAVR population. Methods We prospectively included 153 patients suffering from severe aortic stenosis who underwent TAVR from September 2013 to August 2014. This population was compared to an external validation cohort of 205 patients with severe aortic stenosis undergoing TAVR. The primary endpoint was all cause mortality. Results During a median follow-up of 258 days, 17 out of 153 patients who underwent TAVR died (11%). Patients with MR-proADM levels above the 75th percentile (? 1.3 nmol/l) had higher mortality (31% vs. 4%, HR 8.9, 95% CI 3.026.0, P < 0.01), whereas patients with EuroSCORE II scores above the 75th percentile (> 6.8) only showed a trend towards higher mortality (18% vs. 9%, HR 2.1, 95% CI 0.85.6, P = 0.13). The Harrells C-statistic was 0.58 (95% CI 0.450.82) for the EuroSCORE II, and consideration of baseline MR-proADM levels significantly improved discrimination (AUC = 0.84, 95% CI 0.710.92, P = 0.01). In bivariate analysis adjusted for EuroSCORE II, MR-proADM levels ?1.3 nmol/l persisted as an independent predictor of mortality (HR 9.9, 95% CI (3.131.3), P <0.01) and improved the models net reclassification index (0.89, 95% CI (0.281.59). These results were confirmed in the independent validation cohort. Conclusions Our study identified MR-proADM as a novel predictor of mortality in patients undergoing TAVR. In the future, MR-proADM should be added to the commonly used EuroSCORE II for better risk stratification of patients suffering from severe aortic stenosis. PMID:26630012

  12. Risk stratification tools for transient ischemic attack: which patients require hospital admission?

    PubMed

    Cumbler, Ethan; Glasheen, Jeffrey J

    2009-04-01

    Stroke and transient ischemic attack (TIA) arise from identical etiologies and many fatal or disabling strokes are preceded by a TIA. Ten percent of patients presenting with a TIA will suffer a stroke within 3 months with half occurring in the first 48 hours. Still, many patients with a TIA do not receive timely evaluation or therapy. Hospitalization offers the opportunity for rapid evaluation and secondary prevention, reduced time to thrombolysis for early second strokes, and can be cost effective for high risk patients. Stratification tools are now available which allow individualized assessment of risk for early second strokes based on patient characteristics on presentation. The use of scoring systems such as the ABCD(2) score to predict risk of stroke after TIA are useful in making an evidence-based judgment regarding need for hospitalization. High-risk patients have an 8.1% risk for stroke in the 48 hours after a TIA and warrant hospital admission. Intermediate-risk patients have a 4.1% risk of early second stroke and may be considered for admission, observation, or expedited clinic evaluation. Low-risk patients have a 2-day stroke risk of only 1% and are likely appropriate for prompt outpatient evaluation. TIA is a medical emergency, similar to unstable angina, and high risk patients should receive treatment and prevention measures instituted with comparable urgency. PMID:19388066

  13. [Updated criteria for diagnosis and risk stratification in patients with multiple myeloma].

    PubMed

    Djurdjevi?, Predrag; Andjelkovi?, Neboja; Bila, Jelena

    2011-12-01

    Search and disclosure of most adequate diagnostic criteria and prognostic indicators of disease represents one of the most difficult tasks in the understanding of any disease, which creates the way toward a more successful treatment and longer survival. The recent advances in research techniques that have helped refine the diagnostic work up and prognosis of myeloma include serum-free light chains, especially in oligosecretory myeloma, magnetic resonance and positron emission tomography in the diagnosis of bone diseases, cytogenetics and fluorescent in situ hibridization (FISH) technique to determine prognosis. The International Staging System and Durie/Salmon PLUS system are the current standards for staging myeloma. Newer risk stratification protocols are based on international staging system and chromosomal changes detected by conventional cytogenetics and FISH. These improved predictive risk stratification models have enabled the determination of prognosis in patients with myeloma which has a considerable influence on the choice of therapeutic algorism. Novel therapies enable a significant increase in achieving complete remission in a significant number of patients which also results in the definition of more precise criteria regarding the response to therapy. A firm and complete remission with a very good partial remission represent new categories defined by the international uniform criteria of response to therapy. This paper provides the current criteria for diagnosis, staging, risk stratification and response assessment of myeloma. PMID:22352190

  14. Stroke risk in atrial fibrillation patients on warfarin. Predictive ability of risk stratification schemes for primary and secondary prevention.

    PubMed

    Poli, Daniela; Antonucci, Emilia; Grifoni, Elisa; Abbate, Rosanna; Gensini, Gian Franco; Prisco, Domenico

    2009-02-01

    Atrial fibrillation (AF) patients are widely heterogeneous in terms of ischaemic stroke risk, and several risk stratification schemes have been developed. We performed a prospective study on 662 AF patients on long-term oral anticoagulant therapy (OAT), evaluating the agreement among the different schemes and their correlation with adverse events recorded during follow-up. Patients at low risk were similarly distributed among the different models. Instead, patients classed at moderate risk were 49.2% by CHADS(2) score, 27.6% by NICE and 2.3% by ACCP. As a consequence patients classed at high risk were 46.1% by CHADS(2), 69.8% by NICE and 95.3% by ACCP. CHADS(2 )and NICE scores were associated to the best predictive accuracy. A separate analysis was performed for patients on treatment for secondary prevention, and we observed that they were included in high risk groups by all models, except for 14 patients (6.3%) classed at moderate risk by CHADS(2) even though these patients are at very high risk and the use of aspirin could be unsafe for them. During follow-up 32 major bleeding (1.35 per 100 patient/years) and 39 thrombotic events (1.64 per 100 patient/years) were observed. Among patients on OAT for secondary prevention, both bleeding and thrombotic events mostly occurred in high-risk patients. Even if the absolute rate of adverse events is low, this finding seems to confirm the high stroke risk of this group of patients. For patients on secondary prevention there is no need for further stratification and warfarin should be the treatment of choice. PMID:19190823

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

    SciTech Connect

    Gibson, R.S.; Watson, D.D. )

    1991-09-01

    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.

  16. Isoniazid-induced polyneuropathy in a tuberculosis patient – implication for individual risk stratification with genotyping?

    PubMed Central

    Stettner, Mark; Steinberger, Daniela; Hartmann, Christian J; Pabst, Tatjana; Konta, Lidija; Hartung, Hans Peter; Kieseier, Bernd C

    2015-01-01

    Background Development of polyneuropathy (PNP) under treatment for tuberculosis (TB), including isoniazid (INH), is a highly relevant adverse drug effect. The NAT2 acetylation status is a predictor of potential toxic effects of INH. The question as to whether individual risk stratification by genotyping is useful to avoid suffering of patients and to lower costs for the health care system is of considerable clinical importance. Case Presentation After drug treatment for TB, including INH, a 23-year-old man developed severe PNP. During the treatment, laboratory results have been indicating incipient liver and renal injury. Later, molecular genetic analyses were performed and revealed a variation in the NAT2 gene and the c1/c2 genotype of the CYP2E1 gene, both described to contribute to an elevated risk for anti-tuberculostatic-induced liver damages (ATIL). Conclusion The combination of metabolizer genotypes should be taken into account as a cause for toxic effects and the development of PNP. Individual genotyping, performed before medication or at least if an elevation of liver parameters is observed, may reduce the risk of severe cases of PNP by early adjustment of treatment. Our case study indicates that evaluation of individual risk stratification with systematic pharmacogenetic genotyping of metabolizer gene combinations in the context of TB treatment should be addressed in clinical studies with larger cohorts. PMID:26355945

  17. Preoperative risk stratification models fail to predict hospital cost of cardiac surgery patients

    PubMed Central

    2013-01-01

    Background Preoperative risk stratification models have previously been suggested to predict cardiac surgery unit costs. However, there is a lack of consistency in their reliability in this field. In this study we aim to test the correlation between the values of six commonly known preoperative scoring systems and evaluate their reliability at predicting unit costs of cardiac surgery patients. Methods Over a period of 14 months all consecutive adult patients undergoing cardiac surgery on cardiopulmonary bypass were prospectively classified using six preoperative scoring models (EuroSCORE, Parsonnet, Ontario, French, Pons and CABDEAL). Transplantation patients were the only patients we excluded. Total hospital costs for each patient were calculated independently on a daily basis using the bottom up method. The full unit costs were calculated including preoperative diagnostic tests, operating room cost, disposable materials, drugs, blood components as well as costs for personnel and fixed hospital costs. The correlation between hospital cost and the six models was determined by linear regression analysis. Both Spearmans and Pearsons correlation coefficients were calculated from the regression lines. An analysis of residuals was performed to determine the quality of the regression. Results A total of 887 patients were operated on for CABG (n?=?608), valve (n?=?142), CABG plus valve (n?=?100), thoracic aorta (n?=?33) and ventricular assist devices (n?=?4). Mean age of the patients was 68.39.9 years, 27.6% were female. 30-day mortality rate was 4.1%. Correlation between the six models and hospital cost was weak (Pearsons: r?risk stratification models in this study are not reliable at predicting total costs of cardiac surgical patients. We therefore do not recommend their use for this purpose. PMID:23659251

  18. Tools for risk stratification of sudden cardiac death: A review of the literature in different patient populations

    PubMed Central

    Ragupathi, Loheetha; Pavri, Behzad B.

    2014-01-01

    While various modalities to determine risk of sudden cardiac death (SCD) have been reported in clinical studies, currently reduced left ventricular ejection fraction remains the cornerstone of SCD risk stratification. However, the absolute burden of SCD is greatest amongst populations without known cardiac disease. In this review, we summarize the evidence behind current guidelines for implantable cardioverter defibrillator (ICD) use for the prevention of SCD in patients with ischemic heart disease (IHD). We also evaluate the evidence for risk stratification tools beyond clinical guidelines in the general population, patients with IHD, and patients with other known or suspected medical conditions. PMID:24568833

  19. Stratification of brachytherapy-treated intermediate-risk prostate cancer patients into favorable and unfavorable cohorts

    PubMed Central

    Butler, Wayne M.; Galbreath, Robert W.; Fiano, Ryan; Adamovich, Edward

    2015-01-01

    Purpose To evaluate biochemical failure (BF) and prostate cancer specific mortality (PCSM) in intermediate-risk (IR) brachytherapy patients stratified into favorable and unfavorable cohorts, and to compare those outcomes to patients with low (LR) and high-risk (HR) disease. Material and methods From March 1995 till February 2012, 2,502 consecutive patients underwent permanent interstitial brachytherapy for clinically localized prostate cancer. Patients were stratified into risk groups as per the NCCN guidelines with further stratification of the intermediate risk cohort into unfavorable (primary Gleason pattern 4, ? 50% positive biopsies or ? 2 IR features) and favorable cohorts. Median follow-up was 8.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure was defined as a PSA > 0.40 ng/ml after nadir. Patients with metastatic prostate cancer or non-metastatic castrate resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes. Results Fifteen year BF for LR, favorable IR, unfavorable IR, and HR were 1.4%, 2.2%, 7.1%, and 11.1% (p < 0.001), respectively. At 15 years, PCSM for LR, favorable IR, unfavorable IR, and HR was 0.3%, 0.6%, 2.2% and 4.6% (p < 0.001), respectively. In multivariate analysis, BF was best predicted by risk group, pre-implant PSA, percent positive biopsies, prostate volume, and ADT duration, while PCSM was most closely related to risk group, percent positive biopsies and prostate volume. Conclusions Patients with favorable IR disease have biochemical and PCSM outcomes comparable to those of patients with LR disease. Although unfavorable IR has greater than a 3-fold increased risk of BF and PCSM when compared to favorable IR, the outcomes remain superior to those men with HR disease. PMID:26816337

  20. Impact of gene expression profiling-based risk stratification in patients with myeloma receiving initial therapy with lenalidomide and dexamethasone.

    PubMed

    Kumar, Shaji K; Uno, Hajime; Jacobus, Susanna J; Van Wier, Scott A; Ahmann, Greg J; Henderson, Kimberly J; Callander, Natalie S; Haug, Jessica L; Siegel, David S; Greipp, Philip R; Fonseca, Rafael; Rajkumar, S Vincent

    2011-10-20

    Detection of specific chromosomal abnormalities by FISH and metaphase cytogenetics allows risk stratification in multiple myeloma; however, gene expression profiling (GEP) based signatures may enable more specific risk categorization. We examined the utility of 2 GEP-based risk stratification systems among patients undergoing initial therapy with lenalidomide in the context of a phase 3 trial. Among 45 patients studied at baseline, 7 (16%) and 10 (22%), respectively, were high-risk using the GEP70 and GEP15 signatures. The median overall survival for the GEP70 high-risk group was 19 months versus not reached for the rest (hazard ratio = 14.1). Although the medians were not reached, the GEP15 also predicted a poor outcome among the high-risk patients. The C-statistic for the GEP70, GEP15, and FISH based risk stratification systems was 0.74, 0.7, and 0.7, respectively. Here we demonstrate the prognostic value for GEP risk stratification in a group of patients primarily treated with novel agents. This trial was registered at www.clinicaltrials.gov as #NCT00098475. PMID:21860025

  1. Risk stratification for arrhythmic events in patients with idiopathic dilated cardiomyopathy: a review of the literature and current perspectives.

    PubMed

    Cal, Leonardo; Peichl, Petr; Bulava, Alan; Lamberti, Filippo; Loricchio, Maria Luisa; Castro, Antonio; Meo, Antonella; Pandozi, Claudio; Santini, Massimo

    2003-09-01

    The prognosis for patients with idiopathic dilated cardiomyopathy (DCM) has markedly improved during the last decade, mainly because of advancements in therapeutic strategies. However, sudden death still accounts for a significant part of the total mortality in patients with moderate disease. Recent primary prophylactic trials failed to demonstrate any benefit of cardioverter-defibrillator implantation in an unselected group of idiopathic DCM patients and thus the identification of the subgroup of patients at high arrhythmic risk is crucial. Although different risk stratification methods have been evaluated in risk assessment, the reported clinical value differs in studies, mainly because of differences in either methodology and/or patient selection. The present review focuses on arrhythmic events in idiopathic DCM and on the value of noninvasive methods and electrophysiological study in the risk stratification of this group of patients. PMID:14635374

  2. Risk Stratification in Multiple Myeloma.

    PubMed

    Ooi, Melissa Gaik-Ming; de Mel, Sanjay; Chng, Wee Joo

    2016-04-01

    There are many prognostic variables in multiple myeloma and the difficulty is in deciding which is truly significant. The widely used International Staging System (ISS) does not incorporate genetics, age, and other important variables in its risk stratification. Although it has its own limitations, the recently published Revised International Staging System (R-ISS) that was built upon the framework of ISS, is a more comprehensive and predictive tool for multiple myeloma patients and should be henceforth utilised. We will review the current prognostic variables and their significance in this paper. PMID:26883334

  3. Multicenter Development and Validation of a Risk Stratification Tool for Ward Patients

    PubMed Central

    Yuen, Trevor C.; Winslow, Christopher; Robicsek, Ari A.; Meltzer, David O.; Gibbons, Robert D.; Edelson, Dana P.

    2014-01-01

    Rationale: Most ward risk scores were created using subjective opinion in individual hospitals and only use vital signs. Objectives: To develop and validate a risk score using commonly collected electronic health record data. Methods: All patients hospitalized on the wards in five hospitals were included in this observational cohort study. Discrete-time survival analysis was used to predict the combined outcome of cardiac arrest (CA), intensive care unit (ICU) transfer, or death on the wards. Laboratory results, vital signs, and demographics were used as predictor variables. The model was developed in the first 60% of the data at each hospital and then validated in the remaining 40%. The final model was compared with the Modified Early Warning Score (MEWS) using the area under the receiver operating characteristic curve and the net reclassification index (NRI). Measurements and Main Results: A total of 269,999 patient admissions were included, with 424 CAs, 13,188 ICU transfers, and 2,840 deaths occurring during the study period. The derived model was more accurate than the MEWS in the validation dataset for all outcomes (area under the receiver operating characteristic curve, 0.83 vs. 0.71 for CA; 0.75 vs. 0.68 for ICU transfer; 0.93 vs. 0.88 for death; and 0.77 vs. 0.70 for the combined outcome; P value < 0.01 for all comparisons). This accuracy improvement was seen across all hospitals. The NRI for the electronic Cardiac Arrest Risk Triage compared with the MEWS was 0.28 (0.180.38), with a positive NRI of 0.19 (0.090.29) and a negative NRI of 0.09 (0.090.09). Conclusions: We developed an accurate ward risk stratification tool using commonly collected electronic health record variables in a large multicenter dataset. Further study is needed to determine whether implementation in real-time would improve patient outcomes. PMID:25089847

  4. Update on pharmacological cardiac stress testing: efficacy, risk stratification and patient selection.

    PubMed

    Blankstein, Ron; Cannon, Christopher; Udelson, James

    2014-11-01

    Despite greater control of risk factors and improved treatments, coronary heart disease (CHD) remains a significant cause of mortality with 1 in every 4 deaths in the United States due to this disorder.(1) Cardiac stress tests have long been one of the most often utilized testing modalities used to identify patients suspected of having CHD, specifically coronary artery disease (CAD). These tests allow for noninvasive assessment of the coronary circulation and its ability to augment flow in response to physiologic demand. As with any diagnostic testing however, potential health risks as well as the financial burden of cardiovascular stress testing, must be weighed against the benefits and utility of the data procured. Given the rapidly evolving field of cardiac stress testing with respect to new risk stratification guidelines, new agents, and new assessment methods, it is difficult for physicians to remain up to date on the latest research and the benefits andrisks of different testing modalities. A recent survey of primary care physicians and cardiologists conducted by the Elsevier Office of Continuing Medical Education found that approximately one-quarter of the cardiologists and primary care physicians surveyed do not feel confident identifying the factors which should be considered before ordering a cardiac stress test as part of pre-operative screening for a patient. Additionally, this survey also reported that primary care physicians reported a high degree of confidence in ordering the appropriate cardiac screening tests for patients yet, cardiologists reported that they frequently/somewhat frequently felt the need to change the test ordered by the internist. This educational intervention focuses on patient selection, exercise vs. pharmacologic stress testing, pharmacologic agents, and the importance of patient and doctor communication in ensuring the right test is recommended for the right patient. This CME Multimedia Activity is also available through the Website of The American Journal of Cardiology (www.amjmed.com). Click on the Multimedia button in the navigation bar for full access. Or access: http://elseviercme.com/538. PMID:25447629

  5. Risk stratification of ICU patients using topic models inferred from unstructured progress notes.

    PubMed

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

    2012-01-01

    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. PMID:23304322

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

    SciTech Connect

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

    1985-05-01

    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.

  7. Individual patient risk stratification of high-risk neuroblastomas using a two-gene score suited for clinical use.

    PubMed

    von Stedingk, Kristoffer; De Preter, Katleen; Vandesompele, Jo; Noguera, Rosa; ra, Ingrid; Koster, Jan; Versteeg, Rogier; Phlman, Sven; Lindgren, David; Axelson, Hkan

    2015-08-15

    Several gene expression-based prognostic signatures have been described in neuroblastoma, but none have successfully been applied in the clinic. Here we have developed a clinically applicable prognostic gene signature, both with regards to number of genes and analysis platform. Importantly, it does not require comparison between patients and is applicable amongst high-risk patients. The signature is based on a two-gene score (R-score) with prognostic power in high-stage tumours (stage 4 and/or MYCN-amplified diagnosed after 18 months of age). QPCR-based and array-based analyses of matched cDNAs confirmed cross platform (array-qPCR) transferability. We also defined a fixed cut-off value identifying prognostically differing subsets of high-risk patients on an individual patient basis. This gene expression signature independently contributes to the current neuroblastoma classification system, and if prospectively validated could provide further stratification of high-risk patients, and potential upfront identification of a group of patients that are in need of new/additional treatment regimens. PMID:25652004

  8. Genomic imbalance defines three prognostic groups for risk stratification of patients with chronic lymphocytic leukemia.

    PubMed

    Houldsworth, Jane; Guttapalli, Asha; Thodima, Venkata; Yan, Xiao Jie; Mendiratta, Geetu; Zielonka, Tania; Nanjangud, Gouri; Chen, Weiyi; Patil, Sujata; Mato, Anthony; Brown, Jennifer R; Rai, Kanti; Chiorazzi, Nicholas; Chaganti, R S K

    2014-04-01

    Array comparative genomic hybridization (aCGH) has yet to be fully leveraged in a prognostic setting in chronic lymphocytic leukemia (CLL). Genomic imbalance was assessed in 288 CLL specimens using a targeted array. Based on 20 aberrations in a hierarchical manner, all 228 treatment-naive specimens were classified into a group with poor outcome (20.6%) exhibiting at least one aberration that was univariately associated with adverse outcome (gain: 2p, 3q, 8q, 17q, loss: 7q, 8p, 11q, 17p, 18p), good outcome (32.5%) showing 13q14 loss without any of the other 10 aberrations (gain: 1p, 7p, 12, 18p, 18q, 19, loss: 4p, 5p, 6q, 7p) or intermediate outcome (remainder). The three groups were significantly separated with respect to time to first treatment and overall survival (p < 0.001), and validation of the stratification scheme was performed in two independent datasets. Gain of 3q and 8q, and 17p loss were determined to be independent unfavorable prognostic biomarkers. TP53, NOTCH1 and SF3B1 mutations correlated with the presence of one poor outcome aCGH marker, at a considerably higher frequency than when only considering poor risk aberrations routinely detected by fluorescence in situ hybridization (FISH). These data support genomic imbalance evaluation in CLL by aCGH to assist in risk stratification. PMID:24047479

  9. A simple risk stratification model that predicts 1-year postoperative mortality rate in patients with solid-organ cancer.

    PubMed

    Chou, Wen-Chi; Wang, Frank; Cheng, Yu-Fan; Chen, Miao-Fen; Lu, Chang-Hsien; Wang, Cheng-Hsu; Lin, Yung-Chang; Yeh, Ta-Sen

    2015-11-01

    This study aimed to construct a scoring system developed exclusively from the preoperative data that predicts 1-year postoperative mortality in patients with solid cancers. A total of 20,632 patients who had a curative resection for solid-organ cancers between 2007 and 2012 at Chang Gung Memorial Hospital Linkou Medical Center were included in the derivation cohort. Multivariate logistic regression analysis was performed to develop a risk model that predicts 1-year postoperative mortality. Patients were then stratified into four risk groups (low-, intermediate-, high-, and very high-risk) according to the total score (0-43) form mortality risk analysis. An independent cohort of 16,656 patients who underwent curative cancer surgeries at three other hospitals during the same study period (validation cohort) was enrolled to verify the risk model. Age, gender, cancer site, history of previous cancer, tumor stage, Charlson comorbidity index, American Society of Anesthesiologist score, admission type, and Eastern Cooperative Oncology Group performance status were independently predictive of 1-year postoperative mortality. The 1-year postoperative mortality rates were 0.5%, 3.8%, 14.6%, and 33.8%, respectively, among the four risk groups in the derivation cohort (c-statistic, 0.80), compared with 0.9%, 4.2%, 14.6%, and 32.6%, respectively, in the validation cohort (c-statistic, 0.78). The risk stratification model also demonstrated good discrimination of long-term survival outcome of the four-tier risk groups (P<0.01 for both cohorts). The risk stratification model not only predicts 1-year postoperative mortality but also differentiates long-term survival outcome between the risk groups. PMID:26311149

  10. A simple risk stratification model that predicts 1-year postoperative mortality rate in patients with solid-organ cancer

    PubMed Central

    Chou, Wen-Chi; Wang, Frank; Cheng, Yu-Fan; Chen, Miao-Fen; Lu, Chang-Hsien; Wang, Cheng-Hsu; Lin, Yung-Chang; Yeh, Ta-Sen

    2015-01-01

    This study aimed to construct a scoring system developed exclusively from the preoperative data that predicts 1-year postoperative mortality in patients with solid cancers. A total of 20,632 patients who had a curative resection for solid-organ cancers between 2007 and 2012 at Chang Gung Memorial Hospital Linkou Medical Center were included in the derivation cohort. Multivariate logistic regression analysis was performed to develop a risk model that predicts 1-year postoperative mortality. Patients were then stratified into four risk groups (low-, intermediate-, high-, and very high-risk) according to the total score (043) form mortality risk analysis. An independent cohort of 16,656 patients who underwent curative cancer surgeries at three other hospitals during the same study period (validation cohort) was enrolled to verify the risk model. Age, gender, cancer site, history of previous cancer, tumor stage, Charlson comorbidity index, American Society of Anesthesiologist score, admission type, and Eastern Cooperative Oncology Group performance status were independently predictive of 1-year postoperative mortality. The 1-year postoperative mortality rates were 0.5%, 3.8%, 14.6%, and 33.8%, respectively, among the four risk groups in the derivation cohort (c-statistic, 0.80), compared with 0.9%, 4.2%, 14.6%, and 32.6%, respectively, in the validation cohort (c-statistic, 0.78). The risk stratification model also demonstrated good discrimination of long-term survival outcome of the four-tier risk groups (P<0.01 for both cohorts). The risk stratification model not only predicts 1-year postoperative mortality but also differentiates long-term survival outcome between the risk groups. PMID:26311149

  11. Operative risk stratification in the older adult.

    PubMed

    Scandrett, Karen G; Zuckerbraun, Brian S; Peitzman, Andrew B

    2015-02-01

    As the population ages, the health care system must to adapt to the needs of the older population. Hospitalization risks are particularly significant in the frail geriatric patients, with costly and morbid consequences. Appropriate preoperative assessment can identify sources of increased risk and enable the surgical team to manage this risk, through "prehabilitation," intraoperative modification, and postoperative care. Geriatric preoperative assessment expands usual risk stratification and careful medication review to include screening for functional disability, cognitive impairment, nutritional deficiency, and frailty. The information gathered can also equip the surgeon to develop a patient-centered and realistic treatment plan. PMID:25459549

  12. BAYESIAN BICLUSTERING FOR PATIENT STRATIFICATION.

    PubMed

    Khakabimamaghani, Sahand; Ester, Martin

    2016-01-01

    The move from Empirical Medicine towards Personalized Medicine has attracted attention to Stratified Medicine (SM). Some methods are provided in the literature for patient stratification, which is the central task of SM, however, there are still significant open issues. First, it is still unclear if integrating different datatypes will help in detecting disease subtypes more accurately, and, if not, which datatype(s) are most useful for this task. Second, it is not clear how we can compare different methods of patient stratification. Third, as most of the proposed stratification methods are deterministic, there is a need for investigating the potential benefits of applying probabilistic methods. To address these issues, we introduce a novel integrative Bayesian biclustering method, called B2PS, for patient stratification and propose methods for evaluating the results. Our experimental results demonstrate the superiority of B2PS over a popular state-of-the-art method and the benefits of Bayesian approaches. Our results agree with the intuition that transcriptomic data forms a better basis for patient stratification than genomic data. PMID:26776199

  13. Risk stratification and mitigation in multiple sclerosis

    PubMed Central

    Ontaneda, Daniel; Cohn, Samuel; Fox, Robert J.

    2014-01-01

    The increasing availability of new agents to treat multiple sclerosis poses new challenges for clinicians who seek therapies that are both safe and effective for their patients. The introduction of additional effective therapies has been accompanied by the recognition of serious side effects. The clinician now must weigh both the benefits and risks of therapies to help patients decide which treatment best fits each patients risk/benefit profile. An optimal selection of therapies relies on a complete understanding of the risks of therapies and the factors that may help evaluate and mitigate those risks. An individualized treatment approach that incorporates patient and disease factors is needed for each patient. In this review we present risk stratification and mitigation strategies of disease modifying agents for multiple sclerosis. PMID:25221744

  14. Risk Stratification in Atrial Fibrillation Patients A Review Focused on Mortality

    PubMed Central

    Lombardi, Federico

    2012-01-01

    Atrial fibrillation (AF) is associated with increased mortality that is largely due to the severe co-morbidities of patients with this rhythm disturbance rather than to its electrocardiographic features. Available evidence indicated that ageing, heart failure and stroke are the most important predictors of all-cause mortality. Additional clinical parameters such as smoking, renal impairment, chronic obstructive pulmonary disease may also identify patients at risk. The prevention of thromboembolic events is based on oral anticoagulant therapy, which reduces the severity and mortality of ischaemic strokes but slightly increase the rate of haemorrhagic events. Most of the traditional risk stratifiers commonly used in patients in sinus rhythm such as New York Heart Association (NYHA) functional class, left ventricular ejection fraction (LVEF) and resting heart rate seem to be less effective in AF patients thus leaving to the physician judgment the main responsibility of identifying patients with an increased mortality risk.

  15. Proposal for a new risk stratification classification for meningioma based on patient age, WHO tumor grade, size, localization, and karyotype

    PubMed Central

    Domingues, Patrcia Henriques; Sousa, Pablo; Otero, lvaro; Gonalves, Jesus Maria; Ruiz, Laura; de Oliveira, Catarina; Lopes, Maria Celeste; Orfao, Alberto; Tabernero, Maria Dolores

    2014-01-01

    Background Tumor recurrence remains the major clinical complication of meningiomas, the majority of recurrences occurring among WHO grade I/benign tumors. In the present study, we propose a new scoring system for the prognostic stratification of meningioma patients based on analysis of a large series of meningiomas followed for a median of >5 years. Methods Tumor cytogenetics were systematically investigated by interphase fluorescence in situ hybridization in 302 meningioma samples, and the proposed classification was further validated in an independent series of cases (n = 132) analyzed by high-density (500K) single-nucleotide polymorphism (SNP) arrays. Results Overall, we found an adverse impact on patient relapse-free survival (RFS) for males, presence of brain edema, younger patients (<55 years), tumor size >50 mm, tumor localization at intraventricular and anterior cranial base areas, WHO grade II/III meningiomas, and complex karyotypes; the latter 5 variables showed an independent predictive value in multivariate analysis. Based on these parameters, a prognostic score was established for each individual case, and patients were stratified into 4 risk categories with significantly different (P < .001) outcomes. These included a good prognosis group, consisting of approximately 20% of cases, that showed a RFS of 100% 0% at 10 years and a very poor-prognosis group with a RFS rate of 0% 0% at 10 years. The prognostic impact of the scoring system proposed here was also retained when WHO grade I cases were considered separately (P < .001). Conclusions Based on this risk-stratification classification, different strategies may be adopted for follow-up, and eventually also for treatment, of meningioma patients at different risks for relapse. PMID:24536048

  16. Integration of Different Risk Assessment Tools to Improve Stratification of Patients with Coronary Artery Disease.

    PubMed

    Paredes, S; Rocha, T; de Carvalho, P; Henriques, J; Morais, J; Ferreira, J

    2015-10-01

    Cardiovascular disease (CVD) causes unaffordable social and health costs that tend to increase as the European population ages. In this context, clinical guidelines recommend the use of risk scores to predict the risk of a cardiovascular disease event. Some useful tools have been developed to predict the risk of occurrence of a cardiovascular disease event (e.g. hospitalization or death). However, these tools present some drawbacks. These problems are addressed through two methodologies: (i) combination of risk assessment tools: fusion of nave Bayes classifiers complemented with a genetic optimization algorithm and (ii) personalization of risk assessment: subtractive clustering applied to a reduced-dimensional space to create groups of patients. Validation was performed based on two ACS-NSTEMI patient data sets. This work improved the performance in relation to current risk assessment tools, achieving maximum values of sensitivity, specificity, and geometric mean of, respectively, 79.8, 83.8, and 80.9%. Additionally, it assured clinical interpretability, ability to incorporate of new risk factors, higher capability to deal with missing risk factors and avoiding the selection of a standard CVD risk assessment tool to be applied in the clinical practice. PMID:26215518

  17. Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain.

    PubMed

    Lavand'homme, P; Thienpont, E

    2015-10-01

    The patient with a painful arthritic knee awaiting total knee arthroplasty (TKA) requires a multidisciplinary approach. Optimal control of acute post-operative pain and the prevention of chronic persistent pain remains a challenge. The aim of this paper is to evaluate whether stratification of patients can help identify those who are at particular risk for severe acute or chronic pain. Intense acute post-operative pain, which is itself a risk factor for chronic pain, is more common in younger, obese female patients and those suffering from central pain sensitisation. Pre-operative pain, in the knee or elsewhere in the body, predisposes to central sensitisation. Pain due to osteoarthritis of the knee may also trigger neuropathic pain and may be associated with chronic medication like opioids, leading to a state of nociceptive sensitisation called 'opioid-induced hyperalgesia'. Finally, genetic and personality related risk factors may also put patients at a higher risk for the development of chronic pain. Those identified as at risk for chronic pain would benefit from specific peri-operative management including reduction in opioid intake pre-operatively, the peri-operative use of antihyperalgesic drugs such as ketamine and gabapentinoids, and a close post-operative follow-up in a dedicated chronic pain clinic. PMID:26430086

  18. Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints: An Interventional Multicenter Pilot Study.

    PubMed

    Nickel, Christian Hans; Messmer, Anna Sarah; Ghanim, Leyla; Ilsemann-Karakoumis, Julia; Giersdorf, Sven; Hertel, Sabine; Ernst, Susanne; Geigy, Nicolas; Bingisser, Roland

    2016-01-01

    Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting.Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission.The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected.Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change.ClinicalTrials. gov Identifier: NCT00920491. PMID:26735540

  19. D-dimer testing for safe exclusion and risk stratification in patients with acute pulmonary embolism in primary care

    PubMed Central

    Yin, Zhou; Chen, Yiyi; Xie, Qiong; Shao, Zhexin

    2015-01-01

    Background: Safe exclusion and risk stratification are currently recommended for the initial management of patients with acute pulmonary embolism (APE). The aim of this study was to assess the safe exclusion and risk stratification value of D-dimer (DD) for APE when tested at the beginning of admission. Materials and Methods: All consecutive Chinese APE patients and controls were recruited from January 2010 to December 2012. All measurements of serum indexes were made in duplicate and blinded to the patients status. All the 40 patients with the first episode of APE were confirmed by multi-detector computed tomographic pulmonary angiography. The plasma prothrombin time (PT), activated partial thromboplastin time, thrombin time, fibrinogen, and DD levels were measured within 24 h of admission. We used the Mann-Whitney U-test to determine the differences between groups and drew receiver operator characteristic curve to evaluate the indexes value in the APE screening. Results: The PT and DD in the APE group were significantly higher than those in the disease control group (P < 0.05). Taking PT and DD as the useful screening tests for APE and AUC was 0.765 and 0.822, respectively. DD yielded the higher screening efficiency, with DD >1820 ?g/L as cut-off value, the sensitivity, specificity, positive and negative predictive value was 82.5%, 75.2%, 56.9%, and 91.6%, respectively. Conclusion: The patients with APE showed significant higher DD levels compared with disease controls, suggesting a negative qualitative DD test result can safely and efficiently exclude APE in primary care. PMID:26622257

  20. Risk Stratification of Patients with Peripheral Arterial Disease and Abdominal Aortic Aneurysm Using Aortic Augmentation Index

    PubMed Central

    Beckmann, Marianne; Husmann, Marc

    2015-01-01

    Background Central augmentation index (cAIx) is an indicator for vascular stiffness. Obstructive and aneurysmatic vascular disease can affect pulse wave propagation and reflection, causing changes in central aortic pressures. Aim To assess and compare cAIx in patients with peripheral arterial disease (PAD) and / or abdominal aortic aneurysm (AAA). Methods cAIx was assessed by radial applanation tonometry (Sphygmocor) in a total of 184 patients at a tertiary referral centre. Patients were grouped as having PAD only, AAA only, or both AAA and PAD. Differences in cAIx measurements between the three patient groups were tested by non-parametric tests and stepwise multivariate linear regression analysis to investigate associations with obstructive or aneurysmatic patterns of vascular disease. Results In the study sample of 184 patients, 130 had PAD only, 20 had AAA only, and 34 patients had both AAA and PAD. Mean cAIx (%) was 30.5 8.2 across all patients. It was significantly higher in females (35.2 6.1, n = 55) than males (28.4 8.2, n = 129), and significantly higher in patients over 80 years of age (34.4 6.9, n = 22) than in those under 80 years (30.0 8.2, n = 162). Intergroup comparison revealed a significant difference in cAIx between the three patient groups (AAA: 27.3 9.5; PAD: 31.4 7.8; AAA & PAD: 28.8 8.5). cAIx was significantly lower in patients with AAA, higher in patients with both AAA and PAD, and highest in patients with PAD only (beta = 0.21, p = 0.006). Conclusion Non-invasive assessment of arterial stiffness in high-risk patients indicates that cAIx differs according to the pattern of vascular disease. Measurements revealed significantly higher cAIx values for patients with obstructive peripheral arterial disease than for patients with aneurysmatic disease. PMID:26452151

  1. Usefulness of Relative Hypochromia in Risk Stratification for Nonanemic Patients With Chronic Heart Failure.

    PubMed

    Hammadah, Muhammad; Brennan, Marie-Luise; Wu, Yuping; Hazen, Stanley L; Tang, W H Wilson

    2016-04-15

    The purpose of this study is to investigate the impact of a reduction of hemoglobin (Hb) content in the erythrocytes as estimated by mean corpuscular hemoglobin concentration (MCHC) on long-term clinical outcomes in nonanemic patients with heart failure (HF). We prospectively enrolled 1,579 subjects with HF who underwent coronary angiography enrolled in the GeneBank study with 5-year follow-up of all-cause mortality. Levels of Hb and MCHC were assessed at enrollment and after 6 months of follow-up. Anemia was defined as Hb levels <13 g/dl in men and <12 g/dl in women. In our nonanemic cohort (n = 785, 49.7%), mean Hb and median MCHC were 13.8 ± 1.1 g/dl and 34.3 g/dL (interquartile range 33.6 to 35), respectively. Nonanemic patients with heart failure with lower MCHC had higher mortality risk (quartiles 1 vs 4, hazard ratio = 2.1, 95% confidence interval 1.4 to 3.3, p = 0.001). In a subset of nonanemic patients with persistent normal Hb on follow-up (n = 206), the mean time between baseline and follow-up MCHC levels was 169.3 ± 41.6 days. In comparison with patients with levels of MCHC more than the first quartile (≥33.6 g/dl) on baseline and follow-up, patients with persistently low MCHC (<33.6 g/dl) had a significantly increased mortality risk (log rank <0.001). All models remained significant even after adjusting for traditional cardiac risk factors, left ventricular ejection fraction, baseline Hb levels, and mean corpuscular volume. In conclusion, relative hypochromia is an independent predictor of increased mortality risk in patients with HF, even in the setting of normal Hb levels. PMID:26897638

  2. Novel risk stratification of patients with neuroblastoma by genomic signature, which is independent of molecular signature.

    PubMed

    Tomioka, N; Oba, S; Ohira, M; Misra, A; Fridlyand, J; Ishii, S; Nakamura, Y; Isogai, E; Hirata, T; Yoshida, Y; Todo, S; Kaneko, Y; Albertson, D G; Pinkel, D; Feuerstein, B G; Nakagawara, A

    2008-01-17

    Human neuroblastoma remains enigmatic because it often shows spontaneous regression and aggressive growth. The prognosis of advanced stage of sporadic neuroblastomas is still poor. Here, we investigated whether genomic and molecular signatures could categorize new therapeutic risk groups in primary neuroblastomas. We conducted microarray-based comparative genomic hybridization (array-CGH) with a DNA chip carrying 2464 BAC clones to examine genomic aberrations of 236 neuroblastomas and used in-house cDNA microarrays for gene-expression profiling. Array-CGH demonstrated three major genomic groups of chromosomal aberrations: silent (GGS), partial gains and/or losses (GGP) and whole gains and/or losses (GGW), which well corresponded with the patterns of chromosome 17 abnormalities. They were further classified into subgroups with different outcomes. In 112 sporadic neuroblastomas, MYCN amplification was frequent in GGS (22%) and GGP (53%) and caused serious outcomes in patients. Sporadic tumors with a single copy of MYCN showed the 5-year cumulative survival rates of 89% in GGS, 53% in GGP and 85% in GGW. Molecular signatures also segregated patients into the favorable and unfavorable prognosis groups (P=0.001). Both univariate and multivariate analyses revealed that genomic and molecular signatures were mutually independent, powerful prognostic indicators. Thus, combined genomic and molecular signatures may categorize novel risk groups and confer new clues for allowing tailored or even individualized medicine to patients with neuroblastoma. PMID:17637744

  3. Risk stratification after myocardial infarction. Clinical overview

    SciTech Connect

    O'Rourke, R.A. )

    1991-09-01

    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.

  4. Syncope: risk stratification and clinical decision making.

    PubMed

    Peeters, Suzanne Y G; Hoek, Amber E; Mollink, Susan M; Huff, J Stephen

    2014-04-01

    Syncope is a common occurrence in the emergency department, accounting for approximately 1% to 3% of presentations. Syncope is best defined as a brief loss of consciousness and postural tone followed by spontaneous and complete recovery. The spectrum of etiologies ranges from benign to life threatening, and a structured approach to evaluating these patients is key to providing care that is thorough, yet cost-effective. This issue reviews the most relevant evidence for managing and risk stratifying the syncope patient, beginning with a focused history, physical examination, electrocardiogram, and tailored diagnostic testing. Several risk stratification decision rules are compared for performance in various scenarios, including how age and associated comorbidities may predict short-term and long-term adverse events. An algorithm for structured, evidence-based care of the syncope patient is included to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely. PMID:25105200

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

    PubMed

    Marchaux, Sylvestre; Hachicha, Zeineb; Bellouin, Annak; Dumesnil, Jean G; Meimoun, Patrick; Pasquet, Agns; Bergeron, Sbastien; Arsenault, Marie; Le Tourneau, Thierry; Ennezat, Pierre Vladimir; Pibarot, Philippe

    2010-06-01

    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

  6. Deep vein thrombosis risk stratification.

    PubMed

    Nitta, Daisuke; Mitani, Haruo; Ishimura, Rieko; Moriya, Manabu; Fujimoto, Yo; Ishiwata, Sugao; Yamaguchi, Tetsu; Ohno, Minoru

    2013-01-01

    Pulmonary thromboembolism (PTE) is a life-threatening disease which always presents in patients with deep vein thrombosis (DVT). There are few statements in guidelines regarding indications for anticoagulation based on the location of DVT. We investigated whether the relative risk of PTE depends on thrombus location and bleeding complications with anticoagulation therapy. Between January 1 and July 10, 2007, 461 patients underwent lower extremity venous ultrasound studies, and 129 patients were diagnosed as DVT (60 males, 66.9 13.3 years). We retrospectively studied the incidence of PTE and bleeding complications associated with anticoagulation therapy. Average follow-up period was 536 324 days. Above and below knee thrombosis was present in 60 and 69 patients, respectively. Warfarin was administered in 60 patients. Nine patients developed PTE. Multivariate analysis showed the absence of anticoagulation therapy and location of DVT (above knee) to be significantly correlated with onset of PTE (anticoagulation; P < 0.01, location; P = 0.02). However, the incidence of bleeding was not significantly different between above knee and below knee vein thrombosis (P = 0.72). In conclusion, below knee vein thrombosis carries a relatively low risk of PTE, but the incidence of bleeding complications does not depend on thrombosis location. This suggests that the indication of anticoagulation therapy should be based on DVT location. PMID:23774241

  7. Artificial neural network modeling enhances risk stratification and can reduce downstream testing for patients with suspected acute coronary syndromes, negative cardiac biomarkers, and normal ECGs.

    PubMed

    Isma'eel, Hussain A; Cremer, Paul C; Khalaf, Shaden; Almedawar, Mohamad M; Elhajj, Imad H; Sakr, George E; Jaber, Wael A

    2016-04-01

    Despite uncertain yield, guidelines endorse routine stress myocardial perfusion imaging (MPI) for patients with suspected acute coronary syndromes, unremarkable serial electrocardiograms, and negative troponin measurements. In these patients, outcome prediction and risk stratification models could spare unnecessary testing. This study therefore investigated the use of artificial neural networks (ANN) to improve risk stratification and prediction of MPI and angiographic results. We retrospectively identified 5354 consecutive patients referred from the emergency department for rest-stress MPI after serial negative troponins and normal ECGs. Patients were risk stratified according to thrombolysis in myocardial infarction (TIMI) scores, ischemia was defined as >5 % reversible perfusion defect, and obstructive coronary artery disease was defined as >50 % angiographic obstruction. For ANN, the network architecture employed a systematic method where the number of neurons is changed incrementally, and bootstrapping was performed to evaluate the accuracy of the models. Compared to TIMI scores, ANN models provided improved discriminatory power. With regards to MPI, an ANN model could reduce testing by 59 % and maintain a 96 % negative predictive value (NPV) for ruling out ischemia. Application of an ANN model could also avoid 73 % of invasive coronary angiograms while maintaining a 98 % NPV for detecting obstructive CAD. An online calculator for clinical use was created using these models. The ANN models improved risk stratification when compared to the TIMI score. Our calculator could also reduce downstream testing while maintaining an excellent NPV, though further study is needed before the calculator can be used clinically. PMID:26626458

  8. Pharmacogenetic Risk Stratification in Angiotensin-Converting Enzyme Inhibitor-Treated Patients with Congestive Heart Failure: A Retrospective Cohort Study

    PubMed Central

    Nelveg-Kristensen, Karl Emil; Busk Madsen, Majbritt; Torp-Pedersen, Christian; Køber, Lars; Egfjord, Martin; Berg Rasmussen, Henrik; Riis Hansen, Peter

    2015-01-01

    Background Evidence for pharmacogenetic risk stratification of angiotensin-converting enzyme inhibitor (ACEI) treatment is limited. Therefore, in a cohort of ACEI-treated patients with congestive heart failure (CHF), we investigated the predictive value of two pharmacogenetic scores that previously were found to predict ACEI efficacy in patients with ischemic heart disease and hypertension, respectively. Score A combined single nucleotide polymorphisms (SNPs) of the angiotensin II receptor type 1 gene (rs275651 and rs5182) and the bradykinin receptor B1 gene (rs12050217). Score B combined SNPs of the angiotensin-converting enzyme gene (rs4343) and ABO blood group genes (rs495828 and rs8176746). Methods Danish patients with CHF enrolled in the previously reported Echocardiography and Heart Outcome Study were included. Subjects were genotyped and categorized according to pharmacogenetic scores A and B of ≤1, 2 and ≥3 each, and followed for up to 10 years. Difference in cumulative incidences of cardiovascular death and all-cause death were assessed by the cumulative incidence estimator. Survival was modeled by Cox proportional hazard analyses. Results We included 667 patients, of whom 80% were treated with ACEIs. Differences in cumulative incidences of cardiovascular death (P = 0.346 and P = 0.486) and all-cause death (P = 0.515 and P = 0.486) were not significant for score A and B, respectively. There was no difference in risk of cardiovascular death or all-cause death between subjects with score A ≤1 vs. 2 (HR 1.03 [95% CI 0.79–1.34] and HR 1.11 [95% CI 0.88–1.42]), score A ≤1 vs. ≥3 (HR 0.80 [95% CI 0.59–1.08] and HR 0.91 [95% CI 0.70–1.20]), score B ≤1 vs. 2 (HR 1.02 [95% CI 0.78–1.32] and HR 0.98 [95% CI 0.77–1.24]), and score B ≤1 vs. ≥3 (HR 1.03 [95% CI 0.75–1.41] and HR 1.05 [95% CI 0.79–1.40]), respectively. Conclusions We found no association between either of the analyzed pharmacogenetic scores and fatal outcomes in ACEI-treated patients with CHF. PMID:26633885

  9. Comparison of risk stratification tools in predicting outcomes of patients with higher-risk myelodysplastic syndromes treated with azanucleosides.

    PubMed

    Zeidan, A M; Sekeres, M A; Garcia-Manero, G; Steensma, D P; Zell, K; Barnard, J; Ali, N A; Zimmerman, C; Roboz, G; DeZern, A; Nazha, A; Jabbour, E; Kantarjian, H; Gore, S D; Maciejewski, J P; List, A; Komrokji, R

    2016-03-01

    Established prognostic tools in patients with myelodysplastic syndromes (MDS) were largely derived from untreated patient cohorts. Although azanucleosides are standard therapies for higher-risk (HR)-MDS, the relative prognostic performance of existing prognostic tools among patients with HR-MDS receiving azanucleoside therapy is unknown. In the MDS Clinical Research Consortium database, we compared the prognostic utility of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Prognostic Scoring System (MDAPSS), World Health Organization-based Prognostic Scoring System (WPSS) and the French Prognostic Scoring System (FPSS) among 632 patients who presented with HR-MDS and were treated with azanucleosides as the first-line therapy. Median follow-up from diagnosis was 15.7 months. No prognostic tool predicted the probability of achieving an objective response. Nonetheless, all five tools were associated with overall survival (OS, P=0.025 for the IPSS, P=0.011 for WPSS and P<0.001 for the other three tools). The corrected Akaike Information Criteria, which were used to compare OS with the different prognostic scoring systems as covariates (lower is better) were 4138 (MDAPSS), 4156 (FPSS), 4196 (IPSS-R), 4186 (WPSS) and 4196 (IPSS). Patients in the highest-risk groups of the prognostic tools had a median OS from diagnosis of 11-16 months and should be considered for up-front transplantation or experimental approaches. PMID:26464171

  10. Comparison of risk stratification tools in predicting outcomes of patients with higher-risk myelodysplastic syndromes treated with azanucleosides

    PubMed Central

    Zeidan, AM; Sekeres, MA; Garcia-Manero, G; Steensma, DP; Zell, K; Barnard, J; Ali, NA; Zimmerman, C; Roboz, G; DeZern, A; Nazha, A; Jabbour, E; Kantarjian, H; Gore, SD; Maciejewski, JP; List, A; Komrokji, R

    2016-01-01

    Established prognostic tools in patients with myelodysplastic syndromes (MDS) were largely derived from untreated patient cohorts. Although azanucleosides are standard therapies for higher-risk (HR)-MDS, the relative prognostic performance of existing prognostic tools among patients with HR-MDS receiving azanucleoside therapy is unknown. In the MDS Clinical Research Consortium database, we compared the prognostic utility of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Prognostic Scoring System (MDAPSS), World Health Organization-based Prognostic Scoring System (WPSS) and the French Prognostic Scoring System (FPSS) among 632 patients who presented with HR-MDS and were treated with azanucleosides as the first-line therapy. Median follow-up from diagnosis was 15.7 months. No prognostic tool predicted the probability of achieving an objective response. Nonetheless, all five tools were associated with overall survival (OS, P = 0.025 for the IPSS, P = 0.011 for WPSS and P < 0.001 for the other three tools). The corrected Akaike Information Criteria, which were used to compare OS with the different prognostic scoring systems as covariates (lower is better) were 4138 (MDAPSS), 4156 (FPSS), 4196 (IPSS-R), 4186 (WPSS) and 4196 (IPSS). Patients in the highest-risk groups of the prognostic tools had a median OS from diagnosis of 11 16 months and should be considered for up-front transplantation or experimental approaches. PMID:26464171

  11. Risk Stratification in Differentiated Thyroid Cancer: An Ongoing Process

    PubMed Central

    Omry-Orbach, Gal

    2016-01-01

    Thyroid cancer is an increasingly common malignancy, with a rapidly rising prevalence worldwide. The social and economic ramifications of the increase in thyroid cancer are multiple. Though mortality from thyroid cancer is low, and most patients will do well, the risk of recurrence is not insignificant, up to 30%. Therefore, it is important to accurately identify those patients who are more or less likely to be burdened by their disease over years and tailor their treatment plan accordingly. The goal of risk stratification is to do just that. The risk stratification process generally starts postoperatively with histopathologic staging, based on the AJCC/UICC staging system as well as others designed to predict mortality. These do not, however, accurately assess the risk of recurrence/persistence. Patients initially considered to be at high risk may ultimately do very well yet be burdened by frequent unnecessary monitoring. Conversely, patients initially thought to be low risk, may not respond to their initial treatment as expected and, if left unmonitored, may have higher morbidity. The concept of risk-adaptive management has been adopted, with an understanding that risk stratification for differentiated thyroid cancer is dynamic and ongoing. A multitude of variables not included in AJCC/UICC staging are used initially to classify patients as low, intermediate, or high risk for recurrence. Over the course of time, a response-to-therapy variable is incorporated, and patients essentially undergo continuous risk stratification. Additional tools such as biochemical markers, genetic mutations, and molecular markers have been added to this complex risk stratification process such that this is essentially a continuum of risk. In recent years, additional considerations have been discussed with a suggestion of pre-operative risk stratification based on certain clinical and/or biologic characteristics. With the increasing prevalence of thyroid cancer but stable mortality, this risk stratification may identify those in whom the risk of conventional surgical treatment may outweigh the benefit. This review aims to outline the process of risk stratification and highlight the important concepts that are involved and those that are continuously evolving. PMID:26886959

  12. Development of a Risk Stratification Model for Delayed Inpatient Recovery of Physical Activities in Patients Undergoing Total Hip Replacement.

    PubMed

    Elings, Jordi; van der Sluis, Geert; Goldbohm, R Alexandra; Galindo Garre, Francisca; de Gast, Arthur; Hoogeboom, Thomas; van Meeteren, Nico L U

    2016-03-01

    Study Design Prospective cohort design using data derived from usual care. Background It is important that patients are able to function independently as soon as possible after total hip replacement. However, the speed of regaining activities differs significantly. Objectives To develop a risk stratification model (RSM) to predict delayed inpatient recovery of physical activities in people who underwent total hip replacement surgery. Methods This study was performed in 2 routine orthopaedic settings: Diakonessenhuis Hospital (setting A) and Nij Smellinghe Hospital (setting B). Preoperative screening was performed for all consecutive patients. In-hospital recovery of activities was assessed with the Modified Iowa Level of Assistance Scale. Delayed inpatient recovery of activities was defined as greater than 5 days. The RSM, developed using logistic regression analysis and bootstrapping, was based on data from setting A (n = 154). External validation was performed on the data set from setting B (n = 271). Results Twenty-one percent of the patients in setting A had a delayed recovery of activities during their hospital stay. Multivariable logistic regression modeling yielded a preliminary RSM that included the following factors: male sex (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.2, 2.6), 70 or more years of age (OR = 1.2; 95% CI: 0.4, 3.4), body mass index of 25 kg/m(2) or greater (OR = 2.2; 95% CI: 0.7, 7.4), an American Society of Anesthesiologists score of 3 (OR = 1.2; 95% CI: 0.3, 4.4), a Charnley score of B or C (OR = 6.1; 95% CI: 2.2, 17.4), and a timed up-and-go score of 12.5 seconds or greater (OR = 3.1; 95% CI: 1.1, 9.0). The area under the receiver operating characteristic (ROC) curve was 0.82 (95% CI: 0.74, 0.90) and the Hosmer-Lemeshow test score was 3.57 (P>.05). External validation yielded an area under the ROC curve of 0.71 (95% CI: 0.61, 0.81). Conclusion We demonstrated that the risk for delayed recovery of activities during the hospital stay can be predicted by using preoperative data. Level of Evidence Prognosis, level 1b. J Orthop Sports Phys Ther 2016;46(3):135-143. Epub 26 Jan 2016. doi:10.2519/jospt.2016.6124. PMID:26813752

  13. Mechanical thromboembolic prophylaxis with risk stratification in total knee arthroplasty.

    PubMed

    Hamilton, William G; Reeves, James D; Fricka, Kevin B; Goyal, Nitin; Engh, Gerard A; Parks, Nancy L

    2015-01-01

    The purpose of this study was to determine the rate of thromboembolic and bleeding complications when using mechanical prophylaxis with preoperative risk stratification following total knee arthroplasty (TKA). Between 1994 and 2007, 4037 TKAs were performed on 3144 patients at our institution. Mechanical VTE prophylaxis was used for standard risk patients, which included AV impulse foot pumps, thigh high stockings, and early mobilization. Chemoprophylaxis was only given to patients who were at increased thromboembolic risk. The incidence of DVT identified by ultrasound following TKA was 2.1%. A retrospective review showed 1 patient had a fatal pulmonary embolism, and 5 patients had bleeding complications in the knee. We conclude that mechanical thromboembolic prophylaxis using risk stratification is safe and effective following TKA. PMID:25224874

  14. Genetic markers used for risk stratification in multiple myeloma.

    PubMed

    Segges, Priscilla; Braggio, Esteban

    2011-01-01

    While no specific genetic markers are required in the diagnosis of multiple myeloma (MM), multiple genetic abnormalities and gene signatures are used in disease prognostication and risk stratification. This is particularly important for the adequate identification of the high-risk MM group, which does not benefit from any of the current therapies, and novel approaches need to be proposed. Fluorescence in situ hybridization (FISH) has been employed for establishing risk-based stratification and still remains the most used genetic technique in the clinical routine. The incorporation of gene expression profiling (GEP) in the study of MM has shown to be a very powerful test in the patient stratification, but its incorporation in clinical routine depends on some technical and logistic resolutions. Thus, FISH still remains the gold standard test for detecting genomic abnormalities and outcome discrimination in MM. PMID:22567368

  15. Risk Stratification for Sudden Cardiac Death: Current Approaches and Predictive Value

    PubMed Central

    Lopera, Gustavo; Curtis, Anne B.

    2009-01-01

    Sudden cardiac death (SCD) is a serious public health problem; the annual incidence of out-of-hospital cardiac arrest in North America is approximately 166,200. Identifying patients at risk is a difficult proposition. At the present time, left ventricular ejection fraction (LVEF) remains the single most important marker for risk stratification. According to current guidelines, most patients with LVEF <35% could benefit from prophylactic ICD implantation, particularly in the setting of symptomatic heart failure. Current risk stratification strategies fail to identify patients at risk of SCD in larger population groups encompassing a greater number of potential SCD victims. However, the best approach to identifying patients and the value of various risk stratification tools is not entirely clear. The goal of this review is to discuss the problem of SCD and the value of the different risk stratification markers and their potential clinical use either alone or in combination with other risk stratification markers. PMID:20066150

  16. Percutaneous biopsy for risk stratification of renal masses

    PubMed Central

    Blute, Michael L.; Drewry, Anna

    2015-01-01

    The increased use of abdominal imaging has led to identification of more patients with incidental renal masses, and renal mass biopsy (RMB) has become a popular method to evaluate unknown renal masses prior to definitive treatment. Pathologic data obtained from biopsy may be used to guide decisions for treatment and may include the presence or absence of malignant tumor, renal cell cancer subtype, tumor grade and the presence of other aggressive pathologic features. However, prior to using RMB for risk stratification, it is important to understand whether RMB findings are equivalent to pathologic analysis of surgical specimens and to identify any potential limitations of this approach. This review outlines the advantages and limitations of the current studies that evaluate RMB as a guide for treatment decision in patients with unknown renal masses. In multiple series, RMB has demonstrated low morbidity and a theoretical reduction in cost, if patients with benign tumors are identified from biopsy and can avoid subsequent treatment. However, when considering the routine use of RMB for risk stratification, it is important to note that biopsy may underestimate risk in some patients by undergrading, understaging or failing to identify aggressive tumor features. Future studies should focus on developing treatment algorithms that integrate RMB to identify the optimal use in risk stratification of patients with unknown renal masses. PMID:26425141

  17. Percutaneous biopsy for risk stratification of renal masses.

    PubMed

    Blute, Michael L; Drewry, Anna; Abel, Edwin Jason

    2015-10-01

    The increased use of abdominal imaging has led to identification of more patients with incidental renal masses, and renal mass biopsy (RMB) has become a popular method to evaluate unknown renal masses prior to definitive treatment. Pathologic data obtained from biopsy may be used to guide decisions for treatment and may include the presence or absence of malignant tumor, renal cell cancer subtype, tumor grade and the presence of other aggressive pathologic features. However, prior to using RMB for risk stratification, it is important to understand whether RMB findings are equivalent to pathologic analysis of surgical specimens and to identify any potential limitations of this approach. This review outlines the advantages and limitations of the current studies that evaluate RMB as a guide for treatment decision in patients with unknown renal masses. In multiple series, RMB has demonstrated low morbidity and a theoretical reduction in cost, if patients with benign tumors are identified from biopsy and can avoid subsequent treatment. However, when considering the routine use of RMB for risk stratification, it is important to note that biopsy may underestimate risk in some patients by undergrading, understaging or failing to identify aggressive tumor features. Future studies should focus on developing treatment algorithms that integrate RMB to identify the optimal use in risk stratification of patients with unknown renal masses. PMID:26425141

  18. Value of reserve pulse pressure in improving the risk stratification of patients with normal myocardial perfusion imaging

    PubMed Central

    Thomas, Deepak; Al-Mallah, Mouaz; Govindarajulu, Usha; Forman, Daniel E.; Mora, Samia; Di Carli, Marcelo F.; Dorbala, Sharmila

    2013-01-01

    Aims To evaluate the incremental prognostic value of reserve-pulse pressure (reserve-PP: exercise-PP minus rest-PP) to standard risk factors among patients with suspected coronary artery disease (CAD) but normal exercise myocardial perfusion imaging (MPI). Methods and results We studied 4269 consecutive symptomatic patients without known CAD who were referred for exercise MPI but had normal MPI results (mean age 58 12 years, 56% females, 84% referred for evaluation of chest pain or dyspnoea, 95% with intermediate pretest likelihood of CAD). There were 202 deaths over 5.1 1.4 years of follow-up. Reserve-PP was abnormal (<44 mmHg increase in PP from rest) in 1894 patients (44%). Patients with an abnormal reserve-PP had a higher risk of death compared with patients with normal reserve-PP [hazard ratio (HR): 2.47, 95% CI, 1.83.3]. In multivariable models adjusting for age, sex, ejection fraction, medications, heart rate recovery, Duke treadmill score (DTS), and rest-PP, each 10 mmHg lower reserve-PP was associated with a 20.6% increase in risk-adjusted mortality (adjusted HR 0.83, 95% CI 0.760.91). Models incorporating reserve-PP significantly reclassified risk compared with models without these parameters (net reclassification index 14.3%, P = 0.0007; integrated discrimination index 0.69, P = 0.01). Conclusion In patients without a history of CAD and a normal MPI, an abnormal reserve-PP identified and reclassified those at higher risk of death independent of known risk factors and DTS. PMID:23539339

  19. Risk stratification model in elderly patients with multiple myeloma: clinical role of magnetic resonance imaging combined with international staging system and cytogenetic abnormalities.

    PubMed

    Song, Moo-Kon; Chung, Joo-Seop; Lee, Je-Jung; Lee, Jae-Hoon; Song, Ik-Chan; Lee, Sang-Min; Shin, Dong-Yeop; Lee, Gyeong-Won; Lee, In-Sook

    2015-01-01

    The International Staging System (ISS) does not take into consideration the clinical role of imaging modalities in multiple myeloma (MM), even though these are important. Some studies have indicated a lack of impact of ISS in MM patients who receive novel agents. Therefore, accessible novel risk stratification might be needed in elderly MM patients receiving conventional therapy or novel agents. We analyzed 198 newly diagnosed and symptomatic MM patients who were not eligible for transplantation. The initial treatment regimen was therapy with melphalan-prednisone (MP, n = 44), thalidomide-cyclophosphamide-dexamethasone (n = 89) or bortezomib-MP (VMP, n = 65). The magnetic resonance imaging (MRI) pattern was normal in 34 patients, focal in 30 and diffuse/variegated in 134. High-risk cytogenetic abnormalities were not associated with the diffuse/variegated MRI pattern (p = 0.182). ISS stage III [progression-free survival (PFS) p = 0.005; overall survival (OS) p = 0.027], high-risk cytogenetic abnormalities (PFS p = 0.001; OS p < 0.001) and diffuse/variegated MRI pattern (PFS p < 0.001; OS p < 0.001) were independently associated with poorer PFS and OS. Patients were further stratified according to the 3 prognostic factors. The PFS and OS of the 3 groups differed significantly. The addition of the diffuse/variegated MRI pattern may improve the prognostic potential of the current staging system which includes ISS and cytogenetic abnormalities. PMID:25832367

  20. Distant Metastasis Risk Stratification for Patients Undergoing Curative Resection Followed by Adjuvant Chemoradiation for Extrahepatic Bile Duct Cancer

    SciTech Connect

    Kim, Kyubo; Chie, Eui Kyu; Jang, Jin-Young; Kim, Sun Whe; Han, Sae-Won; Oh, Do-Youn; Im, Seock-Ah; Kim, Tae-You; Bang, Yung-Jue; Ha, Sung W.; Institute of Radiation Medicine, Medical Research Center, Seoul National University

    2012-09-01

    Purpose: To analyze the prognostic factors predicting distant metastasis in patients undergoing adjuvant chemoradiation for extrahepatic bile duct (EHBD) cancer. Methods and Materials: Between January 1995 and August 2006, 166 patients with EHBD cancer underwent resection with curative intent, followed by adjuvant chemoradiation. There were 120 males and 46 females, and median age was 61 years (range, 34-86). Postoperative radiotherapy was delivered to tumor bed and regional lymph nodes (median dose, 40 Gy; range, 34-56 Gy). A total of 157 patients also received fluoropyrimidine chemotherapy as a radiosensitizer, and fluoropyrimidine-based maintenance chemotherapy was administered to 127 patients. Median follow-up duration was 29 months. Results: The treatment failed for 97 patients, and the major pattern of failure was distant metastasis (76 patients, 78.4%). The 5-year distant metastasis-free survival rate was 49.4%. The most common site of distant failure was the liver (n = 36). On multivariate analysis, hilar tumor, tumor size {>=}2 cm, involved lymph node, and poorly differentiated tumor were associated with inferior distant metastasis-free survival (p = 0.0348, 0.0754, 0.0009, and 0.0078, respectively), whereas T stage was not (p = 0.8081). When patients were divided into four groups based on these risk factors, the 5-year distant metastasis-free survival rates for patients with 0, 1, 2, and 3 risk factors were 86.4%, 59.9%, 32.5%, and 0%, respectively (p < 0.0001). Conclusion: Despite maintenance chemotherapy, distant metastasis was the major pattern of failure in patients undergoing adjuvant chemoradiation for EHBD cancer after resection with curative intent. Intensified chemotherapy is warranted to improve the treatment outcome, especially in those with multiple risk factors.

  1. Thyroid Incidentalomas: Epidemiology, Risk Stratification with Ultrasound and Workup

    PubMed Central

    Russ, Gilles; Leboulleux, Sophie; Leenhardt, Laurence; Hegeds, Laszlo

    2014-01-01

    A thyroid incidentaloma is an unexpected, asymptomatic thyroid tumor fortuitously discovered during the investigation of an unrelated condition. The prevalence rate is 67% with ultrasonography (US) imaging, 15% with computed tomography (CT) or magnetic resonance imaging (MRI) of the neck, and 1-2% with fluorodeoxyglucose (FDG) positron emission tomography. In the absence of a history of external beam radiation or familial medullary thyroid cancer, the risk of malignancy ranges between 5 and 13% when discovered with US, CT or MRI, but is much higher if based on focal FDG uptake (30%). All patients with a thyroid incidentaloma, independent of the mode of detection, should undergo a dedicated neck US with risk stratification: US imaging allows a quantitative risk stratification of malignancy in thyroid nodules, named reporting system or TIRADs' (thyroid imaging reporting and data system). The reported sensitivity ranges from 87 to 95% for the detection of carcinomas and the negative predictive value from 88 to 99.8%. We suggest that the indications for fine-needle aspiration be based mainly on size and US risk stratification. However, the diagnosis and workup of thyroid incidentalomas leads to superfluous surgery for benign conditions, and excess diagnosis and treatment of papillary microcarcinomas, the vast majority of which would cause no harm. Recognizing this must form the basis of any decision as to supplementary investigations and whether to offer therapy, in a close dialogue between patient and physician. The current use of minimally invasive nonsurgical ablation options, as alternatives to surgery, is highlighted. PMID:25538897

  2. Spontaneous baroreceptor reflex sensitivity for risk stratification of heart failure patients: optimal cut-off and age effects.

    PubMed

    Gouveia, Sónia; Scotto, Manuel G; Pinna, Gian Domenico; Maestri, Roberto; La Rovere, Maria Teresa; Ferreira, Paulo J S G

    2015-12-01

    Baroreceptor reflex sensitivity (BRS) is an important prognostic factor because a reduced BRS has been associated with an adverse cardiovascular outcome. The threshold for a 'reduced' BRS was established by the ATRAMI study at BRS <3 ms/mmHg in patients with a previous myocardial infarction, and has been shown to improve risk assessment in many other cardiac dysfunctions. The successful application of this cut-off to other populations suggests that it may reflect an inherent property of baroreflex functioning, so our goal is to investigate whether it represents a 'natural' partition of BRS values. As reduced baroreflex responsiveness is also associated with ageing, we investigated whether a BRS estimate <3 ms/mmHg could be the result of a process of physiological senescence as well as a sign of BRS dysfunction. This study involved 228 chronic heart failure patients and 60 age-matched controls. Our novel method combined transfer function BRS estimation and automatic clustering of BRS probability distributions, to define indicative levels of different BRS activities. The analysis produced a fit clustering (cophenetic correlation coefficient 0.9 out of 1) and identified one group of homogeneous patients (well separated from the others by 3 ms/mmHg) with an increased BRS-based mortality risk [hazard ratio (HR): 3.19 (1.73, 5.89), P<0.001]. The age-dependent BRS cut-off, estimated by 5% quantile regression of log (BRS) with age (considering the age-matched controls), provides a similar mortality value [HR: 2.44 (1.37, 4.43), P=0.003]. In conclusion, the 3 ms/mmHg cut-off identifies two large clusters of homogeneous heart failure (HF) patients, thus supporting the hypothesis of a natural cut-off in the HF population. Furthermore, age was found to have no statistical impact on risk assessment, suggesting that there is no need to establish age-based cut-offs because 3 ms/mmHg optimally identifies patients at high mortality risk. PMID:26432088

  3. Outcome of azacitidine treatment in patients with therapy-related myeloid neoplasms with assessment of prognostic risk stratification models.

    PubMed

    Duong, Vu H; Lancet, Jeffrey E; Alrawi, Ezzideen; Al-Ali, Najla H; Perkins, Janelle; Field, Teresa; Epling-Burnette, Pearlie K; Zhang, Ling; List, Alan F; Komrokji, Rami S

    2013-05-01

    Azacitidine's efficacy in therapy-related myeloid neoplasms (t-MN) has not been well-studied. In our retrospective review of 84 t-MN patients treated with azacitidine, median overall survival (OS) was 14.5 months and overall response rate was 43%, including 11% complete remission, 4% marrow complete remission, and 11% partial remission. In patients who underwent allogeneic transplant (25%), median OS was 19.2 versus 12.8 months (P=0.023) for those who did not. Response rates were comparable to those reported for de novo myelodysplastic syndrome. When we analyzed outcomes according to five scoring systems, only the Global MD Anderson Risk Model predicted survival with statistical significance. PMID:23332452

  4. Cardiac risk stratification in cardiac rehabilitation programs: a review of protocols

    PubMed Central

    da Silva, Anne Kastelianne França; Barbosa, Marianne Penachini da Costa de Rezende; Bernardo, Aline Fernanda Barbosa; Vanderlei, Franciele Marques; Pacagnelli, Francis Lopes; Vanderlei, Luiz Carlos Marques

    2014-01-01

    Objective Gather and describe general characteristics of different protocols of risk stratification for cardiac patients undergoing exercise. Methods We conducted searches in LILACS, IBECS, MEDLINE, Cochrane Library, and SciELO electronic databases, using the following descriptors: Cardiovascular Disease, Rehabilitation Centers, Practice Guideline, Exercise and Risk Stratification in the past 20 years. Results Were selected eight studies addressing methods of risk stratification in patients undergoing exercise. Conclusion None of the methods described could cover every situation the patient can be subjected to; however, they are essential to exercise prescription. PMID:25140477

  5. Ventricular repolarization measures for arrhythmic risk stratification

    PubMed Central

    Monitillo, Francesco; Leone, Marta; Rizzo, Caterina; Passantino, Andrea; Iacoviello, Massimo

    2016-01-01

    Ventricular repolarization is a complex electrical phenomenon which represents a crucial stage in electrical cardiac activity. It is expressed on the surface electrocardiogram by the interval between the start of the QRS complex and the end of the T wave or U wave (QT). Several physiological, pathological and iatrogenic factors can influence ventricular repolarization. It has been demonstrated that small perturbations in this process can be a potential trigger of malignant arrhythmias, therefore the analysis of ventricular repolarization represents an interesting tool to implement risk stratification of arrhythmic events in different clinical settings. The aim of this review is to critically revise the traditional methods of static analysis of ventricular repolarization as well as those for dynamic evaluation, their prognostic significance and the possible application in daily clinical practice. PMID:26839657

  6. Stratification and Risk Reduction of Perioperative Acute Kidney Injury.

    PubMed

    Ishag, Selma; Thakar, Charuhas V

    2016-03-01

    Perioperative acute kidney injury (AKI) is associated with an increased morbidity and mortality. The incidence of AKI varies depending on preoperative risk factors and the surgical setting. Preoperative risk stratification is critical for informed consent and perioperative planning. Perioperative renal protection strategies are potentially invaluable in the prevention of AKI. Current advances in the development of biomarkers may offer the opportunity for early diagnosis and the implementation of therapeutic strategies. Increased awareness and concerted efforts by all perioperative physicians are needed to provide an improved outcome for surgical patients. PMID:26927741

  7. Clinical Risk Stratification for Primary Prevention Implantable Cardioverter Defibrillators

    PubMed Central

    Hardy, Judy; Yee, Raymond; Healey, Jeffrey S.; Birnie, David; Simpson, Christopher S.; Crystal, Eugene; Mangat, Iqwal; Nanthakumar, Kumaraswamy; Wang, Xuesong; Krahn, Andrew D.; Dorian, Paul; Austin, Peter C.; Tu, Jack V.

    2015-01-01

    Background A conceptualized model may be useful for understanding risk stratification of primary prevention implantable cardioverter defibrillators considering the competing risks of appropriate implantable cardioverter defibrillator shock versus mortality. Methods and Results In a prospective, multicenter, population-based cohort with left ventricular ejection fraction ?35% referred for primary prevention implantable cardioverter defibrillator, we developed dual risk stratification models to determine the competing risks of appropriate defibrillator shock versus mortality using a Fine-Gray subdistribution hazard model. Among 7020 patients referred, 3445 underwent defibrillator implant (79.7% men, median, 66 years [25th, 75th: 5873]). During 5918 person-years of follow-up, appropriate shock occurred in 204 patients (3.6 shocks/100 person-years) and 292 died (4.9 deaths/100 person-years). Competing risk predictors of appropriate shock included nonsustained ventricular tachycardia, atrial fibrillation, serum creatinine concentration, digoxin or amiodarone use, and QRS duration near 130-ms peak. One-year cumulative incidence of appropriate shock was 0.9% in the lowest risk category, and 1.7%, 2.5%, 4.9%, and 9.3% in low, intermediate, high, and highest risk groups, respectively. Hazard ratios for appropriate shock ranged from 4.04 to 7.79 in the highest 3 deciles (all P?0.001 versus lowest risk). Cumulative incidence of 1-year death was 0.6%, 1.9%, 3.3%, 6.2%, and 17.7% in lowest, low, intermediate, high, and highest risk groups, respectively. Mortality hazard ratios ranged from 11.48 to 36.22 in the highest 3 deciles (all P<0.001 versus lowest risk). Conclusions Simultaneous estimation of risks of appropriate shock and mortality can be performed using clinical variables, providing a potential framework for identification of patients who are unlikely to benefit from prophylactic implantable cardioverter defibrillator. PMID:26224792

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

    PubMed Central

    Kones, Richard

    2010-01-01

    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

  9. Risk stratification for wilms tumor: current approach and future directions.

    PubMed

    Dome, Jeffrey S; Perlman, Elizabeth J; Graf, Norbert

    2014-01-01

    Wilms tumor, or nephroblastoma, has provided a paradigm for progressive improvement in clinical outcomes achieved through serial cooperative group studies. With modern surgery, chemotherapy, and radiation therapy approaches, the overall survival rate for patients with Wilms tumor has reached 90%. Remarkably, the increase in survival has been achieved with a reduction in therapy for most patient subgroups, leading not only to more survivors, but also to healthier survivors. A key contributor to improved outcomes has been the development of clinical and biologic prognostic markers that have enabled risk-directed therapy. Whereas the early cooperative group studies used only tumor stage for risk stratification, current Children's Oncology Group (COG) and International Society of Pediatric Oncology (SIOP) protocols employ a multitude of prognostic factors to guide therapy. Prognostic factors used in the current generation of COG studies include stage, histology, patient age, tumor weight, completeness of lung nodule response, and loss of heterozygosity at chromosomes 1p and 16q. Future COG studies seek to incorporate gain of chromosome 1q and methylation pattern of chromosome 11p15 into the risk classification schema. Prognostic factors used in the current SIOP studies include stage, histology, tumor volume, and responsiveness to therapy. Future SIOP studies seek to incorporate absolute blastemal volume and novel molecular markers for resistant blastema into the risk stratification approach. PMID:24857079

  10. Risk stratification in non-ST elevation acute coronary syndromes: Risk scores, biomarkers and clinical judgment

    PubMed Central

    Corcoran, David; Grant, Patrick; Berry, Colin

    2015-01-01

    Undifferentiated chest pain is one of the most common reasons for emergency department attendance and admission to hospitals. Non-ST elevation acute coronary syndrome (NSTE-ACS) is an important cause of chest pain, and accurate diagnosis and risk stratification in the emergency department must be a clinical priority. In the future, the incidence of NSTE-ACS will rise further as higher sensitivity troponin assays are implemented in clinical practice. In this article, we review contemporary approaches for the diagnosis and risk stratification of NSTE-ACS during emergency care. We consider the limitations of current practices and potential improvements. Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE) risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom), in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment. PMID:26753174

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

    SciTech Connect

    Nanda, Akash Chen, M.-H.; Renshaw, Andrew A.; D'Amico, Anthony V.

    2009-08-01

    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.

  12. Biomarkers for Risk Stratification of Neoplastic Progression in Barrett Esophagus

    PubMed Central

    Kerkhof, Marjon; Kusters, Johannes G.; van Dekken, Herman; Kuipers, Ernst J.; Siersema, Peter D.

    2007-01-01

    Barrett esophagus (BE) is caused by chronic gastroesophageal reflux and predisposes to the development of esophageal adenocarcinoma through different grades of dysplasia. Only a subset of BE patients will finally develop esophageal adenocarcinoma. The majority will therefore not benefit from an endoscopic surveillance program, based on the histological identification of dysplasia. Several studies have been performed to find additional biomarkers that can be used to detect the subgroup of patients with an increased risk of developing malignancy in BE. In this review, we will summarize the most promising tissue biomarkers, i.e. proliferation/cell cycle proteins, tumor suppressor genes, adhesion molecules, DNA ploidy status and inflammation associated markers, that can be used for risk stratification in BE, and discuss their respective clinical application. PMID:18032827

  13. Risk stratification by p16 immunostaining of CIN1 biopsies: a retrospective study of patients from the quadrivalent HPV vaccine trials.

    PubMed

    Mills, Anne M; Paquette, Cherie; Castle, Philip E; Stoler, Mark H

    2015-05-01

    Previous studies of p16 immunohistochemistry (IHC) on CIN1 have suggested the likely utility of p16 in stratification of women at risk for subsequent CIN2/3. But those studies had limitations in statistical power, histologic diagnosis, and disease ascertainment. We conducted a retrospective study of p16 IHC on adjudicated CIN1 tissue diagnosed in young women participating in the placebo arm of the quadrivalent human papillomavirus (HPV) vaccine trials. Tissue sections were stained with p16 IHC and hematoxylin and eosin. p16 IHC was scored using LAST criteria, and hematoxylin and eosin-stained sections were reviewed for concordance with the adjudicated diagnosis. p16 IHC, antecedent high-grade cytology, review diagnosis, and HPV16 detection were assessed as independent risk factors for subsequent CIN2/3. Five hundred twenty-four patients with CIN1 biopsies and complete data were identified, 63 (12.0%) of whom developed CIN2/3 in follow-up. p16 positivity (P=0.06), review diagnosis of CIN2/3 (P=0.04), HPV16 positivity (P=0.01), and antecedent high-grade cytology (P=0.02) were (marginally) associated with CIN2/3. In a logistic regression model, the associations with CIN2/3 (vs. other), expressed as odds ratios (95% confidence intervals), were 1.6 (0.91-2.8) for p16, 2.0 (1.0-3.7) for HPV16, and 2.2 (1.1-2.4) for antecedent high-grade cytology. The mean risks for CIN2/3 estimated from the model ranged from 7.6% for negative for all markers to 36.3% for positive for all 3 markers. p16 IHC does not risk stratify CIN1 patients in a manner that would alter recommended management for CIN1. This reinforces the LAST recommendations that p16 should only be used selectively for problematic scenarios, such as CIN2 because of its inherent lack of reproducibility, cases in which one is struggling between CIN1 and CIN2, and benign mimics of CIN3. PMID:25602791

  14. Role of risk stratification by SPECT, PET, and hybrid imaging in guiding management of stable patients with ischaemic heart disease: expert panel of the EANM cardiovascular committee and EACVI.

    PubMed

    Acampa, Wanda; Gaemperli, Oliver; Gimelli, Alessia; Knaapen, Paul; Schindler, Thomas H; Verberne, Hein J; Zellweger, Michael J

    2015-12-01

    Risk stratification has become increasingly important in the management of patients with suspected or known ischaemic heart disease (IHD). Recent guidelines recommend that these patients have their care driven by risk assessment. The purpose of this position statement is to summarize current evidence on the value of cardiac single-photon emission computed tomography, positron emission tomography, and hybrid imaging in risk stratifying asymptomatic or symptomatic patients with suspected IHD, patients with stable disease, patients after coronary revascularization, heart failure patients, and specific patient population. In addition, this position statement evaluates the impact of imaging results on clinical decision-making and thereby its role in patient management. The document represents the opinion of the European Association of Nuclear Medicine (EANM) Cardiovascular Committee and of the European Association of Cardiovascular Imaging (EACVI) and intends to stimulate future research in this field. PMID:25902767

  15. Standardized Reporting Guidelines for Emergency Department Syncope Risk Stratification Research

    PubMed Central

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

    2012-01-01

    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. PMID:22687184

  16. Simplified risk stratification criteria for identification of patients with MRSA bacteremia at low risk of infective endocarditis: implications for avoiding routine transesophageal echocardiography in MRSA bacteremia.

    PubMed

    Buitron de la Vega, P; Tandon, P; Qureshi, W; Nasr, Y; Jayaprakash, R; Arshad, S; Moreno, D; Jacobsen, G; Ananthasubramaniam, K; Ramesh, M; Zervos, M

    2016-02-01

    The aim of this study was to identify patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with low risk of infective endocarditis (IE) who might not require routine trans-esophageal echocardiography (TEE). We retrospectively evaluated 398 patients presenting with MRSA bacteremia for the presence of the following clinical criteria: intravenous drug abuse (IVDA), long-term catheter, prolonged bacteremia, intra-cardiac device, prosthetic valve, hemodialysis dependency, vertebral/nonvertebral osteomyelitis, cardio-structural abnormality. IE was diagnosed using the modified Duke criteria. Of 398 patients with MRSA bacteremia, 26.4% of cases were community-acquired, 56.3% were health-care-associated, and 17.3% were hospital-acquired. Of the group, 44 patients had definite IE, 119 had possible IE, and 235 had a rejected diagnosis. Out of 398 patients, 231 were evaluated with transthoracic echocardiography (TTE) or TEE. All 44 patients with definite IE fulfilled at least one criterion (sensitivity 100%). Finally, a receiver operator characteristic (ROC) curve was obtained to evaluate the total risk score of our proposed criteria as a predictor of the presence of IE, and this was compared to the ROC curve of a previously proposed criteria. The area under the ROC curve for our criteria was 0.710, while the area under the ROC curve for the criteria previously proposed was 0.537 (p?Patients with MRSA bacteremia without any of our proposed clinical criteria have very low risk of developing IE and may not require routine TEE. PMID:26676855

  17. Novel Molecular Imaging Approaches to Abdominal Aortic Aneurysm Risk Stratification.

    PubMed

    Toczek, Jakub; Meadows, Judith L; Sadeghi, Mehran M

    2016-01-01

    Selection of patients for abdominal aortic aneurysm repair is currently based on aneurysm size, growth rate, and symptoms. Molecular imaging of biological processes associated with aneurysm growth and rupture, for example, inflammation and matrix remodeling, could improve patient risk stratification and lead to a reduction in abdominal aortic aneurysm morbidity and mortality. (18)F-fluorodeoxyglucose-positron emission tomography and ultrasmall superparamagnetic particles of iron oxide magnetic resonance imaging are 2 novel approaches to abdominal aortic aneurysm imaging evaluated in clinical trials. A variety of other tracers, including those that target inflammatory cells and proteolytic enzymes (eg, integrin ?v?3 and matrix metalloproteinases), have proven effective in preclinical models of abdominal aortic aneurysm and show great potential for clinical translation. PMID:26763279

  18. Stratification of ALS patients' survival: a population-based study.

    PubMed

    Marin, Benoît; Couratier, Philippe; Arcuti, Simona; Copetti, Massimiliano; Fontana, Andrea; Nicol, Marie; Raymondeau, Marie; Logroscino, Giancarlo; Preux, Pierre Marie

    2016-01-01

    The natural history of amyotrophic lateral sclerosis (ALS) and patient risk stratification are areas of considerable research interest. We aimed (1) to describe the survival of a representative cohort of French ALS patients, and (2) to identify covariates associated with various patterns of survival using a risk classification analysis. ALS patients recruited in the FRALim register (2000-2013) were included. Time-to-death analyses were performed using Kaplan-Meier method and Cox model. A recursive partitioning and amalgamation (RECPAM) algorithm analysis identified subgroups of patients with different patterns of survival. Among 322 patients, median survival times were 26.2 and 15.6 months from time of onset and of diagnosis, respectively. Four groups of patients were identified, depending on their baseline characteristics and survival (1) ALSFRS-R slope >0.46/month and definite or probable ALS (median survival time (MST) 10.6 months); (2) ALSFRS-R slope >0.46/month and possible or probable laboratory-supported ALS (MST: 18.1 months); (3) ALSFRS-R slope ≤0.46/month and definite or probable ALS (MST: 22.5 months), and (4) ALSFRS-R slope ≤0.46/month and possible or probable laboratory-supported ALS (MST: 37.6 months). Median survival time is among the shortest ever reported by a worldwide population-based study. This is probably related to the age structure of the patients (the oldest identified to date), driven by the underlying population (30 % of subjects older than 60 years). Further research in the field of risk stratification could help physicians better anticipate prognosis of ALS patients, and help improve the design of randomized controlled trials. PMID:26518423

  19. Multiple biomarker strategies for risk stratification in heart failure.

    PubMed

    Bayes-Genis, Antoni; Ordonez-Llanos, Jordi

    2015-03-30

    Biomarkers of cardiovascular diseases are indispensable tools for diagnosis and prognosis, and the use of biomarkers is now considered standard-of-care. New markers continue to be developed, but few prove to be substantially better than established markers. Heart failure (HF) risk stratification may be refined by the use of biomarkers for different pathobiological processes that established mortality risk factors do not directly reflect. Biomarkers that are currently available can provide information about at least seven pathobiological processes operative in HF, help to identify the specific processes involved in individual patients, and aid in constructing management plans. However, the additional prognostic information gained by any biomarker over a clinical risk model plus other biomarkers needs to be determined with adequate statistical tools. A major problem in selecting a biomarker profile is the proportional increase in economic burden; thus, the addition of any biomarker to a profile should be justified by adequate discrimination, calibration, reclassification, and likelihood analyses. This review assesses the value of multimarker strategies in both acutely decompensated (ADHF) and chronic HF. Most data on biomarkers have been derived from patient cohorts with chronic HF. However, risk prediction in patients admitted with ADHF remains a challenge. ADHF is not a single disease, it presents in various manners and different etiologies may underlie ADHF, which are reflected by different biomarkers. The optimal panel of markers, the change in these markers over time, and how these changes might help guide therapeutic interventions remain to be defined. PMID:25451945

  20. Perceived health and geriatric risk stratification

    PubMed Central

    Bluestein, Daniel; Rutledge, Carolyn M.

    2006-01-01

    OBJECTIVE To examine the association between perceived health and self-reported presence of certain geriatric conditions. Perceived health (the way people rate their own health) is a summary measure of health status that predicts functional decline, health care use, and mortality, but has not been examined as a measure of the prevalence of key geriatric conditions among older adults. DESIGN Cross-sectional surveys addressing perceived health and other study variables were mailed to practice patients. SETTING An urban university-based family medicine residency program. PARTICIPANTS In a random sample of 400 patients (from 1327 potential participants) older than 65 years (excluding those with known dementia), more than half (262) responded with usable surveys. MAIN OUTCOME MEASURES Self-reported geriatric syndromes, such as perceived memory loss, depression, falls, incontinence, weight loss, problems with walking, and difficulties with instrumental activities of daily living. RESULTS Of 262 respondents, 102 reported that they perceived their health as poor or fair and were much more likely than people who perceived their health as robust (good, very good, or excellent) to report memory impairment (49.6% vs 23.1%), depression (38.0% vs 13.5%), falls (26.5% vs 12.5%), incontinence (48.5% vs 34.6%), weight loss (33.3% vs 15.4%), needing help with walking (27.3% vs 13.1%), and difficulties with activities of daily living (57.6% vs 24.4%). CONCLUSION These results support the hypothesis that assessment of perceived health can help differentiate low-risk elderly people requiring usual surveillance for geriatric conditions from high-risk elderly people who require timely evaluation and management. PMID:17327894

  1. Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

    PubMed Central

    Brogan, Richard A; Malkin, Christopher J; Batin, Phillip D; Simms, Alexander D; McLenachan, James M; Gale, Christopher P

    2014-01-01

    Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction (NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention (PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed. PMID:25228966

  2. ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY/DYSPLASIA: RISK STRATIFICATION AND THERAPY

    PubMed Central

    Buja, Gianfranco; Estes, N.A. Mark; Wichter, Thomas; Corrado, Domenico; Marcus, Frank; Thiene., Gaetano

    2008-01-01

    Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited heart muscle disease that occurs primarily in young and middle-age individuals. It is characterized by ventricular arrhythmias (VA), sudden death, and by heart failure occurring later in life (15). Ventricular electrical instability may occur at any time during the disease depending upon possible different pathophysiologic mechanisms including: a) Inflammation and apoptosis leading to ventricular fibrillation; or b) Fibro-fatty tissue repair leading to scar-related ventricular tachycardia (VT). Heart failure may occur later in life secondary to slow, progressive loss of right and left ventricular myocardium (18). The role of pharmacological therapy in controlling VA and preventing sudden death has been evaluated in single-center studies (9), and the results of catheter ablation have been described in small series of patients (1015). The efficacy and safety of implantable cardioverter/defibrillator (ICD) have also been reported in small, single-center studies (1619) and recently in larger single and multicenter studies (2027). The main questions regarding the risk stratification and the therapeutic strategy in ARVC/D are: 1) differential diagnosis with idiopathic VT (right ventricular outflow tract VT) in an apparently normal heart. The prognosis of this latter condition is usually excellent with rare cases of sudden cardiac death; 2) prognostic and therapeutic significance of noninvasive and invasive investigations including electrophysiologic study (EPS); 3) efficacy of antiarrhythmic drugs (AAD) to prevent VT and sudden cardiac death and the adverse effects of these drugs in this population; 4) indications and results of catheter ablation; 5) identification of patients at high risk of sudden cardiac death who need ICD implantation as well as the complications of ICD in a diseased right ventricular myocardium. It is important to recognize that ARVC/D is a progressive disease and risk factors may change during follow-up requiring periodic revaluation of risk as well as of therapy. With the identification of family members who carry a disease causing gene, the therapeutic dilemma has broadened to include risk stratification in genotype positive family members who may have occasional ventricular ectopy or have no clinical evidence of the disease. PMID:18156007

  3. First review on psoriasis severity risk stratification: An engineering perspective.

    PubMed

    Shrivastava, Vimal K; Londhe, Narendra D; Sonawane, Rajendra S; Suri, Jasjit S

    2015-08-01

    Computer-aided diagnosis (CAD) systems have been used for characterization of several dermatologic diseases in the last few years. Psoriasis is a potentially life-threatening skin disease which affects 125 million people worldwide. The paper presents the first state-of-the-art review of technology solicitation in psoriasis along with its current practices, challenges and assessment techniques. The paper also conducts in-depth examination of the existing literature for all clinical parameters of Psoriasis Area and Severity Index (PASI) i.e., area, erythema, scaliness and thickness. We suggest a role of risk assessment using a decision support system for stratification of psoriasis in large populations. A balanced insight has been presented in all the components of the design, namely: feature extraction, feature selection, disease stratification and overall CAD performance evaluation. We conclude that CAD systems are promising for risk stratification and assessment of psoriasis. PMID:26005793

  4. New methods for the analysis of heartbeat behavior in risk stratification.

    PubMed

    Glass, Leon; Lerma, Claudia; Shrier, Alvin

    2011-01-01

    Developing better methods for risk stratification for tachyarrhythmic sudden cardiac remains a major challenge for physicians and scientists. Since the transition from sinus rhythm to ventricular tachycardia/fibrillation happens by different mechanisms in different people, it is unrealistic to think that a single measure will be adequate to provide a good index for risk stratification. We analyze the dynamical properties of ventricular premature complexes over 24?h in an effort to understand the underlying mechanisms of ventricular arrhythmias and to better understand the arrhythmias that occur in individual patients. Two dimensional density plots, called heartprints, correlate characteristic features of the dynamics of premature ventricular complexes and the sinus rate. Heartprints show distinctive characteristics in individual patients. Based on a better understanding of the natures of transitions from sinus rhythm to sudden cardiac and the mechanisms of arrhythmia prior to cardiac arrest, it should be possible to develop better methods for risk stratification. PMID:22144963

  5. Risk stratification for sudden cardiac death in hypertrophic cardiomyopathy: systematic review of clinical risk markers.

    PubMed

    Christiaans, Imke; van Engelen, Klaartje; van Langen, Irene M; Birnie, Erwin; Bonsel, Gouke J; Elliott, Perry M; Wilde, Arthur A M

    2010-03-01

    We performed a systematic literature review of recommended 'major' and 'possible' clinical risk markers for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). We searched the Medline, Embase and Cochrane databases for articles published between 1971 and 2007. We included English language reports on HCM patients containing follow-up data on the endpoint (sudden) cardiac death using survival analysis. Analysis was undertaken using the quality of reporting of meta-analyses (QUORUM) statement checklist. The quality was checked using a quality assessment form from the Cochrane Collaboration. Thirty studies met inclusion criteria and passed quality assessment. The use of the six major risk factors (previous cardiac arrest or sustained ventricular tachycardia, non-sustained ventricular tachycardia, extreme left ventricular hypertrophy, unexplained syncope, abnormal blood pressure response, and family history of sudden death) in risk stratification for SCD as recommended by international guidelines was supported by the literature. In addition, left ventricular outflow tract obstruction seems associated with a higher risk of SCD. Our systematic review provides sound evidence for the use of the six major risk factors for SCD in the risk stratification of HCM patients. Left ventricular outflow tract obstruction could be included in the overall risk profile of patients with a marked left ventricular outflow gradient under basal conditions. PMID:20118111

  6. Patient Stratification for Preventive Care in Dentistry

    PubMed Central

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

    2013-01-01

    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 (ClinicalTrials.gov, NCT01584479). PMID:23752171

  7. Risk stratification using data from electronic medical records better predicts suicide risks than clinician assessments

    PubMed Central

    2014-01-01

    Background To date, our ability to accurately identify patients at high risk from suicidal behaviour, and thus to target interventions, has been fairly limited. This study examined a large pool of factors that are potentially associated with suicide risk from the comprehensive electronic medical record (EMR) and to derive a predictive model for 16month risk. Methods 7,399 patients undergoing suicide risk assessment were followed up for 180days. The dataset was divided into a derivation and validation cohorts of 4,911 and 2,488 respectively. Clinicians used an 18-point checklist of known risk factors to divide patients into low, medium, or high risk. Their predictive ability was compared with a risk stratification model derived from the EMR data. The model was based on the continuation-ratio ordinal regression method coupled with lasso (which stands for least absolute shrinkage and selection operator). Results In the year prior to suicide assessment, 66.8% of patients attended the emergency department (ED) and 41.8% had at least one hospital admission. Administrative and demographic data, along with information on prior self-harm episodes, as well as mental and physical health diagnoses were predictive of high-risk suicidal behaviour. Clinicians using the 18-point checklist were relatively poor in predicting patients at high-risk in 3months (AUC 0.58, 95% CIs: 0.50 0.66). The model derived EMR was superior (AUC 0.79, 95% CIs: 0.72 0.84). At specificity of 0.72 (95% CIs: 0.70-0.73) the EMR model had sensitivity of 0.70 (95% CIs: 0.56-0.83). Conclusion Predictive models applied to data from the EMR could improve risk stratification of patients presenting with potential suicidal behaviour. The predictive factors include known risks for suicide, but also other information relating to general health and health service utilisation. PMID:24628849

  8. Non-muscle invasive bladder cancer risk stratification

    PubMed Central

    Isharwal, Sumit; Konety, Badrinath

    2015-01-01

    Introduction: Non-muscle invasive bladder cancer (NMIBC) comprises about 70% of all newly diagnosed bladder cancer, and includes tumors with stage Ta, T1 and carcinoma in situ (CIS.) Since, NMIBC patients with progression to muscle-invasive disease tend to have worse prognosis than with patients with primary muscle-invasive disease, there is a need to significantly improve risk stratification and earlier definitive treatment for high-risk NMIBC. Materials and Methods: A detailed Medline search was performed to identify all publications on the topic of prognostic factors and risk predictions for superficial bladder cancer/NMIBC. The manuscripts were reviewed to identify variables that could predict recurrence and progression. Results: The most important prognostic factor for progression is grade of tumor. T category, tumor size, number of tumors, concurrent CIS, intravesical therapy, response to bacillus CalmetteGuerin at 3- or 6-month follow-up, prior recurrence rate, age, gender, lymphovascular invasion and depth of lamina propria invasion are other important clinical and pathological parameters to predict recurrence and progression in patients with NMIBC. The European Organization for Research and Treatment of Cancer (EORTC) and the Spanish Club UrolgicoEspaol de Tratamiento Oncolgico (CUETO) risk tables are the two best-established predictive models for recurrence and progression risk calculation, although they tend to overestimate risk and have poor discrimination for prognostic outcomes in external validation. Molecular biomarkers such as Ki-67, FGFR3 and p53 appear to be promising in predicting recurrence and progression but need further validation prior to using them in clinical practice. Conclusion: EORTC and CUETO risk tables are the two best-established models to predict recurrence and progression in patients with NMIBC though they tend to overestimate risk and have poor discrimination for prognostic outcomes in external validation. Future research should focus on enhancing the predictive accuracy of risk assessment tools by incorporating additional prognostic factors such as depth of lamina propria invasion and molecular biomarkers after rigorous validation in multi-institutional cohorts. PMID:26604439

  9. Electrophysiologic testing guided risk stratification approach for sudden cardiac death beyond the left ventricular ejection fraction

    PubMed Central

    Gatzoulis, Konstantinos A; Tsiachris, Dimitris; Arsenos, Petros; Tousoulis, Dimitris

    2016-01-01

    Sudden cardiac death threats ischaemic and dilated cardiomyopathy patients. Anti- arrhythmic protection may be provided to these patients with implanted cardiac defibrillators (ICD), after an efficient risk stratification approach. The proposed risk stratifier of an impaired left ventricular ejection fraction has limited sensitivity meaning that a significant number of victims will remain undetectable by this risk stratification approach because they have a preserved left ventricular systolic function. Current risk stratification strategies focus on combinations of non invasive methods like T wave alternans, late potentials, heart rate turbulence, deceleration capacity and others, with invasive methods like the electrophysiologic study. In the presence of an electrically impaired substrate with formed post myocardial infarction fibrotic zones, programmed ventricular stimulation provides important prognostic information for the selection of the patients expected to benefit from an ICD implantation, while due to its high negative predictive value, patients at low risk level may also be detected. Clustering evidence from different research groups and electrophysiologic labs support an electrophysiologic testing guided risk stratification approach for sudden cardiac death. PMID:26839662

  10. Diagnosis and risk stratification in multiple myeloma.

    PubMed

    van de Donk, Niels W C J; Sonneveld, Pieter

    2014-10-01

    Multiple myeloma (MM) is a tumor of monoclonal plasma cells, which produce a monoclonal antibody and expand predominantly in the bone marrow. Patients present with hypercalcemia, renal impairment, anemia, and/or bone disease. Only patients with symptomatic MM require therapy, whereas asymptomatic patients receive regular follow-up. Survival of patients with MM is very heterogeneous. The variety in outcome is explained by host factors as well as tumor-related characteristics reflecting biology of the MM clone and tumor burden. The identification of cytogenetic abnormalities by fluorescence in situ hybridization is currently the most important and widely available prognostic factor in MM. PMID:25212883

  11. Raynaud’s phenomenon and digital ischemia: a practical approach to risk stratification, diagnosis and management

    PubMed Central

    McMahan, Zsuzsanna H.; Wigley, Fredrick M.

    2015-01-01

    Digital ischemia is a painful and often disfiguring event. Such an ischemic event often leads to tissue loss and can significantly affect the patient’s quality of life. Digital ischemia can be secondary to a vasculopathy, vasculitis, embolic disease, trauma, or extrinsic vascular compression. It is an especially serious complication in patients with scleroderma. Risk stratification of patients with scleroderma at risk for digital ischemia is now possible with clinical assessment and autoantibody profiles. Because there are a variety of conditions that lead to digital ischemia, it is important to understand the pathophysiology underlying each ischemic presentation in order to target therapy appropriately. Significant progress has been made in the last two decades in defining the pathophysiological processes leading to digital ischemia in rheumatic diseases. In this article we review the risk stratification, diagnosis, and management of patients with digital ischemia and provide a practical approach to therapy, particularly in scleroderma. PMID:26523153

  12. Risk stratification in multiple myeloma, part 1: characterization of high-risk disease.

    PubMed

    Biran, Noa; Jagannath, Sundar; Chari, Ajai

    2013-08-01

    Survival in multiple myeloma (MM) is variable, ranging from several months to more than 15 years. While survival has recently improved with the use of novel therapy, approximately 25% of patients have a median survival of 2 years or less. Accurate identification of high-risk patients, and risk stratification, are crucial in improving outcomes for all patients. In the first part of this two part series, we review the currently identified prognostic factors characterized by disease burden (Durie-Salmon staging system, International Staging System, magnetic resonance imaging, (18F) fluorodeoxyglucose positron emission tomography, presence of extramedullary disease or plasma-cell leukemia), host factors (age, performance status, and renal function), tumor biology (proliferation rate, conventional cytogenetics, interphase fluorescence in situ hybridization, and gene expression profiling), and depth of response to therapy. Efforts have been made to identify ultra-high-risk patients by combining all the identified variables into a unifying comprehensive model. In the second part of this series, we will discuss the significance of these factors in the context of currently available therapies for MM, distinguishing between treatments that only improve outcomes of high-risk patients when compared with previous therapies, versus those that overcome high-risk status, thereby reclassifying these patients as standard risk. PMID:24518420

  13. Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes

    PubMed Central

    Beck, Ann-Jean CC.; Hagemeijer, Anouk; Tortolani, Bess; Byrd, Bethany A.; Parekh, Amisha; Datillo, Paris; Birkhahn, Robert

    2015-01-01

    Introduction Guidelines are designed to encompass the needs of the majority of patients with a particular condition. The American Heart Association (AHA) in conjunction with the American College of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk stratification guidelines to aid physicians with accurate and efficient diagnosis and management of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the unique environment of an emergency department (ED), the feasibility of incorporating guidelines into clinical workflow remains in question. We aim to compare emergency physicians (EP) clinical risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in predicting ACS. Methods We conducted a prospective observational cohort study in an urban teaching hospital ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk stratification scores assigned: one by the treating physician based on clinical evaluation and the other by the AHA/ACC/ACEP guideline aforementioned. The patients ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30 days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits, and objective cardiac testing performed. Results We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a difference between the physicians clinical assessment used in the ED, and the AHA/ACC/ACEP task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients diagnosed with no ACS. Conclusion In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category. A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population. PMID:26587091

  14. Risk stratification in autoimmune cholestatic liver diseases: Opportunities for clinicians and trialists.

    PubMed

    Trivedi, Palak J; Corpechot, Christophe; Pares, Albert; Hirschfield, Gideon M

    2016-02-01

    Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are infrequent autoimmune cholestatic liver diseases, that disproportionate to their incidence and prevalence, remain very important causes of morbidity and mortality for patients with liver disease. Mechanistic insights spanning genetic risks and biological pathways to liver injury and fibrosis have led to a renewed interest in developing therapies beyond ursodeoxycholic acid that are aimed at both slowing disease course and improving quality of life. International cohort studies have facilitated a much greater understanding of disease heterogeneity, and in so doing highlight the opportunity to provide patients with a more individualized assessment of their risk of progressive liver disease, based on clinical, laboratory, or imaging findings. This has led to a new approach to patient care that focuses on risk stratification (both high and low risk); and furthermore allows such stratification tools to help identify patient subgroups at greatest potential benefit from inclusion in clinical trials. In this article, we review the applicability and validity of risk stratification in autoimmune cholestatic liver disease, highlighting strengths and weaknesses of current and emergent approaches. (Hepatology 2016;63:644-659). PMID:26290473

  15. Risk stratification algorithm for management of patients with dual modular taper total hip arthroplasty: consensus statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons and the Hip Society.

    PubMed

    Kwon, Young-Min; Fehring, Thomas K; Lombardi, Adolph V; Barnes, C Lowry; Cabanela, Miguel E; Jacobs, Joshua J

    2014-11-01

    Although 'dual taper' modular stems with interchangeable modular necks have the potential to optimize hip biomechanical parameters, there is increasing concern regarding the occurrence of adverse local tissue reactions from mechanically assisted crevice corrosion at the neck-stem taper junction. A systematic treatment approach (risk stratification algorithm) based on the currently available data is recommended to optimize patient management. While specialized tests such as metal ion analysis and MARS MRI are useful modalities in evaluating for adverse tissue reactions, over-reliance on any single investigative tool in the clinical decision-making process should be avoided. There should be a low threshold to perform a systematic evaluation of patients with dual taper stem total hip arthroplasty as early recognition and diagnosis will facilitate the initiation of appropriate treatment. PMID:25189673

  16. Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study

    PubMed Central

    2014-01-01

    Background While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30days. Methods/Design We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness?>?5minutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30days of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values ?0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development. Discussion Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety. PMID:24629180

  17. Stratification of the Risk of Sudden Death in Nonischemic Heart Failure

    PubMed Central

    Pimentel, Maurcio; Zimerman, Leandro Ioschpe; Rohde, Luis Eduardo

    2014-01-01

    Despite significant therapeutic advancements, heart failure remains a highly prevalent clinical condition associated with significant morbidity and mortality. In 30%-40% patients, the etiology of heart failure is nonischemic. The implantable cardioverter-defibrillator (ICD) is capable of preventing sudden death and decreasing total mortality in patients with nonischemic heart failure. However, a significant number of patients receiving ICD do not receive any kind of therapy during follow-up. Moreover, considering the situation in Brazil and several other countries, ICD cannot be implanted in all patients with nonischemic heart failure. Therefore, there is an urgent need to identify patients at an increased risk of sudden death because these would benefit more than patients at a lower risk, despite the presence of heart failure in both risk groups. In this study, the authors review the primary available methods for the stratification of the risk of sudden death in patients with nonischemic heart failure. PMID:25352509

  18. Risk stratification after myocardial infarction: is left ventricular ejection fraction enough to prevent sudden cardiac death?

    PubMed

    Dagres, Nikolaos; Hindricks, Gerhard

    2013-07-01

    Patients who have experienced a myocardial infarction (MI) are at increased risk of sudden cardiac death (SCD). With the advent of implantable cardioverter-defibrillators (ICDs), accurate risk stratification has become very relevant. Numerous investigations have proven that a reduced left ventricular ejection fraction (LVEF) significantly increases the SCD risk. Furthermore, ICD implantation in patients with reduced LVEF confers significant survival benefit. As a result, LVEF is the cornerstone of current decision making for prophylactic ICD implantation after MI. However, LVEF as standalone risk stratifier has major limitations: (i) the majority of SCD cases occur in patients with preserved or moderately reduced LVEF, (ii) only relatively few patients with reduced LVEF will benefit from an ICD (most will never experience a threatening arrhythmic event, others have a high risk for non-sudden death), (iii) a reduced LVEF is a risk factor for both sudden and non-sudden death. Several other non-invasive and invasive risk stratifiers, such as ventricular ectopy, QRS duration, signal-averaged electrocardiogram, microvolt T-wave alternans, markers of autonomic tone as well as programmed ventricular stimulation, have been evaluated. However, none of these techniques has unequivocally demonstrated the efficacy when applied alone or in combination with LVEF. Apart from their limited sensitivity, most of them are risk factors for both sudden and non-sudden death. Considering the multiple mechanisms involved in SCD, it seems unlikely that a single test will prove adequate for all patients. A combination of clinical characteristics with selected stratification tools may significantly improve risk stratification in the future. PMID:23644180

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

    PubMed Central

    Razzouk, Louai; Fusaro, Mario; Esquitin, Ricardo

    2012-01-01

    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

  20. Early risk stratification in pediatric type 1 diabetes.

    PubMed

    Broe, Rebecca

    2015-03-01

    In the late 1980s all Danish children with type 1 diabetes were invited for a nationwide evaluation of glycemic control. Approximately 75% (n = 720) participated and have later been referred to as The Danish Cohort of Pediatric Diabetes 1987 (DCPD1987). The results were surprisingly poor glycemic control among these young patients which lead to a great emphasis on glycemic control in the Danish Pediatric Departments. In 1995 the participants were invited for yet another evaluation but this time with main focus on early signs of microvascular complications - 339 participated. The mean HbA1c had remained at high levels (9.6%) and 60% of the participants had some level of Diabetic Retinopathy (DR). However, as the patients with DR mostly had the very milder forms it was believed that stricter glycemic control would reverse or at least stop progression of the disease in accordance with results from the large intervention study DCCT. This was investigated further at follow-up in 2011. The first study in the present thesis aimed to describe the 16-year incidence, progression and regression of DR in 185 participants from the DCPD1987 cohort. The 16-year incidence of proliferative retinopathy (PDR), 2-step progression and regression of DR was 31.0, 64.4, and 0.0%, respectively. As expected, the participants with PDR at follow-up had significantly higher HbA1c-values at both baseline and follow-up than those without PDR. However; a significantly larger decrease in HbA1c was also observed in the group with PDR over the study period, which in accordance with DCCT should have prevented the development of PDR to some extent. A surprisingly high incidence of proliferative retinopathy amongst young patients with type 1 diabetes in Denmark was found despite improvements in HbA1c over time. The improvement in HbA1c was either too small or happened too late. This study highlights that sight-threatening diabetic retinopathy remain a major concern in type 1 diabetes and the importance of early glycemic control. Identifying high-risk patients at a very early stage is not only desired for prevention of diabetic retinopathy - neuropathy and nephropathy similarly remain frequent in type 1 diabetes. Early risk stratification will allow for timely implementation of effective interventions and for individualized screening and diabetes care. The second and third studies of this thesis provide the longest prospective studies to date on both retinal vessel calibers and retinal fractal dimensions and their predictive value on diabetic microvascular complications. Semi-automated computer software has been developed to measure smaller changes in the retinal vessels on retinal photographs. Two of the first parameters to be reliably estimated by these programs were retinal vessel calibers and retinal vascular fractal dimensions (a quantitative measure on vascular complexity). There is very limited knowledge on their predictive value on diabetic complications thus far. In the second and third study, a consistent relation between narrower retinal arteriolar calibers, wider retinal venular calibers, lower fractal dimensions and the 16-year incidences of diabetic neuropathy, nephropathy and proliferative retinopathy was found. This has never been shown before. The results on vessel analyzes provides indications of a common pathogenic pathway for diabetic microvascular complications and therefore a possibility of universal risk estimation for development of neuropathy, nephropathy and retinopathy in type 1 diabetes. PMID:25703648

  1. [Genetic tools for risk-stratification in multiple myeloma].

    PubMed

    Braggio, Esteban; Albarracn Garramuo, Flavio

    2013-01-01

    Genetic studies have a central role in the study of multiple myeloma (MM), as they become a critical component in the risk-based stratification of the disease. Significant efforts have been made to identify genetic changes and signatures that can predict clinical outcome and include them in the routine clinical care. Fluorescence in situ hybridization (FISH) still remains the most used genetic technique in clinical practice, mostly due to its very straightforward implementation and the simplicity of data analysis. The advent of high-resolution genomics (i.e. array CGH, exome and whole genome sequencing) and transcriptomics tests (i.e. gene expression profiling - GEP, and mRNA sequencing) provide a comprehensive analysis of the already defined genetic prognostic factors and are helpful tools for the identification of potential novel disease markers on the MM tumor clone. Indeed, GEP has been successfully implemented in MM as a risk-stratification tool, holding the greatest power in outcome discrimination. Nevertheless, some technical and logistic intricacies (need of a highly purified tumor clone, cost of the assay and complexity of data analysis) need to be considered before the definitive incorporation of high-throughput technologies in routine clinical tests. Until then, FISH remains the standard tool for genomic abnormality detection and disease prognostication. PMID:23924539

  2. Diabetes Mellitus and Prediabetes on Kidney Transplant Waiting List- Prevalence, Metabolic Phenotyping and Risk Stratification Approach

    PubMed Central

    Guthoff, Martina; Vosseler, Dorothea; Langanke, Julia; Nadalin, Silvio; Knigsrainer, Alfred; Hring, Hans-Ulrich; Fritsche, Andreas; Heyne, Nils

    2015-01-01

    Background Despite a significant prognostic impact, little is known about disturbances in glucose metabolism among kidney transplant candidates. We assess the prevalence of diabetes mellitus (DM) and prediabetes on kidney transplant waiting list, its underlying pathophysiology and propose an approach for individual risk stratification. Methods All patients on active kidney transplant waiting list of a large European university hospital transplant center were metabolically phenotyped. Results Of 138 patients, 76 (55%) had disturbances in glucose metabolism. 22% of patients had known DM, 3% were newly diagnosed. 30% were detected to have prediabetes. Insulin sensitivity and-secretion indices allowed for identification of underlying pathophysiology and risk factors. Age independently affected insulin secretion, resulting in a relative risk for prediabetes of 2.95 (95%CI 1.384.83) with a cut-off at 48 years. Body mass index independently affected insulin sensitivity as a continuous variable. Conclusions The prevalence of DM or prediabetes on kidney transplant waiting list is as high as 55%, with more than one third of patients previously undiagnosed. Oral glucose tolerance test is mandatory to detect all patients at risk. Metabolic phenotyping allows for differentiation of underlying pathophysiology and provides a basis for early individual risk stratification and specific intervention to improve patient and allograft outcome. PMID:26398489

  3. Improving risk-stratification of Diabetes complications using temporal data mining.

    PubMed

    Sacchi, Lucia; Dagliati, Arianna; Segagni, Daniele; Leporati, Paola; Chiovato, Luca; Bellazzi, Riccardo

    2015-08-01

    To understand which factor trigger worsened disease control is a crucial step in Type 2 Diabetes (T2D) patient management. The MOSAIC project, funded by the European Commission under the FP7 program, has been designed to integrate heterogeneous data sources and provide decision support in chronic T2D management through patients' continuous stratification. In this work we show how temporal data mining can be fruitfully exploited to improve risk stratification. In particular, we exploit administrative data on drug purchases to divide patients in meaningful groups. The detection of drug consumption patterns allows stratifying the population on the basis of subjects' purchasing attitude. Merging these findings with clinical values indicates the relevance of the applied methods while showing significant differences in the identified groups. This extensive approach emphasized the exploitation of administrative data to identify patterns able to explain clinical conditions. PMID:26736710

  4. Midregional pro-Adrenomedullin in addition to b-type natriuretic peptides in the risk stratification of patients with acute dyspnea: an observational study

    PubMed Central

    2009-01-01

    Introduction The identification of patients at highest risk for adverse outcome who are presenting with acute dyspnea to the emergency department remains a challenge. This study investigates the prognostic value of the newly described midregional fragment of the pro-Adrenomedullin molecule (MR-proADM) alone and combined to B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) in patients with acute dyspnea. Methods We conducted a prospective, observational cohort study in the emergency department of a University Hospital and enrolled 287 unselected, consecutive patients (48% women, median age 77 (range 68 to 83) years) with acute dyspnea. Results MR-proADM levels were elevated in non-survivors (n = 77) compared to survivors (median 1.9 (1.2 to 3.2) nmol/L vs. 1.1 (0.8 to 1.6) nmol/L; P < 0.001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.81 (95% CI 0.73 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for MR-proADM, NT-proBNP and BNP, respectively (MRproADM vs. NTproBNP P = 0.38; MRproADM vs. BNP P = 0.009). For one-year mortality the AUC were 0.75 (95% CI 0.69 to 0.81), 0.75 (95% CI 0.68 to 0.81), 0.69 (95% CI 0.62 to 0.76) for MR-proADM, NT-proBNP and BNP, respectively without any significant difference. Using multivariate linear regression analysis, MR-proADM strongly predicted one-year all-cause mortality independently of NT-proBNP and BNP levels (OR = 10.46 (1.36 to 80.50), P = 0.02 and OR = 24.86 (3.87 to 159.80) P = 0.001, respectively). Using quartile approaches, Kaplan-Meier curve analyses demonstrated a stepwise increase in one-year all-cause mortality with increasing plasma levels (P < 0.0001). Combined levels of MR-proADM and NT-proBNP did risk stratify acute dyspneic patients into a low (90% one-year survival rate), intermediate (72 to 82% one-year survival rate) or high risk group (52% one-year survival rate). Conclusions MR-proADM alone or combined to NT-proBNP has a potential to assist clinicians in risk stratifying patients presenting with acute dyspnea regardless of the underlying disease. PMID:19627611

  5. Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of externally derived risk scores

    PubMed Central

    Pendlebury, Sarah T.; Lovett, Nicola; Smith, Sarah C.; Cornish, Emily; Mehta, Ziyah; Rothwell, Peter M.

    2016-01-01

    Background: reliable delirium risk stratification will aid recognition, anticipation and prevention and will facilitate targeting of resources in clinical practice as well as identification of at-risk patients for research. Delirium risk scores have been derived for acute medicine, but none has been prospectively validated in external cohorts. We therefore aimed to determine the reliability of externally derived risk scores in a consecutive cohort of older acute medicine patients. Methods: consecutive patients aged ≥65 over two 8-week periods (2010, 2012) were screened prospectively for delirium using the Confusion Assessment Method (CAM), and delirium was diagnosed using the DSM IV criteria. The reliability of existing delirium risk scores derived in acute medicine cohorts and simplified for use in routine clinical practice (USA, n = 2; Spain, n = 1; Indonesia, n = 1) was determined by the area under the receiver operating characteristic curve (AUC). Delirium was defined as prevalent (on admission), incident (occurring during admission) and any (prevalent + incident) delirium. Results: among 308 consecutive patients aged ≥65 (mean age/SD = 81/8 years, 164 (54%) female), existing delirium risk scores had AUCs for delirium similar to those reported in their original internal validations ranging from 0.69 to 0.76 for any delirium and 0.73 to 0.83 for incident delirium. All scores performed better than chance but no one score was clearly superior. Conclusions: externally derived delirium risk scores performed well in our independent acute medicine population with reliability unaffected by simplification and might therefore facilitate targeting of multicomponent interventions in routine clinical practice. PMID:26764396

  6. Short-term vs. long-term heart rate variability in ischemic cardiomyopathy risk stratification

    PubMed Central

    Voss, Andreas; Schroeder, Rico; Vallverd, Montserrat; Schulz, Steffen; Cygankiewicz, Iwona; Vzquez, Rafael; Bays de Luna, Antoni; Caminal, Pere

    2013-01-01

    In industrialized countries with aging populations, heart failure affects 0.32% of the general population. The investigation of 24 h-ECG recordings revealed the potential of nonlinear indices of heart rate variability (HRV) for enhanced risk stratification in patients with ischemic heart failure (IHF). However, long-term analyses are time-consuming, expensive, and delay the initial diagnosis. The objective of this study was to investigate whether 30 min short-term HRV analysis is sufficient for comparable risk stratification in IHF in comparison to 24 h-HRV analysis. From 256 IHF patients [221 at low risk (IHFLR) and 35 at high risk (IHFHR)] (a) 24 h beat-to-beat time series (b) the first 30 min segment (c) the 30 min most stationary day segment and (d) the 30 min most stationary night segment were investigated. We calculated linear (time and frequency domain) and nonlinear HRV analysis indices. Optimal parameter sets for risk stratification in IHF were determined for 24 h and for each 30 min segment by applying discriminant analysis on significant clinical and non-clinical indices. Long- and short-term HRV indices from frequency domain and particularly from nonlinear dynamics revealed high univariate significances (p < 0.01) discriminating between IHFLR and IHFHR. For multivariate risk stratification, optimal mixed parameter sets consisting of 5 indices (clinical and nonlinear) achieved 80.4% AUC (area under the curve of receiver operating characteristics) from 24 h HRV analysis, 84.3% AUC from first 30 min, 82.2 % AUC from daytime 30 min and 81.7% AUC from nighttime 30 min. The optimal parameter set obtained from the first 30 min showed nearly the same classification power when compared to the optimal 24 h-parameter set. As results from stationary daytime and nighttime, 30 min segments indicate that short-term analyses of 30 min may provide at least a comparable risk stratification power in IHF in comparison to a 24 h analysis period. PMID:24379785

  7. Prognostic value of cardiac biomarkers in the risk stratification of syncope: a systematic review.

    PubMed

    Thiruganasambandamoorthy, Venkatesh; Ramaekers, Rosa; Rahman, Mohammed Omair; Stiell, Ian Gilmour; Sikora, Lindsey; Kelly, Sarah-Louise; Christ, Michael; Claret, Pierre-Geraud; Reed, Matthew James

    2015-12-01

    The role of cardiac biomarkers in risk stratification of syncope is unclear. We undertook a systematic review to assess their predictive value for short-term major adverse cardiovascular events (MACE). We conducted a systematic review using MEDLINE, EMBASE, DARE and Cochrane databases from inception to July 2014. We included studies involving adult syncope patients that evaluated cardiac biomarker levels for risk stratification during acute management and excluded case reports, reviews and studies involving children. Primary outcome (MACE) included death, cardiopulmonary resuscitation, myocardial infarction (MI), structural heart disease, pulmonary embolism, significant hemorrhage or cardiac procedural interventions. Secondary outcome analysis assessed for prediction of MI, cardiac syncope and death. Two reviewers extracted patient-level data based on the cut-off reported. Pooled sensitivities and specificities were calculated using patient-level data. A total of 1862 articles were identified, and 11 studies with 4246 patients were included. Studies evaluated 3 biomarkers: contemporary troponin (2693 patients), natriuretic peptides (1353 patients) and high-sensitive troponin (819 patients). The pooled sensitivities and specificities for MACE were: contemporary troponin 0.29 (95 % CI 0.24, 0.34) and 0.88 (95 % CI 0.86, 0.89); natriuretic peptides 0.77 (95 % CI 0.69, 0.85) and 0.73 (95 % CI 0.70, 0.76); high-sensitive troponin 0.74 (95 % CI 0.65, 0.83) and 0.65 (95 % CI 0.62, 0.69), respectively. Natriuretic peptides and high-sensitive troponin showed good diagnostic characteristics for both primary and secondary outcomes. Natriuretic peptides and high-sensitive troponin might be useful in risk stratification. PMID:26498335

  8. Bleeding risk stratification in an era of aggressive management of acute coronary syndromes

    PubMed Central

    Abu-Assi, Emad; Raposeiras-Roubn, Sergio; Garca-Acua, Jos Mara; Gonzlez-Juanatey, Jos Ramn

    2014-01-01

    Major bleeding is currently one of the most common non-cardiac complications observed in the treatment of patients with acute coronary syndrome (ACS). Hemorrhagic complications occur with a frequency of 1% to 10% during treatment for ACS. In fact, bleeding events are the most common extrinsic complication associated with ACS therapy. The identification of clinical characteristics and particularities of the antithrombin therapy associated with an increased risk of hemorrhagic complications would make it possible to adopt prevention strategies, especially among those exposed to greater risk. The international societies of cardiology renewed emphasis on bleeding risk stratification in order to decide strategy and therapy for patients with ACS. With this review, we performed an update about the ACS bleeding risk scores most frequently used in daily clinical practice. PMID:25429326

  9. The evolving field of prognostication and risk stratification in MDS: Recent developments and future directions.

    PubMed

    Lee, Eun-Ju; Podoltsev, Nikolai; Gore, Steven D; Zeidan, Amer M

    2016-01-01

    The clinical course of patients with myelodysplastic syndromes (MDS) is characterized by wide variability reflecting the underlying genetic and biological heterogeneity of the disease. Accurate prediction of outcomes for individual patients is an integral part of the evidence-based risk/benefit calculations that are necessary for tailoring the aggressiveness of therapeutic interventions. While several prognostication tools have been developed and validated for risk stratification, each of these systems has limitations. The recent progress in genomic sequencing techniques has led to discoveries of recurrent molecular mutations in MDS patients with independent impact on relevant clinical outcomes. Reliable assays of these mutations have already entered the clinic and efforts are currently ongoing to formally incorporate mutational analysis into the existing clinicopathologic risk stratification tools. Additionally, mutational analysis holds promise for going beyond prognostication to therapeutic selection and individualized treatment-specific prediction of outcomes; abilities that would revolutionize MDS patient care. Despite these exciting developments, the best way of incorporating molecular testing for use in prognostication and prediction of outcomes in clinical practice remains undefined and further research is warranted. PMID:26119927

  10. Percentage of Positive Biopsy Cores: A Better Risk Stratification Model for Prostate Cancer?

    SciTech Connect

    Huang Jiayi; Vicini, Frank A.; Williams, Scott G.; Ye Hong; McGrath, Samuel; Ghilezan, Mihai; Krauss, Daniel; Martinez, Alvaro A.; Kestin, Larry L.

    2012-07-15

    Purpose: To assess the prognostic value of the percentage of positive biopsy cores (PPC) and perineural invasion in predicting the clinical outcomes after radiotherapy (RT) for prostate cancer and to explore the possibilities to improve on existing risk-stratification models. Methods and Materials: Between 1993 and 2004, 1,056 patients with clinical Stage T1c-T3N0M0 prostate cancer, who had four or more biopsy cores sampled and complete biopsy core data available, were treated with external beam RT, with or without a high-dose-rate brachytherapy boost at William Beaumont Hospital. The median follow-up was 7.6 years. Multivariate Cox regression analysis was performed with PPC, Gleason score, pretreatment prostate-specific antigen, T stage, PNI, radiation dose, androgen deprivation, age, prostate-specific antigen frequency, and follow-up duration. A new risk stratification (PPC classification) was empirically devised to incorporate PPC and replace the T stage. Results: On multivariate Cox regression analysis, the PPC was an independent predictor of distant metastasis, cause-specific survival, and overall survival (all p < .05). A PPC >50% was associated with significantly greater distant metastasis (hazard ratio, 4.01; 95% confidence interval, 1.86-8.61), and its independent predictive value remained significant with or without androgen deprivation therapy (all p < .05). In contrast, PNI and T stage were only predictive for locoregional recurrence. Combining the PPC ({<=}50% vs. >50%) with National Comprehensive Cancer Network risk stratification demonstrated added prognostic value of distant metastasis for the intermediate-risk (hazard ratio, 5.44; 95% confidence interval, 1.78-16.6) and high-risk (hazard ratio, 4.39; 95% confidence interval, 1.70-11.3) groups, regardless of the use of androgen deprivation and high-dose RT (all p < .05). The proposed PPC classification appears to provide improved stratification of the clinical outcomes relative to the National Comprehensive Cancer Network classification. Conclusions: The PPC is an independent and powerful predictor of clinical outcomes of prostate cancer after RT. A risk model replacing T stage with the PPC to reduce subjectivity demonstrated potentially improved stratification.

  11. Selectively predictive calcium supplementation using NCCN risk stratification system after thyroidectomy with differentiated thyroid cancer

    PubMed Central

    Sun, Ronghao; Zhang, Jie; Zhang, Fenghua; Fan, Jinchuan; Yuan, Ying; Li, Chao

    2015-01-01

    Background: Hypocalcemia is a common complication following thyroidectomy. To explore reasonable and simple methods for predicting postoperative hypocalcemia and identify the optimal strategies for selective calcium supplement are meaningful for surgeon. Methods: Based on the NCCN risk stratification system, patients were divided into 4 groups (A-D): low-risk group A, who only underwent limited thyroidectomy (LT) and high-risk groups B, C and D, who had received total thyroidectomy (TT) and selective central and/or lateral neck dissection (SND). After surgery, group C patients were orally given calcium gluconate and group D patients were intravenously given calcium 2 g/day for 7 days, while group B patients did not receive any calcium supplement. Serum calcium and parathyroid hormone (PTH) levels were collected before and after surgery. The incidence of asymptomatic and symptomatic hypocalcemia in each group was recorded. Results: A total of 132 patients with differentiated thyroid carcinoma (DTC) were included who received surgical treatment. No a significant change was observed in serum calcium and PTH levels in group A, while significant decreases in serum calcium and PTH levels were seen in group B (P < 0.05). Intravenous calcium supplement in group D resulted in a more rapid recovery in serum calcium levels (P < 0.05). The incidences of symptomatic hypocalcemia and asymptomatic hypocalcemia were significantly lower in group A and group D respectively compared to the other groups (All P values < 0.05). In group B, a highest asymptomatic and symptomatic hypocalcemia incidence was detected. Conclusion: Selective calcium supplementation for DTC based on NCCN risk stratification system could be recommended for the high-risk patients. PMID:26885165

  12. Risk Stratification and Therapeutic Approach in Brugada Syndrome

    PubMed Central

    Probst, Vincent; Chatel, Stphanie; Gourraud, Jean-Baptiste; Marec, Herv Le

    2012-01-01

    Brugada syndrome (BrS) is a clinical entity characterised by an incomplete right bundle branch block associated with an ST segment elevation in the right precordial leads and a risk of ventricular arrhythmia and sudden death in the absence of structural abnormalities. Patients with a personal history of sudden death have an annual arrhythmia risk of recurrence as high as 10 %. Similarly, the presence of syncope is consistently associated with an increased arrhythmic risk. This risk can be estimated at about 1.5 % per year. The risk is lower in asymptomatic patients. Regarding the relatively high rate of complication of Implantable cardioverter defibrillator (ICD) implantation, in most of the cases, asymptomatic patients with a Brugada syndrome revealed during ajmaline challenge do not need to be implanted. The situation is more complex in patients with a spontaneous type 1 aspect since the risk could be estimated to be around 0.8 % per year. For these patients, a careful evaluation of the arrhythmic risk using all the different tools available is mandatory.

  13. T-wave alternans and dispersion of the QT interval as risk stratification markers in patients susceptible to sustained ventricular arrhythmias

    NASA Technical Reports Server (NTRS)

    Armoundas, A. A.; Osaka, M.; Mela, T.; Rosenbaum, D. S.; Ruskin, J. N.; Garan, H.; Cohen, R. J.

    1998-01-01

    T-wave alternans and QT dispersion were compared as predictors of the outcome of electrophysiologic study and arrhythmia-free survival in patients undergoing electrophysiologic evaluation. T-wave alternans was a highly significant predictor of these 2 outcome variables, whereas QT dispersion was not.

  14. Emergence of molecular imaging of aortic aneurysm; implications for risk stratification and management

    PubMed Central

    Golestani, Reza; Sadeghi, Mehran M.

    2014-01-01

    Summary Imaging cellular and molecular processes associated with aneurysm expansion, dissection, and rupture can potentially transform the management of patients with thoracic and abdominal aortic aneurysm (TAA and AAA). Here, we review recent advances in molecular imaging of aortic aneurysm, focusing on imaging modalities with the greatest potential for clinical translation and application, PET, SPECT and MRI. Inflammation (e.g., with 18F-FDG, nanoparticles) and matrix remodeling (e.g., with matrix metalloproteinase-targeted tracers) are highlighted as promising targets for molecular imaging of aneurysm. Potential alternative or complementary approaches to molecular imaging for aneurysm risk stratification are briefly discussed. PMID:24381115

  15. Consensus recommendations for risk stratification in multiple myeloma: report of the International Myeloma Workshop Consensus Panel 2.

    PubMed

    Munshi, Nikhil C; Anderson, Kenneth C; Bergsagel, P Leif; Shaughnessy, John; Palumbo, Antonio; Durie, Brian; Fonseca, Rafael; Stewart, A Keith; Harousseau, Jean-Luc; Dimopoulos, Meletios; Jagannath, Sundar; Hajek, Roman; Sezer, Orhan; Kyle, Robert; Sonneveld, Pieter; Cavo, Michele; Rajkumar, S Vincent; San Miguel, Jesus; Crowley, John; Avet-Loiseau, Herv

    2011-05-01

    A panel of members of the 2009 International Myeloma Workshop developed guidelines for risk stratification in multiple myeloma. The purpose of risk stratification is not to decide time of therapy but to prognosticate. There is general consensus that risk stratification is applicable to newly diagnosed patients; however, some genetic abnormalities characteristic of poor outcome at diagnosis may suggest poor outcome if only detected at the time of relapse. Thus, in good-risk patients, it is necessary to evaluate for high-risk features at relapse. Although detection of any cytogenetic abnormality is considered to suggest higher-risk disease, the specific abnormalities considered as poor risk are cytogenetically detected chromosomal 13 or 13q deletion, t(4;14) and del17p, and detection by fluorescence in situ hybridization of t(4;14), t(14;16), and del17p. Detection of 13q deletion by fluorescence in situ hybridization only, in absence of other abnormalities, is not considered a high-risk feature. High serum ?(2)-microglobulin level and International Staging System stages II and III, incorporating high ?(2)-microglobulin and low albumin, are considered to predict higher risk disease. There was a consensus that the high-risk features will change in the future, with introduction of other new agents or possibly new combinations. PMID:21292777

  16. Molecular Microscope Strategy to Improve Risk Stratification in Early Antibody-Mediated Kidney Allograft Rejection

    PubMed Central

    Loupy, Alexandre; Lefaucheur, Carmen; Vernerey, Dewi; Chang, Jessica; Hidalgo, Luis G.; Beuscart, Thibaut; Verine, Jerome; Aubert, Olivier; Dubleumortier, Sbastien; Duong van Huyen, Jean-Paul; Jouven, Xavier; Glotz, Denis; Legendre, Christophe

    2014-01-01

    Antibody-mediated rejection (ABMR) is the leading cause of kidney allograft loss. We investigated whether the addition of gene expression measurements to conventional methods could serve as a molecular microscope to identify kidneys with ABMR that are at high risk for failure. We studied 939 consecutive kidney recipients at Necker Hospital (20042010; principal cohort) and 321 kidney recipients at Saint Louis Hospital (20062010; validation cohort) and assessed patients with ABMR in the first 1 year post-transplant. In addition to conventional features, we assessed microarray-based gene expression in transplant biopsy specimens using relevant molecular measurements: the ABMR Molecular Score and endothelial donor-specific antibody-selective transcript set. The main outcomes were kidney transplant loss and progression to chronic transplant injury. We identified 74 patients with ABMR in the principal cohort and 54 patients with ABMR in the validation cohort. Conventional features independently associated with failure were donor age and humoral histologic score (g+ptc+v+cg+C4d). Adjusting for conventional features, ABMR Molecular Score (hazard ratio [HR], 2.22; 95% confidence interval [95% CI], 1.37 to 3.58; P=0.001) and endothelial donor-specific antibody-selective transcripts (HR, 3.02; 95% CI, 1.00 to 9.16; P<0.05) independently associated with an increased risk of graft loss. The results were replicated in the independent validation group. Adding a gene expression assessment to a traditional risk model improved the stratification of patients at risk for graft failure (continuous net reclassification improvement, 1.01; 95% CI, 0.57 to 1.46; P<0.001; integrated discrimination improvement, 0.16; P<0.001). Compared with conventional assessment, the addition of gene expression measurement in kidney transplants with ABMR improves stratification of patients at high risk for graft loss. PMID:24700874

  17. Molecular microscope strategy to improve risk stratification in early antibody-mediated kidney allograft rejection.

    PubMed

    Loupy, Alexandre; Lefaucheur, Carmen; Vernerey, Dewi; Chang, Jessica; Hidalgo, Luis G; Beuscart, Thibaut; Verine, Jerome; Aubert, Olivier; Dubleumortier, Sbastien; Duong van Huyen, Jean-Paul; Jouven, Xavier; Glotz, Denis; Legendre, Christophe; Halloran, Philip F

    2014-10-01

    Antibody-mediated rejection (ABMR) is the leading cause of kidney allograft loss. We investigated whether the addition of gene expression measurements to conventional methods could serve as a molecular microscope to identify kidneys with ABMR that are at high risk for failure. We studied 939 consecutive kidney recipients at Necker Hospital (2004-2010; principal cohort) and 321 kidney recipients at Saint Louis Hospital (2006-2010; validation cohort) and assessed patients with ABMR in the first 1 year post-transplant. In addition to conventional features, we assessed microarray-based gene expression in transplant biopsy specimens using relevant molecular measurements: the ABMR Molecular Score and endothelial donor-specific antibody-selective transcript set. The main outcomes were kidney transplant loss and progression to chronic transplant injury. We identified 74 patients with ABMR in the principal cohort and 54 patients with ABMR in the validation cohort. Conventional features independently associated with failure were donor age and humoral histologic score (g+ptc+v+cg+C4d). Adjusting for conventional features, ABMR Molecular Score (hazard ratio [HR], 2.22; 95% confidence interval [95% CI], 1.37 to 3.58; P=0.001) and endothelial donor-specific antibody-selective transcripts (HR, 3.02; 95% CI, 1.00 to 9.16; P<0.05) independently associated with an increased risk of graft loss. The results were replicated in the independent validation group. Adding a gene expression assessment to a traditional risk model improved the stratification of patients at risk for graft failure (continuous net reclassification improvement, 1.01; 95% CI, 0.57 to 1.46; P<0.001; integrated discrimination improvement, 0.16; P<0.001). Compared with conventional assessment, the addition of gene expression measurement in kidney transplants with ABMR improves stratification of patients at high risk for graft loss. PMID:24700874

  18. Prediction of poor mobilization of autologous CD34+ cells with growth factor in multiple myeloma patients: implications for risk-stratification.

    PubMed

    Costa, Luciano J; Nista, Elizabeth J; Buadi, Francis K; Lacy, Martha Q; Dispenzieri, Angela; Kramer, Cindy P; Edwards, Kathy H; Kang, Yubin; Gertz, Morie A; Stuart, Robert K; Kumar, Shaji

    2014-02-01

    It is unknown whether clinical characteristics can successfully predict which multiple myeloma (MM) patients would be poor mobilizers with growth factor (GF) alone so they can be assigned to mobilization with chemotherapy+GF or GF+plerixafor. MM patients (N=477) who underwent autologous mobilization with GF were retrospectively reviewed and assigned into training and validation cohorts. In multiple regression analysis, age, platelet count at time of mobilization, type of GF utilized, and extent of exposure to lenalidomide independently correlated with peripheral blood (PB)-CD34+ and were integrated in a predicting score (PS) for poor mobilizers, defined as PB-CD34+<20/mm(3) 4days after initiation of GF. There was no correlation between institution, gender, time between diagnosis, and mobilization or plasma cells in the bone marrow at time of mobilization and PBCD34+. The PS cut-off found in the training cohort to have 90% sensitivity for prediction of poor mobilizers performed with 89.7% sensitivity but only 34.8% specificity in the validation cohort. Conversely, the PS cut-off developed to have 90% specificity performed with 86.9% specificity but only 37% sensitivity. We conclude that clinical characteristics identifiable before initiation of mobilization should not be used to stratify MM patients for different mobilization strategies. PMID:24211319

  19. Targeted individual prophylaxis offers superior risk stratification for cytomegalovirus reactivation after liver transplantation.

    PubMed

    Sood, Siddharth; Haifer, Craig; Yu, Lijia; Pavlovic, Julie; Gow, Paul J; Jones, Robert M; Visvanathan, Kumar; Angus, Peter W; Testro, Adam G

    2015-12-01

    Cytomegalovirus (CMV) can reactivate following liver transplantation. Management of patients currently considered low risk based on pretransplant serology remains contentious, with universal prophylaxis and preemptive strategies suffering from significant deficiencies. We hypothesized that a CMV-specific T cell assay performed early after transplant as part of a preemptive strategy could better stratify "low-risk" (recipient seropositive) patients. We conducted a prospective, blinded, observational study in 75 adult recipients. QuantiFERON-cytomegalovirus was performed both before and at multiple times after transplant. Low-risk patients (n = 58) were monitored as per unit protocol and treatment was commenced if CMV > 1000 copies/mL (DNAemia). Twenty patients needed antiviral treatment for other reasons and were censored (mainly for rejection or herpes simplex virus infection); 19/38 (50%) of the remaining low-risk patients developed DNAemia at mean 34.6 days after transplant. A week 2 result of <0.1 IU/mL was significantly associated with risk of subsequent DNAemia (hazard ratio [HR], 6.9; P = 0.002). The positive predictive value of 80% suggests these patients are inappropriately labeled low risk and are actually at high likelihood of CMV reactivation. A secondary cutoff of <0.2 IU/mL was associated with moderate risk (HR, 2.8; P = 0.01). In conclusion, a protocol based on a single early CMV-specific T cell based assay would offer improved risk stratification and individualization of patient management after transplant. This could offer improved drug and service utilization and potentially result in significant improvements over both currently used protocols to manage supposedly low-risk patients. Liver Transpl 21:1478-1485, 2015. © 2015 AASLD. PMID:26194446

  20. Surgical outcomes in phacoemulsification after application of a risk stratification system

    PubMed Central

    Tsinopoulos, Ioannis T; Lamprogiannis, Lampros P; Tsaousis, Konstantinos T; Mataftsi, Asimina; Symeonidis, Chrysanthos; Chalvatzis, Nikolaos T; Dimitrakos, Stavros A

    2013-01-01

    Background The purpose of this study was to determine whether application of a risk stratification system during preoperative assessment of cataract patients and subsequent allocation of patients to surgeons with matching experience may reduce intraoperative complications. Methods Nine hundred and fifty-three consecutive patients (1109 eyes) undergoing phacoemulsification cataract surgery were assigned to two groups, ie, group A (n = 498 patients, 578 eyes) and group B (n = 455 patients, 531 eyes). Patients from group A were allocated to surgeons with varying experience with only a rough estimate of the complexity of their surgery. Patients from group B were assigned to three risk groups (no added risk, low risk, and moderate-high risk) according to risk factors established during their preoperative assessment and were respectively allocated to resident surgeons, low-volume surgeons, or high-volume surgeons. Data were collected and entered into a computerized database. The intraoperative complication rate was calculated for each group. Results The intraoperative complication rate was significantly lower in group B than in group A (group A, 5.88%; group B, 3.2%; P < 0.05). Patients from group B with no added risk and allocated to resident surgeons had a significantly lower rate of intraoperative complications than those from group A allocated to resident surgeons (group A, 7.2%; group B, 3.08%; P < 0.05). Conclusion Our study demonstrates that allocation of cataract patients to surgeons matched for experience according to a uniform and reliable preoperative assessment of their risk of complications allows for better surgical outcomes, especially for resident surgeons. PMID:23717035

  1. Comparison of the Global Registry of Acute Coronary Events Risk Score Versus the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse outcomes With Early Implementation of the ACC/AHA Guidelines Risk Score to Predict In-Hospital Mortality and Major Bleeding in Acute Coronary Syndromes.

    PubMed

    Manzano-Fernández, Sergio; Sánchez-Martínez, Marianela; Flores-Blanco, Pedro J; López-Cuenca, Ángel; Gómez-Molina, Miriam; Pastor-Pérez, Francisco J; Sánchez-Galian, María J; Cambronero-Sanchez, Francisco; Guerrero Pérez, Esther; García-Narbón, Andrea; de Las Heras-Gómez, Ignacio; Valdés, Mariano

    2016-04-01

    Risk assessment plays a major role in the management of acute coronary syndrome. The aim was to compare the performance of the Global Registry of Acute Coronary Events (GRACE) and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the American College of Cardiology/American Heart Asociation guidelines (CRUSADE) risk scores to predict in-hospital mortality and major bleeding (MB) in 1,587 consecutive patients with acute coronary syndrome. In-hospital deaths and bleeding complications were prospectively collected. Bleeding complications were defined according to CRUSADE and Bleeding Academic Research Consortium (BARC) criteria. During the hospitalization, 71 patients (4.5%) died, 37 patients (2.3%) had BARC MB and 34 patients (2.1%) had CRUSADE MB. Receiver operating characteristic curves analyses showed GRACE risk score has better discrimination capacity than CRUSADE risk score for both, mortality (0.86 vs 0.79; p = 0.018) and BARC MB (0.80 vs 0.73; p = 0.028), but similar for CRUSADE MB (0.79 vs 0.79; p = 0.921). Both scores had low discrimination for predicting MB in the elderly (>75 years) and patients with atrial fibrillation, whereas CRUSADE risk score was especially poor for predicting MB in patients with <60 ml/min/1.73 m(2) or those treated with new antiplatelets. Reclassification analyses showed GRACE risk score was associated with a significant improvement in the predictive accuracy of CRUSADE risk score for predicting mortality (net reclassification improvement: 22.5%; p <0.001) and MB (net reclassification improvement: 17.6%; p = 0.033) but not for CRUSADE MB. In conclusion, GRACE risk score has a better predictive performance for predicting both in-hospital mortality and BARC MB. In light of these findings, we propose the GRACE score as a single score to predict these in-hospital complications. PMID:26857164

  2. Diagnosis and Therapy of Acute Myeloid Leukemia in the Era of Molecular Risk Stratification.

    PubMed

    Komanduri, Krishna V; Levine, Ross L

    2016-01-14

    The diagnosis and risk stratification of acute myeloid leukemia (AML) primarily rely on morphologic analysis and assessment of karyotype by chromosome banding analysis. For decades, standard AML induction therapy has utilized the combination of anthracyclines and cytarabine. Despite the use of postremission therapy, less than half of patients with AML will be cured of their disease. Allogeneic hematopoietic stem cell transplantation combines cytoreductive chemotherapy with adoptive immunotherapy and may cure patients who fail chemotherapy alone. Recent advances in next-generation sequencing have yielded important insights into the molecular landscape of AML with normal karyotype. Integrated prognostic models incorporating somatic mutation analyses may outperform prediction based on conventional clinical and cytogenetic factors alone. We review the evolution of risk profiling of AML from the cytogenetic to molecular era and describe the implications for AML diagnosis and postremission therapy. PMID:26473413

  3. A new method for IVUS-based coronary artery disease risk stratification: A link between coronary & carotid ultrasound plaque burdens.

    PubMed

    Araki, Tadashi; Ikeda, Nobutaka; Shukla, Devarshi; Londhe, Narendra D; Shrivastava, Vimal K; Banchhor, Sumit K; Saba, Luca; Nicolaides, Andrew; Shafique, Shoaib; Laird, John R; Suri, Jasjit S

    2016-02-01

    Interventional cardiologists have a deep interest in risk stratification prior to stenting and percutaneous coronary intervention (PCI) procedures. Intravascular ultrasound (IVUS) is most commonly adapted for screening, but current tools lack the ability for risk stratification based on grayscale plaque morphology. Our hypothesis is based on the genetic makeup of the atherosclerosis disease, that there is evidence of a link between coronary atherosclerosis disease and carotid plaque built up. This novel idea is explored in this study for coronary risk assessment and its classification of patients between high risk and low risk. This paper presents a strategy for coronary risk assessment by combining the IVUS grayscale plaque morphology and carotid B-mode ultrasound carotid intima-media thickness (cIMT) - a marker of subclinical atherosclerosis. Support vector machine (SVM) learning paradigm is adapted for risk stratification, where both the learning and testing phases use tissue characteristics derived from six feature combinational spaces, which are then used by the SVM classifier with five different kernels sets. These six feature combinational spaces are designed using 56 novel feature sets. K-fold cross validation protocol with 10 trials per fold is used for optimization of best SVM-kernel and best feature combination set. IRB approved coronary IVUS and carotid B-mode ultrasound were jointly collected on 15 patients (2 days apart) via: (a) 40MHz catheter utilizing iMap (Boston Scientific, Marlborough, MA, USA) with 2865 frames per patient (42,975 frames) and (b) linear probe B-mode carotid ultrasound (Toshiba scanner, Japan). Using the above protocol, the system shows the classification accuracy of 94.95% and AUC of 0.95 using optimized feature combination. This is the first system of its kind for risk stratification as a screening tool to prevent excessive cost burden and better patients' cardiovascular disease management, while validating our two hypotheses. PMID:26707374

  4. [Syncope and work: role of the occupational physician and global risk stratification].

    PubMed

    Barbic, F; Angaroni, L; Orlandi, M; Costantino, G; Dipaola, E; Borleri, D; Borchini, R; D'Adda, F; Perego, F; Borella, M; Galli, A; Solbiati, M; Scanella, E; Casazza, G; Seghizzi, P; Furlan, R

    2011-01-01

    Safety risk for subjects suffering from syncope while working has not been as yet addressed by occupational medicine. The present study was aimed at evaluating a new developed methodology for job tasks risk stratification in patients with syncope. During a work-shop on syncope and occupational risk, 149 occupational physicians (OP) with about 10 years of clinical experience were asked to fulfil a Visual Analogue Scale (VAS) concerning the doctor's estimated potential damage (D) to the worker and the probability of a damage to occur (P) should syncope take place during the job task. Five job tasks characterized by different risk for safety (1, driving; 2, toxic products handling; 3, job performed closed to hot surfaces o free flames; 4, surgical activity; 5, office job) were identified. OP correctly stratified the risk associated to the different job tasks in patients with syncope. Unexpectedly, task #3 was given a risk similar to that obtained in drivers. This might be of paramount clinical and social importance when patients with syncope have to return to their job tasks. PMID:23393862

  5. Diabetes and atrial fibrillation: stratification and prevention of stroke risks

    PubMed Central

    2014-01-01

    Background Although evidence is not very clear, diabetes is assumed to be an independent risk factor for atrial fibrillation (AF). One reason for the lack of evidence could be that AF often is not detected due to its paroxysmal or asymptomatic character. A better understanding of the relationship between both diseases and improved detection of AF is necessary since the combination of both diseases dramatically increase the risk of strokes if not treated properly. Methods Available literature about diabetes as an independent risk factor for AF has been evaluated, and limitations of studies are discussed. Results Results from different trials and registers are contradictory concerning diabetes as an independent risk factor for AF. Reasons for these differences can be found in different study designs and neglecting patients with unknown AF. Conclusions Due to the increasing burden of disease of diabetes and AF as common risk factors for stroke, a systematic screening for AF in diabetes patients could provide a better understanding of their correlation and personalized prevention strategies. PMID:25302085

  6. Future directions in risk stratification and therapy for advanced pediatric genitourinary rhabdomyosarcoma.

    PubMed

    Harel, Miriam; Ferrer, Fernando A; Shapiro, Linda H; Makari, John H

    2016-02-01

    Rhabdomyosarcoma (RMS) represents the most common soft tissue sarcoma in infants and children and the third most common pediatric solid tumor, accounting for 5% to 15% of all childhood solid tumors. Of these, 15% to 20% arise from the genitourinary tract, with the most common sites originating from the prostate, bladder, and paratesticular regions, followed by the vagina and uterus. Although upfront radical surgery was used at the initiation of Intergroup RMS Study-I (1972-1978), the treatment paradigm has shifted to include initial biopsy with the goal of organ preservation, systemic chemotherapy for all patients, and local control involving surgical resection with or without radiation therapy for most patients. Collaborative group clinical trials have led to dramatic improvement in survival rates from 1960 to 1996 among patients with low- or intermediate-risk disease; however, outcomes appear to have plateaued in more recent years, and the prognosis for patients with metastatic or relapsed/refractory disease remains poor. Current management goals include minimizing toxicity while maintaining the excellent outcomes in low-risk disease, as well as improving outcomes in patients with intermediate- and high-risk disease. Advances in genetic analysis have allowed further refinement in risk stratification of patients. Perhaps the most significant recent development in RMS research was the discovery of an association of alveolar RMS (ARMS) with translocations t(2;13) and t(1;13). Translocation fusion-positive tumors comprise 80% of ARMS and are more aggressive. Fusion-negative ARMS may have a clinical course similar to embryonal RMS. Future Children?s Oncology Group sarcoma studies will likely incorporate fusion status into risk stratification and treatment allocation. Newer radiotherapy modalities hold promise for providing local control of disease while minimizing morbidity. The addition of traditional cytotoxic chemotherapeutic agents does not seem to improve outcomes in high-risk patients. Ultimately, the most substantial progress may arise from further elucidation of genetic and molecular pathways involved in RMS tumor formation in an effort to identify novel, targeted therapeutic approaches. PMID:26519985

  7. IMWG consensus on risk stratification in multiple myeloma.

    PubMed

    Chng, W J; Dispenzieri, A; Chim, C-S; Fonseca, R; Goldschmidt, H; Lentzsch, S; Munshi, N; Palumbo, A; Miguel, J S; Sonneveld, P; Cavo, M; Usmani, S; Durie, B G M; Avet-Loiseau, H

    2014-02-01

    Multiple myeloma is characterized by underlying clinical and biological heterogeneity, which translates to variable response to treatment and outcome. With the recent increase in treatment armamentarium and the projected further increase in approved therapeutic agents in the coming years, the issue of having some mechanism to dissect this heterogeneity and rationally apply treatment is coming to the fore. A number of robustly validated prognostic markers have been identified and the use of these markers in stratifying patients into different risk groups has been proposed. In this consensus statement, the International Myeloma Working Group propose well-defined and easily applicable risk categories based on current available information and suggests the use of this set of prognostic factors as gold standards in all clinical trials and form the basis of subsequent development of more complex prognostic system or better prognostic factors. At the same time, these risk categories serve as a framework to rationalize the use of therapies. PMID:23974982

  8. Standardized reporting guidelines for emergency department syncope risk-stratification research.

    PubMed

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

    2012-06-01

    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 wanted 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 (ECG) 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 rerated 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, nine items for ECG abnormalities, and 50 items for candidate predictors. Adherence to these guidelines should facilitate comparison of future research in this area. PMID:22687184

  9. The role of fluorescence in situ hybridization and gene expression profiling in myeloma risk stratification.

    PubMed

    Hose, Dirk; Seckinger, Anja; Jauch, Anna; Rme, Thierry; Moreaux, Jrme; Bertsch, Uta; Neben, Kai; Klein, Bernard; Goldschmidt, Hartmut

    2011-12-01

    Multiple myeloma patients' survival under treatment varies from a few months to more than 15 years. Clinical prognostic factors, especially beta2-microglobulin (B2M) and the international staging system (ISS), allow risk assessment to a certain extent, but do not identify patients at very high risk. As malignant plasma cells are characterized by a variety of chromosomal aberrations and changes in gene expression, a molecular characterization ofCD138-purified myeloma cells by interphase fluorescence in situ hybridization (iFISH) and gene expression profiling (GEP) can be used for improved risk assessment, iFISH allows a risk stratification with presence of a translocation t(4;14) and/or deletion of 17p13 being the best documented adverse prognostic factors. A deletion of 13q14 is no longer considered to define adverse risk. Patients harbouring a t(4;14) seems to benefit from a bortezomib- or lenalidomide containing regimen, whereas patients with deletion 17p13 seem only to benefit from a high dose therapy approach using long term bortezomib (in induction and maintenance) and autologous tandem-transplantation as used in the GMMG-HD4 trial, or the total therapy 3 concept. Gene expression profiling allows the assessment of high risk scores (IFM, UAMS), remaining prognostic despite treatment with novel agents, and prognostic surrogates of biological factors (e.g. proliferation) and (prognostic) target gene expression (e.g. Aurora-kinase A). Thus, assessment of B2M and ISS-stage, iFISH, and GEP is considered extended routine diagnostics in therapy requiring multiple myeloma patients for risk assessment and, even now, to a certain extent selection of treatment. PMID:22352188

  10. Adjuvant imatinib treatment in gastrointestinal stromal tumor: which risk stratification criteria and for how long? A case report.

    PubMed

    Blay, Jean-Yves; Levard, Alice

    2016-01-01

    Imatinib mesylate is approved for the adjuvant treatment of KIT-positive gastrointestinal stromal tumor (GIST) following surgical resection. However, uncertainty remains in terms of patient eligibility for adjuvant treatment and the optimal duration of treatment. Here, we present two challenging patient cases encountered in clinical practice that highlight the ambiguity in the current recommendations for adjuvant imatinib in GIST and discuss our approaches and rationales for treatment. The first case involves a 36-year-old man with a 7?cm duodenal GIST and possible tumor rupture during surgical resection. This patient's risk of GIST recurrence was either intermediate or high depending on which risk stratification criteria were used. The patient was treated with adjuvant imatinib for 3 years and experienced disease recurrence 14 months after the completion of treatment. Imatinib treatment was reintroduced, and the patient is in partial response 17 months later. The second case involves a 46-year-old woman at high risk of recurrence following surgical resection. Adjuvant treatment with imatinib was initiated. After considering the patient's initial high risk and good side-effect profile, the decision was made to continue adjuvant imatinib treatment for 5 years. As of May 2013, the patient has been receiving continuous imatinib treatment for 52 months, with no sign of progression. These reports exemplify the challenges faced in clinical practice because of uncertainties in optimal risk stratification criteria and duration of treatment. They stress the importance of individualized treatment and shared decision making between the physician and the patient. PMID:26457546

  11. Prognostic factors and risk stratification in early mycosis fungoides.

    PubMed

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

    2014-01-01

    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

  12. Risk stratification of thyroid nodules on ultrasonography with the French TI-RADS: description and reflections.

    PubMed

    Russ, Gilles

    2016-01-01

    The widespread use of ultrasonography places it in a key position for use in the risk stratification of thyroid nodules. The French proposal is a five-tier system, our version of a thyroid imaging reporting and database system (TI-RADS), which includes a standardized vocabulary and report and a quantified risk assessment. It allows the selection of the nodules that should be referred for fine-needle aspiration biopsies. Effort should be directed towards merging the different risk stratification systems utilized around the world and testing this unified system with multi-center studies. PMID:26324117

  13. Risk stratification of thyroid nodules on ultrasonography with the French TI-RADS: description and reflections

    PubMed Central

    2016-01-01

    The widespread use of ultrasonography places it in a key position for use in the risk stratification of thyroid nodules. The French proposal is a five-tier system, our version of a thyroid imaging reporting and database system (TI-RADS), which includes a standardized vocabulary and report and a quantified risk assessment. It allows the selection of the nodules that should be referred for fine-needle aspiration biopsies. Effort should be directed towards merging the different risk stratification systems utilized around the world and testing this unified system with multi-center studies. PMID:26324117

  14. Renal disease in scleroderma: an update on evaluation, risk stratification, pathogenesis and management

    PubMed Central

    Shanmugam, Victoria K.; Steen, Virginia D.

    2013-01-01

    Purpose of review Renal disease remains an important cause of morbidity and mortality in scleroderma. The spectrum of renal complications in systemic sclerosis includes scleroderma renal crisis (SRC), normotensive renal crisis, antineutrophil cytoplasmic antibodies-associated glomerulonephritis, penacillamine-associated renal disease, and reduced renal functional reserves manifested by proteinuria, microalbuminuria, or isolated reduction in glomerular filtration rate. The purpose of this review is to provide a concise and up-to-date review of the evaluation, risk stratification, pathogenesis, and management of scleroderma-associated renal disease. Recent findings Although SRC survival has significantly improved, mortality of this complication remains high outside of specialized centers. Recent data demonstrate strong associations between anti-RNA polymerase III antibodies and SRC. Subclinical renal impairment affects approximately 50% of scleroderma patients and may be associated with other vascular manifestations. Subclinical renal involvement rarely progresses to end-stage renal failure; however, recent studies suggest it may predict mortality in patients with other vasculopathic manifestations. Summary Testing for anti-RNA polymerase III antibodies should be incorporated into clinical care to identify patients at high risk for SRC. Recommendations from European League Against Rheumatism (EULAR), EULAR Scleroderma Trials and Research, and the Scleroderma Clinical Trials Consortium confirm angiotensin-converting enzyme inhibitors as first-line therapy for SRC, and give recommendations for second-line agents. PMID:22955019

  15. The RAG Model: A New Paradigm for Genetic Risk Stratification in Multiple Myeloma

    PubMed Central

    Prideaux, Steven M.; Conway O'Brien, Emma; Chevassut, Timothy J.

    2014-01-01

    Molecular studies have shown that multiple myeloma is a highly genetically heterogonous disease which may manifest itself as any number of diverse subtypes each with variable clinicopathological features and outcomes. Given this genetic heterogeneity, a universal approach to treatment of myeloma is unlikely to be successful for all patients and instead we should strive for the goal of personalised therapy using rationally informed targeted strategies. Current DNA sequencing technologies allow for whole genome and exome analysis of patient myeloma samples that yield vast amounts of genetic data and provide a mutational overview of the disease. However, the clinical utility of this information currently lags far behind the sequencing technology which is increasingly being incorporated into clinical practice. This paper attempts to address this shortcoming by proposing a novel genetically based traffic-light risk stratification system for myeloma, termed the RAG (Red, Amber, Green) model, which represents a simplified concept of how complex genetic data may be compressed into an aggregate risk score. The model aims to incorporate all known clinically important trisomies, translocations, and mutations in myeloma and utilise these to produce a score between 1.0 and 3.0 that can be incorporated into diagnostic, prognostic, and treatment algorithms for the patient. PMID:25295194

  16. The RAG Model: A New Paradigm for Genetic Risk Stratification in Multiple Myeloma.

    PubMed

    Prideaux, Steven M; Conway O'Brien, Emma; Chevassut, Timothy J

    2014-01-01

    Molecular studies have shown that multiple myeloma is a highly genetically heterogonous disease which may manifest itself as any number of diverse subtypes each with variable clinicopathological features and outcomes. Given this genetic heterogeneity, a universal approach to treatment of myeloma is unlikely to be successful for all patients and instead we should strive for the goal of personalised therapy using rationally informed targeted strategies. Current DNA sequencing technologies allow for whole genome and exome analysis of patient myeloma samples that yield vast amounts of genetic data and provide a mutational overview of the disease. However, the clinical utility of this information currently lags far behind the sequencing technology which is increasingly being incorporated into clinical practice. This paper attempts to address this shortcoming by proposing a novel genetically based "traffic-light" risk stratification system for myeloma, termed the RAG (Red, Amber, Green) model, which represents a simplified concept of how complex genetic data may be compressed into an aggregate risk score. The model aims to incorporate all known clinically important trisomies, translocations, and mutations in myeloma and utilise these to produce a score between 1.0 and 3.0 that can be incorporated into diagnostic, prognostic, and treatment algorithms for the patient. PMID:25295194

  17. Genetic stratification in myeloid diseases: from risk assessment to clinical decision support tool.

    PubMed

    Ofran, Yishai

    2014-10-01

    Genetic aberrations have become a dominant factor in the stratification of myeloid malignancies. Cytogenetic and a few mutation studies are the backbone of risk assessment models of myeloid malignancies which are a major consideration in clinical decisions, especially patient assignment for allogeneic stem cell transplantation. Progress in our understanding of the genetic basis of the pathogenesis of myeloid malignancies and the growing capabilities of mass sequencing may add new roles for the clinical usage of genetic data. A few recently identified mutations recognized to be associated with specific diseases or clinical scenarios may soon become part of the diagnostic criteria of such conditions. Mutational studies may also advance our capabilities for a more efficient patient selection process, assigning the most effective therapy at the best timing for each patient. The clinical utility of genetic data is anticipated to advance further with the adoption of deep sequencing and next-generation sequencing techniques. We herein suggest some future potential applications of sequential genetic data to identify pending deteriorations at time points which are the best for aggressive interventions such as allogeneic stem cell transplantation. Genetics is moving from being mostly a prognostic factor to becoming a multitasking decision support tool for hematologists. Physicians must pay attention to advances in molecular hematology as it will soon be accessible and influential for most of our patients. PMID:25386341

  18. Combination of BCL-2 and MYC protein expression improves high-risk stratification in diffuse large B-cell lymphoma

    PubMed Central

    Wang, Jing; Zhou, Min; Xu, Jing-Yan; Chen, Bing; Ouyang, Jian

    2015-01-01

    Purpose To evaluate whether the addition of two biological markers (MYC and BCL-2 protein overexpression) improves the stratification of high-risk patients with diffuse large B-cell lymphoma (DLBCL). Method Seven risk factors were identified at diagnosis, and a maximum of 7 points were assigned to each patient. The patients were classified according to four risk groups: low (01), low-intermediate (23), high-intermediate (4), and high (57). Only high-risk patients with DLBCL were included in this analysis. We retrospectively examined 20 cases from 2008 to 2013 at the Nanjing Drum Tower Hospital. Results The median expression of MYC protein was 60%, and 17 of 20 (65%) evaluable cases overexpressed MYC. The median expression of BCL-2 protein was also 60%. Eighteen of 20 (90%) evaluable cases showed BCL-2 overexpression. Additionally, 12 out of 20 cases (60%) demonstrated coexpression of MYC and BCL-2 proteins. The percentages of overall survival and progression-free survival at the median follow-up time (36 months) were 33.3%16.1% and 16.9%13.5%, respectively. By comparison, nine, four, and 20 patients were classified as high risk based on the International Prognostic Index (IPI), National Comprehensive Cancer Network(NCCN)-IPI, and revised IPI criteria, respectively. According to the IPI and NCCN-IPI stratification, the risk groups demonstrated closely overlapping survival curves. In addition, four out of 20 cases were identified as low-intermediate risk according to the NCCN-IPI criteria. Conclusion The addition of MYC and BCL-2 protein expression to the IPI could identify a subset of DLBCL patients with high-risk clinicopathological characteristics and poor clinical outcome. PMID:26425100

  19. Improved risk stratification in myeloma using a microRNA-based classifier.

    PubMed

    Wu, Ping; Agnelli, Luca; Walker, Brian A; Todoerti, Katia; Lionetti, Marta; Johnson, David C; Kaiser, Martin; Mirabella, Fabio; Wardell, Christopher; Gregory, Walter M; Davies, Faith E; Brewer, Daniel; Neri, Antonino; Morgan, Gareth J

    2013-08-01

    Multiple myeloma (MM) is a heterogeneous disease. International Staging System/fluorescence hybridization (ISS/FISH)-based model and gene expression profiles (GEP) are effective approaches to define clinical outcome, although yet to be improved. The discovery of a class of small non-coding RNAs (micro RNAs, miRNAs) has revealed a new level of biological complexity underlying the regulation of gene expression. In this work, 163 presenting samples from MM patients were analysed by global miRNA profiling, and distinct miRNA expression characteristics in molecular subgroups with prognostic relevance (4p16, MAF and 11q13 translocations) were identified. Furthermore we developed an "outcome classifier", based on the expression of two miRNAs (MIR17 and MIR886-5p), which is able to stratify patients into three risk groups (median OS 19.4, 40.6 and 65.3 months, P = 0.001). The miRNA-based classifier significantly improved the predictive power of the ISS/FISH approach (P = 0.0004), and was independent of GEP-derived prognostic signatures (P < 0.002). Through integrative genomics analysis, we outlined the potential biological relevance of the miRNAs included in the classifier and their putative roles in regulating a large number of genes involved in MM biology. This is the first report showing that miRNAs can be built into molecular diagnostic strategies for risk stratification in MM. PMID:23718138

  20. Risk stratification of non-contrast CT beyond the coronary calcium scan.

    PubMed

    Madaj, Paul; Budoff, Matthew J

    2012-01-01

    Coronary artery calcification (CAC) is a well-known marker for coronary artery disease andhas important prognostic implications. CAC is able to provide clinicians with a reliable source of information related to cardiovascular atherosclerosis, which carries incremental information beyond Framingham risk. However, non-contrast scans of the heart provide additional information beyond theAgatston score. These studies are also able to measure various sources of fat, including intrathoracic (eg, pericardial or epicardial) and hepatic, both of which are thought to be metabolically active and linked to increased incidence of subclinical atherosclerosis as well as increased prevalence of type 2 diabetes. Testing for CAC is also useful in identifying extracoronary sources of calcification. Specifically, aortic valve calcification, mitral annular calcification, and thoracic aortic calcium (TAC) provide additional risk stratification information for cardiovascular events. Finally, scanning for CAC is able to evaluate myocardial scaring due to myocardial infarcts, which may also add incremental prognostic information. To ensure the benefits outweigh the risks of a scanning for CAC for an appropriately selected asymptomatic patient, the full utility of the scan should be realized. This review describes the current state of the art interpretation of non-contrast cardiac CT, which clinically should go well beyond coronary artery Agatston scoring alone. PMID:22981856

  1. Chronic Obstructive Pulmonary Disease heterogeneity: challenges for health risk assessment, stratification and management

    PubMed Central

    2014-01-01

    Background and hypothesis Heterogeneity in clinical manifestations and disease progression in Chronic Obstructive Pulmonary Disease (COPD) lead to consequences for patient health risk assessment, stratification and management. Implicit with the classical "spill over" hypothesis is that COPD heterogeneity is driven by the pulmonary events of the disease. Alternatively, we hypothesized that COPD heterogeneities result from the interplay of mechanisms governing three conceptually different phenomena: 1) pulmonary disease, 2) systemic effects of COPD and 3) co-morbidity clustering, each of them with their own dynamics. Objective and method To explore the potential of a systems analysis of COPD heterogeneity focused on skeletal muscle dysfunction and on co-morbidity clustering aiming at generating predictive modeling with impact on patient management. To this end, strategies combining deterministic modeling and network medicine analyses of the Biobridge dataset were used to investigate the mechanisms of skeletal muscle dysfunction. An independent data driven analysis of co-morbidity clustering examining associated genes and pathways was performed using a large dataset (ICD9-CM data from Medicare, 13 million people). Finally, a targeted network analysis using the outcomes of the two approaches (skeletal muscle dysfunction and co-morbidity clustering) explored shared pathways between these phenomena. Results (1) Evidence of abnormal regulation of skeletal muscle bioenergetics and skeletal muscle remodeling showing a significant association with nitroso-redox disequilibrium was observed in COPD; (2) COPD patients presented higher risk for co-morbidity clustering than non-COPD patients increasing with ageing; and, (3) the on-going targeted network analyses suggests shared pathways between skeletal muscle dysfunction and co-morbidity clustering. Conclusions The results indicate the high potential of a systems approach to address COPD heterogeneity. Significant knowledge gaps were identified that are relevant to shape strategies aiming at fostering 4P Medicine for patients with COPD. PMID:25472887

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

    PubMed

    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; Brcher, Bjrn Ldm; Stojadinovic, Alexander

    2013-01-01

    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

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

    PubMed Central

    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

    2013-01-01

    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

  4. Primary vesico-ureteric reflux: The need for individualised risk stratification

    PubMed Central

    Hidas, Guy; Nam, Alexander; Soltani, Tandis; Pribish, Maryellen; Watts, Blake; Khoury, Antoine E.

    2013-01-01

    The management of paediatric primary vesico-ureteric reflux (VUR) has undergone serial changes over the last decade. As this disorder is extremely heterogeneous, and high-quality prospective data are limited, the treatment strategies vary among centres. Current treatment options include observation only, continuous antibiotic prophylaxis, and surgery. Surgical intervention is indicated if a child has a breakthrough urinary tract infection (UTI) while on continuous antibiotic prophylaxis or if there are renal scars present. After excluding a secondary cause of VUR the physician should consider the risk factors affecting the severity of VUR and manage the child accordingly. Those factors include demographic factors (age at presentation, gender, ethnicity) and clinical factors (VUR grade, unilateral vs. bilateral, presence of renal scars, initial presentation, the number of UTIs, and presence of any voiding or bowel dysfunction). In this review we summarise the major controversial issues in current reports on VUR and highlight the importance of individualised patient management according to their risk stratification. PMID:26579238

  5. Electrocardiographic methods for diagnosis and risk stratification in the Brugada syndrome

    PubMed Central

    Naseef, Abdulrahman; Behr, Elijah R.; Batchvarov, Velislav N.

    2014-01-01

    The Brugada syndrome (BrS) is a malignant, genetically-determined, arrhythmic syndrome manifesting as syncope or sudden cardiac death (SCD) in individuals with structurally normal hearts. The diagnosis of the BrS is mainly based on the presence of a spontaneous or Na+channel blocker induced characteristic, electrocardiographic (ECG) pattern (type 1 or coved Brugada ECG pattern) typically seen in leads V1 and V2 recorded from the 4th to 2nd intercostal (i.c.) spaces. This pattern needs to be distinguished from similar ECG changes due to other causes (Brugada ECG phenocopies). This review focuses mainly on the ECG-based methods for diagnosis and arrhythmia risk assessment in the BrS. Presently, the main unresolved clinical problem is the identification of those patients at high risk of SCD who need implantable cardioverter-defibrillator (ICD), which is the only therapy with proven efficacy. Current guidelines recommend ICD implantation only in patients with spontaneous type 1 ECG pattern, and either history of aborted cardiac arrest or documented sustained VT (class I), or syncope of arrhythmic origin (class IIa) because they are at high risk of recurrent arrhythmic events (up to 10% or more annually for those with aborted cardiac arrest). The majority of BrS patients are asymptomatic when diagnosed and considered to have low risk (around 0.5% annually) and therefore not indicated for ICD. The majority of SCD victims in the BrS, however, had no symptoms prior to the fatal event and therefore were not protected with an ICD. While some ECG markers such as QRS fragmentation, infero-lateral early repolarisation, and abnormal late potentials on signal-averaged ECG are known to be linked to increased arrhythmic risk, they are not sufficiently sensitive or specific. Potential novel ECG-based strategies for risk stratification are discussed based on computerised methods for depolarisation and repolarisation analysis, a composite approach targeting several major components of ventricular arrhythmogenesis, and the collection of large digital ECG databases in genotyped BrS patients and their relatives. PMID:25870503

  6. Electrocardiographic methods for diagnosis and risk stratification in the Brugada syndrome.

    PubMed

    Naseef, Abdulrahman; Behr, Elijah R; Batchvarov, Velislav N

    2015-04-01

    The Brugada syndrome (BrS) is a malignant, genetically-determined, arrhythmic syndrome manifesting as syncope or sudden cardiac death (SCD) in individuals with structurally normal hearts. The diagnosis of the BrS is mainly based on the presence of a spontaneous or Na+channel blocker induced characteristic, electrocardiographic (ECG) pattern (type 1 or coved Brugada ECG pattern) typically seen in leads V1 and V2 recorded from the 4th to 2nd intercostal (i.c.) spaces. This pattern needs to be distinguished from similar ECG changes due to other causes (Brugada ECG phenocopies). This review focuses mainly on the ECG-based methods for diagnosis and arrhythmia risk assessment in the BrS. Presently, the main unresolved clinical problem is the identification of those patients at high risk of SCD who need implantable cardioverter-defibrillator (ICD), which is the only therapy with proven efficacy. Current guidelines recommend ICD implantation only in patients with spontaneous type 1 ECG pattern, and either history of aborted cardiac arrest or documented sustained VT (class I), or syncope of arrhythmic origin (class IIa) because they are at high risk of recurrent arrhythmic events (up to 10% or more annually for those with aborted cardiac arrest). The majority of BrS patients are asymptomatic when diagnosed and considered to have low risk (around 0.5% annually) and therefore not indicated for ICD. The majority of SCD victims in the BrS, however, had no symptoms prior to the fatal event and therefore were not protected with an ICD. While some ECG markers such as QRS fragmentation, infero-lateral early repolarisation, and abnormal late potentials on signal-averaged ECG are known to be linked to increased arrhythmic risk, they are not sufficiently sensitive or specific. Potential novel ECG-based strategies for risk stratification are discussed based on computerised methods for depolarisation and repolarisation analysis, a composite approach targeting several major components of ventricular arrhythmogenesis, and the collection of large digital ECG databases in genotyped BrS patients and their relatives. PMID:25870503

  7. Social stratification, risk factor prevalence and cancer screening attendance.

    PubMed

    Eisinger, Franois; Viguier, Jrme; Touboul, Chantal; Coscas, Yvan; Pivot, Xavier; Blay, Jean-Yves; Lhomel, Christine; Morre, Jean-Franois

    2015-06-01

    This analysis aimed to assess the extent to which exposure to cancer risk factors and attendance of screening programmes are influenced by social characteristics. The validated Evaluation of deprivation and health inequalities in public health centres (EPICES) index was used to measure social deprivation. A sample of the general population (N=1603) was assessed to search for potential correlations between screening attendance, risk factors and any components of the EPICES score. In 2011, 33% of the population studied was classified as 'vulnerable'. Sex had no significant impact on this rating (32% men, 35% women), whereas occupational status did. Vulnerable individuals were more likely already to have cancer (10 vs. 7%; nonsignificant difference; odds ratio 1.43 [0.98-2.10]). The mean BMI was 26.0?kg/m (SD 4.9) for the vulnerable population versus 24.8?kg/m (SD 3.9) in the nonvulnerable population (P<0.01). The prevalence of current smoking was higher in the vulnerable group (38 vs. 23%, odds ratio 2.03 [1.61-2.56]). In contrast, no statistically significant difference was observed between attendance rates for nationwide organized cancer screening programmes (breast and colorectal; target age group 50-74 years) by the vulnerable and nonvulnerable groups. Social indicators of vulnerable populations are associated with increased rates of risk factors for cancer, but not with screening attendance. Our data support the previously reported marked impact of organized programmes that reduce or even remove inequalities in access to cancer screening. However, although the organized programmes have indeed enabled population-wide, nonselective access to screening, primary prevention as it stands today remains inadequate in the underserved population and further improvements are warranted. PMID:26016792

  8. Implantable Cardioverter-Defibrillators at End of Battery Life: Opportunities for Risk (Re)-Stratification in ICD Recipients.

    PubMed

    Merchant, Faisal M; Quest, Tammie; Leon, Angel R; El-Chami, Mikhael F

    2016-02-01

    Although implantable cardioverter-defibrillators (ICDs) are frequently viewed as a lifelong commitment in that patients are routinely scheduled for generator exchange (GE) at end of battery life, several considerations should prompt a reevaluation of risks and benefits before GE. Compared with initial ICD implant, patients receiving replacement devices are older, and have more comorbidities and shorter life expectancy, all of which may limit the benefit of ICD therapy following GE. Additionally, GE is associated with significant complications, including infection, which may increase the risk of mortality. In this paper, we review recent data regarding opportunities for risk stratification before GE, with a particular focus on those with improved left ventricular function and those who have not experienced ICD therapies during the first battery life. We also provide a broader perspective on ICD therapy, focusing on how decisions regarding GE may affect goals of care at the end of life. PMID:26821633

  9. Hepatic Veno-Occlusive Disease after Hematopoietic Stem Cell Transplantation: Risk Factors and Stratification, Prophylaxis, and Treatment.

    PubMed

    Dalle, Jean-Hugues; Giralt, Sergio A

    2016-03-01

    Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), can develop in a subset of patients, primarily after myeloablative hematopoietic stem cell transplantation, but it also may occur after reduced-intensity conditioning. Severe VOD/SOS, typically characterized by multiorgan failure, has been associated with a mortality rate greater than 80%. Therefore, an accurate and prompt diagnosis of VOD/SOS is essential for early initiation of appropriate therapy to improve clinical outcomes. Moreover, some studies have support the use of prophylaxis for patients who are at high risk of developing VOD/SOS. This review summarizes risk factors associated with development of VOD/SOS, including pretransplantation patient characteristics and factors related to stem cell transplantation, that can facilitate patient stratification according to risk. The incidence of VOD/SOS, clinical features, and diagnostic criteria are reviewed. Data on emerging treatment strategies for patients with VOD/SOS are discussed in the context of recent treatment guidelines. Additionally, options for prophylaxis in individuals who are at increased risk are presented. Although historically only those patients with moderate to severe VOD/SOS have been treated, early therapy and prophylaxis may be appropriate for many patients and may have the potential to improve patients' outcomes and survival, including for those with nonsevere disease. PMID:26431626

  10. A national approach to diabetes foot risk stratification and foot care.

    PubMed

    Leese, G P; Stang, D; Pearson, D W

    2011-08-01

    The Scottish Diabetes Foot Action Group (SDG) has developed and introduced a national strategy plan for diabetic foot care across Scotland. This has involved the implementation of an evidence-based national foot screening and risk stratification programme that has already covered 61% of the population in just the first two years. Nationally agreed patient information foot leaflets and professional education material have been introduced, and a consensus for antibiotic use in the diabetic foot has been published. Information on multidisciplinary specialist foot services has been collected, indicating that 58% of Health Board areas have consultants with dedicated sessions in their job plan to a foot clinic, and 42% had integrated orthotic involvement. The SDG aims to increase these figures. Work has been undertaken to support local podiatry networks and improve communication between the specialist centre and the community. At a national level the SDG is working with Foot in Diabetes UK (FDUK) to recognize key podiatry skills by developing core competencies and a competency framework for the diabetes podiatrist and diabetes orthotist. The annual Scottish Diabetes Survey indicates some improvement in amputation rates with prevalence decreasing from 0.8% to 0.5%, and improved recording of foot ulceration at a national level. This national strategy has helped highlight the importance and difficulties facing diabetes foot care and should help to continue to improve the quality of care of people with diabetes who have foot-related problems. PMID:21873720

  11. SIOP-PODC adapted risk stratification and treatment guidelines: Recommendations for neuroblastoma in low- and middle-income settings.

    PubMed

    Parikh, Nehal S; Howard, Scott C; Chantada, Guillermo; Israels, Trijn; Khattab, Mohammed; Alcasabas, Patricia; Lam, Catherine G; Faulkner, Lawrence; Park, Julie R; London, Wendy B; Matthay, Katherine K

    2015-08-01

    Neuroblastoma is the most common extracranial solid tumor in childhood in high-income countries (HIC), where consistent treatment approaches based on clinical and tumor biological risk stratification have steadily improved outcomes. However, in low- and middle- income countries (LMIC), suboptimal diagnosis, risk stratification, and treatment may occur due to limited resources and unavailable infrastructure. The clinical practice guidelines outlined in this manuscript are based on current published evidence and expert opinions. Standard risk stratification and treatment explicitly adapted to graduated resource settings can improve outcomes for children with neuroblastoma by reducing preventable toxic death and relapse. PMID:25810263

  12. Improved risk stratification by the integration of the revised international prognostic scoring system with the myelodysplastic syndromes comorbidity index.

    PubMed

    van Spronsen, M F; Ossenkoppele, G J; Holman, R; van de Loosdrecht, A A

    2014-12-01

    Myelodysplastic syndromes (MDS) comprise bone marrow failure diseases with a diverse clinical outcome. For improved risk stratification, the International Prognostic Scoring System (IPSS) has recently been revised (IPSS-R). This single-centre study aimed to validate the IPSS-R and to evaluate prior prognostic scoring systems for MDS. We retrospectively analysed 363 patients diagnosed with MDS according to the FAB criteria between 2000 and 2012. The IPSS, MD Anderson Risk Model Score (MDAS), World Health Organisation (WHO)-classification based Prognostic Scoring System (WPSS), refined WPSS (WPSS-R), IPSS-R and MDS-Comorbidity Index (MDS-CI) were applied to 222 patients considered with primary MDS following the WHO criteria and their prognostic power was investigated. According to the IPSS-R, 18 (8%), 81 (37%), 50 (23%), 43 (19%) and 30 (13%) patients were classified as very low, low, intermediate, high and very high risk with, respectively, a median overall survival of 96 (95% Confidence interval (CI) not reached), 49 (95% CI 34-64), 22 (95% CI 0-49), 19 (95% CI 11-27) and 10 (95% CI 6-13) months (p<.000). The IPSS-R showed improved prognostic power as compared to the IPSS, MDAS, WPSS and WPSS-R. Furthermore, the MDS-CI refined the risk stratification of MDS patients stratified according to the IPSS-R. In conclusion, accounting for the disease status by means of the IPSS-R and comorbidity through the MDS-CI considerably improves the prognostic assessment in MDS patients. PMID:25454415

  13. An operative dengue risk stratification system in Argentina based on geospatial technology.

    PubMed

    Porcasi, Ximena; Rotela, Camilo H; Introini, Mara V; Frutos, Nicols; Lanfri, Sofa; Peralta, Gonzalo; De Elia, Estefana A; Lanfri, Mario A; Scavuzzo, Carlos M

    2012-09-01

    Based on an agreement between the Ministry of Health and the National Space Activities Commission in Argentina, an integrated informatics platform for dengue risk using geospatial technology for the surveillance and prediction of risk areas for dengue fever has been designed. The task was focused on developing stratification based on environmental (historical and current), viral, social and entomological situation for >3,000 cities as part of a system. The platform, developed with open-source software with pattern design, following the European Space Agency standards for space informatics, delivers two products: a national risk map consisting of point vectors for each city/town/locality and an approximate 50 m resolution urban risk map modelling the risk inside selected high-risk cities. The operative system, architecture and tools used in the development are described, including a detailed list of end users' requirements. Additionally, an algorithm based on bibliography and landscape epidemiology concepts is presented and discussed. The system, in operation since September 2011, is capable of continuously improving the algorithms producing improved risk stratifications without a complete set of inputs. The platform was specifically developed for surveillance of dengue fever as this disease has reemerged in Argentina but the aim is to widen the scope to include also other relevant vector-borne diseases such as chagas, malaria and leishmaniasis as well as other countries belonging to south region of Latin America. PMID:23032281

  14. From Philadelphia-Negative to JAK2-Positive: Effect of Genetic Discovery on Risk Stratification and Management.

    PubMed

    Pemmaraju, Naveen; Moliterno, Alison R

    2015-01-01

    The 2005 discovery of the JAK2 mutation redefined the diagnosis and natural history of myeloproliferative neoplasms (MPNs). Most importantly, this improvement in the pathobiologic conceptualization has focused our evolution of this field from being defined as what it is not (e.g., Philadelphia [Ph]-negative) to what it is (e.g., JAK2-positive, CALR-positive) in the majority of MPN cases. In the ensuing 10 years, the field has experienced a paradigm shift in terms of understanding of the biologic basis of the development of MPNs, an explosion of knowledge of the genetics of MPNs, and has translated disease knowledge into effective targeted therapies. With greater uniformity and agreement on the diagnosis and differences among the individual MPNs, augmented by improved cytogenetic and molecular classification, attention has turned now to addressing the need for uniformity in risk stratification of patients in the clinic for both disease complications and disease transformation. This article will highlight the developments in the field with regard to risk stratification and prognostication in MPNs with focus on the clinical aspects of the patient who presents with either essential thrombocytosis (ET), polycythemia vera (PV), or myelofibrosis (MF). PMID:25993152

  15. Evidence for cytogenetic and fluorescence in situ hybridization risk stratification of newly diagnosed multiple myeloma in the era of novel therapie.

    PubMed

    Kapoor, Prashant; Fonseca, Rafael; Rajkumar, S Vincent; Sinha, Shirshendu; Gertz, Morie A; Stewart, A Keith; Bergsagel, P Leif; Lacy, Martha Q; Dingli, David D; Ketterling, Rhett P; Buadi, Francis; Kyle, Robert A; Witzig, Thomas E; Greipp, Philip R; Dispenzieri, Angela; Kumar, Shaji

    2010-06-01

    Overall survival (OS) has improved with increasing use of novel agents in multiple myeloma (MM). However, the disease course remains highly variable, and the heterogeneity largely reflects different genetic abnormalities. We studied the impact of the Mayo risk-stratification model of MM on patient outcome in the era of novel therapies, evaluating each individual component of the model-fluorescence in situ hybridization (FISH), conventional cytogenetics (CG), and the plasma cell labeling index-that segregates patients into high- and standard-risk categories. This report consists of 290 patients with newly diagnosed MM, predominantly treated with novel agents, who were risk-stratified at diagnosis and were followed up for OS. Of these patients, 81% had received primarily thalidomide (n=50), lenalidomide (n=199), or bortezomib (n=79) as frontline or salvage therapies. Our retrospective analysis validates the currently proposed Mayo risk-stratification model (median OS, 37 months vs not reached for high- and standard-risk patients, respectively; P=.003). Although the FISH or CG test identifies a high-risk cohort with hazard ratios of 2.1 (P=.006) and 2.5 (P=.006), respectively, the plasma cell labeling index cutoff of 3% fails to independently prognosticate patient risk (hazard ratio, 1.4; P=.41). In those stratified as standard-risk by one of the 2 tests (FISH or CG), the other test appears to be of additional prognostic significance. This study validates the high-risk features defined by FISH and CG in the Mayo risk-stratification model for patients with MM predominantly treated with novel therapies based on immunomodulatory agents. PMID:20511484

  16. A COMBINED MOLECULAR-PATHOLOGICAL SCORE IMPROVES RISK STRATIFICATION OF THYROID PAPILLARY MICROCARCINOMA

    PubMed Central

    Niemeier, Leo A.; Akatsu, Haruko Kuffner; Song, Chi; Carty, Sally E.; Hodak, Steven P.; Yip, Linwah; Ferris, Robert L.; Tseng, George C.; Seethala, Raja R.; LeBeau, Shane O.; Stang, Michael T.; Coyne, Christopher; Johnson, Jonas T.; Stewart, Andrew F.; Nikiforov, Yuri E.

    2011-01-01

    Background Thyroid papillary microcarcinoma (TPMC) is an incidentally discovered papillary carcinoma that is ? 1.0 cm in size. Most TPMCs are indolent, whereas some behave aggressively. The aim of the study was to evaluate whether the combination of BRAF mutation and specific histopathological features allows risk stratification of TPMC. Methods A group of aggressive TPMC was selected based on the presence of lymph node metastasis or tumor recurrence. A group of non-aggressive tumors included TPMCs matched for age, gender, and tumor size, but with no extrathyroidal spread. Molecular analysis was performed and histological slides were scored for multiple histopathological criteria. A separate validation cohort of 40 TPMC was evaluated. Results BRAF mutation was detected in 77% of aggressive TPMC and 32% of non-aggressive tumors (p=0.001). Several histopathological features showed significant difference between the groups. Using multivariate regression analysis, a molecular-pathological (MP) score was developed that included BRAF status and three histopathological features: superficial tumor location, intraglandular tumor spread/multifocality, and tumor fibrosis. By adding the histologic criteria to BRAF status, sensitivity was increased from 77% to 96% and specificity from 68% to 80%. In the independent validation cohort, the MP score stratified tumors into low, moderate, and high risk groups, with the probability of lymph node metastases or tumor recurrence of 0, 20%, and 60%, respectively. Conclusions BRAF status together with several histopathological features allow clinical risk stratification of TPMC. The combined molecular-pathological risk stratification model is a better predictor of extrathyroidal tumor spread than either mutational or histopathological findings alone. PMID:21882177

  17. A new gender-specific model for skin autofluorescence risk stratification

    PubMed Central

    Ahmad, Muhammad S.; Damanhouri, Zoheir A.; Kimhofer, Torben; Mosli, Hala H.; Holmes, Elaine

    2015-01-01

    Advanced glycation endproducts (AGEs) are believed to play a significant role in the pathophysiology of a variety of diseases including diabetes and cardiovascular diseases. Non-invasive skin autofluorescence (SAF) measurement serves as a proxy for tissue accumulation of AGEs. We assessed reference SAF and skin reflectance (SR) values in a Saudi population (n = 1,999) and evaluated the existing risk stratification scale. The mean SAF of the study cohort was 2.06 (SD = 0.57) arbitrary units (AU), which is considerably higher than the values reported for other populations. We show a previously unreported and significant difference in SAF values between men and women, with median (range) values of 1.77 AU (0.79–4.84 AU) and 2.20 AU (0.75–4.59 AU) respectively (p-value « 0.01). Age, presence of diabetes and BMI were the most influential variables in determining SAF values in men, whilst in female participants, SR was also highly correlated with SAF. Diabetes, hypertension and obesity all showed strong association with SAF, particularly when gender differences were taken into account. We propose an adjusted, gender-specific disease risk stratification scheme for Middle Eastern populations. SAF is a potentially valuable clinical screening tool for cardiovascular risk assessment but risk scores should take gender and ethnicity into consideration for accurate diagnosis. PMID:25974028

  18. MRI Risk Stratification for Tumor Relapse in Rectal Cancer Achieving Pathological Complete Remission after Neoadjuvant Chemoradiation Therapy and Curative Resection

    PubMed Central

    Kim, Honsoul; Myoung, Sungmin; Koom, Woong Sub; Kim, Nam Kyu; Kim, Myeong-Jin; Ahn, Joong Bae; Hur, Hyuk; Lim, Joon Seok

    2016-01-01

    Purpose Rectal cancer patients achieving pCR are known to have an excellent prognosis, yet no widely accepted consensus on risk stratification and post-operative management (e.g., adjuvant therapy) has been established. This study aimed to identify magnetic resonance imaging (MRI) high-risk factors for tumor relapse in pathological complete remission (pCR) achieved by rectal cancer patients who have undergone neoadjuvant concurrent chemoradiation therapy (CRT) and curative resection. Materials and Methods We analyzed 88 (male/female = 55/33, median age, 59.5 years [range 34–78]) pCR-proven rectal cancer patients who had undergone pre-CRT MRI, CRT, post-CRT MRI and curative surgery between July 2005 and December 2012. Patients were observed for post-operative tumor relapse. We analyzed the pre/post-CRT MRIs for parameters including mrT stage, mesorectal fascia (mrMRF) status, tumor volume, tumor regression grade (mrTRG), nodal status (mrN), and extramural vessel invasion (mrEMVI). We performed univariate analysis and Kaplan-Meier survival analysis. Results Post-operative tumor relapse occurred in seven patients (8.0%, n = 7/88) between 5.7 and 50.7 (median 16.8) months. No significant relevance was observed between tumor volume, volume reduction rate, mrTRG, mrT, or mrN status. Meanwhile, positive mrMRF (Ppre-CRT = 0.018, Ppre/post-CRT = 0.006) and mrEMVI (Ppre-CRT = 0.026, Ppre-/post-CRT = 0.008) were associated with higher incidence of post-operative tumor relapse. Kaplan-Meier survival analysis revealed a higher risk of tumor relapse in patients with positive mrMRF (Ppre-CRT = 0.029, Ppre-/post-CRT = 0.009) or mrEMVI (Ppre-CRT = 0.024, Ppre-/post-CRT = 0.003). Conclusion Positive mrMRF and mrEMVI status was associated with a higher risk of post-operative tumor relapse of pCR achieved by rectal cancer patients, and therefore, can be applied for risk stratification and to individualize treatment plans. PMID:26730717

  19. A Review on Carotid Ultrasound Atherosclerotic Tissue Characterization and Stroke Risk Stratification in Machine Learning Framework.

    PubMed

    Sharma, Aditya M; Gupta, Ajay; Kumar, P Krishna; Rajan, Jeny; Saba, Luca; Nobutaka, Ikeda; Laird, John R; Nicolades, Andrew; Suri, Jasjit S

    2015-09-01

    Cardiovascular diseases (including stroke and heart attack) are identified as the leading cause of death in today's world. However, very little is understood about the arterial mechanics of plaque buildup, arterial fibrous cap rupture, and the role of abnormalities of the vasa vasorum. Recently, ultrasonic echogenicity characteristics and morphological characterization of carotid plaque types have been shown to have clinical utility in classification of stroke risks. Furthermore, this characterization supports aggressive and intensive medical therapy as well as procedures, including endarterectomy and stenting. This is the first state-of-the-art review to provide a comprehensive understanding of the field of ultrasonic vascular morphology tissue characterization. This paper presents fundamental and advanced ultrasonic tissue characterization and feature extraction methods for analyzing plaque. Additionally, the paper shows how the risk stratification is achieved using machine learning paradigms. More advanced methods need to be developed which can segment the carotid artery walls into multiple regions such as the bulb region and areas both proximal and distal to the bulb. Furthermore, multimodality imaging is needed for validation of such advanced methods for stroke and cardiovascular risk stratification. PMID:26233633

  20. Coronary artery calcium screening: does it perform better than other cardiovascular risk stratification tools?

    PubMed

    Zeb, Irfan; Budoff, Matthew

    2015-01-01

    Coronary artery calcium (CAC) has been advocated as one of the strongest cardiovascular risk prediction markers. It performs better across a wide range of Framingham risk categories (6%-10% and 10%-20% 10-year risk categories) and also helps in reclassifying the risk of these subjects into either higher or lower risk categories based on CAC scores. It also performs better among population subgroups where Framingham risk score does not perform well, especially young subjects, women, family history of premature coronary artery disease and ethnic differences in coronary risk. The absence of CAC is also associated with excellent prognosis, with 10-year event rate of 1%. Studies have also compared with other commonly used markers of cardiovascular disease risk such as Carotid intima-media thickness and highly sensitive C-reactive protein. CAC also performs better compared with carotid intima-media thickness and highly sensitive C-reactive protein in prediction of coronary heart disease and cardiovascular disease events. CAC scans are associated with relatively low radiation exposure (0.9-1.1 mSv) and provide information that can be used not only for risk stratification but also can be used to track the progression of atherosclerosis and the effects of statins. PMID:25807266

  1. Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation.

    PubMed

    Campbell, Aaron D; McIntosh, Scott E; Nyberg, Andy; Powell, Amy P; Schoene, Robert B; Hackett, Peter

    2015-09-01

    High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer. PMID:26340732

  2. Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation.

    PubMed

    Campbell, Aaron D; McIntosh, Scott E; Nyberg, Andy; Powell, Amy P; Schoene, Robert B; Hackett, Peter

    2015-12-01

    High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer. PMID:26617376

  3. The role of early 18F-FDG PET/CT in therapeutic management and ongoing risk stratification of high/intermediate-risk thyroid carcinoma.

    PubMed

    Triviño Ibáñez, E M; Muros, M A; Torres Vela, E; Llamas Elvira, J M

    2016-03-01

    Little is known about the role in ongoing risk stratification of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) performed early after radioactive iodine (RAI) ablation in differentiated thyroid carcinoma (DTC). The aim of the study is to investigate whether 18F-FDG PET/CT performed early after RAI ablation is useful to detect disease and to influence therapy and ongoing risk stratification. Patients with high/intermediate risk of recurrent DTC were included. 18F-FDG PET/CT scan was performed within 6 months after RAI ablation. We confirmed results with other imaging techniques, pathology reports, or follow-up. We classified the patient response as excellent, acceptable, or incomplete. Modified Hicks criteria were used to evaluate clinical impact. We included 81 patients with high/intermediate risk of recurrent DTC. Forty-one (50.6 %) had positive uptake in 18F-FDG PET/CT, with negative (131)I whole-body scan ((131)I WBS). Sensitivity, specificity, and diagnostic accuracy of 18F-FDG PET/CT were 92.5, 90.2, and 91.4 %, respectively. 18F-FDG PET/CT results had an impact on therapy in 38.3 % of patients. One year after initial therapy, 45.7 % showed excellent response, 8.6 % acceptable response, and 45.7 % incomplete response. A statistically significant relationship was found between negative 18F-FDG PET/CT and excellent response (80 vs. 12.2 %, p < 0.001; OR 52.8). 18F-FDG PET/CT scan performed early in surveillance of patients with high/intermediate-risk thyroid carcinoma provides important additional information not available with conventional follow-up methods and had a high impact on therapy. A negative 18F-FDG PET/CT predicts an excellent response to therapy in the new ongoing risk stratification. PMID:26224589

  4. Stratification of Hepatocellular Carcinoma Patients Based on Acetate Utilization.

    PubMed

    Bjrnson, Elias; Mukhopadhyay, Bani; Asplund, Anna; Pristovsek, Nusa; Cinar, Resat; Romeo, Stefano; Uhlen, Mathias; Kunos, George; Nielsen, Jens; Mardinoglu, Adil

    2015-12-01

    Hepatocellular carcinoma (HCC) is a deadly form ofliver cancer that is increasingly prevalent. We analyzed global gene expression profiling of 361 HCC tumors and 49 adjacent noncancerous liver samples by means of combinatorial network-based analysis. We investigated the correlation between transcriptome and proteome of HCC and reconstructed a functional genome-scale metabolic model (GEM) for HCC. We identified fundamental metabolic processes required for cell proliferation using the network centric view provided by the GEM. Our analysis revealed tight regulation of fatty acid biosynthesis (FAB) and highly significant deregulation of fatty acid oxidation in HCC. We predicted mitochondrial acetate as an emerging substrate for FAB through upregulation of mitochondrial acetyl-CoA synthetase (ACSS1) in HCC. We analyzed heterogeneous expression of ACSS1 and ACSS2 between HCC patients stratified by high and low ACSS1 andACSS2 expression and revealed that ACSS1 is associated with tumor growth and malignancy under hypoxic conditions in human HCC. PMID:26655911

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

    SciTech Connect

    Levinson, J.R.; Boucher, C.A.; Coley, C.M.; Guiney, T.E.; Strauss, H.W.; Eagle, K.A. )

    1990-08-15

    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.

  6. The value of exercise radionuclide ventriculography in risk stratification after coronary arterial bypass grafting

    SciTech Connect

    Iskandrian, A.S.; Hakki, A.H.; Goel, I.P.; Mundth, E.D.; Kane, S.; Schenk, C.

    1985-05-01

    Cardiac events after coronary artery bypass surgery (CABG) may be related to left ventricular (LV) function, residual coronary artery diseases (CAD), graft occlusion, and progression of CAD. This study examined the value of rest and exercise (EX) radionuclide ventriculography (RNV) done 3-6 mos after CABG in risk stratification in 212 pts. There were 185 men and 27 women, aged 57 +- 8 years (mean +- SD). During a followup period of up to 4 years, (15 +- 10 months), there were 23 cardiac events; 13 pts died of cardiac causes and 20 had non-fatal acute myocardial infarctions. The pts with and without events did not differ in: clinical presentation after CABG (most were asymptomatic), medications and ECG findings at rest and EX. The pts with events had lower EX systolic blood pressure (p < 0.01); resting LV ejection fraction (EF) (p = 0.002), and EX EF (40 +- 18% vs 54 +- 16%, p = 0.002). The change in EF (rest to EX) was not significantly different (l.6 +- 8.2%, vs 2.1 +- 9.2%). Survival analysis (Cox model) identified the EX EF as the best predictor of death and total events (X/sup 2/ = 4.3 and 2.4, p = 0.04 and 0.07 respectively). Actuarial life table analysis showed that the risk increased as the EX EF decreased when pts were grouped into EX EF greater than or equal to 50, 30-49, and <30%, (p < 0.001, Mantel-Cox). Thus, EX RNA is useful in risk stratification after CABG. The EX LVEF is an important descriptor that categorizes pts into different risks groups. The pts at high risk probably require more aggressive followup and continued medical therapy.

  7. Applications of cellular systems biology in breast cancer patient stratification and diagnostics.

    PubMed

    Critchley-Thorne, Rebecca J; Miller, Steven M; Taylor, D Lansing; Lingle, Wilma L

    2009-11-01

    Tumors are complex structures of malignant cells and stromal cells that function as an integrated system that promotes tumor progression. Immune cells and other stromal components serve vital cooperative functions that often support tumor growth and metastasis; stromal content and function are strongly associated with disease progression and clinical outcome in cancer patients. Cellular systems biology considers tissues and tumors, and the cells within them, as integrated and interactive networks that function in concert as a system. Assessment of tumors as a "system" within the system of a patient using the cellular systems biology approach has the potential to improve on the current diagnostic tools for breast cancer by creating high content profiles of an individual patient's tumor. The application of cellular systems biology (CSB) profiling to early drug discovery using cellular models of disease [1] and to drug development using the CellCiphr Cytotoxicity Profiling panels [2] can optimize the efficacy and decrease the potential toxicity of compounds taken into pre-clinical trials. However, it has become clear that patient sub-populations can respond differently to drug candidates in clinical trials due to patient variability. Therefore, cellular systems biology can also be a powerful approach to patient stratification for clinical trials and could become an important diagnostic tool. This review describes how the cellular systems biology approach can be applied to patient stratification and diagnostics in breast cancer, focusing on the advantages of quantifying functional biomarkers representing key tumor system processes in intact tissues from patients in order to make highly specific and sensitive predictions towards development of individualized medicine for breast cancer. We discuss the state-of-the-art of multiplexing of functional biomarkers in tissues and the practical utilization of the cellular systems biology approach in creating classifiers for patient stratification and diagnostics. PMID:19531004

  8. Non-Rhabdomyosarcoma Soft Tissue Sarcomas in Children: A Surveillance, Epidemiology, and End Results Analysis Validating COG Risk Stratifications

    SciTech Connect

    Waxweiler, Timothy V.; Rusthoven, Chad G.; Proper, Michelle S.; Cost, Carrye R.; Cost, Nicholas G.; Donaldson, Nathan; Garrington, Timothy; Greffe, Brian S.; Heare, Travis; Macy, Margaret E.; Liu, Arthur K.

    2015-06-01

    Purpose: Non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) are a heterogeneous group of sarcomas that encompass over 35 histologies. With an incidence of ∼500 cases per year in the United States in those <20 years of age, NRSTS are rare and therefore difficult to study in pediatric populations. We used the large Surveillance, Epidemiology, and End Results (SEER) database to validate the prognostic ability of the Children's Oncology Group (COG) risk classification system and to define patient, tumor, and treatment characteristics. Methods and Materials: From SEER data from 1988 to 2007, we identified patients ≤18 years of age with NRSTS. Data for age, sex, year of diagnosis, race, registry, histology, grade, primary size, primary site, stage, radiation therapy, and survival outcomes were analyzed. Patients with nonmetastatic grossly resected low-grade tumors of any size or high-grade tumors ≤5 cm were considered low risk. Cases of nonmetastatic tumors that were high grade, >5 cm, or unresectable were considered intermediate risk. Patients with nodal or distant metastases were considered high risk. Results: A total of 941 patients met the review criteria. On univariate analysis, black race, malignant peripheral nerve sheath (MPNST) histology, tumors >5 cm, nonextremity primary, lymph node involvement, radiation therapy, and higher risk group were associated with significantly worse overall survival (OS) and cancer-specific survival (CSS). On multivariate analysis, MPNST histology, chemotherapy-resistant histology, and higher risk group were significantly poor prognostic factors for OS and CSS. Compared to low-risk patients, intermediate patients showed poorer OS (hazard ratio [HR]: 6.08, 95% confidence interval [CI]: 3.53-10.47, P<.001) and CSS (HR: 6.27; 95% CI: 3.44-11.43, P<.001), and high-risk patients had the worst OS (HR: 13.35, 95% CI: 8.18-21.76, P<.001) and CSS (HR: 14.65, 95% CI: 8.49-25.28, P<.001). Conclusions: The current COG risk group stratification for children with NRSTS has been validated with a large number of children in the SEER database.

  9. Stratification of Risk of Early-Onset Sepsis in Newborns ≥34 Weeks’ Gestation

    PubMed Central

    Puopolo, Karen M.; Wi, Soora; Turk, Benjamin J.; Kuzniewicz, Michael W.; Walsh, Eileen M.; Newman, Thomas B.; Zupancic, John; Lieberman, Ellice; Draper, David

    2014-01-01

    OBJECTIVE: To define a quantitative stratification algorithm for the risk of early-onset sepsis (EOS) in newborns ≥34 weeks’ gestation. METHODS: We conducted a retrospective nested case-control study that used split validation. Data collected on each infant included sepsis risk at birth based on objective maternal factors, demographics, specific clinical milestones, and vital signs during the first 24 hours after birth. Using a combination of recursive partitioning and logistic regression, we developed a risk classification scheme for EOS on the derivation dataset. This scheme was then applied to the validation dataset. RESULTS: Using a base population of 608 014 live births ≥34 weeks’ gestation at 14 hospitals between 1993 and 2007, we identified all 350 EOS cases <72 hours of age and frequency matched them by hospital and year of birth to 1063 controls. Using maternal and neonatal data, we defined a risk stratification scheme that divided the neonatal population into 3 groups: treat empirically (4.1% of all live births, 60.8% of all EOS cases, sepsis incidence of 8.4/1000 live births), observe and evaluate (11.1% of births, 23.4% of cases, 1.2/1000), and continued observation (84.8% of births, 15.7% of cases, incidence 0.11/1000). CONCLUSIONS: It is possible to combine objective maternal data with evolving objective neonatal clinical findings to define more efficient strategies for the evaluation and treatment of EOS in term and late preterm infants. Judicious application of our scheme could result in decreased antibiotic treatment in 80 000 to 240 000 US newborns each year. PMID:24366992

  10. A two-stage clinical decision support system for early recognition and stratification of patients with sepsis: an observational cohort study

    PubMed Central

    Lyons, Jason J; Greene, Tracy L; Haley, James M

    2015-01-01

    Objective To examine the diagnostic accuracy of a two-stage clinical decision support system for early recognition and stratification of patients with sepsis. Design Observational cohort study employing a two-stage sepsis clinical decision support to recognise and stratify patients with sepsis. The stage one component was comprised of a cloud-based clinical decision support with 24/7 surveillance to detect patients at risk of sepsis. The cloud-based clinical decision support delivered notifications to the patients designated nurse, who then electronically contacted a provider. The second stage component comprised a sepsis screening and stratification form integrated into the patient electronic health record, essentially an evidence-based decision aid, used by providers to assess patients at bedside. Setting Urban, 284 acute bed community hospital in the USA; 16,000 hospitalisations annually. Participants Data on 2620 adult patients were collected retrospectively in 2014 after the clinical decision support was implemented. Main outcome measure Suspected infection was the established gold standard to assess clinical decision support clinimetric performance. Results A sepsis alert activated on 417 (16%) of 2620 adult patients hospitalised. Applying suspected infection as standard, the patient population characteristics showed 72% sensitivity and 73% positive predictive value. A postalert screening conducted by providers at bedside of 417 patients achieved 81% sensitivity and 94% positive predictive value. Providers documented against 89% patients with an alert activated by clinical decision support and completed 75% of bedside screening and stratification of patients with sepsis within one hour from notification. Conclusion A clinical decision support binary alarm system with cross-checking functionality improves early recognition and facilitates stratification of patients with sepsis. PMID:26688744

  11. Stratification of Prognosis of Triple-Negative Breast Cancer Patients Using Combinatorial Biomarkers

    PubMed Central

    Yue, Yong; Astvatsaturyan, Kristine; Cui, Xiaojiang; Zhang, Xiao; Fraass, Benedick; Bose, Shikha

    2016-01-01

    Background Triple-negative breast cancer (TNBC) is highly diverse group of cancers, and generally considered an aggressive disease associated with poor survival. Stratification of TNBC is highly desired for both prognosis and treatment decisions to identify patients who may benefit from less aggressive therapy. Methods This study retrieved 192 consecutive non-metastasis TNBC patients who had undergone a resection of a primary tumor from 2008 to 2012. All samples were negative for ER, PR, and HER2/neu. Disease-free-survival (DFS) and overall-survival (OS) were evaluated for expression of immunohistochemical biomarkers (P53, Ki-67, CK5/6 and EGFR), as well as clinicopathological variables including age, tumor size, grade, lymph node status, pathologic tumor and nodal stages. The cutoff values of the basal biomarkers, EGFR and CK5/6, were estimated by time-dependent ROC curves. The prognostic values of combinatorial variables were identified by univariate and multivariate Cox analysis. Patients were stratified into different risk groups based on expression status of identified prognostic variables. Results Median age was 57 years (range, 28–92 years). Patients’ tumor stage and nodal stage were significantly associated with OS and DFS. EGFR and CK5/6 were significant prognostic variables at cutoff points of 15% (p = 0.001, AUC = 0.723), and 50% (p = 0.006, AUC = 0.675), respectively. Multivariate Cox analysis identified five significant variables: EGFR (p = 0.016), CK5/6 (p = 0.018), Ki-67 (p = 0.048), tumor stage (p = 0.010), and nodal stage (p = 0.003). Patients were stratified into low basal (EGFR≤15% and CK5/6≤50%) and high basal (EGFR>15% and/or CK5/6>50%) expression groups. In the low basal expression group, patients with low expressions of Ki-67, low tumor and nodal stage had significantly better survival than those with high expressions/stages of three variables, log-rank p = 0.015 (100% vs 68% at 50 months). In the high basal expression group, patient with high basal expression of both biomarkers (EGFR >15% and CK5/6 >50%) had worse survival (mean DFS = 25 months, 41.7% event rate) than those patient with high expression of either one marker (mean DFS = 34 months, 25.5% event rate). Conclusions Immunoexpression of basal biomarkers, EGFR and CK5/6, is useful in predicting survival of TNBC patients. Integrated with Ki-67, tumor and nodal stages, combinatorial biomarker analysis provides a feasible clinical solution to stratify patient risks and help clinical decision-making with respect to selecting the appropriate therapies for individual patients. PMID:26930401

  12. Thromboembolism Prophylaxis in Hip Arthroplasty: Routine and High Risk Patients.

    PubMed

    Nam, Denis; Nunley, Ryan M; Johnson, Staci R; Keeney, James A; Clohisy, John C; Barrack, Robert L

    2015-12-01

    This study's purpose was to present the use of a risk stratification protocol in which "routine" risk patients receive a mobile compression device with aspirin and "high" risk patients receive warfarin for thromboprophylaxis after hip arthroplasty. 1859 hip arthroplasty patients were prospectively enrolled (1402 routine risk - 75.4%, 457 high risk - 24.6%). The cumulative rate of venous thromboembolism events was 0.5% in the routine versus 0.5% in the high-risk cohort within 6weeks postoperatively (P=1.00). Patients in the routine risk cohort had a lower rate of major bleeding (0.5% versus 2.0%, P=0.006) and wound complications (0.2% versus 1.2%, P=0.01). Use of our risk stratification protocol allowed the avoidance of more aggressive anticoagulation in 75% of patients while achieving a low overall incidence of symptomatic VTE. PMID:26182980

  13. The use of molecular-based risk stratification and pharmacogenomics for outcome prediction and personalized therapeutic management of multiple myeloma.

    PubMed

    Johnson, Sarah K; Heuck, Christoph J; Albino, Anthony P; Qu, Pingping; Zhang, Qing; Barlogie, Bart; Shaughnessy, John D

    2011-10-01

    Despite improvement in therapeutic efficacy, multiple myeloma (MM) remains incurable with a median survival of approximately 10years. Gene-expression profiling (GEP) can be used to elucidate the molecular basis for resistance to chemotherapy through global assessment of molecular alterations that exist at diagnosis, after therapeutic treatment and that evolve during tumor progression. Unique GEP signatures associated with recurrent chromosomal translocations and ploidy changes have defined molecular classes with differing clinical features and outcomes. When compared to other stratification systems the GEP70 test remained a significant predictor of outcome, reduced the number of patients classified with a poor prognosis, and identified patients at increased risk of relapse despite their standard clinico-pathologic and genetic findings. GEP studies of serial samples showed that risk increases over time, with relapsed disease showing GEP shifts toward a signature of poor outcomes. GEP signatures of myeloma cells after therapy were prognostic for event-free and overall survival and thus may be used to identify novel strategies for overcoming drug resistance. This brief review will focus on the use of GEP of MM to define high-risk myeloma, and elucidate underlying mechanisms that are beginning to change clinical decision-making and inform drug design. PMID:22002477

  14. The use of molecular-based risk stratification and pharmacogenomics for outcome prediction and personalized therapeutic management of multiple myeloma

    PubMed Central

    Johnson, Sarah K.; Heuck, Christoph J.; Albino, Anthony P.; Qu, Pingping; Zhang, Qing; Barlogie, Bart

    2015-01-01

    Despite improvement in therapeutic efficacy, multiple myeloma (MM) remains incurable with a median survival of approximately 10 years. Gene-expression profiling (GEP) can be used to elucidate the molecular basis for resistance to chemotherapy through global assessment of molecular alterations that exist at diagnosis, after therapeutic treatment and that evolve during tumor progression. Unique GEP signatures associated with recurrent chromosomal translocations and ploidy changes have defined molecular classes with differing clinical features and outcomes. When compared to other stratification systems the GEP70 test remained a significant predictor of outcome, reduced the number of patients classified with a poor prognosis, and identified patients at increased risk of relapse despite their standard clinico-pathologic and genetic findings. GEP studies of serial samples showed that risk increases over time, with relapsed disease showing GEP shifts toward a signature of poor outcomes. GEP signatures of myeloma cells after therapy were prognostic for event-free and overall survival and thus may be used to identify novel strategies for overcoming drug resistance. This brief review will focus on the use of GEP of MM to define high-risk myeloma, and elucidate underlying mechanisms that are beginning to change clinical decision-making and inform drug design. PMID:22002477

  15. Arrhythmogenic right ventricular cardiomyopathy: an update on pathophysiology, genetics, diagnosis, and risk stratification.

    PubMed

    Paul, M; Wichter, T; Fabritz, L; Waltenberger, J; Schulze-Bahr, E; Kirchhof, P

    2012-09-01

    Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy accounting for life-threatening ventricular tachyarrhythmias and sudden death in young individuals and athletes. Over the past years, mutations in desmosomal genes have been identified as disease-causative. However, genetic heterogeneity and variable phenotypic expression alongside with diverse disease progression still render the evaluation of its prognostic implication difficult. ARVC was initially entered into the canon of cardiomyopathies of the World Health Organization in 1995, and international efforts have resulted in the 2010 modified diagnostic criteria for ARVC. Despite all additional insights into pathophysiology, clinical management, and modern risk stratification, under-/misdiagnosing of ARVC remains a problem and hampers reliable statements on the incidence, prevalence, and natural course of the disease.This review provides a comprehensive overview of the current literature on the pathogenesis, diagnosis, treatment, and prognosis of ARVC and sheds some light on potential new developments in these areas. PMID:23011601

  16. iGPSe: A visual analytic system for integrative genomic based cancer patient stratification

    PubMed Central

    2014-01-01

    Background Cancers are highly heterogeneous with different subtypes. These subtypes often possess different genetic variants, present different pathological phenotypes, and most importantly, show various clinical outcomes such as varied prognosis and response to treatment and likelihood for recurrence and metastasis. Recently, integrative genomics (or panomics) approaches are often adopted with the goal of combining multiple types of omics data to identify integrative biomarkers for stratification of patients into groups with different clinical outcomes. Results In this paper we present a visual analytic system called Interactive Genomics Patient Stratification explorer (iGPSe) which significantly reduces the computing burden for biomedical researchers in the process of exploring complicated integrative genomics data. Our system integrates unsupervised clustering with graph and parallel sets visualization and allows direct comparison of clinical outcomes via survival analysis. Using a breast cancer dataset obtained from the The Cancer Genome Atlas (TCGA) project, we are able to quickly explore different combinations of gene expression (mRNA) and microRNA features and identify potential combined markers for survival prediction. Conclusions Visualization plays an important role in the process of stratifying given population patients. Visual tools allowed for the selection of possibly features across various datasets for the given patient population. We essentially made a case for visualization for a very important problem in translational informatics. PMID:25000928

  17. HO-1, RET and PML as possible markers for risk stratification of acute myelocytic leukemia and prognostic evaluation

    PubMed Central

    YU, MEISHENG; WANG, JISHI; MA, DAN; CHEN, SHUYA; LIN, XIAOJING; FANG, QIN; ZHE, NANA

    2015-01-01

    Heme oxygenase-1 (HO-1) is an inducible isoform of HO that is activated in response to oxidative stress and has anti-apoptotic and pro-proliferative effects on leukemia cells. RET, a tyrosine kinase receptor; its expression levels are associated with the differentiation degree of acute myelocytic leukemia (AML) cells. The promyelocytic leukemia (PML) gene inhibits cell proliferation and tumor growth, participates in the differentiation of hematopoietic progenitor cells and induces cell apoptosis. However, the association between the expression levels of HO-1, RET and PML genes and the risk stratification of AML and prognosis have not previously been reported. In the present study, HO-1 was expressed in the human AML Kasumi-1, HL-60 and THP-1 cell lines, and HO-1 expression was regulated by Hemin (20 mol/l) and ZnPPIX (10 mol/l). Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis demonstrated that expression of RET and PML were positively and negatively correlated with HO-1 expression, respectively. Bone marrow samples (18 favorable, 55 intermediate, 15 adverse and 2 unknown karyotype AML cases and 20 healthy donors) were collected from 90 randomly selected AML patients upon their first visit. The mRNA and protein expression of HO-1, RET and PML in samples was detected by RT-qPCR and western blot analysis. At the mRNA level, the adverse group expressed significantly higher levels of HO-1 and RET compared with the levels in the favorable and normal groups. The PML mRNA expression levels in adverse patient samples was lower compared with those of the intermediate group and favorable group. Western blot analysis demonstrated that the expression levels of HO-1, RET and PML proteins in all risk groups exhibited the same pattern of expression as was observed for the mRNA levels. The overall survival and relapse-free survival rates were shortest in AML patients with high HO-1 expression (Kaplan-Meier; log-rank, P<0.01). The results of the present study therefore indicate that HO-1, RET and PML may be critical in the risk-stratification and prognosis of AML. However, additional samples and clinical data should be collected and analyzed in order to provide stronger evidence for this hypothesis. PMID:26722301

  18. Monoclonal B-cell lymphocytosis and early-stage chronic lymphocytic leukemia: diagnosis, natural history, and risk stratification

    PubMed Central

    Strati, Paolo

    2015-01-01

    Monoclonal B lymphocytosis (MBL) is defined as the presence of a clonal B-cell population in the peripheral blood with fewer than 5 109/L B-cells and no other signs of a lymphoproliferative disorder. The majority of cases of MBL have the immunophenotype of chronic lymphocytic leukemia (CLL). MBL can be categorized as either low count or high count based on whether the B-cell count is above or below 0.5 109/L. Low-count MBL can be detected in ?5% of adults over the age of 40 years when assessed using standard-sensitivity flow cytometry assays. A number of biological and genetic characteristics distinguish low-count from high-count MBL. Whereas low-count MBL rarely progresses to CLL, high-count MBL progresses to CLL requiring therapy at a rate of 1% to 2% per year. High-count MBL is distinguished from Rai 0 CLL based on whether the B-cell count is above or below 5 109/L. Although individuals with both high-count MBL and CLL Rai stage 0 are at increased risk of infections and second cancers, the risk of progression requiring treatment and the potential to shorten life expectancy are greater for CLL. This review highlights challenging questions regarding the classification, risk stratification, management, and supportive care of patients with MBL and CLL. PMID:26065657

  19. Update on risk stratification and treatment of newly diagnosed multiple myeloma.

    PubMed

    Kapoor, Prashant; Rajkumar, S Vincent

    2011-10-01

    Multiple myeloma is the second most common hematologic malignancy. Chromosomal aberrations are important prognostic determinants that influence the clinical decision-making in newly-diagnosed multiple myeloma (NDMM). Patients are considered high-risk if any of the following features are detected: hypodiploidy, deletion 13 by cytogenetics, t(4;14), t(14;16), t(14;20) and/or 17 p deletion. In the absence of these features patients are considered standard risk. Outside of trials, risk-adapted therapy in the transplant-eligible high-risk patients advocates use of bortezomib-based induction therapy followed by autologous stem cell transplantation (ASCT) and bortezomib-based maintenance therapy. High-risk, transplant-ineligible patients should also utilize bortezomib as initial therapy since it is known to overcome the poor prognosis associated with some high-risk features. The goal of therapy in high-risk patients is to attain and maintain a state of complete remission as much as possible. In contrast, the standard-risk, transplant-eligible patients may be treated with either lenalidomide-dexamethasone or bortezomib-based therapy followed by ASCT. In such patients, ASCT can also be deferred until first relapse if the patients are tolerating initial therapy well. Lenalidomide maintenance therapy in the post-transplant setting in standard-risk patients is controversial and not recommended routinely. For transplant-ineligible standard-risk patients, multiple options exist, although in the absence direct comparisons, we prefer lenalidomide plus low-dose dexamethasone over melphalan-based combinations. This review outlines evidence-based management approaches in NDMM, with a focus on risk-adapted therapy. PMID:22005834

  20. Biomarker-driven stratification of disease-risk in non-metastatic medulloblastoma: Results from the multi-center HIT-SIOP-PNET4 clinical trial

    PubMed Central

    Lannering, Birgitta; Schwalbe, Ed C.; Hicks, Debbie; O' Toole, Kieran; Nicholson, Sarah Leigh; Goschzik, Tobias; zur Mühlen, Anja; Figarella-Branger, Dominique; Doz, François; Rutkowski, Stefan; Gustafsson, Göran

    2015-01-01

    Purpose To improve stratification of risk-adapted treatment for non-metastatic (M0), standard-risk medulloblastoma patients by prospective evaluation of biomarkers of reported biological or prognostic significance, alongside clinico-pathological variables, within the multi-center HIT-SIOP-PNET4 trial. Methods Formalin-fixed paraffin-embedded tumor tissues were collected from 338 M0 patients (>4.0 years at diagnosis) for pathology review and assessment of the WNT subgroup (MBWNT) and genomic copy-number defects (chromosome 17, MYC/MYCN, 9q22 (PTCH1) and DNA ploidy). Clinical characteristics were reviewed centrally. Results The favorable prognosis of MBWNT was confirmed, however better outcomes were observed for non-MBWNT tumors in this clinical risk-defined cohort compared to previous disease-wide clinical trials. Chromosome 17p/q defects were heterogeneous when assessed at the cellular copy-number level, and predicted poor prognosis when they occurred against a diploid (ch17(im)/diploid(cen)), but not polyploid, genetic background. These factors, together with post-surgical tumor residuum (R+) and radiotherapy delay, were supported as independent prognostic markers in multivariate testing. Notably, MYC and MYCN amplification were not associated with adverse outcome. In cross-validated survival models derived for the clinical standard-risk (M0/R0) disease group, (ch17(im)/diploid(cen); 14% of patients) predicted high disease-risk, while the outcomes of patients without (ch17(im)/diploid(cen)) did not differ significantly from MBWNT, allowing re-classification of 86% as favorable-risk. Conclusion Biomarkers, established previously in disease-wide studies, behave differently in clinically-defined standard-risk disease. Distinct biomarkers are required to assess disease-risk in this group, and define improved risk-stratification models. Routine testing for specific patterns of chromosome 17 imbalance at the cellular level, and MBWNT, provides a strong basis for incorporation into future trials. PMID:26420814

  1. Management of newly diagnosed symptomatic multiple myeloma: updated Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) consensus guidelines 2013.

    PubMed

    Mikhael, Joseph R; Dingli, David; Roy, Vivek; Reeder, Craig B; Buadi, Francis K; Hayman, Suzanne R; Dispenzieri, Angela; Fonseca, Rafael; Sher, Taimur; Kyle, Robert A; Lin, Yi; Russell, Stephen J; Kumar, Shaji; Bergsagel, P Leif; Zeldenrust, Steven R; Leung, Nelson; Drake, Matthew T; Kapoor, Prashant; Ansell, Stephen M; Witzig, Thomas E; Lust, John A; Dalton, Robert J; Gertz, Morie A; Stewart, A Keith; Stewart, Keith; Rajkumar, S Vincent; Chanan-Khan, Asher; Lacy, Martha Q

    2013-04-01

    Multiple myeloma remains an incurable neoplasm of plasma cells that affects more than 20,000 people annually in the United States. There has been a veritable revolution in this disease during the past decade, with dramatic improvements in our understanding of its pathogenesis, the development of several novel agents, and a concomitant doubling in overall survival. Because multiple myeloma is a complex and wide-ranging disorder, its management must be guided by disease- and patient-related factors; emerging as one of the most influential factors is risk stratification, primarily based on cytogenetic features. A risk-adapted approach provides optimal therapy to patients, ensuring intense therapy for aggressive disease and minimizing toxic effects, providing sufficient but less intense therapy for low-risk disease. This consensus statement reflects recommendations from more than 20 Mayo Clinic myeloma physicians, providing a practical approach for newly diagnosed patients with myeloma who are not enrolled in a clinical trial. PMID:23541011

  2. PATIENT-SPECIFIC DATA FUSION FOR CANCER STRATIFICATION AND PERSONALISED TREATMENT.

    PubMed

    Gligorijevi?, Vladimir; Malod-Dognin, Nol; Prulj, Nataa

    2016-01-01

    According to Cancer Research UK, cancer is a leading cause of death accounting for more than one in four of all deaths in 2011. The recent advances in experimental technologies in cancer research have resulted in the accumulation of large amounts of patient-specific datasets, which provide complementary information on the same cancer type. We introduce a versatile data fusion (integration) framework that can effectively integrate somatic mutation data, molecular interactions and drug chemical data to address three key challenges in cancer research: stratification of patients into groups having different clinical outcomes, prediction of driver genes whose mutations trigger the onset and development of cancers, and repurposing of drugs treating particular cancer patient groups. Our new framework is based on graph-regularised non-negative matrix tri-factorization, a machine learning technique for co-clustering heterogeneous datasets. We apply our framework on ovarian cancer data to simultaneously cluster patients, genes and drugs by utilising all datasets.We demonstrate superior performance of our method over the state-of-the-art method, Network-based Stratification, in identifying three patient subgroups that have significant differences in survival outcomes and that are in good agreement with other clinical data. Also, we identify potential new driver genes that we obtain by analysing the gene clusters enriched in known drivers of ovarian cancer progression. We validated the top scoring genes identified as new drivers through database search and biomedical literature curation. Finally, we identify potential candidate drugs for repurposing that could be used in treatment of the identified patient subgroups by targeting their mutated gene products. We validated a large percentage of our drug-target predictions by using other databases and through literature curation. PMID:26776197

  3. TP53 Mutational Status Is a Potential Marker for Risk Stratification in Wilms Tumour with Diffuse Anaplasia

    PubMed Central

    Chagtai, Tasnim; Popov, Sergey D.; Sebire, Neil J.; Vujanic, Gordan; Perlman, Elizabeth; Anderson, James R.; Grundy, Paul; Dome, Jeffrey S.; Pritchard-Jones, Kathy

    2014-01-01

    Purpose The presence of diffuse anaplasia in Wilms tumours (DAWT) is associated with TP53 mutations and poor outcome. As patients receive intensified treatment, we sought to identify whether TP53 mutational status confers additional prognostic information. Patients and Methods We studied 40 patients with DAWT with anaplasia in the tissue from which DNA was extracted and analysed for TP53 mutations and 17p loss. The majority of cases were profiled by copy number (n?=?32) and gene expression (n?=?36) arrays. TP53 mutational status was correlated with patient event-free and overall survival, genomic copy number instability and gene expression profiling. Results From the 40 cases, 22 (55%) had TP53 mutations (2 detected only after deep-sequencing), 20 of which also had 17p loss (91%); 18 (45%) cases had no detectable mutation but three had 17p loss. Tumours with TP53 mutations and/or 17p loss (n?=?25) had an increased risk of recurrence as a first event (p?=?0.03, hazard ratio (HR), 3.89; 95% confidence interval (CI), 1.2616.0) and death (p?=?0.04, HR, 4.95; 95% CI, 1.3631.7) compared to tumours lacking TP53 abnormalities. DAWT carrying TP53 mutations showed increased copy number alterations compared to those with wild-type, suggesting a more unstable genome (p?=?0.03). These tumours showed deregulation of genes associated with cell cycle and DNA repair biological processes. Conclusion This study provides evidence that TP53 mutational analysis improves risk stratification in DAWT. This requires validation in an independent cohort before clinical use as a biomarker. PMID:25313908

  4. Post-operative stimulated thyroglobulin and neck ultrasound as personalized criteria for risk stratification and radioactive iodine selection in low- and intermediate-risk papillary thyroid cancer.

    PubMed

    Orlov, Steven; Salari, Farnaz; Kashat, Lawrence; Freeman, Jeremy L; Vescan, Allan; Witterick, Ian J; Walfish, Paul G

    2015-09-01

    The purpose of this study was to demonstrate the utility of a personalized risk stratification and radioactive iodine (RAI) selection protocol (PRSP) using post-operative stimulated thyroglobulin (Stim-Tg) and neck ultrasound in low- and intermediate-risk papillary thyroid carcinoma (PTC) patients. Patients with PTC tumors ?1 cm were prospectively followed after total thyroidectomy and selective therapeutic central compartment neck dissection. Low/intermediate risk was defined as PTC confined to the thyroid or central (level VI) lymph nodes. Stim-Tg and neck ultrasound were performed approximately 3 months after surgery and used to guide RAI selection. Patients with Stim-Tg < 1 g/L did not receive RAI, while those with Stim-Tg >5 g/L routinely did. Those with Stim-Tg 1-5 g/L received RAI on the basis of several clinical risk factors. Patients were followed for >6 years with serial neck ultrasound and basal/stimulated thyroglobulin. Among the 129 patients, 84 (65 %) had undetectable Stim-Tg after initial surgery, 40 (31 %) had Stim-Tg of 1-5 g/L, and 5 (4 %) had Stim-Tg >5 g/L. RAI was administered to 8 (20 %) patients with Stim-Tg 1-5 g/L and 5 (100 %) with Stim-Tg >5 g/L. Using this approach, RAI therapy was avoided in 17/20 (85 %) patients with tumors >4 cm, in 72/81 (89 %) patients older than 45 years, and in 6/9 (67 %) patients with central lymph node involvement. To date, 116 (90 %) patients in this cohort have not received RAI therapy with no evidence of residual/recurrent disease, whereas among the 13 patients who received RAI, 1 (8 %) had pathologic residual/recurrence disease. Using the proposed PRSP, RAI can be avoided in the majority of low/intermediate-risk PTC patients. Moreover, traditional risk factors considered to favor RAI treatment were not always concordant with the PRSP and may lead to overtreatment. PMID:25792004

  5. Risk Stratification in Women with Gestational Diabetes According to and Beyond Current WHO Criteria.

    PubMed

    Much, D; Jaschinski, H; Lack, N; Hummel, S; Fchtenbusch, M; Hummel, M; Ziegler, A-G; Beyerlein, A

    2016-01-01

    The pregnancy outcomes in women with gestational diabetes mellitus (GDM) and 'overt diabetes in pregnancy' were compared and the need for further subclassification was investigated with respect to postpartum outcome risk. Data from 944 women who had been uniformly diagnosed as having GDM in Munich, Germany, between 1998 and 2010, were re-classified into GDM and 'overt diabetes in pregnancy'. Pregnancy related outcomes in the offspring were derived from Bavarian birth registry data. Classification and regression trees were used to identify further GDM sub-phenotypes. In total, 88 women (9.3%) were re-classified as having 'overt diabetes in pregnancy'. Compared to women with GDM, women with 'overt diabetes in pregnancy' used insulin more frequently, and were at increased risk for large for gestational age infants [odds ratio 2.50 (95% confidence interval 1.02, 6.13)], preterm delivery [odds ratio 3.28 (1.02, 10.50)], and low APGAR-score at 5?min [odds ratio 12.70 (1.58, 102.2)]. In the 856 women with GDM, classification and regression tree analyses provided further risk stratification in that a combination of fasting glucose>5.3?mmol/l and 1-h glucose>11.1?mmol/l at GDM diagnosis predicted insulin requirement [OR 5.57 (3.75, 8.27) compared to the rest], and maternal body mass index (BMI)?35?kg/m(2) predicted large for gestational age status. The new differentiation between GDM and 'overt diabetes in pregnancy' is a first step towards refining classification relevant to fetal and maternal postpartum risk. A combination of glucose levels and maternal BMI at diagnosis of GDM may provide further improvement. PMID:26566100

  6. Advances in the translational genomics of neuroblastoma: From improving risk stratification and revealing novel biology to identifying actionable genomic alterations.

    PubMed

    Bosse, Kristopher R; Maris, John M

    2016-01-01

    Neuroblastoma is an embryonal malignancy that commonly affects young children and is remarkably heterogenous in its malignant potential. Recently, the genetic basis of neuroblastoma has come into focus and not only has catalyzed a more comprehensive understanding of neuroblastoma tumorigenesis but also has revealed novel oncogenic vulnerabilities that are being therapeutically leveraged. Neuroblastoma is a model pediatric solid tumor in its use of recurrent genomic alterations, such as high-level MYCN (v-myc avian myelocytomatosis viral oncogene neuroblastoma-derived homolog) amplification, for risk stratification. Given the relative paucity of recurrent, activating, somatic point mutations or gene fusions in primary neuroblastoma tumors studied at initial diagnosis, innovative treatment approaches beyond small molecules targeting mutated or dysregulated kinases will be required moving forward to achieve noticeable improvements in overall patient survival. However, the clonally acquired, oncogenic aberrations in relapsed neuroblastomas are currently being defined and may offer an opportunity to improve patient outcomes with molecularly targeted therapy directed toward aberrantly regulated pathways in relapsed disease. This review summarizes the current state of knowledge about neuroblastoma genetics and genomics, highlighting the improved prognostication and potential therapeutic opportunities that have arisen from recent advances in understanding germline predisposition, recurrent segmental chromosomal alterations, somatic point mutations and translocations, and clonal evolution in relapsed neuroblastoma. Cancer 2016;122:20-33. 2015 American Cancer Society. PMID:26539795

  7. Monoclonal gammopathy of undetermined significance: Using risk stratification to guide follow-up.

    PubMed

    Uddin, Zia; Maennle, Diane; Russell, Kimberly; Boltri, John M

    2015-07-01

    Varying combinations of 3 measurable factors determine a patient's risk of progressing toward multiple myeloma and influence monitoring decisions. This review--and accompanying algorithm--can guide your approach. For monoclonal gammopathy of undetermined significance (MGUS) patients at low risk, repeat serum protein electrophoresis (SPE) in 6 months. If no significant elevation of M-protein is found, repeat SPE every 2 to 3 years. PMID:26324965

  8. The Benefits and Pitfalls of the Use of Risk Stratification Tools in Cardiac Surgery.

    PubMed

    Saxena, Akshat; Dhurandhar, Vikrant; Bannon, Paul G; Newcomb, Andrew E

    2016-04-01

    Risk assessment tools are increasingly used in surgery. In cardiac surgery, risk models are used for patient counselling, surgical decision-making, performance benchmarking, clinical research, evaluation of new therapies and quality assurance, among others. However, they have numerous disadvantages which need to be considered. This article evaluates the utility of risk assessment tools in cardiac surgery including a discussion of their advantages and disadvantages. PMID:26857968

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

    SciTech Connect

    Koontz, Bridget F.; Tsivian, Matvey; Mouraviev, Vladimir; Sun, Leon; Vujaskovic, Zeljko; Moul, Judd; Lee, W. Robert

    2012-01-01

    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.

  10. Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery: a cohort study

    PubMed Central

    2013-01-01

    Background In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction. A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. Methods A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison. Comparative analysis of demographic and outcome data for CPET-pass (AT ? 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs. Results Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (5,387 vs 9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05). Conclusion In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery. PMID:24472159

  11. Oral 4.02: Dynamic contrast-enhanced MR imaging in risk stratification of thymic epithelial tumors

    PubMed Central

    Shen, Yan; Ye, Jianding

    2015-01-01

    Background To evaluate the diagnostic performance of dynamic contrast-enhanced MR imaging (DCE-MRI) in risk stratification of thymic epithelial tumors. Methods Ninety-three patients with suspected thymic masses were prospectively included in the study to undergo DCE-MRI prior to surgery or biopsy. The time-intensity curves (TICs) were categorized with type I (with a slow, continuous increase), type II (with a plateau form), and type III (with a gradual decrease). The semi-quantitative parameters, including relative enhancement, maximum enhancement (ME), maximum relative enhancement, time-of-arrival, time-to-peak (TTP), wash-in rate, wash-out rate, and brevity of enhancement, were analyzed among the tumors. Results Thirty-eight low-risk thymomas, 34 high-risk thymomas, and 21 thymic carcinomas were revealed pathologically. Type II TICs were predominantly observed in high-risk thymomas (85.3%) and thymic carcinomas (100%), while type III TICs was mainly seen in low-risk thymomas (57.9%) (P=0.000). The mean RE of thymic carcinomas (190.35%±94.3%) was higher than that of high-risk thymomas (136.5%±55.7%) (P=0.044). The mean MEs of thymic carcinomas (1,236.1%±389.1%) and low-risk thymomas (1,169.1%±489.9%) were significantly higher than that of high-risk thymomas (928.2%±314.1%) (P=0.012), respectively. The mean MRE of thymic carcinomas (228.1%±99.5%) was higher than those of high-risk thymomas (163.4%±56.7%) (P=0.016). The TTP of low-risk thymomas (126.9±54.8 L/s) was the earliest, then were those of high-risk thymomas (170.6±48.2 L/s) and thymic carcinomas (185.9±33.3 L/s) (P=0.000). The WIR of low-risk thymomas (45.2±30.7 L/s) was the fastest, then were those of thymic carcinomas (35.6±17.5 L/s) and high-risk thymomas (25.4±8.3 L/s) (P=0.001). The cutoff RE and MRE to differentiate high-risk thymomas from thymic carcinomas were 154.1% (sensitivity, 69.4%; specificity, 78.9%; and AUC, 0.680) and 175.2% (sensitivity, 76.2%; specificity, 61.1%; and AUC, 0.688), respectively. The cutoff ME to differentiate high-risk thymomas from thymic carcinomas and low-risk thymomas were 951.6% (sensitivity, 81.0%; specificity, 51.4%; and AUC, 0.661). Conclusions According to the type of TICs and dynamic indices, DCE-MRI is of value in predicting low-risk thymomas, high-risk thymomas, and thymic carcinomas.

  12. Reassessment of Ambulatory Blood Pressure Improves Renal Risk Stratification in Nondialysis Chronic Kidney Disease: Long-Term Cohort Study.

    PubMed

    Minutolo, Roberto; Gabbai, Francis B; Chiodini, Paolo; Garofalo, Carlo; Stanzione, Giovanna; Liberti, Maria Elena; Pacilio, Mario; Borrelli, Silvio; Provenzano, Michele; Conte, Giuseppe; De Nicola, Luca

    2015-09-01

    In nondialysis chronic kidney disease, ambulatory blood pressure (ABP) performs better than clinic BP in predicting outcome, but whether repeated assessment of ABP further refines prognosis remains ill-defined. We recruited 182 consecutive hypertensive patients with nondialysis chronic kidney disease who underwent 2 ABPs 12 months apart to evaluate the enhancement in risk stratification provided by a second ABP obtained 1 year after baseline on the risk (hazard ratio and 95% confidence interval) of composite renal end point (death, chronic dialysis, and estimated glomerular filtration rate decline ≥40%). The difference in daytime and nighttime systolic BP between the 2 ABPs (daytime and nighttime bias) was added to a survival model including baseline ABP. Net reclassification improvement was also calculated. Age was 65.6±13.4 years; 36% had diabetes mellitus and 36% had previous cardiovascular event; estimated glomerular filtration rate was 42.2±19.6 mL/min per 1.73 m(2), and clinic BP was 145±18/80±11 mm Hg. Baseline ABP (daytime, 131±16/75±10 and nighttime, 122±18/66±10 mm Hg) and daytime/nighttime BP goals (58.2% and 43.4%) did not change at month 12. Besides baseline ABP values, bias for daytime and nighttime systolic BP linearly associated with renal outcome (1.12, 1.04-1.21 and 1.18, 1.08-1.29 for every 5-mm Hg increase, respectively). Classification of patients at risk improved when considering nighttime systolic level at second ABP (net reclassification improvement, 0.224; 95% confidence interval, 0.005-0.435). Patients with first and second ABPs above target showed greater renal risk (2.15, 1.29-3.59 and 1.71, 1.07-2.72, for daytime and nighttime, respectively). In nondialysis chronic kidney disease, reassessment of ABP at 1 year further refines renal prognosis; such reassessment should specifically be considered in patients with uncontrolled BP at baseline. PMID:26150434

  13. Risk stratification in multiple myeloma, part 2: the significance of genetic risk factors in the era of currently available therapies.

    PubMed

    Biran, Noa; Jagannath, Sundar; Chari, Ajai

    2013-01-01

    Multiple myeloma (MM) is a heterogeneous disease, and a variety of risk factors at the time of initial diagnosis can be used to stratify patients. In the first part of this 2-part series, we reviewed the currently identified prognostic factors, characterized by disease burden, host factors, tumor biology, and depth of response to therapy. However, these risk factors cannot be interpreted independently of therapies. Novel therapies have the potential to worsen or improve outcomes compared with conventional therapy in high-risk patients, or actually overcome the high-risk status, thereby resulting in reclassification as standard risk. For example, thalidomide (Thalomid, Celgene) is associated with worse outcomes in patients with high-risk cytogenetic abnormalities, such as deletion of chromosomes 13 and 17p, whereas proteasome inhibitors appear to overcome t(4;14). The second part of this series reviews the significance of various genetic risks in the era of novel therapies for MM. PMID:24518521

  14. miRNA Expression Profiling Enables Risk Stratification in Archived and Fresh Neuroblastoma Tumor Samples

    PubMed Central

    De Preter, Katleen; Mestdagh, Pieter; Vermeulen, Jolle; Zeka, Fjoralba; Naranjo, Arlene; Bray, Isabella; Castel, Victoria; Chen, Caifu; Drozynska, Elzbieta; Eggert, Angelika; Hogarty, Michael D.; I?ycka-Swieszewska, Ewa; London, Wendy B.; Noguera, Rosa; Piqueras, Marta; Bryan, Kenneth; Schowe, Benjamin; van Sluis, Peter; Molenaar, Jan J.; Schramm, Alexander; Schulte, Johannes H.; Stallings, Raymond L.; Versteeg, Rogier; Laureys, Genevive; Van Roy, Nadine; Speleman, Frank; Vandesompele, Jo

    2012-01-01

    Purpose More accurate assessment of prognosis is important to further improve the choice of risk-related therapy in neuroblastoma (NB) patients. In this study, we aimed to establish and validate a prognostic miRNA signature for children with NB and tested it in both fresh frozen and archived formalin-fixed paraffin-embedded (FFPE) samples. Experimental Design Four hundred-thirty human mature miRNAs were profiled in two patient subgroups with maximally divergent clinical courses. Univariate logistic regression analysis was used to select miRNAs correlating with NB patient survival. A 25-miRNA gene signature was built using 51 training samples, tested on 179 test samples, and validated on an independent set of 304 fresh frozen tumor samples and 75 archived FFPE samples. Results The 25-miRNA signature significantly discriminates the test patients with respect to progression-free and overall survival (P < 0.0001), both in the overall population and in the cohort of high-risk patients. Multivariate analysis indicates that the miRNA signature is an independent predictor of patient survival after controlling for current risk factors. The results were confirmed in an external validation set. In contrast to a previously published mRNA classifier, the 25-miRNA signature was found to be predictive for patient survival in a set of 75 FFPE neuroblastoma samples. Conclusions In this study, we present the largest NB miRNA expression study so far, including more than 500 NB patients. We established and validated a robust miRNA classifier, able to identify a cohort of high-risk NB patients at greater risk for adverse outcome using both fresh frozen and archived material. PMID:22031095

  15. Frailty and cardiovascular disease: potential role of gait speed in surgical risk stratification in older adults

    PubMed Central

    Chen, Michael A.

    2015-01-01

    Frailty is a state of late life decline and vulnerability, typified by physical weakness and decreased physiologic reserve. The epidemiology and pathophysiology of frailty share features with those of cardiovascular disease. Gait speed can be used as a measure of frailty and is a powerful predictor of mortality. Advancing age is a potent risk factor for cardiovascular disease and has been associated with an increased risk of adverse outcomes. Older adults comprise approximately half of cardiac surgery patients, and account for nearly 80% of the major complications and deaths following surgery. The ability of traditional risk models to predict mortality and major morbidity in older patients being considered for cardiac surgery may improve if frailty, as measured by gait speed, is included in their assessment. It is possible that in the future frailty assessment may assist in choosing among therapies (e.g., surgical vs. percutaneous aortic valve replacement for patients with aortic stenosis). PMID:25678904

  16. Risk stratification in individuals with the Brugada type 1 ECG pattern without previous cardiac arrest: usefulness of a combined clinical and electrophysiologic approach

    PubMed Central

    Delise, Pietro; Allocca, Giuseppe; Marras, Elena; Giustetto, Carla; Gaita, Fiorenzo; Sciarra, Luigi; Calo, Leonardo; Proclemer, Alessandro; Marziali, Marta; Rebellato, Luca; Berton, Giuseppe; Coro, Leonardo; Sitta, Nadir

    2011-01-01

    Aims Risk stratification in individuals with type 1 Brugada electrocardiogram (ECG) pattern (type 1 ECG) for primary prevention of sudden death (SD). Methods and results Three hundred and twenty patients (258 males, median age 43 years) with type 1 ECG were enrolled. No patient had previous cardiac arrest. Fifty-four per cent of patients had a spontaneous and 46% a drug-induced type 1 ECG. One-third had syncope, two-thirds were asymptomatic. Two hundred and forty-five patients underwent electrophysiologic study (EPS) and 110 patients received an implantable cardiac defibrillator (ICD). During follow-up [median length 40 months (IQ20-67)], 17 patients had major arrhythmic events (MAE) (14 resuscitated ventricular fibrillation (VF) and three SD). Both a spontaneous type 1 ECG and syncope significantly increased the risk (2.6 and 3.0% event rate per year vs. 0.4 and 0.8%). Major arrhythmic events occurred in 14% of subjects with positive EPS, in no subjects with negative EPS and in 5.3% of subjects without EPS. All MAE occurred in subjects who had at least two potential risk factors (syncope, family history of SD, and positive EPS). Among these patients, those with spontaneous type 1 ECG had a 30% event rate. Conclusion (1) In subjects with the Brugada type 1 ECG, no single clinical risk factor, nor EPS alone, is able to identify subjects at highest risk; (2) a multiparametric approach (including syncope, family history of SD, and positive EPS) helps to identify populations at highest risk; (3) subjects at highest risk are those with a spontaneous type 1 ECG and at least two risk factors; (4) the remainder are at low risk. PMID:20978016

  17. Myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms: an update on risk stratification, molecular genetics, and therapeutic approaches including allogeneic hematopoietic stem cell transplantation.

    PubMed

    Odenike, Olatoyosi; Onida, Francesco; Padron, Eric

    2015-01-01

    Myelodysplastic syndromes are a heterogeneous group of clonal hematopoietic stem cell disorders characterized by ineffective hematopoiesis, peripheral cytopenias, and a variable propensity for leukemic transformation. In recent years there has been an explosion of information on the molecular genetic changes underlying these disorders. This information has substantial prognostic implications, and the influence on therapeutic approaches and the treatment of patients is evolving. Allogeneic hematopoietic stem cell transplantation (alloSCT) is the only known cure for these diseases, but appropriate patient selection is of utmost importance from a risk-benefit perspective. This review focuses on the factors influencing risk stratification in MDS and optimal choice of front-line therapy in the current era, including the interplay of clinical factors and molecular genetic factors, and factors that determine eligibility for alloSCT. The myelodysplastic/myeloproliferative diseases also will be discussed, including the increasing effort to understand the molecular genetics and natural history of these disorders and treatment approaches. PMID:25993202

  18. An Ultra-Deep Targeted Sequencing Gene Panel Improves the Prognostic Stratification of Patients With Advanced Oral Cavity Squamous Cell Carcinoma

    PubMed Central

    Liao, Chun-Ta; Chen, Shu-Jen; Lee, Li-Yu; Hsueh, Chuen; Yang, Lan-Yan; Lin, Chien-Yu; Fan, Kang-Hsing; Wang, Hung-Ming; Ng, Shu-Hang; Lin, Chih-Hung; Tsao, Chung-Kan; Chen, I-How; Chang, Kai-Ping; Huang, Shiang-Fu; Kang, Chung-Jan; Chen, Hua-Chien; Yen, Tzu-Chen

    2016-01-01

    Abstract An improved prognostic stratification of patients with oral cavity squamous cell carcinoma (OSCC) and pathologically positive (pN+) nodes is urgently needed. Here, we sought to examine whether an ultra-deep targeted sequencing (UDT-Seq) gene panel may improve the prognostic stratification in this patient group. A mutation-based signature affecting 10 genes (including genetic mutations in 6 oncogenes and 4 tumor suppressor genes) was devised to predict disease-free survival (DFS) in 345 primary tumor specimens obtained from pN+ OSCC patients. Of the 345 patients, 144 were extracapsular spread (ECS)-negative and 201 were ECS-positive. The 5-year locoregional control, distant metastases, disease-free, disease-specific, and overall survival (OS) rates served as outcome measures. The UDT-Seq panel was an independent risk factor (RF) for 5-year locoregional control (P = 0.0067), distant metastases (P = 0.0001), DFS (P < 0.0001), disease-specific survival (DSS, P < 0.0001), and OS (P = 0.0003) in pN+ OSCC patients. The presence of ECS and pT3–4 disease were also independent RFs for DFS, DSS, and OS. A prognostic scoring system was formulated by summing up the significant covariates (UDT-Seq, ECS, pT3–4) separately for each survival endpoint. The presence of a positive UDT-Seq panel (n = 77) significantly improved risk stratification for all the survival endpoints as compared with traditional AJCC staging (P < 0.0001). Among ECS-negative patients, those with a UDT-Seq-positive panel (n = 31) had significantly worse DFS (P = 0.0005) and DSS (P = 0.0002). Among ECS-positive patients, those with a UDT-Seq-positive panel (n = 46) also had significantly worse DFS (P = 0.0032) and DSS (P = 0.0098). Our UDT-Seq gene panel consisting of clinically actionable genes was significantly associated with patient outcomes and provided better prognostic stratification than traditional AJCC staging. It was also able to predict prognosis in OSCC patients regardless of ECS presence. PMID:26937903

  19. A novel integrated cytogenetic and genomic classification refines risk stratification in pediatric acute lymphoblastic leukemia.

    PubMed

    Moorman, Anthony V; Enshaei, Amir; Schwab, Claire; Wade, Rachel; Chilton, Lucy; Elliott, Alannah; Richardson, Stacey; Hancock, Jeremy; Kinsey, Sally E; Mitchell, Christopher D; Goulden, Nicholas; Vora, Ajay; Harrison, Christine J

    2014-08-28

    Recent genomic studies have provided a refined genetic map of acute lymphoblastic leukemia (ALL) and increased the number of potential prognostic markers. Therefore, we integrated copy-number alteration data from the 8 most commonly deleted genes, subordinately, with established chromosomal abnormalities to derive a 2-tier genetic classification. The classification was developed using 809 ALL97/99 patients and validated using 742 United Kingdom (UK)ALL2003 patients. Good-risk (GR) genetic features included ETV6-RUNX1, high hyperdiploidy, normal copy-number status for all 8 genes, isolated deletions affecting ETV6/PAX5/BTG1, and ETV6 deletions with a single additional deletion of BTG1/PAX5/CDKN2A/B. All other genetic features were classified as poor risk (PR). Three-quarters of UKALL2003 patients had a GR genetic profile and a significantly improved event-free survival (EFS) (94%) compared with patients with a PR genetic profile (79%). This difference was driven by a lower relapse rate (4% vs 17%), was seen across all patient subgroups, and was independent of other risk factors. Even genetic GR patients with minimal residual disease (>0.01%) at day 29 had an EFS in excess of 90%. In conclusion, the integration of genomic and cytogenetic data defines 2 subgroups with distinct responses to treatment and identifies a large subset of children suitable for treatment deintensification. PMID:24957142

  20. The value of molecular stratification for CEBPA(DM) and NPM1(MUT) FLT3(WT) genotypes in older patients with acute myeloid leukaemia.

    PubMed

    Dickson, Glenda J; Bustraan, Sophia; Hills, Robert K; Ali, Akbar; Goldstone, Anthony H; Burnett, Alan K; Linch, David C; Gale, Rosemary E

    2016-02-01

    Older adult patients (≥60 years) with acute myeloid leukaemia (AML) are generally considered to be poor-risk and there is limited information available regarding risk stratification based on molecular characterization in this age group, particularly for the double-mutant CEBPA (CEBPA(DM) ) genotype. To investigate whether a molecular favourable-risk genotype can be identified, we investigated CEBPA, NPM1 and FLT3 status and prognostic impact in a cohort of 301 patients aged 60 years or more with intermediate-risk cytogenetics, all treated intensively. Overall survival (OS) at 1 year was highest in the 12 patients (4%) that were CEBPA(DM) compared to the 76 (28%) with a mutant NPM1 and wild-type FLT3 (NPM1(MUT) FLT3(WT) ) genotype or all other patients (75%, 54%, 33% respectively), with median survival 15·2, 13·6 and 6·6 months, although the benefit was short-term (OS at 3 years 17%, 29%, 12% respectively). Combination of the CEBPA(DM) and NPM1(MUT) FLT3(WT) genotype patients defined a molecular group with favourable prognosis (P < 0·0001 in multivariate analysis), with 57% of patients alive at 1 year compared to 33% for all other patients. Knowledge of genotype in older cytogenetically intermediate-risk patients might influence therapy decisions. PMID:26847745

  1. Stratification and monitoring of natalizumab-associated progressive multifocal leukoencephalopathy risk: recommendations from an expert group.

    PubMed

    McGuigan, C; Craner, M; Guadagno, J; Kapoor, R; Mazibrada, G; Molyneux, P; Nicholas, R; Palace, J; Pearson, O R; Rog, D; Young, C A

    2016-02-01

    The use of natalizumab for highly active relapsing-remitting multiple sclerosis (MS) is influenced by the occurrence of progressive multifocal leukoencephalopathy (PML). Through measurement of the anti-JCV antibody index, and in combination with the presence or absence of other known risk factors, it may be possible to stratify patients with MS according to their risk of developing PML during treatment with natalizumab and detect early suspected PML using MRI including a diffusion-weighted imaging sequence. This paper describes a practical consensus guideline for treating neurologists, based on current evidence, for the introduction into routine clinical practice of anti-JCV antibody index testing of immunosuppressant-nave patients with MS, either currently being treated with, or initiating, natalizumab, based on their anti-JCV antibody status. Recommendations for the frequency and type of MRI screening in patients with varying index-associated PML risks are also discussed. This consensus paper presents a simple and pragmatic algorithm to support the introduction of anti-JCV antibody index testing and MRI monitoring into standard PML safety protocols, in order to allow some JCV positive patients who wish to begin or continue natalizumab treatment to be managed with a more individualised analysis of their PML risk. PMID:26492930

  2. Stratification and monitoring of natalizumab-associated progressive multifocal leukoencephalopathy risk: recommendations from an expert group

    PubMed Central

    McGuigan, C; Craner, M; Guadagno, J; Kapoor, R; Mazibrada, G; Molyneux, P; Nicholas, R; Palace, J; Pearson, O R; Rog, D; Young, C A

    2016-01-01

    The use of natalizumab for highly active relapsing-remitting multiple sclerosis (MS) is influenced by the occurrence of progressive multifocal leukoencephalopathy (PML). Through measurement of the anti-JCV antibody index, and in combination with the presence or absence of other known risk factors, it may be possible to stratify patients with MS according to their risk of developing PML during treatment with natalizumab and detect early suspected PML using MRI including a diffusion-weighted imaging sequence. This paper describes a practical consensus guideline for treating neurologists, based on current evidence, for the introduction into routine clinical practice of anti-JCV antibody index testing of immunosuppressant-naïve patients with MS, either currently being treated with, or initiating, natalizumab, based on their anti-JCV antibody status. Recommendations for the frequency and type of MRI screening in patients with varying index-associated PML risks are also discussed. This consensus paper presents a simple and pragmatic algorithm to support the introduction of anti-JCV antibody index testing and MRI monitoring into standard PML safety protocols, in order to allow some JCV positive patients who wish to begin or continue natalizumab treatment to be managed with a more individualised analysis of their PML risk. PMID:26492930

  3. Artificial Neural Networks and risk stratification models in Emergency Departments: The policy maker's perspective.

    PubMed

    Casagranda, Ivo; Costantino, Giorgio; Falavigna, Greta; Furlan, Raffaello; Ippoliti, Roberto

    2016-01-01

    The primary goal of Emergency Department (ED) physicians is to discriminate between individuals at low risk, who can be safely discharged, and patients at high risk, who require prompt hospitalization. The problem of correctly classifying patients is an issue involving not only clinical but also managerial aspects, since reducing the rate of admission of patients to EDs could dramatically cut costs. Nevertheless, a trade-off might arise due to the need to find a balance between economic interests and the health conditions of patients. This work considers patients in EDs after a syncope event and presents a comparative analysis between two models: a multivariate logistic regression model, as proposed by the scientific community to stratify the expected risk of severe outcomes in the short and long run, and Artificial Neural Networks (ANNs), an innovative model. The analysis highlights differences in correct classification of severe outcomes at 10 days (98.30% vs. 94.07%) and 1 year (97.67% vs. 96.40%), pointing to the superiority of Neural Networks. According to the results, there is also a significant superiority of ANNs in terms of false negatives both at 10 days (3.70% vs. 5.93%) and at 1 year (2.33% vs. 10.07%). However, considering the false positives, the adoption of ANNs would cause an increase in hospital costs, highlighting the potential trade-off which policy makers might face. PMID:26744086

  4. Exploring the color feature power for psoriasis risk stratification and classification: A data mining paradigm.

    PubMed

    Shrivastava, Vimal K; Londhe, Narendra D; Sonawane, Rajendra S; Suri, Jasjit S

    2015-10-01

    A large percentage of dermatologist׳s decision in psoriasis disease assessment is based on color. The current computer-aided diagnosis systems for psoriasis risk stratification and classification lack the vigor of color paradigm. The paper presents an automated psoriasis computer-aided diagnosis (pCAD) system for classification of psoriasis skin images into psoriatic lesion and healthy skin, which solves the two major challenges: (i) fulfills the color feature requirements and (ii) selects the powerful dominant color features while retaining high classification accuracy. Fourteen color spaces are discovered for psoriasis disease analysis leading to 86 color features. The pCAD system is implemented in a support vector-based machine learning framework where the offline image data set is used for computing machine learning offline color machine learning parameters. These are then used for transformation of the online color features to predict the class labels for healthy vs. diseased cases. The above paradigm uses principal component analysis for color feature selection of dominant features, keeping the original color feature unaltered. Using the cross-validation protocol, the above machine learning protocol is compared against the standalone grayscale features with 60 features and against the combined grayscale and color feature set of 146. Using a fixed data size of 540 images with equal number of healthy and diseased, 10 fold cross-validation protocol, and SVM of polynomial kernel of type two, pCAD system shows an accuracy of 99.94% with sensitivity and specificity of 99.93% and 99.96%. Using a varying data size protocol, the mean classification accuracies for color, grayscale, and combined scenarios are: 92.85%, 93.83% and 93.99%, respectively. The reliability of the system in these three scenarios are: 94.42%, 97.39% and 96.00%, respectively. We conclude that pCAD system using color space alone is compatible to grayscale space or combined color and grayscale spaces. We validated our pCAD system against facial color databases and the results are consistent in accuracy and reliability. PMID:26298486

  5. Breast cancer patient stratification using a molecular regularized consensus clustering method.

    PubMed

    Wang, Chao; Machiraju, Raghu; Huang, Kun

    2014-06-01

    Breast cancers are highly heterogeneous with different subtypes that lead to different clinical outcomes including prognosis, response to treatment and chances of recurrence and metastasis. An important task in personalized medicine is to determine the subtype for a breast cancer patient in order to provide the most effective treatment. In order to achieve this goal, integrative genomics approach has been developed recently with multiple modalities of large datasets ranging from genotypes to multiple levels of phenotypes. A major challenge in integrative genomics is how to effectively integrate multiple modalities of data to stratify the breast cancer patients. Consensus clustering algorithms have often been adopted for this purpose. However, existing consensus clustering algorithms are not suitable for the situation of integrating clustering results obtained from a mixture of numerical data and categorical data. In this work, we present a mathematical formulation for integrative clustering of multiple-source data including both numerical and categorical data to resolve the above issue. Specifically, we formulate the problem as a novel consensus clustering method called Molecular Regularized Consensus Patient Stratification (MRCPS) based on an optimization process with regularization. Unlike the traditional consensus clustering methods, MRCPS can automatically and spontaneously cluster both numerical and categorical data with any option of similarity metrics. We apply this new method by applying it on the TCGA breast cancer datasets and evaluate using both statistical criteria and clinical relevance on predicting prognosis. The result demonstrates the superiority of this method in terms of effectiveness of aggregation and differentiating patient outcomes. Our method, while motivated by the breast cancer research, is nevertheless universal for integrative genomics studies. PMID:24657666

  6. Breast Cancer Patient Stratification using a Molecular Regularized Consensus Clustering Method

    PubMed Central

    Wang, Chao; Machiraju, Raghu; Huang, Kun

    2014-01-01

    Breast cancers are highly heterogeneous with different subtypes that lead to different clinical outcomes including prognosis, response to treatment and chances of recurrence and metastasis. An important task in personalized medicine is to determine the subtype for a breast cancer patient in order to provide the most effective treatment. In order to achieve this goal, integrative genomics approach has been developed recently with multiple modalities of large datasets ranging from genotypes to multiple levels of phenotypes. A major challenge in integrative genomics is how to effectively integrate multiple modalities of data to stratify the breast cancer patients. Consensus clustering algorithms have often been adopted for this purpose. However, existing consensus clustering algorithms are not suitable for the situation of integrating clustering results obtained from a mixture of numerical data and categorical data. In this work, we present a mathematical formulation for integrative clustering of multiple-source data including both numerical and categorical data to resolve the above issue. Specifically, we formulate the problem as a novel consensus clustering method called Molecular Regularized Consensus Patient Stratification (MRCPS) based on an optimization process with regularization. Unlike the traditional consensus clustering methods, MRCPS can automatically and spontaneously cluster both numerical and categorical data with any option of similarity metrics. We apply this new method by applying it on the TCGA breast cancer datasets and evaluate using both statistical criteria and clinical relevance on predicting prognosis. The result demonstrates the superiority of this method in terms of effectiveness of aggregation and differentiating patient outcomes. Our method, while motivated by the breast cancer research, is nevertheless universal for integrative genomics studies. PMID:24657666

  7. Clinical utility of genetic signatures in selecting adjuvant treatment: Risk stratification for early vs. late recurrences.

    PubMed

    Hayes, Daniel F

    2015-11-01

    Adjuvant endocrine therapy (ET) reduces the odds of distant recurrence and mortality by nearly one-half in women with hormone receptor (HR) positive early stage breast cancer. While the risk of recurrence is lower for HR positive than negative patients during the first 5-7 years, HR positive patients suffer ongoing recurrences between 0.5 and 2% year over subsequent years. Extended adjuvant ET further reduces recurrence during this late phase of follow-up. ET is associated with post-menopausal side effects (hot flashes, sexual dysfunction, mood changes, and weight gain), and occasional major toxicities (thrombosis and endometrial cancer with tamoxifen; bone mineral loss and possibly heart disease with AIs) persist throughout therapy. Accurate and reliable estimates of the risk of recurrence after five years of ET for women with prior HR positive breast cancer would permit appropriate extended ET decisions. The risk of long-term relapse is related to lymph node status and size of tumor, but these are relatively crude. Several groups have investigated whether multi-parameter tumor biomarker tests might identify those patients whose risk of recurrence is so low that extended ET is not justified. These assays include IHC4, the 21-gene "OncotypeDX", the 12-gene "Endopredict," the PAM50, and the 2-gene "Breast Cancer Index (BCI)" assays. The clinical validity of all these tests for this use context have been established, with at least one paper for each that shows a statistically significant difference in risk of distant recurrence during the 5-10 years after the initial five years of adjuvant endocrine therapy. However, the stakes are high, and although each of these represents a "prospective retrospective" study, they require further validation in subsequent datasets before they should be considered to have "clinical utility" and are used to withhold potentially life-saving treatment. Perhaps more importantly, the clinical breast cancer community, and especially the patient, need to determine how low the risk of late recurrence needs to be to forego the toxicities and side effects of extended adjuvant ET. PMID:26238437

  8. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI).

    PubMed

    Mills, Joseph L; Conte, Michael S; Armstrong, David G; Pomposelli, Frank B; Schanzer, Andres; Sidawy, Anton N; Andros, George

    2014-01-01

    Critical limb ischemia, first defined in 1982, was intended to delineate a subgroup of patients with a threatened lower extremity primarily because of chronic ischemia. It was the intent of the original authors that patients with diabetes be excluded or analyzed separately. The Fontaine and Rutherford Systems have been used to classify risk of amputation and likelihood of benefit from revascularization by subcategorizing patients into two groups: ischemic rest pain and tissue loss. Due to demographic shifts over the last 40 years, especially a dramatic rise in the incidence of diabetes mellitus and rapidly expanding techniques of revascularization, it has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Perfusion is only one determinant of outcome; wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, the Society for Vascular Surgery Lower Extremity Guidelines Committee undertook the task of creating a new classification of the threatened lower extremity that reflects these important considerations. We term this new framework, the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System. Risk stratification is based on three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population. PMID:24126108

  9. Cost-Effectiveness Analysis: Risk Stratification of Nonalcoholic Fatty Liver Disease (NAFLD) by the Primary Care Physician Using the NAFLD Fibrosis Score

    PubMed Central

    Tapper, Elliot B.; Hunink, M. G. Myriam; Afdhal, Nezam H.; Lai, Michelle; Sengupta, Neil

    2016-01-01

    Background The complications of Nonalcoholic Fatty Liver Disease (NAFLD) are dependent on the presence of advanced fibrosis. Given the high prevalence of NAFLD in the US, the optimal evaluation of NAFLD likely involves triage by a primary care physician (PCP) with advanced disease managed by gastroenterologists. Methods We compared the cost-effectiveness of fibrosis risk-assessment strategies in a cohort of 10,000 simulated American patients with NAFLD performed in either PCP or referral clinics using a decision analytical microsimulation state-transition model. The strategies included use of vibration-controlled transient elastography (VCTE), the NAFLD fibrosis score (NFS), combination testing with NFS and VCTE, and liver biopsy (usual care by a specialist only). NFS and VCTE performance was obtained from a prospective cohort of 164 patients with NAFLD. Outcomes included cost per quality adjusted life year (QALY) and correct classification of fibrosis. Results Risk-stratification by the PCP using the NFS alone costs $5,985 per QALY while usual care costs $7,229/QALY. In the microsimulation, at a willingness-to-pay threshold of $100,000, the NFS alone in PCP clinic was the most cost-effective strategy in 94.2% of samples, followed by combination NFS/VCTE in the PCP clinic (5.6%) and usual care in 0.2%. The NFS based strategies yield the best biopsy-correct classification ratios (3.5) while the NFS/VCTE and usual care strategies yield more correct-classifications of advanced fibrosis at the cost of 3 and 37 additional biopsies per classification. Conclusion Risk-stratification of patients with NAFLD primary care clinic is a cost-effective strategy that should be formally explored in clinical practice. PMID:26905872

  10. 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

    Escherich, Gabriele; Trger, Anja; Gbel, 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.

    2011-01-01

    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 0.800.03 for patients with a sensitive profile, 0.730.03 for those with an intermediate profile and 0.670.08 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 (Spearmans r=0.13; P=0.15) in contrast to T-cell acute lymphoblastic leukemia (Spearmans 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. PMID:21330320

  11. Assessment of PaO2/FiO2 for stratification of patients with moderate and severe acute respiratory distress syndrome

    PubMed Central

    Villar, Jesús; Blanco, Jesús; del Campo, Rafael; Andaluz-Ojeda, David; Díaz-Domínguez, Francisco J; Muriel, Arturo; Córcoles, Virgilio; Suárez-Sipmann, Fernando; Tarancón, Concepción; González-Higueras, Elena; López, Julia; Blanch, Lluis; Pérez-Méndez, Lina; Fernández, Rosa Lidia; Kacmarek, Robert M

    2015-01-01

    Objectives A recent update of the definition of acute respiratory distress syndrome (ARDS) proposed an empirical classification based on ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) at ARDS onset. Since the proposal did not mandate PaO2/FiO2 calculation under standardised ventilator settings (SVS), we hypothesised that a stratification based on baseline PaO2/FiO2 would not provide accurate assessment of lung injury severity. Design A prospective, multicentre, observational study. Setting A network of teaching hospitals. Participants 478 patients with eligible criteria for moderate (100patients were reclassified as severe, moderate, mild (200300). Primary and secondary outcomes Group severity and hospital mortality. Results At ARDS onset, 173 patients had a PaO2/FiO2≤100 but only 38.7% met criteria for severe ARDS at 24 h under SVS. When assessed under SVS, 61.3% of patients with severe ARDS were reclassified as moderate, mild and non-ARDS, while lung severity and hospital mortality changed markedly with every PaO2/FiO2 category (p<0.000001). Our model of risk stratification outperformed the stratification using baseline PaO2/FiO2 and non-standardised PaO2/FiO2 at 24 h, when analysed by the predictive receiver operating characteristic (ROC) curve: area under the ROC curve for stratification at baseline was 0.583 (95% CI 0.525 to 0.636), 0.605 (95% CI 0.552 to 0.658) at 24 h without SVS and 0.693 (95% CI 0.645 to 0.742) at 24 h under SVS (p<0.000001). Conclusions Our findings support the need for patient assessment under SVS at 24 h after ARDS onset to assess disease severity, and have implications for the diagnosis and management of ARDS patients. Trial registration numbers NCT00435110 and NCT00736892. PMID:25818272

  12. Incorporating temporal EHR data in predictive models for risk stratification of renal function deterioration

    PubMed Central

    Singh, Anima; Nadkarni, Girish; Gottesman, Omri; Ellis, Stephen B.; Bottinger, Erwin P.; Guttag, John V.

    2015-01-01

    Predictive models built using temporal data in electronic health records (EHRs) can potentially play a major role in improving management of chronic diseases. However, these data present a multitude of technical challenges, including irregular sampling of data and varying length of available patient history. In this paper, we describe and evaluate three different approaches that use machine learning to build predictive models using temporal EHR data of a patient. The first approach is a commonly used non-temporal approach that aggregates values of the predictors in the patients medical history. The other two approaches exploit the temporal dynamics of the data. The two temporal approaches vary in how they model temporal information and handle missing data. Using data from the EHR of Mount Sinai Medical Center, we learned and evaluated the models in the context of predicting loss of estimated glomerular filtration rate (eGFR), the most common assessment of kidney function. Our results show that incorporating temporal information in patients medical history can lead to better prediction of loss of kidney function. They also demonstrate that exactly how this information is incorporated is important. In particular, our results demonstrate that the relative importance of different predictors varies over time, and that using multi-task learning to account for this is an appropriate way to robustly capture the temporal dynamics in EHR data. Using a case study, we also demonstrate how the multi-task learning based model can yield predictive models with better performance for identifying patients at high risk of short-term loss of kidney function. PMID:25460205

  13. DrugTargetInspector: An assistance tool for patient treatment stratification.

    PubMed

    Schneider, Lara; Stöckel, Daniel; Kehl, Tim; Gerasch, Andreas; Ludwig, Nicole; Leidinger, Petra; Huwer, Hanno; Tenzer, Stefan; Kohlbacher, Oliver; Hildebrandt, Andreas; Kaufmann, Michael; Gessler, Manfred; Keller, Andreas; Meese, Eckart; Graf, Norbert; Lenhof, Hans-Peter

    2016-04-01

    Cancer is a large class of diseases that are characterized by a common set of features, known as the Hallmarks of cancer. One of these hallmarks is the acquisition of genome instability and mutations. This, combined with high proliferation rates and failure of repair mechanisms, leads to clonal evolution as well as a high genotypic and phenotypic diversity within the tumor. As a consequence, treatment and therapy of malignant tumors is still a grand challenge. Moreover, under selective pressure, e.g., caused by chemotherapy, resistant subpopulations can emerge that then may lead to relapse. In order to minimize the risk of developing multidrug-resistant tumor cell populations, optimal (combination) therapies have to be determined on the basis of an in-depth characterization of the tumor's genetic and phenotypic makeup, a process that is an important aspect of stratified medicine and precision medicine. We present DrugTargetInspector (DTI), an interactive assistance tool for treatment stratification. DTI analyzes genomic, transcriptomic, and proteomic datasets and provides information on deregulated drug targets, enriched biological pathways, and deregulated subnetworks, as well as mutations and their potential effects on putative drug targets and genes of interest. To demonstrate DTI's broad scope of applicability, we present case studies on several cancer types and different types of input -omics data. DTI's integrative approach allows users to characterize the tumor under investigation based on various -omics datasets and to elucidate putative treatment options based on clinical decision guidelines, but also proposing additional points of intervention that might be neglected otherwise. DTI can be freely accessed at http://dti.bioinf.uni-sb.de. PMID:26501925

  14. Cardiac Health Risk Stratification System (CHRiSS): A Bayesian-Based Decision Support System for Left Ventricular Assist Device (LVAD) Therapy

    PubMed Central

    Loghmanpour, Natasha A.; Druzdzel, Marek J.; Antaki, James F.

    2014-01-01

    This study investigated the use of Bayesian Networks (BNs) for left ventricular assist device (LVAD) therapy; a treatment for end-stage heart failure that has been steadily growing in popularity over the past decade. Despite this growth, the number of LVAD implants performed annually remains a small fraction of the estimated population of patients who might benefit from this treatment. We believe that this demonstrates a need for an accurate stratification tool that can help identify LVAD candidates at the most appropriate point in the course of their disease. We derived BNs to predict mortality at five endpoints utilizing the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database: containing over 12,000 total enrolled patients from 153 hospital sites, collected since 2006 to the present day, and consisting of approximately 230 pre-implant clinical variables. Synthetic minority oversampling technique (SMOTE) was employed to address the uneven proportion of patients with negative outcomes and to improve the performance of the models. The resulting accuracy and area under the ROC curve (%) for predicted mortality were 30 day: 94.9 and 92.5; 90 day: 84.2 and 73.9; 6 month: 78.2 and 70.6; 1 year: 73.1 and 70.6; and 2 years: 71.4 and 70.8. To foster the translation of these models to clinical practice, they have been incorporated into a web-based application, the Cardiac Health Risk Stratification System (CHRiSS). As clinical experience with LVAD therapy continues to grow, and additional data is collected, we aim to continually update these BN models to improve their accuracy and maintain their relevance. Ongoing work also aims to extend the BN models to predict the risk of adverse events post-LVAD implant as additional factors for consideration in decision making. PMID:25397576

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

    PubMed Central

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

    2011-01-01

    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. PMID:21814373

  16. The acute coagulopathy of trauma: mechanisms and tools for risk stratification.

    PubMed

    Maegele, Marc; Spinella, Philip C; Schchl, Herbert

    2012-11-01

    Trauma remains the leading cause of death, with bleeding as the primary cause of preventable mortality. When death occurs, it happens quickly, typically within the first 6 h after injury. The principal drivers of the acute coagulopathy of trauma have been characterized, but another group of patients with early evidence of coagulopathy both physiologically and mechanistically distinct from this systemic acquired coagulopathy has been identified. This distinct phenotype is present in 25% to 30% of patients with major trauma without being exposed to the traditional triggers and is associated with higher morbidity and a 4-fold increase in mortality. Despite improvements in the resuscitation of exsanguinating patients, one of the remaining keys is to expeditiously and reproducibly identify the patients most likely to require transfusion including massive transfusion with damage control resuscitation principles. Several predictive scoring systems/algorithms for transfusion including massive transfusion in both civilian and military trauma populations have been introduced. The models developed usually suggest combinations of physiologic, hemodynamic, laboratory, injury severity, and demographic triggers identified on the initial evaluation. Many use a combination of dichotomous variables that are readily accessible after the patient's arrival to the trauma bay, but others rely on time-consuming mathematical calculations and may thus have limited real-time application. Weighted and more sophisticated systems including higher numbers of variables perform superiorly. A common limitation to all models is their retrospective nature, and prospective validations are needed. Point-of-care viscoelastic testing may be an alternative to early recognize trauma-induced coagulopathy with the risk of ongoing hemorrhage and transfusion. PMID:23042192

  17. Brugada syndrome: insights of ST elevation, arrhythmogenicity, and risk stratification from experimental observations.

    PubMed

    Morita, Hiroshi; Zipes, Douglas P; Wu, Jiashin

    2009-11-01

    Brugada syndrome (BrS), caused by ion channel abnormalities, is characterized by ST segment elevation and negative T waves in the right precordial electrocardiographic (ECG) leads recorded over the right ventricular outflow tract (RVOT). BrS is sensitive to body temperature and can lead to T-wave alternans (TWA), ventricular tachycardia, and sudden death. Recent studies in an isolated canine RVOT model of BrS demonstrated that reversal of the transmural gradient of repolarization caused the ECG characteristics and that major intraepicardial and transmural dispersion of action potentials (APs) initiated phase 2 reentry, premature ventricular activations, and tachyarrhythmias. Hypothermia enhanced the heterogeneity of the AP and promoted the origination of phase 2 reentry in the epicardium of the RVOT, but the prolonged AP duration frequently blocked reentry. Hyperthermia abbreviated the AP and facilitated the maintenance of reentry and tachyarrhythmias. Bradycardia promoted alternans in the phase 2 dome of the AP within the epicardium of the RVOT, resulting in TWA. The above phenomena were localized in the epicardium of the RVOT. Blockade of the transient outward current, I(to), reduced AP heterogeneity and prevented arrhythmias in the BrS model. In addition, epicardial activation delay led to fragmented QRS, a risk marker of prognosis in BrS. Body surface mapping in patients with BrS supported these experimental findings. In conclusion, the AP heterogeneity within the epicardium of the RVOT contributes to the ECG characteristics, temperature sensitivity, TWA, and arrhythmias in BrS, and body surface mapping and fragmented QRS can be effective predictors of risk in patients with BrS. PMID:19880072

  18. How can neuroimaging facilitate the diagnosis and stratification of patients with psychosis?

    PubMed Central

    Kempton, Matthew J.; McGuire, Philip

    2015-01-01

    Early diagnosis and treatment of patients with psychosis are associated with improved outcome in terms of future functioning, symptoms and treatment response. Identifying neuroimaging biomarkers for illness onset and treatment response would lead to immediate clinical benefits. In this review we discuss if neuroimaging may be utilised to diagnose patients with psychosis, predict those who will develop the illness in those at high risk, and stratify patients. State-of-the-art developments in the field are critically examined including multicentre studies, longitudinal designs, multimodal imaging and machine learning as well as some of the challenges in utilising future neuroimaging biomarkers in clinical trials. As many of these developments are already being applied in neuroimaging studies of Alzheimer?s disease, we discuss what lessons have been learned from this field and how they may be applied to research in psychosis. PMID:25092428

  19. Therapeutic risk management of the suicidal patient: safety planning.

    PubMed

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

    2014-05-01

    This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient. PMID:24847995

  20. Risk stratification for sudden cardiac death: current status and challenges for the future.

    PubMed

    Wellens, Hein J J; Schwartz, Peter J; Lindemans, Fred W; Buxton, Alfred E; Goldberger, Jeffrey J; Hohnloser, Stefan H; Huikuri, Heikki V; Kb, Stefan; La Rovere, Maria Teresa; Malik, Marek; Myerburg, Robert J; Simoons, Maarten L; Swedberg, Karl; Tijssen, Jan; Voors, Adriaan A; Wilde, Arthur A

    2014-07-01

    Sudden cardiac death (SCD) remains a daunting problem. It is a major public health issue for several reasons: from its prevalence (20% of total mortality in the industrialized world) to the devastating psycho-social impact on society and on the families of victims often still in their prime, and it represents a challenge for medicine, and especially for cardiology. This text summarizes the discussions and opinions of a group of investigators with a long-standing interest in this field. We addressed the occurrence of SCD in individuals apparently healthy, in patients with heart disease and mild or severe cardiac dysfunction, and in those with genetically based arrhythmic diseases. Recognizing the need for more accurate registries of the global and regional distribution of SCD in these different categories, we focused on the assessment of risk for SCD in these four groups, looking at the significance of alterations in cardiac function, of signs of electrical instability identified by ECG abnormalities or by autonomic tests, and of the progressive impact of genetic screening. Special attention was given to the identification of areas of research more or less likely to provide useful information, and thereby more or less suitable for the investment of time and of research funds. PMID:24801071

  1. Risk stratification for sudden cardiac death: current status and challenges for the future

    PubMed Central

    Wellens, Hein J.J.; Schwartz, Peter J.; Lindemans, Fred W.; Buxton, Alfred E.; Goldberger, Jeffrey J.; Hohnloser, Stefan H.; Huikuri, Heikki V.; Kb, Stefan; La Rovere, Maria Teresa; Malik, Marek; Myerburg, Robert J.; Simoons, Maarten L.; Swedberg, Karl; Tijssen, Jan; Voors, Adriaan A.; Wilde, Arthur A.

    2014-01-01

    Sudden cardiac death (SCD) remains a daunting problem. It is a major public health issue for several reasons: from its prevalence (20% of total mortality in the industrialized world) to the devastating psycho-social impact on society and on the families of victims often still in their prime, and it represents a challenge for medicine, and especially for cardiology. This text summarizes the discussions and opinions of a group of investigators with a long-standing interest in this field. We addressed the occurrence of SCD in individuals apparently healthy, in patients with heart disease and mild or severe cardiac dysfunction, and in those with genetically based arrhythmic diseases. Recognizing the need for more accurate registries of the global and regional distribution of SCD in these different categories, we focused on the assessment of risk for SCD in these four groups, looking at the significance of alterations in cardiac function, of signs of electrical instability identified by ECG abnormalities or by autonomic tests, and of the progressive impact of genetic screening. Special attention was given to the identification of areas of research more or less likely to provide useful information, and thereby more or less suitable for the investment of time and of research funds. PMID:24801071

  2. Objective estimates improve risk stratification for primary graft dysfunction after lung transplantation

    PubMed Central

    Shah, Rupal J.; Diamond, Joshua M.; Cantu, Edward; Flesch, Judd; Lee, James C.; Lederer, David J.; Lama, Vibha N.; Orens, Jonathon; Weinacker, Ann; Wilkes, David S.; Roe, David; Bhorade, Sangeeta; Wille, Keith M.; Ware, Lorraine B.; Palmer, Scott M.; Crespo, Maria; Demissie, Ejigayehu; Sonnet, Joshua; Shah, Ashish; Kawut, Steven M.; Bellamy, Scarlett L.; Localio, A. Russell; Christie, Jason D.

    2016-01-01

    Primary graft dysfunction (PGD) is a major cause of early mortality after lung transplant. We aimed to define objective estimates of PGD risk based on readily available clinical variables, using a prospective study of 11 centers in Lung Transplant Outcomes Group (LTOG). Derivation included 1255 subjects from 20022010; with separate validation in 382 subjects accrued from 20112012. We used logistic regression to identify predictors of grade 3 PGD at 48/72 hours, and decision curve methods to assess impact on clinical decisions. 211/1255 subjects in the derivation and 56/382 subjects in the validation developed PGD. We developed 3 prediction models, where low-risk recipients had a normal BMI (18.525 kg/m2), COPD/CF, and absent or mild PH (mPAP< 40mmHg). All others were considered higher-risk. Low-risk recipients had a predicted PGD risk of 47%, and high-risk a predicted PGD risk of 1518%. Adding a donor-smoking lung to a higher-risk recipient significantly increased PGD risk, although risk did not change in low-risk recipients. Validation demonstrated that probability estimates were generally accurate and that models worked best at baseline PGD incidences between 525%. We conclude that valid estimates of PGD risk can be produced using readily-available clinical variables. PMID:25877792

  3. Objective Estimates Improve Risk Stratification for Primary Graft Dysfunction after Lung Transplantation.

    PubMed

    Shah, R J; Diamond, J M; Cantu, E; Flesch, J; Lee, J C; Lederer, D J; Lama, V N; Orens, J; Weinacker, A; Wilkes, D S; Roe, D; Bhorade, S; Wille, K M; Ware, L B; Palmer, S M; Crespo, M; Demissie, E; Sonnet, J; Shah, A; Kawut, S M; Bellamy, S L; Localio, A R; Christie, J D

    2015-08-01

    Primary graft dysfunction (PGD) is a major cause of early mortality after lung transplant. We aimed to define objective estimates of PGD risk based on readily available clinical variables, using a prospective study of 11 centers in the Lung Transplant Outcomes Group (LTOG). Derivation included 1255 subjects from 2002 to 2010; with separate validation in 382 subjects accrued from 2011 to 2012. We used logistic regression to identify predictors of grade 3 PGD at 48/72?h, and decision curve methods to assess impact on clinical decisions. 211/1255 subjects in the derivation and 56/382 subjects in the validation developed PGD. We developed three prediction models, where low-risk recipients had a normal BMI (18.5-25?kg/m(2) ), chronic obstructive pulmonary disease/cystic fibrosis, and absent or mild pulmonary hypertension (mPAP<40?mmHg). All others were considered higher-risk. Low-risk recipients had a predicted PGD risk of 4-7%, and high-risk a predicted PGD risk of 15-18%. Adding a donor-smoking lung to a higher-risk recipient significantly increased PGD risk, although risk did not change in low-risk recipients. Validation demonstrated that probability estimates were generally accurate and that models worked best at baseline PGD incidences between 5% and 25%. We conclude that valid estimates of PGD risk can be produced using readily available clinical variables. PMID:25877792

  4. Necrotizing Fasciitis in Hematological Patients: Enterobacteriaceae Predominance and Limited Utility of Laboratory Risk Indicator for Necrotizing Fasciitis Score.

    PubMed

    Foo, Rui Min; Tung, Moon Ley; Poon, Li Mei; Chan, Douglas; Smitasin, Nares; Koh, Liang Piu; Chng, Wee Joo; Chai, Louis Yi Ann

    2015-04-01

    Immune suppression is a recognized risk factor for necrotizing fasciitis. In patients with hematological malignancies, a profoundly immunocompromised group, the predominant causative organisms are Gram negative. Clinical presentation and outcomes in these patients are similar to the immunocompetent. The Laboratory Risk Indicator for Necrotizing Fasciitis score is not reliable for risk stratification of the disease. PMID:26180830

  5. Usefulness of the CHADS2 score for prognostic stratification of patients with acute myocardial infarction.

    PubMed

    Huang, Shao-Sung; Chen, Ying-Hwa; Chan, Wan-Leong; Huang, Po-Hsun; Chen, Jaw-Wen; Lin, Shing-Jong

    2014-11-01

    The Thrombolysis In Myocardial Infarction (TIMI) score and Global Registry of Acute Coronary Events (GRACE) score have been validated as predictors of major adverse cardiovascular events (MACE) in patients with acute myocardial infarction (AMI). This study was undertaken to determine whether the CHADS2 score had good accuracy for predicting clinical outcome in patients with AMI and to compare the discriminatory performance of the 3 risk scores (RSs). We calculated the TIMI RS, GRACE RS, and CHADS2 score for 747 consecutive patients with AMI. The study end point was the combined occurrence of MACE, including death, nonfatal myocardial infarction, and ischemic stroke. All patients were followed up for at least 3years or until the occurrence of a major event. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of each score at different time points. Higher CHADS2 scores were associated with adverse outcome at discharge and 1-year and 3-year follow-ups (chi-square test for linear trend, p <0.001). Both CHADS2 score and GRACE RS demonstrated better discrimination than TIMI RS in predicting 1-year and 3-year MACE (p <0.001). Multivariate Cox regression analysis revealed that the CHADS2 score was an independent predictor of future MACE in patients with AMI (hazard ratio 1.349, 95% confidence interval 1.196 to 1.522). In conclusion, the CHADS2 score provides potentially valuable prognostic information on clinical outcome when applied to patients with AMI. PMID:25205632

  6. Patient stratification and identification of adverse event correlations in the space of 1190 drug related adverse events

    PubMed Central

    Roitmann, Eva; Eriksson, Robert; Brunak, Sren

    2014-01-01

    Purpose: New pharmacovigilance methods are needed as a consequence of the morbidity caused by drugs. We exploit fine-grained drug related adverse event information extracted by text mining from electronic medical records (EMRs) to stratify patients based on their adverse events and to determine adverse event co-occurrences. Methods: We analyzed the similarity of adverse event profiles of 2347 patients extracted from EMRs from a mental health center in Denmark. The patients were clustered based on their adverse event profiles and the similarities were presented as a network. The set of adverse events in each main patient cluster was evaluated. Co-occurrences of adverse events in patients (p-value < 0.01) were identified and presented as well. Results: We found that each cluster of patients typically had a most distinguishing adverse event. Examination of the co-occurrences of adverse events in patients led to the identification of potentially interesting adverse event correlations that may be further investigated as well as provide further patient stratification opportunities. Conclusions: We have demonstrated the feasibility of a novel approach in pharmacovigilance to stratify patients based on fine-grained adverse event profiles, which also makes it possible to identify adverse event correlations. Used on larger data sets, this data-driven method has the potential to reveal unknown patterns concerning adverse event occurrences. PMID:25249979

  7. Sudden Cardiac Risk Stratification with Electrocardiographic Indices - A Review on Computational Processing, Technology Transfer, and Scientific Evidence

    PubMed Central

    Gimeno-Blanes, Francisco J.; Blanco-Velasco, Manuel; Barquero-Pérez, Óscar; García-Alberola, Arcadi; Rojo-Álvarez, José L.

    2016-01-01

    Great effort has been devoted in recent years to the development of sudden cardiac risk predictors as a function of electric cardiac signals, mainly obtained from the electrocardiogram (ECG) analysis. But these prediction techniques are still seldom used in clinical practice, partly due to its limited diagnostic accuracy and to the lack of consensus about the appropriate computational signal processing implementation. This paper addresses a three-fold approach, based on ECG indices, to structure this review on sudden cardiac risk stratification. First, throughout the computational techniques that had been widely proposed for obtaining these indices in technical literature. Second, over the scientific evidence, that although is supported by observational clinical studies, they are not always representative enough. And third, via the limited technology transfer of academy-accepted algorithms, requiring further meditation for future systems. We focus on three families of ECG derived indices which are tackled from the aforementioned viewpoints, namely, heart rate turbulence (HRT), heart rate variability (HRV), and T-wave alternans. In terms of computational algorithms, we still need clearer scientific evidence, standardizing, and benchmarking, siting on advanced algorithms applied over large and representative datasets. New scenarios like electronic health recordings, big data, long-term monitoring, and cloud databases, will eventually open new frameworks to foresee suitable new paradigms in the near future. PMID:27014083

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

    PubMed Central

    Backman, Vadim; Roy, Hemant K.

    2013-01-01

    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. PMID:23459690

  9. Call for standardized definitions of osteoarthritis and risk stratification for clinical trials and clinical use.

    PubMed

    Kraus, V B; Blanco, F J; Englund, M; Karsdal, M A; Lohmander, L S

    2015-08-01

    Osteoarthritis (OA) is a heterogeneous disorder. The goals of this review are (1) To stimulate use of standardized nomenclature for OA that could serve as building blocks for describing OA and defining OA phenotypes, in short to provide unifying disease concepts for a heterogeneous disorder; and (2) To stimulate establishment of ROAD (Risk of OA Development) and ROAP (Risk of OA Progression) tools analogous to the FRAX instrument for predicting risk of fracture in osteoporosis; and (3) To stimulate formulation of tools for identifying disease in its early preradiographic and/or molecular stages - REDI (Reliable Early Disease Identification). Consensus around more sensitive and specific diagnostic criteria for OA could spur development of disease modifying therapies for this entity that has proved so recalcitrant to date. We fully acknowledge that as we move forward, we expect to develop more sophisticated definitions, terminology and tools. PMID:25865392

  10. Ambulatory blood pressure monitoring for risk stratification in obese and non-obese subjects from 10 populations.

    PubMed

    Hansen, T W; Thijs, L; Li, Y; Boggia, J; Liu, Y; Asayama, K; Kikuya, M; Bjrklund-Bodegrd, K; Ohkubo, T; Jeppesen, J; Torp-Pedersen, C; Dolan, E; Kuznetsova, T; Stolarz-Skrzypek, K; Tikhonoff, V; Malyutina, S; Casiglia, E; Nikitin, Y; Lind, L; Sandoya, E; Kawecka-Jaszcz, K; Filipovsk, J; Imai, Y; Wang, J; O'Brien, E; Staessen, J A

    2014-09-01

    Overweight clusters with high blood pressure (BP), but the independent contribution of both risk factors remains insufficiently documented. In a prospective population study involving 8467 participants (mean age 54.6 years; 47.0% women) randomly recruited from 10 populations, we studied the contribution of body mass index (BMI) to risk over and beyond BP, taking advantage of the superiority of ambulatory over conventional BP. Over 10.6 years (median), 1271 participants (15.0%) died and 1092 (12.9%), 637 (7.5%) and 443 (5.2%) experienced a fatal or nonfatal cardiovascular, cardiac or cerebrovascular event. Adjusted for sex and age, low BMI (<20.7?kg?m(-2)) predicted death (hazard ratio (HR) vs average risk, 1.52; P<0.0001) and high BMI (> or = 30.9?kg?m(-2)) predicted the cardiovascular end point (HR, 1.27; P=0.006). With adjustments including 24-h systolic BP, these HRs were 1.50 (P<0.001) and 0.98 (P=0.91), respectively. Across quartiles of the BMI distribution, 24-h and nighttime systolic BP predicted every end point (1.13 < or = standardized HR < or = 1.67; 0.046 < or = P<0.0001). The interaction between systolic BP and BMI was nonsignificant (P > or = .22). Excluding smokers removed the contribution of BMI categories to the prediction of mortality. In conclusion, BMI only adds to BP in risk stratification for mortality but not for cardiovascular outcomes. Smoking probably explains the association between increased mortality and low BMI. PMID:24430701

  11. Risk stratification at the time of diagnosis for children with hypertrophic cardiomyopathy: a report from the Pediatric Cardiomyopathy Registry Study Group

    PubMed Central

    Lipshultz, Steven E; Orav, E John; Wilkinson, James D; Towbin, Jeffrey A; Messere, Jane E; Lowe, April M; Sleeper, Lynn A; Cox, Gerald F; Hsu, Daphne T; Canter, Charles E; Hunter, Juanita A; Colan, Steven D

    2014-01-01

    Summary Background Treatment of children with hypertrophic cardiomyopathy might be improved if the risk of death or heart transplantation could be predicted by risk factors present at the time of diagnosis. Methods The Pediatric Cardiomyopathy Registry collected longitudinal data on 1085 children with hypertrophic cardiomyopathy from 1990 to 2006. The primary outcome was death or heart transplantation. Our goal is to understand how patient factors measured at the time of diagnosis will predict the subsequent risk of death or heart transplantation. The Kaplan-Meier method was used to calculate time-to-event rates from the time of diagnosis to the earlier of heart transplantation or death for children in each subgroup. Cox proportional-hazards regression was used to identify both univariable and multivariable predictors of death or heart transplantation within each aetiologic subgroup. Findings The poorest outcomes (death or transplant) were observed among children with inborn errors of metabolism, for whom the estimated rate of death or heart transplantation was 57% (95% CI: 45%, 69%) at 2 years. Children with mixed functional phenotypes also did poorly, with rates of death or heart transplantation of 45% (95% CI: 33%, 57%) at 2 years for children with mixed hypertrophic and dilated cardiomyopathy, and 38% (95% CI: 24%, 52%) at 2 years for children with mixed hypertrophic and restrictive cardiomyopathy. Excellent outcomes were observed among the 407 children who received a diagnosis of idiopathic hypertrophic cardiomyopathy at 1 year of age or older, with rates of death or heart transplantation of 3% (95% CI: 1%, 50%) at 2 years. The risk factors for poor outcomes varied according to hypertrophic cardiomyopathy subgroup, but they generally included age, weight, congestive heart failure, lower left ventricular (LV) fractional shortening, or higher LV end-diastolic posterior wall thickness or end-diastolic ventricular septal thickness at the time of cardiomyopathy diagnosis. For all hypertrophic cardiomyopathy subgroups, the risk of death or heart transplantation is significantly increased when two or more risk factors are present and also as the number of risk factors increases. Interpretation Among children with hypertrophic cardiomyopathy, the risk of death or heart transplantation is greater for those who present as infants or with inborn errors of metabolism or with mixed hypertrophic and dilated or restrictive cardiomyopathy. Risk stratification by subgroup of cardiomyopathy, by characteristics such as lower weight, congestive heart failure, or abnormal echocardiographic findings, and by the presence of multiple risk factors allows for more informed clinical decision-making and prognosis at the time of diagnosis. PMID:24011547

  12. Development and validation of a clinical score for prognosis stratification in patients requiring antiretroviral therapy in sub-Saharan Africa: a prospective open cohort study

    PubMed Central

    Gerardo, Rivero; Dayana, Prez

    2011-01-01

    Background Mortality rates among patients initiating antiretroviral therapy (ART) in sub-Saharan Africa continue high. Also HIV treatment services from the region are affronting the challenges of been attending more patients than never. In this scenario, there are no integrated scoring systems capable of an adequate risk identification/ prognostic stratification among patients requiring ART; in order of optimize actual programmes outcomes. Several independent risk factors at baseline are associated with a poor prognosis after ART initiation. These include: male sex, low body mass index, anemia, low CD4 count and stage-4 WHO disease. The aim of this research was evaluate prospectively a new scoring system composed by these factors. Methods An open cohort study was conducted in 1769 patients from May 2008 to December 2010 at two HIV clinics of Zimbabwe. A new clinical model (MASIB score) was applied at ART initiation and patients were followed for 4 months. After that, validation characteristics of the score were examined. Results Patients selected in this cohort exhibited similar baseline characteristics that the patients selected in previous cohorts from the region. Overall performance for mortality prediction of MASIB score was accurate, as reflected by the Brier score test result 0.084 (95%CI: 0.0800.088). Calibration was adequate taking in consideration a p>0.05 in the Hosmer Lemeshow test and discrimination was also good (Area Under Curve: 0.915, 95%CI: 0,901 0,928). Conclusion The new model developed exhibited adequate validation characteristics supporting the clinical use. Further evaluations of this model in others scenarios from the sub-Saharan region are needed. PMID:22187587

  13. Malignancy Risk Stratification of Thyroid Nodules: Comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association Management Guidelines.

    PubMed

    Yoon, Jung Hyun; Lee, Hye Sun; Kim, Eun-Kyung; Moon, Hee Jung; Kwak, Jin Young

    2016-03-01

    Purpose To compare malignancy risk stratification of thyroid nodules with the 2014 American Thyroid Association (ATA) management guidelines and the Thyroid Imaging Reporting and Data System (TIRADS). Materials and Methods This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. From November 2013 to July 2014, 1293 thyroid nodules in 1241 patients (mean age, 50.8 years 13.5) were included in this study. All nodules measured at least 10 mm. Solidity, hypoechogenicity or marked hypoechogenicity, microlobulated to irregular margin, microcalcifications or mixed calcifications, and nonparallel shape were considered suspicious features at ultrasonography (US). A TIRADS category and the US pattern as determined with ATA guidelines were assigned to each nodule. The correlation between the TIRADS category or ATA pattern and the malignancy rate was evaluated with the Spearman rank test. Results Of the 1293 thyroid nodules, 1059 (81.9%) were benign and 234 (18.1%) were malignant. Forty-four of the 1293 nodules (3.4%) did not meet the criteria for the ATA patterns and were classified as "not specified." The malignancy rates of TIRADS category 3, 4a, 4b, 4c, and 5 nodules were 1.9% (six of 316 nodules), 4.2% (17 of 408 nodules), 12.9% (33 of 256 nodules), 49.8% (130 of 261 nodules), and 92.3% (48 of 52 nodules), respectively, with significant differences between categories (P < .001). Malignancy rates of nodules with very low, low, intermediate, and high suspicion for malignancy with the ATA guidelines and not specified patterns were 2.7% (11 of 407 nodules), 3.1% (10 of 323 nodules), 16.7% (39 of 233 nodules), 58.0% (166 of 286 nodules), and 18.2% (eight of 44 nodules), respectively, with significant differences between patterns (P < .001). There was high correlation between classification with TIRADS (r = 1.000, P < .001) and ATA guidelines (r = 0.900, P = 0.037), without statistically significant differences (P = .873). Conclusion Both TIRADS and the ATA guidelines provide effective malignancy risk stratification for thyroid nodules. Nodules that do not meet the criteria for a specific pattern with the ATA guidelines have a relatively high risk of malignancy (18.2%). () RSNA, 2015 Online supplemental material is available for this article. PMID:26348102

  14. Underappreciated opportunities for high-density lipoprotein particles in risk stratification and potential targets of therapy.

    PubMed

    Rosenson, Robert S; Davidson, Michael H; Le, Ngoc-Anh; Burkle, Jaime; Pourfarzib, Ray

    2015-02-01

    The inverse relationship between high-density lipoprotein cholesterol (HDL-C) concentrations and coronary heart disease risk is well established. As a result, in recent years there have been significant resources focused on identifying therapies that raise HDL-C and ultimately reduce cardiovascular events. Unfortunately, a number of trials aimed at increasing HDL-C have failed to show improved outcomes, and hence, have cast doubt on the importance of HDL-C as a therapeutic target. HDL-C, however, is only one measure of HDL. HDL levels can also been estimated by quantifying apolipoprotein A-I (apoA-I) levels using enzyme immunoassay or by measuring HDL particle number (HDL-P) using nuclear magnetic resonance spectroscopy (NMR) or ion mobility. While these surrogate measures are correlated, they are not comparable. Lipoprotein-altering therapies have been shown to have different effects on HDL-C, apoA-I and HDL-P and several studies have demonstrated that HDL-P is a stronger predictor of coronary heart disease risk than HDL-C and/or apoA-I. This paper will review available evidence supporting the use of HDL-P as the biomarker of choice to assess the contribution of HDL to cardiovascular risk and as the primary goal of HDL-raising therapies. PMID:25702642

  15. Stratification of the severity of critically ill patients with classification trees

    PubMed Central

    2009-01-01

    Background Development of three classification trees (CT) based on the CART (Classification and Regression Trees), CHAID (Chi-Square Automatic Interaction Detection) and C4.5 methodologies for the calculation of probability of hospital mortality; the comparison of the results with the APACHE II, SAPS II and MPM II-24 scores, and with a model based on multiple logistic regression (LR). Methods Retrospective study of 2864 patients. Random partition (70:30) into a Development Set (DS) n = 1808 and Validation Set (VS) n = 808. Their properties of discrimination are compared with the ROC curve (AUC CI 95%), Percent of correct classification (PCC CI 95%); and the calibration with the Calibration Curve and the Standardized Mortality Ratio (SMR CI 95%). Results CTs are produced with a different selection of variables and decision rules: CART (5 variables and 8 decision rules), CHAID (7 variables and 15 rules) and C4.5 (6 variables and 10 rules). The common variables were: inotropic therapy, Glasgow, age, (A-a)O2 gradient and antecedent of chronic illness. In VS: all the models achieved acceptable discrimination with AUC above 0.7. CT: CART (0.75(0.71-0.81)), CHAID (0.76(0.72-0.79)) and C4.5 (0.76(0.73-0.80)). PCC: CART (72(69-75)), CHAID (72(69-75)) and C4.5 (76(73-79)). Calibration (SMR) better in the CT: CART (1.04(0.95-1.31)), CHAID (1.06(0.97-1.15) and C4.5 (1.08(0.98-1.16)). Conclusion With different methodologies of CTs, trees are generated with different selection of variables and decision rules. The CTs are easy to interpret, and they stratify the risk of hospital mortality. The CTs should be taken into account for the classification of the prognosis of critically ill patients. PMID:20003229

  16. Risk stratification in trauma and haemorrhagic shock: scoring systems derived from the TraumaRegister DGU().

    PubMed

    Wutzler, Sebastian; Maegele, Marc; Wafaisade, Arasch; Wyen, Hendrik; Marzi, Ingo; Lefering, Rolf

    2014-10-01

    Scoring systems commonly attempt to reduce complex clinical situations into one-dimensional values by objectively valuing and combining a variety of clinical aspects. The aim is to allow for a comparison of selected patients or cohorts. To appreciate the true value of scoring systems in patients with multiple injuries it is necessary to understand the different purposes of quantifying the severity of specific injuries and overall trauma load, being: (1) clinical decision making; (2) triage; (3) planning of trauma systems and resources; (4) epidemiological and clinical research; (5) evaluation of outcome and trauma systems, including quality assessment; and (6) estimation of costs and allocation of resources. For the first two, easy-to estimate scores with immediate availability are necessary, mainly based on initial physiology. More sophisticated scores considering age, gender, injury pattern/severity and more are usually used for research and outcome evaluation, once the diagnostic and therapeutic process has been completed. For score development large numbers of data are necessary and thus, it appears as a logical consequence that large registries as the TraumaRegister DGU() of the German Trauma Society (TR-DGU) are used to derive and validate clinical scoring systems. A variety of scoring systems have been derived from this registry, the majority of them with focus on hospital mortality. The most important among these systems is probably the RISC score, which is currently used for quality assessment and outcome adjustment in the annual audit reports. This report summarizes the various scoring systems derived from the TraumaRegister DGU() over the recent years. PMID:25284230

  17. [Preoperative cardiac risk evaluation of vascular surgery patients].

    PubMed

    Van Damme, H; Larbuisson, R; Limet, R

    2003-06-01

    Peripheral vascular surgery (carotid, infrainguinal or aortoiliacal) is characterised by an increased cardiac risk with an infarction rate of 1 to 4%. Sixty percent of the vascular patients present a concomitant coronary artery disease, often infraclinically. Preoperative cardiac risk stratification aims at reducing cardiac related morbidity and mortality. A clinical risk profile (patient's past history) and non-invasive cardiac tests allow subdividing the vascular patients into three categories: high risk, intermediate risk, and low risk. High-risk patients (unstable angina, recent infarction, overt congestive heart failure and critical aortic valve stenosis) require immediate intensive management of their underlying cardiac disease. This means delay or annulation of the planned vascular operation. For intermediate risk patients, a clinical cardiac risk index based on patient's past history (stable angina, previous infarction or episode of congestive heart failure, age of 70 years or more and diabetes) offers a rough orientation. These clinical markers lack specificity, since they are found in almost all vascular patients. The adjunction of a non-invasive cardiac testing allows to optimise the cardiac risk evaluation. Stress echocardiography with dobutamine has become a very popular test, with a negative predicting value exceeding 90%, but with a lack of specificity (many vascular patients have an uneventful postoperative outcome, despite a positive dobutamine test). These inconsistent results of cardiac risk evaluation render their routine use questionable. Nowadays, the management of patients requiring vascular surgery is based on the concept that every vascular patient should be considered as suffering from coronary artery disease. A certain degree of myocardial protection should be offered to every vascular surgery candidate. A preoperative treatment with betablockers provides myocardial protection against the operative stress and lowers myocardial oxygen requirement. There are arguments to continue or start aspirin treatment in the preoperative period, in order to lower the risk of sudden coronary thrombosis. PMID:12945241

  18. Evidence for risk stratification when monitoring for toxicities following initiation of combination antiretroviral therapy

    PubMed Central

    Taiwo, Babafemi; Yanik, Elizabeth L.; Napravnik, Sonia; Ryscavage, Patrick; Koletar, Susan L.; Moore, Richard; Mathews, W. Christopher; Crane, Heidi M.; Mayer, Kenneth; Zinski, Anne; Kahn, James S.; Eron, Joseph J.

    2014-01-01

    Objective Laboratory monitoring is recommended during combination antiretroviral therapy (cART), but the pattern of detected abnormalities and optimal monitoring are unknown. We assessed laboratory abnormalities during initial cART in 20002010 across the United States. Design Observational study in the Centers for AIDS Research Network of Integrated Clinical Systems Cohort. Methods Among patients with normal results within a year prior to cART initiation, time to first significant abnormality was assessed by KaplanMeier curves stratified by event type, with censoring at first of regimen change, loss to follow-up, or 104 weeks. Incidence rates of first events were estimated using Poisson regression; multivariable analyses identified associated factors. Results were stratified by time (16 weeks) from therapy initiation. Results A total of 3470 individuals contributed 3639 person-years. Median age, pre-cART CD4, and follow-up duration were 40 years, 206 cells/?l, and 51 weeks, respectively. Incidence rates for significant abnormalities (per 100 person-years) in the first 16 weeks post-cART initiation were as follows: lipid 49 [95% confidence interval (CI) 41 58]; hematologic = 44 (4049); hepatic = 24 (2027); and renal = 9 (711), dropping substantially during weeks 17104 of cART to lipid = 23 (1829); hematologic = 5 (46); hepatic = 6 (58); and renal = 2 (13) (all P < 0.05). Among patients receiving initial cART with no prior abnormality (N = 1889), strongest associations for hepatic abnormalities after 16 weeks were hepatitis B and C [hazard ratio 2.3 (95% CI 1.24.5) and hazard ratio = 3.0 (1.94.5), respectively]. The strongest association for renal abnormalities was hypertension [hazard ratio = 2.8 (1.45.6)]. Conclusion New abnormalities decreased after week 16 of cART. For abnormalities not present by week 16, subsequent monitoring should be guided by comorbidities. PMID:23435300

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

    PubMed Central

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

    2011-01-01

    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. PMID:21220611

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

    PubMed

    Smart, Andrew; Martin, Paul

    2006-09-01

    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

  1. A Novel Risk Stratification to Predict Local-Regional Failures in Urothelial Carcinoma of the Bladder After Radical Cystectomy

    SciTech Connect

    Baumann, Brian C.; Guzzo, Thomas J.; He Jiwei; Keefe, Stephen M.; Tucker, Kai; Bekelman, Justin E.; Hwang, Wei-Ting; Vaughn, David J.; Malkowicz, S. Bruce; Christodouleas, John P.

    2013-01-01

    Purpose: Local-regional failures (LF) following radical cystectomy (RC) plus pelvic lymph node dissection (PLND) with or without chemotherapy for invasive urothelial bladder carcinoma are more common than previously reported. Adjuvant radiation therapy (RT) could reduce LF but currently has no defined role because of previously reported morbidity. Modern techniques with improved normal tissue sparing have rekindled interest in RT. We assessed the risk of LF and determined those factors that predict recurrence to facilitate patient selection for future adjuvant RT trials. Methods and Materials: From 1990-2008, 442 patients with urothelial bladder carcinoma at University of Pennsylvania were prospectively followed after RC plus PLND with or without chemotherapy with routine pelvic computed tomography (CT) or magnetic resonance imaging (MRI). One hundred thirty (29%) patients received chemotherapy. LF was any pelvic failure detected before or within 3 months of distant failure. Competing risk analyses identified factors predicting increased LF risk. Results: On univariate analysis, pathologic stage {>=}pT3, <10 nodes removed, positive margins, positive nodes, hydronephrosis, lymphovascular invasion, and mixed histology significantly predicted LF; node density was marginally predictive, but use of chemotherapy, number of positive nodes, type of surgical diversion, age, gender, race, smoking history, and body mass index were not. On multivariate analysis, only stage {>=}pT3 and <10 nodes removed were significant independent LF predictors with hazard ratios of 3.17 and 2.37, respectively (P<.01). Analysis identified 3 patient subgroups with significantly different LF risks: low-risk ({<=}pT2), intermediate-risk ({>=}pT3 and {>=}10 nodes removed), and high-risk ({>=}pT3 and <10 nodes) with 5-year LF rates of 8%, 23%, and 42%, respectively (P<.01). Conclusions: This series using routine CT and MRI surveillance to detect LF confirms that such failures are relatively common in cases of locally advanced disease and provides a rubric based on pathological stage and number of nodes removed that stratifies patients into 3 groups with significantly different LF risks to simplify patient selection for future adjuvant radiation therapy trials.

  2. Next-generation-sequencing-based risk stratification and identification of new genes involved in structural and sequence variations in near haploid lymphoblastic leukemia.

    PubMed

    Chen, Cai; Bartenhagen, Christoph; Gombert, Michael; Okpanyi, Vera; Binder, Vera; Rttgers, Silja; Bradtke, Jutta; Teigler-Schlegel, Andrea; Harbott, Jochen; Ginzel, Sebastian; Thiele, Ralf; Fischer, Ute; Dugas, Martin; Hu, Jianda; Borkhardt, Arndt

    2013-06-01

    Near haploidy (23-29 chromosomes) is a numerical cytogenetic aberration in childhood acute lymphoblastic leukemia (ALL) associated with particularly poor outcome. In contrast, high hyperdiploidy (51-67 chromosomes) has a favorable prognosis. Correct classification and appropriate risk stratification of near haploidy is frequently hampered by the presence of apparently high hyperdiploid clones that arise by endoreduplication of the original near haploid clone. We evaluated next-generation-sequencing (NGS) to distinguish between "high hyperdiploid" leukemic clones of near haploid and true high hyperdiploid origin. Five high hyperdiploid ALL cases and the "high hyperdiploid" cell line MHH-CALL-2, derived from a near haploid clone, were tested for uniparental isodisomy. NGS showed that all disomic chromosomes of MHH-CALL-2, but none of the patients, were of uniparental origin, thus reliably discriminating these subtypes. Whole-exome- and whole-genome-sequencing of MHH-CALL-2 revealed homozygous non-synonymous coding mutations predicted to be deleterious for the protein function of 63 genes, among them known cancer-associated genes, such as FANCA, NF1, TCF7L2, CARD11, EP400, histone demethylases, and transferases (KDM6B, KDM1A, PRDM11). Only eight of these were also, but heterozygously, mutated in the high hyperdiploid patients. Structural variations in MHH-CALL-2 include a homozygous deletion (MTAP/CDKN2A/CDKN2B/ANRIL), a homozygous inversion (NCKAP5), and an unbalanced translocation (FAM189A1). Together, the sequence variations provide MHH-CALL-2 with capabilities typically acquired during cancer development, e.g., loss of cell cycle control, enhanced proliferation, lack of DNA repair, cell death evasion, and disturbance of epigenetic gene regulation. Poorer prognosis of near haploid ALL most likely results from full penetrance of a large array of detrimental homozygous mutations. PMID:23508829

  3. A PRIM approach to predictive-signature development for patient stratification.

    PubMed

    Chen, Gong; Zhong, Hua; Belousov, Anton; Devanarayan, Viswanath

    2015-01-30

    Patients often respond differently to a treatment because of individual heterogeneity. Failures of clinical trials can be substantially reduced if, prior to an investigational treatment, patients are stratified into responders and nonresponders based on biological or demographic characteristics. These characteristics are captured by a predictive signature. In this paper, we propose a procedure to search for predictive signatures based on the approach of patient rule induction method. Specifically, we discuss selection of a proper objective function for the search, present its algorithm, and describe a resampling scheme that can enhance search performance. Through simulations, we characterize conditions under which the procedure works well. To demonstrate practical uses of the procedure, we apply it to two real-world data sets. We also compare the results with those obtained from a recent regression-based approach, Adaptive Index Models, and discuss their respective advantages. In this study, we focus on oncology applications with survival responses. PMID:25345685

  4. Clinical Criteria Replenish High-Sensitive Troponin and Inflammatory Markers in the Stratification of Patients with Suspected Acute Coronary Syndrome

    PubMed Central

    Sthli, Barbara Elisabeth; Yonekawa, Keiko; Altwegg, Lukas Andreas; Wyss, Christophe; Hof, Danielle; Fischbacher, Philipp; Brauchlin, Andreas; Schulthess, Georg; Krayenbhl, Pierre-Alexandre; von Eckardstein, Arnold; Hersberger, Martin; Neidhart, Michel; Gay, Steffen; Novopashenny, Igor; Wolters, Regine; Frank, Michelle; Wischnewsky, Manfred Bernd; Lscher, Thomas Felix; Maier, Willibald

    2014-01-01

    Objectives In patients with suspected acute coronary syndrome (ACS), rapid triage is essential. The aim of this study was to establish a tool for risk prediction of 30-day cardiac events (CE) on admission. 30-day cardiac events (CE) were defined as early coronary revascularization, subsequent myocardial infarction, or cardiovascular death within 30 days. Methods and Results This single-centre, prospective cohort study included 377 consecutive patients presenting to the emergency department with suspected ACS and for whom troponin T measurements were requested on clinical grounds. Fifteen biomarkers were analyzed in the admission sample, and clinical parameters were assessed by the TIMI risk score for unstable angina/Non-ST myocardial infarction and the GRACE risk score. Sixty-nine (18%) patients presented with and 308 (82%) without ST-elevations, respectively. Coronary angiography was performed in 165 (44%) patients with subsequent percutaneous coronary intervention accounting for the majority of CE in 123 (33%) patients, respectively. Eleven out of 15 biomarkers were elevated in patients with CE compared to those without. High-sensitive troponin T (hs-cTnT) was the best univariate biomarker to predict CE in Non-ST-elevation patients (AUC 0.80), but did not yield incremental information above clinical TIMI risk score (AUC 0.80 vs 0.82, p?=?0.69). Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE. Conclusions In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT. PMID:24892556

  5. Imaging of cardiovascular risk in patients with Turner's syndrome

    PubMed Central

    Marin, A.; Weir-McCall, J.R.; Webb, D.J.; van Beek, E.J.R.; Mirsadraee, S.

    2015-01-01

    Turner's syndrome is a disorder defined by an absent or structurally abnormal second X chromosome and affects around 1 in 2000 newborn females. The standardised mortality ratio in Turner's syndrome is around three-times higher than in the general female population, mainly as a result of cardiovascular disorders. Most striking is the early age at which Turner's syndrome patients develop the life-threatening complications of cardiovascular disorders compared to the general population. The cardiovascular risk stratification in Turner's syndrome is challenging and imaging is not systematically used. The aim of this article is to review cardiovascular risks in this group of patients and discuss a systematic imaging approach for early identification of cardiovascular disorders in these patients. PMID:25917542

  6. Patient risk from interproximal radiography

    SciTech Connect

    Gibbs, S.J.; Pujol, A. Jr.; Chen, T.S.; Malcolm, A.W.; James, A.E. Jr.

    1984-09-01

    Computer simulation methods for determining patient dose from dental radiography have demonstrated that patient risk from a two-film interproximal examination ranges from 1.1 X 10(-8) to 3.4 X 10(-7) using 90-kVp beams, depending on film speed, projection technique, and age and sex of the patient. Further, changing from a short-cone round-beam to a long-cone technique with rectangular collimation reduces risk by a factor of 2.9, independent of other factors.

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

    SciTech Connect

    Petersen, Johannes Glodny, Bernhard

    2011-10-15

    Purpose: To objectify the influence of the atherosclerotic burden in the proximal landing zone on the development of endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) using objective aortic calcium scoring (ACS). Materials and Methods: This retrospective observation study included 267 patients who received an aortic endograft between 1997 and 2010 and for whom preoperative computed tomography (CT) was available to perform ACS using the CT-based V600 method. The mean follow-up period was 2 {+-} 2.3 years. Results: Type I endoleaks persisted in 45 patients (16.9%), type II in 34 (12.7%), type III in 8 (3%), and type IV or V in 3 patients, respectively (1.1% each). ACS in patients with type I endoleaks was not increased: 0.029 {+-} 0.061 ml compared with 0.075 {+-} 0.1349 ml in the rest of the patients, (p > 0.05; Whitney-Mann U-Test). There were significantly better results for the indication 'traumatic aortic rupture' than for the other indications (p < 0.05). In multivariate logistic regression analyses, age was an independent risk factor for the development of type I endoleaks in the thoracic aorta (Wald 9.5; p = 0.002), whereas ACS score was an independent protective factor (Wald 6.9; p = 0.009). In the abdominal aorta, neither age nor ACS influenced the development of endoleaks. Conclusion: Contrary to previous assumptions, TEVAR and EVAR can be carried out without increasing the risk of an endoleak of any type, even if there is a high atherosclerotic 'hard-plaque' burden of the aorta. The results are significantly better for traumatic aortic.

  8. Benefit of Adjuvant Brachytherapy Versus External Beam Radiation for Early Breast Cancer: Impact of Patient Stratification on Breast Preservation

    SciTech Connect

    Smith, Grace L.; Jiang, Jing; Buchholz, Thomas A.; Xu, Ying; Hoffman, Karen E.; Giordano, Sharon H.; Hunt, Kelly K.; Smith, Benjamin D.

    2014-02-01

    Purpose: Brachytherapy after lumpectomy is an increasingly popular breast cancer treatment, but data concerning its effectiveness are conflicting. Recently proposed “suitability” criteria guiding patient selection for brachytherapy have never been empirically validated. Methods: Using the Surveillance, Epidemiology, and End Results–Medicare linked database, we compared women aged 66 years or older with invasive breast cancer (n=28,718) or ductal carcinoma in situ (n=7229) diagnosed from 2002 to 2007, treated with lumpectomy alone, brachytherapy, or external beam radiation therapy (EBRT). The likelihood of breast preservation, measured by subsequent mastectomy risk, was compared by use of multivariate proportional hazards, further stratified by American Society for Radiation Oncology (ASTRO) brachytherapy suitability groups. We compared 1-year postoperative complications using the χ{sup 2} test and 5-year local toxicities using the log-rank test. Results: For patients with invasive cancer, the 5-year subsequent mastectomy risk was 4.7% after lumpectomy alone (95% confidence interval [CI], 4.1%-5.4%), 2.8% after brachytherapy (95% CI, 1.8%-4.3%), and 1.3% after EBRT (95% CI, 1.1%-1.5%) (P<.001). Compared with lumpectomy alone, brachytherapy achieved a more modest reduction in adjusted risk (hazard ratio [HR], 0.61; 95% CI, 0.40-0.94) than achieved with EBRT (HR, 0.22; 95% CI, 0.18-0.28). Relative risks did not differ when stratified by ASTRO suitability group (P=.84 for interaction), although ASTRO “suitable” patients did show a low absolute subsequent mastectomy risk, with a minimal absolute difference in risk after brachytherapy (1.6%; 95% CI, 0.7%-3.5%) versus EBRT (0.8%; 95% CI, 0.6%-1.1%). For patients with ductal carcinoma in situ, EBRT maintained a reduced risk of subsequent mastectomy (HR, 0.40; 95% CI, 0.28-0.55; P<.001), whereas the small number of patients treated with brachytherapy (n=179) precluded definitive comparison with lumpectomy alone. In all patients, brachytherapy showed a higher postoperative infection risk (16.5% vs 9.9% after lumpectomy alone vs 11.4% after EBRT, P<.001); higher incidence of breast pain (22.9% vs 11.2% vs 16.7%, P<.001); and higher incidence of fat necrosis (15.3% vs 5.3% vs 7.7%, P<.001). Conclusions: In this study era, brachytherapy showed lesser breast preservation benefit compared with EBRT. Suitability criteria predicted differential absolute, but not relative, benefit in patients with invasive cancer.

  9. Patient Protection and Risk Selection

    PubMed Central

    Wynia, Matthew K; Zucker, Deborah; Supran, Stacey; Selker, Harry P

    2002-01-01

    BACKGROUND Individual physicians who are paid prospectively, as in capitated health plans, might tend to encourage patients to avoid or to join these plans according to the patient's health status. Though insurance risk selection has been well documented among organizations paid on a prospective basis, such physician-level risk selection has not been studied. OBJECTIVE To assess physician reports of risk selection in capitated health plans and explore potentially related factors. DESIGN AND PARTICIPANTS National mailed survey of primary care physicians in 19971998, oversampling physicians in areas with more capitated health plans. RESULTS The response rate was 63% (787 of 1,252 eligible recipients). Overall, 44% of physicians reported encouraging patients either to join or to avoid capitated health plans according to the patients' health status: 40% encouraged more complex and ill patients to avoid capitated plans and 23% encouraged healthier patients to join capitated plans. In multivariable models, physicians with negative perceptions of capitated plan quality, with more negative experiences in capitated plans, and those who knew at each patient encounter how they were being compensated had higher odds of encouraging sicker patients to avoid capitated plans (odds ratios, 2.0, 2.2, and 2.0; all confidence intervals >1). CONCLUSIONS Many primary care physicians report encouraging patients to join or avoid capitated plans according to the patient's health status. Although these physicians' recommendations might be associated primarily with concerns about quality, they can have the effect of insulating certain health plans from covering sicker and more expensive patients. PMID:11903774

  10. Cost-Effectiveness of Carotid Plaque MR Imaging as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis.

    PubMed

    Gupta, Ajay; Mushlin, Alvin I; Kamel, Hooman; Navi, Babak B; Pandya, Ankur

    2015-12-01

    Purpose To evaluate the cost-effectiveness of a decision-making rule based on the magnetic resonance (MR) imaging assessment of intraplaque hemorrhage (IPH) in patients with asymptomatic carotid artery stenosis. Materials and Methods Two competing stroke prevention strategies were compared: (a) an intensive medical therapy-based management strategy versus (b) an imaging-based strategy in which the subset of patients with asymptomatic carotid artery stenosis with IPH on MR images would undergo immediate carotid endarterectomy in addition to ongoing intensive medical therapy. Patients in the medical therapy-only group could undergo carotid endarterectomy only with substantial carotid artery stenosis disease progression. Lifetime quality-adjusted life years (QALYs) and costs were modeled for patients with asymptomatic carotid artery stenosis with 70%-89% and 50%-69% carotid artery stenosis at presentation. Risks of stroke and complications from carotid endarterectomy, costs, and quality of life values were estimated from published sources. Results The medical therapy-based strategy had a lower life expectancy (12.65 years vs 12.95 years), lower lifetime QALYs (9.96 years vs 10.05 years), and lower lifetime costs ($13 699 vs $15 297) when compared with the MR imaging IPH-based strategy. The incremental cost-effectiveness ratio (ICER) for the MR imaging IPH strategy compared with the medical therapy-based strategy was $16 000 per QALY by using a base-case 70-year-old patient. When using starting patient ages of 60 and 80 years, the ICERs for the MR imaging IPH strategy were $3100 per QALY and $73 000 per QALY, respectively. The ICERs for the MR imaging IPH strategy were slightly higher at all ages for 50%-69% stenosis but remained below a willingness-to-pay threshold of $100 000 per QALY for starting ages of 60 and 70 years. Conclusion MR imaging IPH can be used as a cost-effective tool to identify patients with asymptomatic carotid artery stenosis most likely to benefit from carotid endarterectomy. () RSNA, 2015 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on July 14, 2015. PMID:26098459

  11. Streptozocin-Based Chemotherapy in Patients with Advanced Neuroendocrine Neoplasms – Predictive and Prognostic Markers for Treatment Stratification

    PubMed Central

    Krug, Sebastian; Boch, Michael; Daniel, Hanna; Nimphius, Wilhelm; Müller, Daniela; Michl, Patrick; Rinke, Anja; Gress, Thomas Matthias

    2015-01-01

    Background and Aim Chemotherapy with streptozocin (STZ) in combination with 5-FU or doxorubicin (Dox) represents a standard of care for patients with metastatic pancreatic neuroendocrine neoplasms (pNEN). However, predictive markers for patient selection are still missing. The aim of this study was a retrospective evaluation of the clinicopathological characteristics of pNEN patients receiving STZ-based chemotherapies and to identify predictive and prognostic markers. Patients and Methods We retrospectively analyzed 77 patients treated at our center between 1995 and 2013. The median overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Meier and Cox regression methods, respectively. Uni- and multivariate analyses were performed. Results The median PFS (mPFS) in patients receiving STZ/5-FU/Dox was 16 months with a median OS (mOS) of 28 months. Objective response rate (ORR) and disease control rate (DCR) were 34% and 72%, respectively. Biochemical response and positive octreotide scintigraphy predicted objective response. Univariate analysis revealed Ki-67 > 10% and the absence of biochemical or objective response by imaging as independent risk factors for shorter PFS. Additionally, performance status (PS) and resection of the primary tumor were observed to influence mOS. Treatment was well tolerated with less than 10% grade 3 and 4 toxicities. Conclusions STZ-based chemotherapy is an effective and well-tolerated treatment option in patients with well differentiated neuroendocrine neoplasms. Positive octreotide scintigraphy and biochemical response predict objective response. PMID:26630134

  12. Integration of copy number and transcriptomics provides risk stratification in prostate cancer: A discovery and validation cohort study

    PubMed Central

    Ross-Adams, H.; Lamb, A.D.; Dunning, M.J.; Halim, S.; Lindberg, J.; Massie, C.M.; Egevad, L.A.; Russell, R.; Ramos-Montoya, A.; Vowler, S.L.; Sharma, N.L.; Kay, J.; Whitaker, H.; Clark, J.; Hurst, R.; Gnanapragasam, V.J.; Shah, N.C.; Warren, A.Y.; Cooper, C.S.; Lynch, A.G.; Stark, R.; Mills, I.G.; Grönberg, H.; Neal, D.E.

    2015-01-01

    Background Understanding the heterogeneous genotypes and phenotypes of prostate cancer is fundamental to improving the way we treat this disease. As yet, there are no validated descriptions of prostate cancer subgroups derived from integrated genomics linked with clinical outcome. Methods In a study of 482 tumour, benign and germline samples from 259 men with primary prostate cancer, we used integrative analysis of copy number alterations (CNA) and array transcriptomics to identify genomic loci that affect expression levels of mRNA in an expression quantitative trait loci (eQTL) approach, to stratify patients into subgroups that we then associated with future clinical behaviour, and compared with either CNA or transcriptomics alone. Findings We identified five separate patient subgroups with distinct genomic alterations and expression profiles based on 100 discriminating genes in our separate discovery and validation sets of 125 and 103 men. These subgroups were able to consistently predict biochemical relapse (p = 0.0017 and p = 0.016 respectively) and were further validated in a third cohort with long-term follow-up (p = 0.027). We show the relative contributions of gene expression and copy number data on phenotype, and demonstrate the improved power gained from integrative analyses. We confirm alterations in six genes previously associated with prostate cancer (MAP3K7, MELK, RCBTB2, ELAC2, TPD52, ZBTB4), and also identify 94 genes not previously linked to prostate cancer progression that would not have been detected using either transcript or copy number data alone. We confirm a number of previously published molecular changes associated with high risk disease, including MYC amplification, and NKX3-1, RB1 and PTEN deletions, as well as over-expression of PCA3 and AMACR, and loss of MSMB in tumour tissue. A subset of the 100 genes outperforms established clinical predictors of poor prognosis (PSA, Gleason score), as well as previously published gene signatures (p = 0.0001). We further show how our molecular profiles can be used for the early detection of aggressive cases in a clinical setting, and inform treatment decisions. Interpretation For the first time in prostate cancer this study demonstrates the importance of integrated genomic analyses incorporating both benign and tumour tissue data in identifying molecular alterations leading to the generation of robust gene sets that are predictive of clinical outcome in independent patient cohorts. PMID:26501111

  13. Risk of Parkinson Disease Onset in Patients With Diabetes

    PubMed Central

    Sun, Yu; Chang, Ya-Hui; Chen, Hua-Fen; Su, Ying-Hwa; Su, Hui-Fang; Li, Chung-Yi

    2012-01-01

    OBJECTIVE We retrospectively assessed the age- and sex-specific incidence and relative risk of Parkinson disease (PD) in Taiwan’s diabetic population. RESEARCH DESIGN AND METHODS Study cohort included 603,416 diabetic patients and 472,188 nondiabetic control subjects. Incidence rate and relative risk of PD (ICD-9-CM 332.0) were evaluated. RESULTS The incidence of PD was 3.59 and 2.15 per 10,000 person-years for the diabetic and control group, respectively, representing a covariate adjusted hazard ratio (HR) of 1.61 (95% CI 1.56–1.66), which was substantially reduced to 1.37 (1.32–1.41) after adjusting for medical visits. Diabetes was associated with a significantly elevated risk of PD in all sex and age stratifications except in young women, with the highest HR noted for young men aged 21–40 years (2.10 [1.01–4.42]), followed by women aged 41–60 (2.05 [1.82–2.30]) and >60 years (1.65 [1.58–1.73]). CONCLUSIONS Diabetes is associated with an increased risk of PD onset in a Chinese population, and the relation is stronger in women and younger patients. PMID:22432112

  14. Predicting mortality in patients with acute heart failure: Role of risk scores.

    PubMed

    Passantino, Andrea; Monitillo, Francesco; Iacoviello, Massimo; Scrutinio, Domenico

    2015-12-26

    Acute heart failure is a leading cause of hospitalization and death, and it is an increasing burden on health care systems. The correct risk stratification of patients could improve clinical outcome and resources allocation, avoiding the overtreatment of low-risk subjects or the early, inappropriate discharge of high-risk patients. Many clinical scores have been derived and validated for in-hospital and post-discharge survival; predictive models include demographic, clinical, hemodynamic and laboratory variables. Data sets are derived from public registries, clinical trials, and retrospective data. Most models show a good capacity to discriminate patients who reach major clinical end-points, with C-indices generally higher than 0.70, but their applicability in real-world populations has been seldom evaluated. No study has evaluated if the use of risk score-based stratification might improve patient outcome. Some variables (age, blood pressure, sodium concentration, renal function) recur in most scores and should always be considered when evaluating the risk of an individual patient hospitalized for acute heart failure. Future studies will evaluate the emerging role of plasma biomarkers. PMID:26730296

  15. Predicting mortality in patients with acute heart failure: Role of risk scores

    PubMed Central

    Passantino, Andrea; Monitillo, Francesco; Iacoviello, Massimo; Scrutinio, Domenico

    2015-01-01

    Acute heart failure is a leading cause of hospitalization and death, and it is an increasing burden on health care systems. The correct risk stratification of patients could improve clinical outcome and resources allocation, avoiding the overtreatment of low-risk subjects or the early, inappropriate discharge of high-risk patients. Many clinical scores have been derived and validated for in-hospital and post-discharge survival; predictive models include demographic, clinical, hemodynamic and laboratory variables. Data sets are derived from public registries, clinical trials, and retrospective data. Most models show a good capacity to discriminate patients who reach major clinical end-points, with C-indices generally higher than 0.70, but their applicability in real-world populations has been seldom evaluated. No study has evaluated if the use of risk score-based stratification might improve patient outcome. Some variables (age, blood pressure, sodium concentration, renal function) recur in most scores and should always be considered when evaluating the risk of an individual patient hospitalized for acute heart failure. Future studies will evaluate the emerging role of plasma biomarkers. PMID:26730296

  16. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic DiabeticPatient: The Imaging Council of the American College of Cardiology.

    PubMed

    Budoff, Matthew J; Raggi, Paolo; Beller, George A; Berman, Daniel S; Druz, Regina S; Malik, Shaista; Rigolin, Vera H; Weigold, Wm Guy; Soman, Prem

    2016-02-01

    Increased cardiovascular morbidity and mortality in patients with type 2 diabetes is well established; diabetes is associated with at least a 2-fold increased risk of coronary heart disease. Approximately two-thirds of deaths among persons with diabetes are related to cardiovascular disease. Previously, diabetes was regarded as a "coronary risk equivalent," implying a high 10-year cardiovascular risk for every diabetes patient. Following the original study by Haffner etal., multiple studies from different cohorts provided varying conclusions on the validity of the concept of coronary risk equivalency in patients with diabetes. New guidelines have started to acknowledge the heterogeneity in risk and include different treatment recommendations for diabetic patients without other risk factors who are considered to be at lower risk. Furthermore, guidelines have suggested that further risk stratification in patients with diabetes is warranted before universal treatment. The Imaging Council of the American College of Cardiology systematically reviewed all modalities commonly used for risk stratification in persons with diabetes mellitus and summarized the data and recommendations. This document reviews the evidence regarding the use of noninvasive testing to stratify asymptomatic patients with diabetes with regard to coronary heart disease risk and develops an algorithm for screening based on available data. PMID:26846937

  17. Body Mass Index as a Predictor of Sudden Cardiac Death and Usefulness of the Electrocardiogram for Risk Stratification.

    PubMed

    Eranti, Antti; Aro, Aapo L; Kerola, Tuomas; Tikkanen, Jani T; Rissanen, Harri A; Anttonen, Olli; Junttila, M Juhani; Knekt, Paul; Huikuri, Heikki V

    2016-02-01

    Evidence of the role of body mass index (BMI) as a risk factor for sudden cardiac death (SCD) is conflicting, and how electrocardiographic (ECG) SCD risk markers perform in subjects with different BMIs is not known. In this study, a general population cohort consisting of 10,543 middle-aged subjects (mean age 44years, 52.7% men) was divided into groups of lean (BMI <20, n= 374), normal weight (BMI 20.0 to 24.9, n= 4,334), overweight (BMI 25.0 to 29.9, n= 4,390), and obese (BMI >30, n= 1,445) subjects. Cox proportional hazards models adjusted for confounders were used to assess the risk for SCD associated with BMI and the risk for SCD associated with ECG abnormalities in subjects with different BMIs. The overweight and obese subjects were at increased risk for SCD (hazard ratios [95% CIs] were 1.33 [1.13 to 1.56], p= 0.001 and 1.79 [1.44 to 2.23], p <0.001 for overweight and obese subjects, respectively). The risk of non-SCD had a similar relation with BMI as SCD. Hazard ratios associated with ECG abnormalities were 3.03, 1.75, 1.74, and 1.34 in groups of lean, normal weight, overweight, and obese subjects, respectively, but no statistical significance was reached in the obese. ECG abnormalities improved integrated discrimination indexes and continuous net reclassification indexes statistically significantly only in the normal weight group. In conclusion, the overweight and obese are at increased risk for SCD but also for non-SCD, and ECG abnormalities are associated with increased risk of SCD also in normal weight subjects presenting with less traditional cardiovascular risk factors. PMID:26723105

  18. Thrombotic risk assessment in 185 WHO-defined essential thrombocythemia patients: single center experience

    PubMed Central

    Gerbutavicius, Rolandas; Juozaityte, Elona; Gerbutaviciene, Rima

    2015-01-01

    Thrombosis risk in essential thrombocythemia (ET) patients can be assessed using different prognostic systems. Conventional risk factors include age more than 60 years and history of previous thrombosis. In addition, other factors such as JAK2 V617F mutations, cardiovascular risk factors, leukocytosis more than 11 109/l, thrombophilic factors and platelet count more than 1500 109/l are used in different hematology centers as high-risk features for thrombosis. Our study compared different risk model groups for thrombosis in 185 WHO-defined ET patients at the Hospital of Lithuanian University of Health Sciences Kaunas Klinikos. We found that patient distribution in low, intermediate- and high-risk groups varies using different risk stratification models. The biggest difference in risk assignment is evident in patients who are older than 60 years and have no other risk factors and in patients who are younger than 60 years but have other risk factors. This observation suggests that new prospective randomized clinical trials are needed to better stratify patients at risk for thrombosis. PMID:26793025

  19. What's the risk? Assessment of patients with stable chest pain

    PubMed Central

    Cubukcu, Arzu; Anderson, Simon

    2015-01-01

    In 2010, the National Institute for Heath and Clinical Excellence published guidelines for the management of stable chest pain of recent onset. Implementation has occurred to various degrees throughout the NHS; however, its effectiveness has yet to be proved. A retrospective study was undertaken to assess the impact and relevance of this guideline, comparing the estimated risk of coronary artery disease (CAD) with angiographic outcomes. Findings were compared with the recently published equivalent European guideline. A total of 457 patients who attended a Rapid Access Chest Pain Clinic were retrospectively reviewed. CAD risk was assessed according to NICE guidelines and patients were separated into typical, atypical and non-anginal chest pain groups. Risk stratification using typicality of symptoms in conjunction with NICE risk scoring and exercise tolerance testing was used to determine the best clinical course for each patient. The results include non-anginal chest pain – 92% discharged without needing further testing; atypical angina – 15% discharged, 40% referred for stress echocardiography, 35% referred for angiogram and significant CAD revealed in 8%; typical angina – 4% discharged, 19% referred for stress echocardiography, 71% referred for angiogram and 40% demonstrated CAD. Both guidelines appear to overestimate the risk of CAD leading to an excessive number of coronary angiograms being undertaken to investigate patients with typical or atypical sounding angina, with a low pick up rate of CAD. Given the high negative predictive value of stress echocardiography and the confidence this brings, there is much scope for expanding its use and potentially reduce the numbers going for invasive angiography. PMID:26693332

  20. From differences in means between cases and controls to risk stratification: A business plan for biomarker development

    PubMed Central

    Wentzensen, Nicolas; Wacholder, Sholom

    2012-01-01

    Researchers developing biomarkers for early detection can determine the potential for clinical benefit at early stages of development. We provide the theoretical background showing the quantitative connection between biomarker levels in cases and controls and clinically meaningful risk measures and a spreadsheet for researchers to use in their own research. We provide researchers with tools to decide whether a test is useful, whether it needs technical improvement, whether it may only work in specific populations, or whether any further development is futile. The methods described here apply to any method that aims to estimate risk of disease based on biomarkers, clinical tests, genetics, environment or behavior. PMID:23299199

  1. Lake Layers: Stratification.

    ERIC Educational Resources Information Center

    Brothers, Chris; And Others

    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

  2. Cytogenetic and molecular diagnostic characterization combined to postconsolidation minimal residual disease assessment by flow cytometry improves risk stratification in adult acute myeloid leukemia.

    PubMed

    Buccisano, Francesco; Maurillo, Luca; Spagnoli, Alessandra; Del Principe, Maria Ilaria; Fraboni, Daniela; Panetta, Paola; Ottone, Tiziana; Consalvo, Maria Irno; Lavorgna, Serena; Bulian, Pietro; Ammatuna, Emanuele; Angelini, Daniela F; Diamantini, Adamo; Campagna, Selenia; Ottaviani, Licia; Sarlo, Chiara; Gattei, Valter; Del Poeta, Giovanni; Arcese, William; Amadori, Sergio; Lo Coco, Francesco; Venditti, Adriano

    2010-09-30

    A total of 143 adult acute myeloid leukemia (AML) patients with available karyotype (K) and FLT3 gene mutational status were assessed for minimal residual disease (MRD) by flow cytometry. Twenty-two (16%) patients had favorable, 115 (80%) intermediate, and 6 (4%) poor risk K; 19 of 129 (15%) carried FLT3-ITD mutation. Considering postconsolidation MRD status, patients with good/intermediate-risk K who were MRD(-) had 4-year relapse-free survival (RFS) of 70% and 63%, and overall survival (OS) of 84% and 67%, respectively. Patients with good- and intermediate-risk K who were MRD(+) had 4-year RFS of 15% and 17%, and OS of 38% and 23%, respectively (P < .001 for all comparisons). FLT3 wild-type patients achieving an MRD(-) status, had a better outcome than those who remained MRD(+) (4-year RFS, 54% vs 17% P < .001; OS, 60% vs 23%, P = .002). Such an approach redefined cytogenetic/genetic categories in 2 groups: (1) low-risk, including good/intermediate K-MRD(-) with 4-year RFS and OS of 58% and 73%, respectively; and (2) high risk, including poor-risk K, FLT3-ITD mutated cases, good/intermediate K-MRD(+) categories, with RFS and OS of 22% and 17%, respectively (P < .001 for all comparisons). In AML, the integrated evaluation of baseline prognosticators and MRD improves risk-assessment and optimizes postremission therapy. PMID:20548095

  3. Risk assessment of forensic patients: nurses' role.

    PubMed

    Encinares, Maxima; McMaster, Jeff James; McNamee, Jim

    2005-03-01

    One of the unique roles of forensic nurses is to conduct risk assessments. Establishing a therapeutic nurse-patient relationship helps forensic nurses perform accurate and useful risk assessments. Accurate risk assessments can facilitate formulation of individualized risk management plans, designed to meet patients' needs and ensure public safety. The importance of forensic nurses' knowledge and application of appropriate communication and proper documentation cannot be overemphasized. PMID:15794530

  4. Treatment of Immunoglobulin Light Chain Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement.

    PubMed

    Dispenzieri, Angela; Buadi, Francis; Kumar, Shaji K; Reeder, Craig B; Sher, Tamur; Lacy, Martha Q; Kyle, Robert A; Mikhael, Joseph R; Roy, Vivek; Leung, Nelson; Grogan, Martha; Kapoor, Prashant; Lust, John A; Dingli, David; Go, Ronald S; Hwa, Yi Lisa; Hayman, Suzanne R; Fonseca, Rafael; Ailawadhi, Sikander; Bergsagel, P Leif; Chanan-Khan, Ascher; Rajkumar, S Vincent; Russell, Stephen J; Stewart, Keith; Zeldenrust, Steven R; Gertz, Morie A

    2015-08-01

    Immunoglobulin light chain amyloidosis (AL amyloidosis) has an incidence of approximately 1 case per 100,000 person-years in Western countries. The rarity of the condition not only poses a challenge for making a prompt diagnosis but also makes evidenced decision making about treatment even more challenging. Physicians caring for patients with AL amyloidosis have been borrowing and customizing the therapies used for patients with multiple myeloma with varying degrees of success. One of the biggest failings in the science of the treatment of AL amyloidosis is the paucity of prospective trials, especially phase 3 trials. Herein, we present an extensive review of the literature with an aim of making recommendations in the context of the best evidence and expert opinion. PMID:26250727

  5. Systematic Review of Metabolic Syndrome Biomarkers: A Panel for Early Detection, Management, and Risk Stratification in the West Virginian Population

    PubMed Central

    Srikanthan, Krithika; Feyh, Andrew; Visweshwar, Haresh; Shapiro, Joseph I.; Sodhi, Komal

    2016-01-01

    Introduction: Metabolic syndrome represents a cluster of related metabolic abnormalities, including central obesity, hypertension, dyslipidemia, hyperglycemia, and insulin resistance, with central obesity and insulin resistance in particular recognized as causative factors. These metabolic derangements present significant risk factors for cardiovascular disease, which is commonly recognized as the primary clinical outcome, although other outcomes are possible. Metabolic syndrome is a progressive condition that encompasses a wide array of disorders with specific metabolic abnormalities presenting at different times. These abnormalities can be detected and monitored via serum biomarkers. This review will compile a list of promising biomarkers that are associated with metabolic syndrome and this panel can aid in early detection and management of metabolic syndrome in high risk populations, such as in West Virginia. Methods: A literature review was conducted using PubMed, Science Direct, and Google Scholar to search for markers related to metabolic syndrome. Biomarkers searched included adipokines (leptin, adiponectin), neuropeptides (ghrelin), pro-inflammatory cytokines (IL-6, TNF-α), anti-inflammatory cytokines (IL-10), markers of antioxidant status (OxLDL, PON-1, uric acid), and prothrombic factors (PAI-1). Results: According to the literature, the concentrations of pro-inflammatory cytokines (IL-6, TNF-α), markers of pro-oxidant status (OxLDL, uric acid), and prothrombic factors (PAI-1) were elevated in metabolic syndrome. Additionally, leptin concentrations were found to be elevated in metabolic syndrome as well, likely due to leptin resistance. In contrast, concentrations of anti-inflammatory cytokines (IL-10), ghrelin, adiponectin, and antioxidant factors (PON-1) were decreased in metabolic syndrome, and these decreases also correlated with specific disorders within the cluster. Conclusion: Based on the evidence presented within the literature, the aforementioned biomarkers correlate significantly with metabolic syndrome and could provide a minimally-invasive means for early detection and specific treatment of these disorders. Further research is encouraged to determine the efficacy of applying these biomarkers to diagnosis and treatment in a clinical setting. PMID:26816492

  6. Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary syndromes according to initial risk stratification

    PubMed Central

    Jedrzkiewicz, Sean; Goodman, Shaun G; Yan, Raymond T; Welsh, Robert C; Kornder, Jan; DeYoung, J Paul; Wong, Graham C; Rose, Barry; Grondin, Franois R; Gallo, Richard; Huang, Wei; Gore, Joel M; Yan, Andrew T

    2009-01-01

    BACKGROUND: Current guidelines support an early invasive strategy in the management of high-risk non-ST elevation acute coronary syndromes (NSTE-ACS). Although studies in the 1990s suggested that high-risk patients received less aggressive treatment, there are limited data on the contemporary management patterns of NSTE-ACS in Canada. OBJECTIVE: To examine the in-hospital use of coronary angiography and revascularization in relation to risk among less selected patients with NSTE-ACS. METHODS: Data from the prospective, multicentre Global Registry of Acute Coronary Events (main GRACE and expanded GRACE2) were used. Between June 1999 and September 2007, 7131 patients from across Canada with a final diagnosis of NSTE-ACS were included the study. The study population was stratified into low-, intermediate- and high-risk groups, based on their calculated GRACE risk score (a validated predictor of in-hospital mortality) and according to time of enrollment. RESULTS: While rates of in-hospital death and reinfarction were significantly (P<0.001) greater in higher-risk patients, the in-hospital use of cardiac catheterization in low- (64.7%), intermediate- (60.3%) and high-risk (42.3%) patients showed an inverse relationship (P<0.001). This trend persisted despite the increase in the overall rates of cardiac catheterization over time (47.9% in 1999 to 2003 versus 51.6% in 2004 to 2005 versus 63.8% in 2006 to 2007; P<0.001). After adjusting for confounders, intermediate-risk (adjusted OR 0.80 [95% CI 0.70 to 0.92], P=0.002) and high-risk (adjusted OR 0.38 [95% CI 0.29 to 0.48], P<0.001) patients remained less likely to undergo in-hospital cardiac catheterization. CONCLUSION: Despite the temporal increase in the use of invasive cardiac procedures, they remain paradoxically targeted toward low-risk patients with NSTE-ACS in contemporary practice. This treatment-risk paradox needs to be further addressed to maximize the benefits of invasive therapies in Canada. PMID:19898699

  7. Cardiac magnetic resonance and computed tomography angiography for clinical imaging of stable coronary artery disease. Diagnostic classification and risk stratification

    PubMed Central

    Korosoglou, Grigorios; Giusca, Sorin; Gitsioudis, Gitsios; Erbel, Christian; Katus, Hugo A.

    2014-01-01

    Despite advances in the pharmacologic and interventional treatment of coronary artery disease (CAD), atherosclerosis remains the leading cause of death in Western societies. X-ray coronary angiography has been the modality of choice for diagnosing the presence and extent of CAD. However, this technique is invasive and provides limited information on the composition of atherosclerotic plaque. Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) have emerged as promising non-invasive techniques for the clinical imaging of CAD. Hereby, CCTA allows for visualization of coronary calcification, lumen narrowing and atherosclerotic plaque composition. In this regard, data from the CONFIRM Registry recently demonstrated that both atherosclerotic plaque burden and lumen narrowing exhibit incremental value for the prediction of future cardiac events. However, due to technical limitations with CCTA, resulting in false positive or negative results in the presence of severe calcification or motion artifacts, this technique cannot entirely replace invasive angiography at the present time. CMR on the other hand, provides accurate assessment of the myocardial function due to its high spatial and temporal resolution and intrinsic blood-to-tissue contrast. Hereby, regional wall motion and perfusion abnormalities, during dobutamine or vasodilator stress, precede the development of ST-segment depression and anginal symptoms enabling the detection of functionally significant CAD. While CT generally offers better spatial resolution, the versatility of CMR can provide information on myocardial function, perfusion, and viability, all without ionizing radiation for the patients. Technical developments with these 2 non-invasive imaging tools and their current implementation in the clinical imaging of CAD will be presented and discussed herein. PMID:25147526

  8. An Electronic Patient Risk Communication Board

    PubMed Central

    Ohashi, Kumiko; Caligtan, Christine A.; Benoit, Angela N.; Breydo, Eugene M.; Carroll, Diane L.; Keohane, Carol A.; Bates, David W.; Dykes, John S.; Dykes, Patricia C.

    2012-01-01

    Communication failures have been identified as the root cause of the majority of medical malpractice claims and patient safety violations. We believe it is essential to share key patient risk information with healthcare team members at the patients bedside. In this study, we developed an electronic Patient Risk Communication Board (ePRCB) to assist in bridging the communication gap between all health care team members. The goal of the ePRCB is to effectively communicate the patients key risk factors, such as a fall risk or risk of aspiration, to the healthcare team and to reduce adverse events caused by communication failures. The ePRCB will transmit patient risk information and tailored interventions with easy-to-understand icons on an LCD screen at the point of care. A set of patient risk reminder icons was developed and validated by focus groups. We used the results of the evaluation to refine the icons for the ePRCB. PMID:24199109

  9. Cancer specific risk in multiple sclerosis patients.

    PubMed

    Kyritsis, Athanasios P; Boussios, Stergios; Pavlidis, Nicholas

    2016-02-01

    Multiple sclerosis (MS) is a chronic central nervous system (CNS) autoimmune disease. Studies of cancer risk in MS patients have shown inconsistent findings. A pubmed search of the literature on cancer risk in patients with MS was conducted and found published relative studies. The majority of these studies concluded that there was overall either reduced or no increased risk of developing malignancies between patients with MS compared to the general population. However, several studies suggested that patients with MS may have reduced risk in specific cancers such as of the digestive and respiratory organs, prostate, ovary, or increased risk in breast, brain and bladder tumors. At present it is uncertain if the immunologic profile of MS patients may be related to the increased or reduced frequency of some cancers and warrants further investigation. PMID:26481954

  10. Initial clinical validation of Health Heritage, a patient-facing tool for personal and family history collection and cancer risk assessment.

    PubMed

    Baumgart, Leigh A; Postula, Kristen J Vogel; Knaus, William A

    2016-04-01

    Personal and family health histories remain important independent risk factors for cancer; however they are currently not being well collected or used effectively. Health Heritage was designed to address this need. The purpose of this study was to validate the ability of Health Heritage to identify patients appropriate for further genetic evaluation and to accurately stratify cancer risk. A retrospective chart review was conducted on 100 random patients seen at an adult genetics clinic presenting with concern for an inherited predisposition to cancer. Relevant personal and family history obtained from the patients' medical records was entered into Health Heritage. Recommendations by Health Heritage were compared to national guidelines of eligibility for genetic evaluation. Agreement between Health Heritage referral for genetic evaluation and guideline eligibility for genetic evaluation was 97 % (sensitivity 98 % and specificity 88 %). Risk stratification for cancer was also compared between Health Heritage and those documented by a geneticist. For patients at increased risk for breast, ovarian, or colorectal cancer as determined by the geneticist, risk stratification by Health Heritage agreed 90, 93, and 75 %, respectively. Discordances in risk stratification were attributed to both complex situations better handled by the geneticist and Health Heritage's adherence to incorporating all information into its algorithms. Health Heritage is a clinically valid tool to identify patients appropriate for further genetic evaluation and to encourage them to confirm the assessment and management recommendations with cancer genetic experts. Health Heritage also provides an estimate of cancer risk that is complementary to a genetics team. PMID:26711915

  11. Microbial signatures in post-infectious irritable bowel syndrome - toward patient stratification for improved diagnostics and treatment.

    PubMed

    Jalanka, Jonna; Salonen, Anne; Fuentes, Susana; de Vos, Willem M

    2015-11-01

    Irritable bowel syndrome (IBS) is a multifactorial and heterogeneous disorder estimated to affect over 10% of the Western population. A subset of the patients reports the start of the disease after an episode of gastroenteritis. The alterations in the intestinal microbiota of the post-infectious IBS (PI-IBS) patients were recently investigated in a British cohort and shown to differentiate from the healthy controls and resemble that of diarrhea-predominant IBS (IBS-D) patients. The altered 27 genus-like groups created a microbial signature, which could be used to objectively stratify patients and healthy controls. In this addendum, we combine the microbiota data derived from the British cohort with that of a recently reported Swedish PI-IBS cohort. Remarkably, robust and reproducible microbiota signatures were observed in these PI-IBS patients. We discuss these results with attention on the emerging role of microbiota in the classification, development and treatment of PI-IBS. PMID:26512631

  12. CFD-based Thrombotic Risk Assessment in Kawasaki Disease Patients with Coronary Artery Aneurysms

    NASA Astrophysics Data System (ADS)

    Sengupta, Dibyendu; Kung, Ethan; Kahn, Andrew; Burns, Jane; Marsden, Alison

    2012-11-01

    Coronary aneurysms occur in 25% of untreated Kawasaki Disease (KD) patients and put patients at increased risk for myocardial infarction and sudden death. Clinical guidelines recommend using aneurysm diameter >8 mm as the arbitrary criterion for treating with anti-coagulation therapy. This study uses patient-specific modeling to non-invasively determine hemodynamic parameters and quantify thrombotic risk. Anatomic models were constructed from CT angiographic image data from 5 KD aneurysm patients and one normal control. CFD simulations were performed to obtain hemodynamic data including WSS and particle residence times (PRT). Thrombosis was clinically observed in 4/9 aneurysmal coronaries. Thrombosed vessels required twice as many cardiac cycles (mean 8.2 vs. 4.2) for particles to exit, and had lower mean WSS (1.3 compared to 2.8 dynes/cm2) compared to vessels with non-thrombosed aneurysms of similar max diameter. 1 KD patient in the cohort with acute thrombosis had diameter < 8 mm. Regions of low WSS and high PRT predicted by simulations correlated with regions of subsequent thrombus formation. Thrombotic risk stratification for KD aneurysms may be improved by incorporating both hemodynamic and geometric quantities. Current clinical guidelines to assess patient risk based only on aneurysm diameter may be misleading. Further prospective study is warranted to evaluate the utility of patient-specific modeling in risk stratifying KD patients with coronary aneurysms. NIH R21.

  13. Cancer Stratification by Molecular Imaging

    PubMed Central

    Weber, Justus; Haberkorn, Uwe; Mier, Walter

    2015-01-01

    The lack of specificity of traditional cytotoxic drugs has triggered the development of anticancer agents that selectively address specific molecular targets. An intrinsic property of these specialized drugs is their limited applicability for specific patient subgroups. Consequently, the generation of information about tumor characteristics is the key to exploit the potential of these drugs. Currently, cancer stratification relies on three approaches: Gene expression analysis and cancer proteomics, immunohistochemistry and molecular imaging. In order to enable the precise localization of functionally expressed targets, molecular imaging combines highly selective biomarkers and intense signal sources. Thus, cancer stratification and localization are performed simultaneously. Many cancer types are characterized by altered receptor expression, such as somatostatin receptors, folate receptors or Her2 (human epidermal growth factor receptor 2). Similar correlations are also known for a multitude of transporters, such as glucose transporters, amino acid transporters or hNIS (human sodium iodide symporter), as well as cell specific proteins, such as the prostate specific membrane antigen, integrins, and CD20. This review provides a comprehensive description of the methods, targets and agents used in molecular imaging, to outline their application for cancer stratification. Emphasis is placed on radiotracers which are used to identify altered expression patterns of cancer associated markers. PMID:25749472

  14. Using Computational Approaches to Improve Risk-Stratified Patient Management: Rationale and Methods

    PubMed Central

    Stone, Bryan L; Sakaguchi, Farrant; Sheng, Xiaoming; Murtaugh, Maureen A

    2015-01-01

    Background Chronic diseases affect 52% of Americans and consume 86% of health care costs. A small portion of patients consume most health care resources and costs. More intensive patient management strategies, such as case management, are usually more effective at improving health outcomes, but are also more expensive. To use limited resources efficiently, risk stratification is commonly used in managing patients with chronic diseases, such as asthma, chronic obstructive pulmonary disease, diabetes, and heart disease. Patients are stratified based on predicted risk with patients at higher risk given more intensive care. The current risk-stratified patient management approach has 3 limitations resulting in many patients not receiving the most appropriate care, unnecessarily increased costs, and suboptimal health outcomes. First, using predictive models for health outcomes and costs is currently the best method for forecasting individual patient’s risk. Yet, accuracy of predictive models remains poor causing many patients to be misstratified. If an existing model were used to identify candidate patients for case management, enrollment would miss more than half of those who would benefit most, but include others unlikely to benefit, wasting limited resources. Existing models have been developed under the assumption that patient characteristics primarily influence outcomes and costs, leaving physician characteristics out of the models. In reality, both characteristics have an impact. Second, existing models usually give neither an explanation why a particular patient is predicted to be at high risk nor suggestions on interventions tailored to the patient’s specific case. As a result, many high-risk patients miss some suitable interventions. Third, thresholds for risk strata are suboptimal and determined heuristically with no quality guarantee. Objective The purpose of this study is to improve risk-stratified patient management so that more patients will receive the most appropriate care. Methods This study will (1) combine patient, physician profile, and environmental variable features to improve prediction accuracy of individual patient health outcomes and costs; (2) develop the first algorithm to explain prediction results and suggest tailored interventions; (3) develop the first algorithm to compute optimal thresholds for risk strata; and (4) conduct simulations to estimate outcomes of risk-stratified patient management for various configurations. The proposed techniques will be demonstrated on a test case of asthma patients. Results We are currently in the process of extracting clinical and administrative data from an integrated health care system’s enterprise data warehouse. We plan to complete this study in approximately 5 years. Conclusions Methods developed in this study will help transform risk-stratified patient management for better clinical outcomes, higher patient satisfaction and quality of life, reduced health care use, and lower costs. PMID:26503357

  15. 18FDG-PET/CT for prognostic stratification of patients with multiple myeloma relapse after stem cell transplantation

    PubMed Central

    Malzahn, Uwe; Samnick, Samuel; Einsele, Herrmann; Buck, Andreas K.; Herrmann, Ken; Knop, Stefan

    2014-01-01

    The aim of this study was to investigate the prognostic value of 18F-fluorodeoxyglucose positron emission tomographycomputed tomography (18F-FDG-PET/CT) in 37 patients with a history of multiple myeloma (MM) and suspected or confirmed recurrence after stem cell transplantation (SCT). All patients had been heavily pretreated. Time to progression (TTP) and overall survival (OS) were correlated to a number of different PET-derived as well as clinical parameters. Impact on patient management was assessed. Absence of FDG-avid MM foci was a positive prognostic factor for both TTP and OS (p<0.01). Presence of >10 focal lesions correlated with both TTP (p<0.01) and OS (p<0.05). Interestingly, presence of >10 lesions in the appendicular skeleton proved to have the strongest association with disease progression. Intensity of glucose uptake and presence of extramedullary disease were associated with shorter TTP (p=0.037 and p=0.049, respectively). Manifestations in soft tissue structures turned out to be a strong negative predictor for both, TTP and OS (p<0.01, respectively). PET resulted in a change of management in 30% of patients. Our data underline the prognostic value of 18F-FDG-PET/CT in MM patients also in the setting of post-SCT relapse. PET/CT has a significant impact on patient management. PMID:25277179

  16. Cancer Risk in HBV Patients With Statin and Metformin Use

    PubMed Central

    Chen, Chang-I.; Kuan, Ching-Feng; Fang, Yu-Ann; Liu, Shing-Hwa; Liu, Ju-Chi; Wu, Li-Li; Chang, Chun-Jen; Yang, Hsuan-Chia; Hwang, Jaulang; Miser, James S.; Wu, Szu-Yuan

    2015-01-01

    Abstract Chronic infection with hepatitis B virus (HBV) often causes chronic inflammation of the liver with an increased incidence of hepatocellular carcinoma (HCC). HBV-infected individuals may also have an increased incidence of nonliver cancers. Taking statin or metformin may decrease inflammation and infiltration, which may, as a result, reduce the risk of liver cancer or other major cancers in patients with HBV infection. The purpose of this study was to evaluate the hypothesis that statin and metformin could reduce the incidence of liver cancer (HCC) or nonliver cancers in patients with HBV. Using the Taiwan Longitudinal Health Insurance Database 2000 to 2008, this cohort study comprised patients with a recorded diagnosis of HBV (N?=?71,847) between January 1, 2000 and December 31, 2008. Each patient was followed-up until the end of 2008. The occurrence of HCC or a nonliver cancer was evaluated in patients who either were or were not taking statin or metformin. Cox proportional hazard regressions were used to evaluate the cancer incidence after adjusting for known confounding factors. In total, 71,824 HBV-infected patients comprised the study cohort. Our study showed that either metformin or statin use was associated with a reduction in the incidence of cancer. This was most prominent in patients taking both statin and metformin. The adjusted hazard ratios (HRs) for patients using only statin were 0.52 (95% confidence interval [CI], 0.480.57) for all cancers, 0.28 (95% CI, 0.230.35) for liver cancer, and 0.63 (95% CI, 0.570.70) for nonliver cancers. Patients taking only metformin had risk-adjusted HRs of 0.82 (95% CI, 0.750.90) for all cancers, 0.97 (95% CI, 0.841.14) for liver cancer, and 0.75 (95% CI, 0.670.84) for nonliver cancers. A dose-dependent effect of statin use for chemoprevention was observed for all cancers, including both liver cancer and nonliver cancers. A dose-dependent effect of metformin was also seen in liver cancer and nonliver cancers without stratification into different cumulative daily doses of statin use. This population-based cohort study investigated the protective effect of statin and metformin against cancer events in patients with HBV infection. Our study demonstrated that either statin or metformin served as independent chemopreventive agents with a doseresponse effect in reducing the incidence of cancer with a doseresponse effect of the agents and an additive or synergistic effect of combining statin and metformin use in reducing the incidence of many cancers. PMID:25674734

  17. Dry Eye Syndrome Risks in Patients With Fibromyalgia: A National Retrospective Cohort Study.

    PubMed

    Chen, Chao-Hsien; Yang, Tse-Yen; Lin, Cheng-Li; Chen, Chih-Sheng; Lin, Wei-Ming; Kuo, Chia-Nan; Lin, Ming-Chia; Kao, Chia-Hung

    2016-01-01

    The coexistence of fibromyalgia (FM) and dry eye syndrome (DES) has been previously reported. However, there are few studies on how patients with FM may develop concomitant DES. Patients with chronic widespread pain, like FM, chronic fatigue syndrome, and irritable bowel syndrome (IBS), was concerned for the rheumatic or psychosomatic disorders which might adequately reflect the long-term risk of DES.We retrieved data on FM patients from the National Health Insurance Research Database of Taiwan covering the years 2000 to 2011. Our FM population consisted of 25,777 patients versus 103,108 patients in the non-FM group: the overall incidence of DES in these populations was 7.37/10,000 and 4.81/10,000, respectively.Male FM patients had a higher incidence of DES, with a 1.39-fold DES risk for males and a 1.45-fold for females after adjustment for confounding factor. Notably, FM patients aged ?49 years had an elevated 80% risk of DES compared with the non-FM group. Without comorbidities, FM patients had an approximately 1.40-fold risk of DES than those without FM. The additive effects of FM and IBS or FM and sleep disturbance were pointed out that the risk for DES would be elevated when the FM patients with IBS or sleep disturbance.FM patients have a higher incidence of DES than that of non-FM patients. They carry long-term DES risks from a relatively young age, particularly those with psychiatric problems. Risk stratification for a timely psychiatric medication intervention and risk modifications are not intended. PMID:26825913

  18. Constipation Risk in Patients Undergoing Abdominal Surgery

    PubMed Central

    Celik, Sevim; Atar, Nurdan Yalcin; Ozturk, Nilgun; Mendes, Guler; Kuytak, Figen; Bakar, Esra; Dalgiran, Duygu; Ergin, Sumeyra

    2015-01-01

    Background: Problems regarding bowel elimination are quite common in patients undergoing abdominal surgery. Objectives: To determine constipation risk before the surgery, bowel elimination during postoperative period, and the factors affecting bowel elimination. Patients and Methods: This is a cross-sectional study. It was conducted in a general surgery ward of a university hospital in Zonguldak, Turkey between January 2013 and May 2013. A total of 107 patients were included in the study, who were selected by convenience sampling. Constipation Risk Assessment Scale (CRAS), patient information form, medical and nursing records were used in the study. Results: The mean age of the patients was found to be 55.97 ± 15.74 (year). Most of the patients have undergone colon (37.4%) and stomach surgeries (21.5%). Open surgical intervention (83.2%) was performed on almost all patients (96.3%) under general anesthesia. Patients were at moderate risk for constipation with average scores of 11.71 before the surgery. A total of 77 patients (72%) did not have bowel elimination problem during postoperative period. The type of the surgery (P < 0.05), starting time for oral feeding after the surgery (P < 0.05), and mobilization (P < 0.05) were effective on postoperative bowel elimination. Conclusions: There is a risk for constipation after abdominal surgery. Postoperative practices are effective on the risk of constipation. PMID:26380107

  19. At-Risk Drinking Among Diabetic Patients

    PubMed Central

    Ramsey, Susan E.; Engler, Patricia A.

    2009-01-01

    Diabetes Mellitus is a serious chronic disease, affecting an increasing number of individuals worldwide. Adherence to diabetes self-care behaviors is key to the successful management of the disease. At-risk drinking is common among diabetic patients and is associated with inferior diabetes treatment adherence and outcomes, resulting in increased mortality and morbidity. Furthermore, individuals with diabetes who engage in at-risk drinking are also in danger of incurring the negative consequences of at-risk drinking found in the general population. Research suggests that alcohol use screening and intervention do not commonly occur during the course of primary care treatment for diabetes. While methods for reducing alcohol use in this population have been largely unexplored to date, brief interventions to reduce at-risk drinking have been well-validated in other patient populations and offer the promise to reduce at-risk drinking among diabetic patients, resulting in improved diabetes treatment adherence and outcomes. PMID:24357927

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

    PubMed Central

    Hermans, Michel P.; Fruchart, Jean-Charles

    2011-01-01

    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. PMID:23251757

  1. 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)

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

    2003-03-01

    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.

  2. A multidisciplinary approach to therapeutic risk management of the suicidal patient

    PubMed Central

    Grant, Cynthia L; Lusk, Jaimie L

    2015-01-01

    As health care trends toward a system of care approach, providers from various disciplines strive to collaborate to provide optimal care for their patients. While a multidisciplinary approach to suicide risk assessment and management has been identified as important for reducing suicidality, standardized clinical guidelines for such an approach do not yet exist. In this article, the authors propose the adoption of the therapeutic risk management of the suicidal patient (TRMSP) to improve suicide risk assessment and management within multidisciplinary systems of care. The TRMSP, which has been fully articulated in previous articles, involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. Augmenting clinical risk assessments with reliable and valid structured instruments serves several functions, including ensuring important aspects of suicide are addressed, establishing a baseline for suicidal thoughts and behaviors, facilitating interprofessional communication, and mitigating risk. Similarly, a two-dimensional risk stratification qualifying suicide risk in terms of both severity and temporality can enhance communication across providers and settings and improve understanding of acute crises in the context of chronic risk. Finally, safety planning interventions allow providers and patients to collaboratively create a personally meaningful plan for managing a suicidal crisis that can be continually modified across time with multiple providers in different care settings. In a busy care environment, the TRMSP can provide concrete guidance on conducting clinically and medicolegally sound suicide risk assessment and management. This collaborative and comprehensive process would potentially improve care of patients with suicidality, optimize clinical resources, decrease unnecessary and costly admissions, and mitigate medicolegal risk. The TRMSP may serve as a foundation for building a standardized, collaborative, stepped-care approach that patients, individual providers, and the health care system can all benefit from. PMID:26150725

  3. Dissecting DNA repair in adult high grade gliomas for patient stratification in the post-genomic era.

    PubMed

    Perry, Christina; Agarwal, Devika; Abdel-Fatah, Tarek M A; Lourdusamy, Anbarasu; Grundy, Richard; Auer, Dorothee T; Walker, David; Lakhani, Ravi; Scott, Ian S; Chan, Stephen; Ball, Graham; Madhusudan, Srinivasan

    2014-07-30

    Deregulation of multiple DNA repair pathways may contribute to aggressive biology and therapy resistance in gliomas. We evaluated transcript levels of 157 genes involved in DNA repair in an adult glioblastoma Test set (n=191) and validated in 'The Cancer Genome Atlas' (TCGA) cohort (n=508). A DNA repair prognostic index model was generated. Artificial neural network analysis (ANN) was conducted to investigate global gene interactions. Protein expression by immunohistochemistry was conducted in 61 tumours. A fourteen DNA repair gene expression panel was associated with poor survival in Test and TCGA cohorts. A Cox multivariate model revealed APE1, NBN, PMS2, MGMT and PTEN as independently associated with poor prognosis. A DNA repair prognostic index incorporating APE1, NBN, PMS2, MGMT and PTEN stratified patients in to three prognostic sub-groups with worsening survival. APE1, NBN, PMS2, MGMT and PTEN also have predictive significance in patients who received chemotherapy and/or radiotherapy. ANN analysis of APE1, NBN, PMS2, MGMT and PTEN revealed interactions with genes involved in transcription, hypoxia and metabolic regulation. At the protein level, low APE1 (p=0.031) and low PTEN (p=0.042) remain associated with poor prognosis. In conclusion, multiple DNA repair pathways operate to influence biology and clinical outcomes in adult high grade gliomas. PMID:25026297

  4. Dissecting DNA repair in adult high grade gliomas for patient stratification in the post-genomic era

    PubMed Central

    Perry, Christina; Agarwal, Devika; Abdel-Fatah, Tarek M.A.; Lourdusamy, Anbarasu; Grundy, Richard; Auer, Dorothee T.; Walker, David; Lakhani, Ravi; Scott, Ian S.; Chan, Stephen; Ball, Graham; Madhusudan, Srinivasan

    2014-01-01

    Deregulation of multiple DNA repair pathways may contribute to aggressive biology and therapy resistance in gliomas. We evaluated transcript levels of 157 genes involved in DNA repair in an adult glioblastoma Test set (n=191) and validated in ‘The Cancer Genome Atlas’ (TCGA) cohort (n=508). A DNA repair prognostic index model was generated. Artificial neural network analysis (ANN) was conducted to investigate global gene interactions. Protein expression by immunohistochemistry was conducted in 61 tumours. A fourteen DNA repair gene expression panel was associated with poor survival in Test and TCGA cohorts. A Cox multivariate model revealed APE1, NBN, PMS2, MGMT and PTEN as independently associated with poor prognosis. A DNA repair prognostic index incorporating APE1, NBN, PMS2, MGMT and PTEN stratified patients in to three prognostic sub-groups with worsening survival. APE1, NBN, PMS2, MGMT and PTEN also have predictive significance in patients who received chemotherapy and/or radiotherapy. ANN analysis of APE1, NBN, PMS2, MGMT and PTEN revealed interactions with genes involved in transcription, hypoxia and metabolic regulation. At the protein level, low APE1 and low PTEN remain associated with poor prognosis. In conclusion, multiple DNA repair pathways operate to influence biology and clinical outcomes in adult high grade gliomas. PMID:25026297

  5. Delirium Risk Factors in Elderly Hospitalized Patients

    PubMed Central

    Elie, Michel; Cole, Martin G; Primeau, François J; Bellavance, François

    1998-01-01

    OBJECTIVE Delirium is frequent in elderly hospitalized patients. Many studies have examined its risk factors, but results have been quite variable. Thus, the goal of this study is to identify through systematic literature review the risk factors associated with the development of delirium in hospitalized geriatric patients. MEASUREMENTS AND MAIN RESULTS First, medline/current contentsdatabases were screened for relevant articles published from 1966 to December 1995, and from bibliographies of identified articles additional reports were selected. Second, the reports were screened by two different investigators and retained only if meeting the five following criteria: (1) original research in French or English; (2) prospective study; (3) patients over age 50; (4) minimum of one risk factor examined; (5) acceptable definition of delirium. Third, the methodology of each study was graded according to specific criteria for risk factor studies. Fourth, risk factors were identified and tabulated, unadjusted odds ratios (ORs) were computed, and where appropriate a combined OR with the Mantel-Haenszel estimator was calculated. Twenty-seven articles were retained meeting all of the above criteria. Among these studies, 11 were done on medical patients, 9 on surgical patients, 2 on medical and surgical patients, and 5 on psychiatric patients. In total 1,365 subjects with delirium were studied. Sixty-one different risk factors were examined, the five most common being dementia, medication, medical illness, age, and male gender. Mantel-Haenszel estimator was calculated for 10 risk factors, the most strongly associated being dementia (OR 5.2; 95% confidence interval [CI] 4.2, 6.3), medical illness (OR 3.8; 95% CI 2.2, 6.4), alcohol abuse (OR 3.3; 95% CI 1.9, 5.5), and depression (OR 1.9; 95% CI 1.3, 2.6). Methodologic weaknesses were present in many studies. CONCLUSIONS Despite methodologic limitations, certain risk factors for delirium seem to be consistent and could help identify high-risk patients. These risk factors include dementia, advanced age, and medical illness. Other risk factors appear to play a contributory role in the development of delirium in elderly hospitalized patients. PMID:9541379

  6. [Fenestrated Fontan surgery in high risk patients].

    PubMed

    Ramrez Marroqun, S; Caldern Colmenero, J; Lince Varela, R; Zabal, C; Rijlaarsdam, M; Buenda, A

    1998-01-01

    A retrospective analysis is presented of all patients who had fenestrated Fontan procedure between january 1990 and may 1996. Surgery was indicated in the presence of anyone of the following risk factors: mean pulmonary pressure higher than 20 mmHg; pulmonary vascular resistance higher than 2 UW; ejection fraction less than 60%; systemic ventricular end diastolic pressure higher than 8 mmHg; Nakata index less than 200 mm2/m2, McGoon index less than 2. The diagnosis were: Absent right atrio-ventricular connection with concordance ventriculo-arterial connection 10 patients; pulmonary atresia with intact septum, 1 patient; Ebstein's malformation, 1 patient and absent left A-V connection with discordance VA connection, 1 patient. The mean of age was 6.7 years (range 2.5-11 years). Overall mortality was 23%. No significant difference in risk factors was found between survivals and no survivals. Nonsurvivors had between two an four risks factors. Postoperative complications were 1 patient with protein losing enteropathy and stroke (1 patient). The mean duration of pleural effusion was 16 days (range 4-45 days). We consider fenestrated Fontan procedure useful for patients with congenital heart disease with a one hypoplastic ventricle and one o more risks factors. PMID:10365233

  7. [Surgical risk in patients with liver disease].

    PubMed

    Jakab, Ferenc

    2013-06-01

    The author draws attention on the importance surgical risk analysis from patient's safety point of view. Recently the development in quality assurance affected surgical practice as well, hence determination and evaluation of surgical risk are more exactly defined. This resulted in a significant decrease in mortality during surgical interventions on the liver despite a wider indication and increased numbers, recently. Importantly, surgical risk is much higher in patients with liver disease compared to patients with normal liver. The risk of surgical interventions for liver diseases (HCC, tumor) in patients with diffuse liver diseases (cirrhosis, chronic hepatitis, ALD) can be expressed numerically. For many years the Child-Turcotte-Pugh stadium could have been determined by using actual laboratory values. Recently the "50-50 rule" or more frequently the MELD score -- originally used in the practice of liver transplantation -- mean objective expression of surgical risk. Treatment optimalisation can reduce surgical risk, selected on the basis of risk analysis in multidisciplinary settings, which focus on the need of liver surgeons. PMID:23782599

  8. Migration and stratification

    PubMed Central

    Jasso, Guillermina

    2011-01-01

    Migration and stratification are increasingly intertwined. One day soon it will be impossible to understand one without the other. Both focus on life chances. Stratification is about differential life chances - who gets what and why - and migration is about improving life chances - getting more of the good things of life. To examine the interconnections of migration and stratification, we address a mix of old and new questions, carrying out analyses newly enabled by a unique new data set on recent legal immigrants to the United States (the New Immigrant Survey). We look at immigrant processing and lost documents, depression due to the visa process, presentation of self, the race-ethnic composition of an immigrant cohort (made possible by the data for the first time since 1961), black immigration from Africa and the Americas, skin-color diversity among couples formed by U.S. citizen sponsors and immigrant spouses, and English fluency among children age 8–12 and their immigrant parents. We find, inter alia, that children of previously illegal parents are especially more likely to be fluent in English, that native-born U.S. citizen women tend to marry darker, that immigrant applicants who go through the visa process while already in the United States are more likely to have their documents lost and to suffer visa depression, and that immigration, by introducing accomplished black immigrants from Africa (notably via the visa lottery), threatens to overturn racial and skin color associations with skill. Our analyses show the mutual embeddedness of migration and stratification in the unfolding of the immigrants' and their children's life chances and the impacts on the stratification structure of the United States. PMID:26321771

  9. High risk for obstructive sleep apnea in patients with acute myocardial infarction1

    PubMed Central

    Andrechuk, Carla Renata Silva; Ceolim, Maria Filomena

    2015-01-01

    Objectives: to stratify the risk for obstructive sleep apnea in patients with acute myocardial infarction, treated at a public, tertiary, teaching hospital of the state of São Paulo, Brazil, and to identify related sociodemographic and clinical factors. Method: cross-sectional analytical study with 113 patients (mean age 59.57 years, 70.8% male). A specific questionnaire was used for the sociodemographic and clinical characterization and the Berlin Questionnaire for the stratification of the risk of obstructive sleep apnea syndrome. Results: the prevalence of high risk was 60.2% and the outcome of clinical worsening during hospitalization was more frequent among these patients. The factors related to high risk were body mass index over 30 kg/m2, arterial hypertension and waist circumference indicative of cardiovascular risk, while older age (60 years and over) constituted a protective factor. Conclusion: considering the high prevalence of obstructive sleep apnea and its relation to clinical worsening, it is suggested that nurses should monitor, in their clinical practice, people at high risk for this syndrome, guiding control measures of modifiable factors and aiming to prevent the associated complications, including worsening of cardiovascular diseases. PMID:26487128

  10. Risk of Malignant Neoplasms of Kidney and Bladder in a Cohort Study of the Diabetic Population in Taiwan With Age, Sex, and Geographic Area Stratifications

    PubMed Central

    Chen, Hua-Fen; Chen, Shwe-Winn; Chang, Ya-Hui; Li, Chung-Yi

    2015-01-01

    Abstract Diabetes has been reported to increase the risk of malignant neoplasms of kidney and bladder, but the studies results are still inconclusive. Age, sex, and geographical area-specific incidence and relative risks of above neoplasms are also scarce in the literature. We prospectively investigated the age, sex, geographical area-specific incidence and relative risks of kidney and bladder neoplasms in diabetic population of Taiwan. Diabetic patients (n?=?615,532) and age- and sex-matched controls (n?=?614,871) were linked to inpatient claims (20002008) to identify the admissions for malignant neoplasm of kidney (International Classification of Diagnosis, 9th version, Clinical Modification: 189) and bladder (International Classification of Diagnosis, 9th version, Clinical Modification: 188). The person-year approach with Poisson assumption was used to evaluate the incidence density. We also estimated the age, sex, and geographical area-specific relative risks of above malignancy in relation to diabetes with Cox proportional hazard regression model. The overall incidence density of malignant neoplasm of kidney for diabetic men and women were 3.87 and 4.28 per 10,000 patient-years, respectively; the corresponding figures for malignant neoplasm of bladder were 5.73 and 3.25 per 10,000 patient-years. Compared with the controls, diabetic men were at significantly increased hazards of kidney (covariate adjusted hazard ratio [aHR]: 1.31, 95% confidence interval [CI] 1.181.46) and bladder aHR: 1.13, 95% CI 1.041.23). Diabetic women, on the contrary, only experienced significantly elevated hazard of kidney neoplasm (aHR: 1.14, 95% CI 1.041.26). Diabetic men aged >65 years showed the most significantly increased hazard of developing neoplasm of kidney (aHR: 1.40) and bladder (aHR: 1.13). The most significantly increased hazard of kidney neoplasm was noted for women diabetic patients aged >65 years. There was also a significant interactive effect of geographic area with diabetes on the incidence of kidney and bladder neoplasms in both sexes. Diabetic men >45 years and diabetic women >65 years were found to have significantly increased hazard of malignant neoplasm of kidney, but only diabetic men >65 years were at significantly increased hazard of bladder neoplasm. The significant geographic variations in incidence and relative hazard of kidney and bladder neoplasms warrant further investigations of the underlying reasons. PMID:26402804

  11. Strategies for Primary Prevention of Coronary Heart Disease Based on Risk Stratification by the ACC/AHA Lipid Guidelines, ATP III Guidelines, Coronary Calcium Scoring, and C-Reactive Protein, and a Global Treat-All Strategy: A Comparative--Effectiveness Modeling Study

    PubMed Central

    Galper, Benjamin Z.; Wang, Y. Claire; Einstein, Andrew J.

    2015-01-01

    Background Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown. Methods We constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45–75 and women 55–75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe. Results Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event. Conclusions Despite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers. PMID:26422204

  12. Monoclonal gammopathy of undetermined significance and smoldering multiple myeloma: a review of the current understanding of epidemiology, biology, risk stratification, and management of myeloma precursor disease.

    PubMed

    Agarwal, Amit; Ghobrial, Irene M

    2013-03-01

    The term monoclonal gammopathy of undetermined significance (MGUS) was coined in 1978. The recent advances in our knowledge about MGUS and smoldering multiple myeloma (SMM) have helped us better understand the pathogenesis of myeloma. It seems that myeloma evolves from a precursor state in almost all cases. We do not completely understand the multistep process from the precursor state to myeloma, but studies like whole genome sequencing continue to improve our understanding of this process. The process of transformation may not be linear acquisition of changes, but rather a branched heterogeneous process. Clinical features that are prognostic of rapid transformation have been identified, but no specific molecular markers have been identified. Even with recent advances, multiple myeloma remains an incurable disease in the vast majority, and intervening at the precursor state provides a unique opportunity to alter the natural history of the disease. A limitation is that a vast majority of patients with precursor disease, especially low-risk MGUS, will never progress to myeloma in their lifetime, and treating these patients is not only unnecessary but may be potentially harmful. The challenge is to identify a subset of patients with the precursor state that would definitely progress to myeloma and in whom interventions will have a meaningful impact. As our understanding of the molecular and genetic processes improves, these studies will guide the selection of high-risk patients more appropriately and ultimately direct a tailored management strategy to either delay progression to symptomatic myeloma or even "cure" a person at this premalignant stage. PMID:23224402

  13. Monoclonal gammopathy of undetermined significance and Smoldering Multiple Myeloma: A review of the current understanding of epidemiology, biology, risk stratification and management of myeloma precursor disease

    PubMed Central

    Agarwal, Amit; Ghobrial, Irene

    2012-01-01

    The term monoclonal gammopathy of undetermined significance (MGUS) was coined in 1978. The recent advances in our knowledge about MGUS and smoldering MM (SMM) have helped us better understand the pathogenesis of myeloma. It appears that myeloma evolves from a precursor state in almost all cases. We do not completely understand the multistep process from the precursor state to myeloma but studies including whole genome sequencing will continue to help in improving our understanding of this process. The process of transformation may not be linear acquisition of changes but rather a branched heterogeneous process. Clinical features that are prognostic of rapid transformation have been identified but no specific molecular markers have been identified. Even with recent advances, multiple myeloma remains an incurable disease in the vast majority and intervening at the precursor state provides a unique opportunity to alter the natural history of the disease. A limitation is that a vast majority of patients with precursor disease especially low risk MGUS will never progress to myeloma in their lifetime and treating these patients is not only unnecessary but may be potentially harmful. The challenge is to identify a subset of patients with the precursor state that would definitely progress to myeloma and in whom interventions will have a meaningful impact. As our understanding of the molecular and genetic processes improves, these studies will guide the selection of high-risk patients more appropriately and ultimately direct a tailored management strategy to either delay progression to symptomatic myeloma or even cure a person at this premalignant stage. PMID:23224402

  14. Global cardiovascular risk in patients with HIV infection: concordance and differences in estimates according to three risk equations (Framingham, SCORE, and PROCAM).

    PubMed

    Knobel, Hernando; Jeric, Carlos; Montero, Milagro; Sorli, Mara L; Velat, Manuela; Guelar, Ana; Saballs, Pere; Pedro-Botet, Juan

    2007-07-01

    To compare cardiovascular risk stratification according to Framingham, PROCAM (Prospective Cardiovascular Mnster), and SCORE (Systematic Coronary Risk Evaluation) equations in patients with HIV infection, a cross-sectional study of a well-characterized cohort of 760 HIV-infected adults managed at the outpatient Infectious Disease Unit in 2003 was conducted. Cardiovascular risk score was examined and patients were classified as having low, moderate, or high risk using Framingham and PROCAM (<10%, 10%-20%, and <20%, respectively) and SCORE (<3%, 3%-4%, and >/=5%, respectively) equations. The prevalence of patients with low, moderate and high cardiovascular risk was 76.6%, 15.1%, and 8.3% by the Framingham, respectively, 90.1%, 4.9%, and 5% by the PROCAM, respectively, and 88.6%, 3%, and 8.4% by SCORE, respectively. Concordance between these three risk functions was significant, but globally moderate (Framingham and PROCAM, kappa 0.36, p < 0.0001; Framingham and SCORE, kappa 0.32, p < 0.0001; PROCAM and SCORE, kappa 0.46, p < 0.0001). The Framingham equation categorized a higher proportion of HIV-infected male patients with moderate cardiovascular risk and a lower proportion of those with low risk (p < 0.0001) compared with PROCAM and SCORE. The present study showed a high prevalence of HIV-infected patients at low cardiovascular risk regardless of the assessed coronary risk system used. However, compared with PROCAM and SCORE, Framingham risk equation in HIV-infected patients identified a higher number of male patients with moderate cardiovascular risk. PMID:17651026

  15. Cancer Risk in Patients With Empyema

    PubMed Central

    Teng, Chung-Jen; Hu, Yu-Wen; Yeh, Chiu-Mei; Chen, Tzeng-Ji; Liu, Chia-Jen

    2016-01-01

    Abstract This study aimed to evaluate cancer risk and possible risk factors in patients diagnosed with empyema. A total of 31,636 patients with newly diagnosed empyema between January 1, 1999 and December 31, 2010 were included in this study. Standardized incidence ratios (SIRs) were calculated to compare the cancer incidence in these empyema patients to that in the general population. Adjusted hazard ratios were also calculated to investigate whether characteristics increased cancer risk. During the 12-year study period, 2,654 cancers occurred in 31,636 patients with empyema, yielding an SIR of 2.67 (95% confidence interval [CI] 2.57–2.78). We excluded cancer that occurred within 1 year to avoid surveillance bias. The cancer risk remained significantly increased (SIR 1.50, 95% CI 1.41–1.58). Specifically, patients with empyema had higher SIR of cancers of the head and neck (1.50, 95% CI 1.41–1.58), esophagus (2.56, 95% CI 1.92–3.33), stomach (1.49, 95% CI 1.16–1.89), liver and biliary tract (2.18, 95% CI 1.93–2.45), and lung and mediastinum (1.62, 95% CI 1.39–1.86). Age ≥ 60, male sex, diabetes mellitus, and liver cirrhosis were independent risk factors for cancer development. Our study demonstrates an increased incidence of cancer development in patients with empyema, and patients’ age ≥ 60, men, and those with diabetes mellitus and liver cirrhosis showed a higher incidence of developing cancer compared to the general population. The association between such kind of infection and secondary malignancy may be elucidated by further study. PMID:26945399

  16. Application of systematic coronary risk evaluation chart to identify chronic myeloid leukemia patients at risk of cardiovascular diseases during nilotinib treatment.

    PubMed

    Breccia, Massimo; Molica, Matteo; Zacheo, Irene; Serrao, Alessandra; Alimena, Giuliana

    2015-03-01

    Nilotinib is currently approved for the treatment of chronic myeloid leukemia (CML) in chronic (CP) and accelerated phase (AP) after failure of imatinib and in newly diagnosed patients. Atherosclerotic events were retrospectively reported in patients with baseline cardiovascular risk factors during nilotinib treatment. We estimated the risk of developing atherosclerotic events in patients treated with second or first-line nilotinib, with a median follow-up of 48 months, by retrospectively applying the SCORE chart proposed by the European Society of Cardiology (ESC) and evaluating risk factors at baseline (diabetes, obesity, smoking, and hypertension). Overall, we enrolled in the study 82 CP patients treated frontline (42 CP patients at the dose of 600 mg BID) or after failure of other tyrosine kinase inhibitors (40 CP patients treated with 400 mg BID). The SCORE chart is based on the stratification of sex (male vs female), age (from 40 to 65 years), smoker vs non-smoker, systolic pressure (from 120 to 180 mm Hg), and cholesterol (measured in mmol/l, from 150 to 300 mg/dl). For statistical purposes, we considered patients subdivided in low, moderate, high (with a score >5), and very high risk. There were 48 males and 34 females, median age 51 years (range 22-84). According to WHO classification, 42 patients were classified as normal weight (BMI <25), 26 patients were overweight (BMI 26???30), and 14 were obese (BMI >30). Retrospective classification according to the SCORE chart revealed that 27 patients (33 %) were in the low-risk category, 30 patients (36 %) in the moderate risk category, and 24 patients (29 %) in the high risk. As regards risk factors, we revealed that 17 patients (20.7 %) had a concomitant type II controlled diabetes (without organ damage), 23 patients (28 %) were smokers, 29 patients (35 %) were receiving concomitant drugs for hypertension, and 15 patients (18 %) had concomitant dyslipidemia. Overall, the cumulative incidence of atherosclerotic events at 48 months was 8.5 % (95 % CI, 4.55-14.07): None of the low-risk patients according to the SCORE chart experienced atherosclerotic events compared to 10 % in the moderate risk category and 29 % in the high risk (p?=?0.002). Atherosclerotic-free survival was 100, 89, and 69 % in the low, moderate, and high-risk population, respectively (p?=?0.001). SCORE chart evaluation at disease baseline could be a valid tool to identify patients at high risk of atherosclerotic events during nilotinib treatment. PMID:25304102

  17. Risk of Migraine in Patients With Asthma

    PubMed Central

    Peng, Yi-Hao; Chen, Kuan-Fei; Kao, Chia-Hung; Chen, Hsuan-Ju; Hsia, Te-Chun; Chen, Chia-Hung; Liao, Wei-Chih

    2016-01-01

    Abstract Asthma has been described as an “acephalic migraine” and “pulmonary migraine.” However, no study has investigated the temporal frequency of migraine development in patients with asthma, and the results of previous studies may be difficult to generalize. We investigated the effect of asthma on the subsequent development of migraine by using a population-based data set in Taiwan. We retrieved our study sample from the National Health Insurance Research Database. Specifically, 25,560 patients aged 12 years and older with newly diagnosed asthma were identified as the asthma group, and 102,238 sex and age-matched patients without asthma were identified as the nonasthma group. Cox proportional-hazards regression models were employed to measure the risk of migraine for the asthmatic group compared with that for the nonasthmatic group. The risk of migraine in the asthmatic group was 1.45-fold higher (95% confidence interval 1.33–1.59) than that in the nonasthmatic group after adjustment for sex, age, the Charlson comorbidity index, common medications prescribed for patients with asthma, and annual outpatient department visits. An additional stratified analysis revealed that the risk of migraine remained significantly higher in both sexes and all age groups older than 20 years. Asthma could be an independent predisposing risk factor for migraine development in adults. PMID:26945388

  18. Stratification of complexity in congenital heart surgery: comparative study of the Risk Adjustment for Congenital Heart Surgery (RACHS-1) method, Aristotle basic score and Society of Thoracic Surgeons-European Association for Cardio- Thoracic Surgery (STS-EACTS) mortality score

    PubMed Central

    Cavalcanti, Paulo Ernando Ferraz; S, Michel Pompeu Barros de Oliveira; dos Santos, Ceclia Andrade; Esmeraldo, Isaac Melo; Chaves, Mariana Leal; Lins, Ricardo Felipe de Albuquerque; Lima, Ricardo de Carvalho

    2015-01-01

    Objective To determine whether stratification of complexity models in congenital heart surgery (RACHS-1, Aristotle basic score and STS-EACTS mortality score) fit to our center and determine the best method of discriminating hospital mortality. Methods Surgical procedures in congenital heart diseases in patients under 18 years of age were allocated to the categories proposed by the stratification of complexity methods currently available. The outcome hospital mortality was calculated for each category from the three models. Statistical analysis was performed to verify whether the categories presented different mortalities. The discriminatory ability of the models was determined by calculating the area under the ROC curve and a comparison between the curves of the three models was performed. Results 360 patients were allocated according to the three methods. There was a statistically significant difference between the mortality categories: RACHS-1 (1) - 1.3%, (2) - 11.4%, (3)-27.3%, (4) - 50 %, (P<0.001); Aristotle basic score (1) - 1.1%, (2) - 12.2%, (3) - 34%, (4) - 64.7%, (P<0.001); and STS-EACTS mortality score (1) - 5.5 %, (2) - 13.6%, (3) - 18.7%, (4) - 35.8%, (P<0.001). The three models had similar accuracy by calculating the area under the ROC curve: RACHS-1- 0.738; STS-EACTS-0.739; Aristotle- 0.766. Conclusion The three models of stratification of complexity currently available in the literature are useful with different mortalities between the proposed categories with similar discriminatory capacity for hospital mortality. PMID:26107445

  19. Surgical jejunostomy in aspiration risk patients.

    PubMed Central

    Weltz, C R; Morris, J B; Mullen, J L

    1992-01-01

    One hundred patients underwent laparotomy for independent jejunal feeding tube placement. Neurologic disease was present in 50%, and obtundation (28) and oropharyngeal dysmotility (25) were the most common indications for enteral feeding. The post-pyloric route was chosen because of aspiration risk in almost all (94%) patients. Postoperative (30-day) mortality rate was 21%, because of cardiopulmonary failure in most (18). One death resulted directly from aspiration of tube feeds. Two surgical complications required reoperation: one wound dehiscence and one small bowel obstruction. Four wound infections occurred. Two patients underwent reoperation after tube removal, and four tubes required fluoroscopically guided reinsertion for peritubular drainage (2), removal (1), and occlusion (1). Aspiration pneumonia was present in 18 patients preoperatively and in eight postoperatively. None of the patients with feeding-related preoperative aspiration pneumonia (13) had a recurrence while fed by jejunostomy. Three patients developed postoperative aspiration pneumonia before initiation of jejunostomy feedings. Jejunostomy may be performed with low morbidity rate and substantial reduction of feeding-related aspiration pneumonia, and is the feeding route of choice in aspiration risk patients. PMID:1546899

  20. Perioperative use of centrally acting angiotensin-converting enzyme inhibitor may increase patients' risk for postoperative nausea and vomiting.

    PubMed

    Xiong, Chao; Wang, Liting; An, Dongjiao; Lu, Meijiang; Shen, Wenzhen; Wang, Yun; Yue, Yun; Wu, Anshi

    2016-01-01

    Substance P (SP) is involved in the development of postoperative nausea and vomiting (PONV). It is hydrolyzed by angiotensin-converting enzyme (ACE). Centrally acting ACE inhibitors (CACE-Is) are widely used in the perioperative period. The current evidence showed CACE-Is could upregulate SP level in the central nervous system which may contribute to the occurrence of PONV in 0-72h. Here, we present our hypothesis that the use of CACE-Is in the perioperative period may increase patients' risk for both early (0-24h) and late (24-72h) PONV. The identification of this new risk factor may improve patients' risk assessment and thus lead to better prophylaxis strategies for PONV that are base on risk stratification. PMID:26804588

  1. Risk of Hand Syndromes in Patients With Diabetes Mellitus

    PubMed Central

    Chen, Lu-Hsuan; Li, Chung-Yi; Kuo, Li-Chieh; Wang, Liang-Yi; Kuo, Ken N.; Jou, I-Ming; Hou, Wen-Hsuan

    2015-01-01

    Abstract The aim of this study was to assess the overall and cause-specific incidences of diabetic hand syndromes (DHS) in patients with diabetes mellitus (DM) by using age and sex stratifications. The DM and control cohorts comprised 606,152 patients with DM and 609,970 age- and sex-matched subjects, respectively, who were followed up from 2000 to 2008. We estimated the incidence densities (IDs) of overall and cause-specific DHS, namely carpal tunnel syndrome (CTS), stenosing flexor tenosynovitis (SFT), limited joint mobility (LJM), and Dupuytren disease (DD), and calculated the hazard ratios (HRs) of DHS in relation to DM by using a Cox proportional hazards model with adjustment for potential confounders. Over a 9-year period, 51,207 patients with DM (8.45%) and 39,153 matched controls (6.42%) sought ambulatory care visits for various DHS, with an ID of 117.7 and 80.7 per 10,000 person-years, respectively. The highest cause-specific ID was observed for CTS, followed by SFT, LJM, and DD, regardless of the diabetic status. After adjustment for potential confounders, patients with DM had a significantly high HR of overall DHS (1.51, 95% confidence interval [CI] = 1.48–1.53). Men and women aged <35 years had the highest HR (2.64, 95% CI = 2.15–3.24 and 2.99, 95% CI = 2.55–3.50, respectively). Cause-specific analyses revealed that DM was more strongly associated with SFT (HR = 1.90, 95% CI = 1.86–1.95) and DD (HR = 1.83, 95% CI = 1.39–2.39) than with CTS (HR = 1.31, 95% CI = 1.28–1.34) and LJM (HR = 1.24, 95% CI = 1.13–1.35). Men and younger patients with DM have the highest risk of DHS. Certain hand syndromes, such as SFT and DD, were more strongly associated with DM than with other syndromes and require the attention of clinicians. PMID:26469895

  2. Sensemaking of Patient Safety Risks and Hazards

    PubMed Central

    Battles, James B; Dixon, Nancy M; Borotkanics, Robert J; Rabin-Fastmen, Barbara; Kaplan, Harold S

    2006-01-01

    In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events. Sensemaking, as described by Weick (1995), literally means making sense of events. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety. True sensemaking in patient safety must use both retrospective and prospective approach to learning. Sensemaking is as an essential part of the design process leading to risk informed design. Sensemaking serves as a conceptual framework to bring together well established approaches to assessment of risk and hazards: (1) at the single event level using root cause analysis (RCA), (2) at the processes level using failure modes effects analysis (FMEA) and (3) at the system level using probabilistic risk assessment (PRA). The results of these separate or combined approaches are most effective when end users in conversation-based meetings add their expertise and knowledge to the data produced by the RCA, FMEA, and/or PRA in order to make sense of the risks and hazards. Without ownership engendered by such conversations, the possibility of effective action to eliminate or minimize them is greatly reduced. PMID:16898979

  3. Risk Models of Operative Morbidities in 16,930 Critically Ill Surgical Patients Based on a Japanese Nationwide Database

    PubMed Central

    Saze, Zenichiro; Miyata, Hiroaki; Konno, Hiroyuki; Gotoh, Mitsukazu; Anazawa, Takayuki; Tomotaki, Ai; Wakabayashi, Go; Mori, Masaki

    2015-01-01

    Abstract The aim of the study was to evaluate preoperative variables predictive of lethal morbidities in critically ill surgical patients at a national level. There is no report of risk stratification for morbidities associated with mortality in critically ill patients with acute diffuse peritonitis (ADP). We examined data from 16,930 patients operated during 2011 and 2012 in 1546 different hospitals for ADP identified in the National Clinical Database of Japan. We analyzed morbidities significantly associated with operative mortality. Based on 80% of the population, we calculated independent predictors for these morbidities. The risk factors were validated using the remaining 20%. The operative mortality was 14.1%. Morbidity of any grade occurred in 40.2% of patients. Morbidities correlated with mortality, including septic shock, progressive renal insufficiency, prolonged ventilation >48 hours, systemic sepsis, central nervous system (CNS) morbidities, acute renal failure and pneumonia, and surgical site infection (SSI), were selected for risk models. A total of 18 to 29 preoperative variables were selected per morbidity and yielded excellent C-indices for each (septic shock: 0.851; progressive renal insufficiency: 0.878; prolonged ventilation >48?h: 0.849; systemic sepsis: 0.839; CNS morbidities: 0.848; acute renal failure: 0.868; pneumonia: 0.830; and SSI: 0.688). We report the first risk stratification study on lethal morbidities in critically ill patients with ADP using a nationwide surgical database. These risk models will contribute to patient counseling and help predict which patients require more aggressive surgical and novel pharmacological interventions. PMID:26222854

  4. Effect of Patient and Therapist Factors on Suicide Risk Assessment.

    PubMed

    Berman, Noah C; Stark, Abigail; Cooperman, Allison; Wilhelm, Sabine; Cohen, I Glenn

    2015-01-01

    The present study examined how patient risk factors and clinician demographics predict the assessment of suicide risk. Clinicians (N = 333) read two vignettes, one of which manipulated patient risk factors, then rated the patient's likelihood of suicide and need for hospitalization. Clinicians' assessments were heterogeneous. Results indicated that certain patient risk factors (access to excess medication) and clinician demographics (relationship status, religiosity) predicted perceived suicide risk; and, moreover, clinicians' suicide risk assessment did not always align with the decision to hospitalize the patient. The authors discuss methods for standardizing clinicians' judgment of risk and minimizing error through debiasing strategies (cognitive forcing strategy). PMID:25674940

  5. Management of patients with risk factors

    PubMed Central

    Waldfahrer, Frank

    2013-01-01

    This review addresses concomitant diseases and risk factors in patients treated for diseases of the ears, nose and throat in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease, this article also covers disorders of coagulation (including therapy with new oral anticoagulants) and electrolyte imbalance. Special attention is paid to the prophylaxis, diagnosis and treatment of perioperative delirium. It is also intended to help optimise the preparation for surgical procedures and pharmacotherapy during the hospital stay. PMID:24403970

  6. Thromboprophylaxis and Incidence of Venous Thromboembolism in Patients With Hemophilia A or B Who Underwent High-Risk Orthopedic Surgeries.

    PubMed

    Raza, Shahzad; Kale, Gautam; Kim, Daniel; Akbar, Syed A; Holm, Lisa; Naidzionak, Ulad; Hossain, Akm M; Dong, Xiang; Doll, Donald C; Freter, Carl E; Hopkins, Tamara

    2016-03-01

    Total hip replacement (THR) and total knee arthroplasty (TKA) carry a high risk of postoperative venous thromboembolism (VTE); therefore, anticoagulation prophylaxis is recommended in these patients. Unfortunately, there are no guidelines about VTE prophylaxis in patients with hemophilia who underwent these high-risk surgeries. To determine whether these patients have high risk of VTE, we conducted a retrospective study on patients with hemophilia who underwent elective THR/TKA at our institute from 2004 to 2012. Postoperatively, we collected information on duration and method of factor VIII/IX infusion, VTE-prophylaxis, and complications. There were 23 patients with hemophilia, 18 (78%) with hemophilia A and 5 (22%) with hemophilia B, who underwent high-risk surgeries (39% THR and 61% TKA). The VTE prophylaxis included sequential compression device, 12 (52%), and prophylactic enoxaparin, 1 (4%). Ten (43%) patients did not receive VTE prophylaxis. At 1-year follow-up, we did not find any evidence of clinical VTE in our patients. Better risk stratification is needed to identify patients who would benefit from pharmacological prophylaxis. PMID:25008348

  7. Risk of Cerebrovascular Events in Pneumoconiosis Patients

    PubMed Central

    Chuang, Chieh-Sen; Ho, Shang-Chang; Lin, Cheng-Li; Lin, Ming-Chia; Kao, Chia-Hung

    2016-01-01

    Abstract Pneumoconiosis is a parenchymal lung disease that develops through the inhalation of inorganic dust at work. Cerebrovascular and cardiovascular events are leading causes of mortality and adult disability worldwide. This retrospective cohort study investigated the association between pneumoconiosis, and cerebrovascular and cardiovascular events by using a nationwide population-based database in Taiwan. The data analyzed in this study was retrieved from the Taiwan National Health Insurance Research Database. We selected 6940 patients with pneumoconiosis from the database as our study cohort. Another 27,760 patients without pneumoconiosis were selected and matched with those with pneumoconiosis according to age and sex as the comparison cohort. We used univariate and multivariate Cox proportional-hazard regression analyses to determine the association between pneumoconiosis and the risk of cerebrovascular and cardiovascular events after adjusting for medical comorbidities. After adjustment for age, sex, and comorbidities, the patients with pneumoconiosis exhibited a significantly higher incidence of ischemic stroke (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.05–1.24) than did those without pneumoconiosis. The incidence of hemorrhagic stroke was higher, but not significant, in the pneumoconiosis patients (HR 1.20, 95% CI 0.99–1.46). No statistically significant differences were observed between the pneumoconiosis and nonpneumoconiosis groups in acute coronary syndrome (HR 1.10, 95% CI 0.95–1.26). The findings of this study reveal an association between pneumoconiosis and a higher risk of cerebrovascular events after adjustment for comorbidities. Healthcare providers should control the related risk factors for primary prevention of stroke in pneumoconiosis patients. PMID:26945404

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

    PubMed

    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

    2013-01-01

    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

  9. Multiparameter flow cytometry for the identification of the Waldenstrm's clone in IgM-MGUS and Waldenstrm's Macroglobulinemia: new criteria for differential diagnosis and risk stratification.

    PubMed

    Paiva, B; Montes, M C; Garca-Sanz, R; Ocio, E M; Alonso, J; de Las Heras, N; Escalante, F; Cuello, R; de Coca, A G; Galende, J; Hernndez, J; Sierra, M; Martin, A; Pardal, E; Brez, A; Alonso, J; Suarez, L; Gonzlez-Lpez, T J; Perez, J J; Orfao, A; Vidrales, M-B; San Miguel, J F

    2014-01-01

    Although multiparameter flow cytometry (MFC) has demonstrated clinical relevance in monoclonal gammopathy of undetermined significance (MGUS)/myeloma, immunophenotypic studies on the full spectrum of Waldenstrm's Macroglobulinemia (WM) remain scanty. Herein, a comprehensive MFC analysis on bone marrow samples from 244 newly diagnosed patients with an immunoglobulin M (IgM) monoclonal protein was performed, including 67 IgM-MGUS, 77 smoldering and 100 symptomatic WM. Our results show a progressive increase on the number and light-chain-isotype-positive B-cells from IgM-MGUS to smoldering and symptomatic WM (P<.001), with only 1% of IgM-MGUS patients showing >10% B cells or 100% light-chain-isotype-positive B-cells (P<.001). Complete light-chain restriction of the B-cell compartment was an independent prognostic factor for time-to progression in smoldering WM (median 26 months; HR: 19.8, P=0.001) and overall survival in symptomatic WM (median 44 months; HR: 2.6, P=0.004). The progressive accumulation of light-chain-isotype-positive B-cells accompanied the emergence of a characteristic Waldenstrom's phenotype (CD22(+dim) / CD25+ /CD27+ / IgM+) that differed from other B-NHL by negative expression of CD5, CD10, CD11c or CD103. In contrast to myeloma, light-chain-isotype-positive plasma cells in IgM monoclonal gammopathies show otherwise normal antigenic expression. Our results highlight the potential value of MFC immunophenotyping for the characterization of the Waldenstrm's clone, as well as for the differential diagnosis, risk of progression and survival in WM. PMID:23604227

  10. All High-Risk Patients Should Get Blood Pressure Meds

    MedlinePLUS

    ... nlm.nih.gov/medlineplus/news/fullstory_156395.html All High-Risk Patients Should Get Blood Pressure Meds: ... blood pressure-lowering drugs should be offered to all patients at high risk of having a heart ...

  11. Dementia Drug May Lower Risk of Falls Among Parkinson's Patients

    MedlinePLUS

    ... Dementia Drug May Lower Risk of Falls Among Parkinson's Patients Those who took rivastigmine in study were ... potential in reducing the risk of falls among Parkinson's patients, new research suggests. "With the degeneration of ...

  12. Cluster dyads of risk factors and symptoms are associated with major adverse cardiac events in patients with acute myocardial infarction.

    PubMed

    Hwang, Seon Young; Kim, JinShil

    2015-04-01

    The purpose of this study was to examine the cluster dyads of risk factors and symptoms and their impact on the incidence of 12 month major adverse cardiac events (MACEs) among patients with first-time myocardial infarction (MI). In a descriptive study, a total of 522 patients completed semi-structured interviews for data on risk factors and symptoms. Patients were followed for 12 months to determine MACEs. Latent class cluster analysis was performed to identify risk factor clusters and symptom clusters. Logistic regression analysis was performed to determine the impact of cluster dyads on 12 month MACEs. There were 436 event-free survivors and 86 patients with MACEs for 12 months. Ten risk factors and 14 symptoms were clustered into two (dyslipidemia/smoking, hypertension/diabetes dominant) and three (typical, multiple, atypical) memberships, respectively. Six cluster dyads which were generated based on the association between risk factors and symptom clusters were a significant predictor of 12 month MACEs, with the incidence occurring three times higher in a dyad of hypertension/diabetes-and-atypical symptoms than a dyad of dyslipidemia/smoking-and-typical symptoms (odds ratio?=?3.10, P?=?0.01), after adjustment for age, gender and a type of MI diagnosis. The information on cluster dyads suggests that health-care providers need to consider both risk factors and symptoms at hospital presentation for risk stratification to prevent adverse outcomes. PMID:24593680

  13. Incisional Reinforcement in High-Risk Patients

    PubMed Central

    Feldmann, Timothy F.; Young, Monica T.; Pigazzi, Alessio

    2014-01-01

    Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions. PMID:25435823

  14. Analyzing nocturnal noise stratification.

    PubMed

    Rey Gozalo, Guillermo; Barrign Morillas, Juan Miguel; Gmez Escobar, Valentn

    2014-05-01

    Pollution associated to traffic can be considered as one of the most relevant pollution sources in our cities; noise is one of the major components of traffic pollution; thus, efforts are necessary to search adequate noise assessment methods and low pollution city designs. Different methods have been proposed for the evaluation of noise in cities, including the categorization method, which is based on the functionality concept. Until now, this method has only been studied (with encouraging results) for short-term, diurnal measurements, but nocturnal noise presents a behavior clearly different on respect to the diurnal one. In this work 45 continuous measurements of approximately one week each in duration are statistically analyzed to identify differences between the proposed categories. The results show that the five proposed categories highlight the noise stratification of the studied city in each period of the day (day, evening, and night). A comparison of the continuous measurements with previous short-term measurements indicates that the latter can be a good approximation of the former in diurnal period, reducing the resource expenditure for noise evaluation. Annoyance estimated from the measured noise levels was compared with the response of population obtained from a questionnaire with good agreement. The categorization method can yield good information about the distribution of a pollutant associated to traffic in our cities in each period of the day and, therefore, is a powerful tool for town planning and the design of pollution prevention policies. PMID:24548881

  15. The risk of recurrent thromboembolic disorders in patients with unprovoked venous thromboembolism: new scenarios and opportunities.

    PubMed

    Prandoni, Paolo; Barbar, Sofia; Milan, Marta; Vedovetto, Valentina; Pesavento, Raffaele

    2014-01-01

    The risk of recurrent thromboembolic disorders in the 10-year period following an episode of unprovoked venous thromboembolism (VTE) ranges between 30 and 50%, the rate being higher in patients with primary deep venous thrombosis (DVT) than in those with primary pulmonary embolism (PE). The clinical presentation with primary PE increases by more than three times the risk of a new PE episode over that with isolated DVT. Baseline parameters that increase this risk are the proximal location of DVT, obesity, old age and male sex, whereas the role of thrombophilia is controversial. An increasing role is played by post-baseline parameters such as the ultrasound assessment of residual vein thrombosis and the determination of D-dimer. While the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, new scenarios are being offered by the identification of risk stratification models and by strategies that have the potential to help identify patients in whom anticoagulation can be safely discontinued, such as those that incorporate the assessment of D-dimer and residual vein thrombosis. New opportunities are being offered by low-dose aspirin, which has recently been reported to decrease by more than 30% the risk of recurrent events without increasing the bleeding risk; and especially by a few emerging anti-Xa and anti-IIa oral compounds, which are likely to induce fewer haemorrhagic complications than vitamin K antagonists while preserving at least the same effectiveness, do not require laboratory monitoring, and can be used immediately after the thrombotic episode. PMID:24120221

  16. Elevated Biomarkers of Inflammation and Coagulation in Patients with HIV Are Associated with Higher Framingham and VACS Risk Index Scores

    PubMed Central

    Mooney, Sarah; Tracy, Russell; Osler, Turner; Grace, Christopher

    2015-01-01

    Background Biomarkers of inflammation and altered coagulation are of increasing interest as predictors of chronic disease and mortality in HIV patients, as well as the use of risk stratification scores such as the Framingham index and the Veterans Aging Cohort Study (VACS) score. Methods Demographic and laboratory data for 252 HIV patients were assessed for their relationship with 5 biomarkers: hsCRP, D-dimer, Cystatin C, IL-6 and TNF-alpha. Analysis of variance was used to model the association between the number of elevated biomarkers patients had and their Framingham 10 year cardiovascular risk and VACS scores. Results 87% of patients were male and 75.7% were virally suppressed (HIV RNA <48 copies/ml). The median and interquartile ranges for each biomarker were: hsCRP 1.65 ug/mL (0.73, 3.89), D-dimer 0.17 ug/mL (0.09, 0.31), Cystatin C 0.87 mg/L (0.78, 1.01), IL-6 2.13 pg/mL (1.3, 3.59), TNF-alpha 4.65 pg/mL (3.5, 5.97). 62.6% of patients had more than one biomarker >75th percentile, while 18.6% had three or more elevated biomarkers. Increased age, cigarette smoking, CD4 counts of <200 cells/mm3, Framingham scores and VACS scores were most strongly associated with elevations in biomarkers. When biomarkers were used to predict the Framingham and VACS scores, those with a higher number of elevated biomarkers had higher mean VACS scores, with a similar but less robust finding for Framingham scores. Conclusions Despite viral suppression and immunological stability, biomarkers of inflammation and coagulation remain elevated in a significant number of patients with HIV and are associated with higher scores on risk stratification indices. PMID:26641655

  17. Risk Prediction Models of Locoregional Failure After Radical Cystectomy for Urothelial Carcinoma: External Validation in a Cohort of Korean Patients

    SciTech Connect

    Ku, Ja Hyeon; Kim, Myong; Jeong, Chang Wook; Kwak, Cheol; Kim, Hyeon Hoe

    2014-08-01

    Purpose: To evaluate the predictive accuracy and general applicability of the locoregional failure model in a different cohort of patients treated with radical cystectomy. Methods and Materials: A total of 398 patients were included in the analysis. Death and isolated distant metastasis were considered competing events, and patients without any events were censored at the time of last follow-up. The model included the 3 variables pT classification, the number of lymph nodes identified, and margin status, as follows: low risk (≤pT2), intermediate risk (≥pT3 with ≥10 nodes removed and negative margins), and high risk (≥pT3 with <10 nodes removed or positive margins). Results: The bootstrap-corrected concordance index of the model 5 years after radical cystectomy was 66.2%. When the risk stratification was applied to the validation cohort, the 5-year locoregional failure estimates were 8.3%, 21.2%, and 46.3% for the low-risk, intermediate-risk, and high-risk groups, respectively. The risk of locoregional failure differed significantly between the low-risk and intermediate-risk groups (subhazard ratio [SHR], 2.63; 95% confidence interval [CI], 1.35-5.11; P<.001) and between the low-risk and high-risk groups (SHR, 4.28; 95% CI, 2.17-8.45; P<.001). Although decision curves were appropriately affected by the incidence of the competing risk, decisions about the value of the models are not likely to be affected because the model remains of value over a wide range of threshold probabilities. Conclusions: The model is not completely accurate, but it demonstrates a modest level of discrimination, adequate calibration, and meaningful net benefit gain for prediction of locoregional failure after radical cystectomy.

  18. Surgical Risk and Comorbidity in Older Urologic Patients.

    PubMed

    Townsend, Nicole T; Robinson, Thomas N

    2015-11-01

    Almost two-thirds of urology operations are performed in patients 65years and older. Older adults are at higher risk for complications and mortality compared with their younger counterparts. There are 2 primary methods to quantify surgical risk in these patients, frailty measurement and organ/comorbidity-based surgical risk calculators. A frailty assessment can be used to independently forecast the risk of postoperative complications. A paradigm shift in the preoperative assessment of the geriatric patient has occurred, which emphasizes the evaluation of frailty over more traditional surgical risk assessment, which uses comorbidities and single end-organ dysfunction to define risk. PMID:26476118

  19. Health informatics design for assisted diagnosis of subclinical atherosclerosis, structural, and functional arterial age calculus and patient-specific cardiovascular risk evaluation.

    PubMed

    Santana, Daniel Bia; Zcalo, Yanina A; Ventura, Ignacio Farro; Arrosa, Juan Francisco Torrado; Florio, Luca; Lluberas, Ricardo; Armentano, Ricardo L

    2012-09-01

    Traditional methods used to assess cardiovascular risk (i.e., the Framingham Risk Score) exhibit clear limitations. To aid in patient-specific risk stratification and diagnosis it has been proposed to evaluate noninvasively structural and functional arterial parameters. A National Public University Center (CUiiDARTE) was created in Uruguay with the aim of developing and applying strategies to improve cardiovascular risk stratification and subclinical vascular disease detection. To this end a health informatics approach and tool was designed, developed, and implemented in CUiiDARTE. Its goals were to: 1) promote screening for subclinical atherosclerosis, 2) develop a centralized database to store information obtained noninvasively from anywhere in our country, 3) develop a biomathematical model integrating values for arterial structure and function into traditional cardiovascular risk assessment, 4) generate a detailed and comprehensive report for the specialist comparing patient data with reference data from the healthy population, 5) generate a similar report (using a structural and functional arterial age calculator) for the patients assessing the state of their arteries. In this paper, we present the main characteristics of the CUiiDARTE health informatics development. PMID:22434819

  20. Incorporating predictions of individual patient risk in clinical trials.

    PubMed

    Kattan, Michael W; Vickers, Andrew J

    2004-01-01

    A risk prediction model is a statistical technique that gives a predicted probability of a certain event for an individual patient. Prediction models outperform the traditional risk classification systems that work by assigning patients into risk groups based on the presence or absence of particular risk factors, such as stage of disease. As such, risk prediction models have a number of important possible uses in clinical trials. For Phase II studies, prediction models can help adjust comparisons with historical control groups for differences in case mix. For Phase III studies, prediction models can ensure that accrued patients are at sufficiently high risk. This improves statistical power and avoids unethical inclusion of low-risk patients. We also propose that prediction models could potentially be used for applying the results of Phase III trials to individual patients. Clinical decisions could be informed by individualized estimates of treatment benefit, rather than by average treatment effects. PMID:15283895

  1. Meta-Analysis of Methicillin-Resistant Staphylococcus aureus Colonization and Risk of Infection in Dialysis Patients

    PubMed Central

    Zacharioudakis, Ioannis M.; Zervou, Fainareti N.; Ziakas, Panayiotis D.

    2014-01-01

    Patients undergoing dialysis are particularly vulnerable to methicillin-resistant Staphylococcus aureus (MRSA) infections. We performed a meta-analysis of published studies to estimate the prevalence of MRSA colonization in dialysis patients, time trends, and long-term risk of subsequent MRSA infections. Our search of the PubMed and Embase databases returned 5743 nonduplicate citations, from which we identified 38 relevant studies that included data on 5596 dialysis patients. The estimated prevalence of MRSA colonization was 6.2% (95% confidence interval [95% CI], 4.2% to 8.5%). The prevalence increased over time but remained stable after 2000. Stratification of patients according to dialysis modality and setting revealed that 7.2% (95% CI, 4.9% to 9.9%) of patients on hemodialysis were colonized with MRSA compared with 1.3% (95% CI, 0.5% to 2.4%) of patients on peritoneal dialysis (P=0.01), and that a statistically significant difference existed in the percentage of colonized inpatients and outpatients (14.2% [95% CI, 8.0% to 21.8%] versus 5.4% [95% CI, 3.5% to 7.7%], respectively; P=0.04). Notably, the risk of developing MRSA infections increased among colonized hemodialysis patients compared with noncolonized patients (relative risk, 11.5 [95% CI, 4.7 to 28.0]). The long-term (620 months) probability of developing a MRSA infection was 19% among colonized hemodialysis patients compared with only 2% among noncolonized patients. In summary, 6.2% of dialysis patients are MRSA colonized, and the average prevalence of colonization has remained stable since 2000. Colonization in hemodialysis patients is associated with increased risk of MRSA infection. PMID:24652802

  2. Using the STarT Back Tool: Does timing of stratification matter?

    PubMed

    Newell, D; Field, J; Pollard, D

    2015-08-01

    It is likely that individuals with nonspecific LBP (nsLBP) constitute a heterogenic group and targeting treatment appropriately to those most likely to respond is of major relevance. The STarT Back Tool (SBT) has been developed to stratify patients into risk groups to aid management choices. However, there is controversy over its generalisability and uncertainty as to the timing of use. This study investigated whether SBT categorisation early in a course of treatment would prove more prognostic than categorising patients at baseline. Seven hundred and forty nine patients over the age of 16 were recruited at 11 chiropractic clinics within the UK. The SBT was used to categorise these patients at presentation and 2 days following initial treatment with patient characteristics and condition specific markers also collected at baseline. The primary outcome was the Patient Global Impression of Change (PGIC) collected at 14, 30 and 90 days following the initial visit. In this population undergoing chiropractic care, patients had similar outcomes irrespective of their STarT back risk ranking. Multivariate prognostic models included only the post initial visit SBT as an independent predictor of favourable outcome for the medium risk group but only at 30 days. Follow up improvement was dominated by previous improvement in 30 and 90-day models. Over one third of patients swapped SBT risk groups in the 2 day period between initial stratification and post initial visit although there was little difference in eventual improvement at follow-up. Understanding the impact of timing of SBT stratification is indicated. PMID:25175750

  3. Genetic testing and genetic counseling in patients with sudden death risk due to heritable arrhythmias.

    PubMed

    Spoonamore, Katherine G; Ware, Stephanie M

    2016-03-01

    Sudden cardiac death due to heritable ventricular arrhythmias is an important cause of mortality, especially in young healthy individuals. The identification of the genetic basis of Mendelian diseases associated with arrhythmia has allowed the integration of this information into the diagnosis and clinical management of patients and at-risk family members. The rapid expansion of genetic testing options and the increasing complexity involved in the interpretation of results creates unique opportunities and challenges. There is a need for competency to incorporate genetics into clinical management and to provide appropriate family-based risk assessment and information. In addition, disease-specific genetic knowledge is required to order and correctly interpret and apply genetic testing results. Importantly, genetic diagnosis has a critical role in the risk stratification and clinical management of family members. This review summarizes the approach to genetic counseling and genetic testing for inherited arrhythmias and highlights specific genetic principles that apply to long QT syndrome, short QT syndrome, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia. PMID:26582592

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

    PubMed Central

    2013-01-01

    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. PMID:23327460

  5. Novel biomarkers for asthma stratification and personalized therapy.

    PubMed

    Bartminski, Grzegorz; Crossley, Matthew; Turcanu, Victor

    2015-03-01

    A stepwise pharmacological treatment is currently recommended for all asthma patients and is personalized mainly on disease severity, aiming for the lowest disease-controlling step. Nevertheless, asthma comprises several related pathologies with similar clinical manifestations resulting from distinct underlying mechanisms. Therefore novel biomarkers could lead to asthma stratification and thus improve upon the current stepwise approach. The aim of this review is to update the reader with regard to different assays proposed in the recent asthma literature for measuring potential biomarkers for patient stratification and treatment personalization. Promising biomarkers are sputum eosinophils, serum periostin and exhaled nitric oxide. Periostin could differentiate between Th2-high and Th2-low asthma (Th2-high patients are more responsive to glucocorticoids) and the less-defined asthma types which often present a therapeutic challenge. Several other biomarkers, mainly cytokines, leukotrienes and exhaled air components, can be quantified in body fluids and exhaled breath and could also be useful for asthma stratification. PMID:25479456

  6. The influence of disease and comorbidity risk assessments on the survival of MDS and oligoblastic AML patients treated with 5-azacitidine: A retrospective analysis in ten centers of the "Rete Ematologica Lombarda".

    PubMed

    Molteni, Alfredo; Riva, Marta; Borin, Lorenza; Bernardi, Massimo; Pelizzari, Anna Maria; Freyrie, Alessandra; Porta, Matteo Della; Nichelatti, Michele; Ravano, Emanuele; Quaresmini, Giulia; Mariotti, Jacopo; Caramazza, Domenica; Ubezio, Marta; Guarco, Simona; Gigli, Federica; Greco, Rosa; Cairoli, Roberto; Morra, Enrica

    2016-03-01

    5-Azacytidine is an effective therapy in high risk MDS and oligoblastic AML. This "real life" analysis was made on 185 patients treated with 5-azacytidine in 10 centers afferent to REL ("Rete Ematologica Lombarda"), a network in Lombardia region. The aim was to assess the influence of disease and comorbidity risk assessments on the survival. The results confirm the utility of 5-azacitidine in prolonging OS regardless of advanced age and the presence of comorbidities. They also encourage an early treatment since patients with IPSS-R High risk MDS have better outcome with respect to Very High risk ones. According to the IPSS cytogenetic risk, there was no difference in the outcome between Intermediate and High risk patients. Nevertheless, a poorer cytogenetic risk, according to the IPSS-R cytogenetic stratification, negatively influenced the outcome. PMID:26852003

  7. Innovative tools for assessing risks for severe adverse events in areas of overlapping Loa loa and other filarial distributions: the application of micro-stratification mapping

    PubMed Central

    2014-01-01

    Background The wide distribution of Loa loa infection (loiasis) throughout the Democratic Republic of Congo (DRC) is a major obstacle to the plans to eliminate onchocerciasis and lymphatic filariasis (LF) because the standard drug regime is dependent on ivermectin, which cannot be used in co-endemic areas due to the risk of severe adverse events (SAEs). A better understanding of the micro-epidemiology, overlapping low and high risk areas, and how they relate to SAEs is critical to ensure safe and effective treatment. Findings Based on published data from the Bas Congo Province in DRC, this study used geographical information systems (GIS) to re-map and analyse onchocerciasis and loiasis prevalence (<20%, 20 to 40%, >40%) at 144 sites in relation to health district areas reporting SAEs. The new maps highlighted the contrasting patterns of the high prevalence sites, and significant geographical overlap between low onchocerciasis and high loiasis sites. Statistical analyses found that sites with medium to high loiasis prevalence were 10 to 16 times more likely to be in a SAE area than those with low prevalence of loiasis. Sites where both onchocerciasis and loiasis prevalence was >20% were also associated with SAE areas. Conclusions Collaborative efforts between the national onchocerciasis and LF programmes are critical as plans to scale interventions are moving forward and thus, alternative strategies needed in loiasis co-endemic areas which may include the new L. loa test and treat strategy using the Cellscope, or interventions such as integrated vector management, or anti Wolbachia therapy using doxycycline. PMID:24992829

  8. Risk Prediction for Late-Stage Ovarian Cancer by Meta-analysis of 1525 Patient Samples

    PubMed Central

    Riester, Markus; Wei, Wei; Waldron, Levi; Culhane, Aedin C.; Trippa, Lorenzo; Oliva, Esther; Kim, Sung-hoon; Michor, Franziska; Huttenhower, Curtis; Parmigiani, Giovanni

    2014-01-01

    Background Ovarian cancer causes more than 15000 deaths per year in the United States. The survival of patients is quite heterogeneous, and accurate prognostic tools would help with the clinical management of these patients. Methods We developed and validated two gene expression signatures, the first for predicting survival in advanced-stage, serous ovarian cancer and the second for predicting debulking status. We integrated 13 publicly available datasets totaling 1525 subjects. We trained prediction models using a meta-analysis variation on the compound covariable method, tested models by a “leave-one-dataset-out” procedure, and validated models in additional independent datasets. Selected genes from the debulking signature were validated by immunohistochemistry and quantitative reverse-transcription polymerase chain reaction (qRT-PCR) in two further independent cohorts of 179 and 78 patients, respectively. All statistical tests were two-sided. Results The survival signature stratified patients into high- and low-risk groups (hazard ratio = 2.19; 95% confidence interval [CI] = 1.84 to 2.61) statistically significantly better than the TCGA signature (P = .04). POSTN, CXCL14, FAP, NUAK1, PTCH1, and TGFBR2 were validated by qRT-PCR (P < .05) and POSTN, CXCL14, and phosphorylated Smad2/3 were validated by immunohistochemistry (P < .001) as independent predictors of debulking status. The sum of immunohistochemistry intensities for these three proteins provided a tool that classified 92.8% of samples correctly in high- and low-risk groups for suboptimal debulking (area under the curve = 0.89; 95% CI = 0.84 to 0.93). Conclusions Our survival signature provides the most accurate and validated prognostic model for early- and advanced-stage high-grade, serous ovarian cancer. The debulking signature accurately predicts the outcome of cytoreductive surgery, potentially allowing for stratification of patients for primary vs secondary cytoreduction. PMID:24700803

  9. [Assessing the cardiovascular risk in patients with systemic lupus erythematosus].

    PubMed

    Arnaud, L; Mathian, A; Bruckert, E; Amoura, Z

    2014-11-01

    Multiple factors contribute to the increased cardiovascular risk observed in patients with systemic lupus erythematosus (SLE). Among these are the so-called classical cardiovascular risk factors, the disease itself through its activity, treatments, and complications, and the thrombotic risk due to antiphospholipid antibodies (aPL). Observational studies suggest that most classical cardiovascular risk factors are observed more frequently in SLE patients than in the general population, and that these are insufficient to explain the increased cardiovascular risk observed in most studies. Given this high risk, adequate management of cardiovascular risk factors should be recommended in SLE patients. Paradoxically, the benefit due to the anti-inflammatory properties of treatments such as corticosteroids may exceed, in certain cases, their pro-atherogenic effect. Importantly, the tools that were developed for the estimation of cardiovascular risk at the individual level among the general population cannot be used reliably in SLE patients, as these tools appear to underestimate the true cardiovascular risk. The adequate indications and targets of cardiovascular treatments are therefore not fully known in SLE. A better understanding of the determinants of the cardiovascular risk in SLE will allow the identification and more tailored management of these high-risk patients. PMID:25234464

  10. Organizational and individual attributes influencing patient risk detection.

    PubMed

    Despins, Laurel A

    2014-10-01

    This study examined organizational and individual variables impacting patient risk detection by Intensive Care Unit nurses and their decision to reduce the risk of failure to rescue. Thirty-four nurses were randomly assigned to two groups. A video of a manager and staff nurse patient safety discussion was used to prime one group to prioritize patient safety. Participants provided demographic information, received end-of-shift report on two fictional patients, experienced 52 alarm trials during a medication preparation scenario, and completed the Safety Attitude Questionnaire. No difference existed in risk detection; however, nurses who perceived their work environment quality to be good correctly ignored a clinically irrelevant alarm more often and were more apt to classify an alarm as irrelevant. They chose to reduce the risk of medication error rather than that of failure to rescue. This information can assist nurses to balance disregarding distractions with responding to potential patient risk signals. PMID:23759538

  11. Orderedness and Stratificational "and" Nodes.

    ERIC Educational Resources Information Center

    Herrick, Earl M.

    It is possible to apply Lamb's stratificational theory and analysis to English graphonomy, but additional notation devices must be used to explain particular graphemes and their characteristics. The author presents cases where Lamb's notation is inadequate. In those cases, he devises new means for performing the analysis. The result of this

  12. Primary care assessment of patients at risk for suicide.

    PubMed

    Bono, Valerie; Amendola, Christine Lazaros

    2015-12-01

    Primary care providers (PCPs) play a crucial role caring for patients with depression, managing antidepressant therapy, and assessing patients for suicide risk. Ten percent of the more than 20 million primary care visits for depression each year involve mental health issues, and account for 62% of the antidepressants prescribed in the United States. Psychiatric disorders appear to be underrecognized and undertreated in primary care. Suicidal ideation is present in a significant percentage of depressed primary care patients but rarely discussed. This article describes the warning signs and risk factors associated with suicide and recommends screening tools that can help PCPs identify patients at risk. PMID:26556217

  13. Rationale and design of three observational, prospective cohort studies including biobanking to evaluate and improve diagnostics, management strategies and risk stratification in venous thromboembolism: the VTEval Project

    PubMed Central

    Frank, Bernd; Ariza, Liana; Lamparter, Heidrun; Grossmann, Vera; Prochaska, Jrgen H; Ullmann, Alexander; Kindler, Florentina; Weisser, Gerhard; Walter, Ulrich; Lackner, Karl J; Espinola-Klein, Christine; Mnzel, Thomas; Konstantinides, Stavros V; Wild, Philipp S

    2015-01-01

    Introduction Venous thromboembolism (VTE) with its two manifestations deep vein thrombosis (DVT) and pulmonary embolism (PE) is a major public health problem. The VTEval Project aims to investigate numerous research questions on diagnosis, clinical management, treatment and prognosis of VTE, which have remained uncertain to date. Methods and analysis The VTEval Project consists of three observational, prospective cohort studies on VTE comprising cohorts of individuals with a clinical suspicion of acute PE (with or without DVT), with a clinical suspicion of acute DVT (without symptomatic PE) and with an incidental diagnosis of VTE (PE or DVT). The VTEval Project expects to enrol a total of approximately 2000 individuals with subsequent active and passive follow-up investigations over a time period of 5?years per participant. Time points for active follow-up investigations are at months 3, 6, 12, 24 and 36 after diagnosis (depending on the disease cohort); passive follow-up investigations via registry offices and the cancer registry are performed 48 and 60?months after diagnosis for all participants. Primary short-term outcome is defined by overall mortality (PE-related death and all other causes of death), primary long-term outcome by symptomatic VTE (PE-related death, recurrence of non-fatal PE or DVT). The VTEval Project includes three all-comer studies and involves the standardised acquisition of high-quality data, covering the systematic assessment of VTE including symptoms, risk profile, psychosocial, environmental and lifestyle factors as well as clinical and subclinical disease, and it builds up a large state-of-the-art biorepository containing various materials from serial blood samplings. Ethics and dissemination The VTEval Project has been approved by the local data safety commissioner and the responsible ethics committee (reference no. 837.320.12 (8421-F)). Trial results will be published in peer-reviewed journals and presented at national and international scientific meetings. Trial registration number NCT02156401. PMID:26133379

  14. [Cardiovascular risk assessment and intervention in HIV-infected patients].

    PubMed

    Hernndez, Sebastin; Vidal, Magdalena; Pedrol, Enric

    2009-09-01

    Because of the increased cardiovascular risk (CVR) in HIV-positive patients, preventive measures are essential, requiring algorithms for risk estimation, such as the Framingham risk equation, the Prospective Cardiovascular Munster Study (PROCAM) algorithm and the Systematic Coronary Risk Evaluation (SCORE) chart. Classical cardiovascular risk factors (CVRF) are closely related to CVR in HIV-infected patients but whether this risk is comparable to that in the general population is unknown. Therefore, these algorithms probably underestimate the risk in these patients. Currently, application of the same strategies as those used in the general population is recommended, without forgetting the specific characteristics of HIV positive patients or the importance of their inflammatory status, which can accelerate the development of arteriosclerosis and lead to an increase in cardiovascular morbidity and mortality. Therefore, in addition to traditional CVRF, biological markers of inflammation could help to identify the patients most at risk of a cardiovascular event. These markers, as well as the diverse techniques for assessment of subclinical atherosclerosis that could help in the early identification of at-risk patients, are reviewed in the present study. Lifestyle changes (healthy diet, smoking cessation, maintaining a healthy weight and daily physical exercise) reduce the probability of a coronary event by up to 80% in the general population. Traditional therapeutic measures (dyslipidemia, hypertension, diabetes mellitus) and those specific to HIV infection (viral suppression, discontinuous treatment, etc.) are reviewed. PMID:20172414

  15. Risk factors for major amputation in hospitalised diabetic foot patients.

    PubMed

    Namgoong, Sik; Jung, Suyoung; Han, Seung-Kyu; Jeong, Seong-Ho; Dhong, Eun-Sang; Kim, Woo-Kyung

    2016-03-01

    Diabetic foot ulcers are the main cause of non-traumatic lower extremity amputation. The objective of this study was to evaluate the risk factors for major amputation in diabetic foot patients. Eight hundred and sixty diabetic patients were admitted to the diabetic wound centre of the Korea University Guro Hospital for foot ulcers between January 2010 and December 2013. Among them, 837 patients were successfully monitored until complete healing. Ulcers in 809 patients (967%) healed without major amputation and those in 28 patients (33%) healed with major amputation. Data of 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology and serology were collected from patients in the two groups and compared. Among the 88 potential risk factors, statistically significant differences between the two groups were observed in 26 risk factors. In the univariate analysis, which was carried out for these 26 risk factors, statistically significant differences were observed in 22 risk factors. In a stepwise multiple logistic analysis, six of the 22 risk factors remained statistically significant. Multivariate-adjusted odds ratios were 11673 for ulcers penetrating into the bone, 8683 for dialysis, 6740 for gastrointestinal (GI) disorders, 6158 for hind foot ulcers, 0641 for haemoglobin levels and 1007 for fasting blood sugar levels. The risk factors for major amputation in diabetic foot patients were bony invasions, dialysis, GI disorders, hind foot locations, low levels of haemoglobin and elevated fasting blood sugar levels. PMID:26478562

  16. The Matrix Metalloproteinase-7 Polymorphism Rs10895304 Is Associated With Increased Recurrence Risk in Patients With Clinically Localized Prostate Cancer

    SciTech Connect

    Jaboin, Jerry J.; Hwang, Misun; Lopater, Zachary; Chen Heidi; Ray, Geoffrey L.; Perez, Carmen; Cai Qiuyin; Wills, Marcia L.; Lu Bo

    2011-04-01

    Purpose: To evaluate whether selected high-risk matrix metalloproteinase-7 single nucleotide polymorphisms influence clinicopathologic outcomes in patients with early-stage prostate cancer. Methods and Materials: Two hundred twelve prostate cancer patients treated with radical prostatectomy were evaluated with a median follow-up of 9.8 years. Genotyping was performed using hybridization with custom-designed allele-specific probes. Three single nucleotide polymorphisms within the matrix metalloproteinase-7 gene were assessed with respect to age at diagnosis, margin status, extracapsular extension, lymph node involvement, recurrence-free survival, and overall survival in paraffin-embedded prostate tissue specimens from patients with early-stage prostate cancer who underwent radical prostatectomy. Results: Rs10895304 was the sole significant polymorphism. The A/G genotype of rs10895304 had a statistically significant association with recurrence-free survival in postprostatectomy patients (p = 0.0061, log-rank test). The frequency of the risk-reducing genotype (A/A) was 74%, whereas that of the risk-enhancing genotypes (A/G and G/G) were 20% and 6%, respectively. Multivariable Cox regression analyses detected a significant association between rs10895304 and recurrences after adjustment for known prognostic factors. The G allele of this polymorphism was associated with increased risk of prostate cancer recurrence (adjusted hazards ratio, 3.375; 95% confidence interval 1.567-7.269; p < 0.001). The other assayed polymorphisms were not significant, and no correlations were made to other clinical variables. Conclusions: The A/G genotype of rs10895304 is predictive of decreased recurrence-free survival in patients with clinically localized prostate cancer. Our data suggest that for this subset of patients, prostatectomy alone may not be adequate for local control. This is a novel and relevant marker that should be evaluated for improved risk stratification of patients who may be candidates for adjuvant radiation therapy to improve local control.

  17. A Risk Analysis Method to Evaluate the Impact of a Computerized Provider Order Entry System on Patient Safety

    PubMed Central

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

    2008-01-01

    Objectives Quantitative evaluation of safety after the implementation of a computerized provider order entry (CPOE) system, stratification of residual risks to drive future developments. Design Comparative 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. Measurements The failure modes were defined and their criticality indices calculated on the basis of the likelihood of occurrence, potential severity for patients, and detection probability. Criticality indices of handwritten and electronic prescriptions were compared, the acceptability of residual risks was discussed. Further developments were proposed and their potential impact on the safety was estimated. Results The sum of criticality indices of 27 identified failure modes was 3813 for the handwritten prescription, 2930 (?23%) for CPOE system, and 1658 (?57%) with 14 enhancements. The major safety improvements were observed for errors due to ambiguous, incomplete or illegible orders (?245 points), wrong dose determination (?217) and interactions (?196). Implementation of targeted pop-ups to remind treatment adaptation (?189), vital signs (?140), and automatic edition of documents needed for the dispensation (?126) were the most promising proposed improvements. Conclusion The impact of a CPOE system on patient safety strongly depends on the implemented functions and their ergonomics. The use of risk analysis helps to quantitatively evaluate the relationship between a system and patient safety and to build a strategy for continuous quality improvement, by selecting the most appropriate improvements to the system. PMID:18436900

  18. Biomarkers for diagnosis and prognostic stratification of aortic dissection: challenges and perspectives.

    PubMed

    Morello, Fulvio; Piler, Pavel; Novak, Miroslav; Kruzliak, Peter

    2014-01-01

    Aortic dissection (AD) is a severe vascular disease associated with major morbidity and mortality. The diagnosis of AD requires the performance of urgent aortic imaging exams such as computed tomography angiography, but the decision to perform these exams now essentially relies on clinical judgment. Several studies have identified a range of potential biomarkers stemming from the aortic extracellular matrix (matrix metalloproteinases, TGF-β, soluble elastin fragments), vascular smooth muscle cells (smooth muscle myosin heavy chain, creatine kinase, calponin), coagulation (D-dimer, platelets) and inflammation (C-reactive protein), whose circulating levels increase in patients affected by AD. Biomarkers of AD could be potentially used to screen patients with compatible symptoms, to identify patients at higher risk of AD, to rule out AD in patients with non-high clinical probability of AD and/or to obtain prognostic stratification of affected patients. This review will summarize available data and discuss present and future perspectives of circulating biomarkers for the diagnosis and prognostic stratification of AD. PMID:25307547

  19. Risk of left atrial appendage thrombus in patients scheduled for ablation for atrial fibrillation: beyond the CHA2DS2VASc score.

    PubMed

    Sikorska, Agnieszka; Baran, Jakub; Pilichowska-Paszkiet, Ewa; Sikora-Fr?c, Ma?gorzata; Kry?ski, Tomasz; Piotrowski, Roman; Stec, Sebastian; Zaborska, Beata; Ku?akowski, Piotr

    2015-12-22

    INTRODUCTION Atrial fibrillation (AF) increases the risk of thromboembolic events by promoting clot formation in the left atrial appendage (LAA). Transesophageal echocardiography (TEE) is routinely used to exclude the presence of an LAA thrombus before AF ablation. So far, it has not been established what is the optimal combination of noninvasive parameters for thromboembolic risk stratification in this setting and whether patients at very low risk require TEE. OBJECTIVES The aim of the study was to assess predisposing factors for an LAA thrombus in patients scheduled for AF ablation and to identify those patients in whom preprocedural TEE is not necessary. PATIENTS AND METHODS In consecutive 151 patients (107 men; mean age, 57 10 years) the type of AF and renal function were assessed in addition to the CHA2DS2VASc score to improve thromboembolic risk stratification. RESULTS An LAA thrombus or dense echo contrast with a strong suspicion of a probable thrombus was detected in 15 patients (10%). Diabetes, age of 65 years or older, persistent AF, and estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73 m2 were predictors of the LAA thrombus. A multivariate logistic regression analysis showed that only persistent AF and an eGFR of less than 60 ml/min/1.73 m2 were independent predictors of the LAA thrombus. The receiver operating characteristic curves showed that the greatest area under the curve (0.845) was achieved for the CHA2DS2VASc-AFR (CHA2DS2VASc plus the type of AF and renal function); the difference was not significant. A CHA2DS2VASc-AFR score of 2 or greater or a CHA2DS2VASc score of 1 or greater identified patients with the LAA thrombus with a sensitivity of 100% (and specificity of 54% and 36%, respectively). CONCLUSIONS In patients scheduled for AF ablation, an LAA thrombus or dense echo contrast is a relatively common finding despite routine anticoagulant treatment. The addition of AF type and renal function to the CHA2DS2VASc score slightly improves thromboembolic risk stratification and may help identify patients who do not need preprocedural TEE. PMID:26592238

  20. Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment

    PubMed Central

    Phillips, Siobhan M.; Glasgow, Russell E.; Bello, Ghalib; Ory, Marcia G.; Glenn, Beth A.; Sheinfeld-Gorin, Sherri N.; Sabo, Roy T.; Heurtin-Roberts, Suzanne; Johnson, Sallie Beth; Krist, Alex H.

    2014-01-01

    PURPOSE To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices. METHODS Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as at risk or healthy for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices. RESULTS On average, patients had 5.8 (SD = 2.12; range, 013) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important. CONCLUSIONS Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change. PMID:25384812

  1. Venous thromboembolism in cancer patients: risk assessment, prevention and management.

    PubMed

    Tukaye, Deepali N; Brink, Heidi; Baliga, Ragavendra

    2016-03-01

    Thrombosis and thromboembolic events contribute to significant morbidity in cancer patients. Venous thrombosis embolism (which includes deep vein thrombosis and pulmonary embolism) accounts for a large percentage of thromboembolic events. Appropriate identification of cancer patients at high risk for venous thromboembolism and management of thromboembolic event is crucial in improving the quality of care for cancer patients. However, thromboembolism in cancer patients is a complex problem and the management has to be tailored to each individual. The focus of this review is to understand the complex pathology, physiology and risk factors that drive the process of venous thrombosis and embolism in cancer patients and the current guidelines in management. PMID:26919091

  2. Risk of vascular events in patients with polymyalgia rheumatica

    PubMed Central

    Hancock, Adam T.; Mallen, Christian D.; Muller, Sara; Belcher, John; Roddy, Edward; Helliwell, Toby; Hider, Samantha L.

    2014-01-01

    Background: Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events. Methods: We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica. Results: A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.312.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.42.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis. Interpretation: Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk. PMID:25070989

  3. Evaluation of Periodontal Risk in Adult Patients using Two Different Risk Assessment Models A Pilot Study

    PubMed Central

    Bade, Shruthi; Bollepalli, Appaiah Chowdary; Katuri, Kishore Kumar; Devulapalli, Narasimha Swamy; Swarna, Chakrapani

    2015-01-01

    Objective: The aim of the present study was to evaluate the periodontal risk of individuals using periodontal risk assessment (PRA) model and modified PRA model. Materials and Methods: A total of 50 patients with chronic periodontitis, age 30-60 years were selected randomly and charting of the periodontal status was performed and those who met the inclusion criteria were enrolled in the study. Parameters recorded were- percentage of sites with bleeding on probing (BOP), number of sites with pocket depths (PD) ? 5mm, number of the teeth lost, bone loss (BL)/age ratio, Clinical attachment loss(CAL)/age ratio, diabetic and smoking status, dental status, systemic factors like diabetes were assessed. All the risk factors were plotted on the radar chart in (PRA) and (mPRA) models, using Microsoft excel and periodontal risk were categorized as low, moderate and high risk. Results: Among 50 patients 31 were in low risk, 9 in moderate risk, and 10 in high risk identified by modified (PRA) model, whereas 28 patients were in low risk, 13 in moderate risk and 9 in high risk identified by (PRA). Statistical analysis demonstrated that there was no significant difference between the risk scores (X2 = 0.932 with degree of freedom = 2, P = 0.627). Conclusion: Both the periodontal risk models are effective in evaluating the risk factors and can be useful tool for predicting proper diagnosis, disease progression and therapeutic strategies during the supportive periodontal therapy. PMID:25859520

  4. Increased Risk of Stroke in Patients With Fibromyalgia

    PubMed Central

    Tseng, Chun-Hung; Chen, Jiunn-Horng; Wang, Yu-Chiao; Lin, Ming-Chia; Kao, Chia-Hung

    2016-01-01

    Abstract Neuropsychiatric diseases might enhance stroke development, possibly through inflammation and atherosclerosis. Approximately 25% to 40% of patients with stroke, largely younger patients, are not associated with any conventional stroke risk factors. In this research, we explored whether fibromyalgia (FM), a neuropsychosomatic disorder, increases stroke risk. From a claims dataset with one million enrollees sourced of the Taiwan National Health Insurance database, we selected 47,279 patients with FM and randomly selected 189,112 age- and sex-matched controls within a 3-year period from January 1, 2000 to December 31, 2002. Stroke risk was assessed using Cox proportional hazards regression. Comorbidities associated with increased stroke risk, such as hypertension, diabetes, hyperlipidemia, coronary heart disease, irritable bowel syndrome, and interstitial cystitis, were more prevalent in patients with FM and high stroke risk than in the controls. The overall stroke risk was 1.25-fold (95% confidence interval [CI]: 1.21–1.30) higher in the FM group than in the non-FM group. Even without comorbidities, stroke risk was higher in patients with FM than in the controls (adjusted hazard ratio [aHR] = 1.44, 95% CI: 1.35–1.53, P < 0.001). The relative risk of stroke was 2.26-fold between FM and non-FM groups in younger patients (age <35 years, 95% CI: 1.86–2.75). This is the first investigation associating FM with an increased risk of stroke development. The outcomes imply that FM is a significant risk factor for stroke and that patients with FM, particularly younger patients, require close attention and rigorous measures for preventing stroke. PMID:26937918

  5. Perceptions of high-risk patients and their providers on the patient-centered medical home.

    PubMed

    Kangovi, Shreya; Kellom, Katherine; Sha, Christopher; Johnson, Sarah; Chanton, Casey; Carter, Tamala; Long, Judith A; Grande, David

    2015-01-01

    To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room. PMID:25748262

  6. Identifying patients at high risk of breast cancer recurrence: strategies to improve patient outcomes

    PubMed Central

    Martei, Yehoda M; Matro, Jennifer M

    2015-01-01

    Identifying patients at high risk of breast cancer recurrence has important implications not only for enabling the ability to provide accurate information to patients but also the potential to improve patient outcomes. Patients at high recurrence risk can be offered appropriate treatment to improve the overall survival. However, the major challenge is identifying patients with early-stage breast cancer at lower risk who may be spared potentially toxic therapy. The successful integration of molecular assays into clinical practice may address the problem of overtreatment and improve overall patient outcomes. PMID:26504408

  7. Low risk of coronary artery disease in patients with acromegaly.

    PubMed

    Dos Santos Silva, Cintia Marques; Lima, G A B; Volschan, I C M; Gottlieb, I; Kasuki, L; Neto, L Vieira; Gadelha, M R

    2015-12-01

    The aims of this study are to determine the prevalence of coronary atherosclerosis in acromegalic patients and to investigate the relationship between the coronary artery calcium score (CS) and acromegaly status and clinical parameters [Framingham risk score (FRS)]. Fifty-six acromegalic patients and paired non-acromegalic volunteers were stratified according to the FRS into low-, intermediate-, and high-risk groups. CS was assessed using multidetector computed tomography. The patients were considered to have controlled or active acromegaly at the time they were submitted to evaluation. Sixty-six percent of acromegalic patients exhibited arterial hypertension, 36% had diabetes mellitus, and 34% had hypercholesterolemia. The median FRS and the median risk for cardiovascular event within the next 10years were similar in the acromegalics and the controls. The median total CS and CS >75th percentile didn't differ significantly between these groups. In patients with controlled acromegaly, a low, intermediate, or high FRS risk was observed in 86, 14, and 0%, respectively. In patients with active disease, a low, intermediate, or high FRS risk was verified in 94, 3, and 3%, respectively, and differences between the controlled and active groups were not significant. Seventy-two percent of the patients had total CS=0, and there were no differences between the controlled and active groups. The risk of coronary artery disease in acromegalic patients, determined according to FRS and CS, is low despite the high prevalence of metabolic abnormalities. PMID:25982151

  8. Combined Biomarker Analysis for Risk of Acute Kidney Injury in Patients with ST-Segment Elevation Myocardial Infarction

    PubMed Central

    Tung, Ying-Chang; Chang, Chih-Hsiang; Chen, Yung-Chang; Chu, Pao-Hsien

    2015-01-01

    Background Acute kidney injury (AKI) complicating ST-segment elevation myocardial infarction (STEMI) increases subsequent morbidity and mortality. We combined the biomarkers of heart failure (HF; B-type natriuretic peptide [BNP] and soluble ST2 [sST2]) and renal injury (NGAL [neutrophil gelatinase-associated lipocalin] and cystatin C) in predicting the development of AKI in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). Methods and Results From March 2010 to September 2013, 189 STEMI patients were sequentially enrolled and serum samples were collected at presentation for BNP, sST2, NGAL and cystatin C analysis. 37 patients (19.6%) developed AKI of varying severity within 48 hours of presentation. Univariate analysis showed age, Killip class ?2, hypertension, white blood cell counts, hemoglobin, estimated glomerular filtration rate, blood urea nitrogen, creatinine, and all the four biomarkers were predictive of AKI. Serum levels of the biomarkers were correlated with risk of AKI and the Acute Kidney Injury Network (AKIN) stage and all significantly discriminated AKI (area under the receiver operating characteristic [ROC] curve: BNP: 0.86, sST2: 0.74, NGAL: 0.75, cystatin C: 0.73; all P < 0.05). Elevation of ?2 of the biomarkers higher than the cutoff values derived from the ROC analysis improved AKI risk stratification, regardless of the creatine level (creatinine < 1.24 mg/dL: odds ratio [OR] 11.25, 95% confidence interval [CI] 1.63-77.92, P = 0.014; creatinine ? 1.24: OR 15.0, 95% CI 1.23-183.6, P = 0.034). Conclusions In this study of STEMI patients undergoing primary PCI, the biomarkers of heart failure (BNP and sST2) and renal injury (NGAL and cystatin C) at presentation were predictive of AKI. High serum levels of the biomarkers were associated with an elevated risk and more advanced stage of AKI. Regardless of the creatinine level, elevation of ?2 of the biomarkers higher than the cutoff values indicated a further rise in AKI risk. Combined biomarker approach may assist in risk stratification of AKI in patients with STEMI. PMID:25853556

  9. Baseline factors associated with treatment response in patients infected with hepatitis C virus 1b by stratification of IL28B polymorphisms.

    PubMed

    Ling, Qihua; Chen, Jianjie; Zhou, Hua; Zhong, Jun; Chen, Yiyun; Ye, Qingyan; Zhuo, Yunhui; Min, Niehong; Shang, Binyi

    2015-04-01

    Although the single-nucleotide polymorphism (SNP) rs12979860 in the IL28B gene is a better predictor of sustained virological response to treatment of chronic hepatitis C (CHC) than other baseline factors, some CHC patients with the favorable C allele cannot achieve a sustained virological response when treated with peginterferon plus ribavirin. The aim of this study was to examine baseline factors as predictors of rapid virological response (RVR) and complete early virological response (cEVR) to peginterferon alfa-2a plus ribavirin treatment in Chinese CHC patients with hepatitis C virus (HCV) genotype 1b, with emphasis on the difference between the rs129860 CC and CT/TT genotypes. A total of 337 treatment-nave patients participated in this study. All patients were treated with peginterferon alfa-2a plus ribavirin at standard dosage. Serum samples from all patients were collected at baseline, week 4, and week 12 for testing of laboratory parameters, and IL28B genotypes were determined. Multivariate analysis showed that among rs12979860 CC genotype patients, glucose level and aspartate amino transferase (AST) activity were inversely associated with RVR, while abnormal platelet count and allergy inversely associated with cEVR. Among rs12979860 CT genotype patients, age below 40years and short infection duration were associated with RVR, while age below 40years, short infection duration, high body mass index (BMI), and no history of allergies were associated with cEVR. The baseline factors associated with the response to CHC treatment may depend on the IL28B genotype. Refinement of the baseline predictors based on IL28B genotypes may be useful for management of HCV infection. PMID:25687192

  10. Management in high-risk patients.

    PubMed

    Burns, Patrick; Highlander, Pete; Shinabarger, Andrew B

    2014-10-01

    Injuries to the foot and ankle are often missed or underestimated in patients with polytrauma and are a source of long-term limitations. Injures below the knee are among the highest causes for unemployment, longer sick leave, more pain, more follow-up appointments, and decreased overall outcome. As mortalities decrease for patients with polytrauma a greater emphasis on timely diagnosis and treatment of foot and ankle injuries is indicated. Geriatric patients represent nearly one-quarter of trauma admissions in the United States. This article discusses perioperative management and complications associated with foot and ankle injuries in polytrauma, and in diabetic and geriatric patients. PMID:25281513

  11. Risk of lymphoma in patients with dermatitis herpetiformis.

    PubMed Central

    Sigurgeirsson, B.; Agnarsson, B. A.; Lindelf, B.

    1994-01-01

    OBJECTIVE--To provide accurate estimates of the risk of lymphoma in patients with dermatitis herpetiformis. DESIGN--Comparison of observed and expected incidence of cancer in patients with dermatitis herpetiformis. SUBJECTS--976 patients aged 4 to 97 years with no clinical signs of coeliac disease who were admitted to hospital between 1963 and 1983. SETTING--Data from Swedish Cancer Registry. MAIN OUTCOME MEASURES--Incidence and type of cancer. RESULTS--106 cancers were diagnosed in 94 patients. The relative risk was 1.4 (95% confidence interval 1.1 to 1.7) in male patients and 1.2 (0.8 to 1.7) in female patients. When the individual cancer sites were analysed a significant risk was found only for malignant, non-Hodgkin's lymphoma in male patients, with a relative risk of 5.4 (2.2 to 11.1). CONCLUSIONS--The risk of lymphoma is greater in male patients with dermatitis herpetiformis, and this calls for increased surveillance in these patients. PMID:8298344

  12. Minimal residual disease monitoring by quantitative RT-PCR in core binding factor AML allows risk stratification and predicts relapse: results of the United Kingdom MRC AML-15 trial.

    PubMed

    Yin, John A Liu; O'Brien, Michelle A; Hills, Robert K; Daly, Sarah B; Wheatley, Keith; Burnett, Alan K

    2012-10-01

    The clinical value of serial minimal residual disease (MRD) monitoring in core binding factor (CBF) acute myeloid leukemia (AML) by quantitative RT-PCR was prospectively assessed in 278 patients [163 with t(8;21) and 115 with inv(16)] entered in the United Kingdom MRC AML 15 trial. CBF transcripts were normalized to 10(5) ABL copies. At remission, after course 1 induction chemotherapy, a > 3 log reduction in RUNX1-RUNX1T1 transcripts in BM in t(8;21) patients and a > 10 CBFB-MYH11 copy number in peripheral blood (PB) in inv(16) patients were the most useful prognostic variables for relapse risk on multivariate analysis. MRD levels after consolidation (course 3) were also informative. During follow-up, cut-off MRD thresholds in BM and PB associated with a 100% relapse rate were identified: for t(8;21) patients BM > 500 copies, PB > 100 copies; for inv(16) patients, BM > 50 copies and PB > 10 copies. Rising MRD levels on serial monitoring accurately predicted hematologic relapse. During follow-up, PB sampling was equally informative as BM for MRD detection. We conclude that MRD monitoring by quantitative RT-PCR at specific time points in CBF AML allows identification of patients at high risk of relapse and could now be incorporated in clinical trials to evaluate the role of risk directed/preemptive therapy. PMID:22875911

  13. Risk of Nongenitourinary Cancers in Patients With Spinal Cord Injury

    PubMed Central

    Kao, Chia-Hong; Sun, Li-Min; Chen, Yueh-Sheng; Lin, Cheng-Li; Liang, Ji-An; Kao, Chia-Hung; Weng, Ming-Wei

    2016-01-01

    Abstract Little information is available regarding the risk of nongenitourinary (GU) cancers in patients with spinal cord injury (SCI). The authors conducted a nationwide population-based study to investigate whether a higher risk of non-GU cancer is seen among patients with SCI. Data retrieved from the National Health Insurance Research Database of Taiwan were used in this study. A total of 41,900 patients diagnosed with SCI between 2000 and 2011 were identified from the National Health Insurance Research Database and comprised the SCI cohort. Each of these patients was randomly frequency matched with 4 people from the general population (without SCI) according to age, sex, comorbidities, and index year. Cox proportional hazards regression analysis was used to calculate adjusted hazard ratios and 95% confidence intervals and determine how SCI affected non-GU cancer risk. No significant difference in overall non-GU cancer risk was observed between the SCI and control groups. The patients with SCI exhibited a significantly higher risk of developing esophageal, liver, and hematologic malignancies compared with those without SCI. By contrast, the SCI cohort had a significantly lower risk of colorectal cancer compared with the non-SCI cohort (adjusted hazard ratio?=?0.80, 95% confidence interval?=?0.690.93). Additional stratified analyses by sex, age, and follow-up duration revealed various correlations between SCI and non-GU cancer risk. The patients with SCI exhibited higher risk of esophageal, liver, and hematologic malignancies but a lower risk of colorectal cancer compared with those without SCI. The diverse patterns of cancer risk among the patients with SCI may be related to the complications of chronic SCI. PMID:26765443

  14. Postoperative constipation risk assessment in Turkish orthopedic patients.

    PubMed

    ?endir, Merdiye; Byk?ylmaz, Funda; A?t?, Trkinaz; Grp?nar, ?engl; Yazgan, ?lknur

    2012-01-01

    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

  15. Helping Patients Decide: Ten Steps to Better Risk Communication

    PubMed Central

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

    2011-01-01

    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. PMID:21931068

  16. Principal stratification in causal inference.

    PubMed

    Frangakis, Constantine E; Rubin, Donald B

    2002-03-01

    Many scientific problems require that treatment comparisons be adjusted for posttreatment variables, but the estimands underlying standard methods are not causal effects. To address this deficiency, we propose a general framework for comparing treatments adjusting for posttreatment variables that yields principal effects based on principal stratification. Principal stratification with respect to a posttreatment variable is a cross-classification of subjects defined by the joint potential values of that posttreatment variable tinder each of the treatments being compared. Principal effects are causal effects within a principal stratum. The key property of principal strata is that they are not affected by treatment assignment and therefore can be used just as any pretreatment covariate. such as age category. As a result, the central property of our principal effects is that they are always causal effects and do not suffer from the complications of standard posttreatment-adjusted estimands. We discuss briefly that such principal causal effects are the link between three recent applications with adjustment for posttreatment variables: (i) treatment noncompliance, (ii) missing outcomes (dropout) following treatment noncompliance. and (iii) censoring by death. We then attack the problem of surrogate or biomarker endpoints, where we show, using principal causal effects, that all current definitions of surrogacy, even when perfectly true, do not generally have the desired interpretation as causal effects of treatment on outcome. We go on to forrmulate estimands based on principal stratification and principal causal effects and show their superiority. PMID:11890317

  17. The risk of stroke in patients with psoriasis.

    PubMed

    Gelfand, Joel M; Dommasch, Erica D; Shin, Daniel B; Azfar, Rahat S; Kurd, Shanu K; Wang, Xingmei; Troxel, Andrea B

    2009-10-01

    Psoriasis is a chronic Th-1 and Th-17 inflammatory disease. Chronic inflammation has also been associated with atherosclerosis and thrombosis. The purpose of this study was to determine the risk of stroke in patients with psoriasis. We conducted a population-based cohort study of patients seen by general practitioners participating in the General Practice Research Database in the United Kingdom, 1987-2002. Mild psoriasis was defined as any patient with a diagnostic code of psoriasis, but no history of systemic therapy. Severe psoriasis was defined as any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. When adjusting for major risk factors for stroke, both mild (hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.0-1.1) and severe (1.43, 95% CI 1.1-1.9) psoriasis were independent risk factors for stroke. The excess risk of stroke attributable to psoriasis in patients with mild and severe disease was 1 in 4,115 per year and 1 in 530 per year, respectively. Patients with psoriasis, particularly if severe, have an increased risk of stroke that is not explained by major stroke risk factors identified in routine medical care. PMID:19458634

  18. How can we identify the high-risk patient?

    PubMed Central

    Sankar, Ashwin; Beattie, W. Scott; Wijeysundera, Duminda N.

    2015-01-01

    Purpose of review Accurate and early identification of high-risk surgical patients allows for targeted use of perioperative monitoring and interventions that may improve their outcomes. This review summarizes current evidence on how information from the preoperative, operative, and immediate postoperative periods can help identify such individuals. Recent findings Simple risk indices, such as the Revised Cardiac Risk Index or American Society of Anesthesiologists Physical Status scale, and online calculators allow risk to be estimated with moderate accuracy using readily available preoperative clinical information. Both specific specialized tests (i.e., cardiopulmonary exercise testing and cardiac stress testing) and promising novel biomarkers (i.e., troponins and natriuretic peptides) can help refine these risk estimates before surgery. Estimates of perioperative risk can be further informed by information acquired during the operative and immediate postoperative periods, such as risk indices (i.e., surgical Apgar score), individual risk factors (i.e., intraoperative hypotension), or postoperative biomarkers (i.e., troponins and natriuretic peptides). Summary Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Although novel biomarkers, specialized preoperative testing, and immediate postoperative risk indices show promise as methods to refine these risk estimates, more research is needed on how best to integrate risk information from these different sources. PMID:26083327

  19. Increased risk of zoonotic Salmonella and Campylobacter gastroenteritis in patients with haematological malignancies: a population-based study.

    PubMed

    Gradel, Kim O; Nrgaard, Mette; Dethlefsen, Claus; Schnheyder, Henrik C; Kristensen, Brian; Ejlertsen, Tove; Nielsen, Henrik

    2009-08-01

    We hypothesised that haematological malignancies increase the risk of acquiring zoonotic Salmonella or Campylobacter gastroenteritis. The population-based study comprised all first-time Salmonella/Campylobacter gastroenteritis cases in two Danish counties (1991-2003), with age- and gender-matched controls from the background population. We linked the study cohort to registries to obtain data on malignancies, chemotherapy (yes/no), and main comorbidities diagnosed before Salmonella/Campylobacter gastroenteritis. Based on this design, we determined incidence rate ratios (IRR) in conditional logistic regression analyses, and we used weighted mean regression curves to evaluate fluctuations in risk 0-5 years after the malignancy diagnosis. Sixty-eight of 13,324 cases (0.5%) and 29 of 26,648 controls (0.1%) had haematological malignancy before their Salmonella/Campylobacter gastroenteritis. Comorbidity-adjusted IRR for Salmonella/Campylobacter gastroenteritis in patients with haematological malignancy as compared to patients without malignancy were 4.46 [95% confidence intervals (CI), 2.88-6.90] for all individuals, 8.33 (95% CI, 4.31-16.1) for Salmonella, and 2.17 (95% CI, 1.15-4.08) for Campylobacter. Stratification on chemotherapy treatment did not change these estimates. In time-related analyses, IRR were 7-8 in the first 2 years after the haematological malignancy diagnosis and 4-5 in the following 3 years. Patients with haematological malignancy had increased long-term risk of enquiring Salmonella or Campylobacter gastroenteritis. PMID:19083236

  20. High-Risk Lung Cancer Patients May Benefit from Surgery

    MedlinePLUS

    ... High-Risk Lung Cancer Patients May Benefit From Surgery Study showed procedure can be an option for ... 10, 2015 TUESDAY, Nov. 10, 2015 (HealthDay News) -- Surgery to remove part of the lung can be ...

  1. Treating Patients with High-Risk Smoldering Myeloma

    Cancer.gov

    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.

  2. Aspirin increases the risk of venous thromboembolism in surgical patients.

    PubMed

    Barmparas, Galinos; Jain, Monica; Mehrzadi, Devorah; Melo, Nicolas; Chung, Rex; Bloom, Matthew; Ley, Eric J; Margulies, Daniel R

    2014-10-01

    The risk of venous thromboembolism (VTE) for patients taking an antiplatelet agent is largely unknown. This study aimed to investigate the association between antiplatelet agent use before admission with the risk of in-hospital VTE in surgical intensive care unit (ICU) patients. A retrospective review of all patients admitted to the surgical ICU at a Level I trauma center over 30 months was performed. Patients who underwent diagnostic imaging for VTE were selected. Patients were divided based on whether or not antiplatelet agents were used before admission (APTA vs NAPTA). The primary outcome was VTE occurrence. A forward logistic regression model was used to identify factors independently associated with the primary outcome. During the study period, 461 (24%) patients met inclusion criteria: 70 (15%) APTA and 391 (85%) NAPTA. After adjusting for confounding factors, APTA patients were at a significantly higher risk for developing VTE (59 vs 40%; adjusted odds ratio, 1.8; 95% confidence interval, 1.0 to 3.0; adjusted P = 0.04). Whether or not antiplatelet agents were resumed during the hospital stay and the day on which they were resumed did not affect VTE risk. In conclusion, surgical ICU patients receiving antiplatelet agents before admission are at a significantly higher risk for development of VTE. PMID:25264630

  3. Lipoprotein-Associated Phospholipase A2 and High-Sensitivity C-Reactive Protein Improve the Stratification of Ischemic Stroke Risk in the Atherosclerosis Risk in Communities (ARIC) Study

    PubMed Central

    Nambi, Vijay; Hoogeveen, Ron C.; Chambless, Lloyd; Hu, Yijuan; Bang, Heejung; Coresh, Josef; Ni, Hanyu; Boerwinkle, Eric; Mosley, Thomas; Sharrett, Richey; Folsom, Aaron R.; Ballantyne, Christie M.

    2009-01-01

    Background and Purpose Inflammation plays a critical role in the development of vascular disease, and increased levels of the inflammatory biomarkers, lipoprotein-associated phospholipase A2 (Lp-PLA2), and high-sensitivity C-reactive protein (hs-CRP) have been shown to be associated with an increased risk for ischemic stroke. Methods In a prospective case– cohort (n=949) study in 12 762 apparently healthy, middle-aged men and women in the Atherosclerosis Risk in Communities (ARIC) study, we first examined whether Lp-PLA2 and hs-CRP levels improved the area under the receiver operator characteristic curve (AUC) for 5-year ischemic stroke risk. We then examined how Lp-PLA2 and hs-CRP levels altered classification of individuals into low-, intermediate-, or high-risk categories compared with traditional risk factors. Results In a model using traditional risk factors alone, the AUC adjusted for optimism was 0.732, whereas adding hs-CRP improved the AUC to 0.743, and adding Lp-PLA2 significantly improved the AUC to 0.752. Addition of hs-CRP and Lp-PLA2 together in the model improved the AUC to 0.761, and the addition of the interaction between Lp-PLA2 and hs-CRP further significantly improved the AUC to 0.774. With the use of traditional risk factors to assess 5-year risk for ischemic stroke, 86% of participants were categorized as low risk (<2%); 11%, intermediate risk (2% to 5%); and 3%, high risk (>5%). The addition of hs-CRP, Lp-PLA2, and their interaction to the model reclassified 4%, 39%, and 34% of the low-, intermediate- and high-risk categories, respectively. Conclusion Lp-PLA2 and hs-CRP may be useful in individuals classified as intermediate risk for ischemic stroke by traditional risk factors. PMID:19095974

  4. Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks

    PubMed Central

    Decker, Carole; Gialde, Elizabeth; Jones, Philip G; McNulty, Edward J; Bach, Richard; Chhatriwalla, Adnan K

    2015-01-01

    Objective To examine whether prospective bleeding risk estimates for patients undergoing percutaneous coronary intervention could improve the use of bleeding avoidance strategies and reduce bleeding. Design Prospective cohort study comparing the use of bleeding avoidance strategies and bleeding rates before and after implementation of prospective risk stratification for peri-procedural bleeding. Setting Nine hospitals in the United States. Participants All patients undergoing percutaneous coronary intervention for indications other than primary reperfusion for ST elevation myocardial infarction. Main outcome measures Use of bleeding avoidance strategies, including bivalirudin, radial approach, and vascular closure devices, and peri-procedural bleeding rates, stratified by bleeding risk. Observed changes were adjusted for changes observed in a pool of 1135 hospitals without access to pre-procedural risk stratification. Hospital level and physician level variability in use of bleeding avoidance strategies was examined. Results In a comparison of 7408 pre-intervention procedures with 3529 post-intervention procedures, use of bleeding avoidance strategies within intervention sites increased with pre-procedural risk stratification (odds ratio 1.81, 95% confidence interval 1.44 to 2.27), particularly among higher risk patients (2.03, 1.58 to 2.61; 1.41, 1.09 to 1.83 in low risk patients, after adjustment for control sites; P for interaction=0.05). Bleeding rates within intervention sites were significantly lower after implementation of risk stratification (1.0% v 1.7%; odds ratio 0.56, 0.40 to 0.78; 0.62, 0.44 to 0.87, after adjustment); the reduction in bleeding was greatest in high risk patients. Marked variability in use of bleeding avoidance strategies was observed across sites and physicians, both before and after implementation. Conclusions Prospective provision of individualized bleeding risk estimates was associated with increased use of bleeding avoidance strategies and lower bleeding rates. Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care. Study registration Clinicaltrials.gov NCT01383382. PMID:25805158

  5. As HIV Patients Live Longer, Certain Cancer Risks Rise

    MedlinePLUS

    ... system and a higher rate of infection with cancer-related viruses. HIV antiretroviral therapy, launched in 1996, has curbed some of that elevated risk. Now, the study team explained, HIV patients receiving ... 75 years. However, cancer risk has not been brought down to general ...

  6. Behavioral Risk Assessment of the Guarded Suicidal Patient

    ERIC Educational Resources Information Center

    Simon, Robert I.

    2008-01-01

    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

  7. Risk of Ischemic Stroke in Patients With Gastric Cancer

    PubMed Central

    Kuan, Ai-Seon; Chen, San-Chi; Yeh, Chiu-Mei; Hung, Man-Hsin; Hung, Yi-Ping; Chen, Tzeng-Ji; Liu, Chia-Jen

    2015-01-01

    Abstract Improvements in therapeutic modalities have prolonged the survival of gastric cancer patients. Comorbidities such as thromboembolic events that emerge as a result of disease complexities and/or treatments received have not been considered. The objectives of this study are to examine the relationship between gastric cancer and ischemic stroke, and to determine predictive risk factors. A nationwide population-based cohort study was conducted using data from the Taiwan National Health Insurance database. A total of 45,060 gastric cancer patients and non-cancer counterparts without antecedent stroke were recruited. Hazard ratios (HRs) and the cumulative incidence of ischemic stroke were calculated, and risk factors for ischemic stroke were assessed. Gastric cancer patients were associated with higher risk of ischemic stroke (HR 1.11, 95% confidence interval [CI] 1.031.19, P?=?0.007), especially in participants younger than 65 years (HR 1.61, 95% CI 1.391.86, P?risk factors of ischemic stroke in gastric cancer patients included age, hypertension, atrial fibrillation, dyslipidemia, and having received major surgery for gastric cancer. Our findings suggest the importance of stroke surveillance and prevention strategies in high-risk patients. Having received major surgery for gastric cancer is a significant risk factor in these patients. PMID:26376378

  8. Identifying, assessing and managing high-risk patients under Medicare risk contracts.

    PubMed

    Dupee, R; Halpern, R

    2001-01-01

    Physicians participating in Medicare managed care plans are increasingly sharing in the financial risks of providing care to enrollees. Although capitation payments are calculated to reflect the average costs for an entire patient panel, there is typically great variation among patients, from healthy individuals to patients requiring high volume and high-cost care. To be successful, physicians must identify high-risk seniors, develop care plans to maintain health and functioning, and monitor health status and ongoing care and treatment. Techniques for performing a comprehensive geriatric assessment include written questionnaires and interviews during office appointments. The goal is to evaluate each patient's health status, medical risk factors, psychosocial profile, cognitive capacities, and functional capabilities and limitations. After frail and at-risk seniors are identified, the physician must collaborate with the case manager, geriatric nurse practitioner, other caregivers, and the patient and family members to initiate and maintain effective care management. PMID:11497315

  9. Risk Prediction of Hepatocellular Carcinoma in Patients With Cirrhosis: The ADRESS-HCC Risk Model

    PubMed Central

    Flemming, Jennifer A.; Yang, Ju Dong; Vittinghoff, Eric; Kim, W. Ray

    2015-01-01

    BACKGROUND All patients with cirrhosis are at risk of developing hepatocellular carcinoma (HCC). This risk is not uniform because other patient-related factors influence the risk of HCC. The objective of the current study was to develop an HCC risk prediction model to estimate the 1-year probability of HCC to assist with patient counseling. METHODS Between 2002 and 2011, a cohort of 34,932 patients with cirrhosis was identified from a national liver transplantation waitlist database from the United States. Cox proportional hazards regression methods were used to develop and validate a risk prediction model for incident HCC. In the validation cohort, discrimination and calibration of the model was examined. External validation was conducted using patients with cirrhosis who were enrolled in the Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) study. RESULTS HCC developed in 1960 patients (5.6%) during a median follow-up of 1.3 years (interquartile range, 0.47 years-2.83 years). Six baseline clinical variables, including age, diabetes, race, etiology of cirrhosis, sex, and severity (ADRESS) of liver dysfunction were independently associated with HCC and were used to develop the ADRESS-HCC risk model. C-indices in the derivation and internal validation cohorts were 0.704 and 0.691, respectively. In the validation cohort, the predicted cumulative incidence of HCC by the ADRESS-HCC model closely matched the observed data. In patients with cirrhosis in the HALT-C cohort, the model stratified patients correctly according to the risk of developing HCC within 5 years. CONCLUSIONS The ADRESS-HCC risk model is a useful tool for predicting the 1-year risk of HCC among patients with cirrhosis. PMID:25042049

  10. Increased Risk of Ischemic Stroke in Young Nasopharyngeal Carcinoma Patients

    SciTech Connect

    Lee, Ching-Chih; Su, Yu-Chieh; Ho, Hsu-Chueh; Hung, Shih-Kai; Lee, Moon-Sing; Chiou, Wen-Yen; Chou, Pesus; Huang, Yung-Sung

    2011-12-01

    Purpose: Radiation/chemoradiotherapy-induced carotid stenosis and cerebrovascular events in patients with nasopharyngeal carcinoma (NPC) can cause severe disability and even death. This study aimed to estimate the risk of ischemic stroke in this patient population over more than 10 years of follow-up. Methods and Materials: The study cohorts consisted of all patients hospitalized with a principal diagnosis of NPC (n = 1094), whereas patients hospitalized for an appendectomy during 1997 and 1998 (n = 4376) acted as the control group and surrogate for the general population. Cox proportional hazard model was performed as a means of comparing the stroke-free survival rate between the two cohorts after adjusting for possible confounding and risk factors. Results: Of the 292 patients with ischemic strokes, 62 (5.7%) were from the NPC cohort and 230 (5.3%) were from the control group. NPC patients ages 35-54 had a 1.66 times (95% CI, 1.16-2.86; p = 0.009) higher risk of ischemic stroke after adjusting for patient characteristics, comorbidities, geographic region, urbanization level of residence, and socioeconomic status. There was no statistical difference in ischemic stroke risk between the NPC patients and appendectomy patients ages 55-64 years (hazard ratio = 0.87; 95% CI, 0.56-1.33; p = 0.524) after adjusting for other factors. Conclusions: Young NPC patients carry a higher risk for ischemic stroke than the general population. Besides regular examinations of carotid duplex, different irradiation strategies or using new technique of radiotherapy, such as intensity modulated radiation therapy or volumetric modulated arc therapy, should be considered in young NPC patients.

  11. Risk factors for osteoporosis in inflammatory bowel disease patients

    PubMed Central

    Lima, Carla Andrade; Lyra, Andre Castro; Rocha, Raquel; Santana, Genoile Oliveira

    2015-01-01

    Inflammatory bowel disease (IBD) patients exhibit higher risk for bone loss than the general population. The chronic inflammation causes a reduction in bone mineral density (BMD), which leads to osteopenia and osteoporosis. This article reviewed each risk factor for osteoporosis in IBD patients. Inflammation is one of the factors that contribute to osteoporosis in IBD patients, and the main system that is involved in bone loss is likely RANK/RANKL/osteoprotegerin. Smoking is a risk factor for bone loss and fractures, and many mechanisms have been proposed to explain this loss. Body composition also interferes in bone metabolism and increasing muscle mass may positively affect BMD. IBD patients frequently use corticosteroids, which stimulates osteoclastogenesis. IBD patients are also associated with vitamin D deficiency, which contributes to bone loss. However, infliximab therapy is associated with improvements in bone metabolism, but it is not clear whether the effects are because of inflammation improvement or infliximab use. Ulcerative colitis patients with proctocolectomy and ileal pouches and Crohn’s disease patients with ostomy are also at risk for bone loss, and these patients should be closely monitored. PMID:26600979

  12. Risk factors for osteoporosis in inflammatory bowel disease patients.

    PubMed

    Lima, Carla Andrade; Lyra, Andre Castro; Rocha, Raquel; Santana, Genoile Oliveira

    2015-11-15

    Inflammatory bowel disease (IBD) patients exhibit higher risk for bone loss than the general population. The chronic inflammation causes a reduction in bone mineral density (BMD), which leads to osteopenia and osteoporosis. This article reviewed each risk factor for osteoporosis in IBD patients. Inflammation is one of the factors that contribute to osteoporosis in IBD patients, and the main system that is involved in bone loss is likely RANK/RANKL/osteoprotegerin. Smoking is a risk factor for bone loss and fractures, and many mechanisms have been proposed to explain this loss. Body composition also interferes in bone metabolism and increasing muscle mass may positively affect BMD. IBD patients frequently use corticosteroids, which stimulates osteoclastogenesis. IBD patients are also associated with vitamin D deficiency, which contributes to bone loss. However, infliximab therapy is associated with improvements in bone metabolism, but it is not clear whether the effects are because of inflammation improvement or infliximab use. Ulcerative colitis patients with proctocolectomy and ileal pouches and Crohn's disease patients with ostomy are also at risk for bone loss, and these patients should be closely monitored. PMID:26600979

  13. Gun Safety Management with Patients at Risk for Suicide

    ERIC Educational Resources Information Center

    Simon, Robert I.

    2007-01-01

    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…

  14. Gun Safety Management with Patients at Risk for Suicide

    ERIC Educational Resources Information Center

    Simon, Robert I.

    2007-01-01

    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

  15. Increased Arterial Stiffness in Systemic Lupus Erythematosus (SLE) Patients at Low Risk for Cardiovascular Disease: A Cross-Sectional Controlled Study

    PubMed Central

    Sacre, Karim; Escoubet, Brigitte; Pasquet, Blandine; Chauveheid, Marie-Paule; Zennaro, Maria-Christina; Tubach, Florence; Papo, Thomas

    2014-01-01

    Cardiovascular disease (CVD) is a major cause of death in systemic lupus erythematosus (SLE) patients. Although the risk for cardiovascular events in patients with SLE is significant, the absolute number of events per year in any given cohort remains small. Thus, CVD risks stratification in patients with SLE focuses on surrogate markers for atherosclerosis at an early stage, such as reduced elasticity of arteries. Our study was designed to determine whether arterial stiffness is increased in SLE patients at low risk for CVD and analyze the role for traditional and non-traditional CVD risk factors on arterial stiffness in SLE. Carotid-femoral pulse wave velocity (PWV) was prospectively assessed as a measure of arterial stiffness in 41 SLE patients and 35 controls (CTL). Adjustment on age or Framingham score was performed using a logistic regression model. Factors associated with PWV were identified separately in SLE patients and in controls using Pearson's correlation coefficient for univariate analysis and multiple linear regression for multivariate analysis. SLE patients and controls displayed a low 10-year risk for CVD according to Framingham score (1.83.6% in SLE vs 1.62.8% in CTL, p?=?0.46). Pulse wave velocity was, however, higher in SLE patients (7.11.6 m/s) as compared to controls (6.30.8 m/s; p?=?0.01, after Framingham score adjustment) and correlated with internal carotid wall thickness (p?=?0.0017). In multivariable analysis, only systolic blood pressure (p?=?0.0005) and cumulative dose of glucocorticoids (p?=?0.01) were associated with PWV in SLE patients. Interestingly, the link between systolic blood pressure (SBP) and arterial stiffness was also confirmed in SLE patients with normal systolic blood pressure. In conclusion, arterial stiffness is increased in SLE patients despite a low risk for CVD according to Framingham score and is associated with systolic blood pressure and glucocorticoid therapy. PMID:24722263

  16. Chemical stratification of the mantle

    NASA Technical Reports Server (NTRS)

    Anderson, D. L.

    1979-01-01

    A possible scenario for the chemical stratification of the earth's mantle is presented. Differentiation of the mantle by either the production of basaltic magmas or partial melting by the upper mantle is proposed to lead to a thick basalt layer, the lower part of which is converted to eclogite as the earth cools. Density estimates indicate that the eclogite formed would not be able to sink to below 670 km. The eclogite layer is thus demonstrated to be trapped as a result of whole-mantle convection and possible irreversible differentiation of the mantle into eclogite and overlying residual peridotite layers.

  17. Risk perception after genetic counseling in patients with increased risk of cancer

    PubMed Central

    Rantala, Johanna; Platten, Ulla; Lindgren, Gunilla; Nilsson, Bo; Arver, Brita; Lindblom, Annika; Brandberg, Yvonne

    2009-01-01

    Background Counselees are more aware of genetics and seek information, reassurance, screening and genetic testing. Risk counseling is a key component of genetic counseling process helping patients to achieve a realistic view for their own personal risk and therefore adapt to the medical, psychological and familial implications of disease and to encourage the patient to make informed choices [1,2]. The aim of this study was to conceptualize risk perception and anxiety about cancer in individuals attending to genetic counseling. Methods The questionnaire study measured risk perception and anxiety about cancer at three time points: before and one week after initial genetic counseling and one year after completed genetic investigations. Eligibility criteria were designed to include only index patients without a previous genetic consultation in the family. A total of 215 individuals were included. Data was collected during three years period. Results Before genetic counseling all of the unaffected participants subjectively estimated their risk as higher than their objective risk. Participants with a similar risk as the population overestimated their risk most. All risk groups estimated the risk for children's/siblings to be lower than their own. The benefits of preventive surveillance program were well understood among unaffected participants. The difference in subjective risk perception before and directly after genetic counseling was statistically significantly lower in all risk groups. Difference in risk perception for children as well as for population was also statistically significant. Experienced anxiety about developing cancer in the unaffected subjects was lower after genetic counseling compared to baseline in all groups. Anxiety about cancer had clear correlation to perceived risk of cancer before and one year after genetic investigations. The affected participants overestimated their children's risk as well as risk for anyone in population. Difference in risk perception for children/siblings as for the general population was significant between the first and second measurement time points. Anxiety about developing cancer again among affected participants continued to be high throughout this investigation. Conclusion The participant's accuracy in risk perception was poor, especially in low risk individuals before genetic counseling. There was a general trend towards more accurate estimation in all risk groups after genetic counseling. The importance of preventive programs was well understood. Cancer anxiety was prevalent and associated with risk perception, but decreased after genetic counseling. [1] National Society of Genetic Counselors (2005), Genetic Counseling as a Profession. Available at (accessed November 25th 2007) [2] Julian-Reynier C., Welkenhuysen M-, Hagoel L., Decruyenaere M., Hopwood P. (2003) Risk communication strategies: state of the art and effectiveness in the context of cancer genetic services. Eur J of Human Genetics 11, 725-736. PMID:19698175

  18. [Man at risk. Preventive strategies and risk management for patient safety].

    PubMed

    Grube, C; Schaper, N; Graf, B M

    2002-04-01

    Anaesthesia-related risk has been significantly reduced within the last decade. Nevertheless the risk and the possibility of dying or suffering permanent damage still exist. To improve patient safety, risk assessment and analysis must lead to the development of preventive strategies. For this purpose anaesthesia can rely on the concepts of other "high reliability" organisations such as aviation or nuclear power plants. Analyses of critical incidents in the different fields confirm that next to technical problems human factors account for most of the preventable mishaps. Human factors are responsible for individual mistakes as well as for organisational errors. Therefore besides traditional concepts of risk reduction (e.g. guidelines) new strategies (e.g. full-scale simulation) must be applied to minimise the negative impact of human factors on patient safety. Risk management has to consider technical, organisational and human factors to implement a higher standard of patient safety. PMID:12063713

  19. Risk and experience: effects of experiential learning and patient characteristics in interpretation of dynamic risk graphics.

    PubMed

    Ancker, Jessica S; Senathirajah, Yalini; Weber, Elke U; Kukafka, Rita

    2006-01-01

    Risks can be explained to patients in narratives, numbers, or graphs. All these methods depend upon description. However, decisions from description differ systematically from decisions about risks that are experienced through activities such as drawing cards from a deck. We have developed a dynamic graphic interface that provides a virtual experience of event probabilities, with potential applications in patient education and decision support. PMID:17238464

  20. Aortic stenosis: assessment of the patient at risk.

    PubMed

    Yeo, Khung Keong; Low, Reginald I

    2007-12-01

    The true incidence of aortic stenosis among the general population is unknown but aortic sclerosis, its precursor, has been estimated to affect about 25% of people over age 65, while an estimated 3% of the population over age 75 have severe aortic stenosis. Severe aortic stenosis, when accompanied by symptoms of angina, syncope, or heart failure, is associated with high mortality rates. Two-dimensional and Doppler echocardiography are cornerstone tools for the evaluation and monitoring of aortic stenosis. Echocardiography helps identify the patient at risk of death and guide timing of aortic valve replacement. Other important diagnostic tools include cardiac catheterization, treadmill stress testing, and dobutamine stress echocardiography, although their use is limited to specific patient populations. Aortic valve replacement carries a significant operative risk of approximately 4.0%. However, risk of operative mortality varies according to comorbidities and disease presentation. There are many risk models that guide estimation of the risk of operative mortality. Understanding operative risk is important in patient care and the selection of patients for aortic valve replacement. PMID:18042056

  1. Venous thromboembolism: identifying patients at risk and establishing prophylaxis.

    PubMed

    Shirvanian, Shant; Tapson, Victor F

    2015-12-01

    Venous thromboembolism (VTE) is a major cause of morbidity and mortality and is associated with substantial healthcare costs. Identification of patients at risk of developing VTE enables appropriate thromboprophylaxis to be implemented. Although no predisposing risk factors can be identified in many patients in whom VTE develops, most have at least one underlying risk factor which can be categorized according to whether it confers low, moderate, or high risk. Clinical trials have demonstrated the effectiveness of thromboprophylaxis, both non-pharmacological and pharmacological, in a host of medical settings and there is sufficient evidence to support routine prophylaxis in many groups of patients. The implementation of decision making tools based on risk factor assessment improves the prescription of appropriate VTE prophylaxis. Nonetheless, thromboprophylaxis is often inadequate, with haphazard risk assessment and application of guidelines, leading to easily preventable instances of VTE. The most commonly used agents for pharmacological thromboprophylaxis of VTE are low dose unfractionated heparin; a low molecular weight heparin such as dalteparin, enoxaparin or tinzaparin; fondaparinux; warfarin; or aspirin. However, these have a number of drawbacks, principally the need for parenteral administration (with heparins) and frequent coagulation monitoring (with warfarin). The optimal anticoagulant would be orally administered, with a wide therapeutic window, rapid onset of action, predictable pharmacodynamics and pharmacokinetics, minimal interactions with food and other drugs, an ability to inhibit free and clot-bound coagulation factors, low, non-specific binding, and no requirement for routine coagulation monitoring or dose adjustment. A number of novel, single-target oral anticoagulants have been developed that appear to fulfill many of these requirements. This narrative review discusses the use of guidelines and risk assessment tools to identify patients at risk of VTE; it provides an overview of appropriate prophylaxis strategies in these patients with a summary of clinical trial results with novel oral anticoagulants. PMID:26414590

  2. Prediction of cardiac risk in patients undergoing vascular surgery

    SciTech Connect

    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.

    1987-03-01

    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.

  3. Aetiological stratification as a conceptual framework for gene-by-environment interaction research in psychiatry.

    PubMed

    van Winkel, Ruud

    2015-02-01

    It has been argued that gene-by-environment interactions (GנE) research is unlikely to progress knowledge about psychiatric disorders, in contrast to genome-wide association (GWA) studies. However, GנE approaches are not alternatives for gene-hunting but a way to identify genetic and biological mechanisms within subgroups of patients exposed to a similar aetiological (environmental) factor via a process of 'aetiological stratification'. This is important as diagnostic categories targeted by GWA studies are inherently heterogeneous and lack biological validity. Aetiological stratification builds on examining possible phenotypic and/or molecular specificity associated with exposure to the environmental factor across multiple potentially relevant disorders, combined with efforts to identify an underlying biological substrate. GנE hypotheses within this framework investigate (1) which genes influence the degree to which individuals develop identified biological alterations that link environmental exposure to specific phenotypic and/or molecular characteristics within or across psychiatric disorders and (2) which genes are implicated in determining the development of psychopathology once this biological alteration has been brought about. As gene-hunting is not a goal in itself, the examination of pathway and/or polygenic risk scores may be more informative than the examination of individual markers, at the same time reducing multiple testing and the associated risk of spurious findings. PMID:25693861

  4. Comparative accuracy of different risk scores in assessing cardiovascular risk in Indians: A study in patients with first myocardial infarction

    PubMed Central

    Bansal, Manish; Kasliwal, Ravi R.; Trehan, Naresh

    2014-01-01

    Background Although a number of risk assessment models are available for estimating 10-year risk of cardiovascular (CV) events in patients requiring primary prevention of CV disease, the predictive accuracy of the contemporary risk models has not been adequately evaluated in Indians. Methods 149 patients [mean age 59.410.6 years; 123 (82.6%) males] without prior CV disease and presenting with acute myocardial infarction (MI) were included. The four clinically most relevant risk assessment models [Framingham Risk score (RiskFRS), World Health Organization risk prediction charts (RiskWHO), American College of Cardiology/American Heart Association pooled cohort equations (RiskACC/AHA) and the 3rd Joint British Societies' risk calculator (RiskJBS)] were applied to estimate what would have been their predicted 10-year risk of CV events if they had presented just prior to suffering the acute MI. Results RiskWHO provided the lowest risk estimates with 86.6% patients estimated to be having <20% 10-year risk. In comparison, RiskFRS and RiskACC/AHA returned higher risk estimates (61.7% and 69.8% with risk <20%, respectively; p values <0.001 for comparison with RiskWHO). However, the RiskJBS identified the highest proportion of the patients as being at high-risk (only 44.1% at <20% risk, p values 0<0.01 for comparison with all the other 3 risk scores). Conclusions This is the first study to show that in Indian patients presenting with acute MI, RiskJBS is likely to identify the largest proportion of the patients as at high-risk as compared to RiskWHO, RiskFRS and RiskACC/AHA. However, large-scale prospective studies are needed to confirm these findings. PMID:25634388

  5. Radioiodine Treatment and Thyroid Hormone Suppression Therapy for Differentiated Thyroid Carcinoma: Adverse Effects Support the Trend toward Less Aggressive Treatment for Low-Risk Patients

    PubMed Central

    Klein Hesselink, E.N.; Links, T.P.

    2015-01-01

    Over the past decades, the incidence of differentiated thyroid carcinoma (DTC) has steadily increased, with especially a growing number of low-risk patients. Whereas DTC used to be treated rather aggressively, it is now acknowledged that aggressive treatment does not affect outcome for low-risk patients and that it can induce adverse effects. In this review an overview of the most clinically relevant adverse effects of radioiodine treatment and thyroid hormone suppression therapy (THST) is presented, and the trend toward less aggressive treatment for low-risk patients is outlined. Salivary gland dysfunction occurs in roughly 30% of patients, and is probably due to the concentration of radioiodine in the salivary glands by the sodium/iodide symporter. Beta radiation from radioiodine can result in sialoadenitis and eventually fibrosis and loss of salivary function. Furthermore, patients can experience bone marrow dysfunction following radioiodine treatment. Although this is in general subclinical and transient, patients that receive very high cumulative radioiodine doses may be at risk for more severe bone marrow dysfunction. THST can induce adverse cardiovascular effects in patients with DTC, such as diastolic and systolic dysfunction, and also adverse vascular and prothrombotic effects have been described. Finally, the effects of THST on bone formation and resorption are outlined; especially postmenopausal women with DTC on THST seem to be at risk of bone loss. In the past years, advances have been made in preventing low-risk patients from being overtreated. Improved biomarkers are still needed to further optimize risk stratification and personalize medicine. PMID:26279993

  6. Nutritional risk assessment in critically ill cancer patients: systematic review

    PubMed Central

    Fruchtenicht, Ana Valéria Gonçalves; Poziomyck, Aline Kirjner; Kabke, Geórgia Brum; Loss, Sérgio Henrique; Antoniazzi, Jorge Luiz; Steemburgo, Thais; Moreira, Luis Fernando

    2015-01-01

    Objective To systematically review the main methods for nutritional risk assessment used in critically ill cancer patients and present the methods that better assess risks and predict relevant clinical outcomes in this group of patients, as well as to discuss the pros and cons of these methods according to the current literature. Methods The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, LILACS and SciELO databases by searching for the key words “nutritional risk assessment”, “critically ill” and “cancer”. Results Only 6 (17.7%) of 34 initially retrieved papers met the inclusion criteria and were selected for the review. The main outcomes of these studies were that resting energy expenditure was associated with undernourishment and overfeeding. The high Patient-Generated Subjective Global Assessment score was significantly associated with low food intake, weight loss and malnutrition. In terms of biochemical markers, higher levels of creatinine, albumin and urea were significantly associated with lower mortality. The worst survival was found for patients with worse Eastern Cooperative Oncologic Group - performance status, high Glasgow Prognostic Score, low albumin, high Patient-Generated Subjective Global Assessment score and high alkaline phosphatase levels. Geriatric Nutritional Risk Index values < 87 were significantly associated with mortality. A high Prognostic Inflammatory and Nutritional Index score was associated with abnormal nutritional status in critically ill cancer patients. Among the reviewed studies that examined weight and body mass index alone, no significant clinical outcome was found. Conclusion None of the methods reviewed helped to define risk among these patients. Therefore, assessment by a combination of weight loss and serum measurements, preferably in combination with other methods using scores such as Eastern Cooperative Oncologic Group - performance status, Glasgow Prognostic Score and Patient-Generated Subjective Global Assessment, is suggested given that their use is simple, feasible and useful in such cases. PMID:26270855

  7. Discordance between patient report and chart review of risk factors for antimicrobial resistance in ED patients?

    PubMed Central

    Caterino, Jeffrey M.; Graham, Lauren

    2014-01-01

    Objectives The objective of this study is to identify the level of agreement between patient self-report and chart review for presence of antimicrobial resistance (AR) risk factors in emergency department (ED) patients. Methods This is a cross-sectional analysis of adult ED patients from July 2010 to January 2011. All ED patients 18 years or older were eligible. Exclusion criteria included pregnant women, prisoners, altered mental status, non-English speakers, traumas, and patients unable to provide consent. Data were obtained by ED patient interview and review of the preceding 3 months of the medical record. We report the difference between patient self-report and chart review of identifying 1 or more AR risk factors using McNemars ?2. The test statistic was also calculated for individual risk factors and significance adjusted for multiple comparisons (P < .003). Agreement was calculated using ? with 95% confidence intervals (CIs). Risk factor domains assessed included nursing home residence, recent health care utilization, current indwelling devices, and medical history. Results Among 289 patients, 1 or more risk factors were reported by 68% (95% CI, 63%74%) of patients and found in 59% (95% CI, 53%65%) of charts, a difference of 9.7% (95% CI, 5.3%14%) (P < .001; ? = 0.72). Patients were more likely to report recent antibiotic use (42% vs 29%; P < .001; ? = 0.52) and recent surgery (17% vs 11%; P < .001; ? = 0.64). Conclusions There is disagreement between ED patient self-report and medical record review for many AR risk factors. This could affect both clinical care and results of ED research studies relying on chart reviews. Patient self-report identifies a greater number of AR risk factors than chart review. PMID:23906619

  8. Self-criticism of physicians, patient participation and risk competence

    PubMed Central

    Wolffsohn, Michael

    2015-01-01

    Self-criticism of physicians and patient participation are the pillars of modern medical ethics and medical programmes. Patients expect risk minimisation from physicians, mostly without realising how much they could actively do themselves in this respect. But what about the willingness of German people to take risks, how high is it really at present? Direct empirical data are not available, but results from general empirical research show that people’s willingness to take risks is probably rather low. Post-heroic societies of welfare states are less likely to take risks than supposedly heroic ones. Therefore, the question whether it is responsible for medical experts to transfer even more responsibility to non-medical laypeople becomes increasingly important in a social context. PMID:26195919

  9. Risk assessment and psychosocial interventions for suicidal patients

    PubMed Central

    Chesin, Megan; Stanley, Barbara

    2013-01-01

    Objectives Suicide is a leading cause of death in the US. Although factors elevating long-term risk for suicide are known and include bipolar disorder, signs of imminent suicide risk are difficult to study and not well-specified. Acute risk determinations must be made to determine the appropriate level of care to safeguard patients. To increase safety among at-risk patients in the short term and to decrease risk over time, psychosocial interventions to prevent suicide have been developed and tested in acute care and outpatient settings. Methods A narrative review of studies of imminent risk factors for suicide, suicide risk decision making, and psychosocial suicide prevention interventions was conducted. Results While some long-term risk factors of suicide have been established, accurate identification of individuals at imminent risk for suicide is difficult. Therefore, prevention efforts targeting individuals at high suicide behavior risk discharging from acute care settings tend to be generic and focus on psychoeducation and supportive follow-up contact. Data regarding the effectiveness of brief interventions (i.e., those not requiring more than one individualized treatment session) is mixed, showing better outcomes in the shorter term and when incidence of suicidal behavior or ideation is the outcome. With respect to longer term suicide prevention interventions (i.e., those with a minimum of 10 sessions), Dialectical Behavior Therapy has the largest evidence base. Conclusions To improve suicide prevention efforts, more rigorous study of imminent risk factors and psychosocial interventions is needed. Adaptations specific to individuals with bipolar disorder are possible and needed. PMID:23782460

  10. Risk of healthcare associated infections in HIV positive patients.

    PubMed

    Mitha, Mohammed; Furuya, E Yoko; Larson, Elaine

    2014-11-01

    HIV positive patients are a high risk population due to the alteration in their immune status. Health-care associated infections (HAI) have not been well described in this population, with some risk factors reported inconsistently in the literature. The aim of this study was to describe the epidemiology as well as the underlying risk factors for HAI, specifically urinary tract infection (UTI), bloodstream infection (BSI) and respiratory tract infection (RTI). This was a retrospective cohort study conducted at an academic health system in New York City which included three hospitals over a two year period from 2006 to 2008. There were 3,877 HIV positive patient discharges in 1,911 patients. There were a total of 142 UTI, 106 BSI, and 100 RTI. The incidence rates were 4.35 for UTI, 3.16 for BSI and 2.98 for RTI. CD4 count and antiretroviral therapy were not associated with HAI. Significant predictors of UTI included urinary catheter, length of stay, female gender, steroids and trimethoprim-sulphamethoxazole (TMP-SMX); of BSI were steroids and TMP-SMX; and RTI were mechanical ventilation, steroids and TMP-SMX. Multivariable analysis indicated that TMP-SMX was significantly associated with an increased risk of infection for all three types of HAI [BSI odds ratio 2.55, 95% confidence interval (1.22-5.34); UTI odds ratio 3.1, 95% confidence interval (1.41-7.22); RTI odds ratio 5.15, 95% confidence interval (1.70-15.62)]. HIV positive patients are at significant risk for developing HAI, but the risk factors differ depending on the specific type of infection. The fact that TMP-SMX is a risk factor in these patients warrants further research as this may have significant health policy implications. PMID:25484924

  11. Colonoscopy-induced ischemic colitis in patients without risk factors

    PubMed Central

    Lee, Sang Ok; Kim, Sae Hee; Jung, Sung Hee; Park, Chan Woong; Lee, Min Ji; Lee, Jin A; Koo, Hyun Cheol; Kim, Anna; Han, Hyun-Young; Kang, Dong-Wook

    2014-01-01

    Ischemic colitis is the most common form of intestinal ischemia. It is a condition that is commonly seen in the elderly and among individuals with risk factors for ischemia. Common predisposing conditions for ischemic colitis are major vascular occlusion, small vessel disorder, shock, some medications, colonic obstructions and hematologic disorders. Ischemic colitis following colonoscopy is rare. Here, we report two cases of ischemic colitis after a routine screening colonoscopy in patients without risk factors for ischemia. PMID:24707156

  12. Cardiovascular risk assessment in antiretroviral-nave HIV patients.

    PubMed

    Maggi, Paolo; Quirino, Tiziana; Ricci, Elena; De Socio, Giuseppe Vittorio L; Gadaleta, Aurora; Ingrassia, Fabrizio; Perilli, Francesco; Lillo, Antonio; Bonfanti, Paolo

    2009-10-01

    Various studies have been conducted to evaluate the role of antiretroviral therapy in the onset of cardiovascular risk among HIV-1-infected patients, while fewer data are available regarding antiretroviral-nave patients. Our objective was to evaluate the cardiovascular risk among nave subjects examining traditional risk factors, immunovirologic parameters, assessing the Framingham risk score (FRS), and detecting the presence of subclinical carotid lesions by means of color Doppler ultrasonography. One hundred seventy-two antiretroviral-nave patients underwent color Doppler ultrasonography. An intima-media thickness (IMT) greater than 0.9 mm and/or atherosclerotic plaques were considered pathologic findings. Demographic, immunovirologic data, and risk factors for cardiovascular disease were collected. The 10-year probability of acute coronary events was assessed by the FRS. The statistical analysis was performed using t test and chi(2), Fisher's test, and conditional multiple logistic. Thirty-six patients (20.9%) had lesions at ultrasonographic investigation. The presence of lesions was significantly related to male gender (p = 0.005), age (p = 0.003), sedentary life (p = 0.05), Centers for Disease Control and Prevention (CDC) group C or CD4(+) less than 150 cells/mm(3), and viral load (VL) > 100,000 copies per milliliter (p = 0.04). The presence of subclinical carotid lesions showed a highly significant direct association with the estimated FRS (p < 0.002). The presence of subclinical atheromasic lesion results was also high among antiretroviral-nave patients. FRS is highly predictive of the lesions, but also an advanced stage of disease plays a significant role. Our data support the hypothesis that HIV infection per se is a risk factor for atherosclerosis. We recommend an ultrasonographic assessment both among patients with FRS 6% or more and among those in advanced stage of disease. PMID:19824809

  13. Risk of new primary cancer in patients with oropharyngeal cancer.

    PubMed Central

    Sderholm, A. L.; Pukkala, E.; Lindqvist, C.; Teppo, L.

    1994-01-01

    The relative risk of subsequent cancers was evaluated for a total of 9,092 patients with lip and oropharyngeal cancer recorded between 1953 and 1989 in the nationwide Finnish Cancer Registry. The observed numbers of patients were compared with those expected on the basis of the incidence rates in the Finnish population. There were 1,130 patients (12%) with a new cancer. The standardised incidence ratio (SIR) of contracting a new primary cancer was 1.2 for lip cancer patients (95% CI 1.1-1.3) and 1.4 for patients with oropharyngeal cancer (95% CI 1.2-1.4). Among lip cancer patients, a statistically significant excess risk was found for subsequent cancers in the oropharyngeal area (SIR 1.9, 95% CI 1.1-3.1), larynx (SIR 2.0, 95% CI 1.2-2.9) and lung (SIR 1.4, 95% CI 1.3-1.6), i.e. for cancers with tobacco aetiology. Among patients with oropharyngeal cancer there was an excess of lip cancer (SIR, 3.5, 95% CI 1.5-6.9), lung cancer (SIR 1.8, 95% CI 1.3-2.3) and leukaemia (SIR 2.3, 95% CI 1.0-4.3). Radiotherapy for the first primary did not increase the risk of new cancer. PMID:8142267

  14. Patients awareness of the surgical risks of smoking

    PubMed Central

    Bottorff, Joan L.; Seaton, Cherisse L.; Lamont, Sonia

    2015-01-01

    Objective To describe the smoking patterns of patients receiving elective surgery and their knowledge about the benefits of smoking cessation to inform and strengthen support for patients to quit smoking in order to optimize surgical outcomes. Design Patients who had elective surgery were screened for smoking status, and eligible patients completed a telephone survey. Setting Two regional hospitals in northern British Columbia. Participants Of 1722 patients screened, 373 reported smoking before surgery. Of these, 161 (59.0% women) completed a telephone survey. Main outcome measures Patient smoking cessation, knowledge of the perioperative risks of smoking, use of resources, and health care provider advice and assistance. Results Participants included 66 men and 95 women (mean [SD] age of 51.9 [14.0] years). In total, 7.5% of these patients quit smoking in the 8 weeks before their surgeries, although an additional 38.8% reduced their smoking. Only about half of the patients surveyed were aware that continuing to smoke increased their surgical risks. Further, only half of the patients surveyed reported being advised to quit before their surgeries by a health care professional. Few were using the provincial resources available to support smoking cessation (eg, QuitNow), and 39.6% were unaware of the provincial program to cover the cost of smoking cessation aids (eg, nicotine gum or patches), yet 62.7% of respondents were thinking about quitting smoking. Conclusion Many surgical patients in northern British Columbia who smoked were unaware of the perioperative risks of smoking and the cessation support available to them. An opportunity exists for all health care professionals to encourage more patients to quit in order to optimize their surgical outcomes.

  15. Management of intermediate-risk pulmonary embolism: uncertainties and challenges.

    PubMed

    Klok, Frederikus Albertus; Meyer, Guy; Konstantinides, Stavros

    2015-12-01

    Current guidelines on the treatment of acute pulmonary embolism (PE) recommend stratification of hemodynamically stable patients in 'low risk' and 'intermediate risk'. Validated risk scores, cardiac biomarkers, and imaging of the right ventricle all help in distinguishing both patient categories. The relevance of this risk stratification lies in the determination of the most optimal treatment for the individual patient. In this clinical review, we will discuss how patients with 'intermediate-risk' PE can be identified as well as recent advances in their therapeutic management. Based on a clinical case, we will highlight the indications for reperfusion therapy and the current experience with non-vitamin K-dependent oral anticoagulant (NOACs) in this specific patient's category. PMID:26109174

  16. Traditional Risk Factors Versus Biomarkers for Prediction of Secondary Events in Patients With Stable Coronary Heart Disease: From the Heart and Soul Study

    PubMed Central

    Beatty, Alexis L; Ku, Ivy A; Bibbins-Domingo, Kirsten; Christenson, Robert H; DeFilippi, Christopher R; Ganz, Peter; Ix, Joachim H; Lloyd-Jones, Donald; Omland, Torbjrn; Sabatine, Marc S; Schiller, Nelson B; Shlipak, Michael G; Skali, Hicham; Takeuchi, Madoka; Vittinghoff, Eric; Whooley, Mary A

    2015-01-01

    Background Patients with stable coronary heart disease (CHD) have widely varying prognoses and treatment options. Validated models for risk stratification of patients with CHD are needed. We sought to evaluate traditional and novel risk factors as predictors of secondary cardiovascular (CV) events, and to develop a prediction model that could be used to risk stratify patients with stable CHD. Methods and Results We used independent derivation (912 participants in the Heart and Soul Study) and validation (2876 participants in the PEACE trial) cohorts of patients with stable CHD to develop a risk prediction model using Cox proportional hazards models. The outcome was CV events, defined as myocardial infarction, stroke, or CV death. The annual rate of CV events was 3.4% in the derivation cohort and 2.2% in the validation cohort. With the exception of smoking, traditional risk factors (including age, sex, body mass index, hypertension, dyslipidemia, and diabetes) did not emerge as the top predictors of secondary CV events. The top 4 predictors of secondary events were the following: N-terminal pro-type brain natriuretic peptide, high-sensitivity cardiac troponin T, urinary albumin:creatinine ratio, and current smoking. The 5-year C-index for this 4-predictor model was 0.73 in the derivation cohort and 0.65 in the validation cohort. As compared with variables in the Framingham secondary events model, the Heart and Soul risk model resulted in net reclassification improvement of 0.47 (95% CI 0.25 to 0.73) in the derivation cohort and 0.18 (95% CI 0.01 to 0.40) in the validation cohort. Conclusions Novel risk factors are superior to traditional risk factors for predicting 5-year risk of secondary events in patients with stable CHD. PMID:26150476

  17. Stable density stratification solar pond

    NASA Technical Reports Server (NTRS)

    Lansing, F. L. (Inventor)

    1985-01-01

    A stable density-stratification solar pond for use in the collection and storage of solar thermal energy including a container having a first section characterized by an internal wall of a substantially cylindrical configuration and a second section having an internal wall of a substantially truncated conical configuration surmounting the first section in coaxial alignment therewith, the second section of said container being characterized by a base of a diameter substantially equal to the diameter of the first section and a truncated apex defining a solar energy acceptance opening is discussed. A body of immiscible liquids is disposed within the container and comprises a lower portion substantially filling the first section of the container and an upper portion substantially filling the second section of the container, said lower portion being an aqueous based liquid of a darker color than the upper portion and of a greater density. A protective cover plate is removably provided for covering the acceptance opening.

  18. Cardiac arrest in a patient with Ebstein's anomaly without accessory pathways.

    PubMed

    Nikoli?, Borka Pezo; Lovri?, Daniel; Puljevi?, Davor; Milici?, Davor; Buljevi?, Bruno; Skori?, Bosko; Hanzevacki, Jadranka Separovi?

    2013-12-01

    We describe a case report of a patient with cardiac arrest and Ebstein's anomaly. This case report shows us necessity for arrhythmia evaluation and sudden death risk stratification even in asymptomatic patients. Prophylactic ICD implantation in this patient population is limited to observational studies and the selection of patients is impeded by the absence of randomized trials and weak predictors. PMID:24611357

  19. Sarcopenia in patients undergoing maintenance hemodialysis: incidence rate, risk factors and its effect on survival risk.

    PubMed

    Ren, Hongqi; Gong, Dehua; Jia, Fengyu; Xu, Bin; Liu, Zhihong

    2016-04-01

    Background Sarcopenia is a degenerative syndrome mainly characterized by the atrophy of skeletal muscle, along with the decrease of muscle strength and function. However, there are currently few studies concerning sarcopenia in patients undergoing maintenance hemodialysis dialysis (MHD). This study was aimed to investigate the incidence of sarcopenia in MHD patients and its influencing factors, as well as its impact on survival risk. Method All 131 MHD patients enrolled in our study were tested with bioelectrical impedance analysis (BIA) and grip strength. Demographic data was collected and anthropometric measurement and laboratory examination were conducted. Results The total incidence of sarcopenia within the 131 MHD patients was 13.7% and the incidence of sarcopenia in patients over 60 years was 33.3%. The dialysis duration, with or without diabetes, serum phosphorus and pre-albumin levels of sarcopenic patients were significantly different from those of non-sarcopenicones; the modified quantitative subjective global assessment (MQSGA) scores of sarcopenic patients were higher than those without sarcopenia. Multivariate analysis showed that dialysis duration, diabetes and serum phosphorus level were independent risk factors for sarcopenia in MHD patients. Kaplan-Meier survival analysis showed a one-year survival of 88.9% in sarcopenic patients, which was significantly lower than non-sarcopenic patients. Conclusion The incidence of sarcopenia in MHD patients was high and increased gradually with age. Dialysis duration, diabetes, serum phosphorus level and malnutrition predisposed the patients to sarcopenia. One-year follow-up found that the mortality risk of sarcopenic patients was higher than that of non-sarcopenic patients. PMID:26738817

  20. Risk of Sleep Apnea in Hospitalized Older Patients

    PubMed Central

    Shear, Talia C.; Balachandran, Jay S.; Mokhlesi, Babak; Spampinato, Lisa M.; Knutson, Kristen L.; Meltzer, David O.; Arora, Vineet M.

    2014-01-01

    Background/Objectives: To assess the prevalence of undiagnosed obstructive sleep apnea (OSA) among general medical inpatients and to investigate whether OSA risk is associated with in-hospital sleep quantity and quality. Design: Prospective cohort study. Setting: General medicine ward in academic medical center Participants: 424 hospitalized adult patients ≥ 50 years old without a sleep disorder diagnosis (mean age 65 years, 57% female, 72% African American). Main Measures: The Berlin questionnaire, a validated screen for determining risk of OSA, was administered to hospitalized medical patients. Sleep duration and efficiency were measured via wrist actigraphy. Self-reported sleep quality was evaluated using Karolinska Sleep Quality Index (KSQI). Key Results: Two of every 5 inpatients ≥ 50 years old (39.5%, n = 168) were found to be at high risk for OSA. Mean in-hospital sleep duration was ∼ 5 h and mean sleep efficiency was 70%. Using random effects linear regression models, we found that patients who screened at high risk for OSA obtained ∼ 40 min less sleep per night (-39.6 min [-66.5, -12.8], p = 0.004). These findings remained significant after controlling for African American race, sex, and age quartiles. In similar models, those patients who screened at high risk had ∼ 5.5% less sleep efficiency per night (-5.50 [-9.96, -1.05], p = 0.015). In multivariate analysis, patients at high risk for OSA also had lower self-reported sleep quality on KSQI (-0.101 [-0.164, -0.037], p = 0.002). Conclusion: Two of every 5 inpatients older than 50 years screened at high risk for OSA. Those screening at high risk have worse in-hospital sleep quantity and quality. Commentary: A commentary on this article appears in this issue on page 1067. Citation: Shear TC, Balachandran JS, Mokhlesi B, Spampinato LM, Knutson KL, Meltzer DO, Arora VM. Risk of sleep apnea in hospitalized older patients. J Clin Sleep Med 2014;10(10):1061-1066. PMID:25317085

  1. Managing CAP patients at risk of clinical failure.

    PubMed

    Welte, Tobias

    2015-02-01

    Community-acquired pneumonia (CAP) is a curable disease. Both the European and American clinical practice guidelines provide algorithms how to manage patients with CAP. However, as populations worldwide are ageing and bacteria are becoming multidrug resistant, it is necessary to address the major factors that put patients at risk of poor outcome. These may include age, comorbidities, the settings where pneumonia was acquired or treated, the need for hospitalisation or ICU admission, likely causative pathogen (bacteria or virus) in a certain region and their local susceptibility pattern. One complicating fact is the lack of definite causative pathogen in approximately 50% of patients making it difficult to choose the most appropriate antibiotic treatment. When risk factors are present simultaneously in patients, fewer treatment options could be rather challenging for physicians. For example, the presence of comorbidities (renal, cardiac, hepatic) may exclude certain antibiotics due to potential adverse events. Assessing the severity of the disease and monitoring biomarkers, however, could help physicians to estimate patient prognosis once diagnosis is confirmed and treatment has been initiated. This review article addresses the most important risk factors of poor outcome in CAP patients. PMID:25434652

  2. Risk assessment of the overweight and obese patient.

    PubMed

    Kushner, Robert F; Blatner, Dawn Jackson

    2005-05-01

    Risk assessment of the overweight and obese patient is an important and necessary first step in the treatment process. Risk classification begins with determination of body mass index (BMI), waist circumference for those with a BMI of 35 or less, and presence of comorbid conditions. With the exception of measuring a fasting blood glucose and lipid panel on all patients, other diagnostic laboratory tests are selected based on the patient's risk factor status. Understanding the reasons leading to and sustaining the patient's overweight and obesity is the next major step and is paramount to designing individualized and targeted treatment. This information is ascertained by having the patient graph his or her weight pattern with associated life events and by assessing detailed dietary and physical activity histories. Calculating estimated energy balance has both benefits and limitations in clinical practice. Pediatric and geriatric patients represent special populations that require additional focus. Improvement in the assessment process will likely be achieved by using a team approach along with future developments in practical measurement of body composition and energy expenditure. PMID:15867897

  3. Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and inflammatory bowel disease: a meta-analysis of 16 observational studies.

    PubMed

    Zheng, Han-Han; Jiang, Xue-Liang

    2016-04-01

    Ulcerative colitis (UC) patients with concomitant primary sclerosing cholangitis (PSC) carry an increased risk of colorectal neoplasia (dysplasia and cancer), whereas the association between PSC and the development of colorectal neoplasia in Crohn's disease (CD) is controversial. A meta-analysis was carried out to compare the risk of this neoplasia in patients with inflammatory bowel disease (IBD) with and without PSC. A systematic research of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials was performed to identify studies that compared the risk of colorectal neoplasia (dysplasia and cancer) in patients with IBD with and without PSC. Quality assessment was performed using the Newcastle-Ottawa Scale. Pooled odds ratio (OR) was calculated using the random-effects model by STATA 12.0. A total of 16 studies (four cohort studies, 12 case-control studies; nine prospective studies and seven retrospective studies) were selected for further study. These studies included 13 379 IBD patients, of whom 1022 also had PSC. Patients with IBD and PSC were at an increased risk of colorectal dysplasia and cancer compared with patients with IBD alone [OR 3.24; 95% confidence interval (CI): 2.14-4.90]. This increased risk was present even when the risk of colorectal cancer alone was analysed (OR 3.41; 95% CI: 2.13-5.48). Data only from patients with UC showed that PSC was associated with an increased risk for the development of colorectal neoplasia and cancer in patients with UC (OR 2.98; 95% CI: 1.54-5.76) (OR 3.01; 95% CI: 1.44-6.29), but there were high heterogeneity among studies (I=76.9 and 62.8%, respectively). Heterogeneity of the studies was affected by the study design (prospective or retrospective). The OR of colorectal neoplasia was 2.32 (95% CI: 0.70-7.70, P=0.133) and that of cancer was 2.91 (95% CI: 0.84-10.16, P=0.388) for patients with CD and concurrent PSC. Patients with IBD and PSC have a markedly higher risk for the development of colorectal neoplasia than patients with IBD, but not PSC. Stratification by IBD type show that the presence of PSC is associated with an increased risk for the development of colorectal neoplasia in patients with UC; however, there is a nonsignificant association in CD patients. When the risk of colorectal cancer alone is analysed, the conclusion does not change. PMID:26938805

  4. Influenza Vaccination Reduces Dementia Risk in Chronic Kidney Disease Patients

    PubMed Central

    Liu, Ju-Chi; Hsu, Yi-Ping; Kao, Pai-Feng; Hao, Wen-Rui; Liu, Shing-Hwa; Lin, Chao-Feng; Sung, Li-Chin; Wu, Szu-Yuan

    2016-01-01

    Abstract Taiwan has the highest prevalence of chronic kidney disease (CKD) worldwide. CKD, a manifestation of vascular diseases, is associated with a high risk of dementia. Here, we estimated the association between influenza vaccination and dementia risk in patients with CKD. Data from the National Health Insurance Research Database of Taiwan were used in this study. The study cohort included all patients diagnosed with CKD (according to International Classification of Disease, Ninth Revision, Clinical Modification codes) at healthcare facilities in Taiwan (n = 32,844) from January 1, 2000, to December 31, 2007. Each patient was followed up to assess dementia risk or protective factors: demographic characteristics of age and sex; comorbidities of diabetes, hypertension, dyslipidemia, cerebrovascular diseases, parkinsonism, epilepsy, substance and alcohol use disorders, mood disorder, anxiety disorder, psychotic disorder, and sleep disorder; urbanization level; monthly income; and statin, metformin, aspirin, and angiotensin-converting enzyme inhibitor (ACEI) use. A propensity score was derived using a logistic regression model for estimating the effect of vaccination by accounting for covariates that predict receiving the intervention (vaccine). A time-dependent Cox proportional hazard model was used to calculate the hazard ratios (HRs) of dementia among vaccinated and unvaccinated CKD patients. The study population comprised 11,943 eligible patients with CKD; 5745 (48%) received influenza vaccination and the remaining 6198 (52%) did not. The adjusted HRs (aHRs) of dementia decreased in vaccinated patients compared with those in unvaccinated patients (influenza season, noninfluenza season, and all seasons: aHRs = 0.68, 0.58, and 0.64; P < 0.0001, P < 0.0001, and P < 0.0001, respectively). In the sensitivity analysis, adjustments were made to estimate the association of age and sex; diabetes, dyslipidemia, hypertension, cerebrovascular diseases, anxiety disorder; and statin, metformin, ACEI, and aspirin use with the incidence of dementia in various models. A stronger protective effect against dementia risk was demonstrated during the noninfluenza season. Regardless of comorbidities or drug use, influenza vaccination was an independent protective factor and dose-dependently reduced the risk of dementia in CKD patients. Influenza vaccination exerts dose–response and synergistic protective effects against dementia in CKD patients with dementia risk factors by reducing the incidence of dementia. PMID:26945371

  5. The cardiovascular polypill in high-risk patients.

    PubMed

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

    2012-12-01

    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

  6. Pressure ulcer risk of patient handling sling use.

    PubMed

    Peterson, Matthew J; Kahn, Julie A; Kerrigan, Michael V; Gutmann, Joseph M; Harrow, Jeffrey J

    2015-01-01

    Patient handling slings and lifts reduce the risk of musculoskeletal injuries for healthcare providers. However, no published evidence exists of their safety with respect to pressure ulceration for vulnerable populations, specifically persons with spinal cord injury, nor do any studies compare slings for pressure distribution. High-resolution interface pressure mapping was used to describe and quantify risks associated with pressure ulceration due to normal forces and identify at-risk anatomical locations. We evaluated 23 patient handling slings with 4 nondisabled adults. Sling-participant interface pressures were recorded while participants lay supine on a hospital bed and while suspended during typical patient transfers. Sling-participant interface pressures were greatest while suspended for all seated and supine slings and exceeded 200 mm Hg for all seated slings. Interface pressures were greatest along the sling seams (edges), regardless of position or sling type. The anatomical areas most at risk while participants were suspended in seated slings were the posterior upper and lower thighs. For supine slings, the perisacral area, ischial tuberosities, and greater trochanters were most at risk. The duration of time spent in slings, especially while suspended, should be limited. PMID:26237005

  7. Metformin use and lung cancer risk in patients with diabetes

    PubMed Central

    Sakoda, Lori C.; Ferrara, Assiamira; Achacoso, Ninah S.; Peng, Tiffany; Ehrlich, Samantha F.; Quesenberry, Charles P.; Habel, Laurel A.

    2015-01-01

    Methodologic biases may explain why observational studies examining metformin use in relation to lung cancer risk have produced inconsistent results. We conducted a cohort study to further investigate this relationship, accounting for potential biases. For 47,351 patients with diabetes aged ≥40 years, who completed a health-related survey administered between 1994 and 1996, data on prescribed diabetes medications were obtained from electronic pharmacy records. Follow-up for incident lung cancer occurred from January 1, 1997, until June 30, 2012. Using Cox regression, we estimated lung cancer risk associated with new use of metformin, along with total duration, recency, and cumulative dose (all modeled as time-dependent covariates), adjusting for potential confounding factors. During 428,557 person-years of follow-up, 747 patients were diagnosed with lung cancer. No association was found with duration, dose, or recency of metformin use and overall lung cancer risk. Among never smokers, however, ever use was inversely associated with lung cancer risk (hazard ratio (HR) 0.57; 95% confidence interval (CI), 0.33-0.99), and risk appeared to decrease monotonically with longer use (≥5 years: HR, 0.48; 95% CI, 0.21-1.09). Among current smokers, corresponding risk estimates were >1.0, although not statistically significant. Consistent with this variation in effect by smoking history, longer use was suggestively associated with lower adenocarcinoma risk (HR, 0.69; 95% CI, 0.40-1.17), but higher small cell carcinoma risk (HR, 1.82; 95% CI, 0.85-3.91). In this population, we found no evidence that metformin use affects overall lung cancer risk. The observed variation in association by smoking history and histology requires further confirmation. PMID:25644512

  8. Providing Appropriate Risk Information on Genome Editing for Patients.

    PubMed

    Araki, Motoko; Ishii, Tetsuya

    2016-02-01

    Genome editing, represented by CRISPR/Cas9, facilitates somatic and germline gene modifications in many species, including humans. However, one of key issues, off-target mutation deserves special consideration prior to clinical applications. We herein discuss the importance of risk information on genome editing for obtaining legitimate patient consent and social acceptance. PMID:26802361

  9. Therapeutic Amenorrhea in Patients at Risk for Thrombocytopenia

    PubMed Central

    Martin-Johnston, Meredith K.; Okoji, Olanma Y.; Armstrong, Alicia

    2016-01-01

    To examine the need for and evaluate the method of menses suppression in women at risk for thrombocytopenia. A systematic review of the published literature in MEDLINE using the search terms thrombocytopenia, menorrhagia, therapeutic amenorrhea, progestin intrauterine device, combination oral contraceptive—extended and cyclic, gonadotropin releasing hormone agonist, danazol, and progestins. There are an increased number of reproductive age women at risk for thrombocytopenia who would benefit from menses suppression. A number of effective medical regimens are available. In patients who fail medical therapy, endometrial ablation appears to be effective in women with thrombocytopenia. As a result of the increased number of women at risk for thrombocytopenia, there is a need for therapeutic amenorrhea. The type of regimen selected depends upon the patients need for contraception and the ability to tolerate estrogen-containing medications. For women who fail medical therapy, there are surgical options, which are associated with less morbidity than hysterectomy. PMID:18492296

  10. Dementia Risk in Irradiated Patients With Head and Neck Cancer.

    PubMed

    Chen, Jin-Hua; Yen, Yu-Chun; Liu, Shing-Hwa; Lee, Fei-Peng; Lin, Kuan-Chou; Lai, Ming-Tang; Wu, Chia-Che; Chen, Tsung-Ming; Yuan, Sheng-Po; Chang, Chia-Lun; Wu, Szu-Yuan

    2015-11-01

    Patients with head and neck cancer are treated through surgery, radiotherapy (RT), and chemotherapy (CT). Carotid artery damage and neurotoxicity were previously observed in these patients. This study estimated the dementia risk associated with different treatment modalities in a head and neck cancer population with long-term follow-up. Taiwan's National Health Insurance claims database and a cancer registry database from the Collaboration Center of Health Information Application were linked for the present analysis. Patients with head and neck cancer, treated from January 1, 2002 to December 31, 2010, were included in the study. The follow-up duration was the period from the index date to December 31, 2012. Inclusion criteria were head and neck cancer; an age >20 years; and having undergone surgery, CT, concurrent CT, or surgery with adjuvant treatment. Exclusion criteria were another cancer diagnosed before the head and neck cancer, death or being diagnosed with dementia within 2 years after the treatment of the head and neck cancer, stroke before the index date, distant metastasis, in situ carcinoma, sarcoma, head and neck cancer recurrence, an unknown sex, and an age <20 years. In total, 20,135 patients were included. In patient groups that underwent surgery alone, surgery and adjuvant chemoradiotherapy, and chemoradiotherapy alone, the dementia incidence per 1000 person-years was 1.44, 1.04, and 1.98, respectively. The crude hazard ratio (HR) of dementia was 1.84 (95% confidence interval [CI] 1.21-2.81) in the RT with or without CT group. After adjustment for age, sex, clinical stage, and comorbidity, the HR was 1.92 (95% CI 1.14-3.24). Examining the dementia risk in patients who received different treatment modalities according to the Cox proportional-hazard model revealed that an age >65 years and having undergone RT with or without CT were risk factors (P?risk in patients at different clinical stages was not significantly different among the various treatment groups, regardless of whether the patients received RT. However, younger (<65 y) patients who received RT with or without CT had a 2.96-fold (95% CI 1.24-7.08) higher risk of dementia and a 3.54-fold (95% CI 1.32-9.51) higher adjusted HR compared with the surgery-alone group. Patients who received a total radiation dose >6660 cGy exhibited a 1.69-fold (95% CI 0.97-2.95, P?=?0.063) higher dementia risk compared with those who received a total radiation dose <6660 cGy. Receiving a higher radiation dose increased the dementia risk and persistently escalated the dementia incidence even 9 years after RT. Younger (<65 y) patients have a high risk of dementia after RT. The selection of young patients for dose de-escalation requires improvement for reducing irradiation to the neck and areas near brain tissues, particularly in Taiwan, where the median patient age is 53 years. PMID:26559280

  11. Comorbidities and risk factors among patients with schizophrenia.

    PubMed

    Harrison, Christopher; Charles, Janice; Britt, Helena

    2015-01-01

    General practitioners (GPs) are charged with maintaining a holistic approach to their patients' health. While most patients with schizophrenia attend public mental health services and/or non-government organisations supporting people with mental illness, 88.2% of people with a psychotic illness (the majority being schizophrenia or schizoaffective disorder) had visited a GP in the previous year. For at least 30-40% of people living with schizophrenia in Australia, ongoing management is provided by their GP alone. Moreover, there is evidence that patients with schizophrenia value the help provided by GPs. Patients with schizophrenia have reduced life expectancy. Overseas research (primarily from the UK and US) has found that the poor physical health of patients with schizophrenia can be attributed to a number of factors such as modifiable lifestyle risk factors and side effects of medication, compounded by causes intrinsic to the illness such as mental stress and loss of initiative. PMID:26590615

  12. Risk factors and prognosis of hypoalbuminemia in surgical septic patients

    PubMed Central

    Sun, Jia-Kui; Sun, Fang; Wang, Xiang; Yuan, Shou-Tao; Zheng, Shu-Yun

    2015-01-01

    The aim of this study was to investigate the risk factors of hypoalbuminemia and effects of different albumin levels on the prognosis of surgical septic patients. We preformed a retrospective clinical study including 135 adult patients from September 2011 to June 2014. The albumin levels and severity markers were recorded during the first 48 h after enrollment, and logistic regression analyses were used to determine the risk factors. The outcomes of patients with different albumin levels were also compared. The acute physiology and chronic health evaluation II (APACHE II) score (OR 1.786, 95% CI [1.3792.314], P < 0.001), C-reactive protein (CRP) (OR 1.016, 95% CI [1.0051.027], P = 0.005), and blood lactate (OR 1.764, 95% CI [1.1412.726], P = 0.011) were established as the independent risk factors of hypoalbuminemia in patients with surgical sepsis. The severity markers and outcomes of patients with albumin levels ?20 g/L were significantly worse than that of 2125 g/L and ?26 g/L, whereas the latter two groups had similar prognosis. Every 1 g/L decrease of albumin level below the optimal cut-off (23 g/L) was associated with a 19.4% increase in hospital mortality and a 28.7% increase in the incidence of multiple organ dysfunction syndrome. In conclusion, APACHE II score (?14.5), CRP (?34.25 mg/L), and blood lactate (?.35 mmol/L) were established as the independent risk factors of hypoalbuminemia in the early stage of surgical sepsis. Patients with baseline albumin level ?20 g/L had worse prognosis than that of albumin level ?21 g/L. Albumin levels were negatively correlated the prognosis of surgical sepsis when below about 23 g/L. PMID:26557421

  13. Free Tissue Transfer for Limb Salvage in High-Risk Patients: Worth the Risk

    PubMed Central

    Endara, Matthew; Ducic, Ivica; Attinger, Christopher

    2013-01-01

    Significance Mircosurgical free tissue transfer is a powerful tool in the arsenal of reconstructive surgeons, oftentimes as the final option in limb salvage before amputation. Patients presenting for limb salvage frequently carry with them multiple co-morbidities such as diabetes mellitus, end-stage renal disease, and peripheral vascular disease. Surgeons are oftentimes hesitant to attempt free tissue tranfer in these medically complex individuals due to beliefs that the patient would not tolerate prolonged anesthesia, the surgery is doomed to fail, or the patient would be better off with an amputation. Because amputees actually demonstrate higher mortality rates, the decision to not to proceed with limb salvage should be made with great care. Recent Advances By reviewing the success rates with free tissue transfer for limb salvage in high-risk patients, the target articles have shown that this option is indeed viable even in this patient population. Specifically, reasonable success rates are presented for limb salvage using free tissue transfer in patients with end-stage renal disease, a single-vessel leg and critical limb ischemia. Critical Issues The articles reviewed demonstrate that free tissue transfer for limb salvage in properly selected patients with end-stage renal disease or severe peripheral vascular disease is worth attempting. Before surgery, these patients must undergo a complete cardiac work-up regardless of previous cardiac history. Future Directions When necessary, free tissue transfer should be pursued by the reconstructive surgeon even in high-risk medically complex patients. PMID:24527327

  14. Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations?

    PubMed

    Sand-Jecklin, Kari; Johnson, Jennifer Ray; Tylka, Sharon

    2016-01-01

    Despite implementation of many prevention strategies, patient falls in hospitals continue to be a significant safety problem, causing nursing staff and administrators to seek innovative means to further reduce falls among hospitalized patients. This article describes the feasibility and impact of implementing centralized video monitoring on the safety of patients identified as high risk for falls, as well as implications of video monitoring in the acute care setting. PMID:26513398

  15. Risk of rupture of unruptured cerebral aneurysms in elderly patients

    PubMed Central

    Date, Isao; Tokunaga, Koji; Tominari, Shinjiro; Nozaki, Kazuhiko; Shiokawa, Yoshiaki; Houkin, Kiyohiro; Murayama, Yuichi; Ishibashi, Toshihiro; Takao, Hiroyuki; Kimura, Toshikazu; Nakayama, Takeo; Morita, Akio

    2015-01-01

    Objectives: The aim of this study was to identify risk factors for rupture of unruptured cerebral aneurysms (UCAs) in elderly Japanese patients aged 70 years or older. Methods: The participants included all patients 70 years of age or older in 3 prospective studies in Japan (the Unruptured Cerebral Aneurysm Study of Japan [UCAS Japan], UCAS II, and the prospective study at the Jikei University School of Medicine). A total of 1,896 patients aged 70 years or older with 2,227 UCAs were investigated. The median and mean follow-up periods were 990 and 802.7 days, respectively. Results: The mean aneurysm size was 6.2 3.9 mm. Sixty-eight patients (3.6%) experienced subarachnoid hemorrhage during the follow-up period. Multivariable analysis per patient revealed that in patients aged 80 years or older (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.163.49, p = 0.012), aneurysms 7 mm or larger (HR, 3.08; 95% CI, 1.357.03, p = 0.007 for 79 mm; HR, 7.82; 95% CI, 3.6016.98, p < 0.001 for 1024 mm; and HR, 43.31; 95% CI, 12.55149.42, p < 0.001 for ?25 mm) and internal carotidposterior communicating artery aneurysms (HR, 2.45; 95% CI, 1.234.88,