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Sample records for risk stratification strategy

  1. A staged screening strategy for prenatal alcohol exposure and maternal risk stratification.

    PubMed

    Burd, Larry; Klug, Marilyn G; Martsolf, John T; Martsolf, Cathy; Deal, Eric; Kerbeshian, Jacob

    2006-03-01

    To present an incremental process for a staged screening strategy to identify women at increased risk of having a child with fetal alcohol spectrum disorder (FASD) and to enhance the management of women using alcohol during pregnancy. We include an illustrative example of the development of a screening component using an existing data set. We describe a seven-step protocol to screen for alcohol use during pregnancy. The screening process begins with a one-question initial screen, followed by exposure assessment, maternal risk stratification to estimate risk for FASD, and concludes with recommendations for intervention and monitoring of exposure for women drinking during pregnancy. This screening process has very modest time commitments in the early stages. Time commitments increase for women drinking during pregnancy and the process focuses on the population at highest risk of having a child with FASD. The process has the benefit of risk specificity, since the process refines risk estimates for an adverse outcome specific for FASD. The process concludes with a programme to facilitate intervention and to monitor changes in prenatal alcohol exposure during pregnancy. Prevention of FASD is an important public health priority. In addition to the ongoing study of clinical strategies to improve detection rates of alcohol exposure at all stages of pregnancy, additional research on the tools and the process used in screening efforts is urgently needed. The efforts should also include research on both the screening tools and the outcome of the screening process in routine prenatal care settings.

  2. Thrombocytosis: Diagnostic Evaluation, Thrombotic Risk Stratification, and Risk-Based Management Strategies

    PubMed Central

    Bleeker, Jonathan S.; Hogan, William J.

    2011-01-01

    Thrombocytosis is a commonly encountered clinical scenario, with a large proportion of cases discovered incidentally. The differential diagnosis for thrombocytosis is broad and the diagnostic process can be challenging. Thrombocytosis can be spurious, attributed to a reactive process or due to clonal disorder. This distinction is important as it carries implications for evaluation, prognosis, and treatment. Clonal thrombocytosis associated with the myeloproliferative neoplasms, especially essential thrombocythemia and polycythemia vera, carries a unique prognostic profile, with a markedly increased risk of thrombosis. This risk is the driving factor behind treatment strategies in these disorders. Clinical trials utilizing targeted therapies in thrombocytosis are ongoing with new therapeutic targets waiting to be explored. This paper will outline the mechanisms underlying thrombocytosis, the diagnostic evaluation of thrombocytosis, complications of thrombocytosis with a special focus on thrombotic risk as well as treatment options for clonal processes leading to thrombocytosis, including essential thrombocythemia and polycythemia vera. PMID:22084665

  3. 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, Sébastien; 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 (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

  4. 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, Sébastien; 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.

  5. Caprini Scores, Risk Stratification, and Rivaroxaban in Plastic Surgery: Time to Reconsider Our Strategy

    PubMed Central

    2016-01-01

    Summary: Limited data are available regarding the pathophysiology of venous thromboembolism in plastic surgery patients. In an effort to identify patients at greater risk, some investigators promote individual risk assessment using Caprini scores. However, these scores do not correlate with relative risk values. Affected patients cannot be reliably predicted (97% false positive rate). Caprini scores make many body contouring patients candidates for chemoprophylaxis, an intervention that introduces risks related to anticoagulation. Caprini has financial conflicts with several companies that manufacture products such as enoxaparin, commonly used for chemoprophylaxis. Rivaroxaban, taken orally, has been used by some plastic surgeons as an alternative to enoxaparin injections. However, this medication is not United States Food and Drug Administration approved for venous thromboembolism prophylaxis in plastic surgery patients, and a reversal agent is unavailable. This article challenges the prevailing wisdom regarding individual risk stratification and chemoprophylaxis. Alternative methods to reduce risk for all patients include safer anesthesia methods and Doppler ultrasound surveillance. Clinical findings alone are unreliable in diagnosing deep venous thromboses. Only by using a reliable diagnostic tool such as Doppler ultrasound are we able to learn more about the natural history of this problem in our patients. Such knowledge is likely to better inform our treatment recommendations. PMID:27482481

  6. Caprini Scores, Risk Stratification, and Rivaroxaban in Plastic Surgery: Time to Reconsider Our Strategy.

    PubMed

    Swanson, Eric

    2016-06-01

    Limited data are available regarding the pathophysiology of venous thromboembolism in plastic surgery patients. In an effort to identify patients at greater risk, some investigators promote individual risk assessment using Caprini scores. However, these scores do not correlate with relative risk values. Affected patients cannot be reliably predicted (97% false positive rate). Caprini scores make many body contouring patients candidates for chemoprophylaxis, an intervention that introduces risks related to anticoagulation. Caprini has financial conflicts with several companies that manufacture products such as enoxaparin, commonly used for chemoprophylaxis. Rivaroxaban, taken orally, has been used by some plastic surgeons as an alternative to enoxaparin injections. However, this medication is not United States Food and Drug Administration approved for venous thromboembolism prophylaxis in plastic surgery patients, and a reversal agent is unavailable. This article challenges the prevailing wisdom regarding individual risk stratification and chemoprophylaxis. Alternative methods to reduce risk for all patients include safer anesthesia methods and Doppler ultrasound surveillance. Clinical findings alone are unreliable in diagnosing deep venous thromboses. Only by using a reliable diagnostic tool such as Doppler ultrasound are we able to learn more about the natural history of this problem in our patients. Such knowledge is likely to better inform our treatment recommendations.

  7. Sudden cardiac death risk stratification.

    PubMed

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

    2015-06-05

    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.

  8. [Cardiovascular risk stratification].

    PubMed

    Martínez Réding, Jesús

    2006-01-01

    In often cited statistic cardiovascular disease is the number 1 cause of death in the worldwide and not only in the developed world. This represents an aggressive identification and management of risk factors. With the many advances in our understanding and practices of risk factor management we hope to change this tendency predicted to be in 2020 the same. Now we know that exists major factor risk and others who predispose. The presence of major risk factors was associated with development of cardiovascular disease. The process of risk factor management is a multidisciplinary one, directly involving both the patient his doctor as well as many others, including nurses, other healthcare and family. The goal is preventing future cardiac events.

  9. Recent biologic and genetic advances in neuroblastoma: Implications for diagnostic, risk stratification, and treatment strategies.

    PubMed

    Newman, Erika A; Nuchtern, Jed G

    2016-10-01

    Neuroblastoma is an embryonic cancer of neural crest cell lineage, accounting for up to 10% of all pediatric cancer. The clinical course is heterogeneous ranging from spontaneous regression in neonates to life-threatening metastatic disease in older children. Much of this clinical variance is thought to result from distinct pathologic characteristics that predict patient outcomes. Consequently, many research efforts have been focused on identifying the underlying biologic and genetic features of neuroblastoma tumors in order to more clearly define prognostic subgroups for treatment stratification. Recent technological advances have placed emphasis on the integration of genetic alterations and predictive biologic variables into targeted treatment approaches to improve patient survival outcomes. This review will focus on these recent advances and the implications they have on the diagnostic, staging, and treatment approaches in modern neuroblastoma clinical management.

  10. Is risk stratification ever the same as 'profiling'?

    PubMed

    Braithwaite, R Scott; Stevens, Elizabeth R; Caplan, Arthur

    2016-05-01

    Physicians engage in risk stratification as a normative part of their professional duties. Risk stratification has the potential to be beneficial in many ways, and implicit recognition of this potential benefit underlies its acceptance as a cornerstone of the medical profession. However, risk stratification also has the potential to be harmful. We argue that 'profiling' is a term that corresponds to risk stratification strategies in which there is concern that ethical harms exceed likely or proven benefits. In the case of risk stratification for health goals, this would occur most frequently if benefits were obtained by threats to justice, autonomy or privacy. We discuss implications of the potential overlap between risk stratification and profiling for researchers and for clinicians, and we consider whether there are salient characteristics that make a particular risk stratification algorithm more or less likely to overlap with profiling, such as whether the risk stratification algorithm is based on voluntary versus non-voluntary characteristics, based on causal versus non-causal characteristics, or based on signifiers of historical disadvantage. We also discuss the ethical challenges created when a risk stratification scheme helps all subgroups but some more than others, or when risk stratification harms some subgroups but benefits the aggregate group. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  11. Cardiac risk stratification and protection.

    PubMed

    Halub, Meghan E; Sidwell, Richard A

    2015-04-01

    The goal of preoperative cardiac evaluation is to screen for undiagnosed cardiac disease or to find evidence of known conditions that are poorly controlled to allow management that reduces the risk of perioperative cardiac complications. A careful history and physical examination combined with the procedure-specific risk is the cornerstone of this assessment. This article reviews a brief history of prior cardiac risk stratification indexes, explores current practice guidelines by the American College of Cardiology and the American Heart Association Task Force, reviews current methods for preoperative evaluation, discusses revascularization options, and evaluates perioperative medication recommendations.

  12. Novel concepts for risk stratification in prostate cancer

    PubMed Central

    Patel, Keval M; Gnanapragasam, Vincent J

    2016-01-01

    Since Partin introduced the analysis of prostate-specific antigen, clinical T-stage and Gleason scores to estimate the risk of progression in men with localised prostate cancer, our understanding of factors that modify this risk has changed drastically. There are now multiple risk stratification tools available, including look-up tables, risk stratification/classification analyses, regression-tree analyses, nomograms and artificial neural networks. Concurrently, descriptions of novel biopsy strategies, imaging modalities and biomarkers are frequently published with the aim of improving risk stratification. With an abundance of new information available, incorporating advances into clinical practice can be confusing. This article aims to outline the major novel concepts in prostate cancer risk stratification for men with biopsy confirmed prostate cancer. We will detail which of these novel techniques and tools are likely to be adopted to aid treatment decisions and enable more accurate post-diagnosis, pretreatment risk stratification.

  13. Novel concepts for risk stratification in prostate cancer.

    PubMed

    Patel, Keval M; Gnanapragasam, Vincent J

    2016-12-01

    Since Partin introduced the analysis of prostate-specific antigen, clinical T-stage and Gleason scores to estimate the risk of progression in men with localised prostate cancer, our understanding of factors that modify this risk has changed drastically. There are now multiple risk stratification tools available, including look-up tables, risk stratification/classification analyses, regression-tree analyses, nomograms and artificial neural networks. Concurrently, descriptions of novel biopsy strategies, imaging modalities and biomarkers are frequently published with the aim of improving risk stratification. With an abundance of new information available, incorporating advances into clinical practice can be confusing. This article aims to outline the major novel concepts in prostate cancer risk stratification for men with biopsy confirmed prostate cancer. We will detail which of these novel techniques and tools are likely to be adopted to aid treatment decisions and enable more accurate post-diagnosis, pretreatment risk stratification.

  14. Modern risk stratification in coronary heart disease.

    PubMed

    Ginghina, C; Bejan, I; Ceck, C D

    2011-11-14

    The prevalence and impact of cardiovascular diseases in the world are growing. There are 2 million deaths due to cardiovascular disease each year in the European Union; the main cause of death being the coronary heart disease responsible for 16% of deaths in men and 15% in women. Prevalence of cardiovascular disease in Romania is estimated at 7 million people, of which 2.8 million have ischemic heart disease. In this epidemiological context, risk stratification is required for individualization of therapeutic strategies for each patient. The continuing evolution of the diagnosis and treatment techniques combines personalized medicine with the trend of therapeutic management leveling, based on guidelines and consensus, which are in constant update. The guidelines used in clinical practice have involved risk stratification and identification of patient groups in whom the risk-benefit ratio of using new diagnostic and therapeutic techniques has a positive value. Presence of several risk factors may indicate a more important total risk than the presence / significant increase from normal values of a single risk factor. Modern trends in risk stratification of patients with coronary heart disease are polarized between the use of simple data versus complex scores, traditional data versus new risk factors, generally valid scores versus personalized scores, depending on patient characteristics, type of coronary artery disease, with impact on the suggested therapy. All known information and techniques can be integrated in a complex system of risk assessment. The current trend in risk assessment is to identify coronary artery disease in early forms, before clinical manifestation, and to guide therapy, particularly in patients with intermediate risk, which can be classified in another class of risk based on new obtained information.

  15. Brugada Syndrome:Risk Stratification And Management.

    PubMed

    Letsas Md Fesc, Konstantinos P; Georgopoulos Md, Stamatis; Vlachos Md, Konstantinos; Karamichalakis Md, Nikolaos; Liatakis Md, Ioannis; Korantzopoulos Md PhD, Panagiotis; Liu Md PhD, Tong; Efremidis Md, Michael; Sideris Md, Antonios

    2016-01-01

    The Brugada syndrome (BrS) is an arrhythmogenic disease associated with an increased risk of ventricular fibrillation and sudden cardiac death. The risk stratification and management of BrS patients, particularly of asymptomatic ones, still remains challenging. A previous history of aborted sudden cardiac death or arrhythmic syncope in the presence of spontaneous type 1 ECG pattern of BrS phenotype appear to be the most reliable predictors of future arrhythmic events. Several other ECG parameters have been proposed for risk stratification. Among these ECG markers, QRS-fragmentation appears very promising. Although the value of electrophysiological study still remains controversial, it appears to add important information on risk stratification, particularly when incorporated in multiparametric scores in combination with other known risk factors. The present review article provides an update on the pathophysiology, risk stratification and management of patients with BrS.

  16. Towards actionable risk stratification: a bilinear approach.

    PubMed

    Wang, Xiang; Wang, Fei; Hu, Jianying; Sorrentino, Robert

    2015-02-01

    Risk stratification is instrumental to modern clinical decision support systems. Comprehensive risk stratification should be able to provide the clinicians with not only the accurate assessment of a patient's risk but also the clinical context to be acted upon. However, existing risk stratification techniques mainly focus on predicting the risk score for individual patients; at the cohort level, they offer little insight beyond a flat score-based segmentation. This essentially reduces a patient to a score and thus removes him/her from his/her clinical context. To address this limitation, in this paper we propose a bilinear model for risk stratification that simultaneously captures the three key aspects of risk stratification: (1) it predicts the risk of each individual patient; (2) it stratifies the patient cohort based on not only the risk score but also the clinical characteristics; and (3) it embeds all patients into clinical contexts with clear interpretation. We apply our model to a cohort of 4977 patients, 1127 among which were diagnosed with Congestive Heart Failure (CHF). We demonstrate that our model cannot only accurately predict the onset risk of CHF but also provide rich and actionable clinical insights into the patient cohort.

  17. Validation of dynamic risk stratification in pediatric differentiated thyroid cancer.

    PubMed

    Sohn, Seo Young; Kim, Young Nam; Kim, Hye In; Kim, Tae Hyuk; Kim, Sun Wook; Chung, Jae Hoon

    2017-08-18

    There has been increasing interest in a risk-adopted management strategy known as dynamic risk stratification following the revised American Thyroid Association guidelines for differentiated thyroid cancer. We aimed to evaluate the usefulness of dynamic risk stratification for predicting structural disease in pediatric differentiated thyroid cancer patients. We retrospectively reviewed 130 pediatric differentiated thyroid cancer patients (≤19 years) who were treated between 1996 and 2015 at Samsung Medical Center. Patients were stratified according to three American Thyroid Association initial risk group (low, intermediate, or high risk) and four dynamic risk stratification group (excellent, indeterminate, biochemical incomplete, or structural incomplete). Based on dynamic risk stratification strategy, structural disease was identified 3.9% in the excellent group, 9.7% in the indeterminate group, 76.9% in the biochemical incomplete group, and 100% in the structural incomplete group. The hazard ratios of the structural disease were 18.10 (P < 0.001) in the biochemical incomplete group, and 19.583 (P < 0.001) in the structural incomplete group compared to the excellent group. The prevalence of structural disease also increased as American Thyroid Association initial risk classification increased (5.9% in the low-risk group, 13.6% in the intermediate-risk group, and 45% in the high-risk group). The hazard ratios of structural disease in the high-risk group was 10.296 (P < 0.001) in compared to the low-risk group. Dynamic risk stratification based on patient responses to initial therapy was able to effectively predict the risk of structural disease in a pediatric population, and as a follow-up strategy, may work as well in pediatric differentiated thyroid cancer patients as it does in adult differentiated thyroid cancer patients.

  18. Prospective stratification of patients at risk for emergency department revisit: resource utilization and population management strategy implications.

    PubMed

    Jin, Bo; Zhao, Yifan; Hao, Shiying; Shin, Andrew Young; Wang, Yue; Zhu, Chunqing; Hu, Zhongkai; Fu, Changlin; Ji, Jun; Wang, Yong; Zhao, Yingzhen; Jiang, Yunliang; Dai, Dorothy; Culver, Devore S; Alfreds, Shaun T; Rogow, Todd; Stearns, Frank; Sylvester, Karl G; Widen, Eric; Ling, Xuefeng B

    2016-02-03

    Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities. We set to develop and validate a method to estimate patient ED revisit risk in the subsequent 6 months from an ED discharge date. An ensemble decision-tree-based model with Electronic Medical Record (EMR) encounter data from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), was developed and validated, assessing patient risk for a subsequent 6 month return ED visit based on the ED encounter-associated demographic and EMR clinical history data. A retrospective cohort of 293,461 ED encounters that occurred between January 1, 2012 and December 31, 2012, was assembled with the associated patients' 1-year clinical histories before the ED discharge date, for model training and calibration purposes. To validate, a prospective cohort of 193,886 ED encounters that occurred between January 1, 2013 and June 30, 2013 was constructed. Statistical learning that was utilized to construct the prediction model identified 152 variables that included the following data domains: demographics groups (12), different encounter history (104), care facilities (12), primary and secondary diagnoses (10), primary and secondary procedures (2), chronic disease condition (1), laboratory test results (2), and outpatient prescription medications (9). The c-statistics for the retrospective and prospective cohorts were 0.742 and 0.730 respectively. Total medical expense and ED utilization by risk score 6 months after the discharge were analyzed. Cluster analysis identified discrete subpopulations of high-risk patients with distinctive resource utilization patterns, suggesting the need for diversified care management strategies. Integration of our method into the HIN secure statewide data system in real time prospectively validated its

  19. Risk Stratification for Second Primary Lung Cancer.

    PubMed

    Han, Summer S; Rivera, Gabriel A; Tammemägi, Martin C; Plevritis, Sylvia K; Gomez, Scarlett L; Cheng, Iona; Wakelee, Heather A

    2017-09-01

    Purpose This study estimated the 10-year risk of developing second primary lung cancer (SPLC) among survivors of initial primary lung cancer (IPLC) and evaluated the clinical utility of the risk prediction model for selecting eligibility criteria for screening. Methods SEER data were used to identify a population-based cohort of 20,032 participants diagnosed with IPLC between 1988 and 2003 and who survived ≥ 5 years after the initial diagnosis. We used a proportional subdistribution hazards model to estimate the 10-year risk of developing SPLC among survivors of lung cancer LC in the presence of competing risks. Considered predictors included age, sex, race, treatment, histology, stage, and extent of disease. We examined the risk-stratification ability of the prediction model and performed decision curve analysis to evaluate the clinical utility of the model by calculating its net benefit in varied risk thresholds for screening. Results Although the median 10-year risk of SPLC among survivors of LC was 8.36%, the estimated risk varied substantially (range, 0.56% to 14.3%) when stratified by age, histology, and extent of IPLC in the final prediction model. The stratification by deciles of estimated risk showed that the observed incidence of SPLC was significantly higher in the tenth-decile group (12.5%) versus the first-decile group (2.9%; P < 10(-10)). The decision curve analysis yielded a range of risk thresholds (1% to 11.5%) at which the clinical net benefit of the risk model was larger than those in hypothetical all-screening or no-screening scenarios. Conclusion The risk stratification approach in SPLC can be potentially useful for identifying survivors of LC to be screened by computed tomography. More comprehensive environmental and genetic data may help enhance the predictability and stratification ability of the risk model for SPLC.

  20. Brugada syndrome: Diagnosis, risk stratification and management.

    PubMed

    Gourraud, Jean-Baptiste; Barc, Julien; Thollet, Aurélie; Le Marec, Hervé; Probst, Vincent

    2017-03-01

    Brugada syndrome is a rare inherited arrhythmia syndrome leading to an increased risk of sudden cardiac death, despite a structurally normal heart. Diagnosis is based on a specific electrocardiogram pattern, observed either spontaneously or during a sodium channel blocker test. Among affected patients, risk stratification remains a challenge, despite recent insights from large population cohorts. As implantable cardiac defibrillators - the main therapy in Brugada syndrome - are associated with a high rate of complications in this population, the main challenge is risk stratification of patients with Brugada syndrome. Aside from the two main predictors of arrhythmia (symptoms and spontaneous electrocardiogram pattern), many risk factors have been recently suggested for stratifying risk of sudden cardiac death in Brugada syndrome. We have reviewed these data and discuss current guidelines in light of recent progress in this complex field.

  1. Recurrence Risk Stratification After Preoperative Chemoradiation of Esophageal Adenocarcinoma.

    PubMed

    Xi, Mian; Hallemeier, Christopher L; Merrell, Kenneth W; Liao, Zhongxing; Murphy, Mariela A Blum; Ho, Linus; Hofstetter, Wayne L; Mehran, Reza; Lee, Jeffrey H; Bhutani, Manoop S; Weston, Brian; Maru, Dipen M; Komaki, Ritsuko; Ajani, Jaffer A; Lin, Steven H

    2017-06-16

    To discern recurrence risk stratification and investigate its influence on postoperative surveillance in patients with esophageal adenocarcinoma (EAC) after neoadjuvant chemoradiotherapy (CRT). Reports documenting recurrence risk stratification in EAC after neoadjuvant CRT are scarce. Between 1998 and 2014, 601 patients with EAC who underwent neoadjuvant CRT followed by esophagectomy were included for analysis. The pattern, site, timing, and frequency of the first recurrence and potential prognostic factors for developing recurrences were analyzed. This cohort was used as the training set to propose a recurrence risk stratification system, and the stratification was further validated in another cohort of 172 patients. A total of 150 patients (25.0%) achieved pathologic complete response (pCR) after neoadjuvant CRT and the rest were defined as the non-pCR group (n = 451) in the training cohort. After a median follow-up of 63.6 months, the pCR group demonstrated a significantly lower locoregional (4.7% vs 19.1%) and distant recurrence rate (22.0% vs.44.6%) than the non-pCR group (P < 0.001). Based on independent prognostic factors, patients were stratified into 4 recurrence risk categories: pCR with clinical stage I/II, pCR with clinical stage III, non-pCR with pN0, and non-pCR with pN+, with corresponding 5-year recurrence-free survival rates of 88.7%, 65.8%, 55.3%, and 33.0%, respectively (P < 0.001). The risk stratification was reproducible in the validation cohort. We proposed a recurrence risk stratification system for EAC patients based on pathologic response and pretreatment clinical stage. Risk-based postoperative surveillance strategies could be developed for different risk categories.

  2. Risk-adapted stratification for optimally intensive treatment assignment of pediatric patients with non-Hodgkin lymphoma is an effective strategy in developing countries.

    PubMed

    Belgaumi, Asim F; Anas, Mohammed; Siddiqui, Khawar S; Akhter, Mohammed F; Al-Kofide, Amani

    2017-06-01

    Pediatric patients with non-Hodgkin lymphoma (NHL) in developing countries (DCs) present with greater tumor load even at lower stages and with comorbidities that impact therapy delivery. This causes toxic mortality with "standard" intensive protocols or recurrences with "gentler" treatment. We developed and evaluated a risk stratification schema that guides intensity of therapy. Sixty-nine patients were prospectively assigned to five risk groups (A-E; n = 6, 15, 16, 15, and 17) following staging and treated with protocols of risk-stratified intensity. Risk stratification utilized St. Jude stage, disease bulk, and sites involved. Between 2006 and 2011, 69 patients with B-cell NHL were enrolled. Among these, 72.5% were boys with mean age of 6.9 years (±3.33 [SD]; range 2.4-14.2 years). Eighty-seven percent had Burkitt lymphoma, 82.6% had advanced stage (25 [36.2%] stage III; 32 [46.4%] stage IV), and 24.6% were central nervous system positive. Mean lactate dehydrogenase increased progressively across the risk strata. Among these, 0/6, 1/15, 3/16, 2/15, and 7/17 patients relapsed/progressed within each risk stratum. Fifteen patients died; three from treatment-related toxicity. At a median follow-up of 6.2 years, the overall and event-free survival (EFS) for all patients was 78.1 and 75.4%, respectively; EFS was related to risk assignment. The frequency of documented infectious and noninfectious toxicities increased with higher risk group assignment causing prolongation of admissions and potential treatment delays. Reduction in treatment intensity for an identified subset of patients with NHL is feasible, while high-intensity therapy is required for high-risk groups. This risk stratification system may be a first step toward improving the outcomes in some DCs. © 2016 Wiley Periodicals, Inc.

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

    PubMed Central

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

    2010-01-01

    Premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (NSVT) are frequently encountered and a marker of electrocardiomyopathy. In some instances, they increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death. While often associated with a primary cardiomyopathy, they have also been known to cause tachycardia-induced cardiomyopathy in patients without preceding structural heart disease. Medical therapy including beta-blockers and class III anti-arrhythmic agents can be effective while implantable cardiac defibrillators (ICD) are indicated in certain patients. Radiofrequency ablation (RFA) is the preferred, definitive treatment in those patients that improve with anti-arrhythmic therapy, have tachycardia-induced cardiomyopathy, or have certain subtypes of PVCs/NSVT. We present a review of PVCs and NSVT coupled with case presentations on RFA of fascicular ventricular tachycardia, left-ventricular outflow tract ventricular tachycardia, and Purkinje arrhythmia leading to polymorphic ventricular tachycardia. PMID:20811538

  4. Life insurance: genomic stratification and risk classification.

    PubMed

    Joly, Yann; Burton, Hilary; Knoppers, Bartha Maria; Feze, Ida Ngueng; Dent, Tom; Pashayan, Nora; Chowdhury, Susmita; Foulkes, William; Hall, Alison; Hamet, Pavel; Kirwan, Nick; Macdonald, Angus; Simard, Jacques; Van Hoyweghen, Ine

    2014-05-01

    With the development and increasing accessibility of new genomic tools such as next-generation sequencing, genome-wide association studies, and genomic stratification models, the debate on genetic discrimination in the context of life insurance became even more complex, requiring a review of current practices and the exploration of new scenarios. In this perspective, a multidisciplinary group of international experts representing different interests revisited the genetics and life insurance debate during a 2-day symposium 'Life insurance: breast cancer research and genetic risk prediction seminar' held in Quebec City, Canada on 24 and 25 September 2012. Having reviewed the current legal, social, and ethical issues on the use of genomic information in the context of life insurance, the Expert Group identified four main questions: (1) Have recent developments in genomics and related sciences changed the contours of the genetics and life insurance debate? (2) Are genomic results obtained in a research context relevant for life insurance underwriting? (3) Should predictive risk assessment and risk stratification models based on genomic data also be used for life insurance underwriting? (4) What positive actions could stakeholders in the debate take to alleviate concerns over the use of genomic information by life insurance underwriters? This paper presents a summary of the discussions and the specific action items recommended by the Expert Group.

  5. Life insurance: genomic stratification and risk classification

    PubMed Central

    Joly, Yann; Burton, Hilary; Knoppers, Bartha Maria; Feze, Ida Ngueng; Dent, Tom; Pashayan, Nora; Chowdhury, Susmita; Foulkes, William; Hall, Alison; Hamet, Pavel; Kirwan, Nick; Macdonald, Angus; Simard, Jacques; Van Hoyweghen, Ine

    2014-01-01

    With the development and increasing accessibility of new genomic tools such as next-generation sequencing, genome-wide association studies, and genomic stratification models, the debate on genetic discrimination in the context of life insurance became even more complex, requiring a review of current practices and the exploration of new scenarios. In this perspective, a multidisciplinary group of international experts representing different interests revisited the genetics and life insurance debate during a 2-day symposium ‘Life insurance: breast cancer research and genetic risk prediction seminar' held in Quebec City, Canada on 24 and 25 September 2012. Having reviewed the current legal, social, and ethical issues on the use of genomic information in the context of life insurance, the Expert Group identified four main questions: (1) Have recent developments in genomics and related sciences changed the contours of the genetics and life insurance debate? (2) Are genomic results obtained in a research context relevant for life insurance underwriting? (3) Should predictive risk assessment and risk stratification models based on genomic data also be used for life insurance underwriting? (4) What positive actions could stakeholders in the debate take to alleviate concerns over the use of genomic information by life insurance underwriters? This paper presents a summary of the discussions and the specific action items recommended by the Expert Group. PMID:24129434

  6. 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.

  7. Risk stratification for benign prostatic hyperplasia.

    PubMed

    Zattoni, Fabio; Ficarra, Vincenzo; Novara, Giacomo

    2017-03-18

    Benign prostatic hyperplasia (BPH) represents an important public health problem in ageing men due to frequently associated lower urinary tract symptoms (LUTS), which may impair quality of life. BPH is also a progressive disease, mainly characterized by a worsening of LUTS over time, and in some patients by the occurrence of serious outcomes such as acute urinary retention and need for BPH-related surgery. The management of BPH and LUTS in men should move forward its focus on symptom control only. Indeed, the goals of therapy for BPH are not only to improve bothersome LUTS but also to identify those patients at risk of unfavourable outcomes in order to optimize their management and reduce complications. Risk stratification and tailored treatment should improve the reductions in both symptoms and the long-term consequences of BPH and BPH treatments. To do this, clinicians need to know possible factors that may support the develop of PBH and possible risks due to the BPH itself.

  8. Cytogenetic risk stratification in chronic myelomonocytic leukemia

    PubMed Central

    Such, Esperanza; Cervera, José; Costa, Dolors; Solé, Francesc; Vallespí, Teresa; Luño, Elisa; Collado, Rosa; Calasanz, María J.; Hernández-Rivas, Jesús M.; Cigudosa, Juan C.; Nomdedeu, Benet; Mallo, Mar; Carbonell, Felix; Bueno, Javier; Ardanaz, María T.; Ramos, Fernando; Tormo, Mar; Sancho-Tello, Reyes; del Cañizo, Consuelo; Gómez, Valle; Marco, Victor; Xicoy, Blanca; Bonanad, Santiago; Pedro, Carmen; Bernal, Teresa; Sanz, Guillermo F.

    2011-01-01

    Background The prognostic value of cytogenetic findings in chronic myelomonocytic leukemia is unclear. Our purpose was to evaluate the independent prognostic impact of cytogenetic abnormalities in a large series of patients with chronic myelomonocytic leukemia included in the database of the Spanish Registry of Myelodysplastic Syndromes. Design and Methods We studied 414 patients with chronic myelomonocytic leukemia according to WHO criteria and with a successful conventional cytogenetic analysis at diagnosis. Different patient and disease characteristics were examined by univariate and multivariate methods to establish their relationship with overall survival and evolution to acute myeloid leukemia. Results Patients with abnormal karyotype (110 patients, 27%) had poorer overall survival (P=0.001) and higher risk of acute myeloid leukemia evolution (P=0.010). Based on outcome analysis, three cytogenetic risk categories were identified: low risk (normal karyotype or loss of Y chromosome as a single anomaly), high risk (presence of trisomy 8 or abnormalities of chromosome 7, or complex karyotype), and intermediate risk (all other abnormalities). Overall survival at five years for patients in the low, intermediate, and high risk cytogenetic categories was 35%, 26%, and 4%, respectively (P<0.001). Multivariate analysis confirmed that this new CMML-specific cytogenetic risk stratification was an independent prognostic variable for overall survival (P=0.001). Additionally, patients belonging to the high-risk cytogenetic category also had a higher risk of acute myeloid leukemia evolution on univariate (P=0.001) but not multivariate analysis. Conclusions Cytogenetic findings have a strong prognostic impact in patients with chronic myelomonocytic leukemia. PMID:21109693

  9. 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

  10. A probabilistic topic model for clinical risk stratification from electronic health records.

    PubMed

    Huang, Zhengxing; Dong, Wei; Duan, Huilong

    2015-12-01

    Risk stratification aims to provide physicians with the accurate assessment of a patient's clinical risk such that an individualized prevention or management strategy can be developed and delivered. Existing risk stratification techniques mainly focus on predicting the overall risk of an individual patient in a supervised manner, and, at the cohort level, often offer little insight beyond a flat score-based segmentation from the labeled clinical dataset. To this end, in this paper, we propose a new approach for risk stratification by exploring a large volume of electronic health records (EHRs) in an unsupervised fashion. Along this line, this paper proposes a novel probabilistic topic modeling framework called probabilistic risk stratification model (PRSM) based on Latent Dirichlet Allocation (LDA). The proposed PRSM recognizes a patient clinical state as a probabilistic combination of latent sub-profiles, and generates sub-profile-specific risk tiers of patients from their EHRs in a fully unsupervised fashion. The achieved stratification results can be easily recognized as high-, medium- and low-risk, respectively. In addition, we present an extension of PRSM, called weakly supervised PRSM (WS-PRSM) by incorporating minimum prior information into the model, in order to improve the risk stratification accuracy, and to make our models highly portable to risk stratification tasks of various diseases. We verify the effectiveness of the proposed approach on a clinical dataset containing 3463 coronary heart disease (CHD) patient instances. Both PRSM and WS-PRSM were compared with two established supervised risk stratification algorithms, i.e., logistic regression and support vector machine, and showed the effectiveness of our models in risk stratification of CHD in terms of the Area Under the receiver operating characteristic Curve (AUC) analysis. As well, in comparison with PRSM, WS-PRSM has over 2% performance gain, on the experimental dataset, demonstrating that

  11. The Delayed Risk Stratification System in the Risk of Differentiated Thyroid Cancer Recurrence

    PubMed Central

    Walczyk, Agnieszka; Pałyga, Iwona; Gąsior-Perczak, Danuta; Gadawska-Juszczyk, Klaudia; Szymonek, Monika; Trybek, Tomasz; Lizis-Kolus, Katarzyna; Szyska-Skrobot, Dorota; Mikina, Estera; Hurej, Stefan; Słuszniak, Janusz; Mężyk, Ryszard; Góźdź, Stanisław

    2016-01-01

    Context There has been a marked increase in the detection of differentiated thyroid carcinoma (DTC) over the past few years, which has improved the prognosis. However, it is necessary to adjust treatment and monitoring strategies relative to the risk of an unfavourable disease course. Materials and Methods This retrospective study examined data from 916 patients with DTC who received treatment at a single centre between 2000 and 2013. The utility of the American Thyroid Association (ATA) and the European Thyroid Association (ETA) recommended systems for early assessment of the risk of recurrent/persistent disease was compared with that of the recently recommended delayed risk stratification (DRS) system. Results The PPV and NPV for the ATA (24.59% and 95.42%, respectively) and ETA (24.28% and 95.68%, respectively) were significantly lower than those for the DRS (56.76% and 98.5%, respectively) (p<0.0001). The proportion of variance for predicting the final outcome was 15.8% for ATA, 16.1% for ETA and 56.7% for the DRS. Recurrent disease was rare (1% of patients), and was nearly always identified in patients at intermediate/high risk according to the initial stratification (9/10 cases). Conclusions The DRS showed a better correlation with the risk of persistent disease than the early stratification systems and allows personalisation of follow-up. If clinicians plan to alter the intensity of surveillance, patients at intermediate/high risk according to the early stratification systems should remain within the specialized centers; however, low risk patients can be referred to endocrinologists or other appropriate practitioners for long-term follow-up, as these patients remained at low risk after risk re-stratification. PMID:27078258

  12. [Risk stratification of sudden death in hypertrophic cardiomyopathy in 2016].

    PubMed

    Dubourg, Olivier; Charron, Philippe; Sirol, Marc; Siam-Tsieu, Valérie; Mansencal, Nicolas

    2016-10-01

    Patients with hypertrophic cardiomyopathy (HCM) are at an increased risk of death from many causes and sudden cardiac death is one of them. The study of the sudden cardiac death of patients with HCM has allowed the identification of risk factors and among them major risk factor are: family history of sudden cardiac death, the occurrence of syncope/dizziness, the existence of non-sustained ventricular tachycardia an abnormal blood pressure response during stress test, presence of severe left ventricular hypertrophy≥30mm. Risk stratification for sudden cardiac death is essential, for symptomatic or asymptomatic HCM patients. Two approaches are possible: the classical approach or risk stratification methods with major risk factors and the new approach using the risk-calculator recommended by the ESC. Both methods are not in opposition but complementary. The risk stratification in hypertrophic cardiomyopathy should be still improved to be sure that only the most high-risk patients receive an implantable cardiac defibrillator.

  13. The prostate cancer risk stratification project: database construction and risk stratification outcome analysis.

    PubMed

    Rodrigues, George; Lukka, Himu; Warde, Padraig; Brundage, Michael; Souhami, Luis; Crook, Juanita; Cury, Fabio; Catton, Charles; Mok, Gary; Martin, Andre-Guy; Vigneault, Eric; Morris, Jim; Warner, Andrew; Maldonado, Sandra Gonzalez; Pickles, Tom

    2014-01-01

    This investigation reports on the biochemical and clinical outcomes of a newly created pan-Canadian Prostate Cancer Risk Stratification (ProCaRS) database developed by the Genitourinary Radiation Oncologists of Canada (GUROC). GUROC ProCaRS template-compliant data on 7974 patients who underwent radiotherapy were received from 7 unique databases. Descriptive analysis, Cox proportional hazards, and Kaplan-Meier analyses were performed using American Society for Radiation Oncology (ASTRO) biochemical failure-free survival (BFFS), prostate cancer-specific survival, and overall survival. Multivariable modeling for the primary ASTRO BFFS end point showed that age, prostate-specific antigen, T stage, and Gleason score and components such as hormonal therapy, and radiation treatment (brachytherapy with better outcome than external-beam) were predictive of outcome. Kaplan-Meier analysis of the existing GUROC and new NCCN classification system both showed good separation of all clinical outcome curves. The construction of a pan-Canadian database has informed important prostate cancer radiotherapy outcomes and risk stratification.

  14. Is Coronary Computed Tomography Angiography a Resource Sparing Strategy in the Risk Stratification and Evaluation of Acute Chest Pain? Results of a Randomized Controlled Trial

    PubMed Central

    Miller, Adam H.; Pepe, Paul E.; Peshock, Ron; Bhore, Rafia; Yancy, Clyde C.; Xuan, Lei; Miller, Margarita M.; Huet, Gisselle R.; Trimmer, Clayton; Davis, Rene; Chason, Rebecca; Kashner, Micheal T.

    2011-01-01

    Objectives Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. Methods Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. Results The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ± $14,239) versus the SC-only group ($16,579; SD ± $19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = −$1,291; 95% confidence interval [CI] = −$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = −33%; 95% CI = −56% to −10%; p

  15. Molecular risk stratification in advanced heart failure patients

    PubMed Central

    Lamirault, Guillaume; Meur, Nolwenn Le; Roussel, Jean-Christian; Cunff, Marie-France Le; Baron, Daniel; Bihouée, Audrey; Guisle, Isabelle; Raharijaona, Mahatsangy; Ramstein, Gérard; Teusan, Raluca; Chevalier, Catherine; Gueffet, Jean-Pierre; Trochu, Jean-Noël; Léger, Jean J; Houlgatte, Rémi; Steenman, Marja

    2010-01-01

    Abstract 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

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

    PubMed

    Corcoran, David; Grant, Patrick; Berry, Colin

    2015-09-01

    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.

  17. [The role of inflammatory biomarkers in cardiovascular risk stratification].

    PubMed

    Пузік, Світлана Г

    The increase in cardiovascular diseases requires the search for ways to predict complications based on research additional to traditional risk factors, conduct a study of the formation mechanisms of these complications and to design new treatment strategies. To get an idea about the relationship between inflammation in the blood vessels, atherosclerosis and cardiovascular consequences based on the study of the role of biomarkers of inflammation. the literature on the estimation of risk development of cardiovascular diseases based on the study of the role of biomarkers of vascular inflammation; bibliographic, a systematic approach. Algorithm stratification of cardiovascular risk includes a review of the traditional risk factors for the purpose of preventive therapy. A large number of cases of cardiovascular events (myocardial infarction, stroke) occurs in bessimptomnom patients with normal lipid. The use of additional risk factors for development of cerebral and cardiac disorders will allow to foresee the consequences and to prevent mortality from cardiovascular disease. Study of the role of inflammation in development of cardiovascular diseases allows the use of SB and PL-ФЛА2 as an important additional cardiovascular markers, independent of traditional risk factors. The use of biomarkers LP-ФЛА2 and SB specific to vascular inflammation, allows to establish the relationship between endovascular inflammation, atherosclerosis development and progression of cardiovascular diseases and to prevent cerebral and cardiac disorders in patients with traditional risk factor .

  18. Transient Ischemic Attack Definition, Diagnosis, and Risk Stratification

    PubMed Central

    Sorensen, A. Gregory

    2011-01-01

    Transient ischemic attack (TIA) can convey a high imminent risk for the development of a major stroke and is therefore considered to be a medical emergency. Recent evidence indicates that TIA with imaging proof of brain infarction represents an extremely unstable condition with early risk of stroke that is as much as 20 times higher than the risk after TIA without tissue damage. The use of neuroimaging in TIA is therefore critical not only for diagnosis but also for accurate risk-stratification. In this article, we discuss recent advances in diagnostic imaging, categorizations, and risk stratification in TIA. PMID:21640301

  19. Integration of genetic and epigenetic markers for risk stratification: opportunities and challenges.

    PubMed

    Pashayan, Nora; Reisel, Daniel; Widschwendter, Martin

    2016-03-01

    Common genetic susceptibility variants could be used for risk stratification in risk-tailored cancer screening and prevention programmes. Combining genetic variants with environmental risk factors would improve risk stratification. Epigenetic changes are surrogate markers of environmental exposures during individual's lifetime. Integrating epigenetic markers, in lieu of environmental exposure data, with genetic markers would potentially improve risk stratification. Epigenetic changes are reversible and acquired gradually, providing potentials for prevention and early detection strategies. The epigenetic changes are tissue-specific and stage-of-development-specific, raising challenges in choice of sample and timing for evaluation of cancer-associated changes. The Horizon 2020 funded research programme, FORECEE, using empirical data, will investigate the value of integration of epigenomics with genomics for risk prediction and prevention of women-specific cancers.

  20. From Humoral Theory to Performant Risk Stratification in Kidney Transplantation.

    PubMed

    Lefaucheur, C; Viglietti, D; Mangiola, M; Loupy, A; Zeevi, A

    2017-01-01

    The purpose of the present review is to describe how we improve the model for risk stratification of transplant outcomes in kidney transplantation by incorporating the novel insights of donor-specific anti-HLA antibody (DSA) characteristics. The detection of anti-HLA DSA is widely used for the assessment of pre- and posttransplant risks of rejection and allograft loss; however, not all anti-HLA DSA carry the same risk for transplant outcomes. These antibodies have been shown to cause a wide spectrum of effects on allografts, ranging from the absence of injury to indolent or full-blown acute antibody-mediated rejection. Consequently, the presence of circulating anti-HLA DSA does not provide a sufficient level of accuracy for the risk stratification of allograft outcomes. Enhancing the predictive performance of anti-HLA DSA is currently one of the most pressing unmet needs for facilitating individualized treatment choices that may improve outcomes. Recent advancements in the assessment of anti-HLA DSA properties, including their strength, complement-binding capacity, and IgG subclass composition, significantly improved the risk stratification model to predict allograft injury and failure. Although risk stratification based on anti-HLA DSA properties appears promising, further specific studies that address immunological risk stratification in large and unselected populations are required to define the benefits and cost-effectiveness of such comprehensive assessment prior to clinical implementation.

  1. From Humoral Theory to Performant Risk Stratification in Kidney Transplantation

    PubMed Central

    Viglietti, D.; Mangiola, M.; Loupy, A.; Zeevi, A.

    2017-01-01

    The purpose of the present review is to describe how we improve the model for risk stratification of transplant outcomes in kidney transplantation by incorporating the novel insights of donor-specific anti-HLA antibody (DSA) characteristics. The detection of anti-HLA DSA is widely used for the assessment of pre- and posttransplant risks of rejection and allograft loss; however, not all anti-HLA DSA carry the same risk for transplant outcomes. These antibodies have been shown to cause a wide spectrum of effects on allografts, ranging from the absence of injury to indolent or full-blown acute antibody-mediated rejection. Consequently, the presence of circulating anti-HLA DSA does not provide a sufficient level of accuracy for the risk stratification of allograft outcomes. Enhancing the predictive performance of anti-HLA DSA is currently one of the most pressing unmet needs for facilitating individualized treatment choices that may improve outcomes. Recent advancements in the assessment of anti-HLA DSA properties, including their strength, complement-binding capacity, and IgG subclass composition, significantly improved the risk stratification model to predict allograft injury and failure. Although risk stratification based on anti-HLA DSA properties appears promising, further specific studies that address immunological risk stratification in large and unselected populations are required to define the benefits and cost-effectiveness of such comprehensive assessment prior to clinical implementation. PMID:28133619

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

    PubMed

    Omry-Orbach, Gal

    2016-01-28

    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

  3. Testicular cancer: risk stratification in adolescents with nonseminoma.

    PubMed

    Looijenga, Leendert H J

    2014-07-01

    Data are lacking on the role of histological risk factors (such as embryonal carcinoma and lymphovascular invasion) for occult metastasis in adolescents with testicular germ cell tumours. Investigators of a pilot study have now retrospectively reviewed a testis cancer database to identify risk stratification criteria in this population.

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

    PubMed

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

    2014-08-26

    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.

  5. 2012 consensus document of the Italian Society of Hypertension (SIIA): strategies to improve blood pressure control in Italy: from global cardiovascular risk stratification to combination therapy.

    PubMed

    Volpe, Massimo; Rosei, Enrico Agabiti; Ambrosioni, Ettore; Cottone, Santina; Cuspidi, Cesare; Borghi, Claudio; De Luca, Nicola; Fallo, Francesco; Ferri, Claudio; Morganti, Alberto; Muiesan, Maria Lorenza; Sarzani, Riccardo; Sechi, Leonardo; Virdis, Agostino; Tocci, Giuliano; Trimarco, Bruno; Filippi, Alessandro; Mancia, Giuseppe

    2013-03-01

    Observational clinical studies have demonstrated that only 30-40% of patients with arterial hypertension achieve the recommended blood pressure goals (below 140/90 mmHg). In contrast, interventional trials consistently showed that it is possible to achieve effective blood pressure targets in about 70% of treated hypertensive patients with different cardiovascular risk profiles, especially through the use of rational, effective and well tolerated combination therapies. In order to bridge the gap between current and desired blood pressure control and to achieve more effective prevention of cardiovascular diseases, the Italian Society of Hypertension (SIIA) has developed an interventional strategy aimed at reaching nearly 70% of treated controlled hypertensive patients by 2015. This ambitious goal can be realistically achieved by a more rational use of modern tools and supports, and also through the use of combination therapy in hypertension in daily clinical practice, especially if this approach can be simplified into a single pill (fixed combination therapy), which is a therapeutic option now also available in Italy. Since about 70-80% of treated hypertensive patients require a combination therapy based on at least two classes of drugs in order to achieve the recommended blood pressure goals, it is of key importance to implement this strategy in routine clinical practice. Amongst the various combination therapies currently available for hypertension treatment and control, the use of those strategies based on drugs that antagonize the renin-angiotensin system, such as angiotensin II type 1 receptor antagonists (angiotensin receptor blockers) and ACE inhibitors, in combination with diuretics and/or calcium channel blockers, has been shown to significantly reduce the risk of major cardiovascular events and to improve patient compliance to treatment, resulting in a greater antihypertensive efficacy and better tolerability compared with monotherapy. The present document

  6. 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. Copyright © 2015 Elsevier Ltd. All rights reserved.

  7. Epidemiological risk stratification of malaria in the Americas.

    PubMed

    Castillo-Salgado, C

    1992-01-01

    During the last years, malaria had a significant increase in Latin America, emerging again as one critical health problem in the Region of the Americas. More than 1.04 million new cases were reported in 1990. This resurgence of malaria needed a comprehensive strategy for its prevention and control. National malaria control programs recognized the epidemiological stratification of malaria as a valuable method to assist them in the recognition of local variations and factors that specifically contribute to the level and intensity of transmission in critical malarious areas. Also it serves as a useful instrument for the selection of needed malaria prevention and control activities. The principal feature of this approach is to provide a dynamic and ongoing process for assessing the epidemiological importance of different risk factors (socio-economic, ecological, organization of health services) in malaria transmission. Health interventions are based on this assessment and are aimed directly at the reduction or elimination of the identified risk factors operating at the local level. Intersectorial co-participation and the integration of malaria programs in local health services are also important aspects of this public health approach.

  8. [Cardiovascular risk assessment and risk stratification- guided therapy: predict, prevent and individualize].

    PubMed

    Ural, Dilek

    2011-09-01

    Modern concept in primary prevention of cardiovascular diseases (CVD) entails assessing the person's global risk and making the right management in accordance with these results. Correspondingly, 3 steps recommended for the prevention of CVD under risk guidance are: (a) risk assessment via a proper system like Framingham Risk Score, SCORE, QRISK, PROCAM; (b) decision-making in the proper management in terms of informing the patient about lifestyle changes that he or she can cope and drug selection; and (c) evaluation of treatment decision in terms of cost effectiveness. Although, a significant decline is observed in CVD morbidity and mortality, particularly in the western countries, we still are trying to approach to competent quality measures about management under CV risk guidance. This review summarizes the main challenges regarding risk stratification-guided management strategy in primary prevention of CVD.

  9. Cardiovascular risk stratification in familial hypercholesterolaemia

    PubMed Central

    Sharifi, Mahtab; Rakhit, Roby D; Humphries, Steve E; Nair, Devaki

    2016-01-01

    Familial hypercholesterolaemia (FH) is a common autosomal-dominant disorder in most European countries. Patients with FH are characterised by a raised level of low-density lipoprotein cholesterol and a high risk of premature coronary heart disease (CHD). Currently there is no consensus regarding the clinical utility to predict future coronary events or testing for the presence of subclinical atherosclerotic disease in asymptomatic patients with FH. Family screening of patients with FH as recommended by the UK National Institute of Health and Care Excellence guideline would result in finding many young individuals with a diagnosis of FH who are clinically asymptomatic. The traditional CHD risk scores, that is, the Framingham score, are insufficient in risk prediction in this group of young individuals. In addition, a better understanding of the genetic aetiology of the FH phenotype and CHD risk in monogenic FH and polygenic hypercholesterolaemia is needed. Non-invasive imaging methods such as carotid intima-media thickness measurement might produce more reliable information in finding high-risk patients with FH. The potential market authorisation of novel therapeutic agents such as PCSK9 monoclonal inhibitors makes it essential to have a better screening programme to prioritise the candidates for treatment with the most severe form of FH and at higher risk of coronary events. The utility of new imaging techniques and new cardiovascular biomarkers remains to be determined in prospective trials. PMID:27126396

  10. 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. Copyright © 2014 Elsevier Inc. All rights reserved.

  11. Risk stratification in prostate cancer screening.

    PubMed

    Roobol, Monique J; Carlsson, Sigrid V

    2013-01-01

    Screening for prostate cancer is a controversial topic within the field of urology. The US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial did not demonstrate any difference in prostate-cancer-related mortality rates between men screened annually rather than on an 'opportunistic' basis. However, in the world's largest trial to date--the European Randomised Study of Screening for Prostate Cancer--screening every 2-4 years was associated with a 21% reduction in prostate-cancer-related mortality rate after 11 years. Citing the uncertain ratio between potential harm and potential benefit, the US Preventive Services Task Force recently recommended against serum PSA screening. Although this ratio has yet to be elucidated, PSA testing--and early tumour detection--is undoubtedly beneficial for some individuals. Instead of adopting a 'one size fits all' approach, physicians are likely to perform personalized risk assessment to minimize the risk of negative consequences, such as anxiety, unnecessary testing and biopsies, overdiagnosis, and overtreatment. The PSA test needs to be combined with other predictive factors or be used in a more thoughtful way to identify men at risk of symptomatic or life-threatening cancer, without overdiagnosing indolent disease. A risk-adapted approach is needed, whereby PSA testing is tailored to individual risk.

  12. Stroke risk stratification in acute dizziness presentations

    PubMed Central

    Meurer, William J.; Brown, Devin L.; Burke, James F.; Hofer, Timothy P.; Tsodikov, Alexander; Hoeffner, Ellen G.; Fendrick, A.M.; Adelman, Eric E.; Morgenstern, Lewis B.

    2015-01-01

    Objective: To estimate the ability of bedside information to risk stratify stroke in acute dizziness presentations. Methods: Surveillance methods were used to identify patients with acute dizziness and nystagmus or imbalance, excluding those with benign paroxysmal positional vertigo, medical causes, or moderate to severe neurologic deficits. Stroke was defined as acute infarction or intracerebral hemorrhage on a clinical or research MRI performed within 14 days of dizziness onset. Bedside information comprised history of stroke, the ABCD2 score (age, blood pressure, clinical features, duration, and diabetes), an ocular motor (OM)-based assessment (head impulse test, nystagmus pattern [central vs other], test of skew), and a general neurologic examination for other CNS features. Multivariable logistic regression was used to determine the association of the bedside information with stroke. Model calibration was assessed using low (<5%), intermediate (5% to <10%), and high (≥10%) predicted probability risk categories. Results: Acute stroke was identified in 29 of 272 patients (10.7%). Associations with stroke were as follows: ABCD2 score (continuous) (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.20–2.51), any other CNS features (OR 2.54; 95% CI 1.06–6.08), OM assessment (OR 2.82; 95% CI 0.96–8.30), and prior stroke (OR 0.48; 95% CI 0.05–4.57). No stroke cases were in the model's low-risk probability category (0/86, 0%), whereas 9 were in the moderate-risk category (9/94, 9.6%) and 20 were in the high-risk category (20/92, 21.7%). Conclusion: In acute dizziness presentations, the combination of ABCD2 score, general neurologic examination, and a specialized OM examination has the capacity to risk-stratify acute stroke on MRI. PMID:26511453

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

    PubMed

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

    2016-01-26

    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.

  14. Risk Stratification System for Oral Cancer Screening.

    PubMed

    Pereira, Lutécia H Mateus; Reis, Isildinha M; Reategui, Erika P; Gordon, Claudia; Saint-Victor, Sandra; Duncan, Robert; Gomez, Carmen; Bayers, Stephanie; Fisher, Penelope; Perez, Aymee; Goodwin, W Jarrard; Hu, Jennifer J; Franzmann, Elizabeth J

    2016-06-01

    Oral cavity and oropharyngeal cancer (oral cancer) is a deadly disease that is increasing in incidence. Worldwide 5-year survival is only 50% due to delayed intervention with more than half of the diagnoses at stage III and IV, whereas earlier detection (stage I and II) yields survival rates up to 80% to 90%. Salivary soluble CD44 (CD44), a tumor-initiating marker, and total protein levels may facilitate oral cancer risk assessment and early intervention. This study used a hospital-based design with 150 cases and 150 frequency-matched controls to determine whether CD44 and total protein levels in oral rinses were associated with oral cancer independent of age, gender, race, ethnicity, tobacco and alcohol use, and socioeconomic status (SES). High-risk subjects receiving oral cancer prevention interventions as part of a community-based program (n = 150) were followed over 1 year to determine marker specificity and variation. CD44 ≥5.33 ng/mL was highly associated with case status [adjusted OR 14.489; 95% confidence interval (CI), 5.973-35.145; P < .0001, vs. reference group CD44 <2.22 ng/mL and protein <1.23 mg/mL]. Total protein aided prediction above CD44 alone. Sensitivity and specificity in the frequency-matched study was 80% and 48.7%, respectively. However, controls were not representative of the target screening population due, in part, to a high rate of prior cancer. In contrast, specificity in the high-risk community was 74% and reached 95% after annual retesting. Simple and inexpensive salivary CD44 and total protein measurements may help identify individuals at heightened risk for oral cancer from the millions who partake in risky behaviors. Cancer Prev Res; 9(6); 445-55. ©2016 AACR. ©2016 American Association for Cancer Research.

  15. Cardiovascular disease risk stratification and comparison in a California population.

    PubMed

    Lin, Z; Meng, Y-Y; Leung, K-M; Jatulis, D E; Welsh, N J; Zaher, C A; Legorreta, A P

    2001-01-01

    This study was designed to identify the need for primary prevention of cardiovascular disease in an HMO population and to develop appropriate interventions for individuals in different risk groups, based on risk stratification and comparison. The analysis is based on a cross-sectional survey of the HMO members of a large employer group. Respondents (n=17,878) were stratified based on the Framingham model; 34% of respondents without cardiovascular disease were classified as moderate to high attributable risk for the disease, and 66% were classified as low attributable risk. Results of logistic regression analyses suggest that, compared with respondents with pre-existing cardiovascular disease, moderate- to high-risk respondents are more likely to smoke, have unhealthy diets, and be overweight, hypertensive, and hypercholesterolemic. More low-risk respondents had unhealthy diets than did those with pre-existing cardiovascular disease. There were no differences between these groups for physical activity and stress. Respondents had fewer modifiable risk factors and healthier lifestyles than did those who were at risk. These findings suggest that primary prevention should be enhanced, especially among those with significantly increased risk for the disease. Moreover, the approaches of this project-population-based risk assessment, stratification, and comparison-were instrumental in identifying the target population and designing appropriate interventions. (c) 2001 by CHF, Inc.

  16. A strategy combining imaging and laboratory biomarkers in comparison with a simplified clinical score for risk stratification of patients with acute pulmonary embolism.

    PubMed

    Lankeit, Mareike; Gómez, Vicente; Wagner, Carolin; Aujesky, Drahomir; Recio, Mónica; Briongos, Sem; Moores, Col Lisa K; Yusen, Roger D; Konstantinides, Stavros; Jiménez, David

    2012-04-01

    This study aimed to assess the performance of two prognostic models-the European Society of Cardiology (ESC) model and the simplified Pulmonary Embolism Severity Index (sPESI)-in predicting short-term mortality in patients with pulmonary embolism (PE). We compared the test characteristics of the ESC model and the sPESI for predicting 30-day outcomes in a cohort of 526 patients with objectively confirmed PE. The primary end point of the study was all-cause mortality. The secondary end point included all-cause mortality, nonfatal symptomatic recurrent VTE, or nonfatal major bleeding. Overall, 40 of 526 patients died (7.6%; 95% CI, 5.3%-9.9%) during the first month of follow-up. The sPESI classified fewer patients as low risk (31% [165 of 526], 95% CI, 27%-35%) compared with the ESC model (39% [207 of 526], 95% CI, 35% to 44%; P < .01). Importantly however, low-risk patients based on the sPESI had no 30-day mortality compared with 3.4% (95% CI, 0.9-5.8) in low-risk patients by the ESC model. The secondary end point occurred in 1.8% of patients in the sPESI low-risk and 5.8% in the ESC low-risk group (difference, 4.0 percentage points; 95% CI, 0.2-7.8). The prognostic ability of the ESC model remained significant in the subgroup of patients at high-risk according to the sPESI model (OR 1.95, 95% CI, 1.41 to 2.71, P < .001). Both the sPESI and the ESC model successfully predict 30-day mortality after acute symptomatic PE, but exclusion of an adverse early outcome does not appear to require routine imaging procedures or laboratory biomarker testing.

  17. Risk stratification after acute myocardial infarction: which studies are best?

    PubMed

    Figueredo, V M

    1996-04-01

    The prognosis for a patient who has survived an acute myocardial infarction depends on three general prognostic factors: (1) residual left ventricular function, (2) remaining viable myocardium at risk (residual ischemia), and (3) presence of substrate for the development of malignant arrhythmias. Multiple clinical and historical factors predict the presence of one or more of these prognostic indicators. Electrocardiographic exercise treadmill testing needs to be done in all patients with uncomplicated infarctions. Guidelines of the American College of Cardiology/American Heart Association Task Force are recommended for risk stratification in most patients after acute myocardial infarction.

  18. Cardiac risk stratification for postmyocardial infarction dental patients.

    PubMed

    Roberts, H W; Mitnitsky, E F

    2001-06-01

    Traditional dental management guidelines of myocardial infarction survivors mandate a 6-month waiting period before elective treatment can be considered. Technological advances in cardiac disease diagnosis, management, and revascularization treatment may make this older mandatory 6-month waiting period obsolete. The purposes of this literature review are to provide an overview of the historical development of cardiac risk stratification and discuss current developments and guidelines in cardiac risk assessment. We hope that this review and update will stimulate the development of updated dental guidelines for treating the cardiac patient.

  19. Quantitative risk stratification of oral leukoplakia with exfoliative cytology.

    PubMed

    Liu, Yao; Li, Jianying; Liu, Xiaoyong; Liu, Xudong; Khawar, Waqaar; Zhang, Xinyan; Wang, Fan; Chen, Xiaoxin; Sun, Zheng

    2015-01-01

    Exfoliative cytology has been widely used for early diagnosis of oral squamous cell carcinoma (OSCC). Test outcome is reported as "negative", "atypical" (defined as abnormal epithelial changes of uncertain diagnostic significance), and "positive" (defined as definitive cellular evidence of epithelial dysplasia or carcinoma). The major challenge is how to properly manage the "atypical" patients in order to diagnose OSCC early and prevent OSCC. In this study, we collected exfoliative cytology data, histopathology data, and clinical data of normal subjects (n=102), oral leukoplakia (OLK) patients (n=82), and OSCC patients (n=93), and developed a data analysis procedure for quantitative risk stratification of OLK patients. This procedure involving a step called expert-guided data transformation and reconstruction (EdTAR) which allows automatic data processing and reconstruction and reveals informative signals for subsequent risk stratification. Modern machine learning techniques were utilized to build statistical prediction models on the reconstructed data. Among the several models tested using resampling methods for parameter pruning and performance evaluation, Support Vector Machine (SVM) was found to be optimal with a high sensitivity (median>0.98) and specificity (median>0.99). With the SVM model, we constructed an oral cancer risk index (OCRI) which may potentially guide clinical follow-up of OLK patients. One OLK patient with an initial OCRI of 0.88 developed OSCC after 40 months of follow-up. In conclusion, we have developed a statistical method for qualitative risk stratification of OLK patients. This method may potentially improve cost-effectiveness of clinical follow-up of OLK patients, and help design clinical chemoprevention trial for high-risk populations.

  20. 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: 58–73]). 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

  1. Clinical Risk Stratification for Primary Prevention Implantable Cardioverter Defibrillators.

    PubMed

    Lee, Douglas S; 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

    2015-09-01

    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. 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: 58-73]). 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). 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. © 2015 The Authors.

  2. 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, Jürgen H; Ullmann, Alexander; Kindler, Florentina; Weisser, Gerhard; Walter, Ulrich; Lackner, Karl J; Espinola-Klein, Christine; Münzel, 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

  3. Role of risk stratification and genetics in sudden cardiac death.

    PubMed

    Rai, Vikrant; Agrawal, Devendra K

    2017-03-01

    Sudden cardiac death (SCD) is a major public health issue due to its increasing incidence in the general population and the difficulty in identifying high-risk individuals. Nearly 300 000 - 350 000 patients in the United States and 4-5 million patients in the world die annually from SCD. Coronary artery disease and advanced heart failure are the main etiology for SCD. Ischemia of any cause precipitates lethal arrhythmias, and ventricular tachycardia and ventricular fibrillation are the most common lethal arrhythmias precipitating SCD. Pulseless electrical activity, bradyarrhythmia, and electromechanical dissociation also result in SCD. Most SCDs occur outside of the hospital setting, so it is difficult to estimate the public burden, which results in overestimating the incidence of SCD. The insufficiency and limited predictive value of various indicators and criteria for SCD result in the increasing incidence. As a result, there is a need to develop better risk stratification criteria and find modifiable variables to decrease the incidence. Primary and secondary prevention and treatment of SCD need further research. This critical review is focused on the etiology, risk factors, prognostic factors, and importance of risk stratification of SCD.

  4. 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

    Frank, Bernd; Ariza, Liana; Lamparter, Heidrun; Grossmann, Vera; Prochaska, Jürgen H; Ullmann, Alexander; Kindler, Florentina; Weisser, Gerhard; Walter, Ulrich; Lackner, Karl J; Espinola-Klein, Christine; Münzel, Thomas; Konstantinides, Stavros V; Wild, Philipp S

    2015-07-01

    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. 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. 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. NCT02156401. Published by the

  5. Early Molecular Stratification of High-risk Primary Biliary Cholangitis.

    PubMed

    Hardie, Claire; Green, Kile; Jopson, Laura; Millar, Ben; Innes, Barbara; Pagan, Sarah; Tiniakos, Dina; Dyson, Jessica; Haniffa, Muzlifah; Bigley, Venetia; Jones, David E; Brain, John; Walker, Lucy J

    2016-12-01

    High-risk primary biliary cholangitis (PBC), defined by inadequate response at one year to Ursodeoxycholic acid (UDCA), is associated with disease progression and liver transplantation. Stratifying high-risk patients early would facilitate improved approaches to care. Using long-term follow-up data to define risk at presentation, 6 high-risk PBC patients and 8 low-risk patients were identified from biopsy, transplant and biochemical archival records. Formalin-fixed paraffin-embedded (FFPE) liver biopsies taken at presentation were graded (Scheuer and Nakanuma scoring) and gene expression analysed using the NanoString® nCounter PanCancer Immunity 770-gene panel. Principle component analysis (PCA) demonstrated discrete gene expression clustering between controls and high- and low-risk PBC. High-risk PBC was characterised by up-regulation of genes linked to T-cell activation and apoptosis, INF-γ signalling and leukocyte migration and down-regulation of those linked to the complement pathway. CDKN1a, up-regulated in high-risk PBC, correlated with significantly increased expression of its gene product, the senescence marker p21(WAF1/Cip), by biliary epithelial cells. Our findings suggest high- and low-risk PBC are biologically different from disease outset and senescence an early feature in high-risk disease. Identification of a high-risk 'signal' early from standard FFPE tissue sections has clear clinical utility allowing for patient stratification and second-line therapeutic intervention.

  6. Proposals for enhanced health risk assessment and stratification in an integrated care scenario

    PubMed Central

    Dueñas-Espín, Ivan; Vela, Emili; Pauws, Steffen; Bescos, Cristina; Cano, Isaac; Cleries, Montserrat; Contel, Joan Carles; de Manuel Keenoy, Esteban; Garcia-Aymerich, Judith; Gomez-Cabrero, David; Kaye, Rachelle; Lahr, Maarten M H; Lluch-Ariet, Magí; Moharra, Montserrat; Monterde, David; Mora, Joana; Nalin, Marco; Pavlickova, Andrea; Piera, Jordi; Ponce, Sara; Santaeugenia, Sebastià; Schonenberg, Helen; Störk, Stefan; Tegner, Jesper; Velickovski, Filip; Westerteicher, Christoph; Roca, Josep

    2016-01-01

    Objectives Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario. Settings The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). Participants Responsible teams for regional data management in the five ACT regions. Primary and secondary outcome measures We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction. Results There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment. Conclusions The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches

  7. Proposals for enhanced health risk assessment and stratification in an integrated care scenario.

    PubMed

    Dueñas-Espín, Ivan; Vela, Emili; Pauws, Steffen; Bescos, Cristina; Cano, Isaac; Cleries, Montserrat; Contel, Joan Carles; de Manuel Keenoy, Esteban; Garcia-Aymerich, Judith; Gomez-Cabrero, David; Kaye, Rachelle; Lahr, Maarten M H; Lluch-Ariet, Magí; Moharra, Montserrat; Monterde, David; Mora, Joana; Nalin, Marco; Pavlickova, Andrea; Piera, Jordi; Ponce, Sara; Santaeugenia, Sebastià; Schonenberg, Helen; Störk, Stefan; Tegner, Jesper; Velickovski, Filip; Westerteicher, Christoph; Roca, Josep

    2016-04-15

    Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario. The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). Responsible teams for regional data management in the five ACT regions. We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction. There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment. The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require

  8. 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

  9. Key aspects related to implementation of risk stratification in health care systems-the ASSEHS study.

    PubMed

    Mora, Joana; Iturralde, Miren David; Prieto, Lucía; Domingo, Cristina; Gagnon, Marie-Pierre; Martínez-Carazo, Catalina; March, Anna Giné; De Massari, Daniele; Martí, Tino; Nalin, Marco; Avolio, Francesca; Bousquet, Jean; Keenoy, Esteban de Manuel

    2017-05-05

    The lack of proven efficacy of new healthcare interventions represents a problem for health systems globally. It is partly related to suboptimal implementation processes, leading to poor adoption of new interventions. Activation of Stratification Strategies and Results of the interventions on frail patients of Healthcare Services (ASSEHS) EU project (N° 2013 12 04) aims to study current existing health Risk Stratification (RS) strategies and tools on frail elderly patients. This paper aims at identifying variables that make the implementation of population RS tools feasible in different healthcare services. Two different methods have been used to identify the key elements in stratification implementation; i) a Scoping Review, in order to search and gather scientific evidence and ii) Semi-structured interviews with six key experts that had been actively involved in the design and/or implementation of RS strategies. It aims to focus the implementation construct on real-life contextual understandings, multi-level perspectives, and cultural influences. A Feasibility Framework has been drawn. Two dimensions impact the feasibility of RS: (i) Planning, deployment and change management and (ii) Care intervention. The former comprises communication, training and mutual learning, multidisciplinarity of the team, clinicians' engagement, operational plan and ICT display and functionalities. The latter includes case finding and selection of the target population, pathway definition and quality improvement process. The Feasibility Framework provides a list of key elements that should be considered for an effective implementation of population risk stratification interventions. It helps to identify, plan and consider relevant elements to ensure a proper RS implementation.

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

    PubMed Central

    Abu-Assi, Emad; Raposeiras-Roubín, Sergio; García-Acuña, José María; González-Juanatey, José Ramón

    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

  11. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification.

    PubMed

    Nicolaides, Andrew N; Kakkos, Stavros K; Kyriacou, Efthyvoulos; Griffin, Maura; Sabetai, Michael; Thomas, Dafydd J; Tegos, Thomas; Geroulakos, George; Labropoulos, Nicos; Doré, Caroline J; Morris, Tim P; Naylor, Ross; Abbott, Anne L

    2010-12-01

    The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis. This was a prospective, multicenter, cohort study of patients undergoing medical intervention for vascular disease. Hazard ratios for ICA stenosis, clinical features, and plaque texture features associated with ipsilateral cerebrovascular or retinal ischemic (CORI) events were calculated using proportional hazards models. A total of 1121 patients with 50% to 99% asymptomatic ICA stenosis in relation to the bulb (European Carotid Surgery Trial [ECST] method) were followed-up for 6 to 96 months (mean, 48). A total of 130 ipsilateral CORI events occurred. Severity of stenosis, age, systolic blood pressure, increased serum creatinine, smoking history of more than 10 pack-years, history of contralateral transient ischemic attacks (TIAs) or stroke, low grayscale median (GSM), increased plaque area, plaque types 1, 2, and 3, and the presence of discrete white areas (DWAs) without acoustic shadowing were associated with increased risk. Receiver operating characteristic (ROC) curves were constructed for predicted risk versus observed CORI events as a measure of model validity. The areas under the ROC curves for a model of stenosis alone, a model of stenosis combined with clinical features and a model of stenosis combined with clinical, and plaque features were 0.59 (95% confidence interval [CI] 0.54-0.64), 0.66 (0.62-0.72), and 0.82 (0.78-0.86), respectively. In the last model, stenosis, history of contralateral TIAs or stroke, GSM, plaque area, and DWAs were independent predictors of ipsilateral CORI events. Combinations of these could stratify patients into different levels of risk for ipsilateral CORI and stroke, with predicted risk close to observed risk. Of the 923 patients with ≥ 70% stenosis, the predicted cumulative

  12. Risk stratification in heart failure using artificial neural networks.

    PubMed Central

    Atienza, F.; Martinez-Alzamora, N.; De Velasco, J. A.; Dreiseitl, S.; Ohno-Machado, L.

    2000-01-01

    Accurate risk stratification of heart failure patients is critical to improve management and outcomes. Heart failure is a complex multisystem disease in which several predictors are categorical. Neural network models have successfully been applied to several medical classification problems. Using a simple neural network, we assessed one-year prognosis in 132 patients, consecutively admitted with heart failure, by classifying them in 3 groups: death, readmission and one-year event-free survival. Given the small number of cases, the neural network model was trained using a resampling method. We identified relevant predictors using the Automatic Relevance Determination (ARD) method, and estimated their mean effect on the 3 different outcomes. Only 9 individuals were misclassified. Neural networks have the potential to be a useful tool for making prognosis in the domain of heart failure. PMID:11079839

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

    PubMed Central

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

    2015-01-01

    Selection of patients for abdominal aortic aneurysm (AAA) repair is currently based on aneurysm size, growth rate and symptoms. Molecular imaging of biological processes associated with aneurysm growth and rupture, e.g., inflammation and matrix remodeling, could improve patient risk stratification and lead to a reduction in AAA morbidity and mortality. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and ultrasmall superparamagnetic particles of iron oxide (USPIO) magnetic resonance imaging are two novel approaches to AAA imaging evaluated in clinical trials. A variety of other tracers, including those that target inflammatory cells and proteolytic enzymes (e.g., integrin αvβ3 and matrix metalloproteinases), have proven effective in preclinical models of AAA and show great potential for clinical translation. PMID:26763279

  14. 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 αvβ3 and matrix metalloproteinases), have proven effective in preclinical models of abdominal aortic aneurysm and show great potential for clinical translation.

  15. Risk stratification for coronary artery disease using pharmacological stress tests.

    PubMed

    El-Hajj, Stephanie; Hage, Fadi G

    2014-01-01

    Cardiac stress testing is frequently used for diagnosis of coronary artery disease and for risk stratification which can facilitate decision making and help in the overall management of patients with known or suspected coronary disease. Exercise remains the preferred stress modality and should be performed when feasible but it is often contraindicated, impractical or unable to provide the needed information. In these circumstances pharmacologic stress tests can provide a wealth of prognostic data and should be performed instead of non-diagnostic or suboptimal exercise stress tests. Here we will review the use of pharmacologic stress tests including the indications for ordering them and the different stress agents and imaging modalities that can be utilized with emphasis on practical information that the primary care physician and general practitioner need on a daily basis in their practice.

  16. Cost-effectiveness of various risk stratification methods for asymptomatic ventricular pre-excitation.

    PubMed

    Czosek, Richard J; Anderson, Jeffrey; Cassedy, Amy; Spar, David S; Knilans, Timothy K

    2013-07-15

    Accessory pathways with "high-risk" properties confer a small but potential risk of sudden cardiac death. Pediatric guidelines advocate for either risk stratification or ablation in patients with ventricular pre-excitation but do not advocate specific methodology. We sought to compare the cost of differing risk-stratification methodologies in pediatric patients with ventricular pre-excitation in this single institutional, retrospective cohort study of asymptomatic pediatric patients who underwent risk stratification for ventricular pre-excitation. Institutional methodology consisted of stratification using graded exercise testing (GXT) followed by esophageal testing in patients without loss of pre-excitation and ultimately ablation in high-risk patients or patients who became clinically symptomatic during follow-up. A decision analysis model was used to compare this methodology with hypothetical methodologies using different components of the stratification technique and an "ablate all" method. One hundred and two pediatric patients with asymptomatic ventricular pre-excitation underwent staged risk stratification; 73% of patients were deemed low risk and avoided ablation and the remaining 27% ultimately were successfully ablated. The use of esophageal testing was associated with a 23% (p ≤0.0001) reduction in cost compared with GXT stratification alone and a 48% (p ≤0.0001) reduction compared with the "ablate all" model. GXT as a lone stratification method was also associated with a 15% cost reduction (p ≤0.0001) compared with the "ablate all" method. In conclusion, risk stratification of pediatric patients with asymptomatic ventricular pre-excitation is associated with reduced cost. These outcomes of cost-effectiveness need to be combined with the risks and benefits associated with ablation and risk stratification.

  17. Implementing system-wide risk stratification approaches: A review of critical success and failure factors.

    PubMed

    Huckel Schneider, Carmen; Gillespie, James A; Wilson, Andrew

    2017-01-01

    Risk stratification has become a widely used tool for linking people identified at risk of health deterioration to the most appropriate evidence-based care. This article systematically reviews recent literature to determine key factors that have been identified as critical enablers and/or barriers to successful implementation of risk stratification tools at a system level. A systematic search found 23 articles and four promising protocols for inclusion in the review, covering the use to 20 different risk stratification tools. These articles reported on only a small fraction of the risk stratification tools used in health systems; suggesting that while the development and statistical validation of risk stratification algorithms is widely reported, there has been little published evaluation of how they are implemented in real-world settings. Controlled studies provided some evidence that the use of risk stratification tools in combination with a care management plan offer patient benefits and that the use of a risk stratification tool to determine components of a care management plan may contribute to reductions in hospital readmissions, patient satisfaction and improved patient outcomes. Studies with the strongest focus on implementation used qualitative and case study methods. Among these, the literature converged on four key areas of implementation that were found to be critical for overcoming barriers to success: the engagement of clinicians and safeguarding equity, both of which address barriers of acceptance; the health system context to address administrative, political and system design barriers; and data management and integration to address logistical barriers.

  18. Epidemiology, Natural History, and Risk Stratification of Crohn's Disease.

    PubMed

    Aniwan, Satimai; Park, Sang Hyoung; Loftus, Edward V

    2017-09-01

    Crohn's disease (CD) is a chronic condition that can result in significant morbidity and disability. By studying the association between demographics and initial clinical features and subsequent natural history, one may be able to stratify patients by their risks of clinical relapse, hospitalization, and surgery. Understanding the potential environmental risk factors and natural history of CD in a given patient guides the physician when counseling the patient and selecting a treatment strategy. In this review, updated data regarding the incidence and prevalence of CD, important environmental risk factors, natural history of the disease, and important prognostic factors are discussed. Copyright © 2017 Elsevier Inc. All rights reserved.

  19. 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

  20. Risk-stratification management of febrile neutropenia in pediatric hematology-oncology patients: Results of a French nationwide survey.

    PubMed

    Delebarre, Mathilde; Tiphaine, Aude; Martinot, Alain; Dubos, François

    2016-12-01

    In 2012, new international guidelines for children with chemotherapy-induced febrile neutropenia (FN) were issued, recommending reduced-intensity management strategy based on stratification of infectious risks. Some studies have highlighted practice disparities in different countries and within the same country. Our aim was to assess the current management strategies for the treatment of chemotherapy-induced FN in children in France. This survey of all French pediatric oncology-hematology reference centers (n = 30) in late 2012 and early 2013 sent a standardized questionnaire to each center inquiring about their definition of an FN episode, its initial empiric treatment and ongoing management, use of management stratified by risk, and any criteria used for the risk assessment. Each center's management protocol was also analyzed. All French reference centers participated in this survey, completing 88% of the questionnaire items. Definitions of both fever and neutropenia varied between centers. Ten centers used a risk-stratification strategy for initial management. In all, 42 probabilistic first-line antibiotic treatments were identified. After 48 hr of apyrexia, 17 units applied different forms of step-down therapy. Most French centers already offered some form of reduced-intensity or step-down therapy, although they differed substantially in their management of FN episodes. Risk stratification with validated tools is essential to facilitate the implementation of the international recommendations, which would ultimately help to standardize practices in France. © 2016 Wiley Periodicals, Inc.

  1. Indiana chronic disease management program risk stratification analysis.

    PubMed

    Li, Jingjin; Holmes, Ann M; Rosenman, Marc B; Katz, Barry P; Downs, Stephen M; Murray, Michael D; Ackermann, Ronald T; Inui, Thomas S

    2005-10-01

    The objective of this study was to compare the ability of risk stratification models derived from administrative data to classify groups of patients for enrollment in a tailored chronic disease management program. This study included 19,548 Medicaid patients with chronic heart failure or diabetes in the Indiana Medicaid data warehouse during 2001 and 2002. To predict costs (total claims paid) in FY 2002, we considered candidate predictor variables available in FY 2001, including patient characteristics, the number and type of prescription medications, laboratory tests, pharmacy charges, and utilization of primary, specialty, inpatient, emergency department, nursing home, and home health care. We built prospective models to identify patients with different levels of expenditure. Model fit was assessed using R statistics, whereas discrimination was assessed using the weighted kappa statistic, predictive ratios, and the area under the receiver operating characteristic curve. We found a simple least-squares regression model in which logged total charges in FY 2002 were regressed on the log of total charges in FY 2001, the number of prescriptions filled in FY 2001, and the FY 2001 eligibility category, performed as well as more complex models. This simple 3-parameter model had an R of 0.30 and, in terms in classification efficiency, had a sensitivity of 0.57, a specificity of 0.90, an area under the receiver operator curve of 0.80, and a weighted kappa statistic of 0.51. This simple model based on readily available administrative data stratified Medicaid members according to predicted future utilization as well as more complicated models.

  2. The Financial Impact of a Multidisciplinary Preoperative Risk Stratification Program for Joint Arthroplasty.

    PubMed

    Duplantier, Neil; Briski, David; Ochsner, John Lockwood; Meyer, Mark; Stanga, Daryl; Chimento, George F

    2015-09-01

    This study's purpose was to assess the impact of a preoperative risk stratification program on joint arthroplasty outcomes at a single institution. We hypothesized that by using a standardized preoperative risk stratification center we would see better outcomes and decreased costs. The triage cohort (T) included 1498 patients assessed at a standardized risk stratification center, and the non-triage cohort (NT) included 1100 patients who did not utilize the center. The T cohort had significantly higher ASA classification (P<0.0001) and ACCI scores (P=0.028). We found no significant difference in complication rates. The T cohort showed a significant decrease in LOS (P<0.0001) and an increase in average reimbursement (P=0.009). A standardized preoperative risk stratification center can contribute to decreased LOS, increased reimbursement and help prevent complications. Copyright © 2015 Elsevier Inc. All rights reserved.

  3. Population-based genetic risk prediction and stratification for ovarian cancer: views from women at high risk.

    PubMed

    Rahman, Belinda; Meisel, Susanne F; Fraser, Lindsay; Side, Lucy; Gessler, Sue; Wardle, Jane; Lanceley, Anne

    2015-03-01

    There is an opportunity to improve outcomes for ovarian cancer (OC) through advances in risk stratification, early detection and diagnosis. A population-based OC genetic risk prediction and stratification program is being developed. A previous focus group study with individuals from the general population showed support for the proposed program. This qualitative interview study explores the attitudes of women at high risk of OC. Eight women participated in one-on-one, in-depth, semi-structured interviews to explore: experiences of learning of OC risk, risk perceptions, OC knowledge and awareness, and opinions on risk stratification approach. There was evidence of strong support for the proposed program. Benefits were seen as providing reassurance to women at low risk, and reducing worry in women at high risk through appropriate clinical management. Stratification into 'low' and 'high' risk groups was well-received. Participants were more hesitant about stratification to the 'intermediate' risk group. The data suggest formats to effectively communicate OC risk estimates will require careful thought. Interactions with GPs were highlighted as a barrier to OC risk assessment and diagnosis. These results are encouraging for the possible introduction and uptake of a risk prediction and stratification program for OC in the general population.

  4. 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

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

    PubMed

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

    2015-01-01

    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. 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. 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. Selective calcium supplementation for DTC based on NCCN risk stratification system could be recommended for the high-risk patients.

  6. [Epidemiology, Risk Factors and Risk Stratification of Venous Thromboembolism in Pregnancy and the Puerperium].

    PubMed

    Tsikouras, Panagiotis; von Tempelhoff, Georg-Friedrich; Rath, Werner

    2017-08-01

    Venous thromboembolism (VTE) remains a leading cause of direct maternal deaths in the developed countries. The incidence of VTE has increased significantly during the past two decades. The absolute risk of VTE is estimated 0.6-2.2 per 1000 deliveries. Compared with age-matched non-pregnant women, the daily risk of VTE is increased 7- to 10-fold for antepartum VTE, but it is 15- to 35-fold for postpartum VTE. The incidence of pulmonary embolism (PE) during the first 6 weeks postpartum is nearly 15-fold higher compared to the incidence in pregnancy, and remains significantly increased up to 12 weeks postpartum. The case fatality rate of PE ranges from 2.2 to 6.6%.The basis of VTE prevention is careful assessment of individual risk factors of VTE and proper risk stratification.It is necessary to differentiate preexisting maternal from transient pregnancy-specific risk factors. Women with previous VTE or hereditary high-risk thrombophilias or with the antiphospholipid syndrome have the highest risk for VTE in pregnancy and the puerperium.Other most important pregnancy-specific risk factors in the antenatal period are severe ovarian hyperstimulation syndrome, hyperemesis, major surgery, severe comorbidities (e.g., systemic lupus erythematodes), hospitalization in women with a body mass index > 25 kg/m(2), and inflammatory bowel diseases.Heart diseases, stillbirth, systemic infections, severe postpartum hemorrhage in combination with blood product replacement and/or surgery and emergency caesarean section are predominant risk factors in the postpartum period.Recommendations for risk stratification vary among current international guidelines. According to the SOGC (Society of Obstetricians and Gynaecologists of Canada) 2014, pharmacologic VTE prophylaxis is recommended if the estimated absolute risk of one or multiple risk factors is greater than 1%.The ACCP (American College of Chest Physicians) Guideline 2012 presents specific recommendations only for post

  7. Restriction Spectrum Imaging Improves Risk Stratification in Patients with Glioblastoma.

    PubMed

    Krishnan, A P; Karunamuni, R; Leyden, K M; Seibert, T M; Delfanti, R L; Kuperman, J M; Bartsch, H; Elbe, P; Srikant, A; Dale, A M; Kesari, S; Piccioni, D E; Hattangadi-Gluth, J A; Farid, N; McDonald, C R; White, N S

    2017-05-01

    ADC as a marker of tumor cellularity has been promising for evaluating the response to therapy in patients with glioblastoma but does not successfully stratify patients according to outcomes, especially in the upfront setting. Here we investigate whether restriction spectrum imaging, an advanced diffusion imaging model, performed after an operation but before radiation therapy, could improve risk stratification in patients with newly diagnosed glioblastoma relative to ADC. Pre-radiation therapy diffusion-weighted and structural imaging of 40 patients with glioblastoma were examined retrospectively. Restriction spectrum imaging and ADC-based hypercellularity volume fraction (restriction spectrum imaging-FLAIR volume fraction, restriction spectrum imaging-contrast-enhanced volume fraction, ADC-FLAIR volume fraction, ADC-contrast-enhanced volume fraction) and intensities (restriction spectrum imaging-FLAIR 90th percentile, restriction spectrum imaging-contrast-enhanced 90th percentile, ADC-FLAIR 10th percentile, ADC-contrast-enhanced 10th percentile) within the contrast-enhanced and FLAIR hyperintensity VOIs were calculated. The association of diffusion imaging metrics, contrast-enhanced volume, and FLAIR hyperintensity volume with progression-free survival and overall survival was evaluated by using Cox proportional hazards models. Among the diffusion metrics, restriction spectrum imaging-FLAIR volume fraction was the strongest prognostic metric of progression-free survival (P = .036) and overall survival (P = .007) in a multivariate Cox proportional hazards analysis, with higher values indicating earlier progression and shorter survival. Restriction spectrum imaging-FLAIR 90th percentile was also associated with overall survival (P = .043), with higher intensities, indicating shorter survival. None of the ADC metrics were associated with progression-free survival/overall survival. Contrast-enhanced volume exhibited a trend toward significance for overall survival (P

  8. Incorporation of CEA Improves Risk Stratification in Stage II Colon Cancer.

    PubMed

    Spindler, Blake A; Bergquist, John R; Thiels, Cornelius A; Habermann, Elizabeth B; Kelley, Scott R; Larson, David W; Mathis, Kellie L

    2017-03-13

    High-risk features are used to direct adjuvant therapy for stage II colon cancer. Currently, high-risk features are identified postoperatively, limiting preoperative risk stratification. We hypothesized carcinoembryonic antigen (CEA) can improve preoperative risk stratification for stage II colon cancer. The National Cancer Database (NCDB 2004-2009) was reviewed for stage II colon adenocarcinoma patients undergoing curative intent resection. A novel risk stratification including both traditional high-risk features (T4 lesion, <12 lymph nodes sampled, and poor differentiation) and elevated CEA was developed. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyzed overall survival. Concordance Probability Estimates (CPE) assessed discrimination. Seventy-four thousand nine hundred forty-five patients were identified; 40,844 (54.5%) had CEA levels reported and were included. Chemotherapy administration was similar between normal and elevated CEA groups (23.8 vs. 25.1%, p = 0.003). Compared to patients with CEA elevation, 5-year overall survival in patients with normal CEA was improved (74.5 vs. 63.4%, p < 0.001). Restratification incorporating CEA resulted in reclassification of 6912 patients (16.9%) from average to high risk. CPE increased for novel risk stratification (0.634 vs. 0.612, SE = 0.005). The routinely available CEA test improved risk stratification for stage II colon cancer. CEA not only may improve staging of colon cancer but may also help guide additional therapy.

  9. Early risk stratification in pediatric type 1 diabetes.

    PubMed

    Broe, Rebecca

    2015-03-01

    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. © 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

  10. 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

  11. 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

  12. Performance and agreement of risk stratification instruments for postoperative delirium in persons aged 50 years or older.

    PubMed

    Jansen, Carolien J; Absalom, Anthony R; de Bock, Geertruida H; van Leeuwen, Barbara L; Izaks, Gerbrand J

    2014-01-01

    Several risk stratification instruments for postoperative delirium in older people have been developed because early interventions may prevent delirium. We investigated the performance and agreement of nine commonly used risk stratification instruments in an independent validation cohort of consecutive elective and emergency surgical patients aged ≥50 years with ≥1 risk factor for postoperative delirium. Data was collected prospectively. Delirium was diagnosed according to DSM-IV-TR criteria. The observed incidence of postoperative delirium was calculated per risk score per risk stratification instrument. In addition, the risk stratification instruments were compared in terms of area under the receiver operating characteristic (ROC) curve (AUC), and positive and negative predictive value. Finally, the positive agreement between the risk stratification instruments was calculated. When data required for an exact implementation of the original risk stratification instruments was not available, we used alternative data that was comparable. The study population included 292 patients: 60% men; mean age (SD), 66 (8) years; 90% elective surgery. The incidence of postoperative delirium was 9%. The maximum observed incidence per risk score was 50% (95%CI, 15-85%); for eight risk stratification instruments, the maximum observed incidence per risk score was ≤25%. The AUC (95%CI) for the risk stratification instruments varied between 0.50 (0.36-0.64) and 0.66 (0.48-0.83). No AUC was statistically significant from 0.50 (p≥0.11). Positive predictive values of the risk stratification instruments varied between 0-25%, negative predictive values between 89-95%. Positive agreement varied between 0-66%. No risk stratification instrument showed clearly superior performance. In conclusion, in this independent validation cohort, the performance and agreement of commonly used risk stratification instruments for postoperative delirium was poor. Although some caution is needed

  13. Recommendations on breast cancer screening and prevention in the context of implementing risk stratification: impending changes to current policies.

    PubMed

    Gagnon, J; Lévesque, E; Borduas, F; Chiquette, J; Diorio, C; Duchesne, N; Dumais, M; Eloy, L; Foulkes, W; Gervais, N; Lalonde, L; L'Espérance, B; Meterissian, S; Provencher, L; Richard, J; Savard, C; Trop, I; Wong, N; Knoppers, B M; Simard, J

    2016-12-01

    In recent years, risk stratification has sparked interest as an innovative approach to disease screening and prevention. The approach effectively personalizes individual risk, opening the way to screening and prevention interventions that are adapted to subpopulations. The international perspective project, which is developing risk stratification for breast cancer, aims to support the integration of its screening approach into clinical practice through comprehensive tool-building. Policies and guidelines for risk stratification-unlike those for population screening programs, which are currently well regulated-are still under development. Indeed, the development of guidelines for risk stratification reflects the translational aspects of perspective. Here, we describe the risk stratification process that was devised in the context of perspective, and we then explain the consensus-based method used to develop recommendations for breast cancer screening and prevention in a risk-stratification approach. Lastly, we discuss how the recommendations might affect current screening policies.

  14. Application of Biomarkers for Risk Stratification in Patients with Atrial Fibrillation.

    PubMed

    Hijazi, Ziad; Oldgren, Jonas; Siegbahn, Agneta; Wallentin, Lars

    2017-01-01

    Atrial fibrillation is the most common sustained arrhythmia and an important contributor to cardiovascular morbidity and mortality. Several strategies have been proposed for prediction of outcomes and individualization of treatments to better balance the benefits of stroke prevention and risks of bleeding during anticoagulation. The availability of analytically more specific and sensitive methods to measure circulating biomarkers of cellular and organ stress and dysfunction has led to testing of their utility in several cardiovascular conditions. In patients with atrial fibrillation, biomarkers of myocardial injury (troponin) and cardiovascular stress and dysfunction (natriuretic peptides, growth differentiation factor 15), myocardial fibrosis (galectin-3), renal dysfunction (creatinine, cystatin C), inflammation (C-reactive protein, cytokines) and coagulation activity (d-dimer) have been found associated with underlying pathophysiology, clinical outcomes and effects of treatment. Measurements of these markers might therefore expand the understanding of the pathophysiology, improve risk assessment and optimize treatment in individual patients with atrial fibrillation. Biomarkers for risk stratification have potential roles as tools for evaluation of patients with atrial fibrillation and for selection of the best treatment strategies to prevent stroke, major bleeding, and mortality. © 2016 American Association for Clinical Chemistry.

  15. [Cardiovascular risk stratification. Systolic, diastolic or pulse pressure?].

    PubMed

    Pede, S; Lombardo, M

    2001-04-01

    and prognostic implications and account for the possible diversity of significance to attribute to systolic, diastolic, mean and pulse BP, factors which, in their entirety, can represent an element, albeit partial, of resolvability of problems in managing hypertension. In fact, possibilities of diversification in the stratification of risk of the hypertensive patients may be considered on a pathophysiological basis, with the prospect of better aimed therapeutic interventions. On the whole, it appears that the clinical significance to attribute to pulse BP should be considered not as an alternative to that of systolic and diastolic BP, but rather in complementary terms, with age kept in careful consideration. In practice, by simplifying to a maximum the state of present knowledge, the values of systolic, diastolic, mean and pulse BP are all important in subjects under 60 years old. This indicates that the clinical significance to attribute to diastolic hypertension in young or middle-aged patients, which have been so accurately described by well-known meta-analyses, is not presently under discussion. What seems to change, with respect to the past, is the importance that should be attributed to the systolic and pulse BP in subjects of all ages and in particular to pulse BP in subjects over 60 years old: in these persons, the increase in pulse BP summarizes and integrates the adverse prognostic value of an elevated systolic BP and a low diastolic BP. It should be clearly understood that, in subjects over 60 years old, a high systolic BP and a low diastolic BP mean rigidity of the wall of the aorta and of the main elastic arteries; in these subjects, the isolated increase in diastolic BP, usually easily controllable by antihypertensive treatment, should not cause excessive clinical concern; instead, an increase in systolic BP - even if isolated - and, above all, an increase in pulse BP, should cause greater preoccupation, inasmuch as they are signs of consistent serious

  16. Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

    PubMed

    Reddy, Ashok; Sessums, Laura; Gupta, Reshma; Jin, Janel; Day, Tim; Finke, Bruce; Bitton, Asaf

    2017-09-01

    Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services. © 2017 Annals of Family Medicine, Inc.

  17. 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

  18. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.

    PubMed

    Moffatt-Bruce, Susan D; Cook, Charles H; Steinberg, Steven M; Stawicki, Stanislaw P

    2014-08-01

    Retained surgical items (RSI) are designated as completely preventable "never events". Despite numerous case reports, clinical series, and expert opinions few studies provide quantitative insight into RSI risk factors and their relative contributions to the overall RSI risk profile. Existing case-control studies lack the ability to reliably detect clinically important differences within the long list of proposed risks. This meta-analysis examines the best available data for RSI risk factors, seeking to provide a clinically relevant risk stratification system. Nineteen candidate studies were considered for this meta-analysis. Three retrospective, case-control studies of RSI-related risk factors contained suitable group comparisons between patients with and without RSI, thus qualifying for further analysis. Comprehensive Meta-Analysis 2.0 (BioStat, Inc, Englewood, NJ) software was used to analyze the following "common factor" variables compiled from the above studies: body-mass index, emergency procedure, estimated operative blood loss >500 mL, incorrect surgical count, lack of surgical count, >1 subprocedure, >1 surgical team, nursing staff shift change, operation "afterhours" (i.e., between 5 PM and 7 AM), operative time, trainee presence, and unexpected intraoperative factors. We further stratified resulting RSI risk factors into low, intermediate, and high risk. Despite the fact that only between three and six risk factors were associated with increased RSI risk across the three studies, our analysis of pooled data demonstrates that seven risk factors are significantly associated with increased RSI risk. Variables found to elevate the RSI risk include intraoperative blood loss >500 mL (odds ratio [OR] 1.6); duration of operation (OR 1.7); >1 subprocedure (OR 2.1); lack of surgical counts (OR 2.5); >1 surgical team (OR 3.0); unexpected intraoperative factors (OR 3.4); and incorrect surgical count (OR 6.1). Changes in nursing staff, emergency surgery, body

  19. Applying risk assessment models in non-surgical patients: effective risk stratification.

    PubMed

    Eldor, A

    1999-08-01

    Pulmonary embolism and deep vein thrombosis are serious complications of non-surgical patients, but scarcity of data documenting prophylaxis means antithrombotic therapy is rarely used. Prediction of risk is complicated by the variation in the medical conditions associated with venous thromboembolism (VTE), and lack of data defining risk in different groups. Accurate risk assessment is further confounded by inherited or acquired factors for VTE, additional risk due to medical interventions, and interactions between risk factors. Acquired and inherited risk factors may underlie thromboembolic complications in a range of conditions, including pregnancy, ischaemic stroke, myocardial infarction and cancer. Risk stratification may be feasible in non-surgical patients by considering individual risk factors and their cumulative effects. Current risk assessment models require expansion and modification to reflect emerging evidence in the non-surgical field. A large on-going study of prophylaxis with low-molecular-weight heparin in non-surgical patients will clarify our understanding of the components of risk, and assist in developing therapy recommendations.

  20. New Methods for the Analysis of Heartbeat Behavior in Risk Stratification

    PubMed Central

    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

  1. Children with heart disease: Risk stratification for non-cardiac surgery.

    PubMed

    Saettele, Angela K; Christensen, Jacob L; Chilson, Kelly L; Murray, David J

    2016-12-01

    Children with congenital or acquired heart disease have an increased risk of anesthesia related morbidity and mortality. The child's anesthetic risk is related to the severity of their underlying cardiac disease, associated comorbidities, and surgical procedure. The goal of this project was to determine the ease of use of a preoperative risk stratification tool for assigning pediatric cardiac staff and to determine the relative frequency that children with low, moderate, and high risk cardiac disease present for non-cardiac surgery at a tertiary pediatric hospital. A risk-stratification tool was prospectively applied to children with congenital heart disease who presented for non-cardiac surgery. Perioperative. We identified a subset of 100 children with congenital heart disease out of 2200 children who required general anesthesia for surgical or radiological procedures over a 6 week period. A risk stratification tool was utilized to place the patient into low, moderate, or high risk categories to help predict anticipated anesthetic risk. Each grouping specified assignment of staff caring for the patient, clarified preoperative expectations for cardiac assessment, and determined if patient care could be performed at our freestanding ambulatory surgical center. Electronic perioperative records were reviewed to obtain demographic information, the underlying heart disease, prior cardiac surgery, associated conditions, anesthetic management, complications, and provider type. Approximately 4.5% of children presented with cardiac disease over a 6 week period. In 100 consecutive children with cardiac disease, 23 of the children were classified as low risk, 66 patients were classified as moderate risk, and 11 of the patients were classified as high risk. Pediatric cardiac anesthesiologists provided care to all high risk patients. There were no serious adverse events. We found this risk stratification method an effective method to differentiate children into low, moderate

  2. Recommendations on breast cancer screening and prevention in the context of implementing risk stratification: impending changes to current policies

    PubMed Central

    Gagnon, J.; Lévesque, E.; Borduas, F.; Chiquette, J.; Diorio, C.; Duchesne, N.; Dumais, M.; Eloy, L.; Foulkes, W.; Gervais, N.; Lalonde, L.; L’Espérance, B.; Meterissian, S.; Provencher, L.; Richard, J.; Savard, C.; Trop, I.; Wong, N.; Knoppers, B.M.; Simard, J.

    2016-01-01

    In recent years, risk stratification has sparked interest as an innovative approach to disease screening and prevention. The approach effectively personalizes individual risk, opening the way to screening and prevention interventions that are adapted to subpopulations. The international perspective project, which is developing risk stratification for breast cancer, aims to support the integration of its screening approach into clinical practice through comprehensive tool-building. Policies and guidelines for risk stratification—unlike those for population screening programs, which are currently well regulated—are still under development. Indeed, the development of guidelines for risk stratification reflects the translational aspects of perspective. Here, we describe the risk stratification process that was devised in the context of perspective, and we then explain the consensus-based method used to develop recommendations for breast cancer screening and prevention in a risk-stratification approach. Lastly, we discuss how the recommendations might affect current screening policies. PMID:28050152

  3. 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 1–6 month risk. Methods 7,399 patients undergoing suicide risk assessment were followed up for 180 days. 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 3 months (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

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

    PubMed

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

    2011-01-01

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

  5. [Diagnosis, sudden death risk stratification, and treatment of main long QT syndrome molecular-genetic variants].

    PubMed

    Shkol'nikova, M A; Kharlap, M S; Il'darova, R A; Bereznitskaia, V V; Kalinin, L A

    2011-01-01

    Inherited long QT syndrome (LQTS) refers to the primary electrical diseases of the heart. It is characterized by QT prolongation on resting ECG and syncope due to life-threatening ventricular arrhythmias. This review focuses on diagnosis, differential diagnosis, risk stratification of sudden cardiac death, and treatment strategy of patients with most prevalent genetic fOrms of LQTS - LQT1, LQT2 and LQT3, which accounted for about 90% of all genetically confirmed cases. Recent advances in understanding of relationship between clinical, electrocardiographic features (on ECG, body surface mapping, stress test) and genetic variants of LQT presented. Characteristics of syncopal events and ECG features of LQTl, LQT2 and LQT3 in the majority of cases are helpful to make an appropriate choice for therapy, even before positive result of molecular genetic testing. Management has focused on the use of beta blockers as first-line treatment and exclusion of triggers of life-threatening arrhythmia which are specific for each molecular-genetic variant. Implantation of cardioverter defibrillator for secondary prevention of sudden death in the high-risk patients or patients with insufficient effect of antiarrhythmic therapy is required.

  6. World Health Organization cardiovascular risk stratification and target organ damage.

    PubMed

    Piskorz, D; Bongarzoni, L; Citta, L; Citta, N; Citta, P; Keller, L; Mata, L; Tommasi, A

    2016-01-01

    Prediction charts allow treatment to be targeted according to simple markers of cardiovascular risk; many algorithms do not recommend screening asymptomatic target organ damage which could change dramatically the assessment. To demonstrate that target organ damage is present in low cardiovascular risk hypertensive patients and it is more frequent and severe as global cardiovascular risk increases. Consecutive hypertensive patients treated at a single Latin American center. Cardiovascular risk stratified according to 2013 WHO/ISH risk prediction chart America B. Left ventricular mass assessed by Devereux method, left ventricular hypertrophy considered >95g/m(2) in women and >115g/m(2) in men. Transmitral diastolic peak early flow velocity to average septal/lateral peak early diastolic relaxation velocity (E/e' ratio) measured cut off value >13. Systolic function assessed by tissue Doppler average interventricular septum/lateral wall mitral annulus rate systolic excursion (s wave). A total of 292 patients were included of whom 159 patients (54.5%) had cardiovascular risk of <10%, 90 (30.8%) had cardiovascular risk of 10-20% and 43 (14.7%) had cardiovascular risk of >20%. Left ventricular hypertrophy was detected in 17.6% low risk patients, 27.8% in medium risk and 23.3% in high risk (p<0.05), abnormal E/e' ratio was found in 13.8%, 31.1% and 27.9%, respectively (p<0.05). Mean s wave was 8.03+8, 8.1+9 and 8.7+1cm/s for low, intermediate and high risk patients, respectively (p<0.025). Target organ damage is more frequent and severe in high risk; one over four subjects was misclassified due to the presence of asymptomatic target organ damage. Copyright © 2015 SEHLELHA. Published by Elsevier España, S.L.U. All rights reserved.

  7. Validation of risk stratification models in acute myeloid leukemia using sequencing-based molecular profiling.

    PubMed

    Wang, M; Lindberg, J; Klevebring, D; Nilsson, C; Mer, A S; Rantalainen, M; Lehmann, S; Grönberg, H

    2017-10-01

    Risk stratification of acute myeloid leukemia (AML) patients needs improvement. Several AML risk classification models based on somatic mutations or gene-expression profiling have been proposed. However, systematic and independent validation of these models is required for future clinical implementation. We performed whole-transcriptome RNA-sequencing and panel-based deep DNA sequencing of 23 genes in 274 intensively treated AML patients (Clinseq-AML). We also utilized the The Cancer Genome Atlas (TCGA)-AML study (N=142) as a second validation cohort. We evaluated six previously proposed molecular-based models for AML risk stratification and two revised risk classification systems combining molecular- and clinical data. Risk groups stratified by five out of six models showed different overall survival in cytogenetic normal-AML patients in the Clinseq-AML cohort (P-value<0.05; concordance index >0.5). Risk classification systems integrating mutational or gene-expression data were found to add prognostic value to the current European Leukemia Net (ELN) risk classification. The prognostic value varied between models and across cohorts, highlighting the importance of independent validation to establish evidence of efficacy and general applicability. All but one model replicated in the Clinseq-AML cohort, indicating the potential for molecular-based AML risk models. Risk classification based on a combination of molecular and clinical data holds promise for improved AML patient stratification in the future.

  8. Risk Stratification and Shared Decision Making for Colorectal Cancer Screening: A Randomized Controlled Trial.

    PubMed

    Schroy, Paul C; Duhovic, Emir; Chen, Clara A; Heeren, Timothy C; Lopez, William; Apodaca, Danielle L; Wong, John B

    2016-05-01

    Eliciting patient preferences within the context of shared decision making has been advocated for colorectal cancer (CRC) screening, yet providers often fail to comply with patient preferences that differ from their own. To determine whether risk stratification for advanced colorectal neoplasia (ACN) influences provider willingness to comply with patient preferences when selecting a desired CRC screening option. Randomized controlled trial. Asymptomatic, average-risk patients due for CRC screening in an urban safety net health care setting. Patients were randomized 1:1 to a decision aid alone (n= 168) or decision aid plus risk assessment (n= 173) arm between September 2012 and September 2014. The primary outcome was concordance between patient preference and test ordered; secondary outcomes included patient satisfaction with the decision-making process, screening intentions, test completion rates, and provider satisfaction. Although providers perceived risk stratification to be useful in selecting an appropriate screening test for their average-risk patients, no significant differences in concordance were observed between the decision aid alone and decision aid plus risk assessment groups (88.1% v. 85.0%,P= 0.40) or high- and low-risk groups (84.5% v. 87.1%,P= 0.51). Concordance was highest for colonoscopy and relatively low for tests other than colonoscopy, regardless of study arm or risk group. Failure to comply with patient preferences was negatively associated with satisfaction with the decision-making process, screening intentions, and test completion rates. Single-institution setting; lack of provider education about the utility of risk stratification into their decision making. Providers perceived risk stratification to be useful in their decision making but often failed to comply with patient preferences for tests other than colonoscopy, even among those deemed to be at low risk of ACN. © The Author(s) 2016.

  9. Comparison of dermatoscopic ABCD rule and risk stratification in the diagnosis of malignant melanoma.

    PubMed

    Lorentzen, H; Weismann, K; Kenet, R O; Secher, L; Larsen, F G

    2000-01-01

    For didactic and documentation purposes the dermatoscopic ABCD rule and the dermatoscopic risk stratification have been proposed. The aim of this investigation was to compare the ability of the 2 methods to separate patients with cutaneous malignant melanoma from individuals with other pigmented skin lesions. Three dermatologists, experienced users of dermatoscopy, assessed macroscopic clinical and dermatoscopic slides from 258 patients referred to the skin cancer outpatient clinic by the ABCD rule and risk stratification methods. Diagnostic performance of the 2 methods was compared by receiver operating characteristics curve analysis. When all pigmented skin lesions were compared, there was a trend for the observers to perform better using risk stratification. When only lesions with a well-defined pigment network were included, the diagnostic performance of the risk stratification method was superior to the dermatoscopic ABCD rule (areas under the receiver operating characteristics curve median 0.93 vs. 0.80, p<0.004) for all observers. The agreement between the 2 methods was moderate to substantial (kappa coefficient 0.53-0.62). More melanomas were identified when the rules were combined. The dermatoscopic ABCD rule has been accepted as a standard for identifying melanomas with the dermatoscope, but should be considered secondary to pigment network analysis.

  10. Double Stratification and Psychological Risk: Adaptational Processes and School Achievement of Black Children.

    ERIC Educational Resources Information Center

    Spencer, Margaret Beale; And Others

    1987-01-01

    The experiences of children are affected by both their ethnicity and socioeconomic status. Black children's performance in school reflects the group's marginality. The following issues affect the child's educability: (1) double stratification; (2) psychological risk; (3) adaptational processes; and (4) the relationship between psychological health…

  11. Risk stratification in ductal carcinoma in situ: the role of genomic testing.

    PubMed

    Freedman, Gary M

    2013-02-01

    From the earliest days of conservative surgery for ductal carcinoma in situ (DCIS) of the breast, there have been attempts to identify patients who may not need postoperative radiation. Randomized prospective trials have not identified a population for whom there is no benefit to radiation. However, decades of studies of clinical, radiological and pathologic correlates to local recurrence have led to criteria for a patient subgroup at low risk for local recurrence after omission of radiation. Gene expression profiling for invasive breast cancer has been used to identify patients at low, intermediate or high risk for distant recurrence. Application of this methodology to DCIS aims to identify patients at low, intermediate or high risk for local recurrence. Whether this method of risk stratification will prove more accurate than clinical, radiological and pathologic risk stratification, or identify patients with little to no clinical benefit from radiation, remains to be seen.

  12. Modified risk stratification grouping using standard clinical and biopsy information for patients undergoing radical prostatectomy: Results from SEARCH.

    PubMed

    Zumsteg, Zachary S; Chen, Zinan; Howard, Lauren E; Amling, Christopher L; Aronson, William J; Cooperberg, Matthew R; Kane, Christopher J; Terris, Martha K; Spratt, Daniel E; Sandler, Howard M; Freedland, Stephen J

    2017-10-10

    Prostate cancer is a heterogeneous disease, and risk stratification systems have been proposed to guide treatment decisions. However, significant heterogeneity remains for those with unfavorable-risk disease. This study included 3335 patients undergoing radical prostatectomy without adjuvant radiotherapy in the SEARCH database. High-risk patients were dichotomized into standard and very high-risk (VHR) groups based on primary Gleason pattern, percentage of positive biopsy cores (PPBC), number of NCCN high-risk factors, and stage T3b-T4 disease. Similarly, intermediate-risk prostate cancer was separated into favorable and unfavorable groups based on primary Gleason pattern, PPBC, and number of NCCN intermediate-risk factors. Median follow-up was 78 months. Patients with VHR prostate cancer had significantly worse PSA relapse-free survival (PSA-RFS, P < 0.001), distant metastasis (DM, P = 0.004), and prostate cancer-specific mortality (PCSM, P = 0.015) in comparison to standard high-risk (SHR) patients in multivariable analyses. By contrast, there was no significant difference in PSA-RFS, DM, or PCSM between SHR and unfavorable intermediate-risk (UIR) patients. Therefore, we propose a novel risk stratification system: Group 1 (low-risk), Group 2 (favorable intermediate-risk), Group 3 (UIR and SHR), and Group 4 (VHR). The c-index of this new grouping was 0.683 for PSA-RFS and 0.800 for metastases, compared to NCCN-risk groups which yield 0.666 for PSA-RFS and 0.764 for metastases. Patients classified as VHR have markedly increased rates of PSA relapse, DM, and PCSM in comparison to SHR patients, whereas UIR and SHR patients have similar prognosis. Novel therapeutic strategies are needed for patients with VHR, likely involving multimodality therapy. © 2017 Wiley Periodicals, Inc.

  13. Risk stratification based on screening history: the NELSON lung cancer screening study.

    PubMed

    Yousaf-Khan, Uraujh; van der Aalst, Carlijn; de Jong, Pim A; Heuvelmans, Marjolein; Scholten, Ernst; Walter, Joan; Nackaerts, Kristiaan; Groen, Harry; Vliegenthart, Rozemarijn; Ten Haaf, Kevin; Oudkerk, Matthijs; de Koning, Harry

    2017-09-01

    Debate about the optimal lung cancer screening strategy is ongoing. In this study, previous screening history of the Dutch-Belgian Lung Cancer Screening trial (NELSON) is investigated on if it predicts the screening outcome (test result and lung cancer risk) of the final screening round. 15 792 participants were randomised (1:1) of which 7900 randomised into a screening group. CT screening took place at baseline, and after 1, 2 and 2.5 years. Initially, three screening outcomes were possible: negative, indeterminate or positive scan result. Probability for screening outcome in the fourth round was calculated for subgroups of participants. Based on results of the first three rounds, three subgroups were identified: (1) those with exclusively negative results (n=3856; 73.0%); (2) those with ≥1 indeterminate result, but never a positive result (n=1342; 25.5%); and (3) with ≥1 positive result (n=81; 1.5%). Group 1 had the highest probability for having a negative scan result in round 4 (97.2% vs 94.8% and 90.1%, respectively, p<0.001), and the lowest risk for detecting lung cancer in round 4 (0.6% vs 1.6%, p=0.001). 'Smoked pack-years' and 'screening history' significantly predicted the fourth round test result. The third round results implied that the risk for detecting lung cancer (after an interval of 2.5 years) was 0.6% for those with negative results compared with 3.7% of those with indeterminate results. Previous CT lung cancer screening results provides an opportunity for further risk stratifications of those who undergo lung cancer screening. Results, ISRCTN63545820. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  14. Impact of fusion gene status versus histology on risk-stratification for rhabdomyosarcoma: Retrospective analyses of patients on UK trials.

    PubMed

    Selfe, Joanna; Olmos, David; Al-Saadi, Reem; Thway, Khin; Chisholm, Julia; Kelsey, Anna; Shipley, Janet

    2017-07-01

    Long-term toxicities from current treatments are a major issue in paediatric cancer. Previous studies, including our own, have shown prognostic value for the presence of PAX3/7-FOXO1 fusion genes in rhabdomyosarcoma (RMS). It is proposed to introduce PAX3/7-FOXO1 positivity as a component of risk stratification, rather than alveolar histology, in future clinical trials. To assess the potential impact of this reclassification, we have determined the changes to risk category assignment of 210 histologically reviewed patients treated in the UK from previous malignant mesenchymal tumour clinical trials for non-metastatic RMS based on identification of PAX3/7-FOXO1 by fluorescence in situ hybridisation and/or reverse transcription PCR. Using fusion gene positivity in the current risk stratification would reassign 7% of patients to different European Paediatric Soft Tissue Sarcoma Study Group (EpSSG) risk groups. The next European trial would have 80% power to detect differences in event-free survival of 15% over 10 years and 20% over 5 years in reassigned patients. This would decrease treatment for over a quarter of patients with alveolar histology tumours that lack PAX3/7-FOXO1. Fusion gene status used in stratification may result in significant numbers of patients benefitting from lower treatment-associated toxicity. Prospective testing to show this reassignment maintains current survival rates is now required and is shown to be feasible based on estimated recruitment to a future EpSSG trial. Together with developing novel therapeutic strategies for patients identified as higher risk, this may ultimately improve the outcome and quality of life for patients with RMS. © 2016 Wiley Periodicals, Inc.

  15. Incurring greater health care costs: risk stratification of employees with bipolar disorder.

    PubMed

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

    2006-01-01

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

  16. 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

  17. Clinical decision support software for diabetic foot risk stratification: development and formative evaluation.

    PubMed

    Schoen, Deborah E; Glance, David G; Thompson, Sandra C

    2015-01-01

    Identifying people at risk of developing diabetic foot complications is a vital step in prevention programs in primary healthcare settings. Diabetic foot risk stratification systems predict foot ulceration. The aim of this study was to explore the views and experiences of potential end users during development and formative evaluations of an electronic diabetic foot risk stratification tool based on evidence-based guidelines and determine the accuracy of the tool. Formative evaluation of the risk tool occurred in five stages over an eight-month period and employed a mixed methods research design consisting of semi-structured interviews, focus group and participant observation, online survey, expert review, comparison to the Australian Guidelines and clinical testing. A total of 43 healthcare practitioners trialled the computerised clinical decision support system during development, with multiple software changes made as a result of feedback. Individual and focus group participants exposed critical design flaws. Live testing revealed risk stratification errors and functional limitations providing the basis for practical improvements. In the final product, all risk calculations and recommendations made by the clinical decision support system reflect current Australian Guidelines. Development of the computerised clinical decision support system using evidence-based guidelines can be optimised by a multidisciplinary iterative process of feedback, testing and software adaptation by experts in modern development technologies.

  18. 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

  19. Mortality Risk Stratification in Fontan Patients Who Underwent Heart Transplantation.

    PubMed

    Berg, Christopher J; Bauer, Brenton S; Hageman, Abbie; Aboulhosn, Jamil A; Reardon, Leigh C

    2017-03-01

    The number of patients who require orthotopic heart transplantation (OHT) for failing Fontan physiology continues to grow; however, the methods and tools to evaluate risk of OHT are limited. This study aimed to identify a set of preoperative variables and characteristics that were associated with a greater risk of postoperative mortality in patients who received OHT for failing Fontan physiology. Thirty-six Fontan patients were identified as having undergone OHT at University of California-Los Angeles Medical Center from 1991 to 2014. Data were collected retrospectively and analyzed. The primary end point was designated as postoperative mortality. After an average follow-up time of 3.5 years, 17 (44%) patients suffered postoperative mortality. Patient characteristics including (1) age <18 years at the time of OHT, (2) Fontan-OHT interval of <10 years, (3) systemic ventricular ejection fraction <20%, (4) moderate-to-severe atrioventricular valve insufficiency, (5) an elevated Model of End-stage Liver Disease, eXcluding INR score, or (6) need for advanced mechanical support before surgery were associated with an increased incidence of postoperative mortality. Using these risk factors, we present a theoretical framework to stratify risk of postoperative death in failing Fontan patients after OHT. In conclusion, a method such as this may aid in the transplantation evaluation and listing process of patients with failing Fontan physiology.

  20. Endothelial function and cardiovascular risk stratification in menopausal women.

    PubMed

    Mulvagh, S L; Behrenbeck, T; Lahr, B A; Bailey, K R; Zais, T G; Araoz, P A; Miller, V M

    2010-02-01

    Peripheral arterial, endothelium-dependent, flow-mediated reactive hyperemia is reduced in individuals with atherosclerosis. This study tested the hypothesis that digital tonometry, as a surrogate of endothelial function, is useful to stratify cardiovascular risk in recently menopausal women who are asymptomatic for cardiovascular disease. Women undergoing screening for the Kronos Early Estrogen Prevention Study (KEEPS) were evaluated for conventional risk factors, flow-mediated reactive hyperemia by digital tonometry (RHI), carotid intima-media thickness (CIMT) by ultrasound, and coronary arterial calcium (CAC) by 64-slice CT scanner. One hundred and two non-diabetic Caucasian women (53.0 +/- 2.3 years old, 18.0 +/- 9.0 months past their last menses) participated; 72% were never-smokers. Fourteen women had positive CAC scores (range 0.5-133 Agatston units); CIMT ranged from 0.57 to 1.06 mm. RHI ranged from 1.26 to 5.44. RHI did not correlate with time past menopause, CAC, CIMT, total cholesterol or low density lipoprotein cholesterol. The significant negative correlation of RHI with body mass index (r = -0.21, p = 0.031) was lost in non-smokers (r = - 0.17, p = 0.14). There was also a negative correlation of high density lipoprotein cholesterol with CAC, both in the overall group and non-smokers (rho = -0.20, p = 0.05 and rho = -0.27, p = 0.02, respectively). RHI varies widely in healthy women within the first 3 years of menopause. RHI was not associated with standard risk assessment algorithms, CAC or CIMT. RHI may indicate an additional, independent component and non-invasive tool to further stratify cardiovascular risk in recently menopausal women. As KEEPS continues, data on RHI will provide information regarding hormonal therapy, endovascular biology and atherosclerotic risk.

  1. [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.

  2. Risk Stratification of Hospitalized Patients on the Wards

    PubMed Central

    Churpek, Matthew M.; Yuen, Trevor C.

    2013-01-01

    Patients who suffer adverse events on the wards, such as cardiac arrest and death, often have vital sign abnormalities hours before the event. Early warning scores have been developed with the aim of identifying clinical deterioration early and have been recommended by the National Institute for Health and Clinical Excellence. In this review, we discuss recently developed and validated risk scores for use on the general inpatient wards. In addition, we compare newly developed systems with more established risk scores such as the Modified Early Warning Score and the criteria used in the Medical Early Response Intervention and Therapy (MERIT) trial in our database of > 59,000 ward admissions. In general we found the single-parameter systems, such as the MERIT criteria, to have the lowest predictive accuracy for adverse events, whereas the aggregate weighted scoring systems had the highest. The Cardiac Arrest Risk Triage (CART) score was best for predicting cardiac arrest, ICU transfer, and a composite outcome (area under the receiver operating characteristic curve [AUC], 0.83, 0.77, and 0.78, respectively), whereas the Standardized Early Warning Score, VitalPAC Early Warning Score, and CART score were similar for predicting mortality (AUC, 0.88). Selection of a risk score for a hospital or health-care system should be guided by available variables, calculation method, and system resources. Once implemented, ensuring high levels of adherence and tying them to specific levels of interventions, such as activation of a rapid response team, are necessary to allow for the greatest potential to improve patient outcomes. PMID:23732586

  3. Risk stratification of hospitalized patients on the wards.

    PubMed

    Churpek, Matthew M; Yuen, Trevor C; Edelson, Dana P

    2013-06-01

    Patients who suffer adverse events on the wards, such as cardiac arrest and death, often have vital sign abnormalities hours before the event. Early warning scores have been developed with the aim of identifying clinical deterioration early and have been recommended by the National Institute for Health and Clinical Excellence. In this review, we discuss recently developed and validated risk scores for use on the general inpatient wards. In addition, we compare newly developed systems with more established risk scores such as the Modified Early Warning Score and the criteria used in the Medical Early Response Intervention and Therapy (MERIT) trial in our database of > 59,000 ward admissions. In general we found the single-parameter systems, such as the MERIT criteria, to have the lowest predictive accuracy for adverse events, whereas the aggregate weighted scoring systems had the highest. The Cardiac Arrest Risk Triage (CART) score was best for predicting cardiac arrest, ICU transfer, and a composite outcome (area under the receiver operating characteristic curve [AUC], 0.83, 0.77, and 0.78, respectively), whereas the Standardized Early Warning Score, VitalPAC Early Warning Score, and CART score were similar for predicting mortality (AUC, 0.88). Selection of a risk score for a hospital or health-care system should be guided by available variables, calculation method, and system resources. Once implemented, ensuring high levels of adherence and tying them to specific levels of interventions, such as activation of a rapid response team, are necessary to allow for the greatest potential to improve patient outcomes.

  4. 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

  5. Improving Clinical Risk Stratification at Diagnosis in Primary Prostate Cancer: A Prognostic Modelling Study

    PubMed Central

    Wright, Karen A.; Muir, Kenneth R.; Gavin, Anna

    2016-01-01

    Introduction Over 80% of the nearly 1 million men diagnosed with prostate cancer annually worldwide present with localised or locally advanced non-metastatic disease. Risk stratification is the cornerstone for clinical decision making and treatment selection for these men. The most widely applied stratification systems use presenting prostate-specific antigen (PSA) concentration, biopsy Gleason grade, and clinical stage to classify patients as low, intermediate, or high risk. There is, however, significant heterogeneity in outcomes within these standard groupings. The International Society of Urological Pathology (ISUP) has recently adopted a prognosis-based pathological classification that has yet to be included within a risk stratification system. Here we developed and tested a new stratification system based on the number of individual risk factors and incorporating the new ISUP prognostic score. Methods and Findings Diagnostic clinicopathological data from 10,139 men with non-metastatic prostate cancer were available for this study from the Public Health England National Cancer Registration Service Eastern Office. This cohort was divided into a training set (n = 6,026; 1,557 total deaths, with 462 from prostate cancer) and a testing set (n = 4,113; 1,053 total deaths, with 327 from prostate cancer). The median follow-up was 6.9 y, and the primary outcome measure was prostate-cancer-specific mortality (PCSM). An external validation cohort (n = 1,706) was also used. Patients were first categorised as low, intermediate, or high risk using the current three-stratum stratification system endorsed by the National Institute for Health and Care Excellence (NICE) guidelines. The variables used to define the groups (PSA concentration, Gleason grading, and clinical stage) were then used to sub-stratify within each risk category by testing the individual and then combined number of risk factors. In addition, we incorporated the new ISUP prognostic score as a discriminator

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

    PubMed Central

    Trivedi, Palak J.; Corpechot, Christophe; Pares, Albert

    2015-01-01

    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

  7. External validation of scoring systems in risk stratification of upper gastrointestinal bleeding.

    PubMed

    Anchu, Anna Cherian; Mohsina, Subair; Sureshkumar, Sathasivam; Mahalakshmy, T; Kate, Vikram

    2017-03-01

    The aim of this study was to externally validate the four commonly used scoring systems in the risk stratification of patients with upper gastrointestinal bleed (UGIB). Patients of UGIB who underwent endoscopy within 24 h of presentation were stratified prospectively using the pre-endoscopy Rockall score (PRS) >0, complete Rockall score (CRS) >2, Glasgow Blatchford bleeding scores (GBS) >3, and modified GBS (m-GBS) >3 scores. Patients were followed up to 30 days. Prognostic accuracy of the scores was done by comparing areas under curve (AUC) in terms of overall risk stratification, re-bleeding, mortality, need for intervention, and length of hospitalization. One hundred and seventy-five patients were studied. All four scores performed better in the overall risk stratification on AUC [PRS = 0.566 (CI: 0.481-0.651; p-0.043)/CRS = 0.712 (CI: 0.634-0.790); p<0.001)/GBS = 0.810 (CI: 0.744-0.877; p->0.001); m-GBS = 0.802 (CI: 0.734-0.871; p<0.001)], whereas only CRS achieved significance in identifying re-bleed [AUC-0.679 (CI: 0.579-0.780; p = 0.003)]. All the scoring systems except PRS were found to be significantly better in detecting 30-day mortality with a high AUC (CRS = 0.798; p-0.042)/GBS = 0.833; p-0.023); m-GBS = 0.816; p-0.031). All four scores demonstrated significant accuracy in the risk stratification of non-variceal patients; however, only GBS and m-GBS were significant in variceal etiology. Higher cutoff scores achieved better sensitivity/specificity [RS > 0 (50/60.8), CRS > 1 (87.5/50.6), GBS > 7 (88.5/63.3), m-GBS > 7(82.3/72.6)] in the risk stratification. GBS and m-GBS appear to be more valid in risk stratification of UGIB patients in this region. Higher cutoff values achieved better predictive accuracy.

  8. Risk stratification of children being evaluated for intussusception.

    PubMed

    Weihmiller, Sarah N; Buonomo, Carlo; Bachur, Richard

    2011-02-01

    Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation. To determine predictive clinical criteria and develop a decision tree to risk-stratify children with possible intussusception. This is a prospective observational cohort study of children aged 1 month to 6 years who presented with possible intussusception. A data-collection form was completed before knowledge of any advanced imaging. Univariate analysis was performed, and decision trees were developed using recursive partitioning. In the study, 310 patients were enrolled, including 38 (12.3%) with intussusception. The median age was 21.1 months and 61% were male. Univariate predictors of intussusception included age older than 6 months (P = 0.04), male gender (P = .007), history of lethargy (P = .001), and abnormal plain x-ray (P = .0001). Multivariate analysis through recursive partitioning identified decision trees (with and without the result of a plain abdominal x-ray) and allowed identification of patients at low risk. The decision tree based on the results of an abdominal x-ray (negative or positive), age (≤ 5 or >5 months), diarrhea (present or absent), and bilious emesis (present or absent) had the best test performance (sensitivity: 97% [95% confidence interval (CI): 86-100]; negative predictive value: 99% [95% CI: 93-100]; negative likelihood ratio: 0.08 [95% CI: 0.01-0.6]). Among children who were being evaluated for intussusception, we prospectively determined clinical criteria and developed a decision tree to risk-stratify children with possible intussusception.

  9. Copeptin and risk stratification in patients with acute dyspnea

    PubMed Central

    2010-01-01

    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 Copeptin, the C-terminal part of the vasopressin prohormone alone and combined to N-terminal pro B-type natriuretic peptide (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 patients with acute dyspnea. Results Copeptin levels were elevated in non-survivors (n = 29) compared to survivors at 30 days (108 pmol/l, interquartile range (IQR) 37 to 197 pmol/l) vs. 18 pmol/l, IQR 7 to 43 pmol/l; P < 0.0001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.83 (95% confidence interval (CI) 0.76 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for Copeptin, NT-proBNP and BNP, respectively (Copeptin vs. NTproBNP P = 0.21; Copeptin vs. BNP P = 0.002). When adjusted for common cardiovascular risk factors and NT-proBNP, Copeptin was the strongest independent predictor for short-term mortality in all patients (HR 3.88 (1.94 to 7.77); P < 0.001) and especially in patients with acute decompensated heart failure (ADHF) (HR 5.99 (2.55 to 14.07); P < 0.0001). With the inclusion of Copeptin to the adjusted model including NTproBNP, the net reclassification improvement (NRI) was 0.37 (P < 0.001). An additional 30% of those who experienced events were reclassified as high risk, and an additional 26% without events were reclassified as low risk. Conclusions Copeptin is a new promising prognostic marker for short-term mortality independently and additive to natriuretic peptide levels in patients with acute dyspnea. PMID:21106053

  10. Risk stratification and selection for statin therapy: going beyond Framingham.

    PubMed

    Fitchett, David H; Mancini, G B John; Gregoire, Jean; Anderson, Todd; McPherson, Ruth

    2014-06-01

    Decisions for statin therapy in the primary prevention of atherosclerotic cardiovascular disease are generally made using the 10-year Framingham Risk Score (FRS). Even when a family history of premature cardiovascular disease is taken into account, there is often ambiguity about the need for statin therapy for patients with a 10-year FRS of 5%-19% and low-density lipoprotein cholesterol <3.5 mmol/L. Current Canadian dyslipidemia guidelines recommend consideration of a diversity of other factors, including biochemical measurements and imaging studies to help determine whether the calculated FRS might be misleadingly low and whether statin therapy might, therefore, be prudent. However, efficient use of the plethora of secondary factors makes this decision process itself potentially ambiguous. This brief summary provides a practical approach for using clinical information, basic biochemical tests, and more specialized tests, such as carotid ultrasound and coronary artery calcium scoring, to identify groups of patients at greater risk for atherosclerotic cardiovascular disease than suggested by the FRS.

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

    PubMed Central

    Schuetz, Philipp; Huber, Andreas; Müller, Beat; Maisano, Francesco; Taramasso, Maurizio; Moarof, Igal; Obeid, Slayman; Stähli, Barbara E.; Cahenzly, Martin; Binder, Ronald K.; Liebetrau, Christoph; Möllmann, Helge; Kim, Won-Keun; Hamm, Christian; Lüscher, 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 3.0–26.0, 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 0.8–5.6, P = 0.13). The Harrell’s C-statistic was 0.58 (95% CI 0.45–0.82) for the EuroSCORE II, and consideration of baseline MR-proADM levels significantly improved discrimination (AUC = 0.84, 95% CI 0.71–0.92, 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 (3.1–31.3), P <0.01) and improved the model’s net reclassification index (0.89, 95% CI (0.28–1.59). 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

  12. Dynamic risk stratification for predicting the recurrence in differentiated thyroid cancer.

    PubMed

    Ozkan, Elgin; Soydal, Cigdem; Nak, Demet; Kucuk, Nuriye O; Kir, Kemal M

    2017-09-27

    To analyze the predictive value of the dynamic risk stratification (DRS) system for assessing the risk of recurrent/persistent disease in our large group of differentiated thyroid carcinoma (DTC) patients. We retrospectively included 2184 consecutive patients who received radioiodine ablation therapy following a total or near total thyroidectomy in our department between 1998 and 2014. The American Thyroid Association (ATA) classification was used for initial risk classification. At the second year of follow-up period after radioiodine ablation therapy, DRS was performed also. The ATA and DRS risk classification results were compared with clinical outcome. According to DRS, more than half of the ATA high-risk patients (73.2%) moved to the DRS low-risk category and the 6.4% of ATA low-risk patients comprised the DRS high-risk category. In comparison of variables within the ATA and the DRS risk groups with clinical outcome, combined use of the ATA and the DRS systems was statistically significant to predict the recurrent/persistent disease (P<0.005). The present study revealed that the DRS system is a necessary stratification system in addition to the initial risk evaluation. The DRS can discriminate those patients who does not require closer follow-up in the long-term period.

  13. 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

  14. 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

  15. Diagnosis, risk stratification, and response evaluation in classical myeloproliferative neoplasms.

    PubMed

    Rumi, Elisa; Cazzola, Mario

    2017-02-09

    Philadelphia-negative classical myeloproliferative neoplasms (MPNs) include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision of the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues includes new criteria for the diagnosis of these disorders. Somatic mutations in the 3 driver genes, that is, JAK2, CALR, and MPL, represent major diagnostic criteria in combination with hematologic and morphological abnormalities. PV is characterized by erythrocytosis with suppressed endogenous erythropoietin production, bone marrow panmyelosis, and JAK2 mutation. Thrombocytosis, bone marrow megakaryocytic proliferation, and presence of JAK2, CALR, or MPL mutation are the main diagnostic criteria for ET. PMF is characterized by bone marrow megakaryocytic proliferation, reticulin and/or collagen fibrosis, and presence of JAK2, CALR, or MPL mutation. Prefibrotic myelofibrosis represents an early phase of myelofibrosis, and is characterized by granulocytic/megakaryocytic proliferation and lack of reticulin fibrosis in the bone marrow. The genomic landscape of MPNs is more complex than initially thought and involves several mutant genes beyond the 3 drivers. Comutated, myeloid tumor-suppressor genes contribute to phenotypic variability, phenotypic shifts, and progression to more aggressive disorders. Patients with myeloid neoplasms are at variable risk of vascular complications, including arterial or venous thrombosis and bleeding. Current prognostic models are mainly based on clinical and hematologic parameters, but innovative models that include genetic data are being developed for both clinical and trial settings. In perspective, molecular profiling of MPNs might also allow for accurate evaluation and monitoring of response to innovative drugs that target the mutant clone.

  16. Diagnosis, risk stratification, and response evaluation in classical myeloproliferative neoplasms

    PubMed Central

    2017-01-01

    Philadelphia-negative classical myeloproliferative neoplasms (MPNs) include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision of the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues includes new criteria for the diagnosis of these disorders. Somatic mutations in the 3 driver genes, that is, JAK2, CALR, and MPL, represent major diagnostic criteria in combination with hematologic and morphological abnormalities. PV is characterized by erythrocytosis with suppressed endogenous erythropoietin production, bone marrow panmyelosis, and JAK2 mutation. Thrombocytosis, bone marrow megakaryocytic proliferation, and presence of JAK2, CALR, or MPL mutation are the main diagnostic criteria for ET. PMF is characterized by bone marrow megakaryocytic proliferation, reticulin and/or collagen fibrosis, and presence of JAK2, CALR, or MPL mutation. Prefibrotic myelofibrosis represents an early phase of myelofibrosis, and is characterized by granulocytic/megakaryocytic proliferation and lack of reticulin fibrosis in the bone marrow. The genomic landscape of MPNs is more complex than initially thought and involves several mutant genes beyond the 3 drivers. Comutated, myeloid tumor-suppressor genes contribute to phenotypic variability, phenotypic shifts, and progression to more aggressive disorders. Patients with myeloid neoplasms are at variable risk of vascular complications, including arterial or venous thrombosis and bleeding. Current prognostic models are mainly based on clinical and hematologic parameters, but innovative models that include genetic data are being developed for both clinical and trial settings. In perspective, molecular profiling of MPNs might also allow for accurate evaluation and monitoring of response to innovative drugs that target the mutant clone. PMID:28028026

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

    PubMed Central

    Voss, Andreas; Schroeder, Rico; Vallverdú, Montserrat; Schulz, Steffen; Cygankiewicz, Iwona; Vázquez, Rafael; Bayés de Luna, Antoni; Caminal, Pere

    2013-01-01

    In industrialized countries with aging populations, heart failure affects 0.3–2% 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

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

    PubMed

    Voss, Andreas; Schroeder, Rico; Vallverdú, Montserrat; Schulz, Steffen; Cygankiewicz, Iwona; Vázquez, Rafael; Bayés de Luna, Antoni; Caminal, Pere

    2013-01-01

    In industrialized countries with aging populations, heart failure affects 0.3-2% 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.

  19. Stratification, competition and risk distribution: health insurance in Germany and the United States.

    PubMed

    Abel, T; Wysong, J A

    1992-01-01

    Issues of unequal risk distribution among sickness funds are given increasing attention in the current discussions on the reform of the statutory health insurance system in Germany. This paper examines the structural determinants of risk distribution and points toward the links between social stratification, competition, health risk and insurance status. A model showing the links between basic structural determinants is presented. Using health survey data from Germany and the U.S., statistical analyses are conducted. The results support the model and indicate its applicability for both health care systems. The paper concludes by indicating the relevance of such findings for health policy and future research.

  20. Diagnosis and risk stratification of women with stable ischemic heart disease.

    PubMed

    Isiadinso, Ijeoma; Shaw, Leslee J

    2016-10-01

    Although mortality rates for cardiovascular disease are on the decline, it remains the leading cause of death among men and women in the United States. Until recently, more women died of heart disease every year than men. Significant effort has been focused on increasing the awareness of cardiovascular disease among women, but ethnic disparities in awareness still exist. Early symptom recognition, risk assessment, and diagnosis of CAD are paramount in reducing cardiovascular morbidity and mortality in women. This review will highlight the unique risk factors for CAD in women, variability in clinical presentation for ischemic heart disease, and risk stratification for CAD in symptomatic women.

  1. Probabilistic Modeling Of Ocular Biomechanics In VIIP: Risk Stratification

    NASA Technical Reports Server (NTRS)

    Feola, A.; Myers, J. G.; Raykin, J.; Nelson, E. S.; Mulugeta, L.; Samuels, B.; Ethier, C. R.

    2016-01-01

    the peak strains, we ranked and then normalized these coefficients, considering that normalized values 0.5 implied a substantial influence on the range of the peak strains in the optic nerve head (ONH). IOP and ICP were found to have a major influence on the peak strains in the ONH, as did optic nerve and LC stiffness. Interestingly, the stiffness of the sclera far from the scleral canal did not have a large influence on peak strains in ONH tissues; however, the collagen fiber stiffness in the peripapillary sclera and annular ring both influenced the peak strains within the ONH. We have created a physiologically relevant model that incorporated collagen fibers to study the effects of elevated ICP. Elevated ICP resulted in strains in the optic nerve that are not predicted to occur on earth: the upright or supine conditions. We found that IOP, ICP, lamina cribrosa stiffness and optic nerve stiffness had the highest association with these extreme strains in the ONH. These extreme strains may activate mechanosensitive cells that induce tissue remodeling and are a risk factor for the development of VIIP.

  2. A risk stratification approach to assessing for true cases of measles in a highly vaccinated population.

    PubMed

    Bond, Katherine; Martin-Gall, Veronica; Franklin, Lucinda; Sutton, Brett

    2016-08-01

    In Australia, the notification rate for measles fluctuates greatly between baseline and outbreak periods. We aimed to identify characteristics of notified cases that allow risk stratification in order to improve the efficiency of the public health response in an outbreak setting. Retrospective descriptive case series for all measles notifications made to the Victorian Government Department of Health between 1 August and 30 September 2013. A total of 151 notifications were included in the analyses, of which 17 (11%) were confirmed as measles. Applying the clinical criteria of the measles case definition or identifying susceptible cases (determined by vaccination status) correctly identified all measles cases. Requiring cases to meet both criteria reduced sensitivity to 88%, but improved the positive predictive value (48% vs 25%) and retained a high negative predictive value (98.33%). Application of a risk stratification approach based on these features would have saved intensive public health follow-up for 79.5% of notifications in this outbreak. Immune status and clinical features can reliably be used to predict which notifications are unlikely to become confirmed cases. Risk stratification and modification of current surveillance practices may provide for a more efficient public health response, particularly during periods of increased case notification. © 2016 Public Health Association of Australia.

  3. Risk stratification for sudden cardiac death in North America - current perspectives.

    PubMed

    Buxton, Alfred E; Waks, Jonathan W; Shen, Changyu; Chen, Peng-Sheng

    Sudden cardiac death (SCD) accounts for approximately 360,000 deaths annually in the United States, and is the cause of half of all cardiovascular deaths. In patients with severely depressed left ventricular ejection fraction (LVEF), implantable cardioverter-defibrillators (ICDs) have been shown to significantly reduce total mortality, but many factors beyond LVEF influence the relative benefit afforded by ICD implantation. In fact, among patients with prior myocardial infarction, approximately half of all SCDs occur in patients without severe LV dysfunction, and in analyses of large ICD trials, certain patient subgroups derive no benefit to ICD implantation despite having low LVEF, often due to competing non-arrhythmic mortality. Improved risk stratification tools to help select patients who are likely to derive the most benefit from ICD implantation are therefore needed. This manuscript will review studies evaluating use of ICDs in patients with mild LV systolic dysfunction and LVEF >35%, currently available ICD risk stratification models, and the rationale for designing a cohort study to prospectively validate use of an ICD risk stratification score.

  4. Analytical and assay issues for use of cardiac troponin testing for risk stratification in primary care.

    PubMed

    Wu, Alan H B; Christenson, Robert H

    2013-08-01

    Cardiac troponin is the standard marker for diagnosis of acute myocardial infarction and risk stratification of patients who present to an emergency department with signs and symptoms of acute cardiac ischemia. Over the past few years, the analytical sensitivity of assays for cardiac troponin has improved significantly to the point where a detectable amount of troponin can be measured in essentially all healthy subjects. Recent studies have shown that use of a highly sensitive troponin assays may provide value to traditional markers of primary disease risk for patients, i.e., for those who have no history of heart disease. There are barriers to the adoption of cardiac troponin for screening high risk cohorts such as the elderly, diabetics and perhaps even the asymptomatic population. Strategies used for the assignment of cutoff concentrations in acute care, i.e., the 99 th percentile, may not be appropriate for primary care as changes over baseline levels may provide more accurate information of risk than cross-sectional results. A review of biological variation has shown that cardiac troponin as a biomarker has low index of individuality, indicating that reference values are of little utility. Whether or not cardiac troponin can be released in reversible injury is a debate that could have significance for detecting minor myocardial injury. A major hurdle for use of troponin in primary care is the lack of assay standardization and nomenclature for the different generations of troponin assays. Standardization requires knowledge of what is released after cardiac injury and what the various cardiac troponin assays are measuring. Currently it is not clear if the cardiac troponin release after ischemic injury is identical to that in circulation of healthy individuals. This may affect the design of future assays and standardization approaches. There is potential that a marker of myocardial injury such as troponin can add to the value of existing indicators and biomarkers

  5. 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

  6. Stratification of responders towards eculizumab using a structural epitope mapping strategy

    PubMed Central

    Volk, Anna-Luisa; Hu, Francis Jingxin; Berglund, Magnus M.; Nordling, Erik; Strömberg, Patrik; Uhlen, Mathias; Rockberg, Johan

    2016-01-01

    The complement component 5 (C5)-binding antibody eculizumab is used to treat patients with paroxysmal nocturnal hemoglobinuria (PNH) and atypical haemolytic uremic syndrome (aHUS). As recently reported there is a need for a precise classification of eculizumab responsive patients to allow for a safe and cost-effective treatment. To allow for such stratification, knowledge of the precise binding site of the drug on its target is crucial. Using a structural epitope mapping strategy based on bacterial surface display, flow cytometric sorting and validation via haemolytic activity testing, we identified six residues essential for binding of eculizumab to C5. This epitope co-localizes with the contact area recently identified by crystallography and includes positions in C5 mutated in non-responders. The identified epitope also includes residue W917, which is unique for human C5 and explains the observed lack of cross-reactivity for eculizumab with other primates. We could demonstrate that Ornithodorus moubata complement inhibitor (OmCI), in contrast to eculizumab, maintained anti-haemolytic function for mutations in any of the six epitope residues, thus representing a possible alternative treatment for patients non-responsive to eculizumab. The method for stratification of patients described here allows for precision medicine and should be applicable to several other diseases and therapeutics. PMID:27509843

  7. An electrophysiologist perspective on risk stratification in heart failure: can better understanding of the condition of the cardiac sympathetic nervous system help?

    PubMed

    Borgquist, Rasmus; Singh, Jagmeet P

    2015-06-01

    Heart failure is often complicated by arrhythmias that can adversely affect the quality of life and increase the risk for sudden cardiac death. Current risk stratification strategies for sudden cardiac death in the heart failure patient are not ideal, with much potential for further refinement. Overactivation of the sympathetic nervous system has been shown to be associated with worsening heart failure as well as arrhythmic events. Recent advances in our understanding of the autonomic nervous system and new methods for quantification of the pathologic activation of the sympathetic nerves have triggered increasing interest in this field. This viewpoint focuses on the need for and challenges of risk stratification of sudden death in the heart failure patient and discusses the potential value of measuring sympathetic nervous system activity to better stratify risk and to select patients with heart failure for implantable cardioverter defibrillator therapy.

  8. Risk Stratification for Opioid Misuse in Children, Adolescents, and Young Adults: A Quality Improvement Project.

    PubMed

    Thienprayoon, Rachel; Porter, Kelly; Tate, Michelle; Ashby, Marshall; Meyer, Mark

    2017-01-01

    The Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children's Hospital Medical Center (CCHMC) provides opioids to a large population of patients in the ambulatory setting. Before this project, PACT had no reliable system to risk stratify patients for opioid misuse. The global aim was safe opioid prescribing by the palliative care team. The specific, measurable, achievable, realistic, and timely aim was as follows: "In patients who present for follow up with PACT, we will use the "opioid bundle" to increase risk stratification for opioid misuse from 0% to 90% over 5 months." The opioid bundle includes a urine drug screen, Ohio Automated Rx Reporting System report, pill count, and screening history for drug abuse and mental health disorders. The setting was multiple CCHMC ambulatory clinics. Participants included all PACT members. Since implementing the new system, we have increased risk stratification for opioid misuse among outpatients from 0% to >90%. Results have been sustained for 12 months. Key processes have become reliable: obtaining informed consent and controlled substance agreements for all new patients and obtaining the opioid bundle to enable risk stratification in a consistent and timely fashion. A total of 34% of patients have been stratified as high risk, and an additional 27% have been stratified as moderate risk. A system to ensure safe opioid prescribing practices to all patients is critical for providers. Identifying key processes and executing them reliably has enabled the palliative care team at CCHMC to risk stratify >90% of patients receiving opioids in the ambulatory setting for opioid misuse. Copyright © 2017 by the American Academy of Pediatrics.

  9. Broadly applicable risk stratification system for predicting duration of hospitalization and mortality.

    PubMed

    Sessler, Daniel I; Sigl, Jeffrey C; Manberg, Paul J; Kelley, Scott D; Schubert, Armin; Chamoun, Nassib G

    2010-11-01

    Hospitals are increasingly required to publicly report outcomes, yet performance is best interpreted in the context of population and procedural risk. We sought to develop a risk-adjustment method using administrative claims data to assess both national-level and hospital-specific performance. A total of 35,179,507 patient stay records from 2001-2006 Medicare Provider Analysis and Review (MEDPAR) files were randomly divided into development and validation sets. Risk stratification indices (RSIs) for length of stay and mortality endpoints were derived from aggregate risk associated with individual diagnostic and procedure codes. Performance of RSIs were tested prospectively on the validation database, as well as a single institution registry of 103,324 adult surgical patients, and compared with the Charlson comorbidity index, which was designed to predict 1-yr mortality. The primary outcome was the C statistic indicating the discriminatory power of alternative risk-adjustment methods for prediction of outcome measures. A single risk-stratification model predicted 30-day and 1-yr postdischarge mortality; separate risk-stratification models predicted length of stay and in-hospital mortality. The RSIs performed well on the national dataset (C statistics for median length of stay and 30-day mortality were 0.86 and 0.84). They performed significantly better than the Charlson comorbidity index on the Cleveland Clinic registry for all outcomes. The C statistics for the RSIs and Charlson comorbidity index were 0.89 versus 0.60 for median length of stay, 0.98 versus 0.65 for in-hospital mortality, 0.85 versus 0.76 for 30-day mortality, and 0.83 versus 0.77 for 1-yr mortality. Addition of demographic information only slightly improved performance of the RSI. RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data.

  10. Use of mutant-specific ion channel characteristics for risk stratification of long QT syndrome patients.

    PubMed

    Jons, Christian; O-Uchi, Jin; Moss, Arthur J; Reumann, Matthias; Rice, John J; Goldenberg, Ilan; Zareba, Wojciech; Wilde, Arthur A M; Shimizu, Wataru; Kanters, Jorgen K; McNitt, Scott; Hofman, Nynke; Robinson, Jennifer L; Lopes, Coeli M B

    2011-03-30

    Inherited long QT syndrome (LQTS) is caused by mutations in ion channels that delay cardiac repolarization, increasing the risk of sudden death from ventricular arrhythmias. Currently, the risk of sudden death in individuals with LQTS is estimated from clinical parameters such as age, gender, and the QT interval, measured from the electrocardiogram. Even though a number of different mutations can cause LQTS, mutation-specific information is rarely used clinically. LQTS type 1 (LQT1), one of the most common forms of LQTS, is caused by mutations in the slow potassium current (I(Ks)) channel α subunit KCNQ1. We investigated whether mutation-specific changes in I(Ks) function can predict cardiac risk in LQT1. By correlating the clinical phenotype of 387 LQT1 patients with the cellular electrophysiological characteristics caused by an array of mutations in KCNQ1, we found that channels with a decreased rate of current activation are associated with increased risk of cardiac events (hazard ratio=2.02), independent of the clinical parameters usually used for risk stratification. In patients with moderate QT prolongation (a QT interval less than 500 ms), slower activation was an independent predictor for cardiac events (syncope, aborted cardiac arrest, and sudden death) (hazard ratio = 2.10), whereas the length of the QT interval itself was not. Our results indicate that genotype and biophysical phenotype analysis may be useful for risk stratification of LQT1 patients and suggest that slow channel activation is associated with an increased risk of cardiac events.

  11. Risk stratification for 1-year mortality in acute heart failure: classification and regression tree analysis.

    PubMed

    Arenja, Nisha; Breidthardt, Tobias; Socrates, Thenral; Schindler, Christian; Heinisch, Corinna; Tschung, Christopher; Potocki, Mihael; Gualandro, Danielle; Mueller, Christian

    2011-10-09

    Simple tools for risk stratification of patients with acute heart failure (AHF) are an unmet clinical need, particularly regarding long-term mortality. We prospectively enrolled 610 consecutive patients presenting to the emergency department with AHF. The diagnosis of AHF was adjudicated by two independent cardiologists. The classification and regression tree (CART) analysis was used to develop a simple risk algorithm. This was internally validated by cross-validation. One-year follow-up was complete in all patients (100%). A total of 201 patients (33%) died within 360 days. The CART analysis identified blood urea nitrogen (BUN) and age as the best single predictors of 1-year mortality and patients were categorised to three risk groups: high risk group (BUN >27.5 mg/dl and age >86 years), intermediate risk group (BUN >27.5 mg/dl and age ≤ 86 years) and low risk group (BUN ≤ 27.5 mg/dl). The Kaplan-Meier curves showed a significant increase in mortality in the high risk group compared with the lower risk groups (log-rank test p <0.001). The hazard ratio regarding 1-year mortality between patients identified as low and high risk was 2.0 (95% confidence interval, 1.7-2.4), with statistically significant differences between all risk groups (p <0.001). The likelihood-based 95%-confidence set for the age- and the urea-threshold is contained in the rectangular set defined by 25 mg/dl ≤ urea threshold ≤30.6 mg/dl and 76 years ≤ age threshold ≤96 years. These results suggest that AHF patients at low, intermediate and high risk for death within 360 days can be easily identified using patient's demographics and laboratory data obtained at presentation. Application of this simple risk stratification algorithm may help to improve the management of these patients.

  12. Prostate cancer screening using risk stratification based on a multi-state model of genetic variants.

    PubMed

    Yen, Amy Ming-Fang; Auvinen, Anssi; Schleutker, Johanna; Wu, Yi-Ying; Fann, Jean Ching-Yuan; Tammela, Teuvo; Chen, Sam Li-Sheng; Chiu, Sherry Yueh-Hsia; Chen, Hsiu-Hsi

    2015-06-01

    Risk-stratified screening for prostate cancer (PCa) with prostate-specific antigen (PSA) testing incorporating genetic variants has received some attention but has been scarcely investigated. We developed a model to stratify the Finnish population by different risk profiles related to genetic variants to optimize the screening policy. Data from the Finnish randomized controlled trial on screening for PCa with PSA testing were used to estimate a six-state Markov model of disease progression. Blood samples from Finnish men were used to assess the risk of PCa related to three genetic variants (rs4242382, rs138213197, and rs200331695). A risk score-based approach combined with a series of computer simulation models was applied to optimize individual screening policies. The 10-year risk of having progressive prostate cancer detected ranged from 43% in the top 5% risk group to approximately 11% in the bottom half of the population. Using the median group, with screening every four years beginning at 55 years-old, as the reference group, the recommended age beginning screening was approximately 47 years-old for the top 5% risk group and 55 years-old for those in the lower 60% risk group. The recommended interscreening interval has been shortened for individuals in the high risk group. The increased availability of genomic information allows the proposed multistate model to be more discriminating with respect to risk stratification and the suggested screening policy, particularly for the lowest risk groups-. -- A multi-state genetic variant-based model was developed for further application to population risk stratification to optimize the interscreening interval and the age at which to begin screening for PSA. A small sub-group of the population is likely to benefit from more intensive screening with early start and short interval, while half of the population is unlikely to benefit from such protocol (compared with four-year interval after age 55 years). © 2015 Wiley

  13. Attributable fractions, modifiable risk factors and risk stratification using a risk score for peri-implant pathology.

    PubMed

    de Araújo Nobre, Miguel; Mano Azul, António; Rocha, Evangelista; Maló, Paulo; Salvado, Francisco

    2017-01-01

    This study aimed to estimate the impact of risk factors for peri-implant pathology, to identify potentially modifiable factors, and to evaluate the accuracy of the risk algorithm, risk scores and risk stratification. This retrospective case-control study with 1275 patients (255 cases; 1020 controls) retrieved a model according to the predictors: history of Periodontitis, bacterial plaque, bleeding, bone level, lack of passive fit or non-optimal screw joint, metal-ceramic restoration, proximity to other implants/teeth, and smoking habits. Outcome measures were the attributable fraction; the positive and negative likelihood ratios at different disease cut-off points illustrated by the area under the curve statistic. Six predictors may be modified or controlled directly by either the patient or the clinician, accounting for a reduction in up to 95% of the peri-implant pathology cases. The positive and negative likelihood ratios were 9.69 and 0.13, respectively; the area under the curve was 0.96; a risk score was developed, making the complex statistical model useful to clinicians. Based on the results, six predictors for the incidence of peri-implant pathology can be modified to significantly improve the outcome. It was possible to stratify patients per risk category according to the risk score, providing a tool for clinicians to support their decision-making process. Copyright © 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

  14. A combination of clinical risk stratification and fecal immunochemical test results to prioritize colonoscopy screening in asymptomatic participants.

    PubMed

    Aniwan, Satimai; Rerknimitr, Rungsun; Kongkam, Pradermchai; Wisedopas, Naruemon; Ponuthai, Yuwadee; Chaithongrat, Supakarn; Kullavanijaya, Pinit

    2015-03-01

    Stool-based colonoscopy is the preferred strategy for colorectal cancer (CRC) screening. The Asia-Pacific Colorectal Screening System (APCS) score also is helpful in stratifying the risk for advanced neoplasia in the asymptomatic population. The combination of the fecal immunochemical test (FIT) result and clinical risk stratification may be more helpful in stratifying the risk. To evaluate the value of the combination of FIT and APCS scores in stratifying asymptomatic participants for colonoscopy. Cross-sectional study. University hospital. A total of 948 asymptomatic participants eligible for screening colonoscopy. FIT, APCS score evaluation, screening colonoscopy. The prevalence of colorectal neoplasia in 4 different groups of participants according to FIT and APCS score evaluations. The prevalence of non-advanced and advanced neoplasia in the 4 groups (high risk with positive FIT result, high risk with negative FIT result, moderate risk with positive FIT result, and moderate risk with negative FIT result) was 44% versus 36.9%, 30.1% versus 11.6%, 27.1% versus 12%, and 22.6% versus 6.4%, respectively (P < .001). Participants with both high-risk scores and positive FIT results had a significantly higher detection rate of advanced neoplasia (6.15-fold, 95% confidence interval, 3.72-10.17) compared with the other 3 groups. Seven cancers were discovered; 4 were in the high-risk with positive FIT result group. Hospital-based study. In countries with limited resources, participants with positive FIT results and high-risk scores by APCS should be given priority for colonoscopy because this group is most likely to have advanced neoplasia. However, this strategy needs to be confirmed for its cost-effectiveness in a large, population-based study. ( TCTR20140228001.). Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

  15. Recurrence rates for sudden infant death syndrome (SIDS): the importance of risk stratification.

    PubMed

    Campbell, M J; Hall, D; Stephenson, T; Bacon, C; Madan, J

    2008-11-01

    To investigate the importance of stratification by risk factors in computing the probability of a second death from sudden infant death syndrome (SIDS) in a family. Simulation study. The fact that a baby dies suddenly and unexpectedly means that there is a raised probability that the baby's family have risk factors associated with SIDS. Thus one cannot consider the risk of a subsequent death to be that of the general population. The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) identified three major social risk factors: smoking, age<27 and parity>1, and unemployed/unwaged as major risk factors. It gave estimates of risk for families with different numbers of these risk factors. We investigate whether it is reasonable to assume that, conditional on these risk factors, the risk of a second event is independent of the risk of the first and as a consequence one can square the risks to get the risk of two SIDS in a family. We have used CESDI data to estimate the probability of a second SID in a family under different plausible scenarios of the prevalence of the risk factors. We have applied the model to make predictions in the Care of Next Infant (CONI) study. The model gave plausible predictions. The CONI study observed 18 second SIDS. Our model predicted 14 deaths (95% prediction interval 7 to 21). When considering the risk of a subsequent SIDS in a family one should always take into account the known risk factors. If all risks have been identified, then conditional on these risks, the risk of two events is the product of the individual risks. However, for a given family we cannot quantify the magnitude of the increased risk because of other possible risk factors not accounted for in the model.

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

    PubMed

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

    2015-05-14

    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.

  17. Overcoming intratumoural heterogeneity for reproducible molecular risk stratification: a case study in advanced kidney cancer.

    PubMed

    Lubbock, Alexander L R; Stewart, Grant D; O'Mahony, Fiach C; Laird, Alexander; Mullen, Peter; O'Donnell, Marie; Powles, Thomas; Harrison, David J; Overton, Ian M

    2017-06-26

    Metastatic clear cell renal cell cancer (mccRCC) portends a poor prognosis and urgently requires better clinical tools for prognostication as well as for prediction of response to treatment. Considerable investment in molecular risk stratification has sought to overcome the performance ceiling encountered by methods restricted to traditional clinical parameters. However, replication of results has proven challenging, and intratumoural heterogeneity (ITH) may confound attempts at tissue-based stratification. We investigated the influence of confounding ITH on the performance of a novel molecular prognostic model, enabled by pathologist-guided multiregion sampling (n = 183) of geographically separated mccRCC cohorts from the SuMR trial (development, n = 22) and the SCOTRRCC study (validation, n = 22). Tumour protein levels quantified by reverse phase protein array (RPPA) were investigated alongside clinical variables. Regularised wrapper selection identified features for Cox multivariate analysis with overall survival as the primary endpoint. The optimal subset of variables in the final stratification model consisted of N-cadherin, EPCAM, Age, mTOR (NEAT). Risk groups from NEAT had a markedly different prognosis in the validation cohort (log-rank p = 7.62 × 10(-7); hazard ratio (HR) 37.9, 95% confidence interval 4.1-353.8) and 2-year survival rates (accuracy = 82%, Matthews correlation coefficient = 0.62). Comparisons with established clinico-pathological scores suggest favourable performance for NEAT (Net reclassification improvement 7.1% vs International Metastatic Database Consortium score, 25.4% vs Memorial Sloan Kettering Cancer Center score). Limitations include the relatively small cohorts and associated wide confidence intervals on predictive performance. Our multiregion sampling approach enabled investigation of NEAT validation when limiting the number of samples analysed per tumour, which significantly degraded performance

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

    PubMed Central

    Pimentel, Maurício; 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

  19. Risk stratification and skin testing to guide re-exposure in taxane-induced hypersensitivity reactions.

    PubMed

    Picard, Matthieu; Pur, Leyla; Caiado, Joana; Giavina-Bianchi, Pedro; Galvão, Violeta Regnier; Berlin, Suzanne T; Campos, Susana M; Matulonis, Ursula A; Castells, Mariana C

    2016-04-01

    The optimal approach to patients with hypersensitivity reactions (HSRs) to taxanes has not been established. We sought to assess the safety and efficacy of risk stratification based on the severity of the initial HSR and skin testing for guiding taxane reintroduction in patients with an HSR to these agents. Data on 164 patients treated for a taxane-related HSR from April 2011 to August 2014 at the Dana-Farber Cancer Institute and Brigham and Women's Hospital were collected retrospectively. Patients were re-exposed to taxanes either through desensitization, challenge, or regular infusion based on the severity of the initial HSR and skin test response. Depending on the initial risk stratification and tolerance to re-exposure, patients were then treated with shorter desensitization protocols, challenge, or both with the aim of resuming regular infusions, except in patients with a severe immediate initial HSR. Of 138 patients desensitized, 29 (21%) had an immediate and 20 (14%) had a delayed HSR with the procedure. Of 49 patients challenged, 2 (4%) had a mild immediate and 1 (2%) had a delayed HSR with the procedure. No patients had a severe immediate HSR with desensitization or challenge. Thirty-six (22%) patients eventually resumed regular infusions. These patients were more likely to have negative skin test responses and to have experienced a delayed or mild immediate initial HSR. Risk stratification based on the severity of the initial HSR and skin testing to guide taxane reintroduction is safe and allows a significant number of patients to resume regular infusions. Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

  20. Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction

    PubMed Central

    Ciampi, Quirino; Villari, Bruno

    2007-01-01

    Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Echocardiography represents the "gold standard" in the assessment of LV systolic dysfunction and in the recognition of systolic heart failure, since dilatation of the LV results in alteration of intracardiac geometry and hemodynamics leading to increased morbidity and mortality. The functional mitral regurgitation is a consequence of adverse LV remodelling that occurs with a structurally normal valve and it is a marker of adverse prognosis. Diastolic dysfunction plays a major role in signs and symptoms of HF and in the risk stratification, and provides prognostic information independently in HF patients and impaired systolic function. Ultrasound lung comets are a simple echographic sign of extravascular lung water, more frequently associated with left ventricular diastolic and/or systolic dysfunction, which can integrate the clinical and pathophysiological information provided by conventional echocardiography and provide a useful information for prognostic stratification of HF patients. Contractile reserve is defined as the difference between values of an index of left ventricular contractility during peak stress and its baseline values and the presence of myocardial viability predicts a favorable outcome. A non-invasive echocardiographic method for the evaluation of force-frequency relationship has been proposed to assess the changes in contractility during stress echo. In conclusion, in HF patients, the evaluation of systolic, diastolic function and myocardial contractile reserve plays a fundamental role in the risk stratification. The highest risk is present in HF patients with a heart that is weak, big, noisy, stiff and wet. PMID:17910744

  1. Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction.

    PubMed

    Ciampi, Quirino; Villari, Bruno

    2007-10-02

    Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Echocardiography represents the "gold standard" in the assessment of LV systolic dysfunction and in the recognition of systolic heart failure, since dilatation of the LV results in alteration of intracardiac geometry and hemodynamics leading to increased morbidity and mortality. The functional mitral regurgitation is a consequence of adverse LV remodelling that occurs with a structurally normal valve and it is a marker of adverse prognosis. Diastolic dysfunction plays a major role in signs and symptoms of HF and in the risk stratification, and provides prognostic information independently in HF patients and impaired systolic function. Ultrasound lung comets are a simple echographic sign of extravascular lung water, more frequently associated with left ventricular diastolic and/or systolic dysfunction, which can integrate the clinical and pathophysiological information provided by conventional echocardiography and provide a useful information for prognostic stratification of HF patients. Contractile reserve is defined as the difference between values of an index of left ventricular contractility during peak stress and its baseline values and the presence of myocardial viability predicts a favorable outcome. A non-invasive echocardiographic method for the evaluation of force-frequency relationship has been proposed to assess the changes in contractility during stress echo. In conclusion, in HF patients, the evaluation of systolic, diastolic function and myocardial contractile reserve plays a fundamental role in the risk stratification. The highest risk is present in HF patients with a heart that is weak, big, noisy, stiff and wet.

  2. 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.

  3. Clinical Usefulness of Novel Serum and Imaging Biomarkers in Risk Stratification of Patients with Stable Angina

    PubMed Central

    Ikonomidis, Ignatios; Tsantes, Argirios

    2014-01-01

    Inflammatory mediators appear to be the most intriguing yet confusing subject, regarding the management of patients with acute coronary syndromes (ACS). The current inflammatory concept of atherosclerotic coronary artery disease (CAD) led many investigators to concentrate on systemic markers of inflammation, as well as imaging techniques, which may be helpful in risk stratification and prognosis assessment for cardiovascular events. In this review, we try to depict many of the recently studied markers regarding stable angina (SA), their clinical usefulness, and possible future applications in the field. PMID:25045198

  4. Risk stratification of coronary artery disease in asymptomatic diabetic subjects using multidetector computed tomography.

    PubMed

    Shimabukuro, Michio; Saito, Taro; Higa, Toru; Nakamura, Keita; Masuzaki, Hiroaki; Sata, Masataka

    2015-01-01

    Patients with type 2 diabetes mellitus (T2DM) show a greater risk for coronary artery disease (CAD), but the risk stratification in asymptomatic CAD patients has not been established. This study investigated the prevalence and severity for asymptomatic CAD and predictors in T2DM patients. In a multiclinic group, diabetic patients (320 men, 186 women) without known symptoms suggestive of CAD were recruited for multidetector computed tomography (MDCT). Patients were categorized according to severity of coronary atherosclerosis: Grade 1 (normal findings), Grade 2 (mild atherosclerosis without significant stenosis), Grade 3 (moderate stenosis/atherosclerosis, 50-74% stenosis), Grade 4 (moderate stenosis/atherosclerosis, 75-89% stenosis), Grade 5 (severe stenosis/atherosclerosis, ≥90% stenosis). The trend for severity grade of CAD was slightly higher in men than women (P=0.054). For critical lesions (combined Grades 3-5), the prevalence was almost equal (men 44% vs. women 37%; P=0.113). Multivariate models showed that in men, HbA1c≥7.4%, dyslipidemia, duration of diabetes, retinopathy, and other type of cardiovascular diseases were predictors of critical lesions and in women, duration of diabetes and retinopathy were predictors. The prevalence and severity of asymptomatic CAD are comparably high in men and women with T2DM. Risk stratification by using MDCT might be useful to predict asymptomatic coronary lesions requiring coronary revascularization.

  5. Risk stratification for kidney sparing procedure in upper tract urothelial carcinoma

    PubMed Central

    Khene, Zine-Eddine; Mathieu, Romain; Kammerer-Jacquet, Solène-Florence; Seisen, Thomas; Roupret, Morgan; Shariat, Shahrokh F.; Peyronnet, Benoit

    2016-01-01

    Risk stratification for kidney sparing procedures (KSP) to treat upper tract urothelial carcinoma (UTUC) is a major issue. A non-systematic Medline/PubMed literature search was performed using the terms “upper tract urothelial carcinoma” with different combinations of keywords to review the current knowledge on this topic. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Available techniques for KSP include segmental ureterectomy and endoscopic resection through a percutaneous or flexible ureteroscopic access. These approaches were traditionally restricted to patients with imperative indications. Current recommendations suggest that selected patients with normal contralateral kidney should also be candidates for such treatments. Modern imaging and endoscopy have improved to accurately stage and grade the tumor while various prognostic clinical factors and biomarkers have been proposed to identify tumor with aggressive features and worse outcomes. Several predictive models using different combinations of such baseline characteristics may help clinicians in clinical decision making. However, risk-adapted based approach that has been proposed in recent guidelines to identify patients who are more likely to benefit from KSP only relies on few clinical and pathological factors. Despite growing understanding of the disease, treatment of UTUC remains challenging. Further efforts and collaborative multicenter studies are mandatory to improve risk stratification to decide and promote optimal KSP in UTUC. These efforts should focus on the integration of promising biomarkers and predictive tools in clinical decision making. PMID:27785428

  6. Added value of CAC in risk stratification for cardiovascular events: a systematic review.

    PubMed

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

    2012-01-01

    Identification of individuals at high risk for cardiovascular disease (CVD) is important to initiate adequate treatment and to prevent future events. Moreover, identification of low-risk individuals is important to refrain from unneeded therapy. Current risk prediction models do not accurately predict the risk of CVD in individuals, and new markers have been sought to improve the risk assessment in individuals. Coronary artery calcification (CAC) is a marker of atherosclerosis that might improve current risk assessment when added to traditional risk factors. We performed a systematic review on PubMed search (1 February 2011) on studies reporting on the added value of CAC in risk prediction in asymptomatic individuals. Of 39 publications on CAC and CVD, nine studies were carried out in asymptomatic individuals. All studies showed an increase in area under the curve ranging from 0.05 to 0.20 when CAC was added to the risk model. Four studies reported on improvements of individuals in low-, intermediate-, and high-risk categories. Addition of CAC to the risk model resulted in a net reclassification improvement ranging from 14% to 30%, meaning that CAC measurement reclassified a substantial proportion of individuals into correct risk categories. This improvement was most pronounced in those at intermediate Framingham risk. The available studies consistently showed that CAC scoring improves risk stratification in CVD risk categories when added to traditional risk factors only, especially among individuals at intermediate risk for CVD. Cost-effectiveness analyses together with a randomized controlled trial are needed before widespread introduction of CAC in clinical care. © 2011 The Authors. European Journal of Clinical Investigation © 2011 Stichting European Society for Clinical Investigation Journal Foundation.

  7. Developing a Risk Stratification Model for Surgical Site Infection after Abdominal Hysterectomy

    PubMed Central

    Olsen, Margaret A.; Higham-Kessler, James; Yokoe, Deborah S.; Butler, Anne M.; Vostok, Johanna; Stevenson, Kurt B.; Khan, Yosef; Fraser, Victoria J.

    2012-01-01

    Objective The incidence of surgical site infection (SSI) ranges widely from 2-21% after hysterectomy. There is insufficient understanding of risk factors to build a specific risk stratification index. Methods Retrospective case-control study of 545 abdominal and 275 vaginal hysterectomies from 7/1/03 - 6/30/05 at four institutions. SSIs were defined using CDC/NNIS criteria. Independent risk factors for abdominal hysterectomy were identified by logistic regression. Results There were 13 deep incisional, 53 superficial incisional, and 18 organ-space SSI after abdominal and 14 organ-space SSI after vaginal hysterectomy. Because risk factors for organ-space SSI were different in univariate analysis, further analyses focused on incisional SSI after abdominal hysterectomy. The maximum serum glucose within 5 days after operation was highest in patients with deep incisional SSI, lower in patients with superficial incisional SSI and lowest in uninfected patients (median 189, 156, and 141mg/dL, p = .005). Independent risk factors for incisional SSI included blood transfusion (odds ratio (OR) 2.4) and morbid obesity (body mass index (BMI) > 35, OR 5.7). Duration of operation > 75th percentile (OR 1.7), obesity (BMI 30-35, OR 3.0), and lack of private health insurance (OR 1.7) were marginally associated with increased odds of SSI. Conclusions Incisional SSI after abdominal hysterectomy was associated with increased BMI and blood transfusion. Longer operative time and lack of private health insurance were marginally associated with SSI. A specific risk stratification index could help to more accurately predict the risk of incisional SSI following abdominal hysterectomy. PMID:19803722

  8. 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.

  9. 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.

  10. Improved risk stratification in prevention by use of a panel of selected circulating microRNAs.

    PubMed

    Keller, Till; Boeckel, Jes-Niels; Groß, Stefan; Klotsche, Jens; Palapies, Lars; Leistner, David; Pieper, Lars; Stalla, Günnter K; Lehnert, Hendrik; Silber, Sigmund; Pittrow, David; Maerz, Winfried; Dörr, Marcus; Wittchen, Hans-Ulrich; Baumeister, Sebastian E; Völker, Uwe; Felix, Stephan B; Dimmeler, Stefanie; Zeiher, Andreas M

    2017-07-03

    Risk stratification is crucial in prevention. Circulating microRNAs have been proposed as biomarkers in cardiovascular disease. Here a miR panel consisting of miRs related to different cardiovascular pathophysiologies, was evaluated to predict outcome in the context of prevention. MiR-34a, miR-223, miR-378, miR-499 and miR-133 were determined from peripheral blood by qPCR and combined to a risk panel. As derivation cohort, 178 individuals of the DETECT study, and as validation cohort, 129 individuals of the SHIP study were used in a case-control approach. Overall mortality and cardiovascular events were outcome measures. The Framingham Risk Score(FRS) and the SCORE system were applied as risk classification systems. The identified miR panel was significantly associated with mortality given by a hazard ratio(HR) of 3.0 (95% (CI): 1.09-8.43; p = 0.034) and of 2.9 (95% CI: 1.32-6.33; p = 0.008) after adjusting for the FRS in the derivation cohort. In a validation cohort the miR-panel had a HR of 1.31 (95% CI: 1.03-1.66; p = 0.03) and of 1.29 (95% CI: 1.02-1.64; p = 0.03) in a FRS/SCORE adjusted-model. A FRS/SCORE risk model was significantly improved to predict mortality by the miR panel with continuous net reclassification index of 0.42/0.49 (p = 0.014/0.005). The present miR panel of 5 circulating miRs is able to improve risk stratification in prevention with respect to mortality beyond the FRS or SCORE.

  11. Applying Latent Class Analysis to Risk Stratification for Perioperative Mortality in Patients Undergoing Intraabdominal General Surgery.

    PubMed

    Kim, Minjae; Wall, Melanie M; Li, Guohua

    2016-07-01

    Perioperative risk stratification is often performed using individual risk factors without consideration of the syndemic of these risk factors. We used latent class analysis (LCA) to identify the classes of comorbidities and risk factors associated with perioperative mortality in patients presenting for intraabdominal general surgery. The 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program was used to obtain a cohort of patients undergoing intraabdominal general surgery. Risk factors and comorbidities were entered into LCA models to identify the latent classes, and individuals were assigned to a class based on the highest posterior probability of class membership. Relative risk regression was used to determine the associations between the latent classes and 30-day mortality, with adjustments for procedure. A 9-class model was fit using LCA on 466,177 observations. After combining classes with similar adjusted mortality risks, 5 risk classes were obtained. Compared with the class with average mortality risk (class 4), the risk ratios (95% confidence interval) ranged from 0.020 (0.014-0.027) in the lowest risk class (class 1) to 6.75 (6.46-7.02) in the highest risk class. After adjusting for procedure and ASA physical status, the latent classes remained significantly associated with 30-day mortality. The addition of the risk class variable to a model containing ASA physical status and surgical procedure demonstrated a significant increase in the area under the receiver operator characteristic curve (0.892 vs 0.915; P < 0.0001). Latent classes of risk factors and comorbidities in patients undergoing intraabdominal surgery are predictive of 30-day mortality independent of the ASA physical status and improve risk prediction with the ASA physical status.

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

    PubMed

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

    2007-08-01

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

  13. Risk Stratification-based Surveillance of Bacterial Contamination in Metropolitan Ambulances

    PubMed Central

    Noh, Hyun; Kim, Nam Joong; Ro, Young Sun; Oh, Hyang Soon; Joo, Se Ik; Kim, Jung In; Ong, Marcus Eng Hock

    2011-01-01

    We aimed to know the risk-stratification-based prevalence of bacterial contamination of ambulance vehicle surfaces, equipment, and materials. This study was performed in a metropolitan area with fire-based single-tiered Basic Life Support ambulances. Total 13 out of 117 ambulances (11.1%) were sampled and 33 sites per each ambulance were sampled using a soft rayon swab and aseptic containers. These samples were then plated onto a screening media of blood agar and MacConkey agar. Specific identification with antibiotic susceptibility was performed. We categorized sampling sites into risk stratification-based groups (Critical, Semi-critical, and Non-critical equipment) related to the likelihood of direct contact with patients' mucosa. Total 214 of 429 samples showed positive results (49.9%) for any bacteria. Four of these were pathogenic (0.9%) (MRSA, MRCoNS, and K. pneumoniae), and 210 of these were environmental flora (49.0%). However, the prevalence (positive/number of sample) of bacterial contamination in critical, semi-critical airway, semi-critical breathing apparatus group was as high as 15.4% (4/26), 30.7% (16/52), and 46.2% (48/104), respectively. Despite current formal guidelines, critical and semi-critical equipments were contaminated with pathogens and normal flora. This study suggests the need for strict infection control and prevention for ambulance services. PMID:21218040

  14. Extreme Learning Machine Framework for Risk Stratification of Fatty Liver Disease Using Ultrasound Tissue Characterization.

    PubMed

    Kuppili, Venkatanareshbabu; Biswas, Mainak; Sreekumar, Aswini; Suri, Harman S; Saba, Luca; Edla, Damodar Reddy; Marinhoe, Rui Tato; Sanches, J Miguel; Suri, Jasjit S

    2017-08-23

    Fatty Liver Disease (FLD) is caused by the deposition of fat in liver cells and leads to deadly diseases such as liver cancer. Several FLD detection and characterization systems using machine learning (ML) based on Support Vector Machines (SVM) have been applied. These ML systems utilize large number of ultrasonic grayscale features, pooling strategy for selecting the best features and several combinations of training/testing. As result, they are computationally intensive, slow and do not guarantee high performance due to mismatch between grayscale features and classifier type. This study proposes a reliable and fast Extreme Learning Machine (ELM)-based tissue characterization system (a class of Symtosis) for risk stratification of ultrasound liver images. ELM is used to train single layer feed forward neural network (SLFFNN). The input-to-hidden layer weights are randomly generated reducing computational cost. The only weights to be trained are hidden-to-output layer which is done in a single pass (without any iteration) making ELM faster than conventional ML methods. Adapting four types of K-fold cross-validation (K = 2, 3, 5 and 10) protocols on three kinds of data sizes: S0-original, S4-four splits, S8-sixty four splits (a total of 12 cases) and 46 types of grayscale features, we stratify the FLD US images using ELM and benchmark against SVM. Using the US liver database of 63 patients (27 normal/36 abnormal), our results demonstrate superior performance of ELM compared to SVM, for all cross-validation protocols (K2, K3, K5 and K10) and all types of US data sets (S0, S4, and S8) in terms of sensitivity, specificity, accuracy and area under the curve (AUC). Using the K10 cross-validation protocol on S8 data set, ELM showed an accuracy of 96.75% compared to 89.01% for SVM, and correspondingly, the AUC: 0.97 and 0.91, respectively. Further experiments also showed the mean reliability of 99% for ELM classifier, along with the mean speed improvement of 40% using

  15. Self-Reported Stroke Risk Stratification: Reasons for Geographic and Racial Differences in Stroke Study.

    PubMed

    Howard, George; McClure, Leslie A; Moy, Claudia S; Howard, Virginia J; Judd, Suzanne E; Yuan, Ya; Long, D Leann; Muntner, Paul; Safford, Monika M; Kleindorfer, Dawn O

    2017-07-01

    The standard for stroke risk stratification is the Framingham Stroke Risk Function (FSRF), an equation requiring an examination for blood pressure assessment, venipuncture for glucose assessment, and ECG to determine atrial fibrillation and heart disease. We assess a self-reported stroke risk function (SRSRF) to stratify stroke risk in comparison to the FSRF. Participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) were evaluated at baseline and followed for incident stroke. The FSRF was calculated using directly assessed stroke risk factors. The SRSRF was calculated from 13 self-reported questions to exclude those with prevalent stroke and assess stroke risk. Proportional hazards analysis was used to assess incident stroke risk using the FSRF and SRSRF. Over an average 8.2-year follow-up, 939 of 23 983 participants had a stroke. The FSRF and SRSRF produced highly correlated risk scores (rSpearman=0.852; 95% confidence interval, 0.849-0.856); however, the SRSRF had higher discrimination of stroke risk than the FSRF (cSRSRF=0.7266; 95% confidence interval, 0.7076-0.7457; cFSRF=0.7075; 95% confidence interval, 0.6877-0.7273; P=0.0038). The 10-year stroke risk in the highest decile of predicted risk was 11.1% for the FSRF and 13.4% for the SRSRF. A simple self-reported questionnaire can be used to identify those at high risk for stroke better than the gold standard FSRF. This instrument can be used clinically to easily identify individuals at high risk for stroke and also scientifically to identify a subpopulation enriched for stroke risk. © 2017 American Heart Association, Inc.

  16. 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

  17. Magnetic Resonance Imaging Plaque Hemorrhage for Risk Stratification in Carotid Artery Disease With Moderate Risk Under Current Medical Therapy.

    PubMed

    Hosseini, Akram A; Simpson, Richard J; Altaf, Nishath; Bath, Philip M; MacSweeney, Shane T; Auer, Dorothee P

    2017-03-01

    Magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) can predict recurrent cerebrovascular ischemic events in severe symptomatic carotid stenosis. It is less clear whether MRIPH can improve risk stratification despite optimized medical secondary prevention in those with moderate risk. One-hundred fifty-one symptomatic patients with 30% to 99% carotid artery stenosis (median age: 77, 60.5% men) clinically deemed to not benefit from endarterectomy were prospectively recruited to undergo MRI and clinical follow-up (mean, 22 months). The clinical carotid artery risk score could be evaluated in 88 patients. MRIPH+ve was defined as plaque intensity >150% that of adjacent muscle. Survival analyses were performed with recurrent infarction (stroke or diffusion-positive cerebral ischemia) as the main end point. Fifty-five participants showed MRIPH+ve; 47 had low, 36 intermediate, and 5 high carotid artery risk scores. Cox regression showed MRIPH as a strong predictor of future infarction (hazard ratio, 5.2; 95% confidence interval, 1.64-16.34; P=0.005, corrected for degree of stenosis), also in the subgroup with 50% to 69% stenosis (hazard ratio, 4.1; 95% confidence interval, 1-16.8; P=0.049). The absolute risk of future infarction was 31.7% at 3 years in MRIPH+ve versus 1.8% in patients without (P<0.002). MRIPH increased cumulative risk difference of future infarction by 47.1% at 3 years in those with intermediate carotid artery risk score (P=0.004). The study confirms MRIPH to be a powerful risk marker in symptomatic carotid stenosis with added value over current risk scores. For patients undergoing current secondary prevention medication with clinically uncertain benefit from recanalization, that is, those with moderate degree stenosis and intermediate carotid artery risk scores, MRIPH offers additional risk stratification. © 2017 American Heart Association, Inc.

  18. 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.

  19. Drug-induced liver injury: Towards early prediction and risk stratification

    PubMed Central

    Raschi, Emanuel; De Ponti, Fabrizio

    2017-01-01

    Drug-induced liver injury (DILI) is a hot topic for clinicians, academia, drug companies and regulators, as shown by the steadily increasing number of publications and agents listed as causing liver damage (http://livertox.nih.gov/). As it was the case in the past decade with drug-induced QT prolongation/arrhythmia, there is an urgent unmet clinical need to develop tools for risk assessment and stratification in clinical practice and, in parallel, to improve prediction of pre-clinical models to support regulatory steps and facilitate early detection of liver-specific adverse drug events. Although drug discontinuation and therapy reconciliation still remain the mainstay in patient management to minimize occurrence of DILI, especially acute liver failure events, different multidisciplinary attempts have been proposed in 2016 to predict and assess drug-related risk in individual patients; these promising, albeit preliminary, results strongly support the need to pursue this innovative pathway. PMID:28105256

  20. Doppler Endoscopic Probe as a Guide to Risk Stratification and Definitive Hemostasis of Peptic Ulcer Bleeding

    PubMed Central

    Jensen, Dennis M.; Ohning, Gordon V.; Kovacs, Thomas OG; Ghassemi, Kevin A.; Jutabha, Rome; Dulai, Gareth S.; Machicado, Gustavo A.

    2015-01-01

    Background and Aims For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUBs), we used Doppler endoscopic probe (DEP) for: 1. detection of blood flow underlying stigmata of recent hemorrhage (SRH), 2. quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and 3. comparing risks of rebleeding and actual 30 day rebleed rates for spurting arterial bleeding (Forrest – FIA) and oozing bleeding (FIB). Methods Prospective cohort study of 163 consecutive patients with severe PUBs and different SRH. Results All blood flow detected by DEP was arterial. Detection rates were 87.4% in major SRH - spurting arterial bleeding (FIA), non bleeding visible vessel (FIIA), clot (FIIB) - and significantly lower at 42.3% (p<0.0001) for intermediate group of oozing bleeding (FIB) or flat spot (FIIC). For spurting bleeding (FIA) vs. oozing (FIB), baseline DEP arterial flow was 100% vs. 46.7%; residual blood flow detected after endoscopic hemostasis was 35.7% vs. 0%; and 30 day rebleed rates were 28.6% vs. 0% (all p<0.05). Conclusions 1. For major SRH vs. oozing or spot, the arterial blood flow detection rates by DEP was significantly higher, indicating a higher rebleed risk. 2. Before and after endoscopic treatment, spurting FIA PUB’s had significantly higher rates of blood flow detection than oozing FIB PUB’s and a significantly higher 30 rebleed rate. 3. DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUBs. PMID:26318834

  1. 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.

  2. ProACS risk score: An early and simple score for risk stratification of patients with acute coronary syndromes.

    PubMed

    Timóteo, Ana Teresa; Aguiar Rosa, Sílvia; Afonso Nogueira, Marta; Belo, Adriana; Cruz Ferreira, Rui

    2017-02-01

    There are barriers to proper implementation of risk stratification scores in patients with acute coronary syndromes (ACS), including their complexity. Our objective was to develop a simple score for risk stratification of all-cause in-hospital mortality in a population of patients with ACS. The score was developed from a nationwide ACS registry. The development and internal validation cohorts were obtained from the first 31829 patients, randomly separated (60% and 40%, respectively). The external validation cohort consisted of the last 8586 patients included in the registry. This cohort is significantly different from the other cohorts in terms of baseline characteristics, treatment and mortality. Multivariate logistic regression analysis was used to select four variables with the highest predictive potential. A score was allocated to each parameter based on the regression coefficient of each variable in the logistic regression model: 1 point for systolic blood pressure ≤116 mmHg, Killip class 2 or 3, and ST-segment elevation; 2 points for age ≥72 years; and 3 points for Killip class 4. The new score had good discriminative ability in the development cohort (area under the curve [AUC] 0.796), and it was similar in the internal validation cohort (AUC 0.785, p=0.333). In the external validation cohort, there was also excellent discriminative ability (AUC 0.815), with an adequate fit. The ProACS risk score enables easy and simple risk stratification of patients with ACS for in-hospital mortality that can be used at the first medical contact, with excellent predictive ability in a contemporary population. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

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

    PubMed Central

    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.

    2015-01-01

    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. Pediatr Blood Cancer 2015;62:1305–1316. © 2015 The Authors. Pediatric Blood & Cancer, published by Wiley Periodicals, Inc. PMID:25810263

  4. Carotid ultrasound in the cardiovascular risk stratification of patients with rheumatoid arthritis: when and for whom?

    PubMed

    González-Gay, Miguel A; González-Juanatey, Carlos; Llorca, Javier

    2012-06-01

    Adequate stratification of cardiovascular (CV) risk is one of the major points of interest in the management of patients with rheumatoid arthritis (RA). A task force of the European League Against Rheumatism has proposed to adapt CV risk management calculated in RA patients according to the systematic coronary risk evaluation (SCORE) function by application of a multiplier factor of 1.5 in those patients with two of the following three criteria: disease duration >10 years, rheumatoid factor (RF) or anticyclic citrullinated peptide (anti-CCP) antibody positivity, and presence of severe extra-articular manifestations. However, a major concern when using the modified SCORE is to know whether the effect of chronic inflammation on the CV risk of RA patients can be fully determined using this tool. As increased carotid intima-media thickness (IMT) and carotid plaques have been proved to predict the development of CV events in RA, the authors suggest performing carotid ultrasound when SCORE does not yield results indicating high CV risk in RA patients with extra-articular manifestations, RF or anti-CCP positivity as well as in patients with 10 years disease duration or longer. The presence of abnormal carotid IMT (>0.90 mm) or carotid plaques would lead to these patients being considered as having high CV risk regardless of the results derived from the modified SCORE.

  5. Risk Stratification in Older Patients With Acute Myocardial Infarction: Physicians' Perspectives

    PubMed Central

    Feder, Shelli L.; Schulman-Green, Dena; Dodson, John A.; Geda, Mary; Williams, Kathleen; Nanna, Michael G.; Allore, Heather G.; Murphy, Terrence E.; Tinetti, Mary E.; Gill, Thomas M.; Chaudhry, Sarwat I.

    2016-01-01

    Objective Risk stratification models support clinical decision making in acute myocardial infarction (AMI) care. Existing models were developed using data from younger populations, potentially limiting accuracy and relevance in older adults. We describe physician-perceived risk factors, views of existing models, and preferences for future model development in older adults. Method Qualitative study using semi-structured telephone interviews and the constant comparative method. Results Twenty-two physicians from 14 institutions completed the interviews. Median age was 37, and median years of clinical experience was 11.5. Perceived predictors included cardiovascular, comorbid, functional, and social risk factors. Physicians viewed models as easy to use, yet neither inclusive of risk factors nor predictive of non-mortality outcomes germane to clinical decision making in older adults. Ideal models included multidimensional risk domains and operational requirements. Discussion Physicians reported limitations of available risk models when applied to older adults with AMI. New models are needed to guide AMI treatment in this population. PMID:26100619

  6. Risk stratification in motor area-related glioma surgery based on navigated transcranial magnetic stimulation data.

    PubMed

    Rosenstock, Tizian; Grittner, Ulrike; Acker, Güliz; Schwarzer, Vera; Kulchytska, Nataliia; Vajkoczy, Peter; Picht, Thomas

    2017-04-01

    OBJECTIVE Navigated transcranial magnetic stimulation (nTMS) is a noninvasive method for preoperatively localizing functional areas in patients with tumors in presumed motor eloquent areas. The aim of this study was to establish an nTMS-based risk stratification model by examining whether the results of nTMS mapping and its neurophysiological data predict postoperative motor outcome in glioma surgery. METHODS Included in this study were prospectively collected data for 113 patients undergoing bihemispheric nTMS examination prior to surgery for gliomas in presumed motor eloquent locations. Multiple ordinal logistic regression analysis was performed to test for any association between preoperative nTMS-related variables and postoperative motor outcome. RESULTS A new motor deficit or deterioration due to a preexisting deficit was observed in 20% of cases after 7 days and in 22% after 3 months. In terms of tumor location, no new permanent deficit was observed when the distance between tumor and corticospinal tract was greater than 8 mm and the precentral gyrus was not infiltrated (p = 0.014). New postoperative deficits on Day 7 were associated with a pathological excitability of the motor cortices (interhemispheric resting motor threshold [RMT] ratio < 90% or > 110%, p = 0.031). Interestingly, motor function never improved when the RMT was significantly higher in the tumorous hemisphere than in the healthy hemisphere (RMT ratio > 110%). CONCLUSIONS The proposed risk stratification model, based on objective functional-anatomical and neurophysiological measures, enables one to counsel patients about the risk of functional deterioration or the potential for recovery.

  7. Clinical analysis and risk stratification of ventricular septal rupture following acute myocardial infarction.

    PubMed

    Hu, Xiao-Ying; Qiu, Hong; Qiao, Shu-Bin; Kang, Lian-Ming; Song, Lei; Zhang, Jun; Tan, Xiao-Yan; Wu, Yuan; Yang, Yue-Jin; Gao, Run-Lin; Chen, Zai-Jia

    2013-11-01

    Ventricular septal rupture (VSR) remains an infrequent but devastating complication of acute myocardial infarction (AMI). The best time to undergo surgical repair is controversial and there is currently no risk stratification for patients with VSR to guide treatment. The purpose of this study was to review the clinical outcomes of 70 patients with VSR, to analyze the short-term prognosis factors of VSR following AMI, and to make a risk stratification for patients with VSR. A total of 70 consecutive VSR patients following AMI treated in our hospital from January 2002 to October 2010 were enrolled in this study retrospectively. The difference of clinical characteristics were observed between patients with VSR who survived ≤30 days and survived >30 days. We analyzed the short-term prognosis factors of VSR and established the short-term prognosis index of VSR (SPIV) based on the Logistic regression analysis to stratify patients with VSR. Among 12 354 patients with acute ST-segment elevation myocardial infarction, 70 (0.57%) patients (33 males and 37 females) were found to have VSR. The average age was (68.1±8.5) years. Fifty-four (77.1%) patients were diagnosed with an acute anterior infarction. Patients with VSR selected for surgical repair had better outcomes than patients treated conservatively; 1-year mortality 9.5% versus 87.8%, P < 0.005. Logistic regression analysis revealed that female (P = 0.013), anterior AMI (P = 0.023), non-ventricular aneurysm (P = 0.023), non-diabetes (P = 0.009), Killip class 3 or 4 (P = 0.022) and time from AMI to VSR less than 4 days (P = 0.027) were independent risk determinants for shortterm mortality. SPIV ≥9 indicates a high risk as the 30-day mortality is 77.4%; SPIV <8 indicates a low risk as the 30-day mortality is 28.6%; SPIV between 8 and 9 indicates a moderate risk. VSR remains a rare but devastating complication of AMI. The independent risk determinants for short-term mortality of VSR were female gender, anterior AMI

  8. 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 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.

  9. 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

  10. Pulmonary embolism: the diagnosis, risk-stratification, treatment and disposition of emergency department patients

    PubMed Central

    Corrigan, Daniel; Prucnal, Christiana; Kabrhel, Christopher

    2016-01-01

    The diagnosis or exclusion of pulmonary embolism (PE) remains challenging for emergency physicians. Symptoms can be vague or non-existent, and the clinical presentation shares features with many other common diagnoses. Diagnostic testing is complicated, as biomarkers, like the D-dimer, are frequently false positive, and imaging, like computed tomography pulmonary angiography, carries risks of radiation and contrast dye exposure. It is therefore incumbent on emergency physicians to be both vigilant and thoughtful about this diagnosis. In recent years, several advances in treatment have also emerged. Novel, direct-acting oral anticoagulants make the outpatient treatment of low risk PE easier than before. However, the spectrum of PE severity varies widely, so emergency physicians must be able to risk-stratify patients to ensure the appropriate disposition. Finally, PE response teams have been developed to facilitate rapid access to advanced therapies (e.g., catheter directed thrombolysis) for patients with high-risk PE. This review will discuss the clinical challenges of PE diagnosis, risk stratification and treatment that emergency physicians face every day. PMID:27752629

  11. Post-operative bleeding risk stratification in cardiac pulmonary bypass patients using artificial neural network.

    PubMed

    Huang, Richard S P; Nedelcu, Elena; Bai, Yu; Wahed, Amer; Klein, Kimberly; Tint, Hlaing; Gregoric, Igor; Patel, Manish; Kar, Biswajit; Loyalka, Pranav; Nathan, Sriram; Radovancevic, Rajko; Nguyen, Andy N D

    2015-01-01

    The prediction of bleeding risk in cardiopulmonary bypass (CPB) patients plays a vital role in their postoperative management. Therefore, an artificial neural network (ANN) to analyze intra-operative laboratory data to predict postoperative bleeding was set up. The JustNN software (Neural Planner Software, Cheshire, England) was used. This ANN was trained using 15 intra-operative laboratory parameters paired with one output category - risk of bleeding, defined as units of blood components transfused in 48 hours. The ANN was trained with the first 39 CPB cases. The set of input parameters for this ANN was also determined, and the ANN was validated with the next 13 cases. The set of input parameters include five components: pro-thrombin time, platelet count, thromboelastograph-reaction time, D-Dimer, and thromboelastograph-coagulation index. The validation results show 9 cases (69.2%) with exact match, 3 cases (23.1%) with one-grading difference, and 1 case (7.7%) with two-grading difference between actual blood usage versus predicted blood usage. To the best of our knowledge, ours is the first ANN developed for post-operative bleeding risk stratification of CPB patients. With promising results, we have started using this ANN to risk-stratify our CPB patients, and it has assisted us in predicting post-operative bleeding risk. © 2015 by the Association of Clinical Scientists, Inc.

  12. Microalbuminuria could improve risk stratification in patients with TIA and minor stroke.

    PubMed

    Elyas, Salim; Shore, Angela C; Kingwell, Hayley; Keenan, Samantha; Boxall, Leigh; Stewart, Jane; James, Martin A; Strain, William David

    2016-09-01

    Transient ischemic attacks (TIA) and minor strokes are important risk factors for recurrent strokes. Current stroke risk prediction scores such as ABCD2, although widely used, lack optimal sensitivity and specificity. Elevated urinary albumin excretion predicts cardiovascular disease, stroke, and mortality. We explored the role of microalbuminuria (using albumin creatinine ratio (ACR)) in predicting recurrence risk in patients with TIA and minor stroke. Urinary ACR was measured on a spot sample in 150 patients attending a daily stroke clinic with TIA or minor stroke. Patients were followed up at day 7, 30, and 90 to determine recurrent stroke, cardiovascular events, or death. Eligible patients had a carotid ultrasound Doppler investigation. High-risk patients were defined as those who had an event within 90 days or had >50% internal carotid artery (ICA) stenosis. Fourteen (9.8%) recurrent events were reported by day 90 including two deaths. Fifteen patients had severe ICA stenosis. In total, 26 patients were identified as high risk. These patients had a higher frequency of previous stroke or hypercholesterolemia compared to low-risk patients (P = 0.04). ACR was higher in high-risk patients (3.4 [95% CI 2.2-5.2] vs. 1.7 [1.5-2.1] mg/mmol, P = 0.004), independent of age, sex, blood pressure, diabetes, and previous stroke. An ACR greater than 1.5 mg/mmol predicted high-risk patients (Cox proportional hazard ratio 3.5 (95% CI 1.3-9.5, P = 0.01). After TIA or minor stroke, a higher ACR predicted recurrent events and significant ICA stenosis. Incorporation of urinary ACR from a spot sample in the acute setting could improve risk stratification in patients with TIA and minor stroke.

  13. Multiple Myeloma: 2016 update on Diagnosis, Risk-stratification and Management

    PubMed Central

    Rajkumar, S. Vincent

    2017-01-01

    Disease overview Multiple myeloma accounts for approximately 10% of hematologic malignancies. Diagnosis The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. Risk stratification Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Risk-adapted initial therapy Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRD). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRD) is an alternative to VRD. In eligible patients, initial therapy is given for approximately 3–4 months followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with Rd until progression, or alternatively, a triplet regimen such as VRD for approximately 12–18 months. Maintenance therapy After ASCT, lenalidomide maintenance is considered for standard risk patients who are not in very good partial response or better, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Management of refractory disease Patients with indolent relapse can be treated with 2-drug or 3-drug combinations. Patients with more aggressive relapse require a triplet regimen or a combination of multiple active agents. PMID:27291302

  14. Risk stratification in cardiovascular disease primary prevention - scoring systems, novel markers, and imaging techniques.

    PubMed

    Zannad, Faiez; De Backer, Guy; Graham, Ian; Lorenz, Matthias; Mancia, Giuseppe; Morrow, David A; Reiner, Zeljko; Koenig, Wolfgang; Dallongeville, Jean; Macfadyen, Robert J; Ruilope, Luis M; Wilhelmsen, Lars

    2012-04-01

    The aim of this paper is to review and discuss current methods of risk stratification for cardiovascular disease (CVD) prevention, emerging biomarkers, and imaging techniques, and their relative merits and limitations. This report is based on discussions that took place among experts in the area during a special CardioVascular Clinical Trialists workshop organized by the European Society of Cardiology Working Group on Cardiovascular Pharmacology and Drug Therapy in September 2009. Classical risk factors such as blood pressure and low-density lipoprotein cholesterol levels remain the cornerstone of risk estimation in primary prevention but their use as a guide to management is limited by several factors: (i) thresholds for drug treatment vary with the available evidence for cost-effectiveness and benefit-to-risk ratios; (ii) assessment may be imprecise; (iii) residual risk may remain, even with effective control of dyslipidemia and hypertension. Novel measures include C-reactive protein, lipoprotein-associated phospholipase A(2) , genetic markers, and markers of subclinical organ damage, for which there are varying levels of evidence. High-resolution ultrasound and magnetic resonance imaging to assess carotid atherosclerotic lesions have potential but require further validation, standardization, and proof of clinical usefulness in the general population. In conclusion, classical risk scoring systems are available and inexpensive but have a number of limitations. Novel risk markers and imaging techniques may have a place in drug development and clinical trial design. However, their additional value above and beyond classical risk factors has yet to be determined for risk-guided therapy in CVD prevention.

  15. Risk stratification scores for predicting mortality in coronary artery bypass surgery.

    PubMed

    Baretti, R; Pannek, N; Knecht, J-P; Krabatsch, T; Hübler, S; Hetzer, R

    2002-08-01

    Four risk-stratification scores (RSSs - Euro, French, CCS/Higgins, Parsonnet) were tested as predictors of mortality in coronary artery bypass grafting (CABG) surgery. From March to April 2000, the perioperative courses of 245 consecutive CABG patients were compared to the predictions according to the RSSs. Sensitivity and specificity were determined with receiver operating characteristics (ROC) curves. CCS/Higgins uses the most easily acquired patient data, and rates emergency conditions as high-risk. Euro focuses on advanced age and septal rupture. French uses the smallest number of patient parameters and rates rare critical situations as high-risk. Parsonnet is partially based on the physician's subjective assessment of a "catastrophic state," making the scoring arbitrary. All RSSs gave similar (not significant) areas under the ROC curves regarding mortality (Euro 0.826 +/- 0.080, French 0.783 +/- 0.094, CCS/Higgins 0.820 +/- 0.060, Parsonnet 0.831 +/- 0.042). Predicted risk levels for the 11 patients who died differed between the RSSs--Higgins placed these patients in 3 of 5 risk levels with ascending distribution. The other RSSs placed these patients in the highest risk level except for one and two patients, respectively, who were placed in the lowest Euro and French risk level. Euro and Parsonnet placed about half of all patients with non-lethal outcome in the highest risk level. All RSSs satisfactorily estimated the group risk for mortality. No RSS expressed sufficient validity to predict individuals with lethal outcome. In clinical use, CCS/Higgins proved the most practicable.

  16. Predicting Long-Term Outcomes in Pleural Infections. RAPID Score for Risk Stratification.

    PubMed

    White, Heath D; Henry, Christopher; Stock, Eileen M; Arroliga, Alejandro C; Ghamande, Shekhar

    2015-09-01

    Pleural infections are associated with significant morbidity and mortality. The recently developed RAPID (renal, age, purulence, infection source, and dietary factors) score consists of five clinical factors that can identify patients at risk for increased mortality. The objective of this study was to further validate the RAPID score in a diverse cohort, identify factors associated with mortality, and provide long-term outcomes. We evaluated a single-center retrospective cohort of 187 patients with culture-positive pleural infections. Patients were classified by RAPID scores into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. The Social Security Death Index was used to determine date of death. All-cause mortality was assessed at 3 months, 1 year, 3 years, and 5 years. Clinical factors and comorbid conditions were evaluated for association. Three-month mortality for low-, medium-, and high-risk groups was 1.5, 17.8, and 47.8%, respectively. Increased odds were observed among medium-risk (odds ratio, 14.3; 95% confidence interval, 1.8-112.6; P = 0.01) and high-risk groups (odds ratio, 53.3; 95% confidence interval, 6.8-416.8; P < 0.01). This trend continued at 1, 3, and 5 years. Factors associated with high-risk scores include gram-negative rod infections, heart disease, diabetes, cancer, lung disease, and increased length of stay. When applied to a diverse patient cohort, the RAPID score predicts outcomes in patients up to 5 years and may aid in long-term risk stratification on presentation.

  17. The physical phenotype of frailty for risk stratification of older medical inpatients.

    PubMed

    Forti, P; Maioli, F; Zagni, E; Lucassenn, T; Montanari, L; Maltoni, B; Luca Pirazzoli, G; Bianchi, G; Zoli, M

    2014-12-01

    To determine the usefulness of physical phenotype of frailty, cognitive impairment, and serum albumin for risk stratification of elderly medical impatients. Prospective, observational cohort study. A general internal medicine unit of a university hospital in Italy. Inpatients with an average age of 80.8 ± 7.5 yr (N = 470). Frailty was defined using the Study of Osteoporotic Fractures Index, a parsimonious version of the physical phenotype (two of the following markers: weight loss, inability to rise five times from a chair, and exhaustion). Two frailty markers from non-physical dimensions were also evaluated: cognitive impairment (Mini-Cog score < 3) and low serum albumin on ward admission (< 3,5 gr/dl). Logistic regression adjusted for preadmission and admission-related confounders was used to investigate whether the physical phenotype of frailty and the two non-physical markers were associated with ward length of stay and unfavorable discharge (death plus any other ward discharge disposition different from direct return home). Areas Under the receiver operating characteristic Curve (AUCs) and Likelihood Ratios (LRs) were used for evaluation of discriminatory ability and clinical usefulness of significant predictors. The physical phenotype of frailty was associated with both study outcomes (p < 0.010) but the association was mainly mediated by chair standing ability. Non-physical markers were associated only with unfavourable discharge (p < 0.001). All of these predictors, either alone or in combination, had poor discriminatory ability (AUCs < 0.70) and poor clinical usefulness (+LRs near 1) for the study outcomes. The physical phenotype of frailty appears of limited clinical use for risk stratification of older medical inpatients. Combination with markers from non-physical dimensions does not improve its prognostic abilities.

  18. Development and Validation of a Stratification Tool for Predicting Risk of Deep Sternal Wound Infection after Coronary Artery Bypass Grafting at a Brazilian Hospital

    PubMed Central

    Sá, Michel Pompeu Barros Oliveira; Ferraz, Paulo Ernando; Soares, Artur Freire; Miranda, Rodrigo Gusmão Albuquerque; Araújo, Mayara Lopes; Silva, Frederico Vasconcelos; Lima, Ricardo de Carvalho

    2017-01-01

    Objective Deep sternal wound infection following coronary artery bypass grafting is a serious complication associated with significant morbidity and mortality. Despite the substantial impact of deep sternal wound infection, there is a lack of specific risk stratification tools to predict this complication after coronary artery bypass grafting. This study was undertaken to develop a specific prognostic scoring system for the development of deep sternal wound infection that could risk-stratify patients undergoing coronary artery bypass grafting and be applied right after the surgical procedure. Methods Between March 2007 and August 2016, continuous, prospective surveillance data on deep sternal wound infection and a set of 27 variables of 1500 patients were collected. Using binary logistic regression analysis, we identified independent predictors of deep sternal wound infection. Initially we developed a predictive model in a subset of 500 patients. Dataset was expanded to other 1000 consecutive cases and a final model and risk score were derived. Calibration of the scores was performed using the Hosmer-Lemeshow test. Results The model had area under Receiver Operating Characteristic (ROC) curve of 0.729 (0.821 for preliminary dataset). Baseline risk score incorporated independent predictors of deep sternal wound infection: obesity (P=0.046; OR 2.58; 95% CI 1.11-6.68), diabetes (P=0.046; OR 2.61; 95% CI 1.12-6.63), smoking (P=0.008; OR 2.10; 95% CI 1.12-4.67), pedicled internal thoracic artery (P=0.012; OR 5.11; 95% CI 1.42-18.40), and on-pump coronary artery bypass grafting (P=0.042; OR 2.20; 95% CI 1.13-5.81). A risk stratification system was, then, developed. Conclusion This tool effectively predicts deep sternal wound infection risk at our center and may help with risk stratification in relation to public reporting and targeted prevention strategies in patients undergoing coronary artery bypass grafting.

  19. Genetic Stratification to Identify Risk Groups for Alzheimer’s Disease

    PubMed Central

    Marioni, Riccardo E.; Campbell, Archie; Hagenaars, Saskia P.; Nagy, Reka; Amador, Carmen; Hayward, Caroline; Porteous, David J.; Visscher, Peter M.; Deary, Ian J.

    2017-01-01

    Stratification by genetic risk factors for Alzheimer’s disease (AD) may help identify groups with the greatest disease risk. Biological changes that cause late-onset AD are likely to occur years, if not decades prior to diagnosis. Here, we select a subset of the Generation Scotland: Scottish Family Health Study cohort in a likely preclinical age-range of 60–70 years (subset n = 3,495 with cognitive and genetic data). We test for cognitive differences by polygenic risk scores for AD. The polygenic scores are constructed using all available SNPs, excluding those within a 500 kb distance of the APOE locus. Additive and multiplicative effects of APOE status on these associations are investigated. Small memory decrements were observed in those with high polygenic risk scores for AD (standardized beta –0.04, p = 0.020). These associations were independent of APOE status. There was no difference in AD polygenic scores across APOE haplotypes (p = 0.72). Individuals with high compared to low polygenic risk scores for AD (top and bottom 5% of the distribution) show cognitive decrements, albeit much smaller than for APOE ɛ4ɛ4 compared to ɛ3ɛ3 individuals (2.3 versus 3.5 fewer points on the processing speed test, and 1.8 versus 2.8 fewer points on the memory test). Polygenic risk scores for AD may help identify older individuals at greatest risk of cognitive decline and preclinical AD. PMID:28222519

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

    PubMed

    Hose, Dirk; Seckinger, Anja; Jauch, Anna; Rème, Thierry; Moreaux, Jérôme; 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.

  1. Validation of risk stratification for children with febrile neutropenia in a pediatric oncology unit in India.

    PubMed

    Das, Anirban; Trehan, Amita; Oberoi, Sapna; Bansal, Deepak

    2017-06-01

    The study aims to validate a score predicting risk of complications in pediatric patients with chemotherapy-related febrile neutropenia (FN) and evaluate the performance of previously published models for risk stratification. Children diagnosed with cancer and presenting with FN were evaluated in a prospective single-center study. A score predicting the risk of complications, previously derived in the unit, was validated on a prospective cohort. Performance of six predictive models published from geographically distinct settings was assessed on the same cohort. Complications were observed in 109 (26.3%) of 414 episodes of FN over 15 months. A risk score based on undernutrition (two points), time from last chemotherapy (<7 days = two points), presence of a nonupper respiratory focus of infection (two points), C-reactive protein (>60 mg/l = five points), and absolute neutrophil count (<100 per μl = two points) was used to stratify patients into "low risk" (score <7, n = 208) and assessed using the following parameters: overall performance (Nagelkerke R(2) = 34.4%), calibration (calibration slope = 0.39; P = 0.25 in Hosmer-Lemeshow test), discrimination (c-statistic = 0.81), overall sensitivity (86%), negative predictive value (93%), and clinical net benefit (0.43). Six previously published rules demonstrated inferior performance in this cohort. An indigenous decision rule using five simple predefined variables was successful in identifying children at risk for complications. Prediction models derived in developed nations may not be appropriate for low-middle-income settings and need to be validated before use. © 2016 Wiley Periodicals, Inc.

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

    PubMed

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

    2004-10-05

    Management of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is complicated by the incomplete information on the natural history of the disease and by the lack of risk stratification for cardiovascular death. The aim of the study was the identification of risk factors related to long-term prognosis. Data were collected from 130 patients (100 men; age at onset of symptoms, 31.8+/-14.4 years) from a tertiary center between 1977 and 2000 who fulfilled the international standardized diagnostic criteria for ARVD/C. Risk factors for cardiovascular death were determined by a logistic regression model. After a mean follow-up of 8.1+/-7.8 years, 24 deaths were recorded, with a mean age at death of 54+/-19 years (annual mortality rate, 2.3%). There were 21 deaths with a cardiovascular origin (progressive heart failure for 14 patients and sudden death for the remaining 7 patients). All patients who died had a history of ventricular tachycardia. Multivariate analysis showed that after adjustment for sex, history of syncope, chest pain, inaugural ventricular tachycardia, recurrence of ventricular tachycardia, and QRS dispersion, clinical signs of right ventricular failure and left ventricular dysfunction both remained independently associated with cardiovascular mortality. The combined presence of one of these risk factors and ventricular tachycardia identifies high-risk subjects for cardiovascular mortality, whereas patients without ventricular tachycardia displayed the best prognosis. The information on the natural history of patients with ARVD allowed us to identify risks factors for cardiovascular mortality. An analysis of a large international registry is needed to refine these results.

  3. Cardiovascular risk stratification in overweight or obese patients in primary prevention. Implications for use of statins.

    PubMed

    Masson, Walter; Lobo, Martín; Huerín, Melina; Molinero, Graciela; Manente, Diego; Pángaro, Mario; Vitagliano, Laura; Zylbersztejn, Horacio

    2015-02-01

    Cardiovascular risk estimation in patients with overweight/obesity is not standardized. Our objectives were to stratify cardiovascular risk using different scores, to analyze use of statins, to report the prevalence of carotid atherosclerotic plaque (CAP), and to determine the optimal cut-off point (OCP) of scores that discriminate between subjects with or without CAP. Non-diabetic patients with overweight or obesity in primary prevention were enrolled. The Framingham score (FS), the European score (ES), and the score proposed by the new American guidelines (NS) were calculated, and statin indication was evaluated. Prevalence of CAP was determined by ultrasound examination. A ROC analysis was performed. A total of 474 patients (67% with overweight and 33% obese) were enrolled into the study. The FS classified the largest number of subjects as low risk. PAC prevalence was higher in obese as compared to overweight subjects (44.8% vs. 36.1%, P=.04). According to the FS, ES, and NS respectively, 26.7%, 39.1%, and 39.1% of overweight subjects and 28.6%, 39.0%, and 39.0% of obese subjects had an absolute indication for statins. All three scores were shown to acceptably discriminate between subjects with and without CAP (area under the curve>0.7). The OCPs evaluated did not agree with the risk category values. Risk stratification and use of statins varied in the overweight/obese population depending on the function used. Understanding of the relationship between scores and presence of CAP may optimize risk estimate. Copyright © 2014 SEEN. Published by Elsevier España, S.L.U. All rights reserved.

  4. Noninvasive risk stratification after myocardial infarction: Rationale, current evidence and the need for definitive trials

    PubMed Central

    Exner, Derek V

    2009-01-01

    Despite advances in therapies for myocardial infarction (MI), death attributed to a cardiac arrest from ventricular tachycardia (VT) or ventricular fibrillation (VF) remains an important problem. The implantable cardioverter defibrillator (ICD) is effective in preventing death from VT/VF, but reliably identifying which post-MI patients would benefit from an ICD remains a major challenge. Beyond the initial post-MI period, the presence of significant left ventricular (LV) dysfunction, alone or in combination with the induction of sustained VT/VF during invasive testing, is the only proven means of selecting patients for a prophylactic ICD. However, these approaches identify only a fraction of those at risk. Furthermore, most patients with significant LV dysfunction after MI have a low, near-term risk of VT/VF. Noninvasive risk stratification tools have been developed to better identify patients likely to benefit from an ICD. To date, none of these tools has been proven useful in this regard. The factors leading to a cardiac arrest are complex, and a single test is unlikely to reliably predict risk. Noninvasive assessment of cardiac structure, conduction and repolarization along with autonomic modulation appear to be useful in predicting the risk of a cardiac arrest after MI, particularly when assessed in combination. However, randomized trials assessing the efficacy of ICD therapy in patients identified as being at risk are required. Until such data are available, significant LV dysfunction alone and in combination with the induction of VT/VF during invasive testing in the nonacute post-MI period remain the only proven methods to guide prophylactic ICD therapy. PMID:19521570

  5. High-sensitivity cardiac troponin assays: From improved analytical performance to enhanced risk stratification.

    PubMed

    Kozinski, Marek; Krintus, Magdalena; Kubica, Jacek; Sypniewska, Grazyna

    2017-05-01

    Implementation of cardiac troponin (cTn) assays has revolutionized the diagnosis, risk stratification, triage and management of patients with suspected myocardial infarction (MI). The Universal Definition of MI brought about a shift in the diagnostics of MI, from an approach primarily based on electrocardiography (ECG) to one primarily based on biomarkers. Currently, detection of a rise and/or fall in concentration or activity of myocardial necrosis biomarkers, preferentially cTns, with at least one value above the 99th percentile upper reference limit (URL), is the essential component for the diagnosis of MI. High-sensitivity cardiac troponin (hs-cTn) assays with their superior analytical performance were designed to further facilitate clinical decision making. The ability of hs-cTn assays to detect measurable cTn concentrations in at least 50% of healthy individuals, along with their improved precision (expressed as coefficient of variation ≤10% at the 99th percentile URL) associated with increased recognition of changing values, leads to enhanced risk stratification of patients with suspected MI, and also enables them to be used as prognostic tools potentially useful in other patient subsets. In this comprehensive review, we aim to integrate updated laboratory and clinical knowledge regarding hs-cTn assays in order to promote their optimal use in daily practice. We primarily focus on the role of hs-cTn assays in patients with suspected MI, discussing recommended diagnostic algorithms and result interpretation. Emphasis is also placed on the release of cTns following myocardial injury, the characteristics of antibodies used in available cTn immunoassays, and analytical performance of hs-cTn assays. In this paper, we also review potential challenges related to the selection of a healthy reference population in determining 99th percentile values, biological variation of hs-cTns, inequality between hs-cTn assays, and outline the current status of c

  6. Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department.

    PubMed

    Baugh, Christopher W; Greenberg, Jeffrey O; Mahler, Simon A; Kosowsky, Joshua M; Schuur, Jeremiah D; Parmar, Siddharth; Ciociolo, George R; Carr, Christina W; Ghazinouri, Roya; Scirica, Benjamin M

    2016-12-01

    Chest pain is a common complaint in the emergency department, and a small but important minority represents an acute coronary syndrome (ACS). Variation in diagnostic workup, risk stratification, and management may result in underuse, misuse, and/or overuse of resources. From July to October 2014, we conducted a prospective cohort study in an academic medical center by implementing a Standardized Clinical Assessment and Management Plan (SCAMP) for chest pain based on the HEART score. In addition to capturing adherence to the SCAMP algorithm and reasons for any deviations, we measured troponin sample timing; rates of stress test utilization; length of stay (LOS); and 30-day rates of revascularization, ACS, and death. We identified 239 patients during the enrollment period who were eligible to enter the SCAMP, of whom 97 patients were entered into the pathway. Patients were risk stratified into one of 3 risk tiers: high (n = 3), intermediate (n = 40), and low (n = 54). Among low-risk patients, recommendations for troponin testing were not followed in 56%, and 11% received stress tests contrary to the SCAMP recommendation. None of the low-risk patients had elevated troponin measurements, and none had an abnormal stress test. Mean LOS in low-risk patients managed with discordant plans was 22:26 h/min, compared with 9:13 h/min in concordant patients (P < 0.001). Mean LOS in intermediate-risk patients with stress testing was 25:53 h/min, compared with 7:55 h/min for those without (P < 0.001). At 30 days, 10% of intermediate-risk patients and 0% of low-risk patients experienced an ACS event (risk difference 10% [0.7%-19%]); none experienced revascularization or death. The most frequently cited reason for deviation from the SCAMP was lack of confidence in the tool. Compliance with SCAMP recommendations for low- and intermediate-risk patients was poor, largely due to lack of confidence in the tool. However, in our study population, outcomes suggest that deviation

  7. Risk Stratification of Ambulatory Patients with Advanced Heart Failure Undergoing Evaluation for Heart Transplantation

    PubMed Central

    Kato, Tomoko S.; Stevens, Gerin R; Jiang, Jeffrey; Schulze, P. Christian; Gukasyan, Natalie; Lippel, Matthew; Levin, Alison; Homma, Shunichi; Mancini, Donna; Farr, Maryjane

    2014-01-01

    Background Risk stratification of ambulatory heart failure (HF) patients has relied upon peak VO2 (pVO2) <14 mL/min/kg. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS<4) or heart transplantation (HTx; Status 1A or 1B) within one-year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the Model for End-stage Liver Disease-Albumin score (MELD-A) would be additive prognostic predictors. Methods We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within one-year following evaluation. Results Our cohort was 54.9±11.1 year-old, 79.1% male, 37.6% with ischemic etiology (LVEF 21±11% and pVO2 12.6±3.5ml/min/kg). Fifty outcomes (33.1%) occurred (27 HTx, 15 VAD, and 8 deaths). Univariate logistic regression showed significant association of RVSWI (mmHg-L/m2) (OR0.47, p=0.036), PCWP (mmHg) (OR2.65, p=0.007), and MELD-A (OR2.73, p=0.006) with one-year events. Stepwise regression showed independent correlation of RVSWI<5 (OR6.70; p<0.01), PCWP>20 (OR5.48; p<0.01), MELD-A>14 (OR3.72; p<0.01) and pVO2<14 (OR3.36; p=0.024) with one-year events. A scoring system was composed with MELD-A>14 and pVO2<14, 1 point each, and PCWP>20 and RVSWI<5, 2 points each. A cutoff at 4 demonstrated a 54% sensitivity and 88% specificity for one-year events. Conclusions Ambulatory HF patients have significant one-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of one-year prognosis. This study endorses early and timely referral for VAD and/or transplant. PMID:23415315

  8. Use of two gene panels for prostate cancer diagnosis and patient risk stratification.

    PubMed

    Xiao, Kefeng; Guo, Jinan; Zhang, Xuhui; Feng, Xiaoyan; Zhang, Heqiu; Cheng, Zhiqiang; Johnson, Heather; Persson, Jenny L; Chen, Lingwu

    2016-08-01

    Currently, no ideal prostate cancer (PCa) diagnostic or prognostic test is available due to the lack of biomarkers with high sensitivity and specificity. There is an unmet medical need to develop combinations of multiple biomarkers which may have higher accuracy in detection of PCa and stratification of aggressive and indolent cancer patients. The aim of this study was to test two biomarker gene panels in distinguishing PCa from benign prostate and high-risk, aggressive PCa from low-risk, indolent PCa, respectively. We identified a five-gene panel that can be used to distinguish PCa from benign prostate. The messenger RNA (mRNA) expression signature of the five genes was determined in 144 PCa and benign prostate specimens from prostatectomy. We showed that the five-gene panel distinguished PCa from benign prostate with sensitivity of 96.59 %, specificity of 92.86 %, and area under the curve (AUC) of 0.992 (p < 0.0001). The five-gene panel was further validated in a 137 specimen cohort and showed sensitivity of 84.62 %, specificity of 91.84 %, and AUC of 0.942 (p < 0.0001). To define subtypes of PCa for treatment guidance, we examined mRNA expression signature of an eight-gene panel in 87 PCa specimens from prostatectomy. The signature of the eight-gene panel was able to distinguish aggressive PCa (Gleason score >6) from indolent PCa (Gleason score ≤6) with sensitivity of 90.28 %, specificity of 80.00 %, and AUC of 0.967 (p < 0.0001). This panel was further validated in a 158 specimen cohort and showed significant difference between aggressive PCa and indolent PCa with sensitivity of 92.57 %, specificity of 70.00 %, and AUC of 0.962 (p < 0.0001). Our findings in assessing multiple biomarkers in combination may provide new tools to detect PCa and distinguish aggressive and indolent PCa for precision and personalized treatment. The two biomarker panels may be used in clinical settings for accurate PCa diagnosis and patient risk stratification

  9. Psychosis Prediction: Stratification of Risk Estimation With Information-Processing and Premorbid Functioning Variables

    PubMed Central

    Nieman, Dorien H.; Ruhrmann, Stephan; Dragt, Sara; Soen, Francesca; van Tricht, Mirjam J.; Koelman, Johannes H. T .M.; Bour, Lo J; Velthorst, Eva; Becker, Hiske E.; Weiser, Mark; Linszen, Don H.; de Haan, Lieuwe

    2014-01-01

    Background: The period preceding the first psychotic episode is regarded as a promising period for intervention. We aimed to develop an optimized prediction model of a first psychosis, considering different sources of information. The outcome of this model may be used for individualized risk estimation. Methods: Sixty-one subjects clinically at high risk (CHR), participating in the Dutch Prediction of Psychosis Study, were assessed at baseline with instruments yielding data on neuropsychology, symptomatology, environmental factors, premorbid adjustment, and neurophysiology. The follow-up period was 36 months. Results: At 36 months, 18 participants (29.5%) had made a transition to psychosis. Premorbid adjustment (P = .001, hazard ratio [HR] = 2.13, 95% CI = 1.39/3.28) and parietal P300 amplitude (P = .004, HR = 1.27, 95% CI = 1.08/1.45) remained as predictors in the Cox proportional hazard model. The resulting prognostic score (PS) showed a sensitivity of 88.9% and a specificity of 82.5%. The area under the curve of the PS was 0.91 (95% CI = 0.83–0.98, cross-validation: 0.86), indicating an outstanding ability of the model to discriminate between transition and nontransition. The PS was further stratified into 3 risk classes establishing a prognostic index. In the class with the worst social-personal adjustment and lowest P300 amplitudes, 74% of the subjects made a transition to psychosis. Furthermore, transition emerged on average more than 17 months earlier than in the lowest risk class. Conclusions: Our results suggest that predicting a first psychotic episode in CHR subjects could be improved with a model including premorbid adjustment and information-processing variables in a multistep algorithm combining risk detection and stratification. PMID:24142369

  10. Cardiac Magnetic Resonance Scar Imaging for Sudden Cardiac Death Risk Stratification in Patients with Non-Ischemic Cardiomyopathy

    PubMed Central

    Kim, Eun Kyoung; Chattranukulchai, Pairoj

    2015-01-01

    In patients with non-ischemic cardiomyopathy (NICM), risk stratification for sudden cardiac death (SCD) and selection of patients who would benefit from prophylactic implantable cardioverter-defibrillators remains challenging. We aim to discuss the evidence of cardiac magnetic resonance (CMR)-derived myocardial scar for the prediction of adverse cardiovascular outcomes in NICM. From the 15 studies analyzed, with a total of 2747 patients, the average prevalence of myocardial scar was 41%. In patients with myocardial scar, the risk for adverse cardiac events was more than 3-fold higher, and risk for arrhythmic events 5-fold higher, as compared to patients without scar. Based on the available observational, single center studies, CMR scar assessment may be a promising new tool for SCD risk stratification, which merits further investigation. PMID:26175568

  11. Management of acute paracetamol (acetaminophen) toxicity: a standardised proforma improves risk assessment and overall risk stratification by emergency medicine doctors.

    PubMed

    McQuade, David J; Aknuri, Srikanth; Dargan, Paul I; Wood, David M

    2012-12-01

    Paracetamol (acetaminophen) poisoning is the most common toxicological presentation in the UK. Doctors managing patients with paracetamol poisoning need to assess the risk of their patient developing hepatotoxicity before determining appropriate treatment. Patients deemed to be at 'high risk' of hepatotoxicity have lower treatment thresholds than those deemed to be at 'normal risk'. Errors in this process can lead to harmful or potentially fatal under or over treatment. To determine how well treating doctors assess risk factor status and whether a standardised proforma is useful in the risk stratification process. Retrospective 12-month case note review of all patients presenting with paracetamol poisoning to our large inner-city emergency department. Data were collected on the documentation of risk factors, the presence of a local hospital proforma and treatment outcomes. 249 presentations were analysed and only 59 (23.7%) had full documentation of all the risk factors required to make a complete risk assessment. 56 of the 59 (94.9%) had the local hospital proforma included in the notes; the remaining 3 (5.1%) had full documentation of risk factors despite the absence of a proforma. A local hospital proforma was more likely to be included in the emergency department notes in those with 'adequate documentation' (78 out of 120 (65%)) than for those with 'inadequate documentation' (16 out of 129 (12.4%)); X(2), p<0.001. Despite a low overall uptake of the proforma, use of a standardised proforma significantly increased the likelihood of documentation of the risk factors which increase risk for hepatotoxicity following paracetamol poisoning.

  12. 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

  13. Genetic and Clinical Predictors for Breast Cancer Risk Assessment and Stratification Among Chinese Women

    PubMed Central

    Wen, Wanqing; Gao, Yu-Tang; Shyr, Yu; Long, Jirong; Li, Guoliang; Li, Chun; Gu, Kai; Cai, Qiuyin; Shu, Xiao-Ou; Lu, Wei

    2010-01-01

    Background Most of the genetic variants identified from genome-wide association studies of breast cancer have not been validated in Asian women. No risk assessment model that incorporates both genetic and clinical predictors is currently available to predict breast cancer risk in this population. Methods We analyzed 12 single-nucleotide polymorphisms (SNPs) identified in recent genome-wide association studies mostly of women of European ancestry as being associated with the risk of breast cancer in 3039 case patients and 3082 control subjects who participated in the Shanghai Breast Cancer Study. All participants were interviewed in person to obtain information regarding known and suspected risk factors for breast cancer. The c statistic, a measure of discrimination ability with a value ranging from 0.5 (random classification) to 1.0 (perfect classification), was estimated to evaluate the contribution of genetic and established clinical predictors of breast cancer to a newly established risk assessment model for Chinese women. Clinical predictors included in the model were age at menarche, age at first live birth, waist-to-hip ratio, family history of breast cancer, and a previous diagnosis of benign breast disease. The utility of the models in risk stratification was evaluated by estimating the proportion of breast cancer patients in the general population that could be accounted for above a given risk threshold as predicted by the models. All statistical tests were two-sided. Results Eight SNPs (rs2046210, rs1219648, rs3817198, rs8051542, rs3803662, rs889312, rs10941679, and rs13281615), each of which reflected a genetically independent locus, were found to be associated with the risk of breast cancer. A dose–response association was observed between the risk of breast cancer and the genetic risk score, which is an aggregate measure of the effect of these eight SNPs (odds ratio for women in the highest quintile of genetic risk score vs those in the lowest = 1

  14. Emergency department management of syncope: need for standardization and improved risk stratification.

    PubMed

    Thiruganasambandamoorthy, Venkatesh; Taljaard, Monica; Stiell, Ian G; Sivilotti, Marco L A; Murray, Heather; Vaidyanathan, Aparna; Rowe, Brian H; Calder, Lisa A; Lang, Eddy; McRae, Andrew; Sheldon, Robert; Wells, George A

    2015-08-01

    Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians' risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians' prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1-83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.

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

    PubMed

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

    2013-08-01

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

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

    PubMed Central

    Davies, L; Francis, D; Piepoli, M; Scott, A; Ponikowski, P; Coats, A

    2000-01-01

    OBJECTIVE—To assess the value of cardiopulmonary exercise testing in predicting prognosis in a cohort of elderly patients with chronic heart failure (CHF).
DESIGN—A retrospective cohort study of all patients with CHF over the age of 70 years assessed between January 1992 and May 1997.
SETTING—Tertiary centre.
PATIENTS—50 patients (mean (SD) age 75.9 (4.5) years, 8 women) with CHF New York Heart Association (NYHA) class I (3 patients), II (25 patients), III (20 patients), and IV (2 patients). Follow up was complete for two years in all patients.
RESULTS—The patients underwent cardiopulmonary exercise testing (peak oxygen consumption 15.2 (4.5) ml/kg/min, minute ventilation/carbon dioxide production (VE/VCO2) slope 38.7 (11.8)); radionucleide ventriculography (left ventricular ejection fraction 32.8 (14.3)%); serum sodium measurement (139 (2.8) mmol/l); and echocardiography (left ventricular end diastolic dimension 6.1 (1.1) cm, left ventricular end systolic dimension 4.7 (1.5) cm). At the end of follow up in May 1999, 26 patients had died. The median follow up of the survivors was 47.7 months (interquartile range 31.5-53.5 months). On univariate analysis VE/VCO2 slope (p < 0.0001), NYHA class (p < 0.001), peak oxygen uptake (VO2) (p < 0.01), left ventricular end systolic dimension (p < 0.05), and serum sodium concentration (p < 0.05) had significant predictive power. Stepwise multivariate analysis identified only VE/VCO2 slope (p < 0.01), NYHA class (p < 0.05), and peak VO2 (p< 0.05) as conveying significant independent prognostic information.
CONCLUSION—Elderly patients with CHF have a high mortality, with the majority dead within two years. Cardiopulmonary exercise testing provides important information for risk stratification within this group and its use should not be neglected.


Keywords: cardiopulmonary exercise testing; chronic heart failure; elderly patients; risk factor stratification PMID

  17. What is the utility of preoperative frailty assessment for risk stratification in cardiac surgery?

    PubMed

    Bagnall, Nigel Mark; Faiz, Omar; Darzi, Ara; Athanasiou, Thanos

    2013-08-01

    A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether frailty scoring can be used either separately or combined with conventional risk scores to predict survival and complications. Five hundred and thirty-five papers were found using the reported search, of which nine cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There is a paucity of evidence, as advanced age is a criterion for exclusion in most randomized controlled trials. Conventional models of risk following cardiac surgery are not calibrated to accurately predict the outcomes in the elderly and do not currently include frailty parameters. There is no universally accepted definition for frailty, but it is described as a physiological decline in multiple organ systems, decreasing a patient's capacity to withstand the stresses of surgery and disease. Frailty is manifest clinically as deficits in functional capacity, such as slow ambulation and impairments in the activities of daily living (ADL). Analysis of predictive models using area under receiver operating curves (AUC) suggested only a modest benefit by adding gait speed to a Society of Thoracic Surgeons (STS score)-Predicted Risk of Mortality or Major Morbidity (PROM) risk score (AUC 0.04 mean difference). However, a specialist frailty assessment tool named FORECAST was found to be superior at predicting adverse outcomes at 1 year compared with either EuroSCORE or STS score (AUC 0.09 mean difference). However, risk models incorporating frailty parameters require further validation and have not been widely adopted. Routine collection of objective frailty measures such as 5-metre walk time and ADL assessment will help to provide data to develop new risk-assessment models to facilitate risk stratification and

  18. A comparison of non-symmetric entropy-based classification trees and support vector machine for cardiovascular risk stratification.

    PubMed

    Singh, Anima; Guttag, John V

    2011-01-01

    Classification tree-based risk stratification models generate easily interpretable classification rules. This feature makes classification tree-based models appealing for use in a clinical setting, provided that they have comparable accuracy to other methods. In this paper, we present and evaluate the performance of a non-symmetric entropy-based classification tree algorithm. The algorithm is designed to accommodate class imbalance found in many medical datasets. We evaluate the performance of this algorithm, and compare it to that of SVM-based classifiers, when applied to 4219 non-ST elevation acute coronary syndrome patients. We generated SVM-based classifiers using three different strategies for handling class imbalance: cost-sensitive SVM learning, synthetic minority oversampling (SMOTE), and random majority undersampling. We used both linear and radial basis kernel-based SVMs. Our classification tree models outperformed SVM-based classifiers generated using each of the three techniques. On average, the classification tree models yielded a 14% improvement in G-score and a 21% improvement in F-score relative to the linear SVM classifiers with the best performance. Similarly, our classification tree models yielded a 12% improvement in G-score and a 21% improvement in the F-score over the best RBF kernel-based SVM classifiers.

  19. Multiparametric analysis of heart rate variability used for risk stratification among survivors of acute myocardial infarction.

    PubMed

    Voss, A; Hnatkova, K; Wessel, N; Kurths, J; Sander, A; Schirdewan, A; Camm, A J; Malik, M

    1998-01-01

    A multiparametric heart rate variability analysis was performed to prove if combined heart rate variability (HRV) measures of different domains improve the result of risk stratification in patients after myocardial infarction. In this study, standard time domain, frequency domain and non-linear dynamics measures of HRV assessment were applied to 572 survivors of acute myocardial infarction. Three parameter sets each consisting of 4 parameters were applied and compared with the standard measurement of global heart rate variability HRVi. Discriminant analysis technique and t-test were performed to separate the high risk groups from the survivors. The predictive value of this approach was evaluated with receiver operator (ROC) and positive predictive accuracy (PPA) curves. Results--The discriminant analysis shows a separation of patients suffered by all cause mortality in 80% (best single parameter 74%) and sudden arrhythmic death in 86% (73%). All parameters of set 1 show a high significant difference (p < 0.001) between survivors and non-survivors based on two-tailed t-test. The specificity level of the multivariate parameter sets is at the 70% sensitivity level (ROC) about 85-90%, whereas HRVi shows maximum levels of 70%. The PPA in the all cause mortality group is at the 70% sensitivity level twice as high as the univariate HRV measure and increases to more than fourfold as high within the VT/VF group. In conclusion, in this population, the multiparametric approach with the combination of four parameters from all domains especially from NLD seems to be a better predictor of high arrhythmia risk than the standard measurement of global heart rate variability.

  20. Iodine-123-metaiodobenzylguanidine scintigraphy in risk stratification of sudden death in heart failure.

    PubMed

    Martins da Silva, Marta Inês; Vidigal Ferreira, Maria João; Morão Moreira, Ana Paula

    2013-06-01

    Metaiodobenzylguanidine (MIBG) is a false neurotransmitter noradrenaline analogue that is taken up by the 'uptake 1' transporter mechanism in the cell membrane of presynaptic adrenergic neurons and accumulates in catecholamine storage vesicles. Since it is practically unmetabolized, it can be labeled with a radioisotope (iodine-123) in scintigraphic exams to noninvasively assess the functional status of the sympathetic innervation of organs with a significant adrenergic component, including the heart. Studies of its application in nuclear cardiology appear to confirm its value in the assessment of conditions such as coronary artery disease, heart failure, arrhythmias and sudden death. Heart failure is a global problem, with an estimated prevalence of 2% in developed countries. Sudden cardiac death is the main cause of its high mortality. The autonomic nervous system dysfunction, including sympathetic hyperactivity, that accompanies chronic heart failure is associated with progressive myocardial remodeling, declining left ventricular function and worsening symptoms, and contributes to the development of ventricular arrhythmias and sudden death. Since 123I-MIBG cardiac scintigraphy can detect changes in the cardiac adrenergic system, there is considerable interest in its role in obtaining diagnostic and prognostic information in patients with heart failure. In this article we present a literature review on the use of 123I-MIBG scintigraphy for risk stratification of sudden death in patients with heart failure.

  1. Copeptin and risk stratification in patients with ischemic stroke and transient ischemic attack: the CoRisk study.

    PubMed

    De Marchis, Gian Marco; Katan, Mira; Weck, Anja; Brekenfeld, Caspar; Mattle, Heinrich P; Buhl, Daniela; Müller, Beat; Christ-Crain, Mirjam; Arnold, Marcel

    2013-04-01

    Copeptin independently predicts functional outcome and mortality at 90 days and one-year after ischemic stroke. In patients with transient ischemic attack, elevated copeptin values indicate an increased risk of further cerebrovascular events. The Copeptin Risk Stratification (CoRisk) study aims to validate the predictive value of copeptin in patients with ischemic stroke and transient ischemic attack. In patients with ischemic stroke, the CoRisk study aims to further explore the effect of treatment (i.e. thrombolysis) on the predictive value of copeptin. Prospective observational multicenter study analyzing three groups of patients, i.e. patients with ischemic stroke treated with and without thrombolysis and patients with transient ischemic attack. Primary end-point: In patients with ischemic stroke, the primary end-point includes disability (modified Rankin scale from 3 to 5) and mortality (modified Rankin scale 6) at three-months after stroke. In patients with transient ischemic attack, the primary end-point is a recurrent ischemic cerebrovascular event (i.e. ischemic stroke or recurrent transient ischemic attack). Secondary end-point: In patients with ischemic stroke, the secondary end-points include in-house complications (i.e. symptomatic intracerebral hemorrhage, malignant edema, aspiration pneumonia or seizures during hospitalization, and in-house mortality). © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

  2. Derivation of genetic biomarkers for cancer risk stratification in Barrett's oesophagus: a prospective cohort study.

    PubMed

    Timmer, Margriet R; Martinez, Pierre; Lau, Chiu T; Westra, Wytske M; Calpe, Silvia; Rygiel, Agnieszka M; Rosmolen, Wilda D; Meijer, Sybren L; Ten Kate, Fiebo J W; Dijkgraaf, Marcel G W; Mallant-Hent, Rosalie C; Naber, Anton H J; van Oijen, Arnoud H A M; Baak, Lubbertus C; Scholten, Pieter; Böhmer, Clarisse J M; Fockens, Paul; Maley, Carlo C; Graham, Trevor A; Bergman, Jacques J G H M; Krishnadath, Kausilia K

    2016-10-01

    The risk of developing adenocarcinoma in non-dysplastic Barrett's oesophagus is low and difficult to predict. Accurate tools for risk stratification are needed to increase the efficiency of surveillance. We aimed to develop a prediction model for progression using clinical variables and genetic markers. In a prospective cohort of patients with non-dysplastic Barrett's oesophagus, we evaluated six molecular markers: p16, p53, Her-2/neu, 20q, MYC and aneusomy by DNA fluorescence in situ hybridisation on brush cytology specimens. Primary study outcomes were the development of high-grade dysplasia or oesophageal adenocarcinoma. The most predictive clinical variables and markers were determined using Cox proportional-hazards models, receiver operating characteristic curves and a leave-one-out analysis. A total of 428 patients participated (345 men; median age 60 years) with a cumulative follow-up of 2019 patient-years (median 45 months per patient). Of these patients, 22 progressed; nine developed high-grade dysplasia and 13 oesophageal adenocarcinoma. The clinical variables, age and circumferential Barrett's length, and the markers, p16 loss, MYC gain and aneusomy, were significantly associated with progression on univariate analysis. We defined an 'Abnormal Marker Count' that counted abnormalities in p16, MYC and aneusomy, which significantly improved risk prediction beyond using just age and Barrett's length. In multivariate analysis, these three factors identified a high-risk group with an 8.7-fold (95% CI 2.6 to 29.8) increased HR when compared with the low-risk group, with an area under the curve of 0.76 (95% CI 0.66 to 0.86). A prediction model based on age, Barrett's length and the markers p16, MYC and aneusomy determines progression risk in non-dysplastic Barrett's oesophagus. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  3. Multiinstitutional Analysis of Thyroid Nodule Risk Stratification Using the American College of Radiology Thyroid Imaging Reporting and Data System.

    PubMed

    Middleton, William D; Teefey, Sharlene A; Reading, Carl C; Langer, Jill E; Beland, Michael D; Szabunio, Margaret M; Desser, Terry S

    2017-06-01

    Guidelines for managing thyroid nodules are highly dependent on risk stratification based on sonographic findings. The purpose of this study is to evaluate the risk stratification system used by the American College of Radiology Thyroid Imaging Reporting and Data System (TIRADS). Patients with thyroid nodules who underwent sonography and fine-needle aspiration were enrolled in a multiinstitutional study. The sonographic nodule features evaluated in the study were composition, echogenicity, margins, and echogenic foci. Images were reviewed by two radiologists who were blinded to the results of cytologic analysis. Nodules were assigned points for each feature, and the points were totaled to determine the final TIRADS level (TR1-TR5). The risk of cancer associated with each point total and final TIRADS level was determined. A total of 3422 nodules, 352 of which were malignant, were studied. The risk of malignancy was closely associated with the composition, echogenicity, margins, and echogenic foci of the nodules (p < 0.0001, in all cases). An increased aggregate risk of nodule malignancy was noted as the TIRADS point level increased from 0 to 10 (p < 0.0001) and as the final TIRADS level increased from TR1 to TR5 (p < 0.0001). Of the 3422 nodules, 2948 (86.1%) had risk levels that were within 1% of the TIRADS risk thresholds. Of the 474 nodules that were more than 1% outside these thresholds, 88.0% (417/474) had a risk level that was below the TIRADS threshold. The aggregate risk of malignancy for nodules associated with each individual TIRADS point level (0-10) and each final TIRADS level (TR1-TR5) falls within the TIRADS risk stratification thresholds. A total of 85% of all nodules were within 1% of the specified TIRADS risk thresholds.

  4. Heterogeneity of Psychosis Risk Within Individuals at Clinical High Risk: A Meta-analytical Stratification.

    PubMed

    Fusar-Poli, Paolo; Cappucciati, Marco; Borgwardt, Stefan; Woods, Scott W; Addington, Jean; Nelson, Barnaby; Nieman, Dorien H; Stahl, Daniel R; Rutigliano, Grazia; Riecher-Rössler, Anita; Simon, Andor E; Mizuno, Masafumi; Lee, Tae Young; Kwon, Jun Soo; Lam, May M L; Perez, Jesus; Keri, Szabolcs; Amminger, Paul; Metzler, Sibylle; Kawohl, Wolfram; Rössler, Wulf; Lee, Jimmy; Labad, Javier; Ziermans, Tim; An, Suk Kyoon; Liu, Chen-Chung; Woodberry, Kristen A; Braham, Amel; Corcoran, Cheryl; McGorry, Patrick; Yung, Alison R; McGuire, Philip K

    2016-02-01

    Individuals can be classified as being at clinical high risk (CHR) for psychosis if they meet at least one of the ultra-high-risk (UHR) inclusion criteria (brief limited intermittent psychotic symptoms [BLIPS] and/or attenuated psychotic symptoms [APS] and/or genetic risk and deterioration syndrome [GRD]) and/or basic symptoms [BS]. The meta-analytical risk of psychosis of these different subgroups is still unknown. To compare the risk of psychosis in CHR individuals who met at least one of the major inclusion criteria and in individuals not at CHR for psychosis (CHR-). Electronic databases (Web of Science, MEDLINE, Scopus) were searched until June 18, 2015, along with investigation of citations of previous publications and a manual search of the reference lists of retrieved articles. We included original follow-up studies of CHR individuals who reported the risk of psychosis classified according to the presence of any BLIPS, APS and GRD, APS alone, GRD alone, BS, and CHR-. Independent extraction by multiple observers and random-effects meta-analysis of proportions. Moderators were tested with meta-regression analyses (Bonferroni corrected). Heterogeneity was assessed with the I2 index. Sensitivity analyses tested robustness of results. Publication biases were assessed with funnel plots and the Egger test. The proportion of each subgroup with any psychotic disorder at 6, 12, 24, 36, and 48 or more months of follow-up. Thirty-three independent studies comprising up to 4227 individuals were included. The meta-analytical proportion of individuals meeting each UHR subgroup at intake was: 0.85 APS (95%CI, 0.79-0.90), 0.1 BLIPS (95%CI, 0.06-0.14), and 0.05 GRD (95%CI, 0.03-0.07). There were no significant differences in psychosis risk at any time point between the APS and GRD and the APS-alone subgroups. There was a higher risk of psychosis in the any BLIPS greater than APS greater than GRD-alone subgroups at 24, 36, and 48 or more months of follow-up. There was no

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

    PubMed

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

    2012-06-01

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

  6. Analysis of agreement between cardiac risk stratification protocols applied to participants of a center for cardiac rehabilitation

    PubMed Central

    Santos, Ana A. S.; Silva, Anne K. F.; Vanderlei, Franciele M.; Christofaro, Diego G. D.; Gonçalves, Aline F. L.; Vanderlei, Luiz C. M.

    2016-01-01

    ABSTRACT Background Cardiac risk stratification is related to the risk of the occurrence of events induced by exercise. Despite the existence of several protocols to calculate risk stratification, studies indicating that there is similarity between these protocols are still unknown. Objective To evaluate the agreement between the existing protocols on cardiac risk rating in cardiac patients. Method The records of 50 patients from a cardiac rehabilitation program were analyzed, from which the following information was extracted: age, sex, weight, height, clinical diagnosis, medical history, risk factors, associated diseases, and the results from the most recent laboratory and complementary tests performed. This information was used for risk stratification of the patients in the protocols of the American College of Sports Medicine, the Brazilian Society of Cardiology, the American Heart Association, the protocol designed by Frederic J. Pashkow, the American Association of Cardiovascular and Pulmonary Rehabilitation, the Société Française de Cardiologie, and the Sociedad Española de Cardiología. Descriptive statistics were used to characterize the sample and the analysis of agreement between the protocols was calculated using the Kappa coefficient. Differences were considered with a significance level of 5%. Results Of the 21 analyses of agreement, 12 were considered significant between the protocols used for risk classification, with nine classified as moderate and three as low. No agreements were classified as excellent. Different proportions were observed in each risk category, with significant differences between the protocols for all risk categories. Conclusion The agreements between the protocols were considered low and moderate and the risk proportions differed between protocols. PMID:27556385

  7. Identification and risk-stratification of problem alcohol drinkers with minor trauma in the emergency department.

    PubMed

    Stewart, Scott H; Doscher, Ashley; Miles, Sarah; Borg, Keith T

    2010-05-01

    Brief alcohol intervention may improve outcomes for injury patients with hazardous drinking but is less effective with increased severity of alcohol involvement. This study evaluated a brief method for detecting problem drinking in minor trauma patients and differentiating hazardous drinkers from those with more severe alcohol problems. Subjects included 60 minor trauma patients in an academic urban emergency department (ED) who had consumed any amount of alcohol in the prior month. Screening and risk stratification involved the use of a heavy-drinking-day screening item and the Rapid Alcohol Problems Screen (RAPS). We compared the heavy-drinking-day item to past-month alcohol use, as obtained by validated self-reporting methods, and measured the percentage of carbohydrate-deficient transferrin (%CDT) to assess the accuracy of self-reporting. The Alcohol Dependence Scale (ADS) was administered to gauge the severity of alcohol involvement and compared to the RAPS. Eighty percent of the subjects endorsed at least one heavy drinking day in the past year, and all patients who exceeded recommended weekly drinking limits endorsed at least one heavy drinking day. Among those with at least one heavy drinking day, 58% had a positive RAPS result. Persons with no heavy drinking days (n=12) had a median ADS of 0.5 (range 0 to 3). RAPS-negative persons with heavy drinking days (n=20) had a median ADS of 2 (range 0 to 8). RAPS-positive persons with heavy drinking days (n=28) had a median ADS of 8 (range 1 to 43). A heavy-drinking-day item is useful for detecting hazardous drinking patterns, and the RAPS is useful for differentiating more problematic drinkers who may benefit from referral from those more likely to respond to a brief intervention. This represents a time-sensitive approach for risk-stratifying non-abstinent injury patients prior to ED discharge.

  8. Arrhythmia Phenotype during Fetal Life Suggests LQTS Genotype: Risk Stratification of Perinatal Long QT Syndrome

    PubMed Central

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

    2014-01-01

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

  9. Anomalous Coronary Arteries and Myocardial Bridges: Risk Stratification in Children Using Novel Cardiac Catheterization Techniques.

    PubMed

    Agrawal, Hitesh; Molossi, Silvana; Alam, Mahboob; Sexson-Tejtel, S Kristen; Mery, Carlos M; McKenzie, E Dean; Fraser, Charles D; Qureshi, Athar M

    2017-03-01

    The evaluation of the vast majority of children with anomalous aortic origin of a coronary artery (AAOCA) and/or myocardial bridges is performed with non-invasive testing. However, a subset of these patients may benefit from invasive testing for risk stratification. All patients included in the Coronary Anomalies Program (CAP) at Texas Children's Hospital who underwent cardiac catheterization were included. Techniques included selective coronary angiograms (SCA), intravascular ultrasound (IVUS), and fractional flow reserve (FFR) measurements with provocative testing using adenosine and/or dobutamine infusions. Out of the 131 patients followed by the CAP between 12/12-4/16, 8 (6%) patients underwent 9 cath investigations at median age 13.1 (2.6-18.7) years and median weight 49.5 (11.4-142.7) kg. Six patients presented with cardiac signs/symptoms. Four patients had myocardial bridges of the left anterior descending (LAD) coronary artery, 2 patients had isolated AAOCA, and 2 patients had an anomalous left coronary artery (LCA) with an intramyocardial course of the LAD. SCA was performed in all patients. FFR was positive in 4/6 patients: IVUS showed >70% intraluminal narrowing in 3/5 patients. One patient had hemodynamic instability that reversed with catheter removal from the coronary ostium. Based on the catheterization data obtained, findings were reassuring in three patients, surgery was performed in three patients, and two patients are being medically managed/restricted from competitive sports. In our small cohort of patients, we demonstrated that IVUS and FFR can safely be performed in children and may help to risk stratify some patients with AAOCA and myocardial bridges.

  10. Cloning of the first human anti-JCPyV/VP1 neutralizing monoclonal antibody: epitope definition and implications in risk stratification of patients under natalizumab therapy.

    PubMed

    Diotti, Roberta Antonia; Mancini, Nicasio; Clementi, Nicola; Sautto, Giuseppe; Moreno, Guisella Janett; Criscuolo, Elena; Cappelletti, Francesca; Man, Petr; Forest, Eric; Remy, Louise; Giannecchini, Simone; Clementi, Massimo; Burioni, Roberto

    2014-08-01

    JC virus (JCPyV) has gained novel clinical importance as cause of progressive multifocal leukoencephalopathy (PML), a rare demyelinating disease recently associated to immunomodulatory drugs, such as natalizumab used in multiple sclerosis (MS) cases. Little is known about the mechanisms leading to PML, and this makes the need of PML risk stratification among natalizumab-treated patients very compelling. Clinical and laboratory-based risk-stratification markers have been proposed, one of these is represented by the JCPyV-seropositive status, which includes about 54% of MS patients. We recently proposed to investigate the possible protective role of neutralizing humoral immune response in preventing JCPyV reactivation. In this proof-of-concept study, by cloning the first human monoclonal antibody (GRE1) directed against a neutralizing epitope on JCPyV/VP1, we optimized a robust anti-JCPyV neutralization assay. This allowed us to evaluate the neutralizing activity in JCPyV-positive sera from MS patients, demonstrating the lack of correlation between the level of anti-JCPyV antibody and anti-JCPyV neutralizing activity. Relevant consequences may derive from future clinical studies induced by these findings; indeed the study of the serum anti-JCPyV neutralizing activity could allow not only a better risk stratification of the patients during natalizumab treatment, but also a better understanding of the pathophysiological mechanisms leading to PML, highlighting the contribution of peripheral versus central nervous system JCPyV reactivation. Noteworthy, the availability of GRE1 could allow the design of novel immunoprophylactic strategies during the immunomodulatory treatment.

  11. Acute myeloid leukemia in the era of precision medicine: recent advances in diagnostic classification and risk stratification

    PubMed Central

    Kansal, Rina

    2016-01-01

    Acute myeloid leukemia (AML) is a genetically heterogeneous myeloid malignancy that occurs more commonly in adults, and has an increasing incidence, most likely due to increasing age. Precise diagnostic classification of AML requires clinical and pathologic information, the latter including morphologic, immunophenotypic, cytogenetic and molecular genetic analysis. Risk stratification in AML requires cytogenetics evaluation as the most important predictor, with genetic mutations providing additional necessary information. AML with normal cytogenetics comprises about 40%-50% of all AML, and has been intensively investigated. The currently used 2008 World Health Organization classification of hematopoietic neoplasms has been proposed to be updated in 2016, also to include an update on the classification of AML, due to the continuously increasing application of genomic techniques that have led to major advances in our knowledge of the pathogenesis of AML. The purpose of this review is to describe some of these recent major advances in the diagnostic classification and risk stratification of AML. PMID:27144061

  12. Clinical impact and risk stratification of balloon angioplasty for femoropopliteal disease in nitinol stenting era: Retrospective multicenter study using propensity score matching analysis.

    PubMed

    Tsuchiya, Taketsugu; Takamura, Takaaki; Soga, Yoshimitsu; Iida, Osamu; Hirano, Keisuke; Suzuki, Kenji; Yamaoka, Terutoshi; Miyashita, Yusuke; Kitayama, Michihiko; Kajinami, Koji

    2016-01-01

    Nitinol stenting could bring the better outcome in endovascular therapy for femoropopliteal disease. However, it might be expected that recent marked advances in both device technology and operator technique had led to improved efficacy of balloon angioplasty even in this segment. The aims of this study were to evaluate the clinical impact of balloon angioplasty for femoropopliteal disease and make risk stratification clear by propensity score matching analysis. Based on the multicenter retrospective data, 2758 patients (balloon angioplasty: 729 patients and nitinol stenting: 2029 patients), those who underwent endovascular therapy for femoropopliteal disease, were analyzed. The propensity score matching procedure extracted a total of 572 cases per group, and the primary patency rate of balloon angioplasty and nitinol stenting groups after matching was significantly the same (77.2% vs 82.7% at 1 year; 62.2% vs 64.3% at 3 years; 47.8% vs 54.3% at 5 years). In multivariate Cox hazard regression analysis, significant predictors for primary patency were diabetes mellitus, regular dialysis, cilostazol use, chronic total occlusion, and intra-vascular ultra-sonography use. The strategy of balloon angioplasty was not evaluated as a significant predictor for the primary patency. After risk stratification using five items (diabetes mellitus, regular dialysis, no use of intra-vascular ultra-sonography, chronic total occlusion, and no use of cilostazol: the DDICC score), the estimated primary patency rates of each group (low, DDICC score 0-2; moderate, DDICC score 3; high risk, DDICC score 4-5) were 88.6%, 78.3%, and 63.5% at 1 year; 75.2%, 60.7%, and 39.8% at 3 years; and 66.0%, 47.1%, and 26.3% at 5 years (p < 0.0001). The primary patency rate of balloon angioplasty and nitinol stenting groups was significantly the same in each risk stratification. This study suggests that balloon angioplasty does not have inferiority to nitinol stenting but does have

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

    PubMed Central

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

    2011-01-01

    Background/Aims Renal dysfunction is associated with a higher risk of cardiovascular disease in patients with acute myocardial infarction (AMI). The aim of this study was to investigate the independent prognostic value of renal dysfunction and its incremental predictability risk after adjusting for well-known clinical factors in patients with AMI. Methods 751 consecutive patients with AMI admitted to the Coronary Care Unit (CCU) were included. Patients were grouped into 2 categories according to the baseline estimated glomerular filtration rate (eGFR) on admission (eGFR <60 vs. eGFR ≥60 ml/min/1.73 m2). C-reactive protein and white blood cell count (WBC) as well as clinical prognostic variables were assessed. The endpoint was mortality during CCU stay. The discriminatory power was estimated by the C-index. Results The patient group with an eGFR <60 ml/min/1.73 m2 was older, had more cardiovascular risk factors, a lower left ventricular ejection fraction and higher cardiovascular mortality during CCU stay (13 vs. 3%). Logistic regression analysis revealed the following predictors of mortality: degree of renal impairment (eGFR <60 ml/min/1.73 m2), hazard ratio (HR) = 2.2 (95% CI 1.1–4.3; p = 0.028); WBC >11,000 × 106/l, HR = 2.3 (95% CI 1.2–4.5; p = 0.017); Killip class on admission, HR = 3.8 (95% CI 1.7–8.5; p = 0.001), and New York Heart Association Functional Classification, HR = 3.6 (95% CI 1.7–7.4; p = 0.001). The adjusted C-index was 0.78 for baseline clinical variables and 0.84 for eGFR. Conclusions In patients with AMI, decreased eGFR is an important prognostic factor for impaired cardiac function and mortality in the short-term follow-up. The eGFR may be reliably used in the risk stratification of patients with AMI. PMID:22258400

  14. 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 and risks 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

  15. 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 (0.18–0.38), with a positive NRI of 0.19 (0.09–0.29) and a negative NRI of 0.09 (0.09–0.09). 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

  16. Fuzzy risk stratification and risk assessment model for clinical monitoring in the ICU.

    PubMed

    Dervishi, Albion

    2017-08-01

    The decisions that clinicians make in intensive care units (ICUs) based on monitored parameters reflecting physiological deterioration are of major medical and biomedical engineering interest. These parameters have been investigated and assessed for their usefulness in risk assessment. Totally, 127 ICU adult patients were studied. They were selected from a MIMIC II Waveform Database Matched Subset and had continuous monitoring of heart rate, invasive blood pressure, and oxygen saturation. The monitored data were dimension reduced using deep learning autoencoders and then used to train a support vector machine model (SVM). A combination of methods including fuzzy c-means clustering (FCM), and a random forest (RF) was used to determine the risk levels. When classifying patients into stable or deteriorating groups the main performance parameter was the receiver operating characteristics (ROC). The area under the ROC (AUROC) was 93.2 (95% CI (92.9-93.4)) with sensitivity and specificity values of 0.80 and 0.89, respectively. The suggested fuzzy risk levels using the combined method of the FCM clustering and RF achieved an accuracy of 1 (0.9999, 1), with both sensitivity and specificity values equal to 1. The potential for using models in risk assessment to estimate a patient's physiological status, stable or deteriorating, within 4 h has been demonstrated. The study was based on retrospective analysis and further studies are needed to evaluate the impact on clinical outcomes using this model. Copyright © 2017 Elsevier Ltd. All rights reserved.

  17. Prognostic value of health-related quality of life for death risk stratification in patients with unresectable glioblastoma.

    PubMed

    Paquette, Brice; Vernerey, Dewi; Chauffert, Bruno; Dabakuyo, Sandrine; Feuvret, Loic; Taillandier, Luc; Frappaz, Didier; Taillia, Hervé; Schott, Roland; Ducray, François; Fabbro, Michel; Tennevet, Isabelle; Ghiringhelli, François; Guillamo, Jean-Sébastien; Durando, Xavier; Castera, Daniel; Frenay, Marc; Campello, Chantal; Dalban, Cécile; Skrzypski, Jérome; Chinot, Olivier; Anota, Amélie; Bonnetain, Franck

    2016-08-01

    Glioblastoma is the most common malignant brain tumor in adults. Baseline health-related quality of life (HRQoL) is a major subject of concern for these patients. We aimed to assess the independent prognostic value of HRQoL in unresectable glioblastoma (UGB) patients for death risk stratification. One hundred and thirty-four patients with UGB were enrolled from the TEMAVIR trial. HRQoL was evaluated at baseline using the EORTC QLQ-C30 and BN20 brain cancer module. Clinical and HRQoL parameters were evaluated in univariable and multivariable Cox analysis as prognostic factors for overall survival (OS). Performance assessment and internal validation of the final model were evaluated with Harrel's C-index, calibration plot, and bootstrap sample procedure. Two OS independent predictors were identified: future uncertainty and sensitivity deficit. The final model exhibited good calibration and acceptable discrimination (C statistic = 0.63). The internal validity of the model was verified with robust uncertainties around the hazard ratio. The prognostic score identified three groups of patients with distinctly different risk profiles with median OS estimated at 16.2, 9.2, and 4.5 months. We demonstrated the additional prognostic value of HRQoL in UGB for death risk stratification and provided a score that may help to guide clinical management and stratification in future clinical trials.

  18. Stroke Risk Stratification and its Validation using Ultrasonic Echolucent Carotid Wall Plaque Morphology: A Machine Learning Paradigm.

    PubMed

    Araki, Tadashi; Jain, Pankaj K; Suri, Harman S; Londhe, Narendra D; Ikeda, Nobutaka; El-Baz, Ayman; Shrivastava, Vimal K; Saba, Luca; Nicolaides, Andrew; Shafique, Shoaib; Laird, John R; Gupta, Ajay; Suri, Jasjit S

    2017-01-01

    Stroke risk stratification based on grayscale morphology of the ultrasound carotid wall has recently been shown to have a promise in classification of high risk versus low risk plaque or symptomatic versus asymptomatic plaques. In previous studies, this stratification has been mainly based on analysis of the far wall of the carotid artery. Due to the multifocal nature of atherosclerotic disease, the plaque growth is not restricted to the far wall alone. This paper presents a new approach for stroke risk assessment by integrating assessment of both the near and far walls of the carotid artery using grayscale morphology of the plaque. Further, this paper presents a scientific validation system for stroke risk assessment. Both these innovations have never been presented before. The methodology consists of an automated segmentation system of the near wall and far wall regions in grayscale carotid B-mode ultrasound scans. Sixteen grayscale texture features are computed, and fed into the machine learning system. The training system utilizes the lumen diameter to create ground truth labels for the stratification of stroke risk. The cross-validation procedure is adapted in order to obtain the machine learning testing classification accuracy through the use of three sets of partition protocols: (5, 10, and Jack Knife). The mean classification accuracy over all the sets of partition protocols for the automated system in the far and near walls is 95.08% and 93.47%, respectively. The corresponding accuracies for the manual system are 94.06% and 92.02%, respectively. The precision of merit of the automated machine learning system when compared against manual risk assessment system are 98.05% and 97.53% for the far and near walls, respectively. The ROC of the risk assessment system for the far and near walls is close to 1.0 demonstrating high accuracy.

  19. Detection and risk stratification of women at high risk of preterm birth in rural communities near Nagpur, India.

    PubMed

    Patel, Archana; Prakash, Amber Abhijeet; Pusdekar, Yamini V; Kulkarni, Hemant; Hibberd, Patricia

    2017-09-19

    Presently, preterm birth is globally the leading cause of neonatal mortality. Prompt community based identification of women at high risk for preterm births (HRPB) can either help to avert preterm births or avail effective interventions to reduce neonatal mortality due to preterm births. We evaluated the performance of a package to train community workers to detect the presence of signs or symptoms of HRPB. Pregnant women enrolled in the intervention arm of a cluster randomized trial of Antenatal Corticosteroids (ACT Trial) conducted at Nagpur, India were informed about 4 directly observable signs and symptoms of preterm labor. Community health workers actively monitored these women from 24 to 36 weeks of gestation for these signs or symptoms. If they were present (HRPB positive) the identified women were brought to government health facilities for assessment and management. HRPB positive could also be determined by the provider if the woman presented directly to the facility. Risk stratification was based on the number of signs or symptoms present. The outcome of preterm birth was based on the clinical assessment of gestational age < 37 weeks at delivery or a birth weight of <2000 g. Between July 1, 2012 and 30 November, 2013, 686 of 7050 (9.7%) pregnant women studied, delivered preterm. 732 (10.4%) women were HRPB positive, of whom 333 (45.5%) delivered preterm. Of the remaining 6318(89.6%) HRPB negative women 353 (5.6%) delivered preterm. The likelihood ratio (LR) of a preterm birth in the HRPB positives was 8.14 (95% confidence interval 7.16-9.26). The LR of a preterm birth increased in women who had more signs or symptoms of HRBP (p < 0.00001). More signs or symptoms of HRPB were also associated with a shorter time to delivery, lower birth weight and higher rates of stillbirths, neonatal deaths and postnatal complications. Addition of risk stratification improved the prediction of preterm delivery (Integrated Discrimination Improvement 17% (95% CI 15

  20. Usefulness of exhaled nitric oxide to guide risk stratification for bronchiolitis obliterans syndrome after lung transplantation.

    PubMed

    Neurohr, C; Huppmann, P; Leuschner, S; von Wulffen, W; Meis, T; Leuchte, H; Ihle, F; Zimmermann, G; Baezner, C; Hatz, R; Winter, H; Frey, L; Ueberfuhr, P; Bittmann, I; Behr, J

    2011-01-01

    The aim of this study was to assess fractional exhaled nitric oxide (FeNO) for the early diagnosis of bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTX). 611 FeNO measurements in 166 consecutive patients were classified depending on BOS stage at the time of assessment and course during minimum follow-up of 3 months: (1) stable non-BOS, (2) unstable non-BOS, (3) stable BOS and (4) unstable BOS. Unstable course was defined as new onset of BOS≥1 or progression of BOS. FeNO before unstable course was significantly increased in comparison to their stable counterparts (non-BOS: 28.9 ± 1.2 ppb, n = 40 vs. 16.4 ± 0.8 ppb, n = 131 and BOS: 32.5 ± 1.3 ppb, n = 35 vs. 15.3 ± 0.8 ppb, n = 26; p = 0.01 each). Average time from FeNO reading to onset of deterioration was 117 ± 9 days in non-BOS and 136 ± 9 days in BOS patients. The positive and negative predictive value of FeNO >20 ppb for BOS was 69.0% and 96.9%, respectively. Serial measurements demonstrated significantly lower mean individual variation in stable recipients as compared to stable patients switching to unstable course (3.2 ± 0.3 ppb vs. 12.7 ± 1.4 ppb, p = 0.02). In particular, the excellent negative predictive value of persistently low FeNO readings for future BOS make FeNO assessments a useful tool for continuous risk stratification after LTX. ©2010 The Authors Journal compilation©2010 The American Society of Transplantation and the American Society of Transplant Surgeons.

  1. p16 Immunohistochemistry as a standalone test for risk stratification in oropharyngeal squamous cell carcinoma.

    PubMed

    Lewis, James S

    2012-07-01

    It is widely acknowledged that human papillomavirus (HPV)-related oropharyngeal carcinoma is a biologically unique form of head and neck cancer that should be singled out and treated differently. It is now incumbent to find a test (or combination of tests) that accurately identifies cancers with the associated favorable prognosis for proper patient counseling and management and for placing patients in the correct treatment arms in the emerging clinical trials that are attempting to establish unique treatment types and approaches. The test (or combination of tests) that are utilized must be widely available, reliable, easy to interpret, and well-validated. While HPV-specific testing seems completely logical to use as a single test or one of a combination of tests, it turns out to be quite complicated in practice. Because of the different forms of the virus, the differing types of HPV-specific tests can give different information. HPV DNA, RNA, and protein assays have varying sensitivities for virus detection and also varying availability from formalin-fixed, paraffin-embedded tissue. Since p16 protein over expression is very sensitive for the presence of transcriptionally-active HPV and since it correlates strongly with patient outcomes, is widely available, and easy to interpret, it appears to currently be the single test that combines all of the desired attributes in a risk stratification marker for widespread implementation in clinical and research study settings. This article will review the literature on p16 immunohistochemistry and its relation to HPV-specific testing, discuss some practical issues related to its implementation, and present the case for why it should be the single test used for this purpose.

  2. Dynamic risk stratification for medullary thyroid cancer according to the response to initial therapy.

    PubMed

    Kwon, Hyemi; Kim, Won Gu; Jeon, Min Ji; Song, Dong Eun; Lee, Yu-Mi; Sung, Tae-Yon; Chung, Ki-Wook; Yoon, Jong Ho; Hong, Suck Joon; Baek, Jung Hwan; Lee, Jeong Hyun; Kim, Tae Yong; Kim, Won Bae; Shong, Young Kee

    2016-07-01

    Detecting persistent/recurrent disease of medullary thyroid carcinoma (MTC) is important. The tumor-node-metastasis (TNM) staging system is useful for predicting disease-specific mortality, but is a static system and does not include postoperative serum calcitonin levels. We have focused on the clinical usefulness of dynamic risk stratification (DRS) using the best response to the initial therapy in MTC patients. A total of 120 MTC patients were classified into three DRS groups based on their responses to initial therapy. Clinical outcomes were assessed according to TNM staging and DRS. In the DRS, 70, 23 and 7 % of the MTC patients were classified into excellent, biochemical incomplete, or structural incomplete response groups, respectively. On TNM staging, 37, 16, 13 and 35 % of patients were stages I-IV, respectively. There were significant differences in survivals according to TNM staging (p = 0.03) and DRS (p = 0.005). During the median follow-up of 6.2 years, 75 patients (63 %) demonstrated no evidence of disease (NED). About 60 and 17 % of patients in stages III and IV were NED, respectively. DRS predicted NED better than TNM staging according to the proportion of variance explained (PVE) (49.1 vs. 28.7 %, respectively). At the final follow-up, 88, 4 and 0 % of patients in excellent, biochemical incomplete, and structural incomplete response groups attained NED, respectively. DRS based on the best response to the initial therapy can provide useful prognostic information in addition to initial TNM staging for predicting of mortality, as well as the likelihood of NED in MTC patients.

  3. BRAF V600E and risk stratification of thyroid microcarcinoma: a multicenter pathological and clinical study.

    PubMed

    Tallini, Giovanni; de Biase, Dario; Durante, Cosimo; Acquaviva, Giorgia; Bisceglia, Michele; Bruno, Rocco; Bacchi Reggiani, Maria Letizia; Casadei, Gian Piero; Costante, Giuseppe; Cremonini, Nadia; Lamartina, Livia; Meringolo, Domenico; Nardi, Francesco; Pession, Annalisa; Rhoden, Kerry J; Ronga, Giuseppe; Torlontano, Massimo; Verrienti, Antonella; Visani, Michela; Filetti, Sebastiano

    2015-10-01

    Studies from single institutions have analyzed BRAF in papillary microcarcinomas, sometimes with contradictory results. Most of them have provided limited integration of histological and clinical data. To obtain a comprehensive picture of BRAF V600E-mutated microcarcinomas and to evaluate the role of BRAF testing in risk stratification we performed a retrospective multicenter analysis integrating microscopical, pathological, and clinical information. Three hundred and sixty-five samples from 300 patients treated at six medical institutions covering different geographical regions of Italy were analyzed with central review of all cases. BRAF V600E statistical analysis was conducted on 298 microcarcinomas from 264 patients after exclusion of those that did not meet the required criteria. BRAF V600E was identified in 145/298 tumors (49%) including the following subtypes: 35/37 (95%, P<0.0001) tall cell and 72/114 (64%, P<0.0001) classic; conversely 94/129 follicular variant papillary microcarcinomas (73%, P<0.0001) were BRAF wild type. BRAF V600E-mutated microcarcinomas were characterized by markedly infiltrative contours (P<0.0001) with elongated strings of neoplastic cells departing from the tumor, and by intraglandular tumor spread (P<0.0001), typically within 5 mm of the tumor border. Multivariate analysis correlated BRAF V600E with specific microscopic features (nuclear grooves, optically clear nuclei, tall cells within the tumor, and tumor fibrosis), aggressive growth pattern (infiltrative tumor border, extension into extrathyroidal tissues, and intraglandular tumor spread), higher American Thyroid Association recurrence risk group, and non-incidental tumor discovery. The following showed the strongest link to BRAF V600E: tall cell subtype, many neoplastic cells with nuclear grooves or with optically clear nuclei, infiltrative growth, intraglandular tumor spread, and a tumor discovery that was non-incidental. BRAF V600E-mutated microcarcinomas represent a

  4. Feasibility of an automated quantitative computed tomography angiography-derived risk score for risk stratification of patients with suspected coronary artery disease.

    PubMed

    de Graaf, Michiel A; Broersen, Alexander; Ahmed, Wehab; Kitslaar, Pieter H; Dijkstra, Jouke; Kroft, Lucia J; Delgado, Victoria; Bax, Jeroen J; Reiber, Johan H C; Scholte, Arthur J

    2014-06-15

    Coronary computed tomography angiography (CTA) has important prognostic value. Additionally, quantitative CTA (QCT) provides a more detailed accurate assessment of coronary artery disease (CAD) on CTA. Potentially, a risk score incorporating all quantitative stenosis parameters allows accurate risk stratification. Therefore, the purpose of this study was to determine if an automatic quantitative assessment of CAD using QCT combined into a CTA risk score allows risk stratification of patients. In 300 patients, QCT was performed to automatically detect and quantify all lesions in the coronary tree. Using QCT, a novel CTA risk score was calculated based on plaque extent, severity, composition, and location on a segment basis. During follow-up, the composite end point of all-cause mortality, revascularization, and nonfatal infarction was recorded. In total, 10% of patients experienced an event during a median follow-up of 2.14 years. The CTA risk score was significantly higher in patients with an event (12.5 [interquartile range 8.6 to 16.4] vs 1.7 [interquartile range 0 to 8.4], p <0.001). In 127 patients with obstructive CAD (≥50% stenosis), 27 events were recorded, all in patients with a high CTA risk score. In conclusion, the present study demonstrated that a fully automatic QCT analysis of CAD is feasible and can be applied for risk stratification of patients with suspected CAD. Furthermore, a novel CTA risk score incorporating location, severity, and composition of coronary lesion was developed. This score may improve risk stratification but needs to be confirmed in larger studies.

  5. Global cardiovascular risk stratification: comparison of the Framingham method with the SCORE method in the Mexican population.

    PubMed

    Alcocer, Luis Antonio; Lozada, Osvaldo; Fanghänel, Guillermo; Sánchez-Reyes, Leticia; Campos-Franco, Enrique

    2011-01-01

    In the Mexican population we are unaware if the Framingham model is a better system than the SCORE system for stratifying cardiovascular risk. The present study was conducted to compare risk stratification with the Framingham tables using the same procedure but using the SCORE, with the aim of recommending the use of the most appropriate method. We analyzed a database of apparently healthy workers from the Mexico City General Hospital included in the study group "PRIT" (Prevalencia de Factores de Riesgo de Infarto del Miocardio en Trabajadores del Hospital General de México) and we calculated the risk in each simultaneously with the Framingham method and the SCORE method. It was possible to perform risk calculation with both methods in 1990 subjects from a total of 5803 PRITHGM study participants. When using the SCORE method, we stratified 1853 patients into low risk, 133 into medium risk and 4 into high risk. The Framingham method qualified 1586 subjects as low risk, 268 as medium risk and 130 as high risk. Concordance between scales to classify both patients according to the same risk was 98% in those classified as low risk, 19.4% among those classified as intermediate risk and only 3% in those classified as high risk. According to our results, it seems more appropriate in our country to recommend the Framingham model for calculating cardiovascular risk due to the fact that the SCORE model underestimated risk.

  6. The association between ASA status and other risk stratification models on postoperative intensive care unit outcomes.

    PubMed

    Lupei, Monica I; Chipman, Jeffrey G; Beilman, Gregory J; Oancea, S Cristina; Konia, Mojca R

    2014-05-01

    There is limited medical literature investigating the association between perioperative risk stratification methods and surgical intensive care unit (SICU) outcomes. Our hypothesis contends that routine assessments such as higher ASA physical status classification, surgical risk as defined by American College of Cardiology/American Heart Association guidelines, and simplified Revised Cardiac Index (SRCI) can reliably be associated with SICU outcomes. We performed a chart review of all patients 18 years or older admitted to the SICU between October 1, 2010, and March 1, 2011. We collected demographic and preoperative clinical data: age, sex, ASA physical status class, surgical risk, and SRCI. Outcome data included our primary end point, SICU length of stay, and secondary end points: mechanical ventilation and vasopressor treatment duration, number of acquired organ dysfunctions (NOD), readmission to the intensive care unit (ICU) within 7 days, SICU mortality, and 30-day mortality. Regression analysis and nonparametric tests were used, and P < 0.05 was considered significant. We screened 239 patients and included 220 patients in the study. The patients' mean age was 58 ± 16 years. There were 32% emergent surgery and 5% readmissions to the SICU within 7 days. The SICU mortality and the 30-day mortality were 3.2%. There was a significant difference between SICU length of stay (2.9 ± 2.1 vs 5.9 ± 7.4, P = 0.007), mechanical ventilation (0.9 ± 2.0 vs 3.4 ± 6.8, P = 0.01), and NOD (0 [0-2] vs 1 [0-5], P < 0.001) based on ASA physical status class (≤ 2 vs ≥ 3). Outcomes significantly associated with ASA physical status class after adjusting for confounders were: SICU length of stay (incidence rate ratio [IRR] = 1.79, 95% confidence interval [CI], 1.35-2.39, P < 0.001), mechanical ventilation (IRR = 2.57, 95% CI, 1.69-3.92, P < 0.001), vasopressor treatment (IRR = 3.57, 95% CI, 1.84-6. 94, P < 0.001), NOD (IRR = 1.71, 95% CI, 1.46-1.99, P < 0.001), and readmission

  7. Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification.

    PubMed

    McMillan, Matthew T; Malleo, Giuseppe; Bassi, Claudio; Allegrini, Valentina; Casetti, Luca; Drebin, Jeffrey A; Esposito, Alessandro; Landoni, Luca; Lee, Major K; Pulvirenti, Alessandra; Roses, Robert E; Salvia, Roberto; Vollmer, Charles M

    2017-06-01

    This multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD). Recent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinically relevant pancreatic fistula (CR-POPF)-the most common and morbid complication after PD. The protocol was applied to 260 consecutive PDs performed at two institutions over 17 months. Risk for ISGPF CR-POPF was determined intraoperatively using the Fistula Risk Score (FRS); drains were omitted in negligible/low risk patients and drain fluid amylase (DFA) was measured on postoperative day 1 (POD 1) for moderate/high risk patients. Drains were removed early (POD 3) in patients with POD 1 DFA ≤5,000 U/L, whereas patients with POD 1 DFA >5,000 U/L were managed by clinical discretion. Outcomes were compared with a historical cohort (N = 557; 2011-2014). Fistula risk did not differ between cohorts (median FRS: 4 vs 4; P = 0.933). No CR-POPFs developed in the 70 (26.9%) negligible/low risk patients. Overall CR-POPF rates were significantly lower after protocol implementation (11.2 vs 20.6%, P = 0.001). The protocol cohort also demonstrated lower rates of severe complication, any complication, reoperation, and percutaneous drainage (all P < 0.05). These patients also experienced reduced hospital stay (median: 8 days vs 9 days, P = 0.001). There were no differences between cohorts in the frequency of bile or chyle leaks. Drains can be safely omitted for one-quarter of PDs. Drain amylase analysis identifies which moderate/high risk patients benefit from early drain removal. This data-driven, risk-stratified approach significantly decreases the occurrence of clinically relevant pancreatic fistula.

  8. 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

  9. Comparison of the EORTC tables and the EAU categories for risk stratification of patients with nonmuscle-invasive bladder cancer.

    PubMed

    Rieken, Malte; Shariat, Shahrokh F; Kluth, Luis; Crivelli, Joseph J; Abufaraj, Mohammad; Foerster, Beat; Mari, Andrea; Ilijazi, Dafina; Karakiewicz, Pierre I; Babjuk, Marek; Gönen, Mithat; Xylinas, Evanguelos

    2017-09-22

    To characterize outcomes of patients with TaT1 urothelial carcinoma of the bladder stratified by the European Association of Urology (EAU) categories and to compare them with European Organization for Research and Treatment of Cancer (EORTC) risk groups to assess the rate and effect of reclassification. A multi-institutional database of 5,122 patients with TaT1 urothelial carcinoma of the bladder who underwent transurethral resection of the bladder with or without adjuvant therapy at 8 institutions between 1996 and 2007. Multivariable Cox-regression analyses addressed factors associated with disease recurrence and progression. The net reclassification index was used to compare the performance of the EAU categories with the EORTC scoring system. Of 5,122 patients, 632 (12.3%), 2,302 (45.0%), and 2,188 (42.7%) were assigned to the low-, intermediate-, and high-risk EAU category, respectively. Within a median follow-up of 62 months (interquartile range: 27-97), 2,365 (46.2%) and 516 (10.1%) patients experienced disease recurrence and progression, respectively. In multivariable Cox-regression analyses, EAU intermediate- and high-risk categories were associated with a higher risk of disease recurrence (P<0.001) and progression (P<0.001) compared to low-risk patients. Application of the EAU categories reclassified 1,940 (37.9%) patients into a higher risk group for recurrence. Likewise, 602 (11.8%) patients were reclassified to a higher and 278 (5.4%) to a lower risk group for progression. The net reclassification index of the EAU risk stratification was 0.1% (95% CI: -3.1% to 3.2%) for recurrence and 10.1% (95% CI: -8.0% to 12.0%) for progression, respectively. Compared to EORTC risk stratification, the EAU categories reclassifies 37.9% patients into a higher risk group of recurrence and 11.8% into a higher risk of progression. However, the novel risk stratification assigns most patients to the same treatment as the more complex EORTC tables and can be regarded as an

  10. Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis.

    PubMed

    Scott, A J; Mason, S E; Arunakirinathan, M; Reissis, Y; Kinross, J M; Smith, J J

    2015-04-01

    Current management of suspected appendicitis is hampered by the overadmission of patients with non-specific abdominal pain and a significant negative exploration rate. The potential benefits of risk stratification by the Appendicitis Inflammatory Response (AIR) score to guide clinical decision-making were assessed. During this 50-week prospective observational study at one institution, the AIR score was calculated for all patients admitted with suspected appendicitis. Appendicitis was diagnosed by histological examination, and patients were classified as having non-appendicitis pain if histological findings were negative or surgery was not performed. The diagnostic performance of the AIR score and the potential for risk stratification to reduce admissions, optimize imaging and prevent unnecessary explorations were quantified. A total of 464 patients were included, of whom 210 (63·3 per cent) with non-appendicitis pain were correctly classified as low risk. However, 13 low-risk patients had appendicitis. Low-risk patients accounted for 48·1 per cent of admissions (223 of 464), 57 per cent of negative explorations (48 of 84) and 50·7 per cent of imaging requests (149 of 294). An AIR score of 5 or more (intermediate and high risk) had high sensitivity for all severities of appendicitis (90 per cent) and also for advanced appendicitis (98 per cent). An AIR score of 9 or more (high risk) was very specific (97 per cent) for appendicitis, and the majority of patients with appendicitis in the high-risk group (21 of 30, 70 per cent) had perforation or gangrene. Ultrasound imaging could not exclude appendicitis in low-risk patients (negative likelihood ratio (LR) 1·0) but could rule-in the diagnosis in intermediate-risk patients (positive LR 10·2). CT could exclude appendicitis in low-risk patients (negative LR 0·0) and rule-in appendicitis in the intermediate group (positive LR 10·9). Risk stratification of patients with suspected appendicitis by the AIR score could

  11. 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

  12. Establishment and Application of Early Risk Stratification Method for Acute Abdominal Pain in Adults

    PubMed Central

    Wang, Yu; Zhao, Hong; Zhou, Zhen; Tian, Ci; Xiao, Hong-Li; Wang, Bao-En

    2017-01-01

    Background: Acute abdominal pain is a common symptom of emergency patients. The severity was always evaluated based on physicians’ clinical experience. The aim of this study was to establish an early risk stratification method (ERSM) for addressing adults with acute abdominal pain, which would guide physicians to take appropriate and timely measures following the established health-care policies. Methods: In Cohort 1, the records of 490 patients with acute abdominal pain that developed within the past 72 h were enrolled in this study. Measurement data and numeration data were compared with analysis of variance and Chi-square test, respectively. Multiple regression analysis calculated odd ratio (OR) value. P and OR values showed the impacts of factors. ERSM was established by clinical experts and statistical experts according to Youden index. In Cohort 2, data from 305 patients with acute abdominal pain were enrolled to validate the accuracy of the ERSM. Then, ERSM was prospectively used in clinical practice. Results: The ERSM was established based on the scores of the patient's clinical characteristics: right lower abdominal pain + 3 × diffuse abdominal pain + 3 × cutting abdominal pain + 3 × pain frequency + 3 × pain duration + fever + 2 × vomiting + 5 × stop defecation + 3 × history of abdominal surgery + hypertension history + diabetes history + hyperlipidemia history + pulse + 2 × skin yellowing + 2 × sclera yellowing + 2 × double lung rale + 10 × unconsciousness + 2 × right lower abdominal tenderness + 5 × diffuse abdominal tenderness + 4 × peritoneal irritation + 4 × bowel sounds abnormal + 10 × suspicious diagnosis + white blood cell count + hematocrit + glucose + 2 × blood urea nitrogen + 3 × creatine + 4 × serum albumin + alanine aminotransferase + total bilirubin + 3 × conjugated bilirubin + amylase. When the score was <18, the patient did not need hospitalization. A score of ≥18 and <38 indicated that the patient should be under

  13. Risk Stratification for Major Postoperative Complications in Patients Undergoing Intra-abdominal General Surgery Using Latent Class Analysis.

    PubMed

    Kim, Minjae; Wall, Melanie M; Li, Guohua

    2017-08-10

    Preoperative risk stratification is a critical element in assessing the risks and benefits of surgery. Prior work has demonstrated that intra-abdominal general surgery patients can be classified based on their comorbidities and risk factors using latent class analysis (LCA), a model-based clustering technique designed to find groups of patients that are similar with respect to characteristics entered into the model. Moreover, the latent risk classes were predictive of 30-day mortality. We evaluated the use of latent risk classes to predict the risk of major postoperative complications. An observational, retrospective cohort of patients undergoing intra-abdominal general surgery in the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program was obtained. Known preoperative comorbidity and risk factor data were entered into LCA models to identify the latent risk classes. Complications were defined as: acute kidney injury, acute respiratory failure, cardiac arrest, deep vein thrombosis, myocardial infarction, organ space infection, pneumonia, postoperative bleeding, pulmonary embolism, sepsis/septic shock, stroke, unplanned reintubation, and/or wound dehiscence. Relative risk regression determined the associations between the latent classes and the 30-day complication risks, with adjustments for the surgical procedure. The area under the curve (AUC) of the receiver operator characteristic curve assessed model performance. LCA fit a 9-class model on 466,177 observations. The composite complication risk was 18.4% but varied from 7.7% in the lowest risk class to 56.7% in the highest risk class. After adjusting for procedure, the latent risk classes were significantly associated with complications, with risk ratios (95% confidence intervals) (compared to the class with the average risk) varying from 0.56 (0.54-0.58) in the lowest risk class to 2.15 (2.11-2.20) in the highest risk class, a 4-fold difference. In models incorporating surgical

  14. Risk Stratification for Recurrence and Mortality in Embolic Stroke of Undetermined Source.

    PubMed

    Ntaios, George; Vemmos, Konstantinos; Lip, Gregory Y H; Koroboki, Eleni; Manios, Efstathios; Vemmou, Anastasia; Rodríguez-Campello, Ana; Cuadrado-Godia, Elisa; Giralt-Steinhauer, Eva; Arnao, Valentina; Caso, Valeria; Paciaroni, Maurizio; Diez-Tejedor, Exuperio; Fuentes, Blanca; Pérez Lucas, Josefa; Arauz, Antonio; Ameriso, Sebastian F; Hawkes, Maximiliano A; Pertierra, Lucía; Gómez-Schneider, Maia; Bandini, Fabio; Chavarria Cano, Beatriz; Iglesias Mohedano, Ana Maria; García Pastor, Andrés; Gil-Núñez, Antonio; Putaala, Jukka; Tatlisumak, Turgut; Barboza, Miguel A; Athanasakis, George; Makaritsis, Konstantinos; Papavasileiou, Vasileios

    2016-09-01

    The risk of stroke recurrence in patients with Embolic Stroke of Undetermined Source (ESUS) is high, and the optimal antithrombotic strategy for secondary prevention is unclear. We investigated whether congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or transient ischemic attack (TIA; CHADS2) and CHA2DS2-VASc scores can stratify the long-term risk of ischemic stroke/TIA recurrence and death in ESUS. We pooled data sets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. Cox regression analyses were performed to investigate if prestroke CHADS2 and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or TIA, vascular disease, age 65-74 years, sex category (CHA2DS2-VASc) scores were independently associated with the risk of ischemic stroke/TIA recurrence or death. The Kaplan-Meier product limit method was used to estimate the cumulative probability of ischemic stroke/TIA recurrence and death in different strata of the CHADS2 and CHA2DS2-VASc scores. One hundred fifty-nine (5.6% per year) ischemic stroke/TIA recurrences and 148 (5.2% per year) deaths occurred in 1095 patients (median age, 68 years) followed-up for a median of 31 months. Compared with CHADS2 score 0, patients with CHADS2 score 1 and CHADS2 score >1 had higher risk of ischemic stroke/TIA recurrence (hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.41-4.00 and HR, 2.72; 95% CI, 1.68-4.40, respectively) and death (HR, 3.58; 95% CI, 1.80-7.12, and HR, 5.45; 95% CI, 2.86-10.40, respectively). Compared with low-risk CHA2DS2-VASc score, patients with high-risk CHA2DS2-VASc score had higher risk of ischemic stroke/TIA recurrence (HR, 3.35; 95% CI, 1.94-5.80) and death (HR, 13.0; 95% CI, 4.7-35.4). The risk of recurrent ischemic stroke/TIA and death in ESUS is reliably stratified by CHADS2 and CHA2DS2-VASc scores. Compared with the low-risk group

  15. Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies.

    PubMed

    Bourque, Jamieson M; Beller, George A

    2015-11-01

    Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness.

  16. Risk stratification for invasive fungal infections in patients with hematological malignancies: SEIFEM recommendations.

    PubMed

    Pagano, Livio; Busca, Alessandro; Candoni, Anna; Cattaneo, Chiara; Cesaro, Simone; Fanci, Rosa; Nadali, Gianpaolo; Potenza, Leonardo; Russo, Domenico; Tumbarello, Mario; Nosari, Annamaria; Aversa, Franco

    2017-03-01

    Invasive fungal infections (IFIs) are an important cause of morbidity and mortality in immunocompromised patients. Patients with hematological malignancies undergoing conventional chemotherapy, autologous or allogeneic hematopoietic stem cell transplantation are considered at high risk, and Aspergillus spp. represents the most frequently isolated micro-organisms. In the last years, attention has also been focused on other rare molds (e.g., Zygomycetes, Fusarium spp.) responsible for devastating clinical manifestations. The extensive use of antifungal prophylaxis has reduced the infections from yeasts (e.g., candidemia) even though they are still associated with high mortality rates. This paper analyzes concurrent multiple predisposing factors that could favor the onset of fungal infections. Although neutropenia is common to almost all hematologic patients, other factors play a key role in specific patients, in particular in patients with AML or allogeneic HSCT recipients. Defining those patients at higher risk of IFIs may help to design the most appropriate diagnostic work-up and antifungal strategy.

  17. The Role of Cardiac MRI in the Diagnosis and Risk Stratification of Hypertrophic Cardiomyopathy

    PubMed Central

    Maron, Martin S

    2016-01-01

    Hypertrophic cardiomyopathy (HCM), the most common genetic cardiomyopathy, is a disease characterised by substantial heterogeneity. Although the majority of patients with HCM remain asymptomatic with near-normal longevity, a small, but important, subset remain at risk for a wide range of clinical outcomes including sudden death. Cardiovascular magnetic resonance (CMR), with its high spatial resolution and tomographic imaging capability, has emerged as an imaging modality particularly well suited to characterise the phenotypic expression of HCM. CMR helps in the diagnosis of HCM by identifying areas of hypertrophy not well visualised by echocardiography, providing more accurate wall thickness measurements and differentiating HCM from other causes of left ventricular (LV) hypertrophy. CMR has led to the identification of novel subgroups of patients with HCM, including those with LV apical aneurysms (a subgroup at increased risk for ventricular arrhythmias and thromboembolic stroke), as well as abnormalities that contribute to LV outflow obstruction. Additionally, contrast-enhanced CMR with late-gadolinium enhancement (LGE) has recognised patients with extensive LGE (≥15 % LV myocardium) as individuals who may be at increased risk of sudden death, independent of other high-risk features, with implications on management strategies including consideration for primary prevention implantable cardioverter defibrillator therapy. These observations justify an expanded role of CMR in the routine clinical assessment of patients with HCM. PMID:28116085

  18. Impact of hypertension on global cardiovascular risk stratification: analysis of a large cohort of outpatient population in Italy.

    PubMed

    Tocci, Giuliano; Battistoni, Allegra; D'Agostino, Michela; Palano, Francesca; Passerini, Jasmine; Francia, Pietro; Ferrucci, Andrea; Volpe, Massimo

    2015-01-01

    Control of hypertension remains a major unmet need, worldwide. To test whether the presence of hypertension may improve global cardiovascular (CV) risk stratification and achievement of therapeutic targets for CV risk factors in adult outpatients in Italy. Physicians were asked to submit data covering the first 10 consecutive adult outpatients. All data were centrally analyzed for global CV risk assessment and rates of control of major CV risk factors, mostly blood pressure (BP) levels, in different high-risk subgroups of hypertensive patients. Overall, 1078 physicians collected data of 9864 outpatients (46.7% females, age 66.1 ± 10.3 years) with valuable data on BP levels, among which 7147 (72.5%) had a diagnosis of hypertension and 2717 (27.5%) were normotensive subjects. Hypertensive patients were older and had a higher prevalence of major risk factors, including smoking, obesity, dyslipidemia, and family history of cardiovascular disease, as well as comorbidities, than did normotensive subjects (P < 0.001 for all comparisons). Despite worse control of BP (66.9% vs 36.2%, P < 0.001), high-density lipoprotein cholesterol (40.5% vs 37.4%, P < 0.005), triglycerides (72.1% vs 67.8%, P < 0.001), and fasting plasma glucose (71.2% vs 67.0%, P < 0.005), hypertension was associated with larger availability and frequency of diagnostic examinations and greater use of antihypertensive, glucose-lowering, and lipid-lowering drugs, as well as antiplatelet agents, compared with normotension (P < 0.001). Presence of hypertension significantly improved clinical data collection and CV risk stratification. Such an approach, however, was not paralleled by better control of major CV risk factors. © 2015 Wiley Periodicals, Inc.

  19. Negative predictive Value of Dobutamine Stress Echocardiography for Perioperative Risk Stratification in Patients with Cardiac Risk Factors and Reduced Exercise Capacity undergoing Non-cardiac Surgery.

    PubMed

    Go, Gus; Davies, Kathy T; O'Callaghan, Cara; Senior, Wendy; Kostner, Karam; Fagermo, Narelle; Prasad, Sandhir B

    2017-10-02

    Guidelines recommend functional testing for myocardial ischaemia in the perioperative setting in patients with >1 recognised cardiac risk factors and self-reported reduced exercise capacity. We sought to determine the clinical utility of dobutamine stress echocardiography (DSE) for perioperative risk stratification in patients undergoing major noncardiac surgery. Data on 79 consecutive patients undergoing DSE for perioperative risk stratification at a single centre was retrospectively reviewed to determine rates of Major Adverse Cardiac Events (MACE) during the index hospitalisation and 30 days post discharge. Echocardiography and outcomes data were obtained via folder audit and echolab database. Out of the 79 DSEs performed for perioperative risk stratification, 11(14%) were positive (DSE+ve) and 68(86%) were negative (DSE-ve). Management in the DSE+ve group included medical optimisation without invasive intervention [n=7(64%)], diagnostic coronary angiography [n=3(27%)], and coronary artery bypass graft [n=1(9%)]. None of the patients underwent percutaneous coronary intervention pre-operatively. Perioperative MACE in the DSE+ve group was 36% compared to 4% in the DSE-ve group (p=0.006). DSE+ve was a powerful predictor of perioperative inpatient MACE (OR 12.4, 95% CI 2.3-67, p=0.003). The positive predictive value of DSE+ve status was 36%, whist the negative predictive value of DSE-ve status for perioperative MACE was 96%. DSE for perioperative risk stratification had a high clinical utility in patients undergoing major noncardiac surgery. In particular, a normal DSE had a high negative predictive value for perioperative MACE. This article is protected by copyright. All rights reserved.

  20. Predictors of biochemical failure in patients undergoing prostate whole-gland salvage cryotherapy: a novel risk stratification model.

    PubMed

    Spiess, Philippe E; Levy, David A; Mouraviev, Vladimir; Pisters, Louis L; Jones, J Stephen

    2013-08-01

    What's known on the subject? and what does the study add?: Previous studies have identified the most important prognostic factors of the likely outcomes of salvage prostate whole-gland ablation, including initial clinical stage, biopsy Gleason score, and PSA (total and doubling time). There is potential for further optimization of candidate selection for salvage cryoablation with curative intent and nadir PSA achieved after whole-gland cryotherapy may provide additional prognostic value. The study shows that the most important prognostic factors of biochemical progression-free survival for patients who have undergone whole-gland salvage prostate cryotherapy are nadir PSA achieved after therapy and pre-therapy biopsy Gleason score. Based on these two prognostic variables, we have identified risk stratification groups (low, intermediate and high) which help predict the expected outcomes of salvage whole-gland prostate cryotherapy in a given patient. This risk stratification constitutes a useful clinical tool in defining which patients maybe best suited for this local salvage treatment method. To assess the prognostic variables predicting the risk of biochemical progression-free survival (bPFS) after salvage prostate whole-gland cryotherapy using the Phoenix definition of bPFS. A total of 132 patients underwent prostate whole-gland salvage cryotherapy with curative intent. No patient underwent neoadjuvant/adjuvant hormonal ablative therapy, and all had extended post-salvage prostate-specific antigen (PSA) follow-up data. Cox univariate and multivariate logistic regression analyses of potential predictors of bPFS were conducted. Kaplan-Meier analyses of bPFS was also performed. At a mean (range) follow-up of 4.3 (0.9-12.7) years, the median (range) post-cryotherapy nadir PSA achieved was 0.17 (0-33.9) ng/mL. On multivariate analysis, predictors of bPFS were nadir PSA post-cryotherapy and pre-salvage biopsy Gleason score (P < 0.001 and 0.009, respectively). Risk

  1. Can human papillomavirus (HPV) genotyping classify non-16/18 high-risk HPV infection by risk stratification?

    PubMed

    Sung, Yeoun Eun; Ki, Eun Young; Lee, Youn Soo; Hur, Soo Young; Lee, Ahwon; Park, Jong Sup

    2016-11-01

    Infection with high-risk genotypes of human papillomavirus (HR-HPV) is the major cause of invasive cervical cancers. HPV-16 and HPV-18 are known to be responsible for two-thirds of all invasive cervical carcinomas, followed by HPV-45, -31, and -33. Current guidelines only differentiate HPV-16/18 (+) by recommending direct colposcopy for treatment. We tried to evaluate whether there are differences in risk among 12 non-16/18 HR-HPV genotypes in this study. The pathology archive database records of 1,102 consecutive gynecologic patients, who had results for cervical cytology and histology and for HPV testing, as determined by HPV 9G DNA chip, were reviewed. Among the 1,102 patients, 346 were non-16/18 HR-HPV (+) and 231 were HPV-16/18 (+). We calculated the odds ratios for ≥cervical intraepithelial neoplasia 2 (CIN 2) of 14 groups of each HR-HPV genotype compared with a group of HR-HPV (-) patients. Based on the odds ratio of each genotype, we divided patients with non-16/18 HR-HPV genotypes (+) into two groups: HPV-31/33/35/45/52/58 (+) and HPV-39/51/56/59/66/68 (+). The age-adjusted odds ratios for ≥CIN 2 of the HPV-31/33/35/45/52/58 (+) and HPV-39/51/56/59/66/68 (+) groups compared with a HR-HPV (-) group were 11.9 (95% CI, 7.6 to 18.8; p<0.001) and 2.4 (95% CI, 1.4 to 4.3; p<0.001), respectively, while that of the HPV-16/18 (+) group was 18.1 (95% CI, 11.6 to 28.3; p=0.003). The 12 non-16/18 HR-HPV genotypes can be further categorized (HPV-31/33/35/45/52/58 vs. HPV-39/51/56/59/66/68) by risk stratification. The HPV-31/33/35/45/52/58 genotypes might need more aggressive action. Large scale clinical trials or cohort studies are necessary to confirm our suggestion.

  2. The role of non-HDL cholesterol in risk stratification for coronary artery disease.

    PubMed

    Rana, Jamal S; Boekholdt, S Matthijs; Kastelein, John J P; Shah, Prediman K

    2012-04-01

    Despite aggressive lipid-lowering therapy, patients continue to be at significant risk of coronary heart disease (CHD). Assessment of non-high-density lipoprotein cholesterol (non-HDL-C) provides a measure of cholesterol contained in all atherogenic particles. In the third Adult Treatment Panel (ATP III) guidelines of the US National Cholesterol Education Program, non-HDL-C was introduced as a secondary target of therapy in persons with triglycerides ≥200 mg/dL. A recent meta-analysis of the relationship between non-HDL-C reduction and CHD risk showed non-HDL-C as an important target of therapy for CHD prevention. Most lipid-modifying drugs used as monotherapy have a 1:1 relationship between percent non-HDL-C lowering and percent CHD reduction. In the EPIC-Norfolk prospective population study, 21,448 participants without diabetes or CHD between 45 and 79 years of age were followed for 11.0 years. Participants with high non-HDL-C levels were at increased CHD risk independently of their LDL-C levels. Also, compared to apolipoprotein B, non-HDL-C appears to be a better choice given the fact that no additional tests or costs are needed and established cut points are already available. Future guidelines should emphasize the importance of non-HDL-C for guiding cardiovascular prevention strategies with an increased need to have non-HDL-C reported on routine lipid panels.

  3. Presepsin (sCD14-ST) Is a Novel Marker for Risk Stratification in Cardiac Surgery Patients.

    PubMed

    Bomberg, Hagen; Klingele, Matthias; Wagenpfeil, Stefan; Spanuth, Eberhard; Volk, Thomas; Sessler, Daniel I; Schäfers, Hans-Joachim; Groesdonk, Heinrich Volker

    2017-04-01

    Presepsin (soluble cluster-of-differentiation 14 subtype [sCD14-ST]) is a humoral risk stratification marker for systemic inflammatory response syndrome and sepsis. It remains unknown whether presepsin can be used to stratify risk in elective cardiac surgery. The authors therefore determined the usefulness of presepsin for risk stratification in patients having elective cardiac surgery. Eight hundred fifty-six cardiac surgical patients were prospectively studied. Preoperative plasma concentrations of presepsin, procalcitonin, N-terminal pro-hormone natriuretic peptide, cystatin C, and the additive European System of Cardiac Operative Risk Evaluation 2 were compared to mortality at 30 days (primary outcome), 6 months, and 2 yr. Discrimination was assessed with C statistic. Logistic regression analysis was used to calculate univariable and multivariable odds ratios. Thirty-day mortality was 3.2%, 6-month mortality was 6.1%, and 2-yr mortality was 10.4% across the population. Median preoperative presepsin concentrations were significantly greater in 30-day nonsurvivors than in survivors: 842 pg/ml (interquartile range, 306 to 1,246) versus 160 pg/ml (interquartile range, 122 to 234); difference, 167 pg/ml (interquartile range, 92 to 301; P < 0.001). The results were similar for 6-month and 2-yr mortality. Compared to the European System of Cardiac Operative Risk Evaluation 2, presepsin concentration provided better discrimination for postoperative mortality at all follow-up periods, including 30 days (C statistic 0.88 vs. 0.74), 6 months (0.87 vs. 0.76), and 2 yr (0.81 vs. 0.74). Presepsin also provided better discrimination than cystatin C, N-terminal pro-hormone natriuretic peptide, or procalcitonin. Elevated presepsin remained an independent risk predictor after adjustment for potential confounding factors. Elevated preoperative plasma presepsin concentration is an independent predictor of postoperative mortality in elective cardiac surgery patients and is a

  4. Integration of a postoperative calcitonin measurement into an anatomical staging system improves initial risk stratification in medullary thyroid cancer.

    PubMed

    Yang, Ji H; Lindsey, Susan C; Camacho, Cléber P; Valente, Flávia O F; Germano-Neto, Fausto; Machado, Alberto L; Mamone, Maria Conceição O C; Brodskyn, Fábio; Biscolla, Rosa Paula M; Tuttle, Robert Michael; Dias-da-Silva, Magnus R; Maciel, Rui M B

    2015-12-01

    Staging systems applied to medullary thyroid cancer (MTC) rely on initial clinical and pathological features and do not consider the response to treatment. To determine whether MTC staging can be improved by incorporating the first postoperative calcitonin measurement. Eighty-five patients being monitored for MTC (median follow-up 5 years) were retrospectively classified according to both the American Joint Committee on Cancer (AJCC) and the proposed combined risk stratification system (low, intermediate and high risk), which incorporates the first postoperative calcitonin measurement, using the outcomes no evidence of disease (NED), biochemical evidence of disease, structurally identifiable disease and death. Ninety per cent of AJCC I patients were classified as NED at final follow-up. When we added a postoperative calcitonin measurement, 95% low-risk patients were classified as NED at final follow-up. AJCC stages I and IV were associated, respectively, with no occurrence and a high rate (63%) of structurally identifiable disease. Stages II and III yielded similar predictions of structurally identifiable disease, 13% and 14%, respectively. When we included the postoperative calcitonin level, the patients with structural evidence of disease included none from the low-risk group, 10% from the intermediate group and 63% from the high-risk group. The proportion of variance explained analysis (PVE) was better for the combined risk stratification system (54%) than for the AJCC system alone (32%). Including the first postoperative calcitonin measurement with the anatomical staging system can better predict the clinical outcome of patients with MTC and refine the follow-up of these patients. © 2014 John Wiley & Sons Ltd.

  5. Improved Risk Stratification in Pediatric Septic Shock Using Both Protein and mRNA Biomarkers. PERSEVERE-XP.

    PubMed

    Wong, Hector R; Cvijanovich, Natalie Z; Anas, Nick; Allen, Geoffrey L; Thomas, Neal J; Bigham, Michael T; Weiss, Scott L; Fitzgerald, Julie C; Checchia, Paul A; Meyer, Keith; Quasney, Michael; Hall, Mark; Gedeit, Rainer; Freishtat, Robert J; Nowak, Jeffrey; Raj, Shekhar S; Gertz, Shira; Grunwell, Jocelyn R; Lindsell, Christopher J

    2017-08-15

    We previously derived and validated the Pediatric Sepsis Biomarker Risk Model (PERSEVERE) to estimate baseline mortality risk in children with septic shock. The PERSEVERE biomarkers are serum proteins selected from among the proteins directly related to 80 mortality risk assessment genes. The initial approach to selecting the PERSEVERE biomarkers left 68 genes unconsidered. To determine if the 68 previously unconsidered genes can improve upon the performance of PERSEVERE and to provide biological information regarding the pathophysiology of septic shock. We reduced the number of variables by determining the biological linkage of the 68 previously unconsidered genes. The genes identified through variable reduction were combined with the PERSEVERE-based mortality probability to derive a risk stratification model for 28-day mortality using classification and regression tree methodology (n = 307). The derived tree, PERSEVERE-XP, was then tested in a separate cohort (n = 77). Variable reduction revealed a network consisting of 18 mortality risk assessment genes related to tumor protein 53 (TP53). In the derivation cohort, PERSEVERE-XP had an area under the receiver operating characteristic curve (AUC) of 0.90 (95% confidence interval, 0.85-0.95) for differentiating between survivors and nonsurvivors. In the test cohort, the AUC was 0.96 (95% confidence interval, 0.91-1.0). The AUC of PERSEVERE-XP was superior to that of PERSEVERE. PERSEVERE-XP combines protein and mRNA biomarkers to provide mortality risk stratification with possible clinical utility. PERSEVERE-XP significantly improves on PERSEVERE and suggests a role for TP53-related cellular division, repair, and metabolism in the pathophysiology of septic shock.

  6. A perspective on the range of gasoline compression ignition combustion strategies for high engine efficiency and low NOx and soot emissions: Effects of in-cylinder fuel stratification

    DOE PAGES

    Dempsey, Adam B.; Curran, Scott J.; Wagner, Robert M.

    2016-01-14

    Many research studies have shown that low temperature combustion in compression ignition engines has the ability to yield ultra-low NOx and soot emissions while maintaining high thermal efficiency. To achieve low temperature combustion, sufficient mixing time between the fuel and air in a globally dilute environment is required, thereby avoiding fuel-rich regions and reducing peak combustion temperatures, which significantly reduces soot and NOx formation, respectively. It has been demonstrated that achieving low temperature combustion with diesel fuel over a wide range of conditions is difficult because of its properties, namely, low volatility and high chemical reactivity. On the contrary, gasolinemore » has a high volatility and low chemical reactivity, meaning it is easier to achieve the amount of premixing time required prior to autoignition to achieve low temperature combustion. In order to achieve low temperature combustion while meeting other constraints, such as low pressure rise rates and maintaining control over the timing of combustion, in-cylinder fuel stratification has been widely investigated for gasoline low temperature combustion engines. The level of fuel stratification is, in reality, a continuum ranging from fully premixed (i.e. homogeneous charge of fuel and air) to heavily stratified, heterogeneous operation, such as diesel combustion. However, to illustrate the impact of fuel stratification on gasoline compression ignition, the authors have identified three representative operating strategies: partial, moderate, and heavy fuel stratification. Thus, this article provides an overview and perspective of the current research efforts to develop engine operating strategies for achieving gasoline low temperature combustion in a compression ignition engine via fuel stratification. In this paper, computational fluid dynamics modeling of the in-cylinder processes during the closed valve portion of the cycle was used to illustrate the opportunities

  7. A perspective on the range of gasoline compression ignition combustion strategies for high engine efficiency and low NOx and soot emissions: Effects of in-cylinder fuel stratification

    SciTech Connect

    Dempsey, Adam B.; Curran, Scott J.; Wagner, Robert M.

    2016-01-14

    Many research studies have shown that low temperature combustion in compression ignition engines has the ability to yield ultra-low NOx and soot emissions while maintaining high thermal efficiency. To achieve low temperature combustion, sufficient mixing time between the fuel and air in a globally dilute environment is required, thereby avoiding fuel-rich regions and reducing peak combustion temperatures, which significantly reduces soot and NOx formation, respectively. It has been demonstrated that achieving low temperature combustion with diesel fuel over a wide range of conditions is difficult because of its properties, namely, low volatility and high chemical reactivity. On the contrary, gasoline has a high volatility and low chemical reactivity, meaning it is easier to achieve the amount of premixing time required prior to autoignition to achieve low temperature combustion. In order to achieve low temperature combustion while meeting other constraints, such as low pressure rise rates and maintaining control over the timing of combustion, in-cylinder fuel stratification has been widely investigated for gasoline low temperature combustion engines. The level of fuel stratification is, in reality, a continuum ranging from fully premixed (i.e. homogeneous charge of fuel and air) to heavily stratified, heterogeneous operation, such as diesel combustion. However, to illustrate the impact of fuel stratification on gasoline compression ignition, the authors have identified three representative operating strategies: partial, moderate, and heavy fuel stratification. Thus, this article provides an overview and perspective of the current research efforts to develop engine operating strategies for achieving gasoline low temperature combustion in a compression ignition engine via fuel stratification. In this paper, computational fluid dynamics modeling of the in-cylinder processes during the closed valve portion of the cycle was used to illustrate the opportunities and

  8. External validation of the ProACS score for risk stratification of patients with acute coronary syndromes.

    PubMed

    Timóteo, Ana Teresa; Aguiar Rosa, Sílvia; Nogueira, Marta Afonso; Belo, Adriana; Cruz Ferreira, Rui

    2016-06-01

    The ProACS risk score is an early and simple risk stratification score developed for all-cause in-hospital mortality in acute coronary syndromes (ACS) from a Portuguese nationwide ACS registry. Our center only recently participated in the registry and was not included in the cohort used for developing the score. Our objective was to perform an external validation of this risk score for short- and long-term follow-up. Consecutive patients admitted to our center with ACS were included. Demographic and admission characteristics, as well as treatment and outcome data were collected. The ProACS risk score variables are age (≥72 years), systolic blood pressure (≤116 mmHg), Killip class (2/3 or 4) and ST-segment elevation. We calculated ProACS, Global Registry of Acute Coronary Events (GRACE) and Canada Acute Coronary Syndrome risk score (C-ACS) risk scores for each patient. A total of 3170 patients were included, with a mean age of 64±13 years, 62% with ST-segment elevation myocardial infarction. All-cause in-hospital mortality was 5.7% and 10.3% at one-year follow-up. The ProACS risk score showed good discriminative ability for all considered outcomes (area under the receiver operating characteristic curve >0.75) and a good fit, similar to C-ACS, but lower than the GRACE risk score and slightly lower than in the original development cohort. The ProACS risk score provided good differentiation between patients at low, intermediate and high mortality risk in both short- and long-term follow-up (p<0.001 for all comparisons). The ProACS score is valid in external cohorts for risk stratification for ACS. It can be applied very early, at the first medical contact, but should subsequently be complemented by the GRACE risk score. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

  9. Diagnostic evaluation of people with hypertension in low income country: cohort study of “essential” method of risk stratification

    PubMed Central

    Montalvo, Gregorio; Anselmi, Mariella; Prandi, Rosanna; Ibarra, Samuel; Marquez, Monica; Armani, Daniela; Moreira, Juan-Martín; Caicedo, Cynthia; Roncaglioni, Maria Carla; Colombo, Fabio; Camisasca, Paola; Milani, Valentina; Quimì, Simon; Gonzabay, Felix; Tognoni, Gianni

    2008-01-01

    Objectives To explore the predictive power of a risk stratification method for people with hypertension based on “essential” procedures (that is, available in economically less developed areas of the world), comparing it in the same population with the results given by the method suggested by the 1999 World Health Organization-International Society of Hypertension (WHO-ISH) guidelines. Design Prospective cohort study of outcomes according to cardiovascular risk profile at baseline. Setting Primary care in a poor rural area of the Ecuadorian forest. Participants 504 people with hypertension prospectively monitored for a mean of 6.7 (SD 2.3) years. Interventions Essential data included blood pressure, medical history, smoking, age, sex, and diagnosis of diabetes; the WHO-ISH methods additionally included measurement of fasting blood glucose, total cholesterol, and creatinine, urinalysis, and electrocardiography. Main outcome measures Cardiovascular events and total deaths. Results With both methods there was a highly significant association between the level of predicted risk and the incidence of cardiovascular events and of total deaths: up to three quarters of all cardiovascular events and two thirds of all deaths were reported among people classified as at high or very high risk with either method. The predictive discrimination of the essential method is comparable with the WHO-ISH with C statistics (95% confidence interval) of 0.788 (0.721 to 0.855) and 0.744 (0.673 to 0.815), respectively, for cardiovascular events and 0.747 (0.678 to 0.816) and 0.705 (0.632 to 0.778) for total mortality. Conclusions The risk stratification of patients with hypertension with an essential package of variables (that is, available and practicable even in the economically less developed areas of the world) serves at least as well as the more comprehensive method proposed by WHO-ISH. PMID:18805835

  10. Cardiovascular Risk Stratification in Patients with Metabolic Syndrome Without Diabetes or Cardiovascular Disease: Usefulness of Metabolic Syndrome Severity Score.

    PubMed

    Masson, Walter; Epstein, Teo; Huerín, Melina; Lobo, Lorenzo Martín; Molinero, Graciela; Angel, Adriana; Masson, Gerardo; Millán, Diana; De Francesca, Salvador; Vitagliano, Laura; Cafferata, Alberto; Losada, Pablo

    2017-05-13

    The estimated cardiovascular risk determined by the different risk scores, could be heterogeneous in patients with metabolic syndrome without diabetes or vascular disease. This risk stratification could be improved by detecting subclinical carotid atheromatosis. To estimate the cardiovascular risk measured by different scores in patients with metabolic syndrome and analyze its association with the presence of carotid plaque. Non-diabetic patients with metabolic syndrome (Adult Treatment Panel III definition) without cardiovascular disease were enrolled. The Framingham score, the Reynolds score, the new score proposed by the 2013 ACC/AHA Guidelines and the Metabolic Syndrome Severity Calculator were calculated. Prevalence of carotid plaque was determined by ultrasound examination. A Receiver Operating Characteristic analysis was performed. A total of 238 patients were enrolled. Most patients were stratified as "low risk" by Framingham score (64%) and Reynolds score (70.1%). Using the 2013 ACC/AHA score, 45.3% of the population had a risk ≥7.5%. A significant correlation was found between classic scores but the agreement (concordance) was moderate. The correlation between classical scores and the Metabolic Syndrome Severity Calculator was poor. Overall, the prevalence of carotid plaque was 28.2%. The continuous metabolic syndrome score used in our study showed a good predictive power to detect carotid plaque (area under the curve 0.752). In this population, the calculated cardiovascular risk was heterogenic. The prevalence of carotid plaque was high. The Metabolic Syndrome Severity Calculator showed a good predictive power to detect carotid plaque.

  11. Risk stratification, treatment selection, and transplant eligibility in multiple myeloma: a qualitative study of the perspectives and self-reported practices of oncologists

    PubMed Central

    LeBlanc, T.W.; Howson, A.; Turell, W.; Sheldon, P.; Locke, S.C.; Tuchman, S.A.; Gasparetto, C.; Kaura, S.; Khan, Z.M.; Abernethy, A.P.

    2016-01-01

    Background Since the early 2000s, treatment options for multiple myeloma have rapidly expanded, adding significant complexity to the management of this disease. To our knowledge, no systematic qualitative research on clinical decision-making in multiple myeloma has been published. We sought to characterize how physicians view and implement guidelines and incorporate novel approaches into patient care. Methods We designed a semi-structured qualitative interview guide informed by literature review and an expert advisory panel. We conducted 60-minute interviews with a diverse sample of oncology physicians in the southeast United States. We used a constant comparative method to code and analyze interview transcripts. The research team and advisory panel discussed and validated emergent themes. Results Participants were 13 oncologists representing 5 academic and 4 community practices. Academic physicians reported using formal risk-stratification schemas; community physicians typically did not. Physicians also described differences in eligibility criteria for transplantation; community physicians emphasized distance, social support, and psychosocial capacity in making decisions about transplantation referral; the academic physicians reported using more specific clinical criteria. All physicians reported using a maintenance strategy both for post-transplant and for transplant-ineligible patients; however, determining the timing of maintenance therapy initiation and the response were reported as challenging, as was recognition or definition of relapse, especially in terms of when treatment re-initiation is indicated. Conclusions Practices reported by both academic and community physicians suggest opportunities for interventions to improve patient care and outcomes through optimal multiple myeloma management and therapy selection. Community physicians in particular might benefit from targeted education interventions about risk stratification, transplant eligibility, and

  12. Mortality after inpatient open ventral hernia repair: developing a risk stratification tool based on 55,760 operations.

    PubMed

    Basta, Marten N; Fischer, John P; Wink, Jason D; Kovach, Stephen J

    2016-06-01

    The medical complexity of hernia patients imparts higher risk for complications, and mortality is a distinct reality. No study has stratified patients based on preoperative risk for open ventral hernia repair (VHR) specifically. We utilized the American College of Surgeons National Surgical Quality Improvement Program to create a mortality risk stratification model following VHR. Patients undergoing open VHR were identified from American College of Surgeons National Surgical Quality Improvement Program databases. Baseline variables correlated with mortality risk were entered into stepwise regression and bootstrap analysis. β-Coefficients were used to weigh each factor, yielding the risk assessment tool. A total of 55,760 patients were included with a mortality of 1.34%. Predictors of mortality included the following: functional status (odds ratio [OR] = 2.87), liver disease (OR = 3.61), malnutrition (OR = 1.43), age greater than 65 years (OR = 2.39), American Society of Anesthesiologists 4 or higher (OR = 2.90), systemic inflammation (OR = 1.99), and contamination (OR = 2.15). Patients were risk stratified into low risk (mortality .33%), moderate risk (mortality 1.86%), high risk (mortality 8.76%), and extreme risk groups (mortality 34.2%). Unplanned reoperations and medical complications increased across risk groups. The model demonstrated high discriminatory ability with a C-statistic value of .86. This study provides an accurate model to predict mortality risk specific to open VHR. The strongest predictors were American Society of Anesthesiologists, liver disease, functional status, and older age. This tool may inform clinical decision making to reduce complications. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. 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.

  14. Risk Assessment and Integration Team (RAIT) Portfolio Risk Analysis Strategy

    NASA Technical Reports Server (NTRS)

    Edwards, Michelle

    2010-01-01

    Impact at management level: Qualitative assessment of risk criticality in conjunction with risk consequence, likelihood, and severity enable development of an "investment policy" towards managing a portfolio of risks. Impact at research level: Quantitative risk assessments enable researchers to develop risk mitigation strategies with meaningful risk reduction results. Quantitative assessment approach provides useful risk mitigation information.

  15. Competing event risk stratification may improve the design and efficiency of clinical trials: Secondary analysis of SWOG 8794

    PubMed Central

    Zakeri, Kaveh; Rose, Brent S.; Gulaya, Sachin; D'Amico, Anthony V.; Mell, Loren K.

    2012-01-01

    Background Composite endpoints can be problematic in the presence of competing risks when a treatment does not affect events comprising the endpoint equally. Methods We conducted secondary analysis of SWOG 8794 trial of adjuvant radiation therapy (RT) for high-risk post-operative prostate cancer. The primary outcome was metastasis-free survival (MFS), defined as time to first occurrence of metastasis or death from any cause (competing mortality (CM)). We developed separate risk scores for time to metastasis and CM using competing risks regression. We estimated treatment effects using Cox models adjusted for risk scores and identified an enriched subgroup of 75 patients at high risk of metastasis and low risk of CM. Results The mean CM risk score was significantly lower in the RT arm vs. control arm (p=0.001). The effect of RT on MFS (HR 0.70; 95% CI, 0.53–0.92; p=0.010) was attenuated when controlling for metastasis and CM risk (HR 0.76; 95% CI, 0.58–1.00; p=0.049), and the effect of RT on overall survival (HR 0.73; 95% CI, 0.55–0.96; p=0.02) was no longer significant when controlling for metastasis and CM risk (HR 0.80; 95% CI, 0.60–1.06; p=0.12). Compared to the whole sample, the enriched subgroup had the same 10-year incidence of MFS (40%; 95% CI, 22–57%), but a higher incidence of metastasis (30% (95% CI, 15–47%) vs. 20% (95% CI, 15–26%)). A randomized trial in the subgroup would have achieved 80% power with 56% less patients (313 vs. 709, respectively). Conclusion Stratification on competing event risk may improve the efficiency of clinical trials. PMID:23063467

  16. Competing event risk stratification may improve the design and efficiency of clinical trials: secondary analysis of SWOG 8794.

    PubMed

    Zakeri, Kaveh; Rose, Brent S; Gulaya, Sachin; D'Amico, Anthony V; Mell, Loren K

    2013-01-01

    Composite endpoints can be problematic in the presence of competing risks when a treatment does not affect events comprising the endpoint equally. We conducted secondary analysis of SWOG 8794 trial of adjuvant radiation therapy (RT) for high-risk post-operative prostate cancer. The primary outcome was metastasis-free survival (MFS), defined as time to first occurrence of metastasis or death from any cause (competing mortality (CM)). We developed separate risk scores for time to metastasis and CM using competing risks regression. We estimated treatment effects using Cox models adjusted for risk scores and identified an enriched subgroup of 75 patients at high risk of metastasis and low risk of CM. The mean CM risk score was significantly lower in the RT arm vs. control arm (p=0.001). The effect of RT on MFS (HR 0.70; 95% CI, 0.53-0.92; p=0.010) was attenuated when controlling for metastasis and CM risk (HR 0.76; 95% CI, 0.58-1.00; p=0.049), and the effect of RT on overall survival (HR 0.73; 95% CI, 0.55-0.96; p=0.02) was no longer significant when controlling for metastasis and CM risk (HR 0.80; 95% CI, 0.60-1.06; p=0.12). Compared to the whole sample, the enriched subgroup had the same 10-year incidence of MFS (40%; 95% CI, 22-57%), but a higher incidence of metastasis (30% (95% CI, 15-47%) vs. 20% (95% CI, 15-26%)). A randomized trial in the subgroup would have achieved 80% power with 56% less patients (313 vs. 709, respectively). Stratification on competing event risk may improve the efficiency of clinical trials. Copyright © 2012 Elsevier Inc. All rights reserved.

  17. Stratification systems as prognostic tools for defining risk of lymph node metastasis in penile squamous cell carcinomas.

    PubMed

    Chaux, Alcides; Cubilla, Antonio L

    2012-05-01

    Inguinal lymph node metastasis is the single most important factor for predicting survival in patients with penile squamous cell carcinomas. To estimate the likelihood of this event, investigators have combined pathologic features of the primary tumor in the form of stratification systems. In this article we review 3 such systems (Solsona et al, J Urol 2001;165:1506; Hungerhuber et al, Urology 68:621, 2006; and Chaux et al, Am J Surg Pathol 2009;33:1049) built upon histologic grade, extent and depth of tumor invasion, and perineural invasion. We evaluate their usefulness, limitations, and possible implications for the management of patients with penile cancer. We also provide clues for the proper identification and interpretation of these pathologic features. Inguinal metastases were observed in 64% to 83% of patients in high-risk groups, 20% to 33% of intermediate groups, and 0% to 8% of low-risk groups. The results of these studies suggest that patients in high-risk groups could benefit from prophylactic bilateral groin dissection. In addition, patients in low-risk groups might be managed by surveillance alone. Finally, the authors suggest that additional approaches, such as sentinel lymph node biopsy, should be used for the intermediate-risk group. The identification of other pathologic features, such as vascular and perineural invasion, could tip the scales in problematic or paradoxical cases. The fate of these risk groups would be better defined by the identification of molecular biomarkers and genetic profiling.

  18. Comparing Population-based Risk-stratification Model Performance Using Demographic, Diagnosis and Medication Data Extracted From Outpatient Electronic Health Records Versus Administrative Claims.

    PubMed

    Kharrazi, Hadi; Chi, Winnie; Chang, Hsien-Yen; Richards, Thomas M; Gallagher, Jason M; Knudson, Susan M; Weiner, Jonathan P

    2017-08-01

    There is an increasing demand for electronic health record (EHR)-based risk stratification and predictive modeling tools at the population level. This trend is partly due to increased value-based payment policies and the increasing availability of EHRs at the provider level. Risk stratification models, however, have been traditionally derived from claims or encounter systems. This study evaluates the challenges and opportunities of using EHR data instead of or in addition to administrative claims for risk stratification. This study used the structured EHR records and administrative claims of 85,581 patients receiving outpatient care at a large integrated provider system. Common data elements for risk stratification (ie, age, sex, diagnosis, and medication) were extracted from outpatient EHR records and administrative claims. The performance of a validated risk-stratification model was assessed using data extracted from claims alone, EHR alone, and claims and EHR combined. EHR-derived metrics overlapped considerably with administrative claims (eg, number of chronic conditions). The accuracy of the model, when using EHR data alone, was acceptable with an area under the curve of ∼0.81 for hospitalization and ∼0.85 for identifying top 1% utilizers using the concurrent model. However, when using EHR data alone, the predictive model explained a lower amount of variation in utilization-based outcomes compared with administrative claims. The results show a promising performance of models predicting cost and hospitalization using outpatient EHR's diagnosis and medication data. More research is needed to evaluate the benefits of other EHR data types (eg, lab values and vital signs) for risk stratification.

  19. Utility of 12-lead and signal-averaged Holter electrocardiograms after pilsicainide provocation for risk stratification in Brugada syndrome.

    PubMed

    Kakihara, Jun; Takagi, Masahiko; Hayashi, Yusuke; Tatsumi, Hiroaki; Doi, Atsushi; Yoshiyama, Minoru

    2017-03-31

    Non-invasive risk stratification for ventricular fibrillation (VF) in Brugada syndrome (BrS) has not been fully evaluated. The aim of this study was to assess the utility of signal-averaged Holter electrocardiogram (Holter SAECG) and 12-lead Holter electrocardiogram (Holter ECG) after a pilsicainide provocation test for non-invasive risk stratification in BrS. We enrolled 30 consecutive patients with BrS [divided into 2 groups: the VF group, those with a previous history of VF (n = 10); and the non-VF group, those without a history of VF (n = 20)] and 10 control subjects without type 1 ECG. We evaluated late potentials [LP: filtered QRS (f-QRS), RMS40, and LAS40] on the Holter SAECG for 4 h after the pilsicainide provocation and in the same patients on another day without performing the pilsicainide provocation. Furthermore, we measured QRS duration and QTc interval in leads V2 and V5, and J amplitude in lead V2 on the Holter ECG after the pilsicainide provocation. On the Holter SAECG, the f-QRS at 1 h and LAS40 at 3 h after the pilsicainide provocation were significantly larger in the VF group than in the non-VF group (f-QRS at 1 h: 113.9 ± 8.9 vs. 104.9 ± 8 ms; p = 0.01, LAS40 at 3 h: 45.4 ± 5.9 vs. 35.5 ± 7.4 ms; p < 0.001). The receiver-operating characteristic curve analysis for a single parameter of VF occurrence was determined [f-QRS at 1 h: area under the curve (AUC) 0.8, with sensitivity 80% and specificity 80%; and LAS40 at 3 h: AUC 0.87, with sensitivity 90% and specificity 75%]. On the Holter ECG, there were no significant differences in these parameters between the VF and non-VF groups. In conclusion, the LP after the pilsicainide provocation using Holter SAECG may be useful for risk stratification of VF episodes in patients with BrS.

  20. Enhancing risk stratification for use in integrated care: a cluster analysis of high-risk patients in a retrospective cohort study

    PubMed Central

    Vuik, Sabine I; Mayer, Erik; Darzi, Ara

    2016-01-01

    Objective To show how segmentation can enhance risk stratification tools for integrated care, by providing insight into different care usage patterns within the high-risk population. Design A retrospective cohort study. A risk score was calculated for each person using a logistic regression, which was then used to select the top 5% high-risk individuals. This population was segmented based on the usage of different care settings using a k-means cluster analysis. Data from 2008 to 2011 were used to create the risk score and segments, while 2012 data were used to understand the predictive abilities of the models. Setting and participants Data were collected from administrative data sets covering primary and secondary care for a random sample of 300 000 English patients. Main measures The high-risk population was segmented based on their usage of 4 different care settings: emergency acute care, elective acute care, outpatient care and GP care. Results While the risk strata predicted care usage at a high level, within the high-risk population, usage varied significantly. 4 different groups of high-risk patients could be identified. These 4 segments had distinct usage patterns across care settings, reflecting different levels and types of care needs. The 2008–2011 usage patterns of the 4 segments were consistent with the 2012 patterns. Discussion Cluster analyses revealed that the high-risk population is not homogeneous, as there exist 4 groups of patients with different needs across the care continuum. Since the patterns were predictive of future care use, they can be used to develop integrated care programmes tailored to these different groups. Conclusions Usage-based segmentation augments risk stratification by identifying patient groups with different care needs, around which integrated care programmes can be designed. PMID:27993905

  1. Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence.

    PubMed

    Santolini, Emmanuele; West, Robert; Giannoudis, Peter V

    2015-12-01

    Non-union continues to be the most devastating complication after fracture fixation. Its treatment can be prolonged and often unpredictable. The burden to the patient, surgeon and health care system can be immense. Strategies to prevent it and or identify early its development are desirable in order to improve the clinical course of the affected patients and their outcomes. We undertook a systematic review of the literature in order to identify the most common and important risk factors based on the hierarchy of level of evidence. Accordingly, a stratification scale was formed which highlighted 10 risk factors including; an open method of fracture reduction, open fracture, presence of post-surgical fracture gap, smoking, infection, wedge or comminuted types of fracture, high degree of initial fracture displacement, lack of adequate mechanical stability provided by the implant used, fracture location in the poor zone of vascularity of the affected bone, and the presence of the fracture in the tibia. Clinicians should take in to account these findings when managing patients with long bone fractures, particularly the femur and tibia in order to minimise the risk of non-union. Copyright © 2015 Elsevier Ltd. All rights reserved.

  2. The impact of occult renal failure on the cardiovascular risk stratification in an elderly population: the PREV-ICTUS study.

    PubMed

    Redón, Josep; Gil, Vicente; Cea-Calvo, Luis; Lozano, José V; Martí-Canales, Juan C; Llisterri, José L; Aznar, Jose; González-Esteban, Jorge

    2008-01-01

    To analyze the impact of occult renal failure (ORF) in the individual risk stratification and on the blood pressures (BP) and low-density lipoprotein (LDL) goals in an aged population, according to the ESH/ESC Hypertension Guidelines. A cross-sectional, population-based study on individuals aged 60 years or more carried out in Primary Care Centers of Spain. Kidney function was estimated from calculated creatinine clearance (eGFR), Cockroft and Gault formula. Ten-year cardiovascular risk was estimated through the ESH/ESC table including or not including the eGFR. Estimates of the modification in BP and LDL-cholesterol (cLDL) goals were calculated. In 6419 subjects, 4242 subjects (66%) had normal renal function, 1971 (31%) had ORF (normal creatinine and low eGFR) and 206 (3%) had insufficient renal function (high creatinine and all of them low eGFR). Inclusion of ORF as target organ damage resulted in an increase in the estimated risk in 10.8% of the total sample, increasing the percentage of high-risk subjects. In the latter case, new BP and cLDL goals (<130/80 mmHg and <100 mg/dl) should be needed in 475 (7.4%) and 413 (6.4%) additional subjects, respectively. Inclusion of the ORF resulted in a significant increase in the percentage of subjects with estimated high cardiovascular risk.

  3. What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding?

    PubMed

    Ghassemi, Kevin A; Jensen, Dennis M

    2017-04-01

    There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).

  4. 68Ga-PSMA-11 PET/CT for prostate cancer staging and risk stratification in Chinese patients

    PubMed Central

    Cui, Can; Li, Tian-Nv; Huang, Yue; Yao, Xiaochen; Fan, Qiu; Chen, Zejun; Du, Jin; Jia, Ruipeng; Sun, Hongbin; Hua, Zichun; Tang, Jun; Wang, Feng

    2017-01-01

    We evaluated the clinical utility of 68Ga-PSMA-11 PET/CT for staging and risk stratification of treatment-naïve prostate cancer (PCa) and metastatic castrate-resistant prostate cancer (mCRPC). Twenty-two consecutive patients with treatment-naïve PCa and 18 with mCRPC were enrolled. 68Ga-PSMA-11 PET/CT and magnetic resonance imaging (MRI) were performed for the evaluation of primary prostatic lesions, and bone scans were used for evaluation bone metastasis. Among the 40 patients, 37 (92.5% [22 treatment-naïve PCa, 15 mCRPC]) showed PSMA-avid lesions on 68Ga-PSMA-11 images. Only 3 patients with stable mCRPC after chemotherapy were negative for PSMA. The sensitivity, specificity and accuracy of 68Ga-PSMA-11 imaging were 97.3%, 100.0% and 97.5%, respectively. The maximum standardized uptake (SUVmax) of prostatic lesions was 17.09 ± 11.08 and 13.33 ± 12.31 in treatment-naïve PCa and mCRPC, respectively. 68Ga-PSMA-11 revealed 105 metastatic lymph nodes in 15 patients; the SUVmax was 16.85 ± 9.70 and 7.54 ± 5.20 in treatment-naïve PCa and mCRPC, respectively. 68Ga-PSMA-11 PET/CT also newly detected visceral metastasis in 9 patients (22.5%) and bone metastasis in 29 patients (72.5%). 68Ga-PSMA-11 PET/CT exhibits potential for staging and risk stratification in naïve PCa, as well as improved sensitivity for detection of lymph node and remote metastasis. PMID:28103574

  5. Robust Derivation of Risk Reduction Strategies

    NASA Technical Reports Server (NTRS)

    Richardson, Julian; Port, Daniel; Feather, Martin

    2007-01-01

    Effective risk reduction strategies can be derived mechanically given sufficient characterization of the risks present in the system and the effectiveness of available risk reduction techniques. In this paper, we address an important question: can we reliably expect mechanically derived risk reduction strategies to be better than fixed or hand-selected risk reduction strategies, given that the quantitative assessment of risks and risk reduction techniques upon which mechanical derivation is based is difficult and likely to be inaccurate? We consider this question relative to two methods for deriving effective risk reduction strategies: the strategic method defined by Kazman, Port et al [Port et al, 2005], and the Defect Detection and Prevention (DDP) tool [Feather & Cornford, 2003]. We performed a number of sensitivity experiments to evaluate how inaccurate knowledge of risk and risk reduction techniques affect the performance of the strategies computed by the Strategic Method compared to a variety of alternative strategies. The experimental results indicate that strategies computed by the Strategic Method were significantly more effective than the alternative risk reduction strategies, even when knowledge of risk and risk reduction techniques was very inaccurate. The robustness of the Strategic Method suggests that its use should be considered in a wide range of projects.

  6. Robust Derivation of Risk Reduction Strategies

    NASA Technical Reports Server (NTRS)

    Richardson, Julian; Port, Daniel; Feather, Martin

    2007-01-01

    Effective risk reduction strategies can be derived mechanically given sufficient characterization of the risks present in the system and the effectiveness of available risk reduction techniques. In this paper, we address an important question: can we reliably expect mechanically derived risk reduction strategies to be better than fixed or hand-selected risk reduction strategies, given that the quantitative assessment of risks and risk reduction techniques upon which mechanical derivation is based is difficult and likely to be inaccurate? We consider this question relative to two methods for deriving effective risk reduction strategies: the strategic method defined by Kazman, Port et al [Port et al, 2005], and the Defect Detection and Prevention (DDP) tool [Feather & Cornford, 2003]. We performed a number of sensitivity experiments to evaluate how inaccurate knowledge of risk and risk reduction techniques affect the performance of the strategies computed by the Strategic Method compared to a variety of alternative strategies. The experimental results indicate that strategies computed by the Strategic Method were significantly more effective than the alternative risk reduction strategies, even when knowledge of risk and risk reduction techniques was very inaccurate. The robustness of the Strategic Method suggests that its use should be considered in a wide range of projects.

  7. Cardiac Magnetic Resonance-Verified Myocardial Fibrosis in Chagas Disease: Clinical Correlates and Risk Stratification

    PubMed Central

    Uellendahl, Marly; de Siqueira, Maria Eduarda Menezes; Calado, Eveline Barros; Kalil-Filho, Roberto; Sobral, Dário; Ribeiro, Clébia; Oliveira, Wilson; Martins, Silvia; Narula, Jagat; Rochitte, Carlos Eduardo

    2016-01-01

    Background Chagas disease (CD) is an important cause of heart failure and mortality, mainly in Latin America. This study evaluated the morphological and functional characteristics of the heart as well the extent of myocardial fibrosis (MF) in patients with CD by cardiac magnetic resonance (CMR). The prognostic value of MF evaluated by myocardial-delayed enhancement (MDE) was compared with that via Rassi score. Methods This study assessed 39 patients divided into 2 groups: 28 asymptomatic patients as indeterminate form group (IND); and symptomatic patients as Chagas Heart Disease (CHD) group. All patients underwent CMR using the techniques of cine-MRI and MDE, and the amount of MF was compared with the Rassi score. Results Regarding the morphological and functional analysis, significant differences were observed between both groups (p < 0.001). Furthermore, there was a strong correlation between the extent of MF and the Rassi score (r = 0.76). Conclusions CMR is an important technique for evaluating patients with CD, stressing morphological and functional differences in all clinical presentations. The strong correlation with the Rassi score and the extent of MF detected by CMR emphasizes its role in the prognostic stratification of patients with CD. PMID:27982271

  8. Application of the MASCC and CISNE Risk-Stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department.

    PubMed

    Coyne, Christopher J; Le, Vivian; Brennan, Jesse J; Castillo, Edward M; Shatsky, Rebecca A; Ferran, Karen; Brodine, Stephanie; Vilke, Gary M

    2017-06-01

    Although validated risk-stratification tools have been used to send low-risk febrile neutropenic patients home from clinic and inpatient settings, there is a dearth of research evaluating these scores in the emergency department (ED). We compare the predictive accuracy of the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores for patients with chemotherapy-induced febrile neutropenia and presenting to the ED. We conducted a retrospective cohort study to evaluate all patients with febrile neutropenia (temperature ≥38°C [100.4°F], absolute neutrophil count <1,000 cells/μL) who presented to 2 academic EDs from June 2012 through January 2015. MASCC and CISNE scores were calculated for all subjects, and each visit was evaluated for several outcome variables, including inpatient length of stay, upgrade in level of care, clinical deterioration, positive blood culture results, and death. Descriptive statistics are reported and continuous variables were analyzed with Wilcoxon rank sum. During our study period, 230 patients presented with chemotherapy-induced febrile neutropenia. The CISNE score identified 53 (23%) of these patients as low risk and was highly specific in the identification of a low-risk cohort for all outcome variables (98.3% specific, 95% confidence interval [CI] 89.7% to 99.9%; positive predictive value 98.1%, 95% CI 88.6% to 99.9%). Median length of stay was shorter for low-risk versus high-risk CISNE patients (3-day difference; P<.001). The MASCC score was much less specific (54.2%; 95% CI 40.8% to 67.1%) in the identification of a low-risk cohort. Our results suggest that the CISNE score may be the most appropriate febrile neutropenia risk-stratification tool for use in the ED. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

  9. Integrating clinical trial findings into practice through risk stratification: the case of heart failure management.

    PubMed

    Smith, David H; Johnson, Eric S; Thorp, Micah L; Crispell, Kathy A; Yang, Xiuhai; Petrik, Amanda F

    2010-06-01

    Heart failure case management programs have been shown in clinical trials to be highly effective at preventing future hospitalizations. But the absolute benefits of these programs depend on the baseline risk of outcome in the treated population. Because baseline risks of hospitalization in trials are often higher than community-based samples, translating trial results to the community setting may be misleading. One solution is to identify subgroups for intervention that have sufficiently high baseline risk. Using estimates of hospitalizations averted from a previously published systematic review of heart failure management, we estimated a program's efficiency based on level of predicted risk. Medical history and demographic data on heart failure patients from a large integrated US health plan were used to build a logistic regression-based prognostic risk score for cardiovascular-related hospitalization over 1 year. We calculated the crude rate of hospitalizations for comparison with trial data. We also calculated the program's potential dollar savings from averting hospitalizations. The average risk of hospitalization in the systematic review's trials was 45%; our population's average observed risk was 18% and the risk among the highest risk patients was 33%. After accounting for the assumed annual intervention cost of $700, the base-case analysis (at $6000 per hospitalization) shows a savings of $122/patient at highest risk; failing to intervene according to predicted risk (no targeting) would actually cost $211/patient. Our findings illustrate how clinical trial findings can be efficiently integrated into community settings by using a prognostic risk score to focus attention on high-risk subgroups.

  10. Malaria ecotypes and stratification.

    PubMed

    Schapira, Allan; Boutsika, Konstantina

    2012-01-01

    To deal with the variability of malaria, control programmes need to stratify their malaria problem into a number of smaller units. Such stratification may be based on the epidemiology of malaria or on its determinants such as ecology. An ecotype classification was developed by the World Health Organization (WHO) around 1990, and it is time to assess its usefulness for current malaria control as well as for malaria modelling on the basis of published research. Journal and grey literature was searched for articles on malaria or Anopheles combined with ecology or stratification. It was found that all malaria in the world today could be assigned to one or more of the following ecotypes: savanna, plains and valleys; forest and forest fringe; foothill; mountain fringe and northern and southern fringes; desert fringe; coastal and urban. However, some areas are in transitional or mixed zones; furthermore, the implications of any ecotype depend on the biogeographical region, sometimes subregion, and finally, the knowledge on physiography needs to be supplemented by local information on natural, anthropic and health system processes including malaria control. Ecotyping can therefore not be seen as a shortcut to determine control interventions, but rather as a framework to supplement available epidemiological and entomological data so as to assess malaria situations at the local level, think through the particular risks and opportunities and reinforce intersectoral action. With these caveats, it does however emerge that several ecotypic distinctions are well defined and have relatively constant implications for control within certain biogeographic regions. Forest environments in the Indo-malay and the Neotropics are, with a few exceptions, associated with much higher malaria risk than in adjacent areas; the vectors are difficult to control, and the anthropic factors also often converge to impose constraints. Urban malaria in Africa is associated with lower risk than savanna

  11. Risk stratification in the patient with non ST segment elevation acute coronary syndrome.

    PubMed

    Escabí-Mendoza, José; Rosales-Alvarez, Claudia

    2005-12-01

    Patients hospitalized with unstable angina (UA) or with a non-ST segment elevation myocardial infarct (NSTEMI) are at increased risk of suffering refractory angina, recurrent myocardial infarct (MI), and death. These patients need to be evaluated more aggressively. According to the last published guidelines (2002) of UA/NSTEMI by the ACC/AHA Task Force, these patients should be categorized in a risk scale as: low, intermediate or high. This should be done in the initial evaluation, which includes: medical history, physical exam, an electrocardiogram (ECG) and cardiac markers. The TIMI risk score should also be used as complementary in this risk assessment. High risk patients, without contraindications, should be managed more aggressively with coronary angiography. On the other end, low risk patients, and some intermediate, may be evaluated more conservatively with early non-invasive studies for further assessment of ischemia and prognosis.

  12. 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 naïve 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.

  13. Risk stratification for long-term mortality after percutaneous coronary intervention.

    PubMed

    Wu, Chuntao; Camacho, Fabian T; King, Spencer B; Walford, Gary; Holmes, David R; Stamato, Nicholas J; Berger, Peter B; Sharma, Samin; Curtis, Jeptha P; Venditti, Ferdinand J; Jacobs, Alice K; Hannan, Edward L

    2014-02-01

    A simple risk score to predict long-term mortality after percutaneous coronary intervention (PCI) using preprocedural risk factors is currently not available. In this study, we created one by simplifying the results of a Cox proportional hazards model. A total of 11,897 patients who underwent PCI from October through December 2003 in New York State were randomly divided into derivation and validation samples. Patients' vital statuses were tracked using the National Death Index through the end of 2008. A Cox proportional hazards model was fit to predict death after PCI using the derivation sample, and a simplified risk score was created. The Cox model identified 12 separate risk factors for mortality including older age, extreme body mass indexes, multivessel disease, a lower ejection fraction, unstable hemodynamic state or shock, several comorbidities (cerebrovascular disease, peripheral vascular disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, and renal failure), and a history of coronary artery bypass graft surgery. The C statistics of this model when applied to the validation sample were 0.787, 0.785, and 0.773 for risks of death within 1, 3, and 5 years after PCI, respectively. In addition, the point-based risk score demonstrated good agreement between patients' observed and predicted risks of death. A simple risk score created from a more complicated Cox proportional hazards model can be used to accurately predict a patient's risk of long-term mortality after PCI.

  14. Decreased ADAMTS-13 level is related to inflammation factors and risk stratification of acute lymphoblastic leukemia patients

    PubMed Central

    Liu, Chen; Zhao, Lei; Zhao, Jingzhong; Xu, Qinzhu; Song, Ying; Wang, Hui

    2017-01-01

    Abstract As a kind of metalloprotease of the ADAMTS family, ADAMTS-13 is crucial for maintaining the normal size of von Willebrand factor. Reduced ADAMTS-13 had been reported in patients with both localized and disseminated malignancies. However, the expression and potential role of ADAMTS-13 in hematological malignancies remain unclear. In this research, we measured and compared ADAMTS-13 levels in plasma of 35 acute lymphoblastic leukemia (ALL) patients and 30 healthy controls and found that ALL patients possessed lower level of ADAMTS-13 than controls. Correlations between ADAMTS-13 and inflammation factors were calculated and ADAMTS-13 was negatively correlated with C-reactive protein and interleukin-1β. ALL patients with infections had lower level of ADAMTS-13 than patients without infections. In addition, high-risk ALL patients possessed lower ADAMTS-13 than patients at low risk. To conclude, ADAMTS-13 level is decreased in the plasma of ALL patients and the level of ADAMTS-13 is related to plasma inflammation factors and risk stratification of ALL patients, which could contribute to better understanding of the clinical significance of ADAMTS-13. PMID:28207543

  15. Assessment of serum 25-hydroxy vitamin D improves coronary heart disease risk stratification in patients with type 2 diabetes.

    PubMed

    Heidari, Behnam; Nargesi, Arash Aghajani; Hafezi-Nejad, Nima; Sheikhbahaei, Sara; Pajouhi, Atieh; Nakhjavani, Manouchehr; Esteghamati, Alireza

    2015-09-01

    A growing body of evidence suggests an association between lower serum 25-hydroxy vitamin D (25(OH)VitD) levels and adverse cardiovascular events. Patients with type 2 diabetes mellitus (T2DM) are at increased risk for developing coronary heart disease (CHD). 25-Hydroxy vitamin D deficiency is highly prevalent, especially among patients with T2DM. This study aimed to evaluate the predictive value of serum 25(OH)VitD in improvement of CHD risk stratification in patients with T2DM. In an open cohort, community-dwelling T2DM patients were followed up for first CHD event. Patients were divided into 4 categories, based on 25(OH)VitD quartiles. Cox regression analysis was used to obtain hazard ratios. A total number of 2,607 T2DM patients were followed up for median time of 8.5 years. During follow-up, 299 patients experienced CHD events. Patients in the lowest quartile experienced more CHD events. Adjusted hazard ratios (95% CI) for developing CHD events were 0.77 (0.55-1.07) for second quartile, 0.52 (0.38-0.73) for third quartile, and 0.43 (0.31-0.60) for fourth quartile, compared with the first quartile. The incidence rate decreased as serum 25(OH)VitD increased, which remained significant after stepwise adjustments (P value for trend ≤.001). Addition of 25(OH)VitD to traditional risk factors in Framingham Risk Score successfully reclassified 29% of study population. Serum 25(OH)VitD is an independent predictor of future adverse CHD events in patients with T2DM. Addition of 25(OH)VitD status to Framingham Risk Score improves CHD risk prediction in patients with T2DM. Copyright © 2015 Elsevier Inc. All rights reserved.

  16. Prognostic stratification of patients with vasospastic angina: a comprehensive clinical risk score developed by the Japanese Coronary Spasm Association.

    PubMed

    Takagi, Yusuke; Takahashi, Jun; Yasuda, Satoshi; Miyata, Satoshi; Tsunoda, Ryusuke; Ogata, Yasuhiro; Seki, Atsushi; Sumiyoshi, Tetsuya; Matsui, Motoyuki; Goto, Toshikazu; Tanabe, Yasuhiko; Sueda, Shozo; Sato, Toshiaki; Ogawa, Satoshi; Kubo, Norifumi; Momomura, Shin-Ichi; Ogawa, Hisao; Shimokawa, Hiroaki

    2013-09-24

    The present study aimed to develop a comprehensive clinical risk score for vasospastic angina (VSA) patients. Previous studies demonstrated various prognostic factors of future adverse events in VSA patients. However, to apply these prognostic factors in clinical practice, the assessment of their accumulation in individual patients is important. The patient database of the multicenter registry study by the Japanese Coronary Spasm Association (JCSA) (n = 1,429; median 66 years; median follow-up 32 months) was utilized for score derivation. Multivariable Cox proportional hazard model selected 7 predictors of major adverse cardiac events (MACE). The integer score was assigned to each predictors proportional to their respective adjusted hazard ratio; history of out-of-hospital cardiac arrest (4 points), smoking, angina at rest alone, organic coronary stenosis, multivessel spasm (2 points each), ST-segment elevation during angina, and beta-blocker use (1 point each). According to the total score in individual patients, 3 risk strata were defined; low (score 0 to 2, n = 598), intermediate (score 3 to 5, n = 639) and high (score 6 or more, n = 192). The incidences of MACE in the low-, intermediate-, and high-risk patients were 2.5%, 7.0%, and 13.0%, respectively (p < 0.001). The Cox model for MACE between the 3 risk strata also showed prognostic utility of the scoring system in various clinical subgroups. The average prediction rate of the scoring system in the internal training and validation sets were 86.6% and 86.5%, respectively. We developed a novel scoring system, the JCSA risk score, which may provide the comprehensive risk assessment and prognostic stratification for VSA patients. Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  17. Outcome Predictors in Prosthetic Joint Infections--Validation of a risk stratification score for Prosthetic Joint Infections in 120 cases.

    PubMed

    Wimmer, Matthias D; Randau, Thomas M; Friedrich, Max J; Ploeger, Milena M; Schmolder, Jan; Strauss, Andreas C; Pennekamp, Peter H; Vavken, Patrick; Gravius, Sascha

    2016-03-01

    Prosthetic joint infections are a major challenge in total joint arthroplasty, especially in times of accumulating drug resistancies. Even though predictive risk classifications are a widely accepted tool to define a suitable treatment protocol a classification is still missing considering the difficulty in treating the -causative pathogen antibiotically. In this study, we present and evaluate a new predictive risk stratification for prosthetic joint infections in 120 cases, treated with a two-stage exchange. Treatment outcomes in 120 patients with proven prosthetic joint infections in hip and knee prostheses were regressed on time of infection, systemic risk factors, local risk factors and the difficulty in treating the causing pathogen. The main outcome variable was "definitely free of infection" after two years as published. Age, gender, and BMI were included as covariables and analyzed in a logistic regression model. 66 male and 54 female patients, with a mean age at surgery of 68.3 years±12.0 and a mean BMI of 26.05±6.21 were included in our survey and followed for 29.0±11.3 months. We found a significant association (p<0.001) between our score and the outcome parameters evaluated. Age, gender and BMI did not show a significant association with the outcome. These results show that our score is an independent and reliable predictor for the cure rate in prosthetic joint infections in hip and knee prostheses treated within a two-stage exchange protocol. Our score illustrates, that there is a statistically significant, sizable decrease in cure rate with an increase in score. In patients with prosthetic joint infections the validation of a risk score may help to identify patients with local and systemic risk factors or with infectious organisms identified as "difficult to treat" prior to the treatment or the decision about the treatment concept. Thus, appropriate extra care should be considered and provided.

  18. 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.

  19. Heart rate variability based on risk stratification for type 2 diabetes mellitus.

    PubMed

    Silva-E-Oliveira, Julia; Amélio, Pâmela Marina; Abranches, Isabela Lopes Laguardia; Damasceno, Dênis Derly; Furtado, Fabianne

    2017-01-01

    To evaluate heart rate variability among adults with different risk levels for type 2 diabetes mellitus. The risk for type 2 diabetes mellitus was assessed in 130 participants (89 females) based on the questionnaire Finnish Diabetes Risk Score and was classified as low risk (n=26), slightly elevated risk (n=41), moderate risk (n=27) and high risk (n=32). To measure heart rate variability, a heart-rate monitor Polar S810i® was employed to obtain RR series for each individual, at rest, for 5 minutes, followed by analysis of linear and nonlinear indexes. The groups at higher risk of type 2 diabetes mellitus had significantly lower linear and nonlinear heart rate variability indexes. The individuals at high risk for type 2 diabetes mellitus have lower heart rate variability. Avaliar a variabilidade da frequência cardíaca em adultos com diferentes níveis de risco para diabetes mellitus tipo 2. O grau de risco para diabetes mellitus tipo 2 de 130 participantes (41 homens) foi avaliado pelo questionário Finnish Diabetes Risk Score. Os participantes foram classificados em baixo risco (n=26), risco levemente elevado (n=41), risco moderado (n=27) e alto risco (n=32). Para medir a variabilidade da frequência cardíaca, utilizou-se o frequencímetro Polar S810i® para obter séries de intervalo RR para cada indivíduo, em repouso, durante 5 minutos; posteriormente, realizou-se análise por meio de índices lineares e não-lineares. O grupo com maior risco para diabetes mellitus tipo 2 teve uma diminuição significante nos índices lineares e não-lineares da variabilidade da frequência cardíaca. Os resultados apontam que indivíduos com risco alto para diabetes mellitus tipo 2 tem menor variabilidade da frequência cardíaca. To evaluate heart rate variability among adults with different risk levels for type 2 diabetes mellitus. The risk for type 2 diabetes mellitus was assessed in 130 participants (89 females) based on the questionnaire Finnish Diabetes Risk Score

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

    PubMed

    Yu, Meisheng; Wang, Jishi; Ma, Dan; Chen, Shuya; Lin, Xiaojing; Fang, Qin; Zhe, Nana

    2015-11-01

    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 µmol/l) and ZnPPIX (10 µmol/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

  1. Value of Donor-Specific Anti-HLA Antibody Monitoring and Characterization for Risk Stratification of Kidney Allograft Loss.

    PubMed

    Viglietti, Denis; Loupy, Alexandre; Vernerey, Dewi; Bentlejewski, Carol; Gosset, Clément; Aubert, Olivier; Duong van Huyen, Jean-Paul; Jouven, Xavier; Legendre, Christophe; Glotz, Denis; Zeevi, Adriana; Lefaucheur, Carmen

    2017-02-01

    The diagnosis system for allograft loss lacks accurate individual risk stratification on the basis of donor-specific anti-HLA antibody (anti-HLA DSA) characterization. We investigated whether systematic monitoring of DSA with extensive characterization increases performance in predicting kidney allograft loss. This prospective study included 851 kidney recipients transplanted between 2008 and 2010 who were systematically screened for DSA at transplant, 1 and 2 years post-transplant, and the time of post-transplant clinical events. We assessed DSA characteristics and performed systematic allograft biopsies at the time of post-transplant serum evaluation. At transplant, 110 (12.9%) patients had DSAs; post-transplant screening identified 186 (21.9%) DSA-positive patients. Post-transplant DSA monitoring improved the prediction of allograft loss when added to a model that included traditional determinants of allograft loss (increase in c statistic from 0.67; 95% confidence interval [95% CI], 0.62 to 0.73 to 0.72; 95% CI, 0.67 to 0.77). Addition of DSA IgG3 positivity or C1q binding capacity increased discrimination performance of the traditional model at transplant and post-transplant. Compared with DSA mean fluorescence intensity, DSA IgG3 positivity and C1q binding capacity adequately reclassified patients at lower or higher risk for allograft loss at transplant (category-free net reclassification index, 1.30; 95% CI, 0.94 to 1.67; P<0.001 and 0.93; 95% CI, 0.49 to 1.36; P<0.001, respectively) and post-transplant (category-free net reclassification index, 1.33; 95% CI, 1.03 to 1.62; P<0.001 and 0.95; 95% CI, 0.62 to 1.28; P<0.001, respectively). Thus, pre- and post-transplant DSA monitoring and characterization may improve individual risk stratification for kidney allograft loss. Copyright © 2017 by the American Society of Nephrology.

  2. An official American Thoracic Society clinical practice guideline: diagnosis, risk stratification, and management of pulmonary hypertension of sickle cell disease.

    PubMed

    Klings, Elizabeth S; Machado, Roberto F; Barst, Robyn J; Morris, Claudia R; Mubarak, Kamal K; Gordeuk, Victor R; Kato, Gregory J; Ataga, Kenneth I; Gibbs, J Simon; Castro, Oswaldo; Rosenzweig, Erika B; Sood, Namita; Hsu, Lewis; Wilson, Kevin C; Telen, Marilyn J; Decastro, Laura M; Krishnamurti, Lakshmanan; Steinberg, Martin H; Badesch, David B; Gladwin, Mark T

    2014-03-15

    In adults with sickle cell disease (SCD), an increased tricuspid regurgitant velocity (TRV) measured by Doppler echocardiography, an increased serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level, and pulmonary hypertension (PH) diagnosed by right heart catheterization (RHC) are independent risk factors for mortality. A multidisciplinary committee was formed by clinician-investigators experienced in the management of patients with PH and/or SCD. Clinically important questions were posed, related evidence was appraised, and questions were answered with evidence-based recommendations. Target audiences include all clinicians who take care of patients with SCD. Mortality risk stratification guides decision making. An increased risk for mortality is defined as a TRV equal to or greater than 2.5 m/second, an NT-pro-BNP level equal to or greater than 160 pg/ml, or RHC-confirmed PH. For patients identified as having increased mortality risk, we make a strong recommendation for hydroxyurea as first-line therapy and a weak recommendation for chronic transfusions as an alternative therapy. For all patients with SCD with elevated TRV alone or elevated NT-pro-BNP alone, and for patients with SCD with RHC-confirmed PH with elevated pulmonary artery wedge pressure and low pulmonary vascular resistance, we make a strong recommendation against PAH-specific therapy. However, for select patients with SCD with RHC-confirmed PH who have elevated pulmonary vascular resistance and normal pulmonary capillary wedge pressure, we make a weak recommendation for either prostacyclin agonist or endothelin receptor antagonist therapy and a strong recommendation against phosphodiesterase-5 inhibitor therapy. Evidence-based recommendations for the management of patients with SCD with increased mortality risk are provided, but will require frequent reassessment and updating.

  3. An Official American Thoracic Society Clinical Practice Guideline: Diagnosis, Risk Stratification, and Management of Pulmonary Hypertension of Sickle Cell Disease

    PubMed Central

    Klings, Elizabeth S.; Machado, Roberto F.; Barst, Robyn J.; Morris, Claudia R.; Mubarak, Kamal K.; Gordeuk, Victor R.; Kato, Gregory J.; Ataga, Kenneth I.; Gibbs, J. Simon; Castro, Oswaldo; Rosenzweig, Erika B.; Sood, Namita; Hsu, Lewis; Wilson, Kevin C.; Telen, Marilyn J.; DeCastro, Laura M.; Krishnamurti, Lakshmanan; Steinberg, Martin H.; Badesch, David B.; Gladwin, Mark T.

    2014-01-01

    Background: In adults with sickle cell disease (SCD), an increased tricuspid regurgitant velocity (TRV) measured by Doppler echocardiography, an increased serum N-terminal pro–brain natriuretic peptide (NT-pro-BNP) level, and pulmonary hypertension (PH) diagnosed by right heart catheterization (RHC) are independent risk factors for mortality. Methods: A multidisciplinary committee was formed by clinician-investigators experienced in the management of patients with PH and/or SCD. Clinically important questions were posed, related evidence was appraised, and questions were answered with evidence-based recommendations. Target audiences include all clinicians who take care of patients with SCD. Results: Mortality risk stratification guides decision making. An increased risk for mortality is defined as a TRV equal to or greater than 2.5 m/second, an NT-pro-BNP level equal to or greater than 160 pg/ml, or RHC-confirmed PH. For patients identified as having increased mortality risk, we make a strong recommendation for hydroxyurea as first-line therapy and a weak recommendation for chronic transfusions as an alternative therapy. For all patients with SCD with elevated TRV alone or elevated NT-pro-BNP alone, and for patients with SCD with RHC-confirmed PH with elevated pulmonary artery wedge pressure and low pulmonary vascular resistance, we make a strong recommendation against PAH-specific therapy. However, for select patients with SCD with RHC-confirmed PH who have elevated pulmonary vascular resistance and normal pulmonary capillary wedge pressure, we make a weak recommendation for either prostacyclin agonist or endothelin receptor antagonist therapy and a strong recommendation against phosphodiesterase-5 inhibitor therapy. Conclusions: Evidence-based recommendations for the management of patients with SCD with increased mortality risk are provided, but will require frequent reassessment and updating. PMID:24628312

  4. Effect of Preoperative Risk Group Stratification on Oncologic Outcomes of Patients with Adverse Pathologic Findings at Radical Prostatectomy

    PubMed Central

    Jang, Won Sik; Kim, Lawrence H. C.; Yoon, Cheol Yong; Rha, Koon Ho; Choi, Young Deuk; Hong, Sung Joon; Ham, Won Sik

    2016-01-01

    Background Current National Comprehensive Cancer Network guidelines recommend postoperative radiation therapy based only on adverse pathologic findings (APFs), irrespective of preoperative risk group. We assessed whether a model incorporating both the preoperative risk group and APFs could predict long-term oncologic outcomes better than a model based on APFs alone. Methods We retrospectively reviewed 4,404 men who underwent radical prostatectomy (RP) at our institution between 1992 and 2014. After excluding patients receiving neoadjuvant therapy or with incomplete pathological or follow-up data, 3,092 men were included in the final analysis. APFs were defined as extraprostatic extension (EPE), seminal vesicle invasion (SVI), or a positive surgical margin (PSM). The adequacy of model fit to the data was compared using the likelihood-ratio test between the models with and without risk groups, and model discrimination was compared with the concordance index (c-index) for predicting biochemical recurrence (BCR) and prostate cancer-specific mortality (PCSM). We performed multivariate Cox proportional hazard model and competing risk regression analyses to identify predictors of BCR and PCSM in the total patient group and each of the risk groups. Results Adding risk groups to the model containing only APFs significantly improved the fit to the data (likelihood-ratio test, p <0.001) and the c-index increased from 0.693 to 0.732 for BCR and from 0.707 to 0.747 for PCSM. A RP Gleason score (GS) ≥8 and a PSM were independently associated with BCR in the total patient group and also each risk group. However, only a GS ≥8 and SVI were associated with PCSM in the total patient group (GS ≥8: hazard ratio [HR] 5.39 and SVI: HR 3.36) and the high-risk group (GS ≥8: HR 6.31 and SVI: HR 4.05). Conclusion The postoperative estimation of oncologic outcomes in men with APFs at RP was improved by considering preoperative risk group stratification. Although a PSM was an

  5. Risk Stratification of Stress Fractures and Prediction of Return-to-Duty

    DTIC Science & Technology

    2016-12-01

    determine the sex - and race-ethnicity-specific bone traits that may contribute to stress fracture risk in military recruits. We are ahead of schedule...with recent stress fracture enrolled. 15. SUBJECT TERMS bone microarchitecture, HRpQCT, race, gender, sex , bone mineral density, vBMD, bone geometry...cross sectional study aimed at identifying the bone properties that may be related to the well-known sex and race/ethnicity differences in risk for

  6. Risk Stratification of Stress Fractures and Prediction of Return to Duty

    DTIC Science & Technology

    2015-12-01

    enrollment. In study Task 1 we aim to determine the sex - and race-ethnicity-specific bone traits that may contribute to stress fracture risk in military...SUBJECT TERMS bone microarchitecture, HRpQCT, race, gender, sex , bone mineral density, vBMD, bone geometry, stress fracture 16. SECURITY...sectional study aimed at identifying the bone properties that may be related to the well-known sex and race/ethnicity differences in risk for stress

  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.

  8. Risk stratification of patients with shoulder pain seen in physical therapy practice.

    PubMed

    Rodeghero, Jason R; Cleland, Joshua A; Mintken, Paul E; Cook, Chad E

    2017-04-01

    Musculoskeletal shoulder pain is commonly treated in physical therapy. There is inconsistency in the literature regarding patient characteristics related to prognosis. Having prognostic information could be useful for improving clinical efficiency and decreasing the cost of associated care. The objective of this study was to identify predictive characteristics related to patients with shoulder pain who have a high-risk of a bad prognosis (lowest functional recovery compared with visit utilization) as well as those who are at low-risk of a bad prognosis (highest functional recovery compared with visit utilization). We completed a secondary analysis of a retrospective cohort using data obtained from an existing commercial outcomes database. Data from 5214 patients with shoulder pain were analysed to determine predictive characteristics that identify patients who either have a low-risk or a high-risk of a bad prognosis to physical therapy care. Multinomial regression was used to identify significant patient characteristics predictive of treatment response. Statistically significant predictors of high-risk categorization included older age, no surgical history, insurance designated as worker's compensation, litigation or automotive and three or more co-morbidities. Predictors of low risk categorization were younger age, shorter duration of symptoms, no surgical history and payer type. Selected variables were associated with both poor and good recovery. Further research on prognosis, efficacy of physical therapy care and cost appear warranted for patients with shoulder pain. © 2016 John Wiley & Sons, Ltd.

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

    PubMed

    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.

  10. Does von Willebrand factor improve the predictive ability of current risk stratification scores in patients with atrial fibrillation?

    PubMed Central

    García-Fernández, Amaya; Roldán, Vanessa; Rivera-Caravaca, José Miguel; Hernández-Romero, Diana; Valdés, Mariano; Vicente, Vicente; Lip, Gregory Y. H.; Marín, Francisco

    2017-01-01

    Von Willebrand factor (vWF) is a biomarker of endothelial dysfunction. We investigated its role on prognosis in anticoagulated atrial fibrillation (AF) patients and determined whether its addition to clinical risk stratification schemes improved event-risk prediction. Consecutive outpatients with non-valvular AF were recruited and rates of thrombotic/cardiovascular events, major bleeding and mortality were recorded. The effect of vWF on prognosis was calculated using a Cox regression model. Improvements in predictive accuracy over current scores were determined by calculating the integrated discrimination improvement (IDI), net reclassification improvement (NRI), comparison of receiver-operator characteristic (ROC) curves and Decision Curve Analysis (DCA). 1215 patients (49% males, age 76 (71–81) years) were included. Follow-up was almost 7 years. Significant associations were found between vWF and cardiovascular events, stroke, mortality and bleeding. Based on IDI and NRI, addition of vWF to CHA2DS2-VASc statistically improved its predictive value, but c-indexes were not significantly different. For major bleeding, the addition of vWF to HAS-BLED improved the c-index but not IDI or NRI. DCA showed minimal net benefit. vWF acts as a simple prognostic biomarker in AF and, whilst its addition to current scores statistically improves prediction for some endpoints, absolute changes and impact on clinical decision-making are marginal. PMID:28134282

  11. Intensity of Left Atrial Spontaneous Echo Contrast as a Correlate for Stroke Risk Stratification in Patients with Nonvalvular Atrial Fibrillation

    PubMed Central

    Zhao, Yuanping; Ji, Lijing; Liu, Jian; Wu, Juefei; Wang, Yan; Shen, Shuxin; Guo, Shengcun; Jian, Rong; Chen, Gangbin; Wei, Xuan; Liao, Wangjun; Kutty, Shelby; Liao, Yulin; Bin, Jianping

    2016-01-01

    The intensity of left atrial spontaneous echo contrast (LASEC) by transesophageal echocardiography (TEE) has been proposed as an important variable in the stratification of thromboembolic risk, particularly in patients with nonvalvular atrial fibrillation (NVAF). We hypothesized that the quantification of LASEC by ultrasound will improve its utility in predicting subsequent stroke events in patients with NVAF. Patients (n = 206) with definite NVAF receiving TEE were included for this prospective cohort study. Baseline clinical risk factors of stroke, CHADS2 score and CHA2DS2-Vasc, left atrial thrombus (LAT), the five-grades of LASEC and video intensity (VI) value of LASEC were measured. During 2 years follow-up, 20 patients (9.7%) developed stroke. VI value of LASEC in the patients with stroke was higher compared to patients without stroke (25.30 ± 3.61 vs. 8.65 ± 0.81, p < 0.001). On logistic regression analysis, LAT, qualitative LASEC, graded LASEC, VI value of LASEC and CHADS2 and CHA2DS2-Vasc score were independent predictors of stroke. Among them, the highest area under the curve of receiver operating characteristic (ROC) in predicting stroke was VI value of LASEC (p < 0.05). These results show that quantification of LASEC by VI value is the most favorable predictor of stroke in patients with NVAF, and calls for improving the utility of LASEC in predicting subsequent stroke events. PMID:27277939

  12. 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

  13. Risk stratification of periprocedural myocardial infarction after percutaneous coronary intervention: Analysis based on the SCAI definition.

    PubMed

    Zhang, Dong; Li, Yiping; Yin, Dong; He, Yuan; Chen, Changzhe; Song, Chenxi; Yan, Ruohua; Zhu, Chen'gang; Xu, Bo; Dou, Kefei

    2017-03-01

    To investigate the predictors of and generate a risk prediction method for periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) using the new PMI definition proposed by the Society for Cardiovascular Angiography and Interventions (SCAI). The SCAI-defined PMI was found to be associated with worse prognosis than the PMI diagnosed by other definitions. However, few large-sample studies have attempted to predict the risk of SCAI-defined PMI. A total of 3,371 patients (3,516 selective PCIs) were included in this single-center retrospective analysis. The diagnostic criteria for PMI were set according to the SCAI definition. All clinical characteristics, coronary angiography findings and PCI procedural factors were collected. Multivariate logistic regression analysis was performed to identify independent predictors of PMI. To evaluate the risk of PMI, a multivariable risk score (PMI score) was constructed with incremental weights attributed to each component variable according to their estimated coefficients. PMI occurred in 108 (3.1%) of all patients. Age, multivessel treatment, at least one bifurcation treatment and total treated lesion length were independent predictors of SCAI-defined PMI. PMI scores ranged from 0 to 20. The C-statistic of PMI score was 0.71 (95% confidence interval: 0.66-0.76). PMI rates increased significantly from 1.96% in the non-high-risk group (PMI score < 10) to 6.26% in the high-risk group (PMI score ≥ 10) (P < 0.001). Age, multivessel treatment, at least one bifurcation treatment, and total treated lesion length are predictive of PMI. The PMI score could help identify patients at high risk of PMI after PCI. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

  14. Performance of 2014 NICE defibrillator implantation guidelines in heart failure risk stratification

    PubMed Central

    Cubbon, Richard M; Witte, Klaus K; Kearney, Lorraine C; Gierula, John; Byrom, Rowenna; Paton, Maria; Sengupta, Anshuman; Patel, Peysh A; MN Walker, Andrew; Cairns, David A; Rajwani, Adil; Hall, Alistair S; Sapsford, Robert J; Kearney, Mark T

    2016-01-01

    Objective Define the real-world performance of recently updated National Institute for Health and Care Excellence guidelines (TA314) on implantable cardioverter-defibrillator (ICD) use in people with chronic heart failure. Methods Multicentre prospective cohort study of 1026 patients with stable chronic heart failure, associated with left ventricular ejection fraction (LVEF) ≤45% recruited in cardiology outpatient departments of four UK hospitals. We assessed the capacity of TA314 to identify patients at increased risk of sudden cardiac death (SCD) or appropriate ICD shock. Results The overall risk of SCD or appropriate ICD shock was 2.1 events per 100 patient-years (95% CI 1.7 to 2.6). Patients meeting TA314 ICD criteria (31.1%) were 2.5-fold (95% CI 1.6 to 3.9) more likely to suffer SCD or appropriate ICD shock; they were also 1.5-fold (95% CI 1.1 to 2.2) more likely to die from non-cardiovascular causes and 1.6-fold (95% CI 1.1 to 2.3) more likely to die from progressive heart failure. Patients with diabetes not meeting TA314 criteria experienced comparable absolute risk of SCD or appropriate ICD shock to patients without diabetes who met TA314 criteria. Patients with ischaemic cardiomyopathy not meeting TA314 criteria experienced comparable absolute risk of SCD or appropriate ICD shock to patients with non-ischaemic cardiomyopathy who met TA314 criteria. Conclusions TA314 can identify patients with reduced LVEF who are at increased relative risk of sudden death. Clinicians should also consider clinical context and the absolute risk of SCD when advising patients about the potential risks and benefits of ICD therapy. PMID:26857212

  15. Targeted deep sequencing improves outcome stratification in chronic myelomonocytic leukemia with low risk cytogenetic features

    PubMed Central

    Palomo, Laura; Garcia, Olga; Arnan, Montse; Xicoy, Blanca; Fuster, Francisco; Cabezón, Marta; Coll, Rosa; Ademà, Vera; Grau, Javier; Jiménez, Maria-José; Pomares, Helena; Marcé, Sílvia; Mallo, Mar; Millá, Fuensanta; Alonso, Esther; Sureda, Anna; Gallardo, David; Feliu, Evarist; Ribera, Josep-Maria; Solé, Francesc; Zamora, Lurdes

    2016-01-01

    Clonal cytogenetic abnormalities are found in 20-30% of patients with chronic myelomonocytic leukemia (CMML), while gene mutations are present in >90% of cases. Patients with low risk cytogenetic features account for 80% of CMML cases and often fall into the low risk categories of CMML prognostic scoring systems, but the outcome differs considerably among them. We performed targeted deep sequencing of 83 myeloid-related genes in 56 CMML patients with low risk cytogenetic features or uninformative conventional cytogenetics (CC) at diagnosis, with the aim to identify the genetic characteristics of patients with a more aggressive disease. Targeted sequencing was also performed in a subset of these patients at time of acute myeloid leukemia (AML) transformation. Overall, 98% of patients harbored at least one mutation. Mutations in cell signaling genes were acquired at time of AML progression. Mutations in ASXL1, EZH2 and NRAS correlated with higher risk features and shorter overall survival (OS) and progression free survival (PFS). Patients with SRSF2 mutations associated with poorer OS, while absence of TET2 mutations (TET2wt) was predictive of shorter PFS. A decrease in OS and PFS was observed as the number of adverse risk gene mutations (ASXL1, EZH2, NRAS and SRSF2) increased. On multivariate analyses, CMML-specific scoring system (CPSS) and presence of adverse risk gene mutations remained significant for OS, while CPSS and TET2wt were predictive of PFS. These results confirm that mutation analysis can add prognostic value to patients with CMML and low risk cytogenetic features or uninformative CC. PMID:27486981

  16. Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department

    PubMed Central

    Deleger, Louise; Brodzinski, Holly; Zhai, Haijun; Li, Qi; Lingren, Todd; Kirkendall, Eric S; Alessandrini, Evaline; Solti, Imre

    2013-01-01

    Objective To evaluate a proposed natural language processing (NLP) and machine-learning based automated method to risk stratify abdominal pain patients by analyzing the content of the electronic health record (EHR). Methods We analyzed the EHRs of a random sample of 2100 pediatric emergency department (ED) patients with abdominal pain, including all with a final diagnosis of appendicitis. We developed an automated system to extract relevant elements from ED physician notes and lab values and to automatically assign a risk category for acute appendicitis (high, equivocal, or low), based on the Pediatric Appendicitis Score. We evaluated the performance of the system against a manually created gold standard (chart reviews by ED physicians) for recall, specificity, and precision. Results The system achieved an average F-measure of 0.867 (0.869 recall and 0.863 precision) for risk classification, which was comparable to physician experts. Recall/precision were 0.897/0.952 in the low-risk category, 0.855/0.886 in the high-risk category, and 0.854/0.766 in the equivocal-risk category. The information that the system required as input to achieve high F-measure was available within the first 4 h of the ED visit. Conclusions Automated appendicitis risk categorization based on EHR content, including information from clinical notes, shows comparable performance to physician chart reviewers as measured by their inter-annotator agreement and represents a promising new approach for computerized decision support to promote application of evidence-based medicine at the point of care. PMID:24130231

  17. 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

  18. Risk stratification of patients with non-ST-elevation acute coronary syndromes by assessing global longitudinal strain.

    PubMed

    Hoshi, Hiromi; Takagi, Atsushi; Uematsu, Shoko; Ashihara, Kyomi; Hagiwara, Nobuhisa

    2014-05-01

    Noninvasive detection of left main/three-vessel diseases (LM/3VD) among patients with non-ST-elevation acute coronary syndromes (NSTEACS) has been difficult using echocardiography. However, two-dimensional (2D) strain/strain-rate analysis is more sensitive in quantitatively assessing contractile abnormality. Accordingly, we aimed to clarify the usefulness of 2D strain/strain-rate analysis for risk stratification of NSTEACS. A total of 50 patients with NSTEACS underwent echocardiography and coronary angiography. We evaluated global longitudinal peak strain (global PS), peak systolic strain rate (global SSR), early diastolic global peak strain rate (global ESR), time from aortic valve closure to peak strain (TAVC-global PS), and global ESR (TAVC-global ESR) in apical four-, two-, and three-chamber views. Patients were divided into two groups according to coronary angiographic findings, the high-risk group (n = 15) with either of left main or three-vessel disease, and the low-risk group (n = 35). There were no significant differences in global SSR and global ESR between the two groups. The amplitude of global PS was significantly reduced in high-risk patients with LM/3VD in comparison with low-risk patients (-17.5 ± 2.4% vs -19.8 ± 2.7%, P = 0.007, respectively). TAVC-global PS and TAVC-global ESR were significantly prolonged in high-risk patients with LM/3VD in comparison with low-risk patients (15.3 ± 25.7 ms vs -36.8 ± 32.7 ms, P < 0.0001 and 162.8 ± 32.7 ms vs 135.7 ± 41.5 ms, P < 0.03, respectively). Receiver-operating characteristic analysis demonstrated that TAVC-global PS most strongly detected high-risk patients with sensitivity of 100% and specificity of 74.3% (area under the curve = 0.938, 95 % confidence interval 0.832-0.986, P = 0.0001). Temporal analysis of 2D strain appeared to be useful in detecting high-risk patients with LM/3VD among patients with NSTEACS.

  19. 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

  20. Advances in biophotonics detection of field carcinogenesis for colon cancer risk stratification.

    PubMed

    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.

  1. Cardiac Magnetic Resonance-Verified Myocardial Fibrosis in Chagas Disease: Clinical Correlates and Risk Stratification.

    PubMed

    Uellendahl, Marly; Siqueira, Maria Eduarda Menezes de; Calado, Eveline Barros; Kalil-Filho, Roberto; Sobral, Dário; Ribeiro, Clébia; Oliveira, Wilson; Martins, Silvia; Narula, Jagat; Rochitte, Carlos Eduardo

    2016-11-01

    Chagas disease (CD) is an important cause of heart failure and mortality, mainly in Latin America. This study evaluated the morphological and functional characteristics of the heart as well the extent of myocardial fibrosis (MF) in patients with CD by cardiac magnetic resonance (CMR). The prognostic value of MF evaluated by myocardial-delayed enhancement (MDE) was compared with that via Rassi score. This study assessed 39 patients divided into 2 groups: 28 asymptomatic patients as indeterminate form group (IND); and symptomatic patients as Chagas Heart Disease (CHD) group. All patients underwent CMR using the techniques of cine-MRI and MDE, and the amount of MF was compared with the Rassi score. Regarding the morphological and functional analysis, significant differences were observed between both groups (p < 0.001). Furthermore, there was a strong correlation between the extent of MF and the Rassi score (r = 0.76). CMR is an important technique for evaluating patients with CD, stressing morphological and functional differences in all clinical presentations. The strong correlation with the Rassi score and the extent of MF detected by CMR emphasizes its role in the prognostic stratification of patients with CD. A doença de Chagas (DC) é importante causa de insuficiência cardíaca e mortalidade, principalmente na América Latina. Este estudo avaliou as características morfológicas e funcionais do coração, assim como a extensão da fibrose miocárdica (FM) em pacientes com DC através de ressonância magnética cardíaca (RMC). O valor prognóstico da FM avaliada por realce tardio miocárdico (RTM) foi comparado àquele do escore de Rassi. Avaliação de 39 pacientes divididos em 2 grupos: grupo 'forma indeterminada' (IND), 28 pacientes assintomáticos; e grupo 'cardiopatia chagásica' (CC), pacientes sintomáticos. Todos os pacientes foram submetidos a RMC com as técnicas de cine-RM e RTM, sendo a quantidade de FM evidenciada ao exame comparada ao escore de

  2. Call for Standardized Definitions of Osteoarthritis and Risk Stratification for Clinical Trials and Clinical Use

    PubMed Central

    Kraus, Virginia Byers; Blanco, Francisco J.; Englund, Martin; Karsdal, Morten A.; Lohmander, L. Stefan

    2015-01-01

    Osteoarthritis is a heterogeneous disorder. The goals of this review are (1) To stimulate use of standardized nomenclature for osteoarthritis (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 Osteoarthritis Development) and ROAP (Risk of Osteoarthritis 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

  3. Brugada syndrome and fitness to fly: risk stratification in two pilot applicants.

    PubMed

    Dobler, Diana; Huber, Samuel W; Maire, René

    2010-08-01

    Brugada syndrome is a condition associated with a characteristic ECG and sudden arrhythmic death. Due to this risk of sudden death, patients with Brugada syndrome are generally not considered fit to fly. In recent years we have gained new insight into this condition and Brugada syndrome patients can now be classified into different risk categories. This then raises the question of whether a subset of patients with the Brugada syndrome exists in whom the risk of sudden death is sufficiently low and is compatible with fitness to fly. We discuss this question with two case reports of persons with Brugada syndrome who applied for an airman medical certificate and we propose an algorithm to aid decision making in this situation.

  4. Diagnosis, risk stratification and management of monoclonal gammopathy of undetermined significance and smoldering multiple myeloma.

    PubMed

    van de Donk, N W C J; Mutis, T; Poddighe, P J; Lokhorst, H M; Zweegman, S

    2016-05-01

    Monoclonal gammopathy of undetermined significance (MGUS) is one of the most common premalignant disorders. IgG and IgA MGUS are precursor conditions of multiple myeloma (MM), whereas light-chain MGUS is a precursor condition of light-chain MM. Smoldering MM (SMM) is a precursor condition with higher tumor burden and higher risk of progression to symptomatic MM compared to MGUS. Assessment of the risk of progression of patients with asymptomatic monoclonal gammopathies is based on various factors including clonal burden, as well as biological characteristics, such as cytogenetic abnormalities and light-chain production. Several models have been constructed that are useful in daily practice for predicting risk of progression of MGUS or SMM. Importantly, the plasma cell clone may occasionally be responsible for severe organ damage through the production of a M-protein which deposits in tissues or has autoantibody activity. These disorders are rare and often require therapy directed at eradication of the underlying clone. Importantly, recent studies have shown that asymptomatic patients with a bone marrow plasma cell percentage ≥60%, free light-chain ratio ≥100, or >1 focal lesion on MRI (myeloma-defining events) have a 80% risk of developing symptomatic MM within 2 years. These patients are now considered to have MM requiring therapy, similar to patients with symptomatic disease. In this review, we provide an overview of the new diagnostic criteria of the monoclonal gammopathies and discuss risk of progression to active MM. We also provide recommendations for the management of patients with MGUS and SMM including risk-adapted follow-up.

  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. Soluble ST2 for Risk Stratification and the Prediction of Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation.

    PubMed

    Stundl, Anja; Lünstedt, Nina-Sophie; Courtz, Florian; Freitag-Wolf, Sandra; Frey, Norbert; Holdenrieder, Stefan; Zur, Berndt; Grube, Eberhard; Nickenig, Georg; Werner, Nikos; Frank, Derk; Sinning, Jan-Malte

    2017-09-15

    This study aimed to assess the prognostic value of soluble ST2 (sST2) for risk stratification in patients undergoing transcatheter aortic valve implantation (TAVI). In 461 patients undergoing TAVI, sST2 was determined at baseline and categorized into quartiles. An optimum cutoff of 29 ng/ml was calculated. Primary end point was 1-year all-cause mortality. Results were validated in an independent cohort. Patients with sST2 >29 ng/ml had an increased 30-day (9.7% vs 4.6%, p = 0.043) and 1-year mortality (38.1% vs 21.8%, p = 0.001). In accordance, patients with N-terminal pro-brain natriuretic peptide (NT-proBNP) >8145 pg/ml revealed a comparable 30-day mortality (7.9% vs 4.7%, p = 0.189) and 1-year mortality (39.5% vs 21.0%, p <0.001). In univariate regression analysis, sST2 and NT-proBNP were associated with increased mortality risk. In multivariate regression analysis, independent predictors of mortality were logistic EuroSCORE, chronic renal failure, left ventricular ejection fraction, and sST2. In receiver operating characteristic curve analysis, sST2 did not provide incremental prognostic information beyond that obtained from surgical risk scores such as the STS-PROM or NT-proBNP. Similar findings could be achieved in an independent validation cohort. In conclusion, sST2 is independently associated with adverse outcome after TAVI but was not superior to NT-proBNP or surgical risk scores for the prediction of postprocedural outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

  7. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy.

    PubMed

    Fernandes Serôdio, João; Martins Oliveira, Mário; Matoso Laranjo, Sérgio; Tavares, Cristiano; Silva Cunha, Pedro; Abreu, Ana; Branco, Luísa; Alves, Sandra; Rocha, Isabel; Cruz Ferreira, Rui

    2016-06-01

    Baroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT. The study population consisted of 25 patients with indication for CRT, aged 65±10 years, NYHA functional class ≥III in 52%, QRS width 159±15 ms, left ventricular ejection fraction (LVEF) 29±5%, left ventricular end-systolic volume (LVESV) 150±48 ml, B-type natriuretic peptide (BNP) 357±270 pg/ml, and peak oxygen consumption (peak VO2) 18.4±5.0 ml/kg/min. An orthostatic tilt test was performed to assess the baroreflex effectiveness index (BEI) by the sequence method. This group was compared with 15 age-matched healthy individuals. HF patients showed a significantly depressed BEI during tilt (31±12% vs. 49±18%, p=0.001). A lower BEI was associated with higher BNP (p=0.038), lower peak VO2 (p=0.048), and higher LVESV (p=0.031). By applying a cut-off value of 25% for BEI, two clusters of patients were identified: lower risk cluster (BEI >25%) QRS 153 ms, LVESV 129 ml, BNP 146 pg/ml, peak VO2 19.0 ml/kg/min; and higher risk cluster (IEB ≤25%) QRS 167 ms, LVESV 189 ml, BNP 590 pg/ml, peak VO2 16.2 ml/kg/min. Candidates for CRT show depressed arterial baroreflex function. Lower BEI was observed in high-risk HF patients. Baroreflex function correlated closely with other clinical HF parameters. Therefore, BEI may improve risk stratification in HF patients undergoing CRT. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

  8. Risk stratification for malignant progression in Barrett's esophagus: Gender, age, duration and year of surveillance.

    PubMed

    Gatenby, Piers; Bhattacharjee, Santanu; Wall, Christine; Caygill, Christine; Watson, Anthony

    2016-12-28

    To clarify risk based upon segment length, diagnostic histological findings, patient age and year of surveillance, duration of surveillance and gender. Patients registered with the United Kingdom Barrett's Oesophagus Registry from 9 United Kingdom centers were included. The outcome measures were (1) development of all grades of dysplasia; (2) development of high-grade of dysplasia or adenocarcinoma; and (3) development of adenocarcinoma. Prevalent cases and subjects with < 1 year of follow-up were excluded. The covariates examined were segment length, previous biopsy findings, age at surveillance, duration of surveillance, year of surveillance and gender. One thousand and one hundred thirty six patients were included (total 6474 patient-years). Fifty-four patients developed adenocarcinoma (0.83% per annum), 70 developed high-grade dysplasia/adenocarcinoma (1.1% per annum) and 190 developed any grade of dysplasia (3.5% per annum). High grade dysplasia and adenocarcinoma increased with age and duration of surveillance. The risk of low-grade dysplasia development was not dependent on age at surveillance. Segment length and previous biopsy findings were also significant factors for development of dysplasia and adenocarcinoma. The risk of development of low-grade dysplasia is independent of age at surveillance, but high-grade dysplasia and adenocarcinoma were more commonly found at older age. Segment length and previous biopsy findings are also markers of risk. This study did not demonstrate stabilisation of the metaplastic segment with prolonged surveillance.

  9. A genetic approach to stratification of risk for age-related macular degeneration.

    PubMed

    Zanke, Brent; Hawken, Steven; Carter, Ronald; Chow, David

    2010-02-01

    The genetic determinants of age-related macular degeneration (AMD) are reviewed and a novel approach to risk determination based upon inherited genetic polymorphisms and smoking history is presented. Although AMD was long thought to have primarily an environmental etiology, genetic variation is now known to account for the majority of the disease risk, with variations in the genes of the complement pathways playing a prominent role. Independent and validated clinical studies have implicated the C3 gene and its regulator, complement factor H (1q31.1), complement component 2 (6q21.33), and complement factor B (6q21.33). Subtle variations in complement activity increase the risk of symptomatic macular inflammation with age. A second group of AMD-associated genetic markers may aggravate complement-mediated inflammation by permitting retinal oxidative damage. Variation within the chromosomal site (10q26) coding a mitochondrial-associated protein (age-related maculopathy susceptibility 2) and an independent variation within the mitochondrial genome itself (A4917G) suggest a contributing pathophysiological role of retinal oxidative stress. A genetic panel of disease-susceptibility markers and smoking history can identify a group of individuals with greater than 65% lifetime risk of AMD. The introduction of genetic marker testing into clinical practice may identify patients with early disease who may be aided by presymptomatic monitoring or inclusion into trials of newer prophylactic agents.

  10. Pulmonary embolism at follow-up outpatient CT pulmonary angiography: implications on patient risk stratification.

    PubMed

    Boldt, Brian M; Cox, Christian W; Dedekam, Erik A; Tsytsik, Bair; Mysliwiec, Vincent

    2013-09-01

    The purpose of this study was to determine the prevalence of pulmonary embolism in outpatients who return to care with clinical suspicion of pulmonary embolism and are evaluated by computed tomography pulmonary angiogram (CTPA) after an initial CTPA was negative for pulmonary embolism within the preceding 12 months. Following institutional review board approval, we performed a retrospective review of all CTPAs performed at our institution from June 2006 through June 2009. One hundred and seventy-two outpatients [102 women; mean age 56.7±18.8 (SD)] with an initial CTPA that was negative for pulmonary embolism and a subsequent CTPA within 12 months of their initial study were included in our analysis. Each patient's CTPA was assessed for evidence of pulmonary embolism and their electronic medical records (EMR) reviewed for the presence of risk factors associated with venous thromboembolism (VTE). Fisher exact test (two-tailed) analysis was used to assess whether thromboembolic risk factors had an effect on developing pulmonary embolism after an initial negative CTPA. CTPAs were negative for pulmonary embolism in 165 (96%) of 172 outpatients who returned to care within 12 months after an initial negative CTPA. Eighty-five (49.4%) of 172 patients had no identified thromboembolic risk factors. In the group with no risk factors none (0%) of 85 patients (P=0.028) had pulmonary embolism at the time of repeat CTPA. This may help appropriately triage patients evaluated for pulmonary embolism and reduce the number of unnecessary CTPAs.

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

    PubMed Central

    De Preter, Katleen; Mestdagh, Pieter; Vermeulen, Joëlle; Zeka, Fjoralba; Naranjo, Arlene; Bray, Isabella; Castel, Victoria; Chen, Caifu; Drozynska, Elzbieta; Eggert, Angelika; Hogarty, Michael D.; Iżycka-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, Geneviève; 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

  12. miRNA expression profiling enables risk stratification in archived and fresh neuroblastoma tumor samples.

    PubMed

    De Preter, Katleen; Mestdagh, Pieter; Vermeulen, Joëlle; Zeka, Fjoralba; Naranjo, Arlene; Bray, Isabella; Castel, Victoria; Chen, Caifu; Drozynska, Elzbieta; Eggert, Angelika; Hogarty, Michael D; Izycka-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, Geneviève; Van Roy, Nadine; Speleman, Frank; Vandesompele, Jo

    2011-12-15

    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. 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. 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. 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. ©2011 AACR.

  13. 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

  14. Usefulness of Relative Hypochromia in Risk Stratification for Non-Anemic Patients with Chronic Heart Failure

    PubMed Central

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

    2016-01-01

    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 non-anemic patients with heart failure (HF). We prospectively enrolled 1,579 subjects with HF undergoing 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 males, and <12 g/dL in females. In our non-anemic cohort (n=785, 49.7%), mean Hb and median MCHC were 13.8±1.1 g/dL and 34.3 (interquartile range 33.6-35) g/dL, respectively. Non-anemic HF patients with lower MCHC had higher mortality risk (Quartiles 1 vs 4, Hazard ratio = 2.1, 95% confidence interval 1.4-3.3, p=0.001). In a subset of non-anemic 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 to patients with levels of MCHC above 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

  15. Impact of Denervated Myocardium on Improving Risk Stratification for Sudden Cardiac Death

    PubMed Central

    Cain, Michael E.

    2014-01-01

    Between 184,000 and 462,000 Americans die suddenly each year. Fifty percent to 70% of these deaths are due to ventricular tachycardia/fibrillation (VT/VF). We tested whether hibernating myocardium or myocardial sympathetic denervation identifies patients at high-risk for developing VT/VF independently of ejection fraction (EF). Positron emission tomography (PET) was used to quantify myocardial sympathetic denervation (11C-meta-hydroxyephedrine [11C-HED]), perfusion (13N-ammonia), and viability (insulin-stimulated 18F-2-deoxyglucose [18FDG]) in patients with ischemic cardiomyopathy (EF < 35%) eligible for a primary prevention implantable cardioverter defibrillator (ICD). The primary end-point was sudden cardiac arrest (SCA) defined as arrhythmic death or ICD discharge for VT/VF > 240 bpm. Volumes of total denervated (P = .001) and viable denervated myocardium (11C-HED-18FDG mismatch, P = .03) predicted SCA, whereas hibernating and infarcted myocardium did not. Multivariate analysis identified four independent predictors of SCA: denervated myocardium > 37.6% of left ventricule (LV), LV end-diastolic volume > 98 mL/m2, creatinine level > 1.49 mg/dL, and no angiotensin- inhibition therapy. Denervated myocardium had a hazard ratio of 3.5 for SCA (10.3%/year vs. 3.0%/year, p=0.001). Absence of all four factors predicted low risk (44% of cohort; SCA <1%/y) whereas two or more factors identified subjects at high-risk (20% of cohort; SCA 12%/y). Denervated myocardium quantified using PET strongly predicts risk of SCA, and is independent of EF, infarct volume, and other clinical variables. PMID:25125727

  16. Impact of denervated myocardium on improving risk stratification for sudden cardiac death.

    PubMed

    Cain, Michael E

    2014-01-01

    Between 184,000 and 462,000 Americans die suddenly each year. Fifty percent to 70% of these deaths are due to ventricular tachycardia/fibrillation (VT/VF). We tested whether hibernating myocardium or myocardial sympathetic denervation identifies patients at high-risk for developing VT/VF independently of ejection fraction (EF). Positron emission tomography (PET) was used to quantify myocardial sympathetic denervation ((11)C-meta-hydroxyephedrine [(11)C-HED]), perfusion ((13)N-ammonia), and viability (insulin-stimulated (18)F-2-deoxyglucose [(18)FDG]) in patients with ischemic cardiomyopathy (EF < 35%) eligible for a primary prevention implantable cardioverter defibrillator (ICD). The primary end-point was sudden cardiac arrest (SCA) defined as arrhythmic death or ICD discharge for VT/VF > 240 bpm. Volumes of total denervated (P = .001) and viable denervated myocardium ((11)C-HED-(18)FDG mismatch, P = .03) predicted SCA, whereas hibernating and infarcted myocardium did not. Multivariate analysis identified four independent predictors of SCA: denervated myocardium > 37.6% of left ventricule (LV), LV end-diastolic volume > 98 mL/m(2), creatinine level > 1.49 mg/dL, and no angiotensin- inhibition therapy. Denervated myocardium had a hazard ratio of 3.5 for SCA (10.3%/year vs. 3.0%/year, p=0.001). Absence of all four factors predicted low risk (44% of cohort; SCA <1%/y) whereas two or more factors identified subjects at high-risk (20% of cohort; SCA 12%/y). Denervated myocardium quantified using PET strongly predicts risk of SCA, and is independent of EF, infarct volume, and other clinical variables.

  17. [Prognostic value of exercise testing in risk stratification of patients with heart failure].

    PubMed

    Lara Vargas, Jorge; Ilarraza-Lomelí, Hermes; García Saldivia, Marianna; Bueno Ayala, Leopoldo

    2015-01-01

    To compare the predictive power of conventional exercise testing (CVET) vs cardiopulmonary exercise testing (CPET). A cohort study of 1,474 patients with heart failure was analyzed. We assessed variables of CVET and CPET. We used Schiller CS200 equipment with modified Balke protocol ramp. The comparison between groups was performed by correlation and contingency tables. It was considered stochastic significance when P<.05. 80% of the patients were male with an average age of 53±15 years. The most prevalent causes of heart failure were 65% for ischemic heart disease and 27% for dilated cardiomyopathy. Left ventricle ejection fraction (LVEF) was 34±10%, the workload were 6.3±2 (87%) METs and VO2 peak was 21±7mlO2/kg/min. CPET qualified 9% more patients at high risk compared to the 78% CVET, P<.001. The variables with more percentage at high risk were: 60% chronotropic incompetence and 49% VO2 recovery. The sensitivity, specificity and accuracy CVET for detecting high-risk subjects, compared to the CPET was 90%, 100% and 91% respectively. Weighted kappa between two tests was 0.7 (P<.001). The CVET has adequate sensitivity and specificity to detect patients with heart failure at high risk relative to the CPET. The degree of agreement is significant, but not enough to consider it as a surrogated test. Copyright © 2015 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.

  18. The influence of preoperative risk stratification on fast-tracking patients after pulmonary resection.

    PubMed

    Bryant, Ayesha S; Cerfolio, Robert J

    2008-02-01

    Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital length of stay and reduce costs; however, not all patients can be fast-tracked. Certain patient characteristics may put patients at increased risk to fail fast-tracking. Additionally some patients have multiple risk factors that have an additive effect that puts them at an even increased risk to fail fast-tracking, and more importantly, to significant morbidity. It is a mistake to force these protocols on all patients because it can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results via accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Once these characteristics are pinpointed, specific changes to the postoperative algorithm can be implemented, and these alterations can lead to improved outcomes. The authors have shown that by using pain pumps instead of epidurals in elderly patients we can improve outcomes and still fast-track octogenarians with minimal morbidity and high-patient satisfaction. We have also shown that the increased use of physical therapy and respiratory treatments (important parts of the care of all patients after pulmonary resection, but a limited resource in most hospitals) may also lead to improved surgical results for those who have low FEV1% and DLco%. Further studies are needed. Although fast-tracking protocols cannot be applied to all, the vast majority of patients who undergo elective pulmonary resection, even those at high risk, can undergo safe, efficient, and cost-saving care via preset postoperative algorithms. When the typical daily events are convened each morning and the planned date of discharge is frequently communicated with the patient and family before surgery and each day in the hospital, most patients can be safely fast-tracked with high satisfaction and outstanding results.

  19. Risk stratification in chest pain patients undergoing nuclear stress testing: the Erlanger Stress Score.

    PubMed

    Fesmire, Francis M; Buchheit, Ron C; Cao, Yu; Severance, Harry W; Jang, Yi; Heath, Gregory W

    2012-12-01

    Studies have individually reported the relationship of age, cardiac risk factors, and history of preexisting coronary artery disease (CAD) for predicting acute coronary syndromes in chest pain patients undergoing cardiac stress testing. In this study, we investigate the interplay of all these factors on the incidence of acute coronary syndromes to develop a tool that may assist physicians in the selection of appropriate chest pain patients for stress testing. Retrospective analysis of a prospectively acquired database of consecutive chest pain patients undergoing nuclear stress testing. Backward stepwise logistic regression was used to develop a model for predicting risk of 30-day acute coronary events (ACE) using information obtained from age, sex, cardiac risk factors, and history of preexisting CAD. A total of 800 chest pain patients underwent nuclear stress testing. ACE occurred in 74 patients (9.3%). Logistic regression analysis found only 6 factors predictive of ACE: age, male sex, preexisting CAD, diabetes, and hyperlipidemia. Area under the receiver operator characteristic curve of this model for predicting ACE was 0.767 (95% confidence interval, 0.719-0.815). There were no cases of ACE in the 173 patients with predicted probability estimates ≤2.5% (95% confidence interval, 0%-2.1%). A regression model using age, sex, preexisting CAD, diabetes, and hyperlipidemia is predictive of 30-day ACE in chest pain patients undergoing nuclear stress testing. Prospective studies need to be performed to determine whether this model can assist physicians in the selection of appropriate low-to-intermediate risk chest pain patients for nuclear stress testing.

  20. Image-based left ventricular shape analysis for sudden cardiac death risk stratification.

    PubMed

    Vadakkumpadan, Fijoy; Trayanova, Natalia; Wu, Katherine C

    2014-10-01

    Low left ventricular ejection fraction (LVEF), the main criterion used in the current clinical practice to stratify sudden cardiac death (SCD) risk, has low sensitivity and specificity. To uncover indices of left ventricular (LV) shape that differ between patients with a high risk of SCD and those with a low risk. By using clinical cardiac magnetic resonance imaging and computational anatomy tools, a novel computational framework to compare 3-dimensional LV endocardial surface curvedness, wall thickness, and relative wall thickness between patient groups was implemented. The framework was applied to cardiac magnetic resonance data of 61 patients with ischemic cardiomyopathy who were selected for prophylactic implantable cardioverter-defibrillator treatment on the basis of reduced LVEF. The patients were classified by outcome: group 0 had no events; group 1, arrhythmic events; and group 2, heart failure events. Segmental differences in LV shape were assessed. Global LV volumes and mass were similar among groups. Compared with patients with no events, patients in groups 1 and 2 had lower mean shape metrics in all coronary artery regions, with statistical significance in 9 comparisons, reflecting wall thinning and stretching/flattening. In patients with ischemic cardiomyopathy and low LVEF, there exist quantifiable differences in 3-dimensional endocardial surface curvedness, LV wall thickness, and LV relative wall thickness between those with no clinical events and those with arrhythmic or heart failure outcomes, reflecting adverse LV remodeling. This retrospective study is a proof of concept to demonstrate that regional LV remodeling indices have the potential to improve the personalized risk assessment for SCD. Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  1. 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.

  2. Different people respond differently to therapy: A demonstration using patient profiling and risk stratification.

    PubMed

    Delgadillo, Jaime; Moreea, Omar; Lutz, Wolfgang

    2016-04-01

    This study aimed to identify patient characteristics associated with poor outcomes in psychological therapy, and to develop a patient profiling method. Clinical assessment data for 1347 outpatients was analysed. Final treatment outcome was based on reliable and clinically significant improvement (RCSI) in depression (PHQ-9) and anxiety (GAD-7) measures. Thirteen patient characteristics were explored as potential outcome predictors using logistic regression in a cross-validation design. Disability, employment status, age, functional impairment, baseline depression and outcome expectancy predicted post-treatment RCSI. Regression coefficients for these factors were used to derive a weighting scheme called Leeds Risk Index (LRI), used to assign risk scores to individual cases. After stratifying cases into three levels of LRI scores, we found significant differences in RCSI and treatment completion rates. Furthermore, LRI scores were significantly correlated with the proportion of treatment sessions classified as 'not on track'. The LRI tool can identify cases at risk of poor progress to inform personalized treatment recommendations for low and high intensity psychological interventions. Copyright © 2016 Elsevier Ltd. All rights reserved.

  3. Usefulness of Neutrophil-to-Lymphocyte Ratio in Risk Stratification of Patients with Advanced Heart Failure

    PubMed Central

    Benites-Zapata, Vicente A.; Hernandez, Adrian V.; Nagarajan, Vijaiganesh; Cauthen, Clay A.; Starling, Randall C.; Tang, W. H. Wilson

    2014-01-01

    Elevated neutrophil-to-lymphocyte Ratio (NLR) has been associated with increased mortality in patients with acute heart failure (HF) as well as in neoplastic diseases. We investigated the association between NLR and mortality or cardiac transplantation in a retrospective cohort of 527 patients presented to the Cleveland Clinic for evaluation of advanced HF therapy options between 2007 and 2010. Patients were divided according to low, intermediate, and high tertiles of NLR, and were followed longitudinally for time to all-causes mortality or heart transplantation (primary outcome). The median NLR was 3.9 (IQR 2.5, 6.5). In univariate analysis, intermediate and highest tertiles of NLR had a higher risk than the lowest tertile for the primary outcome and all-causes mortality. Compared to the lowest tertile, there was no difference in the risk of heart transplantation for intermediate and high tertiles. In multivariate analysis, when compared to the lowest tertile, the intermediate and high NLR tertiles remained significantly associated with the primary outcome (HR=1.61 [95%CI 1.10 to 2.37] and HR=1.55 [95%CI 1.02 to 2.36], respectively), and all-causes mortality (HR=1.83 [95%CI 1.07 to 3.14] and HR=2.16 [95%CI 1.21 to 3.83], respectively). In conclusion, elevated NLR is associated with increased mortality or heart transplantation risk in patients with advanced HF. PMID:25456873

  4. Usefulness of neutrophil-to-lymphocyte ratio in risk stratification of patients with advanced heart failure.

    PubMed

    Benites-Zapata, Vicente A; Hernandez, Adrian V; Nagarajan, Vijaiganesh; Cauthen, Clay A; Starling, Randall C; Tang, W H Wilson

    2015-01-01

    Elevated neutrophil-to-lymphocyte ratio (NLR) has been associated with increased mortality in patients with acute heart failure (HF) and neoplastic diseases. We investigated the association between NLR and mortality or cardiac transplantation in a retrospective cohort of 527 patients presented to the Cleveland Clinic for evaluation of advanced HF therapy options from 2007 to 2010. Patients were divided according to low, intermediate, and high tertiles of NLR and were followed longitudinally for time to all-cause mortality or heart transplantation (primary outcome). The median NLR was 3.9 (interquartile range 2.5 to 6.5). In univariate analysis, intermediate and highest tertiles of NLR had a higher risk than the lowest tertile for the primary outcome and all-causes mortality. Compared with the lowest tertile, there was no difference in the risk of heart transplantation for intermediate and high tertiles. In multivariate analysis, compared with the lowest tertile, the intermediate and high NLR tertiles remained significantly associated with the primary outcome (hazard ratio [HR] = 1.61, 95% confidence interval [CI] 1.10 to 2.37 and HR = 1.55, 95% CI 1.02 to 2.36, respectively) and all-cause mortality (HR = 1.83, 95% CI 1.07 to 3.14 and HR = 2.16, 95% CI 1.21 to 3.83, respectively). In conclusion, elevated NLR is associated with increased mortality or heart transplantation risk in patients with advanced HF.

  5. Computational cardiology and risk stratification for sudden cardiac death: one of the grand challenges for cardiology in the 21st century

    PubMed Central

    Perry, Matthew D.; Abi‐Gerges, Najah; Couderc, Jean‐Philippe; Fermini, Bernard; Hancox, Jules C.; Knollmann, Bjorn C.; Mirams, Gary R.; Skinner, Jon; Zareba, Wojciech; Vandenberg, Jamie I.

    2016-01-01

    Abstract Risk stratification in the context of sudden cardiac death has been acknowledged as one of the major challenges facing cardiology for the past four decades. In recent years, the advent of high performance computing has facilitated organ‐level simulation of the heart, meaning we can now examine the causes, mechanisms and impact of cardiac dysfunction in silico. As a result, computational cardiology, largely driven by the Physiome project, now stands at the threshold of clinical utility in regards to risk stratification and treatment of patients at risk of sudden cardiac death. In this white paper, we outline a roadmap of what needs to be done to make this translational step, using the relatively well‐developed case of acquired or drug‐induced long QT syndrome as an exemplar case. PMID:27060987

  6. Computational cardiology and risk stratification for sudden cardiac death: one of the grand challenges for cardiology in the 21st century.

    PubMed

    Hill, Adam P; Perry, Matthew D; Abi-Gerges, Najah; Couderc, Jean-Philippe; Fermini, Bernard; Hancox, Jules C; Knollmann, Bjorn C; Mirams, Gary R; Skinner, Jon; Zareba, Wojciech; Vandenberg, Jamie I

    2016-12-01

    Risk stratification in the context of sudden cardiac death has been acknowledged as one of the major challenges facing cardiology for the past four decades. In recent years, the advent of high performance computing has facilitated organ-level simulation of the heart, meaning we can now examine the causes, mechanisms and impact of cardiac dysfunction in silico. As a result, computational cardiology, largely driven by the Physiome project, now stands at the threshold of clinical utility in regards to risk stratification and treatment of patients at risk of sudden cardiac death. In this white paper, we outline a roadmap of what needs to be done to make this translational step, using the relatively well-developed case of acquired or drug-induced long QT syndrome as an exemplar case.

  7. Mantle cell lymphoma: 2017 update on diagnosis, risk-stratification, and clinical management.

    PubMed

    Vose, Julie M

    2017-08-01

    Mantle cell lymphoma (MCL) is a non-Hodgkin lymphoma characterized by involvement of the lymph nodes, spleen, blood and bone marrow with a short remission duration to standard therapies and a median overall survival (OS) of 4-5 years. Diagnosis is based on lymph node, bone marrow, or tissue morphology of centrocytic lymphocytes, small cell type, or blastoid variant cells. A chromosomal translocation t (11:14) is the molecular hallmark of MCL, resulting in the overexpression of cyclin D1. Cyclin D1 is detected by immunohistochemistry in 98% of cases. The absence of SOX-11 or a low Ki-67 may correlate with a more indolent form of MCL. The differential diagnosis of MCL includes small lymphocytic lymphoma, marginal zone lymphoma, and follicular lymphoma. The MCL International Prognostic Index (MIPI) is the prognostic model most often used and incorporates ECOG performance status, age, leukocyte count, and lactic dehydrogenase. A modification of the MIPI also adds the Ki-67 proliferative index if available. The median OS for the low-risk group was not reached (5-year OS of 60%). The median OS for the intermediate risk group was 51 months and 29 months for the high risk group. For selected indolent, low MIPI MCL patients, initial observation may be appropriate therapy. For younger patients with intermediate or high risk MIPI MCL, aggressive therapy with a cytotoxic Regimen followed by autologous stem cell transplantation should be considered. Rituximab maintenance after autologous stem cell transplantation has also improved the progression-free and overall survival. For older symptomatic MCL patients with intermediate or high risk MIPI, combination chemotherapy with R-CHOP, R-Bendamustine, or a clinical trial should be considered. In addition, rituximab maintenance therapy may prolong the progression-free survival. At the time of relapse, agents directed at activated pathways in MCL cells such as bortezomib (NFkB inhibitor), lenalidamide (anti-angiogenesis) and

  8. Pre-transplantation minimal residual disease with cytogenetic and molecular diagnostic features improves risk stratification in acute myeloid leukemia

    PubMed Central

    Oran, Betül; Jorgensen, Jeff L.; Marin, David; Wang, Sa; Ahmed, Sairah; Alousi, Amin M.; Andersson, Borje S.; Bashir, Qaiser; Bassett, Roland; Lyons, Genevieve; Chen, Julianne; Rezvani, Katy; Popat, Uday; Kebriaei, Partow; Patel, Keyur; Rondon, Gabriela; Shpall, Elizabeth J.; Champlin, Richard E.

    2017-01-01

    Our aim was to improve outcome prediction after allogeneic hematopoietic stem cell transplantation in acute myeloid leukemia by combining cytogenetic and molecular data at diagnosis with minimal residual disease assessment by multicolor flow-cytometry at transplantation. Patients with acute myeloid leukemia in first complete remission in whom minimal residual disease was assessed at transplantation were included and categorized according to the European LeukemiaNet classification. The primary outcome was 1-year relapse incidence after transplantation. Of 152 patients eligible, 48 had minimal residual disease at the time of their transplant. Minimal residual disease-positive patients were older, required more therapy to achieve first remission, were more likely to have incomplete recovery of blood counts and had more adverse risk features by cytogenetics. Relapse incidence at 1 year was higher in patients with minimal residual disease (32.6% versus 14.4%, P=0.002). Leukemia-free survival (43.6% versus 64%, P=0.007) and overall survival (48.8% versus 66.9%, P=0.008) rates were also inferior in patients with minimal residual disease. In multivariable analysis, minimal residual disease status at transplantation independently predicted 1-year relapse incidence, identifying a subgroup of intermediate-risk patients, according to the European LeukemiaNet classification, with a particularly poor outcome. Assessment of minimal residual disease at transplantation in combination with cytogenetic and molecular findings provides powerful independent prognostic information in acute myeloid leukemia, lending support to the incorporation of minimal residual disease detection to refine risk stratification and develop a more individualized approach during hematopoietic stem cell transplantation. PMID:27540139

  9. Comparison of nonlinear methods symbolic dynamics, detrended fluctuation, and Poincaré plot analysis in risk stratification in patients with dilated cardiomyopathy

    NASA Astrophysics Data System (ADS)

    Voss, Andreas; Schroeder, Rico; Truebner, Sandra; Goernig, Matthias; Figulla, Hans Reiner; Schirdewan, Alexander

    2007-03-01

    Dilated cardiomyopathy (DCM) has an incidence of about 20/100 000 new cases per annum and accounts for nearly 10 000 deaths per year in the United States. Approximately 36% of patients with dilated cardiomyopathy (DCM) suffer from cardiac death within five years after diagnosis. Currently applied methods for an early risk prediction in DCM patients are rather insufficient. The objective of this study was to investigate the suitability of short-term nonlinear methods symbolic dynamics (STSD), detrended fluctuation (DFA), and Poincaré plot analysis (PPA) for risk stratification in these patients. From 91 DCM patients and 30 healthy subjects (REF), heart rate and blood pressure variability (HRV, BPV), STSD, DFA, and PPA were analyzed. Measures from BPV analysis, DFA, and PPA revealed highly significant differences (p<0.0011) discriminating REF and DCM. For risk stratification in DCM patients, four parameters from BPV analysis, STSD, and PPA revealed significant differences between low and high risk (maximum sensitivity: 90%, specificity: 90%). These results suggest that STSD and PPA are useful nonlinear methods for enhanced risk stratification in DCM patients.

  10. 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. © 2015 American Cancer Society.

  11. Risk stratification in the hormonal treatment of patients with prostate cancer.

    PubMed

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

    2009-09-01

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

  12. Risk stratification of metastatic recurrence in invasive upper urinary tract carcinoma after radical nephroureterectomy without lymphadenectomy.

    PubMed

    Colin, Pierre; Ghoneim, Tarek P; Nison, Laurent; Seisen, Thomas; Lechevallier, Eric; Cathelineau, Xavier; Ouzzane, Adil; Zerbib, Marc; Long, Jean-Alexandre; Ruffion, Alain; Crouzet, Sébastien; Cussenot, Olivier; Audouin, Marie; Irani, Jacques; Gardic, Solène; Gres, Pascal; Audenet, François; Roumiguié, Mathieu; Valeri, Antoine; Rouprêt, Morgan

    2014-04-01

    To assess the risk factors of metastasis relapse in pT2-3 upper tract urothelial carcinomas (UTUCs) treated by radical nephroureterectomy (RNU) without lymphadenectomy (LN). A multicentric retrospective study was performed for pT2-3 pNx UTUCs treated by RNU between 1995 and 2010. The following criteria were retrieved: age, gender, American Society of Anaesthesiologists physical status, surgical approach, preoperative hydronephrosis, stage, grade, tumor location, surgical margin, lymphovascular invasion (LVI) status and outcomes. Metastasis-free survival (MFS) was measured by Kaplan-Meier method with the log-rank test. Overall, 151 patients were included. The median follow-up was 18.5 months (IQR 9.5-37.9). The 2- and 5-year MFS were 69 % ± 4.5 and 54.1 % ± 5.8, respectively. In univariate analysis, ureteral location, pT3 stage, positive LVI status and positive surgical margin were significantly associated with worse MFS (p = 0.03; 0.02; 0.01 and 0.006, respectively). In the multivariate analysis of ureteral location and pT3 stage were independent prognostic factors (p = 0.03 and 0.03, respectively). Based on the results of the univariate analysis, we proposed a risk model predicting MFS, which classifies patients into 3 categories with different overall survival (p < 0.001). In view of our data, tumor location, T stage, LVI and surgical margin status are mandatory to predict survival in case of RN without LN. Contingent upon external validation, our risk model based on these variables could be useful to provide relevant information concerning metastasis relapse probability and necessity of close follow-up for these patients.

  13. Tumour budding is a reproducible index for risk stratification of patients with stage II colon cancer.

    PubMed

    Lai, Y-H; Wu, L-C; Li, P-S; Wu, W-H; Yang, S-B; Xia, P; He, X-X; Xiao, L-B

    2014-04-01

    High-risk patients with Stage II colon cancer may benefit from adjuvant chemotherapy, but it is difficult to identify such a patient group. A robust and reproducible index would be helpful to select the subset of Stage II colon cancer patients at high risk. This study investigated the potential prognostic significance of tumour budding in Stage II colon cancer. In all, 135 Stage II colon cancer patients with known outcome were identified. The degree of tumour budding was assessed by two individual observers and was classified, according to the number of tumour buds in the area with the greatest budding intensity on haematoxylin and eosin slides, as high-grade budding (10 or more tumour buds) and low-grade budding (0-9 buds). Inter-observer agreement for two observers was assessed by using the kappa test. Progression-free and cancer-specific survivals were analysed using the Kaplan-Meier method and Cox regression. The 5-year progression-free survival rates for patients with high-grade tumour budding (n = 36) and those with low-grade budding (n = 99) were 57.6% and 89.0% (P < 0.001). The 5-year cancer-specific survival rates were 66.7% vs 92.0% (P < 0.001). Cox regression analyses demonstrated tumour budding as an independent predictor of disease progression (hazard ratio 4.982, P < 0.001) and cancer-related death (hazard ratio 4.142, P = 0.003). The two observers agreed on the classification of tumour budding in 118 cases (87.4%) and the inter-observer agreement was good (κ = 0.692). Tumour budding is a strong and reproducible prognostic factor for adverse outcome in Stage II colon cancer, which may serve as a prognostic marker to identify patients with a high risk of recurrence who may benefit from adjuvant therapy. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

  14. Can Ambulatory Blood Pressure Variability Contribute to Individual Cardiovascular Risk Stratification?

    PubMed

    Magdás, Annamária; Szilágyi, László; Incze, Alexandru

    2016-01-01

    Objective. The aim of this study is to define the normal range for average real variability (ARV) and to establish whether it can be considered as an additional cardiovascular risk factor. Methods. In this observational study, 110 treated hypertensive patients were included and admitted for antihypertensive treatment adjustment. Circadian blood pressure was recorded with validated devices. Blood pressure variability (BPV) was assessed according to the ARV definition. Based on their variability, patients were classified into low, medium, and high variability groups using the fuzzy c-means algorithm. To assess cardiovascular risk, blood samples were collected. Characteristics of the groups were compared by ANOVA tests. Results. Low variability was defined as ARV below 9.8 mmHg (32 patients), medium as 9.8-12.8 mmHg (48 patients), and high variability above 12.8 mmHg (30 patients). Mean systolic blood pressure was 131.2 ± 16.7, 135.0 ± 12.1, and 141.5 ± 11.4 mmHg in the low, medium, and high variability groups, respectively (p = 0.0113). Glomerular filtration rate was 78.6 ± 29.3, 74.8 ± 26.4, and 62.7 ± 23.2 mL/min/1.73 m(2) in the low, medium, and high variability groups, respectively (p = 0.0261). Conclusion. Increased values of average real variability represent an additional cardiovascular risk factor. Therefore, reducing BP variability might be as important as achieving optimal BP levels, but there is need for further studies to define a widely acceptable threshold value.

  15. National Veterans Health Administration inpatient risk stratification models for hospital-acquired acute kidney injury

    PubMed Central

    Cronin, Robert M; VanHouten, Jacob P; Siew, Edward D; Eden, Svetlana K; Fihn, Stephan D; Nielson, Christopher D; Peterson, Josh F; Baker, Clifton R; Ikizler, T Alp; Speroff, Theodore

    2015-01-01

    Objective Hospital-acquired acute kidney injury (HA-AKI) is a potentially preventable cause of morbidity and mortality. Identifying high-risk patients prior to the onset of kidney injury is a key step towards AKI prevention. Materials and Methods A national retrospective cohort of 1,620,898 patient hospitalizations from 116 Veterans Affairs hospitals was assembled from electronic health record (EHR) data collected from 2003 to 2012. HA-AKI was defined at stage 1+, stage 2+, and dialysis. EHR-based predictors were identified through logistic regression, least absolute shrinkage and selection operator (lasso) regression, and random forests, and pair-wise comparisons between each were made. Calibration and discrimination metrics were calculated using 50 bootstrap iterations. In the final models, we report odds ratios, 95% confidence intervals, and importance rankings for predictor variables to evaluate their significance. Results The area under the receiver operating characteristic curve (AUC) for the different model outcomes ranged from 0.746 to 0.758 in stage 1+, 0.714 to 0.720 in stage 2+, and 0.823 to 0.825 in dialysis. Logistic regression had the best AUC in stage 1+ and dialysis. Random forests had the best AUC in stage 2+ but the least favorable calibration plots. Multiple risk factors were significant in our models, including some nonsteroidal anti-inflammatory drugs, blood pressure medications, antibiotics, and intravenous fluids given during the first 48 h of admission. Conclusions This study demonstrated that, although all the models tested had good discrimination, performance characteristics varied between methods, and the random forests models did not calibrate as well as the lasso or logistic regression models. In addition, novel modifiable risk factors were explored and found to be significant. PMID:26104740

  16. Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score.

    PubMed

    Fesmire, Francis M; Martin, Erik J; Cao, Yu; Heath, Gregory W

    2012-11-01

    The HEART score uses elements from patient History, Electrocardiogram, Age, Risk Factors, and Troponin to obtain a risk score on a 0- to 10-point scale for predicting acute coronary syndromes (ACS). This investigation seeks to improve on the HEART score by proposing the HEARTS(3) score, which uses likelihood ratio analysis to give appropriate weight to the individual elements of the HEART score as well as incorporating 3 additional "S" variables: Sex, Serial 2-hour electrocardiogram, and Serial 2-hour delta troponin during the initial emergency department valuation. This is a retrospective analysis of a prospectively acquired database consisting of 2148 consecutive patients with non-ST-segment elevation chest pain. Interval analysis of likelihood ratios was performed to determine appropriate weighting of the individual elements of the HEART(3) score. Primary outcomes were 30-day ACS and myocardial infarction. There were 315 patients with 30-day ACS and 1833 patients without ACS. Likelihood ratio analysis revealed significant discrepancies in weight of the 5 individual elements shared by the HEART and HEARTS(3) score. The HEARTS(3) score outperformed the HEART score as determined by comparison of areas under the receiver operating characteristic curve for myocardial infarction (0.958 vs 0.825; 95% confidence interval difference in areas, 0.105-0.161) and for 30-day ACS (0.901 vs 0.813; 95% confidence interval difference in areas, 0.064-0.110). The HEARTS(3) score reliably risk stratifies patients with chest pain for 30-day ACS. Prospective studies need to be performed to determine if implementation of this score as a decision support tool can guide treatment and disposition decisions in the management of patients with chest pain. Copyright © 2012 Elsevier Inc. All rights reserved.

  17. National Veterans Health Administration inpatient risk stratification models for hospital-acquired acute kidney injury.

    PubMed

    Cronin, Robert M; VanHouten, Jacob P; Siew, Edward D; Eden, Svetlana K; Fihn, Stephan D; Nielson, Christopher D; Peterson, Josh F; Baker, Clifton R; Ikizler, T Alp; Speroff, Theodore; Matheny, Michael E

    2015-09-01

    Hospital-acquired acute kidney injury (HA-AKI) is a potentially preventable cause of morbidity and mortality. Identifying high-risk patients prior to the onset of kidney injury is a key step towards AKI prevention. A national retrospective cohort of 1,620,898 patient hospitalizations from 116 Veterans Affairs hospitals was assembled from electronic health record (EHR) data collected from 2003 to 2012. HA-AKI was defined at stage 1+, stage 2+, and dialysis. EHR-based predictors were identified through logistic regression, least absolute shrinkage and selection operator (lasso) regression, and random forests, and pair-wise comparisons between each were made. Calibration and discrimination metrics were calculated using 50 bootstrap iterations. In the final models, we report odds ratios, 95% confidence intervals, and importance rankings for predictor variables to evaluate their significance. The area under the receiver operating characteristic curve (AUC) for the different model outcomes ranged from 0.746 to 0.758 in stage 1+, 0.714 to 0.720 in stage 2+, and 0.823 to 0.825 in dialysis. Logistic regression had the best AUC in stage 1+ and dialysis. Random forests had the best AUC in stage 2+ but the least favorable calibration plots. Multiple risk factors were significant in our models, including some nonsteroidal anti-inflammatory drugs, blood pressure medications, antibiotics, and intravenous fluids given during the first 48 h of admission. This study demonstrated that, although all the models tested had good discrimination, performance characteristics varied between methods, and the random forests models did not calibrate as well as the lasso or logistic regression models. In addition, novel modifiable risk factors were explored and found to be significant. Published by Oxford University Press on behalf of the American Medical Informatics Association 2015. This work is written by US Government employees and is in the public domain in the US.

  18. Developing a risk stratification model for predicting future health care use in asthmatic children.

    PubMed

    Hanson, Jill R; Lee, Brian R; Williams, David D; Murphy, Helen; Kennedy, Kevin; DeLurgio, Stephen A; Portnoy, Jay; Reddy, Mamta

    2016-01-01

    Previous studies have stratified pediatric asthma patients for risk of future exacerbation and/or health care use, but most incorporate multiple clinical parameters. To determine whether historical acute care visits (ACVs) alone could predict risk of future health care use. Children seen for asthma in an outpatient visit during a 3-year period were identified. The number of ACVs in the 12 months before and after the outpatient visit was determined. Logistic regression models were used to determine the odds of a future ACV. Models were adjusted for age, sex, race, and insurance status. Of 28,047 outpatient visits, 21,099 (75.2%) had no historical ACVs. The probability of a future ACV increased from 30% with one historical ACV to 87% with 5 or more historical ACVs. Outpatient visits with one historical ACV had significantly higher odds of a future ACV compared with those with no historical ACVs (adjusted odds ratio [OR], 3.60; 95% confidence interval [CI], 3.14-4.12; P < .001). The OR increased with each additional historical ACV to an adjusted OR of 58.71 (95% CI, 24.34-141.61; P < .001) with 5 or more historical ACVs. Outpatient visits with 5 or more historical ACVs represented only 1.1% of the study sample but accounted for a higher mean number of future ACVs. The historical count of ACVs was predictive of future ACVs. A significant increase in the probability of future ACVs was observed with each additional historical visit, effectively stratifying risk by the historical visit count. Notably, a small group of patients accounted for a disproportionate number of future ACVs. Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

  19. Procedures for risk-stratification of lung cancer using buccal nanocytology

    PubMed Central

    Subramanian, H.; Viswanathan, P.; Cherkezyan, L.; Iyengar, R.; Rozhok, S.; Verleye, M.; Derbas, J.; Czarnecki, J.; Roy, H. K.; Backman, V.

    2016-01-01

    Lung cancer is the leading cause of cancer deaths in the U.S. with survival dramatically depending on stage at diagnosis. We had earlier reported that nanocytology of buccal cells can accurately risk-stratify smokers for the presence of early and late-stage lung cancer. To translate the technique into clinical practice, standardization of operating procedures is necessary to consistently yield precise and repeatable results. Here, we develop and validate simple, robust, and easily implementable procedures for specimen collection, processing, etc. in addition to a commercially-viable instrument prototype. Results of this work enable translation of the technology from academic lab to physicians’ office. PMID:27699138

  20. Triple rule-out computed tomography for risk stratification of patients with acute chest pain.

    PubMed

    Chae, Minjung Kathy; Kim, Eun Kyoung; Jung, Ka-Young; Shin, Tae Gun; Sim, Min Seob; Jo, Ik-Joon; Song, Keun Jeong; Chang, Sung-A; Song, Young Bin; Hahn, Joo-Yong; Choi, Seung Hyuk; Gwon, Hyeon-Cheol; Lee, Sang-Hoon; Kim, Sung Mok; Eo, Hong; Choe, Yeon Hyeon; Choi, Jin-Ho

    2016-01-01

    Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain. We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings. TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons). Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores. Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights

  1. Procedures for risk-stratification of lung cancer using buccal nanocytology.

    PubMed

    Subramanian, H; Viswanathan, P; Cherkezyan, L; Iyengar, R; Rozhok, S; Verleye, M; Derbas, J; Czarnecki, J; Roy, H K; Backman, V

    2016-09-01

    Lung cancer is the leading cause of cancer deaths in the U.S. with survival dramatically depending on stage at diagnosis. We had earlier reported that nanocytology of buccal cells can accurately risk-stratify smokers for the presence of early and late-stage lung cancer. To translate the technique into clinical practice, standardization of operating procedures is necessary to consistently yield precise and repeatable results. Here, we develop and validate simple, robust, and easily implementable procedures for specimen collection, processing, etc. in addition to a commercially-viable instrument prototype. Results of this work enable translation of the technology from academic lab to physicians' office.

  2. Risk assessment and patient stratification using implantable medical devices. The funding for personal health programs.

    PubMed

    Guillén, Alejandra; Colás, Javier; Gutiérrez, Germán

    2011-01-01

    Chronic diseases are currently recognized as one of the leading causes of mortality and morbidity worldwide. On top of this, these diseases represent a major burden for the healthcare systems in terms of costs and resources, which is driving them to define and adopt novel programs for prevention and chronic disease management. Still, many aspects of the processes of care and follow up of these patients remain unsolved and there is yet uncertainty on how technology can provide an added value to the current processes of care. This paper addresses the importance of the adoption of strategies for the anticipation to acute events within the disease management programs and suggests a holistic approach to embrace the healthcare organizations in the design development and implementation of the new personal health systems.

  3. Cutaneous T-cell lymphoma: 2016 update on diagnosis, risk-stratification, and management

    PubMed Central

    Wilcox, Ryan A.

    2015-01-01

    Disease overview Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). Diagnosis The diagnosis of MF or SS requires the integration of clinical and histopathologic data. Risk-adapted therapy TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a “risk-adapted,” multi-disciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors prior to escalating therapy to include systemic, single-agent chemotherapy. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients. PMID:26607183

  4. Unexpected late rise in plasma acetaminophen concentrations with change in risk stratification in acute acetaminophen overdoses.

    PubMed

    Dougherty, Patrick P; Klein-Schwartz, Wendy

    2012-07-01

    The acetaminophen risk analysis nomogram is used to predict hepatotoxicity risk in acute acetaminophen overdose based on a single plasma acetaminophen concentration (PAC) measured between 4 and 24 h after ingestion. There are case reports of patients with acute overdoses of acetaminophen combination products in whom a toxic PAC occurred later after an initial non-toxic PAC at approximately 4 h. The objective was to describe patients who had an initial non-toxic PAC and a subsequent toxic PAC. A poison center's database was searched for records in which patients were administered N-acetylcysteine. Cases were included if they involved an acute overdose of an acetaminophen-containing product with at least 2 plottable PACs, the first of which was obtained at least 4 h after ingestion and was below the treatment line on the nomogram with a subsequent toxic PAC. Data were analyzed for doses, timed PACs, specific acetaminophen preparation, coingestants, activated charcoal administration, and clinical effects. Twenty patients were included. Thirteen patients ingested combination products. All patients experienced vomiting, neurologic, or cardiovascular effects at presentation or before obtaining the second PAC. Two patients developed hepatotoxicity, one of which died from the complications of acetaminophen-induced hepatotoxicity. The nomogram fails to predict toxicity based on a single PAC in a small subset of patients. Copyright © 2012 Elsevier Inc. All rights reserved.

  5. 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.

  6. Complications of Morbid Obesity in Total Joint Arthroplasty: Risk Stratification Based on BMI.

    PubMed

    Ward, Derek T; Metz, Lionel N; Horst, Patrick K; Kim, Hubert T; Kuo, Alfred C

    2015-09-01

    This study stratifies complication risk in primary total joint arthroplasty (TJA) based on body mass index (BMI). Demographics, co-morbidities, perioperative variables, and complications were reviewed for 22,808 patients. Chi-squared, one-way ANOVA, univariate and multivariable regression analysis were performed. Increasing BMI led to an increase (P<0.05) in combined complications, acute kidney injury (AKI), cardiac arrest (CA), reintubation, reoperation, and superficial infection (SI). Univariate analysis for BMI>40 revealed an increase in combined complications (15.21-vs-17.40%), AKI (1.93-vs-3.87%), CA (0.22-vs-0.57%), reintubation (0.47-vs-0.95%), reoperation (2.36-vs-3.37%), and SI (0.82-vs-1.65%). Multivariable regression showed BMI>40 as an independent predictor for combined complications (OR=1.18), AKI (OR=1.79), CA (OR=3.94), reintubation (OR=2.56), reoperation (OR=1.44), and SI (OR=2.11). Morbid obesity confers increased risk for complications in TJA. Published by Elsevier Inc.

  7. Risk stratification for the development of heart failure after acute coronary syndrome at the time of hospital discharge: Predictive ability of GRACE risk score.

    PubMed

    Raposeiras-Roubín, Sergio; Abu-Assi, Emad; López-López, Andrea; Bouzas-Cruz, Noelia; Castiñeira-Busto, María; Cambeiro-González, Cristina; Álvarez-Álvarez, Belén; Virgós-Lamela, Alejandro; Varela-Román, Alfonso; García-Acuña, José María; González-Juanatey, José Ramón

    2015-09-01

    Despite encouraging declines in the incidence of heart failure (HF) complicating acute coronary syndrome (ACS), it remains a common problem with high mortality. Being able to identify patients at high risk of HF after ACS would have great clinical and economic impact. With this study, we assessed the usefulness of the GRACE score to predict HF after an ACS. We studied 4137 consecutive patients discharged with diagnosis of ACS. We analyzed HF incidence, timing, and association with the follow-up mortality. Cox proportional hazards modeling was performed to assess the accuracy of the GRACE risk score to predict HF admissions in follow-up (median 3.1 years). A total of 433 patients (10.5%) developed HF. GRACE score was an independent predictor of HF after ACS [hazard ratio (HR) 1.02, 95% confidence interval (CI): 1.01-1.03, p<0.001]. A risk gradient for the development of HF with GRACE risk score was shown: high- and moderate-GRACE risk groups have been linked to a sixfold and twofold increased risk of HF. This risk gradient was maintained in patients with and without prior history of HF, in ST elevation myocardial infarction and non-ST elevation myocardial infarction groups, and in patients with depressed and preserved left ventricular ejection fraction. The development of HF was associated with high mortality (54.5% vs 13.4%; HR=4.48; 95% CI: 3.84-5.24; p<0.001). After adjusting for GRACE risk score, HF development resulted as an independent predictor of mortality. GRACE risk score has been shown to provide clinically relevant stratification of follow-up HF admission risk at the time of hospital discharge in patients with ACS. Copyright © 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

  8. Risk stratification simplified: the worst injury predicts mortality for the injured children.

    PubMed

    Tepas, Joseph J; Leaphart, Cynthia L; Celso, Brian G; Tuten, James D; Pieper, Pam; Ramenofsky, Max L

    2008-12-01

    The International Classification Injury Severity Score (ICISS) uses anatomic injury diagnoses to predict probability of survival (Ps) computed as the product of the survival risk ratios (SRR) of the three most severe injuries. SRRs are derived as the proportion of fatalities for every International Classification of Diseases-9th Revision-Clinical Modification diagnosis in a "benchmark" population. Pediatric-specific SRRs were computed from 103,434 entries in the National Pediatric Trauma Registry. We hypothesized that ICISS was a valid pediatric outcome predictor, and that the child's most severe injury; i.e., the lowest SRR, is the major driver of outcome, which can be used alone to predict survival. Receiver operator characteristic analysis was used to assess the predictive validity of ICISS. SRRs derived from 53,235 phase II patients were used as the training set to calculate the Ps for 50,199 phase III children comprising the test set. The survival probability (Ps) computed from the standard three diagnoses was compared with that computed from only the worst injury (lowest SRR). Records with a single diagnosis or Ps of 1, indicating no mortality potential, were excluded from the analysis. Nagelkerke pseudo R2 defined what proportion of the predicted Ps was the effect of the worst injury alone versus the traditional Ps. A total of 25,239 records with at least two diagnoses with SRRs indicating risk of mortality were analyzed. The area under the receiver operator characteristic curve for traditional Ps was 0.935, compared with 0.932 for that calculated using only the lowest SRR. The difference of 0.003 was not significant (z = 1.061, p = 0.2888, NS). Nagelkerke pseudo R2 for the lowest SRR was 0.455 compared with 0.462 for the traditional three diagnosis Ps, which shows that the majority of Ps predictive power is related to the single injury with the lowest SRR. Further analysis demonstrated that this effect was related to frequency of coexistent injuries with no

  9. Risk stratification and consecutive prognosis progresses in childhood Wilms tumors. Two cases report.

    PubMed

    Diaconescu, S; Olaru, C; Mihailă, D; Aprodu, S G; Miron, I

    2013-01-01

    Even if Wilms' tumour is the commonest primary malignant neoplasia in children, it maintained a continuous interest due to actual therapeutic successes contrasting with the customary delayed diagnosis, malignancy and specific risk factors. Two recent illustrative cases from our clinic are presented. The first one - a little girl of 22 months with repeated admissions for habitual constipation and psychomental disturbances revealed at abdominal ultrasonography a hypo-echoic mass at the superior pole of the right kidney. CT confirmed the presence of a solid homogeneous mass of 23/25 mm without node or distant metastases, suggestive for Wilms' tumour. Conforming to SIOP protocol she received chemotherapy and after 4 weeks a superior polar nephrectomy was performed. Pathology confirmed the diagnosis of triphasic nephroblastoma of intermediary risk. Postoperative chemotherapy according to the protocol SIOP assured the cure with a disease free period of 23 months. The second case - also a girl, of 3 years, is admitted for constipation, pain in the left flank and mental retard (QI=40). Ultrasonography determined a huge mass (Ø~6 cm) situated at the superior pole of the left kidney. CT attested a nonhomogeneous, encapsulated tumour image of 6.2/5.4/7.2 cm in large posterolateral contact with the renal parenchyma out of which it appears to be developed. The diagnosis of WT is strongly suggested and after chemotherapy a radical left nephrectomy with initial vessels ligature was performed. Pathology: stage IIb nephroblastoma with focal epithelial anaplasia. After surgery she continued the chemotherapy (HR regime), was cured and excepting a medullar aplasia is in a good health after 24 months. Our both cases were girls under 3 years, presenting nonspecific features: constipation and psychic troubles, the tumour being incidentally discovered by the abdominal ultrasonography. CT established the diagnosis. Conventional chemotherapy framing adapted to the tumour's stage and

  10. 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.

  11. Utility of Imaging in Risk Stratification of Chest Pain in Women.

    PubMed

    Lau, Emily S; Sarma, Amy

    2017-09-01

    Recent decades have seen a growing recognition that the understanding of sex differences in cardiovascular disease (CVD) is vital to optimal diagnosis and management, particularly of women (Mosca et al. Circulation 124:2145-54, 2011). There is simultaneously an increasing appreciation of the multifactorial nature of ischemic heart disease (IHD) in many patients, in whom disease may extend beyond the epicardial coronaries. While obstructive coronary artery disease (CAD) remains underdiagnosed in women and still represents a major burden of disease, women also present with nonobstructive CAD more commonly than men (Patel et al. N Engl J Med 362:886-95, 2010). Indeed, microvascular dysfunction, coronary artery vasospasm, and coronary dissections contribute to a larger proportion of IHD in women than men (Bairey Merz et al. J Am Coll Cardiol 47:S21-9, 2006). Here, we review the symptom presentation of women with IHD and the noninvasive modalities used to risk stratify women with suspected IHD.

  12. Coronary CT and the Coronary Calcium Score, the Future of ED Risk Stratification?

    PubMed Central

    Fernandez-Friera, Leticia; Garcia-Alvarez, Ana; Guzman, Gabriela; Garcia, Mario J

    2012-01-01

    Accurate and efficient evaluation of acute chest pain remains clinically challenging because traditional diagnostic modalities have many limitations. Recent improvement in non-invasive imaging technologies could potentially improve both diagnostic efficiency and clinical outcomes of patients with acute chest pain while reducing unnecessary hospitalizations. However, there is still controversy regarding much of the evidence for these technologies. This article reviews the role of coronary artery calcium score and the coronary computed tomography in the assessment of individual coronary risk and their usefulness in the emergency department in facilitating appropriate disposition decisions. The evidence base and clinical applications for both techniques are also described, together with cost- effectiveness and radiation exposure considerations. PMID:22708911

  13. Radioiodine therapy for thyroid cancer in the era of risk stratification and alternative targeted therapies.

    PubMed

    Pryma, Daniel A; Mandel, Susan J

    2014-09-01

    Differentiated thyroid cancers are typically iodine-avid and can be effectively treated with radioiodine. In most patients, radioiodine treatment is done for ablation of residual tissue, and in these cases the focus should be on using the minimum effective dose. Adjuvant therapy can be done to reduce the risk of recurrence, but optimal patient selection and dose are unclear. Patients with advanced disease benefit most from treatment with the maximum-tolerated dose. Recent research has focused on better patient selection and reduced radioiodine doses for remnant ablation. There are emerging targeted therapeutic approaches in patients who are appropriately shown to have iodine-refractory disease, with 1 drug approved by the Food and Drug Administration. Numerous trials are ongoing to assess targeted therapeutics alone or in combination with radioiodine.

  14. Application of genomics for risk stratification of childhood acute lymphoblastic leukaemia: from bench to bedside?

    PubMed

    Izraeli, Shai

    2010-10-01

    The remarkable progress in the treatment of childhood acute lymphoblastic leukaemia (ALL) has been based on the adjustment of therapy to subgroups of leukaemia stratified by their prognostic implications. Here, the contribution of the last decade of advanced genomic research on the clinical management of childhood ALL is examined. The application of genomics for routine diagnosis of ALL is feasible but depends on commercial development of appropriate certified platforms. The discovery of several novel high-risk markers, such as deletions in IKZF1 might be integrated into clinical protocols in the near future. Several novel targets for therapy have been identified and have led to phase I/II therapeutic trials. This and any future progress depends on the maintenance of high quality bio-banks including biological material and clinical data of each patient enrolled on a prospective clinical protocol. © 2010 Blackwell Publishing Ltd.

  15. 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.

  16. Development of a risk stratification system to guide treatment for female germ cell tumors.

    PubMed

    Meisel, Jane L; Woo, Kaitlin M; Sudarsan, Nora; Eng, Jana; Patil, Sujata; Jacobsen, Erin P; Murali, Rajmohan; Gardner, Ginger J; Bosl, George J; Aghajanian, Carol; Feldman, Darren R

    2015-09-01

    Due to their rarity, little is known about prognostic factors in female germ cell tumors (GCTs) or outcomes following systemic therapy. Management is largely based on studies of male GCT and epithelial ovarian cancer. Chart review was performed for all females with GCT seen at Memorial Sloan Kettering Cancer Center (MSKCC) from 1990 to 2012. Patients receiving chemotherapy were stratified using a modification of the male IGCCCG risk system, and the classifier was correlated with outcome. Of 93 patients, 92 (99%) underwent primary surgery and 85 (92%) received chemotherapy. Modified IGCCCG classification was significantly associated with progression-free survival (PFS) and overall survival (OS), both when applied preoperatively and pre-chemotherapy (p<0.001 for all four analyses). Progression after initial chemotherapy (n=29) was detected by imaging in 14 (48%) patients, by serum tumor markers in 6 (21%) patients, and by multiple methods in the rest. Seven (29%) of 24 patients treated with salvage chemotherapy achieved long-term PFS, including 4/6 who received high-dose chemotherapy (HDCT) as initial salvage versus 3/16 treated with other initial salvage regimens. The estimated 3-year OS rate was 84% (95% CI, 76-92%), with a trend favoring dysgerminoma over non-dysgerminoma histologies (p=0.12). Modified IGCCCG classification was prognostic for female GCT patients in this cohort and identified a poor-risk group who may benefit from more intensive first-line chemotherapy. Both imaging and tumor marker evaluation were important in identifying relapses after first-line chemotherapy. The majority of long-term remissions with salvage therapy were achieved with initial salvage HDCT. Copyright © 2015 Elsevier Inc. All rights reserved.

  17. Risk stratification in acute heart failure: rationale and design of the STRATIFY and DECIDE studies.

    PubMed

    Collins, Sean P; Lindsell, Christopher J; Jenkins, Cathy A; Harrell, Frank E; Fermann, Gregory J; Miller, Karen F; Roll, Sue N; Sperling, Matthew I; Maron, David J; Naftilan, Allen J; McPherson, John A; Weintraub, Neal L; Sawyer, Douglas B; Storrow, Alan B

    2012-12-01

    A critical challenge for physicians facing patients presenting with signs and symptoms of acute heart failure (AHF) is how and where to best manage them. Currently, most patients evaluated for AHF are admitted to the hospital, yet not all warrant inpatient care. Up to 50% of admissions could be potentially avoided and many admitted patients could be discharged after a short period of observation and treatment. Methods for identifying patients that can be sent home early are lacking. Improving the physician's ability to identify and safely manage low-risk patients is essential to avoiding unnecessary use of hospital beds. Two studies (STRATIFY and DECIDE) have been funded by the National Heart Lung and Blood Institute with the goal of developing prediction rules to facilitate early decision making in AHF. Using prospectively gathered evaluation and treatment data from the acute setting (STRATIFY) and early inpatient stay (DECIDE), rules will be generated to predict risk for death and serious complications. Subsequent studies will be designed to test the external validity, utility, generalizability and cost-effectiveness of these prediction rules in different acute care environments representing racially and socioeconomically diverse patient populations. A major innovation is prediction of 5-day as well as 30-day outcomes, overcoming the limitation that 30-day outcomes are highly dependent on unpredictable, post-visit patient and provider behavior. A novel aspect of the proposed project is the use of a comprehensive cardiology review to correctly assign post-treatment outcomes to the acute presentation. Finally, a rigorous analysis plan has been developed to construct the prediction rules that will maximally extract both the statistical and clinical properties of every data element. Upon completion of this study we will subsequently externally test the prediction rules in a heterogeneous patient cohort. Copyright © 2012 Mosby, Inc. All rights reserved.

  18. Rationale, objectives, and design of the EUTrigTreat clinical study: a prospective observational study for arrhythmia risk stratification and assessment of interrelationships among repolarization markers and genotype

    PubMed Central

    Seegers, Joachim; Vos, Marc A.; Flevari, Panagiota; Willems, Rik; Sohns, Christian; Vollmann, Dirk; Lüthje, Lars; Kremastinos, Dimitrios T.; Floré, Vincent; Meine, Mathias; Tuinenburg, Anton; Myles, Rachel C.; Simon, Dirk; Brockmöller, Jürgen; Friede, Tim; Hasenfuß, Gerd; Lehnart, Stephan E.; Zabel, Markus

    2012-01-01

    Aims The EUTrigTreat clinical study has been designed as a prospective multicentre observational study and aims to (i) risk stratify patients with an implantable cardioverter defibrillator (ICD) for mortality and shock risk using multiple novel and established risk markers, (ii) explore a link between repolarization biomarkers and genetics of ion (Ca2+, Na+, K+) metabolism, (iii) compare the results of invasive and non-invasive electrophysiological (EP) testing, (iv) assess changes of non-invasive risk stratification tests over time, and (v) associate arrythmogenomic risk through 19 candidate genes. Methods and results Patients with clinical ICD indication are eligible for the trial. Upon inclusion, patients will undergo non-invasive risk stratification, including beat-to-beat variability of repolarization (BVR), T-wave alternans, T-wave morphology variables, ambient arrhythmias from Holter, heart rate variability, and heart rate turbulence. Non-invasive or invasive programmed electrical stimulation will assess inducibility of ventricular arrhythmias, with the latter including recordings of monophasic action potentials and assessment of restitution properties. Established candidate genes are screened for variants. The primary endpoint is all-cause mortality, while one of the secondary endpoints is ICD shock risk. A mean follow-up of 3.3 years is anticipated. Non-invasive testing will be repeated annually during follow-up. It has been calculated that 700 patients are required to identify risk predictors of the primary endpoint, with a possible increase to 1000 patients based on interim risk analysis. Conclusion The EUTrigTreat clinical study aims to overcome current shortcomings in sudden cardiac death risk stratification and to answer several related research questions. The initial patient recruitment is expected to be completed in July 2012, and follow-up is expected to end in September 2014. Clinicaltrials.gov identifier: NCT01209494. PMID:22117037

  19. Pulmonary embolism risk stratification by European Society of Cardiology is associated with recurrent venous thromboembolism: Findings from a long-term follow-up study.

    PubMed

    Zhang, Shuai; Zhai, Zhenguo; Yang, Yuanhua; Zhu, Jianguo; Kuang, Tuguang; Xie, Wanmu; Yang, Suqiao; Liu, Fangfang; Gong, Juanni; Shen, Ying H; Wang, Chen

    2016-01-01

    Venous thromboembolism (VTE) recurrence carries significant mortality and morbidity. Accurate risk assessment and effective treatment for patients with acute pulmonary embolism (PE) is important for VTE recurrence prevention. We examined the association of VTE recurrence with risk stratification and PE treatment. We enrolled 627 patients with a first episode of confirmed PE. Baseline clinical information was collected. PE severity was assessed by the European Society of Cardiology's (ESC) risk stratification, the simplified PE Severity Index (sPESI) and the Qanadli score of clot burden. Patients were followed for 1-5 years. The cumulative recurrent VTE and all-cause death were documented. The association between recurrent VTE and risk factors was analyzed. The cumulative incidences of recurrent VTE were 4.5%, 7.3%, and 13.9% at 1, 2, and 5 years of follow-up, respectively. The VTE recurrence was associated with higher (high- and intermediate-) risk stratification predicted by ESC model (HR 1.838, 95% CI 1.318-2.571, P<0.001), as well as with unprovoked PE (HR 2.809, 95% CI 1.650-4.781, P b 0.001) and varicose veins (HR 4.747, 95% CI 2.634-8.557, P<0.001). The recurrence was negatively associated with longer (≥6 months) anticoagulation (HR 0.473, 95% CI 0.285-0.787, P=0.004), especially in patients with higher risk (HR 0.394, 95% CI 0.211-0.736, P=0.003) and unprovoked PE (HR 0.248, 95% CI 0.122-0.504, P<0.001). ESC high-risk and intermediate-risk PE, unprovoked PE and varicose veins increase recurrence risk. Longer anticoagulation treatment reduces recurrence, especially in higher risk and unprovoked PE patients.

  20. TP53 mutational status is a potential marker for risk stratification in Wilms tumour with diffuse anaplasia.

    PubMed

    Maschietto, Mariana; Williams, Richard D; 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

    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. 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. 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), 1.26-16.0) and death (p = 0.04, HR, 4.95; 95% CI, 1.36-31.7) 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. 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.

  1. New Pattern-Based Personalized Risk Stratification for Endocervical Adenocarcinoma with Important Clinical Implications and Surgical Outcome

    PubMed Central

    Roma, Andres A.; Mistretta, Toni-Ann; De Vivar, Andrea Diaz; Park, Kay J.; Alvarado-Cabrero, Isabel; Rasty, Golnar; Chanona-Vilchis, Jose G.; Mikami, Yoshiki; Hong, Sung R.; Teramoto, Norihiro; Ali-Fehmi, Rouba; Barbuto, Denise; Rutgers, Joanne K.L.; Silva, Elvio G.

    2016-01-01

    We present a recently introduced three tier pattern-based histopathologic system to stratify endocervical adenocarcinoma (EAC) that better correlates with lymph node (LN) metastases than FIGO staging alone, and has the advantage of safely predicting node-negative disease in a large proportion of EAC patients. The system consists of stratifying EAC into one of three patterns: pattern A tumors characterized by well-demarcated glands frequently forming clusters or groups with relative lobular architecture and lacking destructive stromal invasion or lymphvascular invasion (LVI), pattern B tumors demonstrating localized destructive invasion (small clusters or individual tumor cells within desmoplastic stroma often arising from pattern A glands), and pattern C tumors with diffusely infiltrative glands and associated desmoplastic response. Three hundred and fifty-two cases were included; mean follow-up 52.8 months. Seventy-three patients (21%) had pattern A tumors; all were stage I and there were no LN metastases or recurrences. Pattern B was seen in 90 tumors (26%); all were stage I and LVI was seen in 24 cases (26.6%). Nodal disease was found in only 4 (4.4%) pattern B tumors (one IA2, two IB1, one IB not further specified (NOS)), each of which showed LVI. Pattern C was found in 189 cases (54%), 117 had LVI (61.9%) and 17% were stage II or greater. Forty-five (23.8%) patients showed LN metastases (one IA1, 14 IB1, 5 IB2, 5 IB NOS, 11 II, 5 III and 4 IV) and recurrences were recorded in 41 (21.7%) patients. This new risk stratification system identifies a subset of stage I patients with essentially no risk of nodal disease, suggesting that patients with pattern A tumors can be spared lymphadenectomy. Patients with pattern B tumors rarely present with LN metastases, and sentinel LN examination could potentially identify these patients. Surgical treatment with nodal resection is justified in patients with pattern C tumors. PMID:27016227

  2. Identifying Unique Versus Shared Pre- and Perinatal Risk Factors for ASD and ADHD Using a Simplex-Multiplex Stratification.

    PubMed

    Oerlemans, Anoek M; Burmanje, Marlot J; Franke, Barbara; Buitelaar, Jan K; Hartman, Catharina A; Rommelse, Nanda N J

    2016-07-01

    Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. Besides shared genetic factors, pre- and perinatal risk factors (PPFs) may determine if ASD, ADHD, or the combination of both disorders becomes manifest. This study aimed to test shared and unique involvement of PPFs for ASD and ADHD, using an approach that stratifies the sample into affected/unaffected offspring and single-incidence (SPX) versus multi-incidence (MPX) families. Pre- perinatal data based on retrospective parent-report were collected in 288 children (71 % males) from 31 SPX and 59 MPX ASD families, 476 children (65 % males) from 31 SPX and 171 MPX ADHD families, and 408 control children (42 % males). Except for large family size and more firstborns amongst affected offspring, no shared PFFs were identified for ASD and ADHD. PPFs predominantly related to ASD (maternal infections and suboptimal condition at birth) were more often reported in affected than unaffected siblings. PPFs associated with ADHD (low parental age, maternal diseases, smoking and stress) were shared between affected and unaffected siblings. Firstborn-ship was more frequent in SPX than MPX ASD probands. Our results suggest that the co-morbidity of ASD and ADHD is not likely explained by shared PPFs. Instead, PPFs might play a crucial role in the developmental pathways leading up to either disorder. PPFs in ADHD appear to index an increased shared risk, whereas in ASD PPFs possibly have a more determining role in the disorder. SPX-MPX stratification detected possible etiological differences in ASD families, but provided no deeper insight in the role of PPFs in ADHD.

  3. Validation of a risk stratification tool for fall-related injury in a state-wide cohort

    PubMed Central

    McCoy, Thomas H; Castro, Victor M; Cagan, Andrew; Roberson, Ashlee M; Perlis, Roy H

    2017-01-01

    details. This translatable approach to stratification allows for identification of high-risk individuals in whom interventions are likely to be cost-effective. PMID:28167743

  4. A Prediction Rule for Risk Stratification of Incidentally Discovered Gallstones: Results From a Large Cohort Study.

    PubMed

    Shabanzadeh, Daniel Mønsted; Sørensen, Lars Tue; Jørgensen, Torben

    2016-01-01

    No one knows exactly what proportion of gallstones cause clinical events among subjects unaware of their gallstone status. We investigated the long-term occurrence of clinical events of gallstones and associations between ultrasound observations and clinical events. We analyzed data from 3 randomly selected groups in the general population of urban Copenhagen (age, 30-70 y) participating in an international study of cardiovascular risk factors (the Multinational mONItoring of trends and determinants in CArdiovascular disease study). In this study, participants (n = 6037) were examined from 1982 through 1994, and underwent abdominal ultrasound examinations to detect gallstones. Our study population comprised 664 subjects with gallstones; subjects were not informed of their gallstone status. Participants were followed up for clinical events through central registers until December 31, 2011. Independent variables included ultrasound characteristics, age, sex, comorbidity, and female-associated factors, which were analyzed using Cox regression. Study participants were followed up for a median of 17.4 years (range, 0.1-29.1 y); 99.7% of participants completed the study. A total of 19.6% participants developed events (8.0% complicated and 11.6% uncomplicated). Ten percent had awareness of their gallstones; awareness was associated with uncomplicated and complicated events. Stones larger than 10 mm were associated with all events (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.45-3.69), acute cholecystitis (HR, 9.49; 95% CI, 2.05-43.92), and uncomplicated events (HR, 2.55; 95% CI, 1.38-4.71), including cholecystectomy (HR, 2.69; 95% CI, 1.29-5.60). Multiple stones were associated with all events (HR, 1.68; 95% CI, 1.00-2.81), complicated events (HR, 2.52; 95% CI, 1.05-6.04), and common bile duct stones (HR, 11.83; 95% CI, 1.54-91). There was an association between gallstones more than 5 years old and acute cholecystitis. Female sex was associated with all and

  5. Risk Stratification in Paragangliomas with PASS (Pheochromocytoma of the Adrenal Gland Scaled Score) and Immunohistochemical Markers.

    PubMed

    Kulkarni, Maithili Mandar; Khandeparkar, Siddhi Gaurish Sinai; Deshmukh, Sanjay D; Karekar, R R; Gaopande, Vandana L; Joshi, Avinash R; Kesari, Mrunal V; Shelke, R R

    2016-09-01

    Paragangliomas (PGLs) are rare tumours that arise in sympathetic and parasympathetic paraganglia and are derived from neural crest cells. Presence of metastasis is the only absolute criterion for malignancy. There is no single histo-morphological feature indicating malignant potential and multiple parameters have been proposed to prognosticate the individual case. This includes studies conducted using Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and Immunohistochemical (IHC) markers. We have studied ten cases of paraganglioma and attempted to correlate the prognosis with multiple clinicopathological variables. This study was done in a tertiary care general hospital over a period of five years. Available clinical records and histopathology slides of all patients were reviewed. Using Pheochromocytoma of the Adrenal Gland Scaled Score (PASS), we divided the cases into two groups-tumours showing high risk behaviour (PASS≥4) and tumours showing benign behaviour (PASS<4). IHC analysis was done using synaptophysin, chromogranin, S100 and Ki67. We correlated S100 immunoreactivity and Ki67 proliferative index with PASS score. Both PASS score and IHC markers were also correlated with clinical outcome. There were six Pheochromocytomas (PHC) and four Paragangliomas (PGL). Two paragangliomas were retroperitoneal and one each was located in ear (HNPGL) and broad ligament. PASS score was ≥4 in five cases and <4 in five cases. Out of five cases in which PASS was ≥4, three cases showed clinical evidence of malignancy and two cases were benign. All the cases in which PASS was <4 were clinically benign. S100 immunoreactivity was grade 1 in two cases, grade 2 in six cases and grade 3 in two cases. The cases in which S100 immunoreactivity was grade 1 were malignant. One case in which S100 was grade 2 was clinically malignant. Ki67 labeling index was raised (>3%) in two cases, which were malignant correlated with malignant PASS score. We conclude that the following

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

    PubMed

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

    2011-03-01

    discriminant analysis. These results also suggest that the REIS signal based GMM classifier could be used as a prescreening tool to correctly identify a fraction of younger women at higher risk of developing breast cancer (i.e., 47% sensitivity at 90% specificity). The study confirms that asymmetry in electrical impedance characteristics between two breasts provides valuable information regarding the presence of a developing breast abnormality; hence, REIS data may be useful in classifying younger women into two groups of "average" and "significantly higher than average" risk of having or developing a breast abnormality that would ultimately result in a later imaging-based recommendation for biopsy.

  7. Exercise stress echocardiography with tissue Doppler imaging in risk stratification of mild to moderate aortic stenosis.

    PubMed

    Sonaglioni, Andrea; Lombardo, Michele; Baravelli, Massimo; Trotta, Graziana; Sommese, Carmen; Anzà, Claudio

    2015-12-01

    Patients with mild to moderate aortic stenosis (AS) seem to have a worse outcome than commonly expected. Early identification of subjects who may develop a rapid disease progression or cardiovascular events is critical in order to apply adequate risk management. Observational prospective single-centre study. To determine the prognostic role of exercise stress echocardiography (ESE) in patients with mild and moderate asymptomatic AS. Ninety consecutive patients (mean age 74 ± 12 years) with isolated mild and moderate AS were enrolled into the study protocol over a 20 months period. Follow-up time was 12 months. A complete echocardiographic study with tissue Doppler imaging (TDI) was performed at baseline and during semi-supine symptom-limited exercise test to evaluate: (1) the occurrence of symptoms, (2) ST segment changes, (3) transaortic pressure gradient, (4) the E/A ratio, (5) the E/e' ratio and (6) the systolic pulmonary artery pressure. During the 1 year follow-up time, we evaluated the occurrence of adverse cardiac events, defined as any of the following: (1) cardio-vascular hospitalization; (2) requirement for aortic valve replacement; (3) cardiac death. During follow-up, three patients died, 11 underwent aortic valve replacement and 26 had cardiovascular hospitalizations. On univariate analysis, patients who exhibited symptoms during exercise (HR 2.93, p = 0.003); the occurrence of a ≥ 2 mm exercise-induced ST segment depression (HR 3.12, p = 0.001); a ≥ 15 mmHg increase in mean transaortic pressure gradient during exercise (HR 2.77, p = 0.001); a ≥ 50 mmHg exercise-induced increase in systolic pulmonary artery pressure (HR 2.90, p = 0.009); an exercise-induced pseudo-normalization of the E/A ratio (E/A ≥ 1) (HR 7.50, p = 0.0001) and, particularly, a ≥ 15 exercise-induced increase in the E/e' ratio (HR 7.69, p = 0.0001) had a significantly higher risk of cardiac events during the follow-up time. On multivariate analysis, only the latter covariate

  8. Improved cancer risk stratification and diagnosis via quantitative phase microscopy (Conference Presentation)

    NASA Astrophysics Data System (ADS)

    Liu, Yang; Uttam, Shikhar; Pham, Hoa V.; Hartman, Douglas J.

    2017-02-01

    Pathology remains the gold standard for cancer diagnosis and in some cases prognosis, in which trained pathologists examine abnormality in tissue architecture and cell morphology characteristic of cancer cells with a bright-field microscope. The limited resolution of conventional microscope can result in intra-observer variation, missed early-stage cancers, and indeterminate cases that often result in unnecessary invasive procedures in the absence of cancer. Assessment of nanoscale structural characteristics via quantitative phase represents a promising strategy for identifying pre-cancerous or cancerous cells, due to its nanoscale sensitivity to optical path length, simple sample preparation (i.e., label-free) and low cost. I will present the development of quantitative phase microscopy system in transmission and reflection configuration to detect the structural changes in nuclear architecture, not be easily identifiable by conventional pathology. Specifically, we will present the use of transmission-mode quantitative phase imaging to improve diagnostic accuracy of urine cytology and the nuclear dry mass is progressively correlate with negative, atypical, suspicious and positive cytological diagnosis. In a second application, we will present the use of reflection-mode quantitative phase microscopy for depth-resolved nanoscale nuclear architecture mapping (nanoNAM) of clinically prepared formalin-fixed, paraffin-embedded tissue sections. We demonstrated that the quantitative phase microscopy system detects a gradual increase in the density alteration of nuclear architecture during malignant transformation in animal models of colon carcinogenesis and in human patients with ulcerative colitis, even in tissue that appears histologically normal according to pathologists. We evaluated the ability of nanoNAM to predict "future" cancer progression in patients with ulcerative colitis.

  9. Matrix metalloproteinases and risk stratification in patients undergoing surgical revascularisation for critical limb ischaemia.

    PubMed

    De Caridi, Giovanni; Massara, Mafalda; Spinelli, Francesco; David, Antonio; Gangemi, Sebastiano; Fugetto, Francesco; Grande, Raffaele; Butrico, Lucia; Stefanelli, Roberta; Colosimo, Manuela; de Franciscis, Stefano; Serra, Raffaele

    2016-08-01

    Critical limb ischaemia (CLI) is the most advanced form of peripheral artery disease (PAD) and it is often associated with foot gangrene, which may lead to major amputation of lower limbs, and also with a higher risk of death due to fatal cardiovascular events. Matrix metalloproteinases (MMPs) seem to be involved in atherosclerosis, PAD and CLI. Aim of this study was to evaluate variations in MMP serum levels in patients affected by CLI, before and after lower limb surgical revascularisation through prosthetic or venous bypass. A total of 29 patients (7 females and 22 males, mean age 73·4 years, range 65-83 years) suffering from CLI and submitted to lower extremity bypass (LEB) in our Institution were recruited. Seven patients (group I) underwent LEB using synthetic polytetrafluoroethylene (PTFE) graft material and 22 patients (group II) underwent LEB using autogenous veins. Moreover, 30 healthy age-sex-matched subjects were also enrolled as controls (group III). We documented significantly higher serum MMPs levels (P < 0·01) in patients with CLI (groups I and II) with respect to control group (group III). Finally, five patients with CLI (17·2%) showed poor outcomes (major amputations or death), and enzyme-linked immunosorbent assay (ELISA) test showed very high levels of MMP-1 and MMP-8. MMP serum levels seem to be able to predict the clinical outcomes of patients with CLI.

  10. Prognostic Biomarkers in Acute Coronary Syndromes: Risk Stratification Beyond Cardiac Troponins.

    PubMed

    Eggers, K M; Lindahl, B

    2017-04-01

    Cardiac troponin (cTn) plays an essential role for assessment of outcome in acute coronary syndrome (ACS). However, the prognostic value of cTn is not absolute. In this mini-review, we summarize the evidence on the utility of established biomarkers of left-ventricular dysfunction, hemodynamic stress, inflammation, and renal dysfunction for risk prediction beyond cTn in ACS. Only few biomarkers consistently demonstrate additive prognostic value to cTn levels. The B-type natriuretic peptides (NPs) and growth-differentiation factor-15 (GDF-15) are most promising in this regard. However, there are uncertainties regarding the role of these biomarkers for guidance of treatment decisions, and their prognostic increment to cTn levels measured with high-sensitivity assays is largely unknown. The NPs and GDF-15 provide the strongest prognostic increment to cTn levels in ACS. However, the role of these biomarkers for clinical decision-making in contemporary settings has still to be defined.

  11. 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.; Kääb, 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

  12. D-dimer for risk stratification in haemodynamically stable patients with acute pulmonary embolism.

    PubMed

    Keller, Karsten; Beule, Johannes; Schulz, Andreas; Coldewey, Meike; Dippold, Wolfgang; Balzer, Jörn Oliver

    2015-09-01

    Patients with submassive pulmonary embolism (PE) have a higher short-term mortality than those with low-risk PE. Rapid identification of submassive PE is important for adequate treatment of non-massive PE. We aimed to investigate the utility of D-dimer for the prediction of submassive PE stadium in normotensive PE patients. Normotensive PE patients were classified into submassive or low-risk PE groups. In addition to the comparison of the groups, area under the curve (AUC) and D-dimer cut-off for the prediction of submassive PE stadium, multi-variate logistic regression for association between D-dimer values above this cut-off and submassive PE stadium were also calculated. The data of 129 normotensive PE patients (59.7% women, mean age 70.0 years (60.7/81.0)) were analysed retrospectively. Patients with submassive PE were older (75.0 years (61.7/81.0) vs. 66.5 years (55.7/74.2), P=0.026) and more frequently female (63.6% vs. 53.8%, P=0.35). Heart rate (100.0beats/min (85.0/108.0) vs. 80.0beats/min (70.0/96.2), P<0.0001), systolic pulmonary-artery pressure (41.55±16.79mmHg vs. 22.62±14.81mmHg, P<0.0001), and D-dimer (2.00mg/l (1.09/3.98) vs. 1.21mg/l (0.75/1.99), P=0.011) were higher in patients with submassive PE. D-dimer values >1.32mg/l were indicative of submassive PE and shock-index ≥0.7. The effectiveness (AUC) of the test was 0.63 for submassive PE and 0.64 for shock-index ≥0.7. D-dimer values >1.32mg/l were associated with submassive PE stadium (OR 3.81 (95% CI: 1.74-8.35), P=0.00083) as well as with systolic blood pressure (OR 0.98 (95% CI: 0.97-0.99), P=0.033), heart rate (OR 1.02 (95% CI: 1.00-1.04), P=0.023) and shock-index value (OR 15.89 (95% CI: 1.94-130.08), P=0.0099). D-dimer values >1.32mg/l are indicative of submassive PE stadium and shock-index ≥0.7. Efficacy of D-dimer for predicting submassive PE stadium was only weak to moderate. Copyright © 2015 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All

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

    PubMed

    Maegele, Marc; Spinella, Philip C; Schöchl, 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.

  14. Risk stratification of early stage oral tongue cancers based on HPV status and p16 immunoexpression.

    PubMed

    Ramshankar, Vijayalakshmi; Soundara, Viveka T; Shyamsundar, Vidyarani; Ramani, Prathiba; Krishnamurthy, Arvind

    2014-01-01

    Recent epidemiological data have implicated human papilloma virus (HPV) infection in the pathogenesis of head and neck cancers, especially oropharyngeal cancers. Although, HPV has been detected in varied amounts in persons with oral dysplasia, leukoplakias and malignancies, its involvement in oral tongue carcinogenesis remains ambiguous. HPV DNA prevalence was assessed by PCR with formalin fixed paraffin embedded sections (n=167) of oral tongue squamous cell carcinoma patients and the physical status of the HPV16 DNA was assessed by qPCR. Immunohistochemistry was conducted for p16 evaluation. We found the HPV prevalence in tongue cancers to be 51.2%, HPV 16 being present in 85.2% of the positive cases. A notable finding was a very poor concordance between HPV 16 DNA and p16 IHC findings (kappa<0.2). Further molecular classification of patients based on HPV16 DNA prevalence and p16 overexpression showed that patients with tumours showing p16 overexpression had increased hazard of death (HR=2.395; p=0.005) and disease recurrence (HR=2.581; p=0.002) irrespective of their HPV 16 DNA status. Our study has brought out several key facets which can potentially redefine our understanding of tongue cancer tumorigenesis. It has emphatically shown p16 overexpression to be a single important prognostic variable in defining a high risk group and depicting a poorer prognosis, thus highlighting the need for its routine assessment in tongue cancers. Another significant finding was a very poor concordance between p16 expression and HPV infection suggesting that p16 expression should possibly not be used as a surrogate marker for HPV infection in tongue cancers. Interestingly, the prognostic significance of p16 overexpression is different from that reported in oropharyngeal cancers. The mechanism of HPV independent p16 over expression in oral tongue cancers is possibly a distinct entity and needs to be further studied.

  15. Can risk stratification of transient ischaemic attacks improve patient care in the emergency department?

    PubMed Central

    Byrne, Aoife; Daly, Cathy; Rocke, Laurence; Gray, John

    2007-01-01

    Introduction The ABCD scoring system has been described as a simple way of predicting stroke in the first 7 days after a transient ischaemic attack (TIA). The aims of our pilot study were to find out if emergency department (ED) doctors could use the scoring system effectively and if this system would influence admission rates and patient selection. Method The ED notes were reviewed over a 3‐month period. The ABCD (age, blood pressure, clinical features, duration) scoring system was retrospectively applied to each patient who presented with a TIA (pre‐education (Pre) group). Doctors were then educated on the use of the scoring system, and the system was used for a further 3 months. Patients with high scores were admitted, and those with low scores were reviewed at the hospital's TIA clinic. The authors reviewed the notes retrospectively and each patient was scored again, based on the information available (post‐education (Post) group). The number of appropriate admissions was compared using the χ2 test. Results 37 patients matched the inclusion criteria in the Pre group and 38 patients in the Post group. Baseline characteristics of the groups were similar. There was a significant reduction in the number of patients admitted in the Post group, but the appropriateness of the admission was significantly greater (p<0.01). There were no inappropriate discharges in the Post group. Conclusions The ABCD scoring system for identifying high‐risk patients after TIA is a useful aid in determining which patients require admission from the ED. Its use results in a significant reduction in the number of admissions without any inappropriate discharges. PMID:17711941

  16. [Stratification of clinical risk groups in a population over 65 years: features and nursing assessment].

    PubMed

    Lozano-Vidal, Ruth; López-Pisa, Rosa M; Boyero-Granados, Ana; Recio-Ramos, Sandra; Padín-Minaya, Cristina; Garzón-Quiñones, Marina; Rodríguez-Latre, Luisa M

    2014-01-01

    To analyze the characteristics of the population over 65 years served in a Basic Health Area, according to the Clinical Risk Group (CRG) classification and geriatric assessment test performed by the nurse in relation to their complexity. A descriptive, cross-sectional and observational prevalence study was conducted on the population over 65 years served in a Basic Health Area. The variables collected were: socio-demographic, CRG classification, diseases (ICD-10), healthcare activity, geriatric assessment, and preventive activities. The CRG classification was used as a measurement tool. Data was collected from the Primary Care computerized clinical history (e-CAP). Population over 65 years: 3,219 people; served at home, 130 (4%), and in residential institutions, 92 (2.85%). The population was grouped into: CRG 1-2: 83 (2.5%); CRG 3: 62 (2%); CRG 4: 99 (3%); CRG 5: 537 (17%); CRG 6: 2,077 (64.5%); CRG 7: 276 (8.6%); CRG 8: 61 (2%); CRG 9: 14 (0.4%). Most frequent chronic diseases: 69.12% AHT; 24.94% DM; 19.51% depression; 11.09% kidney failure. The groups 6-7-8 that were analyzed included 2,414 people (75%). Of those within CRG 6-7-8, only 570 (24%) had tests carried out by the geriatric nurse. The mean number of individuals assigned by a nurse for CRG 6-7-8 was 302. The introduction of classification systems in clinical practice, such as the CRG, along with the use of the new information and communication technologies, helps to incorporate predictive models of health needs. It also promotes proactive actions by nurses and the team to prevent complications of diseases, as well as improving efficiency in the use of services and in care of the complex patients. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

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

    PubMed

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

    2015-02-01

    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 patient's 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 patient's 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.

  18. Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study.

    PubMed

    Chang, Alex R; Evans, Michael; Yule, Christina; Bohn, Larissa; Young, Amanda; Lewis, Meredith; Graboski, Elisabeth; Gerdy, Bethany; Ehmann, William; Brady, Jonathan; Lawrence, Leah; Antunes, Natacha; Green, Jamie; Snyder, Susan; Kirchner, H Lester; Grams, Morgan; Perkins, Robert

    2016-11-08

    Measurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in KDIGO (Kidney Disease Improving Global Outcomes) guidelines. Pharmacist medication therapy management (MTM) may be helpful in improving CKD risk stratification and management. We conducted a pragmatic, cluster-randomized trial using seven primary care clinic sites in the Geisinger Health System to evaluate the feasibility of pharmacist MTM in patients with estimated glomerular filtration rate (eGFR) 45-59 ml/min/1.73 m(2) and uncontrolled blood pressure (≥150/85 mmHg). In the three pharmacist MTM sites, pharmacists were instructed to follow a protocol aimed to improve adherence to KDIGO guidelines on testing for proteinuria and lipids, and statin and blood pressure medical therapy. In the four control clinics, patients received usual care. The primary outcome was proteinuria screening over a follow-up of 1 year. A telephone survey was administered to physicians, pharmacists, and patients in the pharmacist MTM arm at the end of the trial. Baseline characteristics were similar between pharmacist MTM (n = 24) and control (n = 23) patients, although pharmacist MTM patients tended to be younger (64 vs. 71 y; p = 0.06) and less likely to have diabetes (17 % vs. 35 %; p = 0.2) or baseline proteinuria screening (41.7 % vs. 60.9 %, p = 0.2). Mean eGFR was 54 ml/min/1.73 m(2) in both groups. The pharmacist MTM intervention did not significantly improve total proteinuria screening at the population level (OR 2.6, 95 % CI: 0.5-14.0; p = 0.3). However, it tended to increase screening of previously unscreened patients (78.6 % in the