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Sample records for risk stratify patients

  1. Cost-Effectiveness of Risk Score-Stratified Hepatocellular Carcinoma Screening in Patients with Cirrhosis.

    PubMed

    Goossens, Nicolas; Singal, Amit G; King, Lindsay Y; Andersson, Karin L; Fuchs, Bryan C; Besa, Cecilia; Taouli, Bachir; Chung, Raymond T; Hoshida, Yujin

    2017-06-22

    Hepatocellular carcinoma (HCC) surveillance with biannual ultrasound is currently recommended for all patients with cirrhosis. However, clinical implementation of this "one-size-fits-all" approach is challenging as evidenced by its low application rate. We aimed to evaluate the cost-effectiveness of risk-stratified HCC surveillance strategies in patients with cirrhosis. A Markov decision-analytic modeling was performed to simulate a cohort of 50-year-old subjects with compensated cirrhosis. Risk-stratified HCC surveillance strategies was implemented, in which patients were stratified into high-, intermediate-, or low-risk groups by HCC risk biomarker-based scores and assigned to surveillance modalities tailored to HCC risk (2 non-risk-stratified and 14 risk-stratified strategies) and compared with non-stratified biannual ultrasound. Quality-adjusted life expectancy gains for biannual ultrasound in all patients and risk-stratified strategies compared with no surveillance were 1.3 and 0.9-2.1 years, respectively. Compared with the current standard of biannual ultrasound in all cirrhosis patients, risk-stratified strategies applying magnetic resonance imaging (MRI) and/or ultrasound only in high- and intermediate-risk patients, without screening in low-risk patients, were cost-effective. Abbreviated MRI (AMRI) for high- and intermediate-risk patients had the lowest incremental cost-effectiveness ratio (ICER) of $2,100 per quality-adjusted life year gained. AMRI in intermediate- and high-risk patients had ICERs <$3,000 across a wide range of HCC incidences. Risk-stratified HCC surveillance strategies targeting high- and intermediate-risk patients with cirrhosis are cost-effective and outperform the currently recommended non-stratified biannual ultrasound in all patients with cirrhosis.

  2. Cost-Effectiveness of Risk Score–Stratified Hepatocellular Carcinoma Screening in Patients with Cirrhosis

    PubMed Central

    Goossens, Nicolas; Singal, Amit G; King, Lindsay Y; Andersson, Karin L; Fuchs, Bryan C; Besa, Cecilia; Taouli, Bachir; Chung, Raymond T; Hoshida, Yujin

    2017-01-01

    Objectives: Hepatocellular carcinoma (HCC) surveillance with biannual ultrasound is currently recommended for all patients with cirrhosis. However, clinical implementation of this “one-size-fits-all” approach is challenging as evidenced by its low application rate. We aimed to evaluate the cost-effectiveness of risk-stratified HCC surveillance strategies in patients with cirrhosis. Methods: A Markov decision-analytic modeling was performed to simulate a cohort of 50-year-old subjects with compensated cirrhosis. Risk-stratified HCC surveillance strategies was implemented, in which patients were stratified into high-, intermediate-, or low-risk groups by HCC risk biomarker–based scores and assigned to surveillance modalities tailored to HCC risk (2 non-risk-stratified and 14 risk-stratified strategies) and compared with non-stratified biannual ultrasound. Results: Quality-adjusted life expectancy gains for biannual ultrasound in all patients and risk-stratified strategies compared with no surveillance were 1.3 and 0.9–2.1 years, respectively. Compared with the current standard of biannual ultrasound in all cirrhosis patients, risk-stratified strategies applying magnetic resonance imaging (MRI) and/or ultrasound only in high- and intermediate-risk patients, without screening in low-risk patients, were cost-effective. Abbreviated MRI (AMRI) for high- and intermediate-risk patients had the lowest incremental cost-effectiveness ratio (ICER) of $2,100 per quality-adjusted life year gained. AMRI in intermediate- and high-risk patients had ICERs <$3,000 across a wide range of HCC incidences. Conclusions: Risk-stratified HCC surveillance strategies targeting high- and intermediate-risk patients with cirrhosis are cost-effective and outperform the currently recommended non-stratified biannual ultrasound in all patients with cirrhosis. PMID:28640287

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

    PubMed

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

    2015-10-26

    Chronic diseases affect 52% of Americans and consume 86% of health care costs. A small portion of patients consume most health care resources and costs. More intensive patient management strategies, such as case management, are usually more effective at improving health outcomes, but are also more expensive. To use limited resources efficiently, risk stratification is commonly used in managing patients with chronic diseases, such as asthma, chronic obstructive pulmonary disease, diabetes, and heart disease. Patients are stratified based on predicted risk with patients at higher risk given more intensive care. The current risk-stratified patient management approach has 3 limitations resulting in many patients not receiving the most appropriate care, unnecessarily increased costs, and suboptimal health outcomes. First, using predictive models for health outcomes and costs is currently the best method for forecasting individual patient's risk. Yet, accuracy of predictive models remains poor causing many patients to be misstratified. If an existing model were used to identify candidate patients for case management, enrollment would miss more than half of those who would benefit most, but include others unlikely to benefit, wasting limited resources. Existing models have been developed under the assumption that patient characteristics primarily influence outcomes and costs, leaving physician characteristics out of the models. In reality, both characteristics have an impact. Second, existing models usually give neither an explanation why a particular patient is predicted to be at high risk nor suggestions on interventions tailored to the patient's specific case. As a result, many high-risk patients miss some suitable interventions. Third, thresholds for risk strata are suboptimal and determined heuristically with no quality guarantee. The purpose of this study is to improve risk-stratified patient management so that more patients will receive the most appropriate care

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

    PubMed Central

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

    2015-01-01

    Background Chronic diseases affect 52% of Americans and consume 86% of health care costs. A small portion of patients consume most health care resources and costs. More intensive patient management strategies, such as case management, are usually more effective at improving health outcomes, but are also more expensive. To use limited resources efficiently, risk stratification is commonly used in managing patients with chronic diseases, such as asthma, chronic obstructive pulmonary disease, diabetes, and heart disease. Patients are stratified based on predicted risk with patients at higher risk given more intensive care. The current risk-stratified patient management approach has 3 limitations resulting in many patients not receiving the most appropriate care, unnecessarily increased costs, and suboptimal health outcomes. First, using predictive models for health outcomes and costs is currently the best method for forecasting individual patient’s risk. Yet, accuracy of predictive models remains poor causing many patients to be misstratified. If an existing model were used to identify candidate patients for case management, enrollment would miss more than half of those who would benefit most, but include others unlikely to benefit, wasting limited resources. Existing models have been developed under the assumption that patient characteristics primarily influence outcomes and costs, leaving physician characteristics out of the models. In reality, both characteristics have an impact. Second, existing models usually give neither an explanation why a particular patient is predicted to be at high risk nor suggestions on interventions tailored to the patient’s specific case. As a result, many high-risk patients miss some suitable interventions. Third, thresholds for risk strata are suboptimal and determined heuristically with no quality guarantee. Objective The purpose of this study is to improve risk-stratified patient management so that more patients will receive the

  5. Stratifying patients at the risk of heart failure hospitalization using existing device diagnostic thresholds

    PubMed Central

    Sharma, Vinod; Rathman, Lisa D.; Small, Roy S.; Whellan, David J.; Koehler, Jodi; Warman, Eduardo; Abraham, William T.

    2015-01-01

    Background Heart failure hospitalizations (HFHs) cost the US health care system ~$20 billion annually. Identifying patients at risk of HFH to enable timely intervention and prevent expensive hospitalization remains a challenge. Implantable cardioverter defibrillators (ICDs) and cardiac resynchronization devices with defibrillation capability (CRT-Ds) collect a host of diagnostic parameters that change with HF status and collectively have the potential to signal an increasing risk of HFH. These device-collected diagnostic parameters include activity, day and night heart rate, atrial tachycardia/atrial fibrillation (AT/AF) burden, mean rate during AT/AF, percent CRT pacing, number of shocks, and intrathoracic impedance. There are thresholds for these parameters that when crossed trigger a notification, referred to as device observation, which gets noted on the device report. We investigated if these existing device observations can stratify patients at varying risk of HFH. Methods We analyzed data from 775 patients (age: 69 ± 11 year, 68% male) with CRT-D devices followed for 13 ± 5 months with adjudicated HFHs. HFH rate was computed for increasing number of device observations. Data were analyzed by both excluding and including intrathoracic impedance. HFH risk was assessed at the time of a device interrogation session, and all the data between previous and current follow-up sessions were used to determine the HFH risk for the next 30 days. Results 2276 follow-up sessions in 775 patients were evaluated with 42 HFHs in 37 patients. Percentage of evaluations that were followed by an HFH within the next 30 days increased with increasing number of device observations. Patients with 3 or more device observations were at 42× HFH risk compared to patients with no device observation. Even after excluding intrathoracic impedance, the remaining device parameters effectively stratified patients at HFH risk. Conclusion Available device observations could provide an effective

  6. Creatine-kinase and dialysis patients, a helpful tool for stratifying cardiovascular risk?

    PubMed

    Quiroga, Borja; Vega, Almudena; Abad, Soraya; Villaverde, Maite; Reque, Javier; López-Gómez, Juan Manuel

    2016-01-01

    Hemodialysis patients have an enhanced risk for cardiovascular events. Cardiac biomarkers provide useful information for stratifying their risk. However the prognosis value of creatine kinase MB isoenzyme (CKMB) has not yet been validated in this population. The aim of the present study is to determine the predictable value of CK-MB in hemodialysis. A cohort of 211 hemodialysis patients (58.3% male, median age 73 (60-80) years) were followed for 39 (19-56) months. Cardiac biomarkers including CKMB were recorded at baseline. Factors associated to CKMB and prognosis value of this biomarker was studied. The median value of CKMB was 1 (1-2) ng/mL with no patient exceeding normal laboratory values. Previous heart disease, diabetes mellitus, peripheral vascular disease and systolic and diastolic dysfunction were associated with higher levels of CKMB. Ninety-four patients (44.5%) cardiovascular events were recorded. CKMB levels ≥2ng/mL was independently associated to cardiovascular events during the follow up after adjusting. Adding CKMB to a model including several variables for predicting cardiovascular events, resulted in 17% improvement in risk discrimination (IDI) with a relative IDI of 9.9% (p=0.04). CKMB is a good marker for stratifying cardiovascular risk in hemodialysis patients and adds prognosis information to other well known independent predictors for cardiovascular events. Copyright © 2015 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

  7. A Prediction Rule to Stratify Mortality Risk of Patients with Pulmonary Tuberculosis.

    PubMed

    Bastos, Helder Novais; Osório, Nuno S; Castro, António Gil; Ramos, Angélica; Carvalho, Teresa; Meira, Leonor; Araújo, David; Almeida, Leonor; Boaventura, Rita; Fragata, Patrícia; Chaves, Catarina; Costa, Patrício; Portela, Miguel; Ferreira, Ivo; Magalhães, Sara Pinto; Rodrigues, Fernando; Sarmento-Castro, Rui; Duarte, Raquel; Guimarães, João Tiago; Saraiva, Margarida

    2016-01-01

    Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted to develop a severity assessment tool for stratifying mortality risk in pulmonary tuberculosis (PTB) patients. A derivation cohort of 681 PTB cases was retrospectively reviewed to generate a model based on multiple logistic regression analysis of prognostic variables with 6-month mortality as the outcome measure. A clinical scoring system was developed and tested against a validation cohort of 103 patients. Five risk features were selected for the prediction model: hypoxemic respiratory failure (OR 4.7, 95% CI 2.8-7.9), age ≥50 years (OR 2.9, 95% CI 1.7-4.8), bilateral lung involvement (OR 2.5, 95% CI 1.4-4.4), ≥1 significant comorbidity-HIV infection, diabetes mellitus, liver failure or cirrhosis, congestive heart failure and chronic respiratory disease-(OR 2.3, 95% CI 1.3-3.8), and hemoglobin <12 g/dL (OR 1.8, 95% CI 1.1-3.1). A tuberculosis risk assessment tool (TReAT) was developed, stratifying patients with low (score ≤2), moderate (score 3-5) and high (score ≥6) mortality risk. The mortality associated with each group was 2.9%, 22.9% and 53.9%, respectively. The model performed equally well in the validation cohort. We provide a new, easy-to-use clinical scoring system to identify PTB patients with high-mortality risk in settings with good healthcare access, helping clinicians to decide which patients are in need of closer medical care during treatment.

  8. A Prediction Rule to Stratify Mortality Risk of Patients with Pulmonary Tuberculosis

    PubMed Central

    Osório, Nuno S.; Castro, António Gil; Ramos, Angélica; Carvalho, Teresa; Meira, Leonor; Araújo, David; Almeida, Leonor; Boaventura, Rita; Fragata, Patrícia; Chaves, Catarina; Costa, Patrício; Portela, Miguel; Ferreira, Ivo; Magalhães, Sara Pinto; Rodrigues, Fernando; Sarmento-Castro, Rui; Duarte, Raquel; Guimarães, João Tiago; Saraiva, Margarida

    2016-01-01

    Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted to develop a severity assessment tool for stratifying mortality risk in pulmonary tuberculosis (PTB) patients. A derivation cohort of 681 PTB cases was retrospectively reviewed to generate a model based on multiple logistic regression analysis of prognostic variables with 6-month mortality as the outcome measure. A clinical scoring system was developed and tested against a validation cohort of 103 patients. Five risk features were selected for the prediction model: hypoxemic respiratory failure (OR 4.7, 95% CI 2.8–7.9), age ≥50 years (OR 2.9, 95% CI 1.7–4.8), bilateral lung involvement (OR 2.5, 95% CI 1.4–4.4), ≥1 significant comorbidity—HIV infection, diabetes mellitus, liver failure or cirrhosis, congestive heart failure and chronic respiratory disease–(OR 2.3, 95% CI 1.3–3.8), and hemoglobin <12 g/dL (OR 1.8, 95% CI 1.1–3.1). A tuberculosis risk assessment tool (TReAT) was developed, stratifying patients with low (score ≤2), moderate (score 3–5) and high (score ≥6) mortality risk. The mortality associated with each group was 2.9%, 22.9% and 53.9%, respectively. The model performed equally well in the validation cohort. We provide a new, easy-to-use clinical scoring system to identify PTB patients with high-mortality risk in settings with good healthcare access, helping clinicians to decide which patients are in need of closer medical care during treatment. PMID:27636095

  9. Improved Method to Stratify Elderly Patients With Cancer at Risk for Competing Events.

    PubMed

    Carmona, Ruben; Zakeri, Kaveh; Green, Garrett; Hwang, Lindsay; Gulaya, Sachin; Xu, Beibei; Verma, Rohan; Williamson, Casey W; Triplett, Daniel P; Rose, Brent S; Shen, Hanjie; Vaida, Florin; Murphy, James D; Mell, Loren K

    2016-04-10

    To compare a novel generalized competing event (GCE) model versus the standard Cox proportional hazards regression model for stratifying elderly patients with cancer who are at risk for competing events. We identified 84,319 patients with nonmetastatic prostate, head and neck, and breast cancers from the SEER-Medicare database. Using demographic, tumor, and clinical characteristics, we trained risk scores on the basis of GCE versus Cox models for cancer-specific mortality and all-cause mortality. In test sets, we examined the predictive ability of the risk scores on the different causes of death, including second cancer mortality, noncancer mortality, and cause-specific mortality, using Fine-Gray regression and area under the curve. We compared how well models stratified subpopulations according to the ratio of the cumulative cause-specific hazard for cancer mortality to the cumulative hazard for overall mortality (ω) using the Akaike Information Criterion. In each sample, increasing GCE risk scores were associated with increased cancer-specific mortality and decreased competing mortality, whereas risk scores from Cox models were associated with both increased cancer-specific mortality and competing mortality. GCE models created greater separation in the area under the curve for cancer-specific mortality versus noncancer mortality (P < .001), indicating better discriminatory ability between these events. Comparing the GCE model to Cox models of cause-specific mortality or all-cause mortality, the respective Akaike Information Criterion scores were superior (lower) in each sample: prostate cancer, 28.6 versus 35.5 versus 39.4; head and neck cancer, 21.1 versus 29.4 versus 40.2; and breast cancer, 24.6 versus 32.3 versus 50.8. Compared with standard modeling approaches, GCE models improve stratification of elderly patients with cancer according to their risk of dying from cancer relative to overall mortality. © 2016 by American Society of Clinical Oncology.

  10. Improved Method to Stratify Elderly Patients With Cancer at Risk for Competing Events

    PubMed Central

    Carmona, Ruben; Zakeri, Kaveh; Green, Garrett; Hwang, Lindsay; Gulaya, Sachin; Xu, Beibei; Verma, Rohan; Williamson, Casey W.; Triplett, Daniel P.; Rose, Brent S.; Shen, Hanjie; Vaida, Florin; Murphy, James D.

    2016-01-01

    Purpose To compare a novel generalized competing event (GCE) model versus the standard Cox proportional hazards regression model for stratifying elderly patients with cancer who are at risk for competing events. Methods We identified 84,319 patients with nonmetastatic prostate, head and neck, and breast cancers from the SEER-Medicare database. Using demographic, tumor, and clinical characteristics, we trained risk scores on the basis of GCE versus Cox models for cancer-specific mortality and all-cause mortality. In test sets, we examined the predictive ability of the risk scores on the different causes of death, including second cancer mortality, noncancer mortality, and cause-specific mortality, using Fine-Gray regression and area under the curve. We compared how well models stratified subpopulations according to the ratio of the cumulative cause-specific hazard for cancer mortality to the cumulative hazard for overall mortality (ω) using the Akaike Information Criterion. Results In each sample, increasing GCE risk scores were associated with increased cancer-specific mortality and decreased competing mortality, whereas risk scores from Cox models were associated with both increased cancer-specific mortality and competing mortality. GCE models created greater separation in the area under the curve for cancer-specific mortality versus noncancer mortality (P < .001), indicating better discriminatory ability between these events. Comparing the GCE model to Cox models of cause-specific mortality or all-cause mortality, the respective Akaike Information Criterion scores were superior (lower) in each sample: prostate cancer, 28.6 versus 35.5 versus 39.4; head and neck cancer, 21.1 versus 29.4 versus 40.2; and breast cancer, 24.6 versus 32.3 versus 50.8. Conclusion Compared with standard modeling approaches, GCE models improve stratification of elderly patients with cancer according to their risk of dying from cancer relative to overall mortality. PMID:26884579

  11. Stratifying Risk for Renal Insufficiency Among Lithium-Treated Patients: An Electronic Health Record Study.

    PubMed

    Castro, Victor M; Roberson, Ashlee M; McCoy, Thomas H; Wiste, Anna; Cagan, Andrew; Smoller, Jordan W; Rosenbaum, Jerrold F; Ostacher, Michael; Perlis, Roy H

    2016-03-01

    Although lithium preparations remain first-line treatment for bipolar disorder, risk for development of renal insufficiency may discourage their use. Estimating such risk could allow more informed decisions and facilitate development of prevention strategies. We utilized electronic health records from a large New England health-care system between 2006 and 2013 to identify patients aged 18 years or older with a lithium prescription. Renal insufficiency was identified using the presence of renal failure by ICD9 code or laboratory-confirmed glomerular filtration rate below 60 ml/min. Logistic regression was used to build a predictive model in a random two-thirds of the cohort, which was tested in the remaining one-third. Risks associated with aspects of pharmacotherapy were also examined in the full cohort. We identified 1445 adult lithium-treated patients with renal insufficiency, matched by risk set sampling 1 : 3 with 4306 lithium-exposed patients without renal insufficiency. In regression models, features associated with risk included older age, female sex, history of smoking, history of hypertension, overall burden of medical comorbidity, and diagnosis of schizophrenia or schizoaffective disorder (p<0.01 for all contrasts). The model yielded an area under the ROC curve exceeding 0.81 in an independent testing set, with 74% of renal insufficiency cases among the top two risk quintiles. Use of lithium more than once daily, lithium levels greater than 0.6 mEq/l, and use of first-generation antipsychotics were independently associated with risk. These results suggest the possibility of stratifying risk for renal failure among lithium-treated patients. Once-daily lithium dosing and maintaining lower lithium levels where possible may represent strategies for reducing risk.

  12. Stratifying Risk for Renal Insufficiency Among Lithium-Treated Patients: An Electronic Health Record Study

    PubMed Central

    Castro, Victor M; Roberson, Ashlee M; McCoy, Thomas H; Wiste, Anna; Cagan, Andrew; Smoller, Jordan W; Rosenbaum, Jerrold F; Ostacher, Michael; Perlis, Roy H

    2016-01-01

    Although lithium preparations remain first-line treatment for bipolar disorder, risk for development of renal insufficiency may discourage their use. Estimating such risk could allow more informed decisions and facilitate development of prevention strategies. We utilized electronic health records from a large New England health-care system between 2006 and 2013 to identify patients aged 18 years or older with a lithium prescription. Renal insufficiency was identified using the presence of renal failure by ICD9 code or laboratory-confirmed glomerular filtration rate below 60 ml/min. Logistic regression was used to build a predictive model in a random two-thirds of the cohort, which was tested in the remaining one-third. Risks associated with aspects of pharmacotherapy were also examined in the full cohort. We identified 1445 adult lithium-treated patients with renal insufficiency, matched by risk set sampling 1 : 3 with 4306 lithium-exposed patients without renal insufficiency. In regression models, features associated with risk included older age, female sex, history of smoking, history of hypertension, overall burden of medical comorbidity, and diagnosis of schizophrenia or schizoaffective disorder (p<0.01 for all contrasts). The model yielded an area under the ROC curve exceeding 0.81 in an independent testing set, with 74% of renal insufficiency cases among the top two risk quintiles. Use of lithium more than once daily, lithium levels greater than 0.6 mEq/l, and use of first-generation antipsychotics were independently associated with risk. These results suggest the possibility of stratifying risk for renal failure among lithium-treated patients. Once-daily lithium dosing and maintaining lower lithium levels where possible may represent strategies for reducing risk. PMID:26294109

  13. Stratified premedication strategy for the prevention of contrast media hypersensitivity in high-risk patients.

    PubMed

    Lee, Suh-Young; Yang, Min Suk; Choi, Young-Hoon; Park, Chang Min; Park, Heung-Woo; Cho, Sang Heon; Kang, Hye-Ryun

    2017-03-01

    Although the severity of hypersensitivity reactions to iodinated contrast media varies, it is well correlated with the severity of recurrent reactions; however, prophylaxis protocols are not severity-stratified. To assess the outcomes of tailored prophylaxis according to the severity of hypersensitivity reactions to iodinated contrast media. Our premedication protocols were stratified based on the severity of previous reactions: (1) 4 mg of chlorpheniramine for mild reactions, (2) adding 40 mg of methylprednisolone for moderate reactions, and (3) adding multiple doses of 40 mg of methylprednisolone for severe index reactions. Cases of reexposure in patients with a history of hypersensitivity reactions were routinely monitored and mandatorily recorded. Among a total of 850 patients who underwent enhanced computed tomography after severity-tailored prophylaxis, breakthrough reactions occurred in 17.1%, but most breakthrough reactions (89.0%) were mild and did not require medical treatment. Additional corticosteroid use did not reduce the breakthrough reaction rate in cases with a mild index reaction (16.8% vs 17.2%, P = .70). However, underpremedication with a single dose of corticosteroid revealed significantly higher rates of breakthrough reaction than did double doses of corticosteroid in cases with a severe index reaction (55.6% vs 17.4%, P = .02). Changing the iodinated contrast media resulted in an additional reduction of the breakthrough reaction rate overall (14.9% vs 32.1%, P = .001). In a total severity-based stratified prophylaxis regimens and changing iodinated contrast media can be considered in patients with a history of previous hypersensitivity reaction to iodinated contrast media to reduce the risk of breakthrough reactions. Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

  14. Mammostrat as a tool to stratify breast cancer patients at risk of recurrence during endocrine therapy.

    PubMed

    Bartlett, John M S; Thomas, Jeremy; Ross, Douglas T; Seitz, Robert S; Ring, Brian Z; Beck, Rodney A; Pedersen, Hans Christian; Munro, Alison; Kunkler, Ian H; Campbell, Fiona M; Jack, Wilma; Kerr, Gillian R; Johnstone, Laura; Cameron, David A; Chetty, Udi

    2010-01-01

    Patients with early-stage breast cancer, treated with endocrine therapy, have approximately 90% 5-year disease-free survival. However, for patients at higher risk of relapse despite endocrine therapy, additional adjuvant therapy, such as chemotherapy, may be indicated. The challenge is to prospectively identify such patients. The Mammostrat® test uses five immunohistochemical markers to stratify patients on tamoxifen therapy into risk groups to inform treatment decisions. We tested the efficacy of this panel in a mixed population of cases treated in a single center with breast-conserving surgery and long-term follow-up. Tissue microarrays from a consecutive series (1981 to 1998) of 1,812 women managed by wide local excision and postoperative radiotherapy were collected following appropriate ethical review. Of 1,390 cases stained, 197 received no adjuvant hormonal or chemotherapy, 1,044 received tamoxifen only, and 149 received a combination of hormonal therapy and chemotherapy. Median age at diagnosis was 57, 71% were postmenopausal, 23.9% were node-positive and median tumor size was 1.5 cm. Samples were stained using triplicate 0.6 mm2 tissue microarray cores, and positivity for p53, HTF9C, CEACAM5, NDRG1 and SLC7A5 was assessed. Each case was assigned a Mammostrat risk score, and distant recurrence-free survival (DRFS), relapse-free survival (RFS) and overall survival (OS) were analyzed by marker positivity and risk score. Increased Mammostrat scores were significantly associated with reduced DRFS, RFS and OS in estrogen receptor (ER)-positive breast cancer (P < 0.00001). In multivariate analyses the risk score was independent of conventional risk factors for DRFS, RFS and OS (P < 0.05). In node-negative, tamoxifen-treated patients, 10-year recurrence rates were 7.6 ± 1.5% in the low-risk group versus 20.0 ± 4.4% in the high-risk group. Further, exploratory analyses revealed associations with outcome in both ER-negative and untreated patients. This is the

  15. Stratifying patients with haematuria into high or low risk groups for bladder cancer: a novel clinical scoring system.

    PubMed

    Hee, Tan Guan; Shah, Shamsul Azhar; Ann, Ho Sue; Hemdan, Siti Nurhafizah; Shen, Lim Chun; Al-Fahmi Abdul Galib, Nurudin; Singam, Praveen; Chee Kong, Christopher Ho; Hong, Goh Eng; Bahadzor, Badrulhisham; Zainuddin, Zulkifli Md

    2013-01-01

    Haematuria is a common presentation of bladder cancer and requires a full urologic evaluation. This study aimed to develop a scoring system capable of stratifying patients with haematuria into high or low risk groups for having bladder cancer to help clinicians decide which patients need more urgent assessment. This cross- sectional study included all adult patients referred for haematuria and subsequently undergoing full urological evaluation in the years 2001 to 2011. Risk factors with strong association with bladder cancer in the study population were used to design the scoring system. Accuracy was determined by the area under the receiver operating characteristic (ROC) curve. A total of 325 patients with haematuria were included, out of which 70 (21.5%) were diagnosed to have bladder cancer. Significant risk factors associated with bladder cancer were male gender, a history of cigarette smoking and the presence of gross haematuria. A scoring system using 4 clinical parameters as variables was created. The scores ranged between 6 to 14, and a score of 10 and above indicated high risk for having bladder cancer. It was found to have good accuracy with an area under the ROC curve of 80.4%, while the sensitivity and specificity were 90.0% and 55.7%, respectively. The scoring system designed in this study has the potential to help clinicians stratify patients who present with haematuria into high or low risk for having bladder cancer. This will enable high-risk patients to undergo urologic assessment earlier.

  16. Competing Risks Regression for Stratified Data

    PubMed Central

    Zhou, Bingqing; Latouche, Aurelien; Rocha, Vanderson; Fine, Jason

    2012-01-01

    Summary For competing risks data, the Fine–Gray proportional hazards model for subdistribution has gained popularity for its convenience in directly assessing the effect of covariates on the cumulative incidence function. However, in many important applications, proportional hazards may not be satisfied, including multicenter clinical trials, where the baseline subdistribution hazards may not be common due to varying patient populations. In this article, we consider a stratified competing risks regression, to allow the baseline hazard to vary across levels of the stratification covariate. According to the relative size of the number of strata and strata sizes, two stratification regimes are considered. Using partial likelihood and weighting techniques, we obtain consistent estimators of regression parameters. The corresponding asymptotic properties and resulting inferences are provided for the two regimes separately. Data from a breast cancer clinical trial and from a bone marrow transplantation registry illustrate the potential utility of the stratified Fine–Gray model. PMID:21155744

  17. Stress Perfusion Cardiovascular Magnetic Resonance Imaging Effectively Risk Stratifies Diabetic Patients With Suspected Myocardial Ischemia

    PubMed Central

    Heydari, Bobak; Juan, Yu-Hsiang; Liu, Hui; Abbasi, Siddique; Shah, Ravi; Blankstein, Ron; Steigner, Michael; Jerosch-Herold, Michael; Kwong, Raymond Y.

    2016-01-01

    Background Diabetics remain at high risk of cardiovascular disease and mortality despite advancements in medical therapy. Noninvasive cardiac risk profiling is often more difficult in diabetics owing to the prevalence of silent ischemia with unrecognized myocardial infarction (MI), reduced exercise capacity, non-diagnostic electrocardiographic changes, and balanced ischemia from diffuse epicardial coronary atherosclerosis and microvascular dysfunction. Methods and Results A consecutive cohort of 173 diabetic patients (mean age 61.7±11.9, 37% female) with suspected myocardial ischemia underwent stress perfusion CMR. Patients were evaluated for adverse cardiac events following CMR with mean follow-up time of 2.9 ± 2.5 years. Mean HbA1C for the population was 7.9±1.8%. Primary endpoint was a composite of cardiac death and nonfatal MI. Diabetics with no inducible ischemia (n=94) experienced an annualized event rate of 1.4% compared to 8.2% (P=0.0003) in those with inducible ischemia (n=79). Diabetics without late gadolinium enhancement or inducible ischemia had a very low annual cardiac event rate (0.5%/year). Presence of inducible ischemia was the strongest unadjusted predictor (HR 4.86, P<0.01) for cardiac death and nonfatal MI. This association remained robust in adjusted stepwise multivariable Cox regression analysis (HR 4.28, P=0.02). In addition, categorical net reclassification index (NRI) using 5-year risk cutoffs of 5% and 10% resulted in reclassification of 43.4% of the diabetic cohort with NRI of 0.38 (95% CI 0.20–0.56, P<0.0001). Conclusions Stress perfusion CMR provided independent prognostic utility and effectively reclassified risk in diabetic patients referred for ischemic assessment. Further evaluation is required to determine if a noninvasive imaging strategy with CMR can favorably impact downstream outcomes and improve cost-effectiveness of care in diabetics. PMID:27059504

  18. Stress Perfusion Cardiac Magnetic Resonance Imaging Effectively Risk Stratifies Diabetic Patients With Suspected Myocardial Ischemia.

    PubMed

    Heydari, Bobak; Juan, Yu-Hsiang; Liu, Hui; Abbasi, Siddique; Shah, Ravi; Blankstein, Ron; Steigner, Michael; Jerosch-Herold, Michael; Kwong, Raymond Y

    2016-04-01

    Diabetics remain at high risk of cardiovascular disease and mortality despite advancements in medical therapy. Noninvasive cardiac risk profiling is often more difficult in diabetics owing to the prevalence of silent ischemia with unrecognized myocardial infarction, reduced exercise capacity, nondiagnostic electrocardiographic changes, and balanced ischemia from diffuse epicardial coronary atherosclerosis and microvascular dysfunction. A consecutive cohort of 173 patients with diabetes mellitus (mean age, 61.7±11.9 years; 37% women) with suspected myocardial ischemia underwent stress perfusion cardiac magnetic resonance imaging. Patients were evaluated for adverse cardiac events after cardiac magnetic resonance imaging with mean follow-up time of 2.9±2.5 years. Mean hemoglobin A1c for the population was 7.9±1.8%. Primary end point was a composite of cardiac death and nonfatal myocardial infarction. Diabetics with no inducible ischemia (n=94) experienced an annualized event rate of 1.4% compared with 8.2% (P=0.0003) in those with inducible ischemia (n=79). Diabetics without late gadolinium enhancement or inducible ischemia had a low annual cardiac event rate (0.5% per year). The presence of inducible ischemia was the strongest unadjusted predictor (hazard ratio, 4.86; P<0.01) for cardiac death and nonfatal myocardial infarction. This association remained robust in adjusted stepwise multivariable Cox regression analysis (hazard ratio, 4.28; P=0.02). In addition, categorical net reclassification index using 5-year risk cutoffs of 5% and 10% resulted in reclassification of 43.4% of the diabetic cohort with net reclassification index of 0.38 (95% confidence interval, 0.20-0.56; P<0.0001). Stress perfusion cardiac magnetic resonance imaging provided independent prognostic utility and effectively reclassified risk in patients with diabetes mellitus referred for ischemic assessment. Further evaluation is required to determine whether a noninvasive imaging strategy with

  19. IPSS-R in 555 Taiwanese patients with primary MDS: Integration of monosomal karyotype can better risk-stratify the patients.

    PubMed

    Yang, Yi-Tsung; Hou, Hsin-An; Liu, Chieh-Yu; Lin, Chien-Chin; Chou, Wen-Chien; Lee, Fen-Yu; Liu, Ming-Chih; Liu, Chia-Wen; Tang, Jih-Luh; Yao, Ming; Li, Chi-Cheng; Kuo, Yuan-Yeh; Huang, Shang-Yi; Ko, Bor-Sheng; Chen, Chien-Yuan; Hsu, Szu-Chun; Lin, Chien-Ting; Wu, Shang-Ju; Tsay, Woei; Chen, Yao-Chang; Tien, Hwei-Fang

    2014-09-01

    The revised International Prognostic Scoring System (IPSS-R) was recently developed to better assess the clinical outcome of adult patients with myelodysplastic syndrome (MDS). In this study, we aimed to investigate the prognostic impact of this new risk model on 555 MDS patients in Taiwan. Generally, the IPSS-R could discriminate MDS patients regarding risk of leukemia evolution and overall survival in our cohort and it further refined prognostic stratification in all IPSS risk categories. However, we could not find the inter-group difference between IPSS-R very low and low risk subgroups in both leukemia-free survival (LFS) and overall survival (OS). IPSS-R couldn't distinguish the prognosis between very good and good and between good and intermediate risk cytogenetic categories in OS, and between very good and good and between intermediate and poor cytogenetic-risk categories in LFS, either. On the other hand, incorporation of monosomal karyotype (MK) into IPSS-R could further stratify MDS patients with higher-risk IPSS-R (intermediate, high and very high risk) into four groups, rather than three groups, with different OS (P < 0.001). Intriguingly, patients receiving allogeneic hematopoietic stem cell transplantation had longer survival than those without in the IPSS-R high and very high, but not other risk groups. Similarly, patients treated with hypomethylating agents had better survival than those not in the IPSS-R very high risk group. In conclusion, IPSS-R can risk-stratify MDS patients in Taiwan but with some limitations, especially in very low risk category, and MK has additional prognostic value in discriminating MDS patients with higher-risk IPSS-R.

  20. Metastatic lymph node ratio can further stratify risk for mortality in medullary thyroid cancer patients: A population-based analysis

    PubMed Central

    Lu, Zhong-wu; Liao, Tian; Wen, Duo; Sun, Guo-hua; Li, Duan-shu; Ji, Qing-hai

    2016-01-01

    Medullary thyroid cancer (MTC) has a propensity to cervical lymph node metastases (LNM). Recent studies have shown that both the number of involved lymph nodes (LNs) and the metastatic lymph node ratio (MLNR) confer prognostic information. This study was to determine the predictive value of MLNR on cancer-specific survival (CSS) in SEER (Surveillance, Epidemiology and End Results)-registered MTC patients treated with thyroidectomy and lymphadenectomy between 1991 and 2012, investigate the cutoff points for MLNR in stratifying risk of mortality and provide evidence for selection of appropriate treatment strategies. X-tile program determined 0.5 as optimal cut-off value for MLNR in terms of CSS in 890 MTC patients. According to multivariate Cox regression analysis, MLNR (0.50–1.00) is a significant independent prognostic factor for CSS (hazard ratio 2.161, 95% confidence interval 1.327–3.519, p=0.002). MLNR (0.50–1.00) has a greater prognostic impact on CSS in female, non-Hispanic white, T3/4, N1b and M1 patients. The lymph node yield (LNY) influences the effect of MLNR on CSS; LNY ≥9 results in MLNR (0.50–1.00) having a higher HR for CSS than MLNR (0.00-0.49). In conclusion, higher MLNRs predict poorer survival in MTC patients. Eradication of involved nodes ensures accurate staging and maximizes the ability of MLNR to predict prognosis. PMID:27588396

  1. Simultaneous measurements of fecal calprotectin and the fecal immunochemical test in quiescent ulcerative colitis patients can stratify risk of relapse.

    PubMed

    Nakarai, Asuka; Hiraoka, Sakiko; Takahashi, Sakuma; Inaba, Tomoki; Higashi, Reiji; Mizuno, Motowo; Takashima, Shiho; Inokuchi, Toshihiro; Sugihara, Yuusaku; Takahara, Masahiro; Harada, Keita; Kato, Jun; Okada, Hiroyuki

    2017-08-31

    Both fecal calprotectin (Fcal) and the fecal immunochemical test (FIT) are useful to predict clinical relapse of ulcerative colitis (UC). However, the difference between Fcal and FIT in the ability to predict relapse has scarcely been reported. Whether the combined use of these two fecal markers increases the predictability is also unknown. UC patients in clinical remission who underwent colonoscopy were enrolled prospectively, and the Fcal and FIT values were examined at enrollment. Their clinical course was observed for 2 years or until relapse. The correlation between the incidence of relapse and the values of the two markers was examined. A total of 113 patients were enrolled, and 48 (42%) relapsed. Fcal ≥ 75 μg/g and FIT ≥ 110 ng/mL were defined as Fcal-positive and FIT-positive, respectively, according to the receiver operating characteristic curves. Both Fcal-positive and FIT-positive statuses were independent predictive factors of clinical relapse (HR 2.29; 95% CI, 1.23-4.49; P = 0.0086, and HR 2.91; 95% CI, 1.49-5.50; P = 0.0022, respectively). Categorization of patients into three groups according to the fecal marker status (FIT-positive, FIT-negative and Fcal-positive, and both-negative) can efficiently stratify the risk of relapse with graded increases in risk (FIT-negative and Fcal-positive: HR 2.05; 95% CI, 1.02-4.43; P = 0.0045, and FIT-positive: HR 5.43; 95% CI, 2.57-11.76; P < 0.0001, compared to both-negative). Fcal vs. FIT showed distinct properties regarding the prediction of relapse in UC. A risk assessment using both fecal markers could increase the predictability for relapse.

  2. Risk-stratified imputation in survival analysis.

    PubMed

    Kennedy, Richard E; Adragni, Kofi P; Tiwari, Hemant K; Voeks, Jenifer H; Brott, Thomas G; Howard, George

    2013-08-01

    Censoring that is dependent on covariates associated with survival can arise in randomized trials due to changes in recruitment and eligibility criteria to minimize withdrawals, potentially leading to biased treatment effect estimates. Imputation approaches have been proposed to address censoring in survival analysis; while these approaches may provide unbiased estimates of treatment effects, imputation of a large number of outcomes may over- or underestimate the associated variance based on the imputation pool selected. We propose an improved method, risk-stratified imputation, as an alternative to address withdrawal related to the risk of events in the context of time-to-event analyses. Our algorithm performs imputation from a pool of replacement subjects with similar values of both treatment and covariate(s) of interest, that is, from a risk-stratified sample. This stratification prior to imputation addresses the requirement of time-to-event analysis that censored observations are representative of all other observations in the risk group with similar exposure variables. We compared our risk-stratified imputation to case deletion and bootstrap imputation in a simulated dataset in which the covariate of interest (study withdrawal) was related to treatment. A motivating example from a recent clinical trial is also presented to demonstrate the utility of our method. In our simulations, risk-stratified imputation gives estimates of treatment effect comparable to bootstrap and auxiliary variable imputation while avoiding inaccuracies of the latter two in estimating the associated variance. Similar results were obtained in analysis of clinical trial data. Risk-stratified imputation has little advantage over other imputation methods when covariates of interest are not related to treatment. Risk-stratified imputation is intended for categorical covariates and may be sensitive to the width of the matching window if continuous covariates are used. The use of the risk-stratified

  3. The National Surgical Quality Improvement Program risk calculator does not adequately stratify risk for patients with clinical stage I non-small cell lung cancer.

    PubMed

    Samson, Pamela; Robinson, Clifford G; Bradley, Jeffrey; Lee, Audrey; Broderick, Stephen; Kreisel, Daniel; Krupnick, A Sasha; Patterson, G Alexander; Puri, Varun; Meyers, Bryan F; Crabtree, Traves

    2016-03-01

    The study objective was to validate the National Surgical Quality Improvement Program (NSQIP) Risk Calculator in stratifying risk estimates for patients who received surgery or stereotactic body radiation therapy for clinical stage I non-small cell lung cancer. A retrospective analysis of patients with clinical stage I non-small cell lung cancer undergoing surgery (N = 279) or stereotactic body radiation therapy (N = 206) from 2009 to 2012 was performed. NSQIP complication risk estimates were calculated for both surgical and stereotactic body radiation therapy cases using the NSQIP Surgical Risk Calculator. NSQIP complication risk estimates were compared as continuous variables and by quartile ranges. Compared with patients undergoing video-assisted thoracoscopic surgery wedge resection, patients receiving stereotactic body radiation therapy were older, had larger tumors, had lower forced expiratory volume (FEV1) in 1 second and diffusing capacity of the lungs (DLCO) for carbon monoxide values, had higher American Society of Anesthesiologists scores, had higher rates of dyspnea, and had higher NSQIP serious complication risk estimates (all P < .05). Compared with patients undergoing video-assisted thoracoscopic surgery lobectomy, patients receiving stereotactic body radiation therapy had similar disparities, along with higher Adult Comorbidity Evaluation-27 (ACE) scores comorbidity scores, higher rates of cardiac comorbidities, and worse functional status (all P < .05). Variables associated with receiving stereotactic body radiation therapy treatment, rather than wedge resection, included increasing age, higher Adult Comorbidity Evaluation (ACE)-27 comorbidity score, dyspnea status, and decreasing FEV1 in 1 second and DLCO for carbon monoxide, but NSQIP serious complication risk score. In addition, surgical patients' actual serious complication rate (16.6% vs 8.8%) and pneumonia rate (6.0% vs 3.2%) were significantly higher than the NSQIP risk calculator predicted

  4. Stratifying risk in the prevention of recurrent variceal hemorrhage: Results of an individual patient meta-analysis.

    PubMed

    Albillos, Agustín; Zamora, Javier; Martínez, Javier; Arroyo, David; Ahmad, Irfan; De-la-Peña, Joaquin; Garcia-Pagán, Juan-Carlos; Lo, Gin-Ho; Sarin, Shiv; Sharma, Barjesh; Abraldes, Juan G; Bosch, Jaime; Garcia-Tsao, Guadalupe

    2017-10-01

    Endoscopic variceal ligation plus beta-blockers (EVL+BB) is currently recommended for variceal rebleeding prophylaxis, a recommendation that extends to all patients with cirrhosis with previous variceal bleeding irrespective of prognostic stage. Individualizing patient care is relevant, and in published studies on variceal rebleeding prophylaxis, there is a lack of information regarding response to therapy by prognostic stage. This study aimed at comparing EVL plus BB with monotherapy (EVL or BB) on all-source rebleeding and mortality in patients with cirrhosis and previous variceal bleeding stratified by cirrhosis severity (Child A versus B/C) by means of individual time-to-event patient data meta-analysis from randomized controlled trials. The study used individual data on 389 patients from three trials comparing EVL plus BB versus BB and 416 patients from four trials comparing EVL plus BB versus EVL. Compared with BB alone, EVL plus BB reduced overall rebleeding in Child A (incidence rate ratio 0.40; 95% confidence interval, 0.18-0.89; P = 0.025) but not in Child B/C, without differences in mortality. The effect of EVL on rebleeding was different according to Child (P for interaction <0.001). Conversely, compared with EVL, EVL plus BB reduced rebleeding in both Child A and B/C, with a significant reduction in mortality in Child B/C (incidence rate ratio 0.46; 95% confidence interval, 0.25-0.85; P = 0.013). Outcomes of therapies to prevent variceal rebleeding differ depending on cirrhosis severity: in patients with preserved liver function (Child A), combination therapy is recommended because it is more effective in preventing rebleeding, without modifying survival, while in patients with advanced liver failure (Child B/C), EVL alone carries an increased risk of rebleeding and death compared with combination therapy, underlining that BB is the key element of combination therapy. (Hepatology 2017;66:1219-1231). © 2017 by the American Association for the Study of

  5. In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair.

    PubMed

    Ali, Mujtaba M; Flahive, Julie; Schanzer, Andres; Simons, Jessica P; Aiello, Francesco A; Doucet, Danielle R; Messina, Louis M; Robinson, William P

    2015-06-01

    Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR. In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups. Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR. This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients

  6. Outcomes of patients with differentiated thyroid cancer risk-stratified according to the American thyroid association and Latin American thyroid society risk of recurrence classification systems.

    PubMed

    Pitoia, Fabián; Bueno, Fernanda; Urciuoli, Carolina; Abelleira, Erika; Cross, Graciela; Tuttle, R Michael

    2013-11-01

    The aims of this study were to validate the proposed Latin American Thyroid Society (LATS) risk of recurrence stratification system and to compare the findings with those of the American Thyroid Association (ATA) risk of recurrence stratification system. This study is a retrospective review of papillary thyroid cancer patients treated with total thyroidectomy and radioactive iodine at a single experienced thyroid cancer center and followed according to the LATS management guidelines. Each patient was risk-stratified using both the LATS and ATA staging systems. The primary endpoints were (i) the best response to initial therapy defined as either remission (stimulated thyroglobulin [Tg] <1 ng/mL, negative ultrasonography) or persistent disease (biochemical and/or structural), and (ii) clinical status at final follow-up defined as no evidence of disease (suppressed Tg <1 ng/mL, negative ultrasonography), biochemical persistent disease (suppressed Tg >1 ng/mL in the absence of structural disease), structural persistent disease (locoregional or distant metastases), or recurrence (biochemical or structural disease identified after a period of no evidence of disease). One hundred seventy-one papillary thyroid cancer patients were included (mean age 45 ± 16 years, followed for a median of 4 years after initial treatment). Both the ATA and LATS risk stratification systems provided clinically meaningful graded estimates with regard to (i) the likelihood of achieving remission in response to initial therapy, (ii) the likelihood of having persistent structural disease in response to initial therapy and at final follow-up, (iii) the likely locations of the persistent structural disease (locoregional vs. distant metastases), (iv) the likelihood of recurrence, and (v) the likelihood of being no evidence of disease at final follow-up. The likelihood of having persistent biochemical evidence of disease was not significantly different across the staging categories. Both the

  7. Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study

    PubMed Central

    Perel, Pablo; Clayton, Tim; Altman, Doug G.; Croft, Peter; Douglas, Ian; Hemingway, Harry; Hingorani, Aroon; Morley, Katherine I.; Riley, Richard; Timmis, Adam; Van der Windt, Danielle; Roberts, Ian

    2014-01-01

    Background Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death. Methods and Findings A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%–20%, 21%–50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p<0.0001, and OR 2.31, 95% CI 1.96–2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been

  8. Red blood cell transfusion and mortality in trauma patients: risk-stratified analysis of an observational study.

    PubMed

    Perel, Pablo; Clayton, Tim; Altman, Doug G; Croft, Peter; Douglas, Ian; Hemingway, Harry; Hingorani, Aroon; Morley, Katherine I; Riley, Richard; Timmis, Adam; Van der Windt, Danielle; Roberts, Ian

    2014-06-01

    Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death. A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%-20%, 21%-50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%-20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08-7.13, p<0.0001, and OR 2.31, 95% CI 1.96-2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47-0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05-3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In

  9. Stratifying the Risk of Venous Thromboembolism in Otolaryngology

    PubMed Central

    Shuman, Andrew G.; Hu, Hsou Mei; Pannucci, Christopher J.; Jackson, Christopher R.; Bradford, Carol R.; Bahl, Vinita

    2015-01-01

    Objective The consequences of perioperative venous thromboembolism (VTE) are devastating; identifying patients at risk is an essential step in reducing morbidity and mortality. The utility of perioperative VTE risk assessment in otolaryngology is unknown. This study was designed to risk-stratify a diverse population of otolaryngology patients for VTE events. Study Design Retrospective cohort study. Setting Single-institution academic tertiary care medical center. Subjects and Methods Adult patients presenting for otolaryngologic surgery requiring hospital admission from 2003 to 2010 who did not receive VTE chemoprophylaxis were included. The Caprini risk assessment was retrospectively scored via a validated method of electronic chart abstraction. Primary study variables were Caprini risk scores and the incidence of perioperative venous thromboembolic outcomes. Results A total of 2016 patients were identified. The overall 30-day rate of VTE was 1.3%. The incidence of VTE in patients with a Caprini risk score of 6 or less was 0.5%. For patients with scores of 7 or 8, the incidence was 2.4%. Patients with a Caprini risk score greater than 8 had an 18.3% incidence of VTE and were significantly more likely to develop a VTE when compared to patients with a Caprini risk score less than 8 (P <.001). The mean risk score for patients with VTE (7.4) was significantly higher than the risk score for patients without VTE (4.8) (P <.001). Conclusion The Caprini risk assessment model effectively risk-stratifies otolaryngology patients for 30-day VTE events and allows otolaryngologists to identify patient subgroups who have a higher risk of VTE in the absence of chemoprophylaxis. PMID:22261490

  10. Cardiovascular event-free survival after adjuvant radiation therapy in breast cancer patients stratified by cardiovascular risk.

    PubMed

    Onwudiwe, Nneka C; Kwok, Young; Onukwugha, Eberechukwu; Sorkin, John D; Zuckerman, Ilene H; Shaya, Fadia T; Daniel Mullins, C

    2014-10-01

    The objective of this study was to estimate the risk of a cardiovascular event or death associated with modern radiation in a population of elderly female breast cancer patients with varying baseline cardiovascular risk. The data used for this analysis are from the linked Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. The retrospective cohort study included women aged 66 years and older with stage 0-III breast cancer diagnosed between 2000 and 2005. Women were grouped as low, intermediate, or high cardiovascular risk based on the presence of certain clinical diagnoses. The risk for the combined outcome of a hospitalization for a cardiovascular event or death within 6 months and 24 months of diagnosis was estimated using a multivariable Cox model. The median follow-up time was 24 months. Among the 91,612 women with American Joint Committee on Cancer (AJCC) stage 0-III breast cancer: 39,555 (43.2%) were treated with radiation therapy and 52,057 (56.8%) were not. The receipt of radiation therapy in the first 6 months was associated with a statistically significant increased risk for the combined outcome in women categorized as high risk (HR = 1.510; 95% CI, 1.396-1.634) or intermediate risk (HR = 1.415; 95% CI, 1.188-1.686) but not low risk (HR = 1.027; 95% CI, 0.798-1.321). Women with a prior medical history of cardiovascular disease treated with radiation therapy are at increased risk for an event and should be monitored for at least 6 months following treatment with radiation therapy. © 2014 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

  11. Corticosteroids and pediatric septic shock outcomes: a risk stratified analysis.

    PubMed

    Atkinson, Sarah J; Cvijanovich, Natalie Z; Thomas, Neal J; Allen, Geoffrey L; Anas, Nick; Bigham, Michael T; Hall, Mark; Freishtat, Robert J; Sen, Anita; Meyer, Keith; Checchia, Paul A; Shanley, Thomas P; Nowak, Jeffrey; Quasney, Michael; Weiss, Scott L; Banschbach, Sharon; Beckman, Eileen; Howard, Kelli; Frank, Erin; Harmon, Kelli; Lahni, Patrick; Lindsell, Christopher J; Wong, Hector R

    2014-01-01

    The potential benefits of corticosteroids for septic shock may depend on initial mortality risk. We determined associations between corticosteroids and outcomes in children with septic shock who were stratified by initial mortality risk. We conducted a retrospective analysis of an ongoing, multi-center pediatric septic shock clinical and biological database. Using a validated biomarker-based stratification tool (PERSEVERE), 496 subjects were stratified into three initial mortality risk strata (low, intermediate, and high). Subjects receiving corticosteroids during the initial 7 days of admission (n = 252) were compared to subjects who did not receive corticosteroids (n = 244). Logistic regression was used to model the effects of corticosteroids on 28-day mortality and complicated course, defined as death within 28 days or persistence of two or more organ failures at 7 days. Subjects who received corticosteroids had greater organ failure burden, higher illness severity, higher mortality, and a greater requirement for vasoactive medications, compared to subjects who did not receive corticosteroids. PERSEVERE-based mortality risk did not differ between the two groups. For the entire cohort, corticosteroids were associated with increased risk of mortality (OR 2.3, 95% CI 1.3-4.0, p = 0.004) and a complicated course (OR 1.7, 95% CI 1.1-2.5, p = 0.012). Within each PERSEVERE-based stratum, corticosteroid administration was not associated with improved outcomes. Similarly, corticosteroid administration was not associated with improved outcomes among patients with no comorbidities, nor in groups of patients stratified by PRISM. Risk stratified analysis failed to demonstrate any benefit from corticosteroids in this pediatric septic shock cohort.

  12. Assessment and Predicting Factors of Repeated Brain Computed Tomography in Traumatic Brain Injury Patients for Risk-Stratified Care Management: A 5-Year Retrospective Study

    PubMed Central

    Sumritpradit, Preeda; Setthalikhit, Thitipong

    2016-01-01

    Background and Objective. To determine the value of repeated brain CT in TBI cases for risk-stratified care management (RSCM) and to identify predicting factors which will change the neurosurgical management after repeated brain CTs. Methods. A 5-year retrospective study from January 2009 to August 2013 was conducted. The primary outcome was the value of repeated brain CT in TBI cases. The secondary outcome is to identify predicting factors which will change the neurosurgical management after repeated brain CTs. Results. There were 145 consecutive patients with TBI and repeated brain CT after initial abnormal brain CT. Forty-two percent of all cases (N = 61) revealed the progression of intracranial hemorrhage after repeated brain CT. In all 145 consecutive patients, 67.6% of cases (N = 98) were categorized as mild TBI. For mild head injury, 8.2% of cases (N = 8) had undergone neurosurgical management after repeated brain CT. Only 1 from 74 mild TBI patients with repeated brain CT had neurosurgical intervention. Clopidogrel and midline shift more than 2 mm on initial brain CT were significant predicting factors to indicate the neurosurgical management in mild TBI cases. Conclusion. Routine repeated brain CT for RSCM had no clinical benefit in mild TBI cases. PMID:27703812

  13. An oral cavity squamous cell carcinoma quantitative histomorphometric-based image classifier of nuclear morphology can risk stratify patients for disease-specific survival.

    PubMed

    Lu, Cheng; Lewis, James S; Dupont, William D; Plummer, W Dale; Janowczyk, Andrew; Madabhushi, Anant

    2017-08-04

    Oral cavity squamous cell carcinoma is the most common type of head and neck carcinoma. Its incidence is increasing worldwide, and it is associated with major morbidity and mortality. It is often unclear which patients have aggressive, treatment refractory tumors vs those whose tumors will be more responsive to treatment. Better identification of patients with high- vs low-risk cancers could help provide more tailored treatment approaches and could improve survival rates while decreasing treatment-related morbidity. This study investigates computer-extracted image features of nuclear shape and texture on digitized images of H&E-stained tissue sections for risk stratification of oral cavity squamous cell carcinoma patients compared with standard clinical and pathologic parameters. With a tissue microarray cohort of 115 retrospectively identified oral cavity squamous cell carcinoma patients, 50 were randomly chosen as the modeling set, and the remaining 65 constituted the test set. Following nuclear segmentation and feature extraction, the Wilcoxon rank sum test was used to identify the five most prognostic quantitative histomorphometric features from the modeling set. These top ranked features were then combined via a machine learning classifier to construct the oral cavity histomorphometric-based image classifier (OHbIC). The classifier was then validated for its ability to risk stratify patients for disease-specific outcomes on the test set. On the test set, the classifier yielded an area under the receiver operating characteristic curve of 0.72 in distinguishing disease-specific outcomes. In univariate survival analysis, high-risk patients predicted by the classifier had significantly poorer disease-specific survival (P=0.0335). In multivariate analysis controlling for T/N-stage, resection margins, and smoking status, positive classifier results were independently predictive of poorer disease-specific survival: hazard ratio (95% confidence interval)=11.023 (2

  14. Cost-effectiveness of risk stratified followup after urethral reconstruction: a decision analysis.

    PubMed

    Belsante, Michael J; Zhao, Lee C; Hudak, Steven J; Lotan, Yair; Morey, Allen F

    2013-10-01

    We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings. Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates. The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010. Assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup, the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol. A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  15. Prevalence of risk factors for cardiovascular disease stratified by body mass index categories in patients with wheelchair-dependent paraplegia after spinal cord injury.

    PubMed

    Flank, Peter; Wahman, Kerstin; Levi, Richard; Fahlström, Martin

    2012-05-01

    To assess risk factors for cardiovascular disease at different body mass index values in persons with wheelchair-dependent paraplegia after spinal cord injuries. Cross-sectional study. A total of 135 individuals, age range 18-79 years, with chronic (≥ 1 year) post-traumatic paraplegia. Body mass index was stratified into 6 categorical groups. Cardiovascular disease risk factors for hypertension, diabetes mellitus and a serum lipid profile were analysed and reported by body mass index category. More than 80% of the examined participants had at least one cardiovascular disease risk factor irrespective of body mass index level. Hypertension was highly prevalent, especially in men. Dyslipidaemia was common at all body mass index categories in both men and women. Higher body mass index values tended to associate with more hypertension and diabetes mellitus, whereas dyslipidaemia was prevalent across all body mass index categories. Studies that intervene to reduce weight and or percentage body fat should be performed to determine the effect on reducing modifiable cardiovascular disease risk factors.

  16. Self-Knowledge and Risk in Stratified Medicine.

    PubMed

    Hordern, Joshua

    2017-04-01

    This article considers why and how self-knowledge is important to communication about risk and behaviour change by arguing for four claims. First, it is doubtful that genetic knowledge should properly be called 'self-knowledge' when its ordinary effects on self-motivation and behaviour change seem so slight. Second, temptations towards a reductionist, fatalist, construal of persons' futures through a 'molecular optic' should be resisted. Third, any plausible effort to change people's behaviour must engage with cultural self-knowledge, values and beliefs, catalysed by the communication of genetic risk. For example, while a Judaeo-Christian notion of self-knowledge is distinctively theological, people's self-knowledge is plural in its insight and sources. Fourth, self-knowledge is found in compassionate, if tense, communion which yields freedom from determinism even amidst suffering. Stratified medicine thus offers a newly precise kind of humanising health care through societal solidarity with the riskiest. However, stratification may also mean that molecularly unstratified, 'B' patients' experience involves accentuated suffering and disappointment, a concern requiring further research.

  17. Preserved cardiorespiratory function and NT-proBNP levels before and during exercise in patients with recent onset of rheumatoid arthritis: the clinical challenge of stratifying the patient cardiovascular risks.

    PubMed

    Zoli, A; Bosello, S; Comerci, G; Galiano, N; Forni, A; Loperfido, F; Ferraccioli, G F

    2017-01-01

    Rheumatoid arthritis (RA) is associated with an increased risk of myocardial infarction and congestive heart failure. In RA patients, elevated NT-proBNP levels have been reported to be a prognostic marker of left ventricular dysfunction. In this study, we evaluated cardiorespiratory functional capacity and NT-proBNP levels before and during cardiopulmonary exercise test in early RA (ERA) patients. Twenty ERA patients and 10 healthy controls were studied by color Doppler echocardiography to evaluate ventricular systolic and diastolic function. Arterial stiffness and wave reflections were quantified non-invasively using applanation tonometry of the radial artery. Cardiopulmonary treadmill test was performed to measure peak VO2 and VE/VCO2 parameters. NT-proBNP plasma levels were measured before and at the exercise peak during cardiopulmonary exercise. The peak oxygen uptake [VO2 (ml/min/kg)], the ventilatory equivalents for carbon dioxide (EqCO2), respiratory exchange ratio and arterial stiffness were similar between patients and controls during cardiopulmonary exercise test. Basal and peak cardiopulmonary exercise NT-proBNP plasma levels were comparable in ERA patients with respect to healthy controls. When we analyzed patients according to disease characteristics and cardiovascular risk factors, ERA patients with high disease activity, BMI > 25 kg/m(2) and ACPA positivity presented significantly higher baseline and exercise peak NT-proBNP levels. Cardiorespiratory function is preserved in patients with recent onset of rheumatoid arthritis. The increased basal and exercise peak NT-proBNP plasma levels in patients with negative disease prognostic factors represent a possible marker to stratify the cardiovascular risk in patients with early rheumatoid arthritis.

  18. A Systematic Review of Predictors of Reintervention After EVAR: Guidance for Risk-Stratified Surveillance.

    PubMed

    Patel, Shaneel R; Allen, Chris; Grima, Matthew J; Brownrigg, Jack R W; Patterson, Benjamin O; Holt, Peter J E; Thompson, Matt M; Karthikesalingam, Alan

    2017-08-01

    Current surveillance protocols after endovascular aneurysm repair (EVAR) are ineffective and costly. Stratifying surveillance by individual risk of reintervention requires an understanding of the factors involved in developing post-EVAR complications. This systematic review assessed risk factors for reintervention after EVAR and proposals for stratified surveillance. A systematic search according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting on risk factors predicting reintervention after EVAR and proposals for stratified surveillance. Twenty-nine studies reporting on 39 898 patients met the primary inclusion criteria for reporting predictors of reintervention or aortic complications with or without suggestions for stratified surveillance. Five secondary studies described external validation of risk scores for reintervention or aortic complications. There was great heterogeneity in reporting risk factors identified at the pre-EVAR, intraoperative, and post-EVAR stages of treatment, although large preoperative abdominal aortic aneurysm diameter was the most commonly observed risk factor for reintervention after EVAR. Existing data on predictors of post-EVAR complications are generally of poor quality and largely derived from retrospective studies. Few studies describing suggestions for stratified surveillance have been subjected to external validation. There is a need to refine risk prediction for EVAR failure and to conduct prospective comparative studies of personalized surveillance with standard practice.

  19. Can we preoperatively risk stratify ovarian masses for malignancy?

    PubMed

    Oltmann, Sarah C; Garcia, Nilda; Barber, Robert; Huang, Rong; Hicks, Barry; Fischer, Anne

    2010-01-01

    Given a 10% malignancy rate in pediatric ovarian masses, what preoperative factors are helpful in distinguishing those at higher risk to risk stratify accordingly? After institutional review board approval (IRB#022008-095), a 15(1/2)-year retrospective review of operative ovarian cases was performed. A total of 424 patients were identified, with a mean age 12.5 years (range, 1 day to 19 years), without an age disparity between benign (12.54 years, 89%) and malignant (11.8 years, 11%) cases. The 1- to 8-year age group had the highest percentage of malignancies (22%; odds ratio [OR], 3.02; 95% confidence interval [CI], 1.33-6.86). A chief complaint of mass or precocious puberty versus one of pain had an OR for malignancy of 4.84 and 5.67, respectively (95% CI, 2.48-9.45 and 1.60-20.30). Imaging of benign neoplasms had a mean size of 8 cm (range, 0.9-36 cm) compared with malignancies at 17.3 cm (6.2-50 cm, P < .001). An ovarian mass size of 8 cm or longer on preoperative imaging had an OR of 19.0 for malignancy (95% CI, 4.42-81.69). Ultrasound or computed tomographic findings of a solid mass, although infrequent, were most commonly associated with malignancy (33%-60%), compared with reads of heterogeneous (15%-21%) or cystic (4%-5%) lesions. The malignancies (n = 46) included germ cell (50%, n = 23), stromal (28%, n = 13), epithelial (17%, n = 8), and other (4%, n = 2). Tumor markers obtained in 71% of malignancies were elevated in only 54%, whereas 6.5% of those sent in benign cases were similarly elevated. Elevated beta-human chorionic gonadotropin (beta-HCG), alpha fetoprotein (alphaFP), and cancer antigen 125 (CA-125) were significantly associated with malignancy (P < .02) and an elevated carcinoembryonic antigen (CEA) was not (P = .1880). This reported series of pediatric ovarian masses demonstrates that preoperative indicators that best predict an ovarian malignancy are a complaint of a mass or precocious puberty, a mass exceeding 8 cm or a mass with solid

  20. An infectious disease/fever screening radar system which stratifies higher-risk patients within ten seconds using a neural network and the fuzzy grouping method.

    PubMed

    Sun, Guanghao; Matsui, Takemi; Hakozaki, Yukiya; Abe, Shigeto

    2015-03-01

    To classify higher-risk influenza patients within 10 s, we developed an infectious disease and fever screening radar system. The system screens infected patients based on vital signs, i.e., respiration rate measured by a radar, heart rate by a finger-tip photo-reflector, and facial temperature by a thermography. The system segregates subjects into higher-risk influenza (HR-I) group, lower-risk influenza (LR-I) group, and non-influenza (Non-I) group using a neural network and fuzzy clustering method (FCM). We conducted influenza screening for 35 seasonal influenza patients and 48 normal control subjects at the Japan Self-Defense Force Central Hospital. Pulse oximetry oxygen saturation (SpO2) was measured as a reference. The system classified 17 subjects into HR-I group, 26 into LR-I group, and 40 into Non-I group. Ten out of the 17 HR-I subjects indicated SpO2 <96%, whereas only two out of the 26 LR-I subjects showed SpO2 <96%. The chi-squared test revealed a significant difference in the ratio of subjects showed SpO2 <96% between HR-I and LR-I group (p < 0.001). There were zero and nine normal control subjects in HR-I and LR-I groups, respectively, and there was one influenza patient in Non-I group. The combination of neural network and FCM achieved efficient detection of higher-risk influenza patients who indicated SpO2 96% within 10 s. Copyright © 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

  1. Risk-stratified versus Non-Risk-stratified Diagnostic Testing for Management of Suspected Acute Biliary Obstruction: Comparative Effectiveness, Costs, and the Role of MR Cholangiopancreatography.

    PubMed

    Kang, Stella K; Hoffman, David; Ferket, Bart; Kim, Michelle I; Braithwaite, R Scott

    2017-08-01

    Purpose To analyze the cost-effectiveness of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification guidelines versus magnetic resonance (MR) cholangiopancreatography-based treatment of patients with possible choledocholithiasis. Materials and Methods A decision-analytic model was constructed to compare cost and effectiveness of three diagnostic strategies for gallstone disease with possible choledocholithiasis: noncontrast MR cholangiopancreatography, contrast material-enhanced MR imaging/MR cholangiopancreatography, and ASGE risk stratification guidelines for diagnostic evaluation recommending endoscopy (high risk), MR cholangiopancreatography (intermediate risk), or no test (low risk). Analysis was performed from a U.S. health system perspective over 1-year and lifetime horizons. The model accounted for benign and malignant causes of biliary obstruction and procedural complications. Cost information was based on Medicare reimbursements. Sensitivity analysis assessed the impact of parameter variability on model results. Results Noncontrast MR cholangiopancreatography was most cost-effective in 45-55-year-old patients (less than $100 000 per quality-adjusted life-year [QALY] gained), while contrast-enhanced MR imaging was favored in younger adults. Risk-stratified testing was less costly than MR cholangiopancreatography, with long-term savings of $1870 and $2068 versus noncontrast and contrast-enhanced MR cholangiopancreatography, respectively, but was also less effective (-0.1814, -0.1831 QALY, respectively). The lifetime incremental cost per QALY for noncontrast MR cholangiopancreatography was $10 311. Contrast-enhanced MR imaging was favored with pretest probabilities of biliary stricture or malignancy 0%-73% for patients aged 20-44 years. For patients older than 55 years, ASGE guidelines maximized QALYs at the lowest cost. Conclusion Although adults older than 55 years of age are optimally evaluated by using ASGE guidelines, younger

  2. Twelve-month outcome of patients with an established indication for oral anticoagulation undergoing coronary artery stenting and stratified by the baseline risk of bleeding: Insights from the Warfarin and Coronary Stenting (War-Stent) Registry.

    PubMed

    Rubboli, Andrea; Saia, Francesco; Sciahbasi, Alessandro; Leone, Antonio M; Palmieri, Cataldo; Bacchi-Reggiani, Maria Letizia; Calabrò, Paolo; Bordoni, Barbara; Piccalò, Giacomo; Franco, Nicoletta; Nicolino, Annamaria; Magnavacchi, Paolo; Vignali, Luigi; Mameli, Stefano; Dallago, Michele; Maggiolini, Stefano; Steffanon, Luigi; Piovaccari, Giancarlo; Di Pasquale, Giuseppe

    2017-09-01

    To evaluate the outcome of patients with an established indication for oral anticoagulation (OAC) undergoing coronary stent implantation (PCI-S) and stratified by the baseline risk of bleeding. The database of the prospective, multicentre, observational WAR-STENT registry (ClinicalTrials.gov identifier NCT00722319) was analyzed and patients with atrial fibrillation and CHA2DS2-VASc score ≥2, mechanical heart valve, prior cardiac embolism, intra-cardiac thrombus and recent venous thromboembolism who were treated with either triple (warfarin, aspirin and clopidogrel) or dual (warfarin and clopidogrel) or dual antiplatelet (aspirin and clopidogrel) therapy, identified. Patients were then sorted into two groups at non-low and low risk of bleeding, as defined by an ATRIA score >3 and ≤3 respectively, and compared regarding major adverse cardiac and vascular events (MACVE) and bleeding. At 12-month follow up, MACVE were comparable in the two groups, whereas total, major and minor bleeding, as well as combined MACVE and total bleeding, were significantly more frequent in the non-low bleeding risk group. Upon Cox univariate and multivariable analysis, non-low bleeding risk category confirmed as an independent predictor of major bleeding. The choice of antithrombotic therapy however, appeared not to be influenced by the bleeding risk category at baseline. In patients with an established indication for OAC undergoing PCI-S, non-low bleeding risk category is the most potent independent predictor of major bleeding. Stratification of the bleeding risk at baseline should therefore be regarded as an indispensable process to be carried out before selection of the antithrombotic therapy. Copyright © 2017 Elsevier Inc. All rights reserved.

  3. Risk-Stratified Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty: Aspirin and Sequential Pneumatic Compression Devices vs Aggressive Chemoprophylaxis.

    PubMed

    Odeh, Khalid; Doran, James; Yu, Stephen; Bolz, Nicholas; Bosco, Joseph; Iorio, Richard

    2016-09-01

    Venous thromboembolism (VTE) is a major concern after total joint arthroplasty (TJA). We evaluated a risk-stratified prophylaxis protocol for patients undergoing TJA. A total of 2611 TJA patients were retrospectively studied. Patients treated with an aggressive VTE chemoprophylaxis protocol were compared with patients treated with a risk-stratified protocol utilizing aspirin and sequential pneumatic compression devices (SPCDs) for standard-risk patients and targeted anticoagulation for high-risk patients. We found equivalence in terms of VTE prevention between the 2 cohorts. There was a decrease in adverse events and readmissions among the risk-stratified cohort, although this did not reach statistical significance. A statistically significant reduction in costs (P < .001) was experienced with the use of aspirin/SPCDs compared with aggressive anticoagulation agents within the risk-stratified cohort. The use of aspirin/SPCDs in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis. Copyright © 2016 Elsevier Inc. All rights reserved.

  4. Self-Knowledge and Risk in Stratified Medicine

    PubMed Central

    Hordern, Joshua

    2017-01-01

    This article considers why and how self-knowledge is important to communication about risk and behaviour change by arguing for four claims. First, it is doubtful that genetic knowledge should properly be called ‘self-knowledge’ when its ordinary effects on self-motivation and behaviour change seem so slight. Second, temptations towards a reductionist, fatalist, construal of persons’ futures through a ‘molecular optic’ should be resisted. Third, any plausible effort to change people's behaviour must engage with cultural self-knowledge, values and beliefs, catalysed by the communication of genetic risk. For example, while a Judaeo-Christian notion of self-knowledge is distinctively theological, people's self-knowledge is plural in its insight and sources. Fourth, self-knowledge is found in compassionate, if tense, communion which yields freedom from determinism even amidst suffering. Stratified medicine thus offers a newly precise kind of humanising health care through societal solidarity with the riskiest. However, stratification may also mean that molecularly unstratified, ‘B’ patients’ experience involves accentuated suffering and disappointment, a concern requiring further research. PMID:28517991

  5. Comparison of risk of local-regional recurrence after mastectomy or breast conservation therapy for patients treated with neoadjuvant chemotherapy and radiation stratified according to a prognostic index score

    SciTech Connect

    Huang, Eugene H.; Strom, Eric A.; Perkins, George H.; Oh, Julia L.; Chen, Allen M.; Meric-Bernstam, Funda; Hunt, Kelly K.; Sahin, Aysegul A.; Hortobagyi, Gabriel N.; Buchholz, Thomas A. . E-mail: tbuchhol@mdanderson.org

    2006-10-01

    Purpose: We previously developed a prognostic index that stratified patients treated with breast conservation therapy (BCT) after neoadjuvant chemotherapy into groups with different risks for local-regional recurrence (LRR). The purpose of this study was to compare the rates of LRR as a function of prognostic index score for patients treated with BCT or mastectomy plus radiation after neoadjuvant chemotherapy. Methods and Materials: We retrospectively analyzed 815 patients treated with neoadjuvant chemotherapy, surgery, and radiation. Patients were assigned an index score from 0 to 4 and given 1 point for the presence of each factor: clinical N2 to N3 disease, lymphovascular invasion, pathologic size >2 cm, and multifocal residual disease. Results: The 10-year LRR rates were very low and similar between the mastectomy and BCT groups for patients with an index score of 0 or 1. For patients with a score of 2, LRR trended lower for those treated with mastectomy vs. BCT (12% vs. 28%, p = 0.28). For patients with a score of 3 to 4, LRR was significantly lower for those treated with mastectomy vs. BCT (19% vs. 61%, p = 0.009). Conclusions: This analysis suggests that BCT can provide excellent local-regional treatment for the vast majority of patients after neoadjuvant chemotherapy. For the few patients with a score of 3 to 4, LRR was >60% after BCT and was <20% with mastectomy. If these findings are confirmed in larger randomized studies, the prognostic index may be useful in helping to select the type of surgical treatment for patients treated with neoadjuvant chemotherapy, surgery, and radiation.

  6. A risk-stratified approach to cytomegalovirus prevention in pediatric solid organ transplant recipients.

    PubMed

    Suresh, Sneha; Lee, Bonita E; Robinson, Joan L; Akinwumi, Michael S; Preiksaitis, Jutta K

    2016-11-01

    Optimal strategies to prevent cytomegalovirus (CMV) disease following pediatric solid organ transplantation remain controversial. The purpose of this study was to review the outcomes of a risk-stratified strategy that uses a hybrid or prophylactic strategy for donor (D)+ recipient (R)- patients, a preemptive strategy for D+R+/D-R+, and clinical follow-up alone for D-R+ patients. A retrospective chart review was undertaken at the Stollery Children's Hospital in Edmonton, Alberta for pediatric solid organ transplants 2004 through 2010. Transplants were risk-stratified according to D/R CMV serostatus, organ group, and type of induction or rejection immunosuppression. The incidence of DNAemia and CMV disease and adverse effects from prophylaxis were analyzed. The study included 197 recipients. CMV DNAemia was detected in 49 of 197 recipients (24.8%), and CMV disease occurred in eight of 197 (4%) of which all but one were D+R-. All recovered. Seventeen of 142 recipients who received prophylaxis (12%) had hematologic toxicity. No other toxicities were identified. In conclusion, A risk-stratified approach resulted in very low rates of CMV disease with minimal adverse effects. Lowering the dosage rather than stopping antivirals in the face of neutropenia has the potential to further lower the rate of CMV disease. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  7. Implementing the Keele stratified care model for patients with low back pain: an observational impact study.

    PubMed

    Bamford, Adrian; Nation, Andy; Durrell, Susie; Andronis, Lazaros; Rule, Ellen; McLeod, Hugh

    2017-02-03

    The Keele stratified care model for management of low back pain comprises use of the prognostic STarT Back Screening Tool to allocate patients into one of three risk-defined categories leading to associated risk-specific treatment pathways, such that high-risk patients receive enhanced treatment and more sessions than medium- and low-risk patients. The Keele model is associated with economic benefits and is being widely implemented. The objective was to assess the use of the stratified model following its introduction in an acute hospital physiotherapy department setting in Gloucestershire, England. Physiotherapists recorded data on 201 patients treated using the Keele model in two audits in 2013 and 2014. To assess whether implementation of the stratified model was associated with the anticipated range of treatment sessions, regression analysis of the audit data was used to determine whether high- or medium-risk patients received significantly more treatment sessions than low-risk patients. The analysis controlled for patient characteristics, year, physiotherapists' seniority and physiotherapist. To assess the physiotherapists' views on the usefulness of the stratified model, audit data on this were analysed using framework methods. To assess the potential economic consequences of introducing the stratified care model in Gloucestershire, published economic evaluation findings on back-related National Health Service (NHS) costs, quality-adjusted life years (QALYs) and societal productivity losses were applied to audit data on the proportion of patients by risk classification and estimates of local incidence. When the Keele model was implemented, patients received significantly more treatment sessions as the risk-rating increased, in line with the anticipated impact of targeted treatment pathways. Physiotherapists were largely positive about using the model. The potential annual impact of rolling out the model across Gloucestershire is a gain in approximately 30

  8. Support of personalized medicine through risk-stratified treatment recommendations - an environmental scan of clinical practice guidelines.

    PubMed

    Yu, Tsung; Vollenweider, Daniela; Varadhan, Ravi; Li, Tianjing; Boyd, Cynthia; Puhan, Milo A

    2013-01-09

    Risk-stratified treatment recommendations facilitate treatment decision-making that balances patient-specific risks and preferences. It is unclear if and how such recommendations are developed in clinical practice guidelines (CPGs). Our aim was to assess if and how CPGs develop risk-stratified treatment recommendations for the prevention or treatment of common chronic diseases. We searched the United States National Guideline Clearinghouse for US, Canadian and National Institute for Health and Clinical Excellence (United Kingdom) CPGs for heart disease, stroke, cancer, chronic obstructive pulmonary disease and diabetes that make risk-stratified treatment recommendations. We included only those CPGs that made risk-stratified treatment recommendations based on risk assessment tools. Two reviewers independently identified CPGs and extracted information on recommended risk assessment tools; type of evidence about treatment benefits and harms; methods for linking risk estimates to treatment evidence and for developing treatment thresholds; and consideration of patient preferences. We identified 20 CPGs that made risk-stratified treatment recommendations out of 133 CPGs that made any type of treatment recommendations for the chronic diseases considered in this study. Of the included 20 CPGs, 16 (80%) used evidence about treatment benefits from randomized controlled trials, meta-analyses or other guidelines, and the source of evidence was unclear in the remaining four (20%) CPGs. Nine CPGs (45%) used evidence on harms from randomized controlled trials or observational studies, while 11 CPGs (55%) did not clearly refer to harms. Nine CPGs (45%) explained how risk prediction and evidence about treatments effects were linked (for example, applying estimates of relative risk reductions to absolute risks), but only one CPG (5%) assessed benefit and harm quantitatively and three CPGs (15%) explicitly reported consideration of patient preferences. Only a small proportion of CPGs

  9. Support of personalized medicine through risk-stratified treatment recommendations - an environmental scan of clinical practice guidelines

    PubMed Central

    2013-01-01

    Background Risk-stratified treatment recommendations facilitate treatment decision-making that balances patient-specific risks and preferences. It is unclear if and how such recommendations are developed in clinical practice guidelines (CPGs). Our aim was to assess if and how CPGs develop risk-stratified treatment recommendations for the prevention or treatment of common chronic diseases. Methods We searched the United States National Guideline Clearinghouse for US, Canadian and National Institute for Health and Clinical Excellence (United Kingdom) CPGs for heart disease, stroke, cancer, chronic obstructive pulmonary disease and diabetes that make risk-stratified treatment recommendations. We included only those CPGs that made risk-stratified treatment recommendations based on risk assessment tools. Two reviewers independently identified CPGs and extracted information on recommended risk assessment tools; type of evidence about treatment benefits and harms; methods for linking risk estimates to treatment evidence and for developing treatment thresholds; and consideration of patient preferences. Results We identified 20 CPGs that made risk-stratified treatment recommendations out of 133 CPGs that made any type of treatment recommendations for the chronic diseases considered in this study. Of the included 20 CPGs, 16 (80%) used evidence about treatment benefits from randomized controlled trials, meta-analyses or other guidelines, and the source of evidence was unclear in the remaining four (20%) CPGs. Nine CPGs (45%) used evidence on harms from randomized controlled trials or observational studies, while 11 CPGs (55%) did not clearly refer to harms. Nine CPGs (45%) explained how risk prediction and evidence about treatments effects were linked (for example, applying estimates of relative risk reductions to absolute risks), but only one CPG (5%) assessed benefit and harm quantitatively and three CPGs (15%) explicitly reported consideration of patient preferences

  10. High-Grade Tumor Budding Stratifies Early-Stage Cervical Cancer with Recurrence Risk

    PubMed Central

    Xu, Xia; Guo, Shuang; Wang, Zehua

    2016-01-01

    Objectives This study investigated prognostic significance of tumor budding in early-stage cervical cancer (ESCC) following radical surgery and its contribution to improve the stratification of patients with recurrence risk. Methods The archival medical records and H&E-stained slides of 643 patients with IA2-IIA stage cervical cancer who underwent radical surgery were retrospectively reviewed. Clinicopathological parameters were noted, and tumor buds were counted using immunohistochemistry for each case. The prognostic significance of tumor budding was analyzed. Prediction models that comprised tumor budding were established, and the performance was compared between the novel models and classic criteria via log-rank test and receiver operating characteristic analysis. Results Tumors with high-grade tumor budding (HTB) exhibited a substantially increased risk of recurrence (hazard ratio = 4.287, P < 0.001). Nine predictive models for recurrence were established, in which HTB was combined with recognized risk factors. The model using of at least two risk factors of HTB, tumor size ≥ 4 cm, deep stromal invasion of outer 1/3, and lymphovascular space invasion to stratify patients with an intermediate risk was most predictive of recurrence compared with the classic criteria. Conclusions Tumor budding is an independent, unfavorable, prognostic factor for ESCC patients following radical surgery and holds promise for improved recurrence risk stratification. PMID:27861522

  11. High-Grade Tumor Budding Stratifies Early-Stage Cervical Cancer with Recurrence Risk.

    PubMed

    Huang, Bangxing; Cai, Jing; Xu, Xia; Guo, Shuang; Wang, Zehua

    2016-01-01

    This study investigated prognostic significance of tumor budding in early-stage cervical cancer (ESCC) following radical surgery and its contribution to improve the stratification of patients with recurrence risk. The archival medical records and H&E-stained slides of 643 patients with IA2-IIA stage cervical cancer who underwent radical surgery were retrospectively reviewed. Clinicopathological parameters were noted, and tumor buds were counted using immunohistochemistry for each case. The prognostic significance of tumor budding was analyzed. Prediction models that comprised tumor budding were established, and the performance was compared between the novel models and classic criteria via log-rank test and receiver operating characteristic analysis. Tumors with high-grade tumor budding (HTB) exhibited a substantially increased risk of recurrence (hazard ratio = 4.287, P < 0.001). Nine predictive models for recurrence were established, in which HTB was combined with recognized risk factors. The model using of at least two risk factors of HTB, tumor size ≥ 4 cm, deep stromal invasion of outer 1/3, and lymphovascular space invasion to stratify patients with an intermediate risk was most predictive of recurrence compared with the classic criteria. Tumor budding is an independent, unfavorable, prognostic factor for ESCC patients following radical surgery and holds promise for improved recurrence risk stratification.

  12. 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.

  13. General Practitioners' and patients' perceptions towards stratified care: a theory informed investigation.

    PubMed

    Saunders, Benjamin; Bartlam, Bernadette; Foster, Nadine E; Hill, Jonathan C; Cooper, Vince; Protheroe, Joanne

    2016-08-31

    Stratified primary care involves changing General Practitioners' (GPs) clinical behaviour in treating patients, away from the current stepped care approach to instead identifying early treatment options that are matched to patients' risk of persistent disabling pain. This article explores the perspectives of UK-based GPs and patients about a prognostic stratified care model being developed for patients with the five most common primary care musculoskeletal pain presentations. The focus was on views about acceptability, and anticipated barriers and facilitators to the use of stratified care in routine practice. Four focus groups and six semi-structured telephone interviews were conducted with GPs (n = 23), and three focus groups with patients (n = 20). Data were analysed thematically; and identified themes examined in relation to the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. A critical approach was taken in using the TDF, examining the nuanced interrelationships between theoretical domains. Four key themes were identified: Acceptability of clinical decision-making guided by stratified care; impact on the therapeutic relationship; embedding a prognostic approach within a biomedical model; and practical issues in using stratified care. Whilst within each theme specific findings are reported, common across themes was the identified relationships between the theoretical domains of knowledge, skills, professional role and identity, environmental context and resources, and goals. Through analysis of these identified relationships it was found that, for GPs and patients to perceive stratified care as being acceptable, it must be seen to enhance GPs' knowledge and skills, not undermine GPs' and patients' respective identities and be integrated within the environmental context of the consultation with minimal disruption. Findings highlight the importance of taking into account the context of

  14. Contemporary invasive imaging modalities that identify and risk-stratify coronary plaques at risk of rupture.

    PubMed

    Brown, Adam J; Costopoulos, Charis; West, Nick Ej; Bennett, Martin R

    2015-01-01

    Atherosclerotic plaque rupture is responsible for the majority of myocardial infarctions, with ruptured plaques exhibiting specific morphological features, including large lipid cores, thinner overlying fibrous caps and micro-calcifications. Contemporary imaging modalities are increasingly able to characterize plaques, potentially leading to the identification of precursor lesions that are at high risk of rupture. Observational studies using invasive imaging consistently find that plaques responsible for an acute coronary event display these high-risk morphological features, and recent prospective imaging studies have now established links between baseline plaque characteristics and future cardiovascular events. Despite these promising advances, subsequent overall event rates remain too low for clinical utility. Novel technologies are now required to refine and improve our ability to identify and risk-stratify lesions at risk of rupture, if plaque-based risk evaluation is ever to become reality.

  15. A cross-specialty survey to assess the application of risk stratified surgery for differentiated thyroid cancer in the UK.

    PubMed

    Craig, W L; Ramsay, C R; Fielding, S; Krukowski, Z H

    2014-09-01

    This study describes variability of treatment for differentiated thyroid cancer among thyroid surgeons, in the context of changing patterns of thyroid surgery in the UK. Hospital Episodes Statistics on thyroid operations between 1997 and 2012 were obtained for England. A survey comprising six scenarios of varying 'risk' was developed. Patient/tumour information was provided, with five risk stratified or non-risk stratified treatment options. The survey was distributed to UK surgical associations. Respondent demographics were categorised and responses analysed by assigned risk stratified preference. From 1997 to 2012, the Hospital Episode Statistics data indicated there was a 55% increase in the annual number of thyroidectomies with a fivefold increase in otolaryngology procedures and a tripling of cancer operations. Of the surgical association members surveyed, 264 respondents reported a thyroid surgery practice. Management varied across and within the six scenarios, and was not related consistently to the level of risk. Associations were demonstrated between overall risk stratified preference and higher volume practice (>25 thyroidectomies per year) (p=0.011), fewer years of consultant practice (p=0.017) and multidisciplinary team participation (p=0.037). Logistic regression revealed fewer years of consultant practice (odds ratio [OR]: 0.96/year in practice, 95% confidence interval [CI]: 0.922-0.997, p=0.036) and caseload of >25/year (OR 1.92, 95% CI: 1.044-3.522, p=0.036) as independent predictors of risk stratified preference. There is a substantial contribution to thyroid surgery in the UK by otolaryngology surgeons. Adjusting management according to established case-based risk stratification is not widely applied. Higher caseload was associated with a preference for management tailored to individual risk.

  16. Comparison of a Stratified Group Intervention (STarT Back) With Usual Group Care in Patients With Low Back Pain: A Nonrandomized Controlled Trial.

    PubMed

    Murphy, Susan E; Blake, Catherine; Power, Camillus K; Fullen, Brona M

    2016-04-01

    A nonrandomized controlled trial. This study aims to explore the effectiveness of group-based stratified care in primary care. Stratified care based on psychosocial screening (STarT Back) has demonstrated greater clinical and cost-effectiveness in patients with low back pain. However, low back pain interventions are often delivered in groups and evaluating this system of care in a group setting is important. Patients were recruited from 60 general practices and linked physiotherapy services. A new group stratified intervention was compared with a historical nonstratified control group. Patients stratified as low, medium and high risk were offered risk-matched group care. Consenting participants completed self-report measures of functional disability (primary outcome measure), pain, psychological distress, and beliefs. The historical control received a generic group intervention. Analysis was by intention to treat. In total, 251 patients in the new stratified intervention and 332 in the historical control were included in the primary analysis at 12 weeks. The mean age of patients was 43 ± 10.98 years. Overall adjusted mean changes in the RMDQ scores were higher in the stratified intervention than in the control arm at 12-week follow-up (P = 0.028). Exploring the risk groups, individually the high-risk stratified group, demonstrated better outcome over the controls (P = 0.031). The medium-risk stratified intervention demonstrated equally good outcomes (P = 0.125), and low-risk stratified patients, despite less intervention, did as well as the historical controls (P = 0.993). Stratified care delivered in a group setting demonstrated superior outcomes in the high-risk patients, and equally good outcomes for the medium and low-risk groups. This model, embedded in primary care, provides an early and effective model of chronic disease management and adds another dimension to the utility of the STarT Back system of care. 2.

  17. Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes.

    PubMed

    Saha, Dujata; Davila, Armando A; Ver Halen, Jon P; Jain, Umang K; Hansen, Nora; Bethke, Kevin; Khan, Seema A; Jeruss, Jacqueline; Fine, Neil; Kim, john Y S

    2013-12-01

    Although breast reconstruction following mastectomy plays a role in the psychological impact of breast cancer, only one in three women undergo reconstruction. Few multi-institutional studies have compared complication profiles of reconstructive patients to non-reconstructive. Using the National Surgical Quality Improvement database, all patients undergoing mastectomy from 2006 to 2010, with or without reconstruction, were identified and risk-stratified using propensity scored quintiles. The incidence of complications and comorbidities were compared. Of 37,723 mastectomies identified, 30% received immediate breast reconstruction. After quintile matching for comorbidities, complications rates between reconstructive and non-reconstructives were similar. This trend was echoed across all quintiles, except in the sub-group with highest comorbidities. Here, the reconstructive patients had significantly more complications than the non-reconstructive (22.8% versus 7.0%, p < 0.001). Immediate breast reconstruction is a well-tolerated surgical procedure. However, in patients with high comorbidities, surgeons must carefully counterbalance surgical risks with psychosocial benefits to maximize patient outcomes. Level 3.

  18. Personalized medicine for prevention: can risk stratified screening decrease colorectal cancer mortality at an acceptable cost?

    PubMed

    Subramanian, Sujha; Bobashev, Georgiy; Morris, Robert J; Hoover, Sonja

    2017-04-01

    Tailored health care interventions are expected to transform clinical practice. The objective of this study was to develop an innovative model to assess the effectiveness, cost, and harms of risk stratified colorectal cancer screening. We updated a previously validated microsimulation model consisting of three interlinked components: risk assessment, natural history, and screening/treatment modules. We used data from representative national surveys and the literature to create a synthetic population that mimics the family history and genetic profile of the US population. We applied risk stratification based on published risk assessment tools to triage individuals into five risk categories: high, increased, medium, decreased, and low. On average, the incremental cost of risk stratified screening for colorectal cancer compared to the current approach at 60% and 80% compliance rates is $18,342 and $23,961 per life year gained. The harms in terms of false positives and perforations are consistently lower for personalized scenarios across all compliance rates. False positives are reduced by more than 47.0% and perforations by at least 9.9%. There is considerable uncertainty in the life years gained, but the reduction in harms remains stable under all scenarios. A key finding is that risk stratified screening can reduce harms at all levels of compliance. Therefore, selection of screening scenarios should include comprehensive comparisons of mortality, harms from screening, and cost. This study provides guidance for evaluating risk stratified cancer screening and further research is required to identify optimal implementation approaches in the real-world setting.

  19. White Matter Hyperintensity Associations with Cerebral Blood Flow in Elderly Subjects Stratified by Cerebrovascular Risk.

    PubMed

    Bahrani, Ahmed A; Powell, David K; Yu, Guoquiang; Johnson, Eleanor S; Jicha, Gregory A; Smith, Charles D

    2017-04-01

    This study aims to add clarity to the relationship between deep and periventricular brain white matter hyperintensities (WMHs), cerebral blood flow (CBF), and cerebrovascular risk in older persons. Deep white matter hyperintensity (dWMH) and periventricular white matter hyperintensity (pWMH) and regional gray matter (GM) and white matter (WM) blood flow from arterial spin labeling were quantified from magnetic resonance imaging scans of 26 cognitively normal elderly subjects stratified by cerebrovascular disease (CVD) risk. Fluid-attenuated inversion recovery images were acquired using a high-resolution 3-dimensional (3-D) sequence that reduced partial volume effects seen with slice-based techniques. dWMHs but not pWMHs were increased in patients at high risk of CVD; pWMHs but not dWMHs were associated with decreased regional cortical (GM) blood flow. We also found that blood flow in WM is decreased in regions of both pWMH and dWMH, with a greater degree of decrease in pWMH areas. WMHs are usefully divided into dWMH and pWMH regions because they demonstrate differential effects. 3-D regional WMH volume is a potentially valuable marker for CVD based on associations with cortical CBF and WM CBF. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

  20. Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups.

    PubMed

    Whitehurst, David G T; Bryan, Stirling; Lewis, Martyn; Hill, Jonathan; Hay, Elaine M

    2012-11-01

    Stratified management for low back pain according to patients' prognosis and matched care pathways has been shown to be an effective treatment approach in primary care. The aim of this within-trial study was to determine the economic implications of providing such an intervention, compared with non-stratified current best practice, within specific risk-defined subgroups (low-risk, medium-risk and high-risk). Within a cost-utility framework, the base-case analysis estimated the incremental healthcare cost per additional quality-adjusted life year (QALY), using the EQ-5D to generate QALYs, for each risk-defined subgroup. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses were performed to consider alternative costing methodologies, including the assessment of societal loss relating to work absence and the incorporation of generic (ie, non-back pain) healthcare utilisation. The stratified management approach was a cost-effective treatment strategy compared with current best practice within each risk-defined subgroup, exhibiting dominance (greater benefit and lower costs) for medium-risk patients and acceptable incremental cost to utility ratios for low-risk and high-risk patients. The likelihood that stratified care provides a cost-effective use of resources exceeds 90% at willingness-to-pay thresholds of £4000 (≈ 4500; $6500) per additional QALY for the medium-risk and high-risk groups. Patients receiving stratified care also reported fewer back pain-related days off work in all three subgroups. Compared with current best practice, stratified primary care management for low back pain provides a highly cost-effective use of resources across all risk-defined subgroups.

  1. Exploring the cost–utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups

    PubMed Central

    Whitehurst, David G T; Bryan, Stirling; Lewis, Martyn; Hill, Jonathan; Hay, Elaine M

    2012-01-01

    Objectives Stratified management for low back pain according to patients' prognosis and matched care pathways has been shown to be an effective treatment approach in primary care. The aim of this within-trial study was to determine the economic implications of providing such an intervention, compared with non-stratified current best practice, within specific risk-defined subgroups (low-risk, medium-risk and high-risk). Methods Within a cost–utility framework, the base-case analysis estimated the incremental healthcare cost per additional quality-adjusted life year (QALY), using the EQ-5D to generate QALYs, for each risk-defined subgroup. Uncertainty was explored with cost–utility planes and acceptability curves. Sensitivity analyses were performed to consider alternative costing methodologies, including the assessment of societal loss relating to work absence and the incorporation of generic (ie, non-back pain) healthcare utilisation. Results The stratified management approach was a cost-effective treatment strategy compared with current best practice within each risk-defined subgroup, exhibiting dominance (greater benefit and lower costs) for medium-risk patients and acceptable incremental cost to utility ratios for low-risk and high-risk patients. The likelihood that stratified care provides a cost-effective use of resources exceeds 90% at willingness-to-pay thresholds of £4000 (≈ 4500; $6500) per additional QALY for the medium-risk and high-risk groups. Patients receiving stratified care also reported fewer back pain-related days off work in all three subgroups. Conclusions Compared with current best practice, stratified primary care management for low back pain provides a highly cost-effective use of resources across all risk-defined subgroups. PMID:22492783

  2. Using the timed up and go test to stratify elderly inpatients at risk of falls.

    PubMed

    Large, Julienne; Gan, Neesha; Basic, David; Jennings, Natalie

    2006-05-01

    To determine whether the Timed Up and Go Test is useful at stratifying acutely unwell elderly inpatients according to their risk for subsequent falls. Prospective cohort study. Multidisciplinary acute care unit for the elderly at Liverpool Hospital, in Sydney, Australia. A total of 2388 consecutive admissions to the unit of mean age 82 years. The Timed Up and Go, administered on admission to the unit, and two modifications (an ordinal scale and a dichotomous scale, both incorporating patients unable to complete the Timed Up and Go) were evaluated. Number of falls, and reasons for the inability to complete the Timed Up and Go. During a median length of stay of nine days, 180 patients had at least one fall. The Timed Up and Go was unable to identify those patients who subsequently fell (P = 0.78). When the Timed Up and Go was modified to include the majority of patients unable to complete the test, both the ordinal (range of values 1-8, odds ratio (OR) 1.12, 95% confidence interval (95% CI) 1.03-1.21, P = 0.01) and dichotomous (OR 1.59, 95% CI 1.09-2.32, P = 0.02) modifications significantly predicted falls in multivariate analyses. Patients unable to do the Timed Up and Go due to non-physical disability had the highest fall rate (11%), followed by those with physical disability (9%), while those able to do the Timed Up and Go had the lowest fall rate (6%) (P< 0.001). Acutely unwell, immobile patients with dementia and delirium were not at excessive risk of falls. In the acute care setting, the value of the Timed Up and Go lies in the inability to complete the test, and the reasons for this inability, rather than the time recorded.

  3. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?

    PubMed

    Durfey, Nicole; Lehnhof, Brian; Bergeson, Andrew; Durfey, Shayla N M; Leytin, Victoria; McAteer, Kristina; Schwam, Eric; Valiquet, Justin

    2017-08-01

    significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35-1.70]). Our findings support the use of the ECG to risk stratify patients with severe hyperkalemia for short-term adverse events.

  4. Risk score to stratify children with suspected serious bacterial infection: observational cohort study

    PubMed Central

    Brent, Andrew J; Lakhanpaul, Monica; Thompson, Matthew; Collier, Jacqueline; Ray, Samiran; Ninis, Nelly; Levin, Michael; MacFaul, Roddy

    2011-01-01

    Objectives To derive and validate a clinical score to risk stratify children presenting with acute infection. Study design and participants Observational cohort study of children presenting with suspected infection to an emergency department in England. Detailed data were collected prospectively on presenting clinical features, laboratory investigations and outcome. Clinical predictors of serious bacterial infection (SBI) were explored in multivariate logistic regression models using part of the dataset, each model was then validated in an independent part of the dataset, and the best model was chosen for derivation of a clinical risk score for SBI. The ability of this score to risk stratify children with SBI was then assessed in the entire dataset. Main outcome measure Final diagnosis of SBI according to criteria defined by the Royal College of Paediatrics and Child Health working group on Recognising Acute Illness in Children. Results Data from 1951 children were analysed. 74 (3.8%) had SBI. The sensitivity of individual clinical signs was poor, although some were highly specific for SBI. A score was derived with reasonable ability to discriminate SBI (area under the receiver operator characteristics curve 0.77, 95% CI 0.71 to 0.83) and risk stratify children with suspected SBI. Conclusions This study demonstrates the potential utility of a clinical score in risk stratifying children with suspected SBI. Further work should aim to validate the score and its impact on clinical decision making in different settings, and ideally incorporate it into a broader management algorithm including additional investigations to further stratify a child's risk. PMID:21266341

  5. Risk factors and outcomes stratified by severity of acute kidney injury in malaria.

    PubMed

    Saravu, Kavitha; Rishikesh, Kumar; Parikh, Chirag R

    2014-01-01

    Severe acute kidney injury (AKI) is known to have prognostic value for in-hospital outcomes in malaria. However, little is known about the association of AKI of lesser severity with malarial risk factors and outcomes--and such a gap is becoming increasingly relevant with the upsurge in the incidence of AKI due to Plasmodium falciparum malaria and Plasmodium vivax malaria over the last decade. We aimed to identify risk factors of AKI in malaria and assessed in-hospital outcomes stratified by severity of AKI. We performed an observational study of 1,191 hospitalized malaria patients enrolled between 2007 and 2011 in a tertiary care academic center in India. Patients were categorized based on peak serum creatinine into one of three groups: no AKI (<1.6 mg/dL), mild AKI (1.6-3.0 mg/dL), and severe AKI (>3 mg/dL). Plasmodium vivax was the predominant species (61.41%), followed by Plasmodium falciparum (36.41%) and mixed infections with both the species (2.18%). Mild and severe AKI were detected in 12% and 5.6% of patients, respectively. Mild AKI due to Plasmodium vivax (49%) and Plasmodium falciparum (48.5%) was distributed relatively equally within the sample population; however, cases of severe AKI due to Plasmodium falciparum (80%) and Plasmodium vivax (13%) was significantly different (P<0.001). On history and physical examination, risk factors for AKI were age, absence of fever, higher heart rate, lower diastolic blood pressure, icterus, and hepatomegaly. The only laboratory parameter associated with risk of AKI on multivariate analysis was direct bilirubin. Patients with mild and severe AKI had greater organ complications, supportive requirements, longer duration of hospital stay and in-hospital mortality in a dose-dependent relationship, than patients with no AKI. Mild AKI is associated with significant (P<0.05) morbidity compared to no AKI, and future studies should assess strategies for early diagnosis of AKI and prevent AKI progression.

  6. Do Health Professionals Need Additional Competencies for Stratified Cancer Prevention Based on Genetic Risk Profiling?

    PubMed Central

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

    2015-01-01

    There is growing evidence that inclusion of genetic information about known common susceptibility variants may enable population risk-stratification and personalized prevention for common diseases including cancer. This would require the inclusion of genetic testing as an integral part of individual risk assessment of an asymptomatic individual. Front line health professionals would be expected to interact with and assist asymptomatic individuals through the risk stratification process. In that case, additional knowledge and skills may be needed. Current guidelines and frameworks for genetic competencies of non-specialist health professionals place an emphasis on rare inherited genetic diseases. For common diseases, health professionals do use risk assessment tools but such tools currently do not assess genetic susceptibility of individuals. In this article, we compare the skills and knowledge needed by non-genetic health professionals, if risk-stratified prevention is implemented, with existing competence recommendations from the UK, USA and Europe, in order to assess the gaps in current competences. We found that health professionals would benefit from understanding the contribution of common genetic variations in disease risk, the rationale for a risk-stratified prevention pathway, and the implications of using genomic information in risk-assessment and risk management of asymptomatic individuals for common disease prevention. PMID:26068647

  7. Do Health Professionals Need Additional Competencies for Stratified Cancer Prevention Based on Genetic Risk Profiling?

    PubMed

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

    2015-06-09

    There is growing evidence that inclusion of genetic information about known common susceptibility variants may enable population risk-stratification and personalized prevention for common diseases including cancer. This would require the inclusion of genetic testing as an integral part of individual risk assessment of an asymptomatic individual. Front line health professionals would be expected to interact with and assist asymptomatic individuals through the risk stratification process. In that case, additional knowledge and skills may be needed. Current guidelines and frameworks for genetic competencies of non-specialist health professionals place an emphasis on rare inherited genetic diseases. For common diseases, health professionals do use risk assessment tools but such tools currently do not assess genetic susceptibility of individuals. In this article, we compare the skills and knowledge needed by non-genetic health professionals, if risk-stratified prevention is implemented, with existing competence recommendations from the UK, USA and Europe, in order to assess the gaps in current competences. We found that health professionals would benefit from understanding the contribution of common genetic variations in disease risk, the rationale for a risk-stratified prevention pathway, and the implications of using genomic information in risk-assessment and risk management of asymptomatic individuals for common disease prevention.

  8. Building a Better Model: A Comprehensive Breast Cancer Risk Model Incorporating Breast Density to Stratify Risk and Apply Resources

    DTIC Science & Technology

    2014-10-01

    o Comparison of Breast Density Measurements with a Mammographic Volumetric and Area Algorithm and Magnetic resonance imaging . O Alonzo-Proulx, JG... Breast Cancer Risk Model Incorporating Breast Density To Stratify Risk and Apply Resources. 5a. CONTRACT NUMBER 5b. GRANT NUMBER W81XWH-11-1-0545 5c...Public Release; Distribution Unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT Purpose: Development and validation of a personalized breast cancer risk

  9. Reducing overdiagnosis by polygenic risk-stratified screening: findings from the Finnish section of the ERSPC

    PubMed Central

    Pashayan, Nora; Pharoah, Paul DP; Schleutker, Johanna; Talala, Kirsi; Tammela, Teuvo LJ; Määttänen, Liisa; Harrington, Patricia; Tyrer, Jonathan; Eeles, Rosalind; Duffy, Stephen W; Auvinen, Anssi

    2015-01-01

    Background: We derived estimates of overdiagnosis by polygenic risk groups and examined whether polygenic risk-stratified screening for prostate cancer reduces overdiagnosis. Methods: We calculated the polygenic risk score based on genotypes of 66 known prostate cancer loci for 4967 men from the Finnish section of the European Randomised Study of Screening for Prostate Cancer. We stratified the 72 072 men in the trial into those with polygenic risk below and above the median. Using a maximum likelihood method based on interval cancers, we estimated the mean sojourn time (MST) and episode sensitivity. For each polygenic risk group, we estimated the proportion of screen-detected cancers that are likely to be overdiagnosed from the difference between the observed and expected number of screen-detected cancers. Results: Of the prostate cancers, 74% occurred among men with polygenic risk above population median. The sensitivity was 0.55 (95% confidence interval (CI) 0.45–0.65) and MST 6.3 (95% CI 4.2–8.3) years. The overall overdiagnosis was 42% (95% CI 37–52) of the screen-detected cancers, with 58% (95% CI 54–65) in men with the lower and 37% (95% CI 31–47) in those with higher polygenic risk. Conclusion: Targeting screening to men at higher polygenic risk could reduce the proportion of cancers overdiagnosed. PMID:26291059

  10. Differences in Gene-Gene Interactions in Graves’ Disease Patients Stratified by Age of Onset

    PubMed Central

    Jurecka-Lubieniecka, Beata; Bednarczuk, Tomasz; Ploski, Rafal; Krajewska, Jolanta; Kula, Dorota; Kowalska, Malgorzata; Tukiendorf, Andrzej; Kolosza, Zofia; Jarzab, Barbara

    2016-01-01

    Background Graves’ disease (GD) is a complex disease in which genetic predisposition is modified by environmental factors. Each gene exerts limited effects on the development of autoimmune disease (OR = 1.2–1.5). An epidemiological study revealed that nearly 70% of the risk of developing inherited autoimmunological thyroid diseases (AITD) is the result of gene interactions. In the present study, we analyzed the effects of the interactions of multiple loci on the genetic predisposition to GD. The aim of our analyses was to identify pairs of genes that exhibit a multiplicative interaction effect. Material and Methods A total of 709 patients with GD were included in the study. The patients were stratified into more homogeneous groups depending on the age at time of GD onset: younger patients less than 30 years of age and older patients greater than 30 years of age. Association analyses were performed for genes that influence the development of GD: HLADRB1, PTPN22, CTLA4 and TSHR. The interactions among polymorphisms were analyzed using the multiple logistic regression and multifactor dimensionality reduction (MDR) methods. Results GD patients stratified by the age of onset differed in the allele frequencies of the HLADRB1*03 and 1858T polymorphisms of the PTPN22 gene (OR = 1.7, p = 0.003; OR = 1.49, p = 0.01, respectively). We evaluated the genetic interactions of four SNPs in a pairwise fashion with regard to disease risk. The coexistence of HLADRB1 with CTLA4 or HLADRB1 with PTPN22 exhibited interactions on more than additive levels (OR = 3.64, p = 0.002; OR = 4.20, p < 0.001, respectively). These results suggest that interactions between these pairs of genes contribute to the development of GD. MDR analysis confirmed these interactions. Conclusion In contrast to a single gene effect, we observed that interactions between the HLADRB1/PTPN22 and HLADRB1/CTLA4 genes more closely predicted the risk of GD onset in young patients. PMID:26943356

  11. Disparate patterns of prenatal care utilization stratified by medical and psychosocial risk.

    PubMed

    Krans, Elizabeth E; Davis, Matthew M; Palladino, Christie L

    2013-05-01

    To evaluate patterns of prenatal care utilization stratified by medical and psychosocial risk. A retrospective cohort of 786 pregnant women who subsequently delivered live births from 1999 to 2003 at the University of Michigan were classified into high medical, high psychosocial, high medical and high psychosocial (dual high risk) and low-risk pregnancies. Chi-square and logistic regression analyses assessed the association between risk and prenatal care utilization using the Kotelchuck Index. Of 786 pregnancies, 202 (25.7%) were high medical risk, 178 (22.7%) were high psychosocial risk, 227 (28.9%) were dual high risk and 179 (22.8%) were low-risk. Over 31% of dual high risk and 25% of high medical risk pregnancies received "adequate plus" prenatal care versus 10% of high psychosocial risk pregnancies. In multivariate analyses, adjusted for risk, race and insurance, high psychosocial risk pregnancies (OR = 1.69; 95% CI 1.06-2.72) were significantly more likely to receive inadequate prenatal care than care of greater intensity. Many high psychosocial risk pregnancies do not receive adequate prenatal care.

  12. Age-Stratified Treatment Response Rates in Hospitalized Patients with Clostridium difficile Infection Treated with Metronidazole.

    PubMed

    Pham, Vy P; Luce, Andrea M; Ruppelt, Sara C; Wei, Wenjing; Aitken, Samuel L; Musick, William L; Roux, Ryan K; Garey, Kevin W

    2015-10-01

    Consensus on the optimal treatment of Clostridium difficile infection (CDI) is rapidly changing. Treatment with metronidazole has been associated with increased clinical failure rates; however, the reasons for this are unclear. The purpose of this study was to assess age-related treatment response rates in hospitalized patients with CDI treated with metronidazole. This was a retrospective, multicenter cohort study of hospitalized patients with CDI. Patients were assessed for refractory CDI, defined as persistent diarrhea after 7 days of metronidazole therapy, and stratified by age and clinical characteristics. A total of 242 individuals, aged 60 ± 18 years (Charlson comorbidity index, 3.8 ± 2.4; Horn's index, 1.7 ± 1.0) were included. One hundred twenty-eight patients (53%) had severe CDI. Seventy patients (29%) had refractory CDI, a percentage that increased from 22% to 28% and to 37% for patients aged less than 50 years, for patients from 50 to 70 years, and for patients aged >70 years, respectively (P = 0.05). In multivariate analysis, Horn's index (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.50 to 2.77; P < 0.001), severe CDI (OR, 2.25; 95% CI, 1.15 to 4.41; P = 0.018), and continued use of antibiotics (OR, 2.65; 95% CI, 1.30 to 5.39; P = 0.0072) were identified as significant predictors of refractory CDI. Age was not identified as an independent risk factor for refractory CDI. Therefore, hospitalized elderly patients with CDI treated with metronidazole had increased refractory CDI rates likely due to increased underlying severity of illness, severity of CDI, and concomitant antibiotic use. These results may help identify patients that may benefit from alternative C. difficile treatments other than metronidazole. Copyright © 2015, American Society for Microbiology. All Rights Reserved.

  13. Age-Stratified Treatment Response Rates in Hospitalized Patients with Clostridium difficile Infection Treated with Metronidazole

    PubMed Central

    Pham, Vy P.; Luce, Andrea M.; Ruppelt, Sara C.; Wei, Wenjing; Aitken, Samuel L.; Musick, William L.; Roux, Ryan K.

    2015-01-01

    Consensus on the optimal treatment of Clostridium difficile infection (CDI) is rapidly changing. Treatment with metronidazole has been associated with increased clinical failure rates; however, the reasons for this are unclear. The purpose of this study was to assess age-related treatment response rates in hospitalized patients with CDI treated with metronidazole. This was a retrospective, multicenter cohort study of hospitalized patients with CDI. Patients were assessed for refractory CDI, defined as persistent diarrhea after 7 days of metronidazole therapy, and stratified by age and clinical characteristics. A total of 242 individuals, aged 60 ± 18 years (Charlson comorbidity index, 3.8 ± 2.4; Horn's index, 1.7 ± 1.0) were included. One hundred twenty-eight patients (53%) had severe CDI. Seventy patients (29%) had refractory CDI, a percentage that increased from 22% to 28% and to 37% for patients aged less than 50 years, for patients from 50 to 70 years, and for patients aged >70 years, respectively (P = 0.05). In multivariate analysis, Horn's index (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.50 to 2.77; P < 0.001), severe CDI (OR, 2.25; 95% CI, 1.15 to 4.41; P = 0.018), and continued use of antibiotics (OR, 2.65; 95% CI, 1.30 to 5.39; P = 0.0072) were identified as significant predictors of refractory CDI. Age was not identified as an independent risk factor for refractory CDI. Therefore, hospitalized elderly patients with CDI treated with metronidazole had increased refractory CDI rates likely due to increased underlying severity of illness, severity of CDI, and concomitant antibiotic use. These results may help identify patients that may benefit from alternative C. difficile treatments other than metronidazole. PMID:26195522

  14. Extent of atypical hyperplasia stratifies breast cancer risk in 2 independent cohorts of women.

    PubMed

    Degnim, Amy C; Dupont, William D; Radisky, Derek C; Vierkant, Robert A; Frank, Ryan D; Frost, Marlene H; Winham, Stacey J; Sanders, Melinda E; Smith, Jeffrey R; Page, David L; Hoskin, Tanya L; Vachon, Celine M; Ghosh, Karthik; Hieken, Tina J; Denison, Lori A; Carter, Jodi M; Hartmann, Lynn C; Visscher, Daniel W

    2016-10-01

    Women with atypical hyperplasia (AH) on breast biopsy have a substantially increased risk of breast cancer (BC). Here the BC risk for the extent and subtype of AH is reported for 2 separate cohorts. All samples containing AH were included from 2 cohorts of women with benign breast disease (Mayo Clinic and Nashville). Histology review quantified the number of foci of atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH). The BC risk was stratified for the number of AH foci within AH subtypes. The study included 708 Mayo AH subjects and 466 Nashville AH subjects. In the Mayo cohort, an increasing number of foci of AH was associated with a significant increase in the risk of BC both for ADH (relative risks of 2.61, 5.21, and 6.36 for 1, 2, and ≥3 foci, respectively; P for linear trend = .006) and for ALH (relative risks of 2.56, 3.50, and 6.79 for 1, 2, and ≥3 foci, respectively; P for linear trend = .001). In the Nashville cohort, the relative risks of BC for ADH were 2.70, 5.17, and 15.06 for 1, 2, and ≥3 foci, respectively (P for linear trend < .001); for ALH, the relative risks also increased but not significantly (2.61, 3.48, and 4.02, respectively; P = .148). When the Mayo and Nashville samples were combined, the risk increased significantly for 1, 2, and ≥3 foci: the relative risks were 2.65, 5.19, and 8.94, respectively, for ADH (P < .001) and 2.58, 3.49, and 4.97, respectively, for ALH (P = .001). In 2 independent cohort studies of benign breast disease, the extent of atypia stratified the long-term BC risk for ADH and ALH. Cancer 2016;122:2971-2978. © 2016 American Cancer Society. © 2016 American Cancer Society.

  15. Variation in Outcomes for Risk-Stratified Pediatric Cardiac Surgical Operations: An Analysis of the STS Congenital Heart Surgery Database

    PubMed Central

    Jacobs, Jeffrey Phillip; O'Brien, Sean M.; Pasquali, Sara K.; Jacobs, Marshall Lewis; Lacour-Gayet, François G.; Tchervenkov, Christo I.; Austin III, Erle H.; Pizarro, Christian; Pourmoghadam, Kamal K.; Scholl, Frank G.; Welke, Karl F.; Gaynor, J. William; Clarke, David R.; Mayer, John E.; Mavroudis, Constantine

    2013-01-01

    Background. We evaluated outcomes for groups of risk-stratified operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database to provide contemporary benchmarks and examine variation between centers. Methods. Patients undergoing surgery from 2005 to 2009 were included. Centers with more than 10% missing data were excluded. Discharge mortality and postoperative length of stay (PLOS) among patients discharged alive were calculated for groups of risk-stratified operations using the five Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories (STAT Mortality Categories). Power for analyzing between-center differences in outcome was determined for each STAT Mortality Category. Variation was evaluated using funnel plots and Bayesian hierarchical modeling. Results. In this analysis of risk-stratified operations, 58,506 index operations at 73 centers were included. Overall discharge mortality (interquartile range among programs with more than 10 cases) was as follows: STAT Category 1 = 0.55% (0% to 1.0%), STAT Category 2 = 1.7% (1.0% to 2.2%), STAT Category 3 = 2.6% (1.1% to 4.4%), STAT Category 4 = 8.0% (6.3% to 11.1%), and STAT Category 5 = 18.4% (13.9% to 27.9%). Funnel plots with 95% prediction limits revealed the number of centers characterized as outliers by STAT Mortality Categories was as follows: Category 1 = 3 (4.1%), Category 2 = 1 (1.4%), Category 3 = 7 (9.7%), Category 4 = 13 (17.8%), and Category 5 = 13 (18.6%). Between-center variation in PLOS was analyzed for all STAT Categories and was greatest for STAT Category 5 operations. Conclusions. This analysis documents contemporary benchmarks for risk-stratified pediatric cardiac surgical operations grouped by STAT Mortality Categories and the range of outcomes among centers. Variation was greatest for the more complex operations. These data may aid in the design and planning of quality assessment and quality improvement

  16. Fall prediction in inpatients by bedside nurses using the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument: a multicenter study.

    PubMed

    Milisen, Koen; Staelens, Nele; Schwendimann, René; De Paepe, Leen; Verhaeghe, Jeroen; Braes, Tom; Boonen, Steven; Pelemans, Walter; Kressig, Reto W; Dejaeger, Eddy

    2007-05-01

    To assess the predictive value of the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument, a simple fall-risk assessment tool, when administered at a patient's hospital bedside by nurses. Prospective multicenter study. Six Belgian hospitals. A total of 2,568 patients (mean age+/-standard deviation 67.2+/-18.4; 55.3% female) on four surgical (n=875, 34.1%), eight geriatric (n=687, 26.8%), and four general medical wards (n=1,006, 39.2%) were included in this study upon hospital admission. All patients were hospitalized for at least 48 hours. Nurses completed the STRATIFY within 24 hours after admission of the patient. Falls were documented on a standardized incident report form. The number of fallers was 136 (5.3%), accounting for 190 falls and an overall rate of 7.3 falls per 1,000 patient days for all hospitals. The STRATIFY showed good sensitivity (> or = 84%) and high negative predictive value (> or = 99%) for the total sample, for patients admitted to general medical and surgical wards, and for patients younger than 75, although it showed moderate (69%) to low (52%) sensitivity and high false-negative rates (31-48%) for patients admitted to geriatric wards and for patients aged 75 and older. Although the STRATIFY satisfactorily predicted the fall risk of patients admitted to general medical and surgical wards and patients younger than 75, it failed to predict the fall risk of patients admitted to geriatric wards and patients aged 75 and older (particularly those aged 75-84).

  17. Characteristics, Treatments, and Outcomes of Hospitalized Heart Failure Patients Stratified by Etiologies of Cardiomyopathy.

    PubMed

    Shore, Supriya; Grau-Sepulveda, Maria V; Bhatt, Deepak L; Heidenreich, Paul A; Eapen, Zubin J; Hernandez, Adrian F; Yancy, Clyde W; Fonarow, Gregg C

    2015-11-01

    The authors sought to describe characteristics, treatments, and in-hospital outcomes of hospitalized heart failure (HF) patients stratified by etiology. Whether characteristics and outcomes of HF patients differ by cardiomyopathy etiology is unknown. The authors analyzed data on 156,013 hospitalized HF patients from 319 U.S. hospitals participating in Get With The Guidelines-HF between 2005 and 2013. Characteristics, treatments, and in-hospital outcomes were assessed by HF etiology. Standard regression techniques adjusted for site and patient-level characteristics were used to examine association between HF etiology and in-hospital outcomes. Median age was 75 years, 69.2% were white, and 49.5% were women. Overall, 92,361 patients (59.2%) had ischemic cardiomyopathy and 63,652 patients (40.8%) had nonischemic cardiomyopathy (NICM). Hypertensive (n = 28,141; 48.5%) and idiopathic (n = 17,808; 30.7%) cardiomyopathies accounted for the vast majority of NICM patients. Post-partum (n = 209; 0.4%), viral (n = 447; 0.8%), chemotherapy (n = 721; 1.2%), substance abuse (n = 2,653; 4.6%), familial (n = 556; 1.0%), and other (n = 7,523; 13.0%) etiologies were far less frequent. There were significant differences in baseline characteristics between those with ischemic cardiomyopathy compared with NICM with respect to age (76 years vs. 72 years), sex (44.4% vs. 56.9% women), and ejection fraction (38% vs. 45%). Risk-adjusted quality of care provided to eligible patients varied minimally by etiology. Similarly, in-hospital mortality did not differ among ischemic compared with NICM patients. However, among NICM patients, only hypertensive cardiomyopathy had a lower mortality rate compared with idiopathic NICM (adjusted odds ratio: 0.83; 95% confidence interval: 0.71 to 0.97). Characteristics of hospitalized HF patients vary by etiology. Both risk-adjusted quality of care and in-hospital outcomes did not differ by etiology. Copyright © 2015 American College of Cardiology

  18. Risk Factors for Emergency Department Short Time Readmission in Stratified Population

    PubMed Central

    Besga, Ariadna; Ayerdi, Borja; Alcalde, Guillermo; Manzano, Alberto; Lopetegui, Pedro; Graña, Manuel; González-Pinto, Ana

    2015-01-01

    Background. Emergency department (ED) readmissions are considered an indicator of healthcare quality that is particularly relevant in older adults. The primary objective of this study was to identify key factors for predicting patients returning to the ED within 30 days of being discharged. Methods. We analysed patients who attended our ED in June 2014, stratified into four groups based on the Kaiser pyramid. We collected data on more than 100 variables per case including demographic and clinical characteristics and drug treatments. We identified the variables with the highest discriminating power to predict ED readmission and constructed classifiers using machine learning methods to provide predictions. Results. Classifier performance distinguishing between patients who were and were not readmitted (within 30 days), in terms of average accuracy (AC). The variables with the greatest discriminating power were age, comorbidity, reasons for consultation, social factors, and drug treatments. Conclusions. It is possible to predict readmissions in stratified groups with high accuracy and to identify the most important factors influencing the event. Therefore, it will be possible to develop interventions to improve the quality of care provided to ED patients. PMID:26682222

  19. Risk Factors for Health Care-Associated Sepsis in Critically Ill Neonates Stratified by Birth Weight.

    PubMed

    Verstraete, Evelien Hilde; De Coen, Kris; Vogelaers, Dirk; Blot, Stijn

    2015-11-01

    Health care-associated bloodstream infection (HABSI) is a frequent complication in neonatal intensive care. Research on risk factors stratified by birth weight and adjusted for severity of illness and comorbidities is limited. Our objective is to describe independent risk factors for HABSI in critically ill neonates with emphasis on risk variation between birth weight groups. We performed a single-center historical cohort study in a tertiary referral center. A neonatal intensive care-audit system was used to identify eligible neonates admitted for ≥72 hours (2002-2011). HABSI is defined according to National Institute of Child Health and Human Development criteria. Risk factors for HABSI were assessed by univariate and logistic regression analysis for the total cohort and for birth weight subgroups, that is, neonates ≤1500 g and >1500 g. A total of 342 neonates developed HABSI in 5134 admissions of ≥72 hours (6.7%). Very low birth weight, total parenteral nutrition (TPN), mechanical ventilation, gastrointestinal disease, surgery (cardiac and other type), and renal insufficiency are independent risk factors for the total cohort. Gastrointestinal disease and cardiac surgery are independent risk factors in both birth weight groups; mechanical ventilation (odds ratio [OR]: 2.6; confidence interval [CI]: 1.6-4.0) and other type of surgery (OR: 4.3; CI: 2.1-8.8) are solely independent risk factors in the ≤1500-g cohort; TPN is exclusively an independent risk factor (OR: 7.9; CI: 3.9-16.2) in the >1500-g cohort. In our neonatal intensive care unit, risk stratification by birth weight revealed some difference. Special attention concerning infection control practices is for neonates receiving TPN, mechanical ventilation, cardiac surgery, and with a gastrointestinal disease.

  20. Public interest in and acceptability of the prospect of risk-stratified screening for breast and prostate cancer.

    PubMed

    Koitsalu, Marie; Sprangers, Mirjam A G; Eklund, Martin; Czene, Kamila; Hall, Per; Grönberg, Henrik; Brandberg, Yvonne

    2016-01-01

    For risk-stratified screening to be implemented as a screening program for breast and prostate cancer it has to be accepted among the general population. Investigating public interest in stratified screening and its acceptability to the public is therefore essential since as yet little is known. Cross-sectional web survey sent to a sample of 10 000 individuals (20-74 years of age) representative of the Swedish population as registered in 2009. Among the responders (28%), a vast majority (94%) expressed an interest in knowing their breast or prostate cancer risk and stated wanting to know to 'avoid worrying'. Men and women were equally interested in knowing their prostate and breast cancer risk, respectively. However, men showed more certainty. Trusting the healthcare workers with personal information (63%) as well as genetic information (70%), in order to calculate the risk, did not seem to be a major issue. Furthermore, 87% would agree to get screened more often if identified with a high risk, whereas, if identified with a low risk, only 27% would agree to get screened less often. Finally, although a consultation with a physician seemed to be the preferred way to communicate the risk, a majority would agree to receive it via a letter or a phone call. Risk-stratified screening has the possibility to be accepted by the general public. Knowledge about interest and acceptability of the prospect of risk-stratified screening for breast and prostate cancer will help when implementing new screening strategies.

  1. Modified STOP-Bang Tool for Stratifying Obstructive Sleep Apnea Risk in Adolescent Children.

    PubMed

    Combs, Daniel; Goodwin, James L; Quan, Stuart F; Morgan, Wayne J; Parthasarathy, Sairam

    2015-01-01

    Obstructive sleep apnea (OSA) is prevalent in children and diagnostic polysomnography is costly and not readily available in all areas. We developed a pediatric modification of a commonly used adult clinical prediction tool for stratifying the risk of OSA and the need for polysomnography. A total of 312 children (age 9-17 years) from phase 2 of the Tucson Children's Assessment of Sleep Apnea cohort study, with complete anthropomorphic data, parent questionnaires, and home polysomnograms were included. An adolescent modification of STOP-Bang (teen STOP-Bang) was developed and included snoring, tired, observed apnea, blood pressure ≥ 95th percentile, BMI > 95th percentile, academic problems, neck circumference >95th percentile for age, and male gender. An apnea-hypopnea index ≥ 1.5 events/hour was considered diagnostic of OSA. Receiver Operator Characteristic (ROC) curves for parent-reported STOP-Bang scores were generated for teenage and pre-teen children. A STOP-Bang score of < 3 in teenagers was associated with a negative predictive value of 0.96. ROC curves were also generated based upon child-reported sexual maturity rating (SMR; n = 291). The ability of teen STOP-Bang to discriminate the presence or absence of OSA as measured by the AUC for children with SMR ≥ 4 (0.83; 95%CI 0.71-0.95) was better than children with SMR < 4 (0.63; 95%CI 0.46-0.81; p = 0.048). In community dwelling adolescents, teen STOP-Bang may be useful in stratifying the risk of OSA.

  2. Modified STOP-Bang Tool for Stratifying Obstructive Sleep Apnea Risk in Adolescent Children

    PubMed Central

    Combs, Daniel; Goodwin, James L.; Quan, Stuart F.; Morgan, Wayne J.; Parthasarathy, Sairam

    2015-01-01

    Purpose Obstructive sleep apnea (OSA) is prevalent in children and diagnostic polysomnography is costly and not readily available in all areas. We developed a pediatric modification of a commonly used adult clinical prediction tool for stratifying the risk of OSA and the need for polysomnography. Methods A total of 312 children (age 9–17 years) from phase 2 of the Tucson Children’s Assessment of Sleep Apnea cohort study, with complete anthropomorphic data, parent questionnaires, and home polysomnograms were included. An adolescent modification of STOP-Bang (teen STOP-Bang) was developed and included snoring, tired, observed apnea, blood pressure ≥ 95th percentile, BMI > 95th percentile, academic problems, neck circumference >95th percentile for age, and male gender. An apnea-hypopnea index ≥ 1.5 events/hour was considered diagnostic of OSA. Results Receiver Operator Characteristic (ROC) curves for parent-reported STOP-Bang scores were generated for teenage and pre-teen children. A STOP-Bang score of < 3 in teenagers was associated with a negative predictive value of 0.96. ROC curves were also generated based upon child-reported sexual maturity rating (SMR; n = 291). The ability of teen STOP-Bang to discriminate the presence or absence of OSA as measured by the AUC for children with SMR ≥ 4 (0.83; 95%CI 0.71–0.95) was better than children with SMR < 4 (0.63; 95%CI 0.46–0.81; p = 0.048). Conclusions In community dwelling adolescents, teen STOP-Bang may be useful in stratifying the risk of OSA. PMID:26581088

  3. Transition Risk Assessment Score to Stratify Health Care Needs and Interventions in Adolescents with Anorectal Malformations: A Pilot Study.

    PubMed

    Connor, Martin J; Springford, Laurie Rigueros; Giuliani, Stefano

    2017-08-01

    Introduction Anorectal malformations (ARMs) are a complex collection of congenital disorders of the anus, rectum, and genitourinary system with possible active morbidities beyond adolescence. Aims To create the first evidence-based inclusive transition risk assessment score (TRAS) to stratify health care needs and interventions in teenagers with ARM transitioning to adult health care. Method MEDLINE, EMBASE, and the Cochrane Library were searched electronically for original articles containing published scoring systems evaluating children with ARM from January 1, 1990 to December 31, 2013. Current published scoring systems identified were weighted to create a novel score (TRAS) to objectively assess the most common active problems present in teenagers with ARM: fecal, urinary, and sexual functions; quality of life; and psychosocial well-being. The TRAS was applied to patients visiting our tertiary anorectal clinic in the period from January 2014 to March 2016. Patients were rescored on each visit to the clinic. Results Total 21 separate scoring systems were identified in the literature, with 3 scoring systems incorporated into the TRAS. The score divided patients into "low" (0-4), "medium" (5-10), and "high" (11-35) risk categories. The TRAS was used to assess 14 adolescents with ARMs during the study period; 14 patients had a single TRAS, 7 had two TRAS, and 3 had three TRAS assessments. At first visit 14 patients with a median age of 13 were assessed with TRAS ranging from 2 to 13 (M = 5, SD 3.33, 95% CI 3.08-7.68). At second visit seven patients with a median age of 15 were assessed with TRAS ranging from 2 to 12 (M = 6.43, SD 3.51, 95% CI 3.19-9.67). At third visit three patients with a median age of 16 were assessed with TRAS ranging from 6 to 12 (M = 8.33, SD 3.21, 95% CI 0.35-16.32). There was no significant difference (p > 0.05) between a patient's TRAS at different visits. Conclusion Preliminary data suggest that the TRAS is a

  4. Outcomes of Patients With Acute Low Back Pain Stratified by the STarT Back Screening Tool: Secondary Analysis of a Randomized Trial.

    PubMed

    Magel, John; Fritz, Julie M; Greene, Tom; Kjaer, Per; Marcus, Robin L; Brennan, Gerard P

    2017-03-01

    The impact of physical therapy on the outcomes of patients with acute low back pain (LBP) stratified by the STart Back Screening Tool (SBST) is unclear. The purpose of this study was to compare the outcomes of patients with acute LBP who were stratified as medium or high risk. This was a secondary analysis of a randomized trial. Patients were recruited between March 2011 and November 2013 from primary care clinics in Salt Lake City, Utah. One hundred eighty-one participants with acute LBP who were stratified as medium risk (n = 120) or high risk (n = 61) by the SBST were included. They were aged 18 through 60 years, with duration of symptoms less than 16 days, no symptoms below the knee, no treatment for LBP in the past 6 months, and an Oswestry Disability Index (ODI) score of 20% or greater. After participants received education on how to manage their LBP, they were randomized to receive usual care (n = 97) by their primary care provider or early intervention (n = 84) by a physical therapist. The primary (3-month ODI score) outcome measure was obtained at baseline and at 4 weeks, 3 months, and 1 year. No differences were detected in the effect of intervention between participants stratified as medium or high risk. For the high-risk subgroup, there was a significant difference between the early intervention and usual care groups for the 3-month ODI (mean difference = -5.87 [95% CI = -11.24, -0.50]) favoring early intervention. The primary study was not designed to examine the SBST. Patients with acute LBP stratified as high risk seem likely to respond well to one session of education. They may experience additional benefit by 3 months from evidence-based physical therapy treatments. These effects disappear at 1 year.

  5. Prognostic impact of body mass index stratified by smoking status in patients with esophageal squamous cell carcinoma

    PubMed Central

    Sun, Peng; Zhang, Fei; Chen, Cui; Ren, Chao; Bi, Xi-Wen; Yang, Hang; An, Xin; Wang, Feng-Hua; Jiang, Wen-Qi

    2016-01-01

    Background As smoking affects the body mass index (BMI) and causes the risk of esophageal squamous cell carcinoma (ESCC), the prognostic impact of BMI in ESCC could be stratified by smoking status. We investigated the true prognostic effect of BMI and its potential modification by smoking status in ESCC. Methods We retrospectively analyzed 459 patients who underwent curative treatment at a single institution between January 2007 and December 2010. BMI was calculated using the measured height and weight before surgery. Chi-square test was used to evaluate the relationships between smoking status and other clinicopathological variables. The Cox proportional hazard models were used for univariate and multivariate analyses of variables related to overall survival. Results BMI <18.5 kg/m2 was a significantly independent predictor of poor survival in the overall population and never smokers after adjusting for covariates, but not in ever smokers. Among never smokers, underweight patients (BMI <18.5 kg/m2) had a 2.218 times greater risk of mortality than non-underweight (BMI ≥18.5 kg/m2) patients (P=0.015). Among ever smokers, BMI <18 kg/m2 increased the risk of mortality to 1.656 (P=0.019), compared to those having BMI ≥18 kg/m2. Conclusion Our study is likely the first to show that the prognostic effect of BMI was substantial in ESCC, even after stratifying by smoking status. Furthermore, the risk of death due to low BMI would be significantly increased in never smokers. We believe that the prognostic impact of BMI is modified but not eliminated by the smoking status in ESCC. PMID:27799787

  6. Robust risk prediction with biomarkers under two-phase stratified cohort design.

    PubMed

    Payne, Rebecca; Yang, Ming; Zheng, Yingye; Jensen, Majken K; Cai, Tianxi

    2016-12-01

    Identification of novel biomarkers for risk prediction is important for disease prevention and optimal treatment selection. However, studies aiming to discover which biomarkers are useful for risk prediction often require the use of stored biological samples from large assembled cohorts, and thus the depletion of a finite and precious resource. To make efficient use of such stored samples, two-phase sampling designs are often adopted as resource-efficient sampling strategies, especially when the outcome of interest is rare. Existing methods for analyzing data from two-phase studies focus primarily on single marker analysis or fitting the Cox regression model to combine information from multiple markers. However, the Cox model may not fit the data well. Under model misspecification, the composite score derived from the Cox model may not perform well in predicting the outcome. Under a general two-phase stratified cohort sampling design, we present a novel approach to combining multiple markers to optimize prediction by fitting a flexible nonparametric transformation model. Using inverse probability weighting to account for the outcome-dependent sampling, we propose to estimate the model parameters by maximizing an objective function which can be interpreted as a weighted C-statistic for survival outcomes. Regardless of model adequacy, the proposed procedure yields a sensible composite risk score for prediction. A major obstacle for making inference under two phase studies is due to the correlation induced by the finite population sampling, which prevents standard inference procedures such as the bootstrap from being used for variance estimation. We propose a resampling procedure to derive valid confidence intervals for the model parameters and the C-statistic accuracy measure. We illustrate the new methods with simulation studies and an analysis of a two-phase study of high-density lipoprotein cholesterol (HDL-C) subtypes for predicting the risk of coronary heart

  7. Robust Risk Prediction with Biomarkers under Two-Phase Stratified Cohort Design

    PubMed Central

    Payne, Rebecca; Yang, Ming; Zheng, Yingye; Jensen, Majken K.; Cai, Tianxi

    2016-01-01

    Summary Identification of novel biomarkers for risk prediction is important for disease prevention and optimal treatment selection. However, studies aiming to discover which biomarkers are useful for risk prediction often require the use of stored biological samples from large assembled cohorts, and thus the depletion of a finite and precious resource. To make efficient use of such these stored samples, two-phase sampling designs are often adopted as resource-efficient sampling strategies, especially when the outcome of interest is rare. Existing methods for analyzing data from two-phase studies focus primarily on single marker analysis or fitting the Cox regression model to combine information from multiple markers. However, the Cox model may not fit the data well. Under model misspecification, the composite score derived from the Cox model may not perform well in predicting the outcome. Under a general two-phase stratified cohort sampling design, we present a novel approach to combining multiple markers to optimize prediction by fitting a flexible non-parametric transformation model. Using inverse probability weighting to account for the outcome dependent sampling, we propose to estimate the model parameters by maximizing an objective function which can be interpreted as a weighted C-statistic for survival outcomes. Regardless of model adequacy, the proposed procedure yields a sensible composite risk score for prediction. A major obstacle for making inference under two phase studies is due to the correlation induced by the finite population sampling, which prevents standard inference procedures such as the bootstrap from being used for variance estimation. We propose a resampling procedure to derive valid confidence intervals for the model parameters and the C-statistic accuracy measure. We illustrate the new methods with simulation studies and an analysis of a two-phase study of high-density lipoprotein cholesterol (HDL-C) subtypes for predicting the risk of

  8. Utility of Doppler Myocardial Imaging, Cardiac Biomarkers and Clonal Immunoglobulin Genes to Assess Left Ventricular Performance and Stratify Risk Following Peripheral Blood Stem Cell Transplantation in Patients with Systemic Light Chain Amyloidosis (AL)

    PubMed Central

    Bellavia, Diego; Abraham, Roshini S.; Pellikka, Patricia A.; Dispenzieri, Angela; Burnett, John C.; Al-Zahrani, Ghormallah B.; Green, Tammy D.; Manske, Michelle K.; Gertz, Morie A.; Miller, Fletcher A.; Abraham, Theodore P.

    2011-01-01

    Cardiac dysfunction is a well-recognized complication of light chain amyloidosis (AL). Autologous stem cell transplant (auto-SCT) has emerged as a successful treatment modality for AL patients. In this study, we examined the effect of clonal immunoglobulin light chain genes (VL), which encodes the immunoglobulin light chain protein that ultimately forms amyloid, on cardiac function, in the context of auto-SCT and its impact on overall survival. Longitudinal Doppler myocardial imaging parameters along with cardiac biomarkers were used to assess for cardiac function pre and post auto-SCT. VL gene analysis revealed that Vλ genes, in particular VλVI, were associated with worse cardiac function parameters than Vκ genes. Clonal VL genes appeared to have an impact on left ventricular (LV) function post-transplant and also influenced mortality, with specific VL gene families associated with lower survival. Another key predictor of mortality in this report was change in tricuspid regurgitant flow velocity following auto-SCT. Correlations were also observed between systolic strain rate, systolic strain and VL genes associated with amyloid formation. In summary, clonal VL gene usage influences global cardiac function in AL, with patients having VλVI and VλII-III-associated amyloid more severely affected than those having Vκ or VλI amyloid. Pulsed wave tissue Doppler imaging along with immunoglobulin gene analysis offers novel insights into prediction of mortality and cardiac dysfunction in AL after auto-SCT. PMID:21315556

  9. Implementing risk-stratified screening for common cancers: a review of potential ethical, legal and social issues.

    PubMed

    Hall, A E; Chowdhury, S; Hallowell, N; Pashayan, N; Dent, T; Pharoah, P; Burton, H

    2014-06-01

    The identification of common genetic variants associated with common cancers including breast, prostate and ovarian cancers would allow population stratification by genotype to effectively target screening and treatment. As scientific, clinical and economic evidence mounts there will be increasing pressure for risk-stratified screening programmes to be implemented. This paper reviews some of the main ethical, legal and social issues (ELSI) raised by the introduction of genotyping into risk-stratified screening programmes, in terms of Beauchamp and Childress's four principles of biomedical ethics--respect for autonomy, non-maleficence, beneficence and justice. Two alternative approaches to data collection, storage, communication and consent are used to exemplify the ELSI issues that are likely to be raised. Ultimately, the provision of risk-stratified screening using genotyping raises fundamental questions about respective roles of individuals, healthcare providers and the state in organizing or mandating such programmes, and the principles, which underpin their provision, particularly the requirement for distributive justice. The scope and breadth of these issues suggest that ELSI relating to risk-stratified screening will become increasingly important for policy-makers, healthcare professionals and a wide diversity of stakeholders. © The Author 2013. Published by Oxford University Press on behalf of Faculty of Public Health.

  10. Airway microbiota and pathogen abundance in age-stratified cystic fibrosis patients.

    PubMed

    Cox, Michael J; Allgaier, Martin; Taylor, Byron; Baek, Marshall S; Huang, Yvonne J; Daly, Rebecca A; Karaoz, Ulas; Andersen, Gary L; Brown, Ronald; Fujimura, Kei E; Wu, Brian; Tran, Diem; Koff, Jonathan; Kleinhenz, Mary Ellen; Nielson, Dennis; Brodie, Eoin L; Lynch, Susan V

    2010-06-23

    Bacterial communities in the airways of cystic fibrosis (CF) patients are, as in other ecological niches, influenced by autogenic and allogenic factors. However, our understanding of microbial colonization in younger versus older CF airways and the association with pulmonary function is rudimentary at best. Using a phylogenetic microarray, we examine the airway microbiota in age stratified CF patients ranging from neonates (9 months) to adults (72 years). From a cohort of clinically stable patients, we demonstrate that older CF patients who exhibit poorer pulmonary function possess more uneven, phylogenetically-clustered airway communities, compared to younger patients. Using longitudinal samples collected form a subset of these patients a pattern of initial bacterial community diversification was observed in younger patients compared with a progressive loss of diversity over time in older patients. We describe in detail the distinct bacterial community profiles associated with young and old CF patients with a particular focus on the differences between respective "early" and "late" colonizing organisms. Finally we assess the influence of Cystic Fibrosis Transmembrane Regulator (CFTR) mutation on bacterial abundance and identify genotype-specific communities involving members of the Pseudomonadaceae, Xanthomonadaceae, Moraxellaceae and Enterobacteriaceae amongst others. Data presented here provides insights into the CF airway microbiota, including initial diversification events in younger patients and establishment of specialized communities of pathogens associated with poor pulmonary function in older patient populations.

  11. Leukemia Risk After Cardiac Fluoroscopic Interventions Stratified by Procedure Number, Exposure Latent Time, and Sex

    PubMed Central

    Wei, Kai-Che; Lin, Hon-Yi; Hung, Shih-Kai; Huang, Yu-Tung; Lee, Moon-Sing; Wang, Wen-Hua; Wu, Chieh-Shan; Su, Yu-Chieh; Shen, Bing-Jie; Tsai, Shiang-Jiun; Tsai, Wei-Ta; Chen, Liang-Cheng; Li, Chung-Yi; Chiou, Wen-Yen

    2016-01-01

    Abstract A number of cardiac fluoroscopic interventions have increased rapidly worldwide over the past decade. Percutaneous transluminal coronary angioplasty (PTCA) and stent implantation have become increasingly popular, and these advancements have allowed patients to receive repetitive treatments for restenosis. However, these advancements also significantly increase radiation exposure that may lead to higher cumulative doses of radiation. In the present study, a nationwide population-based case-controlled study was used to explore the risk of leukemia after cardiac angiographic fluoroscopic intervention. A total of 5026 patients with leukemia and 100,520 control patients matched for age and sex (1:20) by a propensity score method without any cancer history were enrolled using the Registry Data for Catastrophic Illness and the National Health Insurance Research Database (NHIRD) of Taiwan between 2008 and 2010. All subjects were retrospectively surveyed (from year 2000) to determine receipt of cardiac fluoroscopic interventions. Data were analyzed using conditional logistic regression models, and estimated crude and adjusted odds ratios (95% confidence interval). After adjusting for age, gender, and comorbidities, PTCA was found to be associated with an increased risk of leukemia with an adjusted OR of 1.566 (95% CI, 1.282–1.912), whereas coronary angiography alone without PTCA and cardiac electrophysiologic study were not. Our results also showed that an increased frequency of PTCA and coronary angiography was associated with a higher risk of leukemia (adjusted OR: 1.326 to 1.530 [all P < 0.05]). Gender subgroup analyses demonstrated that men were associated with a higher risk of leukemia compared with women. These results provide additional data in the quantification of the long-term health effects of radiation exposure derived from the cardiac fluoroscopic diagnostic and therapeutic intervention. PTCA alone or PTCA with coronary angiography was associated

  12. Effect of risk-stratified, protocol-based perioperative chemoprophylaxis on nosocomial infection rates in a series of 31 927 consecutive neurosurgical procedures (1994-2006).

    PubMed

    Sharma, Manish S; Vohra, Ashma; Thomas, Ponnamma; Kapil, Arti; Suri, Ashish; Chandra, P Sarat; Kale, Shashank S; Mahapatra, Ashok K; Sharma, Bhawani S

    2009-06-01

    Although the use of prophylactic antibiotics has been shown to significantly decrease the incidence of meningitis after neurosurgery, its effect on extra-neurosurgical-site infections has not been documented. The authors explore the effect of risk-stratified, protocol-based perioperative antibiotic prophylaxis on nosocomial infections in an audit of 31 927 consecutive routine and emergency neurosurgical procedures. Infection rates were objectively quantified by bacteriological positivity on culture of cerebrospinal fluid (CSF), blood, urine, wound swab, and tracheal aspirate samples derived from patients with clinicoradiological features of sepsis. Infections were recorded as pulmonary, wound, blood, CSF, and urinary. The total numbers of hospital-acquired infections and the number of patients infected were also recorded. A protocol of perioperative antibiotic prophylaxis of variable duration stratified by patient risk factors was introduced in 2000, which was chosen as the historical turning point. The chi test was used to compare infection rates. A P value of <0.05 was considered significant. A total of 31 927 procedures were performed during the study period 1994-2006; 5171 culture-proven hospital-acquired infections (16.2%) developed in 3686 patients (11.6%). The most common infections were pulmonary (4.4%), followed by bloodstream (3.5%), urinary (3.0%), CSF (2.9%), and wound (2.5%). The incidence of positive tracheal, CSF, blood, wound, and urine cultures decreased significantly after 2000. Chemoprophylaxis, however, altered the prevalent bacterial flora and may have led to the emergence of methicillin-resistant Staphylococcus aureus. A risk-stratified protocol of perioperative antibiotic prophylaxis may help to significantly decrease not only neurosurgical, but also extra-neurosurgical-site body fluid bacteriological culture positivity.

  13. New paradigms in mantle cell lymphoma: is it time to risk-stratify treatment based on the proliferative signature?

    PubMed

    Dreyling, Martin; Ferrero, Simone; Vogt, Niklas; Klapper, Wolfram

    2014-10-15

    The elucidation of crucial biologic pathways of cell survival and proliferation has led to the development of highly effective drugs, some of which have markedly improved mantle cell lymphoma (MCL) therapeutic opportunities in the past 10 years. Moreover, an undeniable clinical heterogeneity in treatment response and disease behavior has become apparent in this neoplasm. Thus, the need for biologic markers stratifying patients with MCL in risk classes deserving different treatment approaches has recently been fervently expressed. Among several newly discovered biomarkers, the dismal predictive value of a high proliferative signature has been broadly recognized in large studies of patients with MCL. Different techniques have been used to assess tumor cell proliferation, including mitotic index, immunostaining with Ki-67 antibody, and gene expression profiling. Ki-67 proliferative index, in particular, has been extensively investigated, and its negative impact on relapse incidence and overall survival has been validated in large prospective clinical trials. However, one important pitfall limiting its widespread use in clinical practice is the reported interobserver variability, due to the previous lack of a standardized approach for quantification among different laboratories. In the present review, we describe some of the major techniques to assess cell proliferation in MCL, focusing in particular on the Ki-67 index and its need for a standardized approach to be used in multicenter clinical trials. The value of MCL biologic prognostic scores (as MIPI-b) is discussed, along with our proposal on how to integrate these scores in the planning of future trials investigating a tailored therapeutic approach for patients with MCL. See all articles in this CCR Focus section, "Paradigm Shifts in Lymphoma."

  14. Preoperative patient assessment: Identifying patients at high risk.

    PubMed

    Boehm, O; Baumgarten, G; Hoeft, A

    2016-06-01

    Postoperative mortality remains alarmingly high with a mortality rate ranging between 0.4% and 4%. A small subgroup of multimorbid and/or elderly patients undergoing different surgical procedures naturally confers the highest risk of complications and perioperative death. Therefore, preoperative assessment should identify these high-risk patients and stratify them to individualized monitoring and treatment throughout all phases of perioperative care. A "tailored" perioperative approach might help further reduce perioperative morbidity and mortality. This article aims to elucidate individual morbidity-specific risks. It further suggests approaches to detect patients at the risk of perioperative complications.

  15. Utility of FVC/DLCO ratio to stratify the risk of mortality in unselected subjects with pulmonary hypertension.

    PubMed

    Donato, Lacedonia; Giovanna Elisiana, Carpagnano; Giuseppe, Galgano; Pietro, Schino; Michele, Correale; Brunetti, Natale Daniele; Valentina, Ventura; Matteo, Di Biase; Maria Pia, Foschino Barbaro

    2017-04-01

    In patients with systemic sclerosis, a ratio between forced vital capacity (FVC) and diffusing capacity of carbon monoxide (DLCO, FCV%/DLCO%) >1.5 might be a predictor of pulmonary hypertension (PH). The aim of this study is, therefore, to evaluate whether this index can be used in patients with PH, regardless of etiology. 83 consecutive outpatients with suspected PH at non-invasive work-up underwent spirometry and DLCO test before right heart catheterization (RHC); FVC%/DLCO% ratio was then calculated and compared with mean pulmonary-artery-pressure (mPAP) and mortality at 5-year follow-up. Significant correlations between FVC%/DLCO% and PAsP and mPAP levels were found (p < 0.05). After ROC curve analysis and definition of best cut-off values for PAsP and FVC%/DLCO%, increased mPAP values at RHC were observed comparing subjects with both PAsP and FVC%/DLCO% values below cut off values (-/-), either PAsP or FVC%/DLCO% above cut off values (±), or both above (+/+) (p < 0.05). Poorer survival rates are observed at follow-up with higher FVC%/DLCO% values (0% for <1, 17.4% for 1-3, 33.3% for >3, p < 0.05), when comparing subjects with either increased PAsP and FVC%/DLCO% values or both with those with lower (log-rank p < 0.05). Even in subjects with mPAP at RHC >25 mmHg, increased FVC%/DLCO% values predicted a worse outcome (p < 0.05). FVC%/DLCO% values are related to mPAP in subjects with suspected PH, and may further stratify the risk of mortality in addition to PAP.

  16. The effectiveness of a stratified group intervention using the STarTBack screening tool in patients with LBP--a non randomised controlled trial.

    PubMed

    Murphy, Susan E; Blake, Catherine; Power, Camillus K; Fullen, Brona M

    2013-12-05

    Low back pain (LBP) is costly to society and improving patient outcomes is a priority. Stratifying LBP patients into more homogenous groups is advocated to improve patient outcome. The STarT Back tool, a prognostic screening tool has demonstrated efficacy and greater cost effectiveness in physiotherapy settings. The management of LBP patients in groups is common but to date the utility of the STarT Back tool in group settings has not been explored. The aim of this study is to determine if the implementation of 'stratified care' when delivered in a group setting will lead to significantly better physical and psychological outcomes and greater cost effectiveness in LBP patients compared to a bestcare historical control group. This study is a non randomised controlled trial. Low back pain patients recruited from the Waterford Primary Care area (population = 47,000) will be stratified into low, medium or high risk of persisting symptoms using the STarT Back Tool. Low risk patients will be offered a single one off education/exercise class offering positive messages on LBP management in line with recommended guidelines. Medium risk patients will be offered a 12 week group exercise/education intervention addressing their dominant physical obstacles to recovery. A 12 week group cognitive behavioural approach will be delivered to the high risk patients, characterised by the presence of high levels of psychosocial prognostic factors. These patients will be compared with a historical control group where therapists were blinded as to the risk stratification of patients and a generic group intervention was delivered to all patients, irrespective of their initial risk stratification. The primary outcome measure will be disability (Roland Morris Disability Questionnaire). Secondary outcomes will include back pain intensity (Visual Analogue Scale), distress (Distress and Risk Assessment Method), back beliefs (Back Beliefs Questionnaire), health status (Euroqol), global benefit (7

  17. Healthy obese persons: How can they be identified and do metabolic profiles stratify risk?

    PubMed Central

    Denis, Gerald V.; Hamilton, James A.

    2014-01-01

    Purpose of the review New research supports the intuitive observation that many persons classified as obese are healthy, and should not treated and categorized medically as diseased. There is increasing agreement that major blood biomarkers are often not discriminatory, as for example, the return to normal blood glucose levels in bariatric patients who do not have long terms benefits. Although weight loss is appreciated to improve metabolic and inflammatory parameters, the cellular and immune factors that couple obesity to cardiometabolic risk are only partially understood. Recent findings Reduced body mass index upon successful bariatric surgery does not always result in reduced pericardial fat; certain patients gain ectopic fat, which should be considered an adverse response. There is emerging evidence that pericardial fat volume and brown fat stores may provide individualized patient assessments. Summary Some obese persons can be relieved of the additional stigma of classification in a major disease category and unnecessary medical interventions and costs can be reduced. Other patients should be monitored more closely for unexpected adverse outcomes. PMID:23974763

  18. Stratifying patients with peripheral neuropathic pain based on sensory profiles: algorithm and sample size recommendations.

    PubMed

    Vollert, Jan; Maier, Christoph; Attal, Nadine; Bennett, David L H; Bouhassira, Didier; Enax-Krumova, Elena K; Finnerup, Nanna B; Freynhagen, Rainer; Gierthmühlen, Janne; Haanpää, Maija; Hansson, Per; Hüllemann, Philipp; Jensen, Troels S; Magerl, Walter; Ramirez, Juan D; Rice, Andrew S C; Schuh-Hofer, Sigrid; Segerdahl, Märta; Serra, Jordi; Shillo, Pallai R; Sindrup, Soeren; Tesfaye, Solomon; Themistocleous, Andreas C; Tölle, Thomas R; Treede, Rolf-Detlef; Baron, Ralf

    2017-08-01

    In a recent cluster analysis, it has been shown that patients with peripheral neuropathic pain can be grouped into 3 sensory phenotypes based on quantitative sensory testing profiles, which are mainly characterized by either sensory loss, intact sensory function and mild thermal hyperalgesia and/or allodynia, or loss of thermal detection and mild mechanical hyperalgesia and/or allodynia. Here, we present an algorithm for allocation of individual patients to these subgroups. The algorithm is nondeterministic-ie, a patient can be sorted to more than one phenotype-and can separate patients with neuropathic pain from healthy subjects (sensitivity: 78%, specificity: 94%). We evaluated the frequency of each phenotype in a population of patients with painful diabetic polyneuropathy (n = 151), painful peripheral nerve injury (n = 335), and postherpetic neuralgia (n = 97) and propose sample sizes of study populations that need to be screened to reach a subpopulation large enough to conduct a phenotype-stratified study. The most common phenotype in diabetic polyneuropathy was sensory loss (83%), followed by mechanical hyperalgesia (75%) and thermal hyperalgesia (34%, note that percentages are overlapping and not additive). In peripheral nerve injury, frequencies were 37%, 59%, and 50%, and in postherpetic neuralgia, frequencies were 31%, 63%, and 46%. For parallel study design, either the estimated effect size of the treatment needs to be high (>0.7) or only phenotypes that are frequent in the clinical entity under study can realistically be performed. For crossover design, populations under 200 patients screened are sufficient for all phenotypes and clinical entities with a minimum estimated treatment effect size of 0.5.

  19. Stratifying patients with peripheral neuropathic pain based on sensory profiles: algorithm and sample size recommendations

    PubMed Central

    Vollert, Jan; Maier, Christoph; Attal, Nadine; Bennett, David L.H.; Bouhassira, Didier; Enax-Krumova, Elena K.; Finnerup, Nanna B.; Freynhagen, Rainer; Gierthmühlen, Janne; Haanpää, Maija; Hansson, Per; Hüllemann, Philipp; Jensen, Troels S.; Magerl, Walter; Ramirez, Juan D.; Rice, Andrew S.C.; Schuh-Hofer, Sigrid; Segerdahl, Märta; Serra, Jordi; Shillo, Pallai R.; Sindrup, Soeren; Tesfaye, Solomon; Themistocleous, Andreas C.; Tölle, Thomas R.; Treede, Rolf-Detlef; Baron, Ralf

    2017-01-01

    Abstract In a recent cluster analysis, it has been shown that patients with peripheral neuropathic pain can be grouped into 3 sensory phenotypes based on quantitative sensory testing profiles, which are mainly characterized by either sensory loss, intact sensory function and mild thermal hyperalgesia and/or allodynia, or loss of thermal detection and mild mechanical hyperalgesia and/or allodynia. Here, we present an algorithm for allocation of individual patients to these subgroups. The algorithm is nondeterministic—ie, a patient can be sorted to more than one phenotype—and can separate patients with neuropathic pain from healthy subjects (sensitivity: 78%, specificity: 94%). We evaluated the frequency of each phenotype in a population of patients with painful diabetic polyneuropathy (n = 151), painful peripheral nerve injury (n = 335), and postherpetic neuralgia (n = 97) and propose sample sizes of study populations that need to be screened to reach a subpopulation large enough to conduct a phenotype-stratified study. The most common phenotype in diabetic polyneuropathy was sensory loss (83%), followed by mechanical hyperalgesia (75%) and thermal hyperalgesia (34%, note that percentages are overlapping and not additive). In peripheral nerve injury, frequencies were 37%, 59%, and 50%, and in postherpetic neuralgia, frequencies were 31%, 63%, and 46%. For parallel study design, either the estimated effect size of the treatment needs to be high (>0.7) or only phenotypes that are frequent in the clinical entity under study can realistically be performed. For crossover design, populations under 200 patients screened are sufficient for all phenotypes and clinical entities with a minimum estimated treatment effect size of 0.5. PMID:28595241

  20. Preoperative Computed Tomography to Predict and Stratify the Risk of Severe Pancreatic Fistula After Pancreatoduodenectomy.

    PubMed

    Sandini, Marta; Bernasconi, Davide Paolo; Ippolito, Davide; Nespoli, Luca; Baini, Melissa; Barbaro, Salvatore; Fior, Davide; Gianotti, Luca

    2015-08-01

    The aim of this article is to assess whether measures of abdominal fat distribution, visceral density, and antropometric parameters obtained from computed tomography (CT) may predict postoperative pancreatic fistula (POPF) occurrence.We analyzed 117 patients who underwent pancreatoduodenectomy (PD) and had a preoperative CT scan as staging in our center. CT images were processed to obtain measures of total fat volume (TFV), visceral fat volume (VFV), density of spleen, and pancreas, and diameter of pancreatic duct. The predictive ability of each parameter was investigated by receiver-operating characteristic (ROC) curves methodology and assessing optimal cutoff thresholds. A stepwise selection method was used to determine the best predictive model.Clinically relevant (grades B and C) POPF occurred in 24 patients (20.5%). Areas under ROC-curves showed that none of the parameters was per se significantly predictive. The multivariate analysis revealed that a VFV >2334 cm, TFV >4408 cm, pancreas/spleen density ratio <0.707, and pancreatic duct diameter <5 mm were predictive of POPF. The risk of POPF progressively increased with the number of factors involved and age.It is possible to deduce objective information on the risk of POPF from a simple and routine preoperative radiologic workup.

  1. Factors Associated With Inadequate Effectiveness of a Multidisciplinary Disease Management Program in Heart Failure Patients Stratified by Galectin 3 Level.

    PubMed

    Liu, Min-Hui; Wang, Chao-Hung; Chiou, Ai-Fu; Yang, Ning-I; Kuo, Li-Tang

    2016-07-21

    This study investigated whether multidisciplinary disease management programs (MDPs) exert the same effects in heart failure (HF) patients across risk levels stratified by galectin-3 (Gal-3) level and what factors are associated with inadequate effectiveness of MDP. We used a longitudinal follow-up design based on a previous randomized trial. A total of 355 stabilized hospitalized HF patients were enrolled. The effects of MDP on death and HF-related rehospitalization were analyzed according to Gal-3 levels. During the 4-year follow-up, Gal-3 levels predicted mortality and composite events (p < .001). Multivariable analysis demonstrated the event-lowering effect of MDP (hazard ratio [HR] = 0.49, p = .001 for death and HR = 0.50, p < .001 for composite events). However, the effect of MDP was inadequate for those with high Gal-3 levels (≥17.9 ng/ml), whose 4-year composite event rate was 43% in the MDP arm. Further analysis showed that, in patients with Gal-3 ≥ 17.9 ng/ml, the independent factors associated with a high composite event rate were no MDP, older age, worse New York Heart Association functional class, no angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, higher predischarge natriuretic peptide levels, and wider QRS complexes. The effectiveness of MDP for HF patients at high risk was inadequate. Our findings identified the characteristics of these MDP nonresponders. Better integration of advanced care plans based on strategies guided by Gal-3 level is needed to improve care quality. © The Author(s) 2016.

  2. Cross-cultural adaptation of the STRATIFY tool in detecting and predicting risk of falling.

    PubMed

    Enríquez de Luna-Rodríguez, Margarita; Aranda-Gallardo, Marta; Canca-Sánchez, José Carlos; Vazquez-Blanco, M José; Moya-Suárez, Ana Belén; Morales-Asencio, José Miguel

    To adapt to Spanish language the STRATIFY tool for clinical use in the Spanish-speaking World. A multicenter, 2 care settings cross-sectional study cultural adaptation study in acute care hospitals and nursing homes was performed in Andalusia during 2014. The adaptation process was divided into 4 stages: translation, back-translation, equivalence between the 2 back-translations and piloting of the Spanish version, thus obtaining the final version. The validity of appearance, content validity and the time required to complete the scale were taken into account. For analysis, the median, central tendency and dispersion of scores, the interquartile range, and the interquartile deviation for the possible variability in responses it was calculated. Content validity measured by content validity index reached a profit of 1. For the validity aspect the clarity and comprehensibility of the questions were taken into account. Of the 5 questions of the instrument, 2 had a small disagreement solved with the introduction of an explanatory phrase to achieve conceptual equivalence. Median both questions were equal or superior to 5. The average time for completion of the scale was less than 3 minutes. The process of adaptation to Spanish of STRATIFY has led to a semantic version and culturally equivalent to the original for easy filling and understanding for use in the Spanish-speaking world. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

  3. Stratifying empiric risk of schizophrenia among first degree relatives using multiple predictors in two independent Indian samples.

    PubMed

    Bhatia, Triptish; Gettig, Elizabeth A; Gottesman, Irving I; Berliner, Jonathan; Mishra, N N; Nimgaonkar, Vishwajit L; Deshpande, Smita N

    2016-12-01

    Schizophrenia (SZ) has an estimated heritability of 64-88%, with the higher values based on twin studies. Conventionally, family history of psychosis is the best individual-level predictor of risk, but reliable risk estimates are unavailable for Indian populations. Genetic, environmental, and epigenetic factors are equally important and should be considered when predicting risk in 'at risk' individuals. To estimate risk based on an Indian schizophrenia participant's family history combined with selected demographic factors. To incorporate variables in addition to family history, and to stratify risk, we constructed a regression equation that included demographic variables in addition to family history. The equation was tested in two independent Indian samples: (i) an initial sample of SZ participants (N=128) with one sibling or offspring; (ii) a second, independent sample consisting of multiply affected families (N=138 families, with two or more sibs/offspring affected with SZ). The overall estimated risk was 4.31±0.27 (mean±standard deviation). There were 19 (14.8%) individuals in the high risk group, 75 (58.6%) in the moderate risk and 34 (26.6%) in the above average risk (in Sample A). In the validation sample, risks were distributed as: high (45%), moderate (38%) and above average (17%). Consistent risk estimates were obtained from both samples using the regression equation. Familial risk can be combined with demographic factors to estimate risk for SZ in India. If replicated, the proposed stratification of risk may be easier and more realistic for family members. Copyright © 2016. Published by Elsevier B.V.

  4. Recent research (N = 9,305) underscores the importance of using age-stratified actuarial tables in sex offender risk assessments.

    PubMed

    Wollert, Richard; Cramer, Elliot; Waggoner, Jacqueline; Skelton, Alex; Vess, James

    2010-12-01

    A useful understanding of the relationship between age, actuarial scores, and sexual recidivism can be obtained by comparing the entries in equivalent cells from "age-stratified" actuarial tables. This article reports the compilation of the first multisample age-stratified table of sexual recidivism rates, referred to as the "multisample age-stratified table of sexual recidivism rates (MATS-1)," from recent research on Static-99 and another actuarial known as the Automated Sexual Recidivism Scale. The MATS-1 validates the "age invariance effect" that the risk of sexual recidivism declines with advancing age and shows that age-restricted tables underestimate risk for younger offenders and overestimate risk for older offenders. Based on data from more than 9,000 sex offenders, our conclusion is that evaluators should report recidivism estimates from age-stratified tables when they are assessing sexual recidivism risk, particularly when evaluating the aging sex offender.

  5. Can Non-HLA Single Nucleotide Polymorphisms Help Stratify Risk in TrialNet Relatives at Risk for Type 1 Diabetes?

    PubMed

    Steck, Andrea K; Xu, Ping; Geyer, Susan; Redondo, Maria J; Antinozzi, Peter; Wentworth, John M; Sosenko, Jay; Onengut-Gumuscu, Suna; Chen, Wei-Min; Rich, Stephen S; Pugliese, Alberto

    2017-08-01

    Genome-wide association studies identified >50 type 1 diabetes (T1D) associated non-human leukocyte antigens (non-HLA) loci. The purpose of this study was to assess the contribution of non-HLA single nucleotide polymorphisms (SNPs) to risk of disease progression. The TrialNet Pathway to Prevention Study follows relatives of T1D patients for development of autoantibodies (Abs) and T1D. Using the Immunochip, we analyzed 53 diabetes-associated, non-HLA SNPs in 1016 Ab-positive, at-risk non-Hispanic white relatives. Effect of SNPs on the development of multiple Abs and T1D. Cox proportional analyses included all substantial non-HLA SNPs, HLA genotypes, relationship to proband, sex, age at initial screening, initial Ab type, and number. Factors involved in progression from single to multiple Abs included age at screening, relationship to proband, HLA genotypes, and rs3087243 (cytotoxic T lymphocyte antigen-4). Significant factors for diabetes progression included age at screening, Ab number, HLA genotypes, rs6476839 [GLIS family zinc finger 3 (GLIS3)], and rs3184504 [SH2B adaptor protein 3 (SH2B3)]. When glucose area under the curve (AUC) was included, factors involved in disease progression included glucose AUC, age at screening, Ab number, relationship to proband, HLA genotypes, rs6476839 (GLIS3), and rs7221109 (CCR7). In stratified analyses by age, glucose AUC, age at screening, sibling, HLA genotypes, rs6476839 (GLIS3), and rs4900384 (C14orf64) were significantly associated with progression to diabetes in participants <12 years old, whereas glucose AUC, sibling, rs3184504 (SH2B3), and rs4900384 (C14orf64) were significant in those ≥12. In conclusion, we identified five non-HLA SNPs associated with increased risk of progression from Ab positivity to disease that may improve risk stratification for prevention trials.

  6. A comparison of methods for the construction of confidence interval for relative risk in stratified matched-pair designs.

    PubMed

    Tang, Nian-Sheng; Li, Hui-Qiong; Tang, Man-Lai

    2010-01-15

    A stratified matched-pair study is often designed for adjusting a confounding effect or effect of different trails/centers/ groups in modern medical studies. The relative risk is one of the most frequently used indices in comparing efficiency of two treatments in clinical trials. In this paper, we propose seven confidence interval estimators for the common relative risk and three simultaneous confidence interval estimators for the relative risks in stratified matched-pair designs. The performance of the proposed methods is evaluated with respect to their type I error rates, powers, coverage probabilities, and expected widths. Our empirical results show that the percentile bootstrap confidence interval and bootstrap-resampling-based Bonferroni simultaneous confidence interval behave satisfactorily for small to large sample sizes in the sense that (i) their empirical coverage probabilities can be well controlled around the pre-specified nominal confidence level with reasonably shorter confidence widths; and (ii) the empirical type I error rates of their associated test statistics are generally closer to the pre-specified nominal level with larger powers. They are hence recommended. Two real examples from clinical laboratory studies are used to illustrate the proposed methodologies.

  7. Prevalence of nutritional risk in the non-demented hospitalised elderly: a cross-sectional study from Norway using stratified sampling.

    PubMed

    Eide, Helene K; Šaltytė Benth, Jūratė; Sortland, Kjersti; Halvorsen, Kristin; Almendingen, Kari

    2015-01-01

    There is a lack of accurate prevalence data on undernutrition and the risk of undernutrition among the hospitalised elderly in Europe and Norway. We aimed at estimating the prevalence of nutritional risk by using stratified sampling along with adequate power calculations. A cross-sectional study was carried out in the period 2011 to 2013 at a university hospital in Norway. Second-year nursing students in acute care clinical studies in twenty hospital wards screened non-demented elderly patients for nutritional risk, by employing the Nutritional Risk Screening 2002 (NRS2002) form. In total, 508 patients (48·8 % women and 51·2 % men) with a mean age of 79·6 (sd 6·4) years were screened by the students. Mean BMI was 24·9 (sd 4·9) kg/m(2), and the patients had been hospitalised for on average 5·3 (sd 6·3) d. WHO's BMI cut-off values identified 6·5 % as underweight, 48·0 % of normal weight and 45·5 % as overweight. Patients nutritionally at risk had been in hospital longer and had lower average weight and BMI compared with those not at risk (all P < 0·001); no differences in mean age or sex were observed. The prevalence of nutritional risk was estimated to be 45·4 (95 % CI 41·7 %, 49·0) %, ranging between 20·0 and 65·0 % on different hospital wards. The present results show that the prevalence of nutritional risk among elderly patients without dementia is high, suggesting that a large proportion of the hospitalised elderly are in need of nutritional treatment.

  8. Reflux time estimation on air-plethysmography may stratify patients with early superficial venous insufficiency.

    PubMed

    Lattimer, C R; Kalodiki, E; Azzam, M; Geroulakos, G

    2013-03-01

    It has been suggested that quantification of haemodynamic parameters of venous disease may complement clinical assessment and may help identify a group of patients with severe venous disease or alternatively patients with early venous disease. However, there has been very little work to prove this hypothesis. The venous filling index (VFI) of air-plethysmography (APG) can quantify severity and treatment effect but has limited discriminatory value. However, the components of the VFI, total venous volume (VV) and time to reach 90% of VV (VFT90), have never been fully studied. The aim was to investigate the contribution of VV and VFT90 to an elevated VFI and determine their relationship to great saphenous vein (GSV) diameter and clinical severity scoring. Ninety-three consecutive patients/legs (22-78 years) with primary GSV reflux (>0.5 seconds) awaiting endovenous treatment were recruited. CEAP (clinical, aetiological, anatomical and pathological elements) assessments were: 33 (35.5%) C₂, 14 (15.0%) C₃, 29 (31.2%) C4a, 5 (5.4%) C4b, 7 (7.5%) C₅ and 5 (5.4%) C₆. The median venous clinical severity score (VCSS) was 6 (2-20) and the averaged GSV diameter at three sites was 7.5 mm (4-12). The VFI, VV and VFT90 were recorded using APG. There was no correlation between the VV and the VFT90 (r = -0.103, P = 0.324). The VFI, VV and VFT90 significantly correlated (P < 0.0005, Spearman) with the GSV diameter: r = 0.623, r = 0.567, r = -0.432, respectively, and the C of CEAP (P < 0.05): r = 0.4, r = 0.225, r = -0.343, respectively. None of the 25 (26.9%) patients with a VFT90 > 25 seconds were among the 17 (18.3%) patients in categories C4b-6 or with a VCSS > 9 (P = 0.005, Fisher's exact test, corrected odds ratio: 17.3). The VFT90 complements the VFI as a marker of severe superficial venous insufficiency. However, in contrast to the VFI, it may have discriminatory value in stratifying patients with early disease into two groups based on the severity of haemodynamic

  9. Logic Learning Machine creates explicit and stable rules stratifying neuroblastoma patients

    PubMed Central

    2013-01-01

    Background Neuroblastoma is the most common pediatric solid tumor. About fifty percent of high risk patients die despite treatment making the exploration of new and more effective strategies for improving stratification mandatory. Hypoxia is a condition of low oxygen tension occurring in poorly vascularized areas of the tumor associated with poor prognosis. We had previously defined a robust gene expression signature measuring the hypoxic component of neuroblastoma tumors (NB-hypo) which is a molecular risk factor. We wanted to develop a prognostic classifier of neuroblastoma patients' outcome blending existing knowledge on clinical and molecular risk factors with the prognostic NB-hypo signature. Furthermore, we were interested in classifiers outputting explicit rules that could be easily translated into the clinical setting. Results Shadow Clustering (SC) technique, which leads to final models called Logic Learning Machine (LLM), exhibits a good accuracy and promises to fulfill the aims of the work. We utilized this algorithm to classify NB-patients on the bases of the following risk factors: Age at diagnosis, INSS stage, MYCN amplification and NB-hypo. The algorithm generated explicit classification rules in good agreement with existing clinical knowledge. Through an iterative procedure we identified and removed from the dataset those examples which caused instability in the rules. This workflow generated a stable classifier very accurate in predicting good and poor outcome patients. The good performance of the classifier was validated in an independent dataset. NB-hypo was an important component of the rules with a strength similar to that of tumor staging. Conclusions The novelty of our work is to identify stability, explicit rules and blending of molecular and clinical risk factors as the key features to generate classification rules for NB patients to be conveyed to the clinic and to be used to design new therapies. We derived, through LLM, a set of four

  10. Stratified polygenic risk prediction model with application to CAGI bipolar disorder sequencing data.

    PubMed

    Wang, Maggie Haitian; Chang, Billy; Sun, Rui; Hu, Inchi; Xia, Xiaoxuan; Wu, William Ka Kei; Chong, Ka Chun; Zee, Benny Chung-Ying

    2017-09-01

    Genetic data consists of a wide range of marker types, including common, low-frequency, and rare variants. Multiple genetic markers and their interactions play central roles in the heritability of complex disease. In this study, we propose an algorithm that uses a stratified variable selection design by genetic architectures and interaction effects, achieved by a dataset-adaptive W-test. The polygenic sets in all strata were integrated to form a classification rule. The algorithm was applied to the Critical Assessment of Genome Interpretation 4 bipolar challenge sequencing data. The prediction accuracy was 60% using genetic markers on an independent test set. We found that epistasis among common genetic variants contributed most substantially to prediction precision. However, the sample size was not large enough to draw conclusions for the lack of predictability of low-frequency variants and their epistasis. © 2017 Wiley Periodicals, Inc.

  11. A blood-based biomarker panel to risk-stratify mild traumatic brain injury

    PubMed Central

    Sharma, Richa; Rosenberg, Alexandra; Bennett, Ellen R.; Laskowitz, Daniel T.; Acheson, Shawn K.

    2017-01-01

    Mild traumatic brain injury (TBI) accounts for the vast majority of the nearly two million brain injuries suffered in the United States each year. Mild TBI is commonly classified as complicated (radiographic evidence of intracranial injury) or uncomplicated (radiographically negative). Such a distinction is important because it helps to determine the need for further neuroimaging, potential admission, or neurosurgical intervention. Unfortunately, imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are costly and not without some risk. The purpose of this study was to screen 87 serum biomarkers to identify a select panel of biomarkers that would predict the presence of intracranial injury as determined by initial brain CT. Serum was collected from 110 patients who sustained a mild TBI within 24 hours of blood draw. Two models were created. In the broad inclusive model, 72kDa type IV collagenase (MMP-2), C-reactive protein (CRP), creatine kinase B type (CKBB), fatty acid binding protein—heart (hFABP), granulocyte-macrophage colony-stimulating factor (GM-CSF) and malondialdehyde modified low density lipoprotein (MDA-LDL) significantly predicted injury visualized on CT, yielding an overall c-statistic of 0.975 and a negative predictive value (NPV) of 98.6. In the parsimonious model, MMP-2, CRP, and CKBB type significantly predicted injury visualized on CT, yielding an overall c-statistic of 0.964 and a negative predictive value (NPV) of 97.2. These results suggest that a serum based biomarker panel can accurately differentiate patients with complicated mild TBI from those with uncomplicated mild TBI. Such a panel could be useful to guide early triage decisions, including the need for further evaluation or admission, especially in those environments in which resources are limited. PMID:28355230

  12. Effect of a risk-stratified grade of nerve-sparing technique on early return of continence after robot-assisted laparoscopic radical prostatectomy.

    PubMed

    Srivastava, Abhishek; Chopra, Sameer; Pham, Anthony; Sooriakumaran, Prasanna; Durand, Matthieu; Chughtai, Bilal; Gruschow, Siobhan; Peyser, Alexandra; Harneja, Niyati; Leung, Robert; Lee, Richard; Herman, Michael; Robinson, Brian; Shevchuk, Maria; Tewari, Ashutosh

    2013-03-01

    The impact of nerve sparing (NS) on urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP) has yet to be defined. To evaluate the effect of a risk-stratified grade of NS technique on early return of urinary continence. Data were collected from 1546 patients who underwent RALP by a single surgeon at a tertiary care center from December 2008 to October 2011. Patients were categorized preoperatively by a risk-stratified approach into risk grades 1-4, with risk grade 1 patients more likely to receive NS grade 1 or complete hammock preservation. This categorization was also conducted for risk grades 2-4, with grade 4 patients receiving a non-NS procedure. Risk-stratified grading of NS RALP. Univariate and multivariate analysis identified predictors of early return of urinary continence, defined as no pad use at ≤ 12 wk postoperatively. Early return of continence was achieved by 791 of 1417 men (55.8%); of those, 199 of 277 (71.8%) were in NS grade 1, 440 of 805 (54.7%) were in NS grade 2, 132 of 289 (45.7%) were in NS grade 3, and 20 of 46 (43.5%) were in NS grade 4 (p<0.001). On multivariate analysis, better NS grade was a significant independent predictor of early return of urinary continence when NS grade 1 was the reference variable compared with NS grade 2 (p<0.001; odds ratio [OR]: 0.46), NS grade 3 (p<0.001; OR: 0.35), and NS grade 4 (p=0.001; OR: 0.29). Lower preoperative International Prostate Symptom Score (p=0.001; OR: 0.97) and higher preoperative Sexual Health Inventory for Men score (p=0.002; OR: 1.03) were indicative of early return of urinary continence. Positive surgical margin rates were 7.2% (20 of 277) of grade 1 cases, 7.6% (61 of 805) of grade 2 cases, 7.6% (22 of 289) of grade 3 cases, and 17.4% (8 of 46) of grade 4 cases (p=0.111). Extraprostatic extension occurred in 6.1% (17 of 277) of NS grade 1 cases, 17.5% (141 of 805) of NS grade 2 cases, 42.5% (123 of 289) of NS grade 3 cases, and 63% (29 of 46) of NS

  13. Comparison of UTI antibiograms stratified by ED patient  disposition.

    PubMed

    Grodin, Lee; Conigliaro, Alyssa; Lee, Song-Yi; Rose, Michael; Sinert, Richard

    2017-09-01

    Institutional antibiograms guide Emergency Department (ED) clinicians' empiric antibiotic selection. For this study, we created and compared antibiograms of ED patients stratified by disposition (admitted or discharged). We conducted a cross-sectional study at two hospitals for 2014, comparing antibiograms limited to Escherichia coli urinary tract infections. Study-Specific Antibiograms, created for the study, excluded polymicrobial samples and multiple cultures from the same patient. Study-Specific Antibiograms were arranged by patient disposition: admitted (IP-Only) vs discharged from the ED (ED-Only). Antibiogram data were presented as average antibiotic sensitivities with 95% confidence intervals and demographic data as medians with interquartile ranges. Sensitivities between Study-Specific Antibiograms were compared by Fisher's Exact Test, alpha=0.05, 2 tails. For Hospital A, 13 antibiotics were compared between Study-Specific ED-Only (n=313) vs IP-Only (n=244). We found that sensitivities to all four antibiotics appropriate for empiric outpatient therapy by Infectious Disease Society of America guidelines were significantly (p<0.0001) higher in the ED-Only compared to IP-Only groups: ciprofloxacin 80% (76-90%) vs 60% (53-69%), levofloxacin 81% (77-91%) vs 63% (57-72%), nitrofurantoin 75% (70-84%) vs 51% (44-58%), and trimethoprim/sulfamethoxazole 73% (68-82%) vs 58% (52-67%). For Hospital B, 14 antibiotics were compared between Study-Specific ED-Only (n=256) and IP-Only (n=168). Two out of the five appropriate empiric outpatient antibiotics had significantly (p<0.0001) higher sensitivities for ED-Only compared to IP-Only: ciprofloxacin 87% (83-91%) vs 71% (64-78%) and levofloxacin 86% (82-91%) vs 71% (65-78%). We found higher antibiotic sensitivities in ED-Only than the IP-Only Study-Specific Antibiograms. Our Study-Specific Antibiograms offer an alternative guide for antibiotic selection in the ED. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. Prognostic Value of Baseline 18F-FDG PET/CT Functional Parameters in Patients with Advanced Lung Adenocarcinoma Stratified by EGFR Mutation Status

    PubMed Central

    Wang, Dalong; Zhang, Minghui; Gao, Xuan; Yu, Lijuan

    2016-01-01

    The study objective was to retrospectively analyze the metabolic variables derived from 18 F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) as predictors of progression-free survival (PFS) and overall survival (OS) in advanced lung adenocarcinoma stratified by epidermal growth factor receptor (EGFR) mutation status. A total of 176 patients (91, EGFR mutation; 85, wild-type EGFR) who underwent 18F-FDG PET/CT before treatment were enrolled. The main 18F-FDG PET/CT-derived variables: primary tumor maximum standardized uptake value (SUVmaxT), primary tumor total lesion glycolysis (TLGT), the maximum SUVmax of all selected lesions in whole body determined using the Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 criteria (SUVmaxWBR), and whole-body total TLG determined using the RECIST 1.1 criteria (TLGWBR) were measured. Survival analysis regarding TLGWBR, and other factors in advanced lung adenocarcinoma patients stratified using EGFR mutation status, were evaluated. The results indicated that high TLGWBR (≥259.85), EGFR wild-type, and high serum LDH were independent predictors of worse PFS and OS in all patients with advanced lung adenocarcinoma. Among patients with wild-type EGFR, only TLGWBR retained significance as an independent predictor of both PFS and OS. Among patients with the EGFR mutation, high serum LDH level was an independent predictor of worse PFS and OS, and high TLGWBR (≥259.85) was an independent predictor of worse PFS but not worse OS. In conclusion, TLGWBR is a promising parameter for prognostic stratification of patients with advanced lung adenocarcinoma and EGFR status; however, it cannot be used to further stratify the risk of worse OS for patients with the EGFR mutation. Further prospective studies are needed to validate our findings. PMID:27336755

  15. Risk stratified usage of antibiotic-loaded bone cement for primary total knee arthroplasty: short term infection outcomes with a standardized cement protocol.

    PubMed

    Qadir, Rabah; Sidhu, Sanbir; Ochsner, J Lockwood; Meyer, Mark S; Chimento, George F

    2014-08-01

    Efficacy of antibiotic cement (ALBC) in primary knee arthroplasty (pTKA) has been debated. The study's purpose was to examine efficacy of ALBC versus plain cement (PBC) in preventing infection in high-risk patients undergoing pTKA. 3292 consecutive pTKAs were divided into three cohorts: (1) patients receiving only PBC, (2) patients receiving only ALBC, and (3) only high-risk patients receiving ALBC. Cohorts' infections were compared. The 30-day infection rates for cohorts 1, 2, 3 were 0.29%, 0.20%, and 0.13% respectively. 6-month rates were 0.39%, 0.54% and 0.38%. 1-year rates were 0.78%, 0.61%, and 0.64%. Differences in infection rates at all time intervals were not statistically significant. The study supports that even judicious risk-stratified usage of ALBC may not confer added benefit in decreasing infection at one year. Copyright © 2014 Elsevier Inc. All rights reserved.

  16. Implications of polygenic risk-stratified screening for prostate cancer on overdiagnosis

    PubMed Central

    Pashayan, Nora; Duffy, Stephen W.; Neal, David E.; Hamdy, Freddie C.; Donovan, Jenny L.; Martin, Richard M.; Harrington, Patricia; Benlloch, Sara; Amin Al Olama, Ali; Shah, Mitul; Kote-Jarai, Zsofia; Easton, Douglas F.; Eeles, Rosalind; Pharoah, Paul D.

    2015-01-01

    Purpose: This study aimed to quantify the probability of overdiagnosis of prostate cancer by polygenic risk. Genet Med 17 10, 789–795. Methods: We calculated the polygenic risk score based on 66 known prostate cancer susceptibility variants for 17,012 men aged 50–69 years (9,404 men identified with prostate cancer and 7,608 with no cancer) derived from three UK-based ongoing studies. We derived the probabilities of overdiagnosis by quartiles of polygenic risk considering that the observed prevalence of screen-detected prostate cancer is a combination of underlying incidence, mean sojourn time (MST), test sensitivity, and overdiagnosis. Genet Med 17 10, 789–795. Results: Polygenic risk quartiles 1 to 4 comprised 9, 18, 25, and 48% of the cases, respectively. For a prostate-specific antigen test sensitivity of 80% and MST of 9 years, 43, 30, 25, and 19% of the prevalent screen-detected cancers in quartiles 1 to 4, respectively, were likely to be overdiagnosed cancers. Overdiagnosis decreased with increasing polygenic risk, with 56% decrease between the lowest and the highest polygenic risk quartiles. Genet Med 17 10, 789–795. Conclusion: Targeting screening to men at higher polygenic risk could reduce the problem of overdiagnosis and lead to a better benefit-to-harm balance in screening for prostate cancer. Genet Med 17 10, 789–795. PMID:25569441

  17. Programmed Ventricular Stimulation to Risk Stratify for Early Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction (PROTECT-ICD): Trial Protocol, Background and Significance.

    PubMed

    Zaman, Sarah; Taylor, Andrew J; Stiles, Martin; Chow, Clara; Kovoor, Pramesh

    2016-11-01

    The 'Programmed Ventricular Stimulation to Risk Stratify for Early Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction' (PROTECT-ICD) trial is an Australian-led multicentre randomised controlled trial targeting prevention of sudden cardiac death in patients who have at least moderately reduced cardiac function following a myocardial infarct (MI). The primary objective of the trial is to assess whether electrophysiological study to guide prophylactic implantation of an implantable cardioverter-defibrillator (ICD) early following MI (first 40 days) will lead to a significant reduction in sudden cardiac death and non-fatal arrhythmia. The secondary objective is to assess the utility of cardiac MRI (CMR) in assessing early myocardial characteristics, and its predictive value for both inducible ventricular tachycardia (VT) at EPS and SCD/ non-fatal arrhythmia at follow-up.

  18. IQ, handedness, and pedophilia in adult male patients stratified by referral source.

    PubMed

    Blanchard, Ray; Kolla, Nathan J; Cantor, James M; Klassen, Philip E; Dickey, Robert; Kuban, Michael E; Blak, Thomas

    2007-09-01

    This study investigated whether the previously observed association of pedophilia with lower IQs is an artifact of heterogeneity in referral source. The subjects were 832 adult male patients referred to a specialty clinic for evaluation of their sexual behavior. The patients' erotic preferences for prepubescent, pubescent, or adult partners were assessed with phallometric testing. Full scale IQ was estimated using six subtests from the WAIS-R. The results showed that the relations between pedophilia and lower IQ, lesser education, and increased rates of non-right-handedness were the same in homogeneous groups referred by lawyers or parole and probation officers as they were in a heterogeneous group referred by a miscellany of other sources. Those results, along with secondary analyses in the study, supported the conclusion that the relation between pedophilia and cognitive function is genuine and not artifactual. The findings were interpreted as evidence for the hypothesis that neurodevelopmental perturbations increase the risk of pedophilia in males.

  19. Risk Factors Associated with Very Low Birth Weight in a Large Urban Area, Stratified by Adequacy of Prenatal Care.

    PubMed

    Xaverius, Pamela; Alman, Cameron; Holtz, Lori; Yarber, Laura

    2016-03-01

    This study examined risk and protective factors associated with very low birth weight (VLBW) for babies born to women receiving adequate or inadequate prenatal care. Birth records from St. Louis City and County from 2000 to 2009 were used (n = 152,590). Data was categorized across risk factors and stratified by adequacy of prenatal care (PNC). Multivariate logistic regression and population attributable risk (PAR) was used to explore risk factors for VLBW infants. Women receiving inadequate prenatal care had a higher prevalence of delivering a VLBW infant than those receiving adequate PNC (4.11 vs. 1.44 %, p < .0001). The distribution of risk factors differed between adequate and inadequate PNC regarding Black race (36.4 vs. 79.0 %, p < .0001), age under 20 (13.0 vs. 33.6 %, p < .0001), <13 years of education (35.9 vs. 77.9 %, p < .0001), Medicaid status (35.7 vs. 74.9, p < .0001), primiparity (41.6 vs. 31.4 %, p < .0001), smoking (9.7 vs. 24.5 %, p < .0001), and diabetes (4.0 vs. 2.4 %, p < .0001), respectively. Black race, advanced maternal age, primiparity and gestational hypertension were significant predictors of VLBW, regardless of adequate or inadequate PNC. Among women with inadequate PNC, Medicaid was protective against (aOR 0.671, 95 % CI 0.563-0.803; PAR -32.6 %) and smoking a risk factor for (aOR 1.23, 95 % CI 1.01, 1.49; PAR 40.1 %) VLBW. When prematurity was added to the adjusted models, the largest PAR shifts to education (44.3 %) among women with inadequate PNC. Community actions around broader issues of racism and social determinants of health are needed to prevent VLBW in a large urban area.

  20. Revised Atlanta classification and determinant-based classification: Which one better at stratifying outcomes of patients with acute pancreatitis?

    PubMed

    Choi, Jun-Ho; Kim, Myung-Hwan; Cho, Dong Hui; Oh, Dongwook; Lee, Hyun Woo; Song, Tae Jun; Park, Do Hyun; Lee, Sang Soo; Seo, Dong-Wan; Lee, Sung Koo

    Two different severity classifications (revised Atlanta classification [RAC] and determinant-based classification [DBC]) were recently proposed. This was a retrospective analysis of a prospective acute pancreatitis (AP) database. This study aims to compare the ability of three classification systems (RAC, DBC, and original Atlanta classification [OAC]) to stratify outcomes of AP and to determine the association between different severity categories and clinical outcomes. Overall, as the grade of severity increased, the morbidity and mortality increased accordingly in the three classification systems. The RAC and DBC were comparable, but performed better than OAC in predicting mortality (AUC 0.92 and 0.95 vs. 0.66, p < 0.001), ICU admission (AUC 0.92 and 0.96 vs. 0.68, p < 0.001), ICU LOS (AUC 0.73 and 0.76 vs. 0.50, p < 0.001), and hospital stay (AUC 0.81 and 0.83 vs. 0.70, p < 0.001). The DBC performed better than the RAC and OAC in predicting the need for intervention (AUC 0.87 vs. 0.79 and 0.68, p < 0.05). The mortality rate in patients with critical DBC category was higher than that in those with severe RAC category (42.1% vs. 24.7%; p = 0.008). POF (OR 19.4, p = 0.001) and IN (OR 11.0, p = 0.025) were independent risk factors for mortality. In tertiary referral setting, patients in the critical category are at the greatest risk for death and should be managed in an intensive care unit. Although IN itself may be less influential on mortality than POF, IN as well as POF should be considered as the key determinants for severity stratification. Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.

  1. [Risk stratified in the National Registry of Acute Coronary Syndromes at the IMSS].

    PubMed

    Borrayo-Sánchez, Gabriela; Madrid-Miller, Alejandra; Arriaga-Nava, Roberto; Ramos-Corrales, Marco Antonio; García-Aguilar, Jorge; Almeida-Gutiérrez, Eduardo

    2010-01-01

    to identify prognostic factors in the National Registry of Acute Coronary Syndromes. patients in medical care units with acute ischemic coronary syndrome (AICS) according to the criteria of the American Heart Association/American College of Cardiology/European Society of Cardiology, considering the GRACE score (GS) were studied. there were 2389 patients, 28.9 % women and 71.1 % men, mean age 63 ± 11.7 years; with AICS with ST-segment elevation (69.11 %) and 30.89 % with AICS without ST elevation. The average of GS was 168. A GS > 150 points in patients with AICS without ST elevation was associated with recurrent ischemia or angina (RR = 1.4, p = 0.05), left ventricular failure (RR = 3.1, p < 0.0001), stroke (RR = 2.9, p = 0.004) and arrhythmias (RR = 2.7, p < 0.0001). The patients with AICS with ST-segment elevation were associated with death (RR = 1.6, p = 0.01), reinfarction (RR = 1.7, p = 0.001), recurrent ischemia (RR = 1.2, p = 0.04), left ventricular failure (RR = 3.4, p < 0.001), stroke (RR = 3.9, p < 0.001) and arrhythmias (RR = 2.3, p < 0.001). Fibrinolytic therapy was used in 40.2 %. There was a negative correlation between GS and fibrinolytic therapy (r -0.04, p = 0.04). the AICS with ST-segment elevation is more frequent and have a high GS.

  2. Kernel machine testing for risk prediction with stratified case cohort studies.

    PubMed

    Payne, Rebecca; Neykov, Matey; Jensen, Majken Karoline; Cai, Tianxi

    2016-06-01

    Large assembled cohorts with banked biospecimens offer valuable opportunities to identify novel markers for risk prediction. When the outcome of interest is rare, an effective strategy to conserve limited biological resources while maintaining reasonable statistical power is the case cohort (CCH) sampling design, in which expensive markers are measured on a subset of cases and controls. However, the CCH design introduces significant analytical complexity due to outcome-dependent, finite-population sampling. Current methods for analyzing CCH studies focus primarily on the estimation of simple survival models with linear effects; testing and estimation procedures that can efficiently capture complex non-linear marker effects for CCH data remain elusive. In this article, we propose inverse probability weighted (IPW) variance component type tests for identifying important marker sets through a Cox proportional hazards kernel machine (CoxKM) regression framework previously considered for full cohort studies (Cai et al., 2011). The optimal choice of kernel, while vitally important to attain high power, is typically unknown for a given dataset. Thus, we also develop robust testing procedures that adaptively combine information from multiple kernels. The proposed IPW test statistics have complex null distributions that cannot easily be approximated explicitly. Furthermore, due to the correlation induced by CCH sampling, standard resampling methods such as the bootstrap fail to approximate the distribution correctly. We, therefore, propose a novel perturbation resampling scheme that can effectively recover the induced correlation structure. Results from extensive simulation studies suggest that the proposed IPW CoxKM testing procedures work well in finite samples. The proposed methods are further illustrated by application to a Danish CCH study of Apolipoprotein C-III markers on the risk of coronary heart disease.

  3. Peripheral blood monocyte gene expression profile clinically stratifies patients with recent-onset type 1 diabetes.

    PubMed

    Irvine, Katharine M; Gallego, Patricia; An, Xiaoyu; Best, Shannon E; Thomas, Gethin; Wells, Christine; Harris, Mark; Cotterill, Andrew; Thomas, Ranjeny

    2012-05-01

    Novel biomarkers of disease progression after type 1 diabetes onset are needed. We profiled peripheral blood (PB) monocyte gene expression in six healthy subjects and 16 children with type 1 diabetes diagnosed ∼3 months previously and analyzed clinical features from diagnosis to 1 year. Monocyte expression profiles clustered into two distinct subgroups, representing mild and severe deviation from healthy control subjects, along the same continuum. Patients with strongly divergent monocyte gene expression had significantly higher insulin dose-adjusted HbA(1c) levels during the first year, compared with patients with mild deviation. The diabetes-associated expression signature identified multiple perturbations in pathways controlling cellular metabolism and survival, including endoplasmic reticulum and oxidative stress (e.g., induction of HIF1A, DDIT3, DDIT4, and GRP78). Quantitative PCR (qPCR) of a 9-gene panel correlated with glycemic control in 12 additional recent-onset patients. The qPCR signature was also detected in PB from healthy first-degree relatives. A PB gene expression signature correlates with glycemic control in the first year after diabetes diagnosis and is present in at-risk subjects. These findings implicate monocyte phenotype as a candidate biomarker for disease progression pre- and postonset and systemic stresses as contributors to innate immune function in type 1 diabetes.

  4. The Impact of Implementation Fidelity on Mortality Under a CD4-Stratified Timing Strategy for Antiretroviral Therapy in Patients With Tuberculosis

    PubMed Central

    Patel, Monita R.; Westreich, Daniel; Yotebieng, Marcel; Nana, Mbonze; Eron, Joseph J.; Behets, Frieda; Van Rie, Annelies

    2015-01-01

    Among patients with tuberculosis and human immunodeficiency virus type 1, CD4-stratified initiation of antiretroviral therapy (ART) is recommended, with earlier ART in those with low CD4 counts. However, the impact of implementation fidelity to this recommendation is unknown. We examined a prospective cohort study of 395 adult patients diagnosed with tuberculosis and human immunodeficiency virus between August 2007 and November 2009 in Kinshasa, Democratic Republic of the Congo. ART was to be initiated after 1 month of tuberculosis treatment at a CD4 count of <100 cells/mm3 or World Health Organization stage 4 (other than extrapulmonary tuberculosis) and after 2 months of tuberculosis treatment at a CD4 count of 100–350 cells/mm3. We used the parametric g-formula to estimate the impact of implementation fidelity on 6-month mortality. Observed implementation fidelity was low (46%); 54% of patients either experienced delays in ART initiation or did not initiate ART, which could be avoided under perfect implementation fidelity. The observed mortality risk was 12.0% (95% confidence interval (CI): 8.2, 15.7); under complete (counterfactual) implementation fidelity, the mortality risk was 7.8% (95% CI: 2.4, 12.3), corresponding to a risk reduction of 4.2% (95% CI: 0.3, 8.1) and a preventable fraction of 35.1% (95% CI: 2.9, 67.9). Strategies to achieve high implementation fidelity to CD4-stratified ART timing are needed to maximize survival benefit. PMID:25787266

  5. Differences in the progesterone receptor contents between familial breast cancers and sporadic breast cancers stratified by patient age.

    PubMed

    Fukutomi, T; Akashi-Tanaka, S

    2001-01-01

    In the present study, we investigated the estrogen (ER) and progesterone receptor (PR) contents of familial breast cancers (FBCs) and compared the findings with those of sporadic breast cancers., stratified by the patients' age. To evaluate the hormone receptor contents of Japanese FBCs, we collected a consecutive series of 250 FBCs and 2,533 sporadic breast cancers (SBCs). These patients were divided into the three groups stratified by the patients' age at initial surgery (group I, under 40 years old; group II, 40-60 years old; group III, over 60 years old). The clinicopathological features of FBCs and SBCs, including ERs and PRs, were analyzed for each group. In all age groups, the PR contents of FBCs were significantly lower than those of SBCs, particularly for group III. In FBCs, the PR content was significantly lower in group III than in groups I or II. In addition, there was a nonsignificant trend towards a high frequency of ER-positive, PR-negative tumors in FBC patients aged 60 years and over. These data indicate that the loss of ER function and/or loss of binding capacity of PR to progesterone was associated with some late-onset FBCS.

  6. Impact of statins therapy on morphological changes in lipid-rich plaques stratified by 10-Year framingham risk score: A serial optical coherence tomography study

    PubMed Central

    Jia, Haibo; Hu, Sining; Li, Lulu; Zhang, Xiling; Zheng, Gonghui; Wang, Yan; Sun, Rong; Afolabi, Abigail; Mustafina, Irina; Hou, Jingbo; Zhang, Shaosong; Yu, Bo

    2017-01-01

    The aim of the study was to investigate the impact of statins therapy on morphological changes of lipid-rich plaques by OCT (optical coherence tomography) in patients with known CHD (coronary heart disease), stratified by FRS. Ninety-seven lipid-rich plaques from sixty-nine patients who received statins therapy and underwent serial OCT images (baseline, 6-month and 12-month) were divided into 2 groups according to the FRS (framingham risk score): low risk group A (FRS<10%, N=35, n=45), moderate to high risk group B (FRS≥10%, N=34, n=52). Fibrous cap thickness (FCT) was measured at its thinnest part 3 times. Baseline characteristics were not different between the 2 groups. FCT sustained increased from baseline to 6-month and 12-month follow up in both group A (59.8±20.4μm, 118.3±62.5μm, and 158.8±83.4μm respectively, P<0.001) and group B (62.2±16.8μm, 125.1±78.7μm, 163.8±75.5μm respectively, P<0.001). Lipid index was significantly decreased in both group A (1862.1±1164.5, 1530.3±1108.7, 1322.9±1080.4, P<0.001) and group B (1646.6±958.5, 1535.1±1049.1, 1258.6±1045, P=0.016). The incidence of TCFA was decreased statistically in both group A (P <0.001) and group B (P <0.001). The patients with known CHD can equivalently benefit from statins therapy by stabilizing the lipid-rich plaques. Patients with moderate to high FRS might benefit more within the first year from event time. PMID:28404965

  7. Non-high-density lipoprotein cholesterol target achievement in patients on lipid-lowering drugs and stratified by triglyceride levels in the Arabian Gulf.

    PubMed

    Al-Hashmi, Khamis; Al-Zakwani, Ibrahim; Al Mahmeed, Wael; Arafah, Mohammed; Al-Hinai, Ali T; Shehab, Abdullah; Al Tamimi, Omer; Al Awadhi, Mahmoud; Al Herz, Shorook; Al Anazi, Faisal; Al Nemer, Khalid; Metwally, Othman; Alkhadra, Akram; Fakhry, Mohammed; Elghetany, Hossam; Medani, Abdel Razak; Yusufali, Afzal Hussein; Al Jassim, Obaid; Al Hallaq, Omar; Baslaib, Fahad Omar Ahmed S; Amin, Haitham; Santos, Raul D; Al-Waili, Khalid; Al-Rasadi, Khalid

    2016-01-01

    Atherogenic dyslipidemia is highly prevalent in the Arabian Gulf. Non-high-density lipoprotein cholesterol (non-HDL-C) reduction has been proposed as an additional goal to low-density lipoprotein cholesterol (LDL-C) lowering to prevent atherosclerotic cardiovascular disease (ASCVD). Data on non-HDL-C goal attainment in patients with high triglycerides (TGs) on lipid-lowering drugs (LLDs) in the region is scarce. Evaluate non-HDL-C target attainment according to the National Lipid Association in patients on LLDs stratified by TG (<150 [1.69], 150-200 [1.69-2.26], >200 [2.26] mg/dL [mmol/L]) levels in the Arabian Gulf. Overall, 4383 patients on LLD treatment from 6 Middle Eastern countries participating in the Centralized Pan-Middle East Survey on the Undertreatment of Hypercholesterolemia study were evaluated. Patients were classified according to TG levels and ASCVD risk. The overall non-HDL-C goal attainment was 41% of the subjects. Non-HDL-C goal was less likely attained in patients with high TGs (12% vs 27% vs 55%; P < .001). Very high ASCVD risk patients with high TGs attained less their non-HDL-C targets compared with those with lower TG levels (8% vs 23% vs 51%; P < .001). Similarly, high ASCVD risk patients with high TGs also failed more in attaining non-HDL-C targets compared with those with lower TGs (26% vs 42% vs 69%; P < .001). In addition, those with high TG also succeeded less in attaining LDL-C and apolipoprotein B goals (P < .001). A large proportion of very high and high ASCVD patients on LLDs in the Arabian Gulf are not at recommended non-HDL-C targets and hence remain at a substantial residual risk. Copyright © 2016 National Lipid Association. Published by Elsevier Inc. All rights reserved.

  8. Alterations in regional homogeneity assessed by fMRI in patients with migraine without aura stratified by disease duration

    PubMed Central

    2013-01-01

    Background Advanced neuroimaging approaches have been employed to prove that migraine was a central nervous system disorder. This study aims to examine resting-state abnormalities in migraine without aura (MWoA) patients stratified by disease duration, and to explore the neuroimaging markers for reflecting the disease duration. Methods 40 eligible MWoA patients and 20 matched healthy volunteers were included in the study. Regional homogeneity (ReHo) analysis was used to identify the local features of spontaneous brain activity in MWoA patients stratified by disease duration, and analysis was performed to investigate the correlation of overlapped brain dysfunction in MWoA patients with different disease duration (long-term and short-term) and course of disease. Results Compared with healthy controls, MWoA patients with long-term disease duration showed comprehensive neuronal dysfunction than patients with short-term disease duration. In addition, increased average ReHo values in the thalamus, brain stem, and temporal pole showed significantly positive correlations with the disease duration. On the contrary, ReHo values were negatively correlated with the duration of disease in the anterior cingulate cortex, insula, posterior cingulate cortex and superior occipital gyrus. Conclusions Our findings of progressive brain damage in relation to increasing disease duration suggest that migraine without aura is a progressive central nervous disease, and the length of the disease duration was one of the key reasons to cause brain dysfunction in MwoA patients. The repeated migraine attacks over time result in resting-state abnormalities of selective brain regions belonging to the pain processing and cognition. We predict that these brain regions are sensitive neuroimaging markers for reflecting the disease duration of migraine patients without aura. PMID:24134520

  9. Alterations in regional homogeneity assessed by fMRI in patients with migraine without aura stratified by disease duration.

    PubMed

    Zhao, Ling; Liu, Jixin; Dong, Xilin; Peng, Yulin; Yuan, Kai; Wu, Fumei; Sun, Jinbo; Gong, Qiyong; Qin, Wei; Liang, Fanrong

    2013-10-17

    Advanced neuroimaging approaches have been employed to prove that migraine was a central nervous system disorder. This study aims to examine resting-state abnormalities in migraine without aura (MWoA) patients stratified by disease duration, and to explore the neuroimaging markers for reflecting the disease duration. 40 eligible MWoA patients and 20 matched healthy volunteers were included in the study. Regional homogeneity (ReHo) analysis was used to identify the local features of spontaneous brain activity in MWoA patients stratified by disease duration, and analysis was performed to investigate the correlation of overlapped brain dysfunction in MWoA patients with different disease duration (long-term and short-term) and course of disease. Compared with healthy controls, MWoA patients with long-term disease duration showed comprehensive neuronal dysfunction than patients with short-term disease duration. In addition, increased average ReHo values in the thalamus, brain stem, and temporal pole showed significantly positive correlations with the disease duration. On the contrary, ReHo values were negatively correlated with the duration of disease in the anterior cingulate cortex, insula, posterior cingulate cortex and superior occipital gyrus. Our findings of progressive brain damage in relation to increasing disease duration suggest that migraine without aura is a progressive central nervous disease, and the length of the disease duration was one of the key reasons to cause brain dysfunction in MwoA patients. The repeated migraine attacks over time result in resting-state abnormalities of selective brain regions belonging to the pain processing and cognition. We predict that these brain regions are sensitive neuroimaging markers for reflecting the disease duration of migraine patients without aura.

  10. Stratified models of care.

    PubMed

    Foster, Nadine E; Hill, Jonathan C; O'Sullivan, Peter; Hancock, Mark

    2013-10-01

    Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions. Copyright © 2013 Elsevier Ltd. All rights reserved.

  11. Risk-Stratified Cardiovascular Screening Including Angiographic and Procedural Outcomes of Percutaneous Coronary Interventions in Renal Transplant Candidates

    PubMed Central

    Möckel, Martin; Mueller, Eda; Bocksch, Wolfgang; Babel, Nina; Schindler, Ralf; Reinke, Petra

    2014-01-01

    Background. Benefits of cardiac screening in kidney transplant candidates (KTC) will be dependent on the availability of effective interventions. We retrospectively evaluated characteristics and outcome of percutaneous coronary interventions (PCI) in KTC selected for revascularization by a cardiac screening approach. Methods. In 267 patients evaluated 2003 to 2006, screening tests performed were reviewed and PCI characteristics correlated with major adverse cardiovascular events (MACE) during a follow-up of 55 months. Results. Stress tests in 154 patients showed ischemia in 28 patients (89% high risk). Of 58 patients with coronary angiography, 38 had significant stenoses and 18 cardiac interventions (6.7% of all). 29 coronary lesions in 17/18 patients were treated by PCI. Angiographic success rate was 93.1%, but procedural success rate was only 86.2%. Long lesions (P = 0.029) and diffuse disease (P = 0.043) were associated with MACE. In high risk patients, cardiac screening did not improve outcome as 21.7% of patients with versus 15.5% of patients without properly performed cardiac screening had MACE (P = 0.319). Conclusion. The moderate procedural success of PCI and poor outcome in long and diffuse coronary lesions underscore the need to define appropriate revascularization strategies in KTC, which will be a prerequisite for cardiac screening to improve outcome in these high-risk patients. PMID:25045528

  12. Sex-Stratified Trends in Enrollment, Patient Characteristics, Treatment, and Outcomes Among Non–ST-Segment Elevation Acute Coronary Syndrome Patients: Insights from Clinical Trials Over 17 Years

    PubMed Central

    Kragholm, Kristian; Halim, Sharif A.; Yang, Qinghong; Schulte, Phillip J.; Hochman, Judith S.; Melloni, Chiara; Mahaffey, Kenneth W.; Moliterno, David J.; Harrington, Robert A.; White, Harvey D.; Armstrong, Paul W.; Ohman, E. Magnus; Van de Werf, Frans; Tricoci, Pierluigi; Alexander, John H.; Giugliano, Robert P.; Newby, L. Kristin

    2015-01-01

    Background Adequate representation by sex in trials allows generalizability of results. We examined representation of women in clinical trials during a 17-year period in which inclusion criteria were broadened and federal mandates for representativeness were launched. Methods and Results Using mixed models, we studied sex-stratified temporal trends in enrollment, clinical characteristics, treatment, and outcomes among 76,148 non–ST-segment elevation (NSTE) acute coronary syndrome (ACS) patients using patient-level data merged from 11 phase III trials conducted from 1994 to 2010. Overall, 33.3% of patients were women, which changed minimally over time. Women were consistently 4–5 years older than men (median age 68 [IQR 61–75] versus 64 [IQR 56–72] years) and more frequently had diabetes, hypertension, and heart failure; men more frequently had prior myocardial infarction and revascularization. GRACE risk scores increased over time for both sexes with the inclusion of older patients with more comorbidities. Use of PCI, in-hospital and discharge angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers, β-blockers, and lipid-lowering drugs also increased among both sexes. Kaplan-Meier estimates of 6-month mortality declined from 7.0% [95% CI 6.5%–7.6%] to 4.5% [95% CI 4.0%–5.0%] among women and 6.3% [95% CI 6.0%–6.7%] to 3.1% [95% CI 2.9%–3.4%] among men during the 17-year period. Conclusions The relative proportion of women in NSTE ACS trials changed minimally over time. Nevertheless, in parallel with men, use of evidence-based care and outcomes improved significantly over time among women. PMID:26152683

  13. Stratifying HPV-positive women for CIN3+ risk after one and two rounds of HPV-based screening.

    PubMed

    Veldhuijzen, Nienke J; Polman, Nicole J; Snijders, Peter J F; Meijer, Chris J L M; Berkhof, Johannes

    2017-10-15

    A main challenge of human papilloma (HPV)-based screening for cervical cancer is to adequately identify HPV-positive women at highest risk of cervical intraepithelial neoplasia grade 3 or worse, CIN3+. The prognostic value of currently used adjunct markers (HPV16/18 genotyping and reflex cytology) may change after multiple rounds of HPV-based screening because of a change in the proportion of HPV-positive women with incident infections. To this end, we re-analyzed results from the POBASCAM trial (Population Based Screening Study Amsterdam). Women were randomized to HPV/cytology cotesting (intervention group) or to cytology-only (HPV blinded; control group) at enrolment. Our analytical population consisted of women with an HPV-positive result at the second round, 5 years after enrolment (n = 381 intervention, n = 392 control). Nine-year CIN3+ risks were estimated by Kaplan-Meier. HPV-positive women were stratified by risk markers: HPV16/18 genotyping, reflex cytology and preceding HPV results. When comparing one to two rounds of HPV-based screening, the prognostic value of an abnormal cytology result did not change (40.0% vs. 42.3%, p = 0.5617), but diminished for an HPV16/18 positive result (25.4% vs. 38.0%, p = 0.0132). HPV16/18 genotyping was nondiscriminative in women with incident HPV infections (HPV16/18 positive 10.0% vs. negative 12.1%, p = 0.3193). Women from the intervention group were more likely to have incident infections compared to women from the control group (incident screen-positive results 75.6% vs. 64.6%, p = 0.001) Our results indicate that at a second round of HPV-based screening, risk differentiation by cytology remained strong, but was diminished for HPV 16/18 genotyping because of a larger proportion of incident infections. © 2017 UICC.

  14. Effects of selective serotonin reuptake inhibitor on treating tinnitus in patients stratified for presence of depression or anxiety.

    PubMed

    Oishi, Naoki; Kanzaki, Sho; Shinden, Seiichi; Saito, Hideyuki; Inoue, Yasuhiro; Ogawa, Kaoru

    2010-01-01

    We evaluated the effects of a selective serotonin reuptake inhibitor, paroxetine, on treating tinnitus.Tinnitus patients stratified for the presence of depression and anxiety were studied retrospectively. Fifty-six patients were observed for more than 6 months. They were initially treated with paroxetine only at a dose of 10 mg/day for 2-4 weeks; thereafter, the dose was increased to 20 mg/day. Tinnitus distress was evaluated with the Tinnitus Handicap Inventory (THI) and with visual analog scales (VASs) for tinnitus loudness and annoyance. Depression and anxiety were measured with the Self-Rating Depression Scale (SDS) and the trait section of the State-Trait Anxiety Inventory (STAI). The patients were grouped according to their SDS and STAI scores, and each variable was compared at baseline and the 6-month follow-up. Changes among these variables were also examined to determine whether reduced tinnitus distress was related to the improvement of depression or anxiety. Patients with both depression and anxiety showed better results (decrease in THI, VASs, SDS and STAI scores) than patients with anxiety alone, or patients without depression and anxiety. In patients with depression and anxiety, changes in tinnitus variables and changes in depression and anxiety scores were strongly correlated. In other patients, however, changes in tinnitus variables and changes in depression and anxiety scores were not correlated. These results suggest that paroxetine is effective in treating distressed tinnitus patients with depression and anxiety by reducing their tinnitus severity as well as their depression and anxiety.

  15. Stroke rehabilitation and risk of mortality: a population-based cohort study stratified by age and gender.

    PubMed

    Hou, Wen-Hsuan; Ni, Cheng-Hua; Li, Chung-Yi; Tsai, Pei-Shan; Lin, Li-Fong; Shen, Hsiu-Nien

    2015-06-01

    To determine the survival of patients with stroke for up to 10 years after a first-time stroke and to investigate whether stroke rehabilitation within the first 3 months reduced long-term mortality in these patients. We used the medical claims data for a random sample of 1 million insured Taiwanese registered in the year 2000. A total of 7767 patients admitted for a first-time stroke between 2000 and 2005; 1285 (16.7%) received rehabilitation within the first 3 months after stroke admission. The other 83.3% of patients served as a comparison cohort. A Cox proportional hazards model was used to estimate the relative risk of mortality in relation to the rehabilitation intervention. In all, 181 patients with rehabilitation and 1123 controls died, representing respective mortality rates of 25.0 and 32.7 per 1000 person-years. Rehabilitation was significantly associated with a lower risk of mortality (hazard ratio .68, 95% confidence interval .58-.79). Such a beneficial effect tended to be more obvious as the frequency of rehabilitation increased (P for the trend <.0001) and was more evident in female patients. Stroke rehabilitation initiated in the first 3 months after a stroke admission may significantly reduce the risk of mortality for 10 years after the stroke. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

  16. Obstacles to the ‘cleanliness of our race’: HIV, reproductive risk, stratified reproduction, and population quality in Hanoi, Vietnam

    PubMed Central

    Hong, Khuat Thu; Nhan, Vu Thi Thanh; Thao, Nguyen Thi Phuong; Hirsch, Jennifer S.

    2013-01-01

    This paper focuses on the interactions between medical professionals in Hanoi, Vietnam and their HIV-positive patients who desire children. Drawing on ethnographic research, we argue that despite ongoing state and civil society efforts to reduce discrimination against people living with HIV (PLHIV), doctors do stigmatize patients who choose to reproduce, even if the patients are found to have carefully considered all associated risks. While the effects of the Social Evils Campaign linger, the doctors’ prejudicial stance towards PLHIV’s reproductive desires and risks also reflects the messages communicated by the more recent governmental campaign on Population Quality. The result of this stigmatization is a stratification of reproduction among the Vietnamese citizenry whereby PLHIV are considered obstacles to ‘the cleanliness of the race’. PMID:25378810

  17. Obstacles to the 'cleanliness of our race': HIV, reproductive risk, stratified reproduction, and population quality in Hanoi, Vietnam.

    PubMed

    Phinney, Harriet M; Hong, Khuat Thu; Nhan, Vu Thi Thanh; Thao, Nguyen Thi Phuong; Hirsch, Jennifer S

    2014-01-01

    This paper focuses on the interactions between medical professionals in Hanoi, Vietnam and their HIV-positive patients who desire children. Drawing on ethnographic research, we argue that despite ongoing state and civil society efforts to reduce discrimination against people living with HIV (PLHIV), doctors do stigmatize patients who choose to reproduce, even if the patients are found to have carefully considered all associated risks. While the effects of the Social Evils Campaign linger, the doctors' prejudicial stance towards PLHIV's reproductive desires and risks also reflects the messages communicated by the more recent governmental campaign on Population Quality. The result of this stigmatization is a stratification of reproduction among the Vietnamese citizenry whereby PLHIV are considered obstacles to 'the cleanliness of the race'.

  18. A score to predict and stratify risk of tuberculosis in adult contacts of tuberculosis index cases: a prospective derivation and external validation cohort study.

    PubMed

    Saunders, Matthew J; Wingfield, Tom; Tovar, Marco A; Baldwin, Matthew R; Datta, Sumona; Zevallos, Karine; Montoya, Rosario; Valencia, Teresa R; Friedland, Jon S; Moulton, Larry H; Gilman, Robert H; Evans, Carlton A

    2017-08-18

    Contacts of tuberculosis index cases are at increased risk of developing tuberculosis. Screening, preventive therapy, and surveillance for tuberculosis are underused interventions in contacts, particularly adults. We developed a score to predict risk of tuberculosis in adult contacts of tuberculosis index cases. In 2002-06, we recruited contacts aged 15 years or older of index cases with pulmonary tuberculosis who lived in desert shanty towns in Ventanilla, Peru. We followed up contacts for tuberculosis until February, 2016. We used a Cox proportional hazards model to identify index case, contact, and household risk factors for tuberculosis from which to derive a score and classify contacts as low, medium, or high risk. We validated the score in an urban community recruited in Callao, Peru, in 2014-15. In the derivation cohort, we identified 2017 contacts of 715 index cases, and median follow-up was 10·7 years (IQR 9·5-11·8). 178 (9%) of 2017 contacts developed tuberculosis during 19 147 person-years of follow-up (incidence 0·93 per 100 person-years, 95% CI 0·80-1·08). Risk factors for tuberculosis were body-mass index, previous tuberculosis, age, sustained exposure to the index case, the index case being in a male patient, lower community household socioeconomic position, indoor air pollution, previous tuberculosis among household members, and living in a household with a low number of windows per room. The 10-year risks of tuberculosis in the low-risk, medium-risk, and high-risk groups were, respectively, 2·8% (95% CI 1·7-4·4), 6·2% (4·8-8·1), and 20·6% (17·3-24·4). The 535 (27%) contacts classified as high risk accounted for 60% of the tuberculosis identified during follow-up. The score predicted tuberculosis independently of tuberculin skin test and index-case drug sensitivity results. In the external validation cohort, 65 (3%) of 1910 contacts developed tuberculosis during 3771 person-years of follow-up (incidence 1·7 per 100 person-years, 95

  19. Androgen receptor expression predicts different clinical outcomes for breast cancer patients stratified by hormone receptor status

    PubMed Central

    Xu, Yan; Zheng, Yi-Zi; Liu, Yi-Rong; Lang, Guan-Tian; Qiao, Feng; Hu, Xin; Shao, Zhi-Ming

    2016-01-01

    In this study we sought to correlate androgen receptor (AR) expression with tumor progression and disease-free survival (DFS) in breast cancer patients. We investigated AR expression in 450 breast cancer patients. We found that breast cancers expressing the estrogen receptor (ER) are more likely to co-express AR compared to ER-negative cancers (56.0% versus 28.1%, P < 0.001). In addition, we found that AR expression is correlated with increased DFS in patients with luminal breast cancer (P < 0.001), and decreased DFS in TNBC (triple negative breast cancer, P = 0.014). In addition, patients with HR+ tumors (Hormone receptor positive tumors) expressing low levels of AR have the lowest DFS among all receptor combinations. We also propose a novel prognostic model using AR receptor status, BRCA1, and present data showing that our model is more predictive of disease free survival compared to the traditional TMN staging system. PMID:27285752

  20. Aligning the economic value of companion diagnostics and stratified medicines.

    PubMed

    Blair, Edward D; Stratton, Elyse K; Kaufmann, Martina

    2012-11-26

    The twin forces of payors seeking fair pricing and the rising costs of developing new medicines has driven a closer relationship between pharmaceutical companies and diagnostics companies, because stratified medicines, guided by companion diagnostics, offer better commercial, as well as clinical, outcomes. Stratified medicines have created clinical success and provided rapid product approvals, particularly in oncology, and indeed have changed the dynamic between drug and diagnostic developers. The commercial payback for such partnerships offered by stratified medicines has been less well articulated, but this has shifted as the benefits in risk management, pricing and value creation for all stakeholders become clearer. In this larger healthcare setting, stratified medicine provides both physicians and patients with greater insight on the disease and provides rationale for providers to understand cost-effectiveness of treatment. This article considers how the economic value of stratified medicine relationships can be recognized and translated into better outcomes for all healthcare stakeholders.

  1. Aligning the Economic Value of Companion Diagnostics and Stratified Medicines

    PubMed Central

    Blair, Edward D.; Stratton, Elyse K.; Kaufmann, Martina

    2012-01-01

    The twin forces of payors seeking fair pricing and the rising costs of developing new medicines has driven a closer relationship between pharmaceutical companies and diagnostics companies, because stratified medicines, guided by companion diagnostics, offer better commercial, as well as clinical, outcomes. Stratified medicines have created clinical success and provided rapid product approvals, particularly in oncology, and indeed have changed the dynamic between drug and diagnostic developers. The commercial payback for such partnerships offered by stratified medicines has been less well articulated, but this has shifted as the benefits in risk management, pricing and value creation for all stakeholders become clearer. In this larger healthcare setting, stratified medicine provides both physicians and patients with greater insight on the disease and provides rationale for providers to understand cost-effectiveness of treatment. This article considers how the economic value of stratified medicine relationships can be recognized and translated into better outcomes for all healthcare stakeholders. PMID:25562363

  2. Serum C-reactive protein level in COPD patients stratified according to GOLD 2011 grading classification

    PubMed Central

    Lin, Yi-Hua; Wang, Wan-Yu; Hu, Su-Xian; Shi, Yong-Hong

    2016-01-01

    Background and Objective: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 grading classification has been used to evaluate the severity of patients with chronic obstructive pulmonary disease (COPD). However, little is known about the relationship between the systemic inflammation and this classification. We aimed to study the relationship between serum CRP and the components of the GOLD 2011 grading classification. Methods: C-reactive protein (CRP) levels were measured in 391 clinically stable COPD patients and in 50 controls from June 2, 2015 to October 31, 2015 in the First Affiliated Hospital of Xiamen University. The association between CRP levels and the components of the GOLD 2011 grading classification were assessed. Results: Correlation was found with the following variables: GOLD 2011 group (0.240), age (0.227), pack year (0.136), forced expiratory volume in one second % predicted (FEV1%; -0.267), forced vital capacity % predicted (-0.210), number of acute exacerbations in the past year (0.265), number of hospitalized exacerbations in the past year (0.165), British medical Research Council dyspnoea scale (0.121), COPD assessment test score (CAT, 0.233). Using multivariate analysis, FEV1% and CAT score manifested the strongest negative association with CRP levels. Conclusions: CRP levels differ in COPD patients among groups A-D based on GOLD 2011 grading classification. CRP levels are associated with several important clinical variables, of which FEV1% and CAT score manifested the strongest negative correlation. PMID:28083044

  3. Axl Expression Stratifies Patients with Poor Prognosis after Hepatectomy for Hepatocellular Carcinoma

    PubMed Central

    Xia, Yong; Li, Jun; Shi, Lehua; Zou, Qifei; Wan, Xuying; Jiao, Binghua; Wang, Hongyang; Wu, Mengchao; Zhang, Yongjie; Shen, Feng

    2016-01-01

    Background Axl is a receptor tyrosine kinase which plays an important role in multiple human malignancies. Design The Axl expression was examined in several hepatocellular carcinoma(HCC) cell lines, paired tumor and nontumorous samples. Then, we examined cell growth curve, cell apoptosis and cell migration in SMMC-7721 cells over-expressed with Axl or siRNA against Axl, respectively. Finally, the prognostic value of Axl was investigated in a prospective cohort of 246 consecutive HCC patients undergoing curative hepatoectomy. Results We found Axl was positive in 22% of examined tumor tissues and all four cell lines. Over-expressing Axl in SMMC-7721 cells accelerated cell growth, cell migration and inhibited cell apoptosis, while knock-down of Axl exerted opposite effect. Axl expression was closely associated with serum AFP, multiple tumors, absence of encapsulation, microvascular invasion, and advanced BCLC or TNM stage. Patients with positive Axl staining had a higher 5-year recurrence rate (92% vs. 71%, P<0.001) and a lower 5-year survival rate (9% vs. 48%, P<0.001) than those with negative staining. The multivariate analyses showed that Axl expression was an independent factor for both tumor recurrence (HR: 1.725; 95% CI: 1.219–2.441) and survival (1.847; 1.291–2.642). Conclusion Axl expression suggests more aggressive tumor invasiveness and predicts worse prognosis for HCC patients undergoing resection. PMID:27182739

  4. Risk of intravenous contrast material-mediated acute kidney injury: a propensity score-matched study stratified by baseline-estimated glomerular filtration rate.

    PubMed

    McDonald, Jennifer S; McDonald, Robert J; Carter, Rickey E; Katzberg, Richard W; Kallmes, David F; Williamson, Eric E

    2014-04-01

    To determine the effect of baseline estimated glomerular filtration rate (eGFR) on the causal association between intravenous iodinated contrast material exposure and subsequent development of acute kidney injury (AKI) in propensity score-matched groups of patients who underwent contrast material-enhanced or unenhanced computed tomography (CT). This retrospective study was HIPAA compliant and institutional review board approved. All patients who underwent contrast-enhanced (contrast material group) or unenhanced (non-contrast material group) CT between 2000 and 2010 were identified and stratified according to baseline eGFR by using Kidney Disease Outcomes Quality Initiative cutoffs for chronic kidney disease into subgroups with eGFR of 90 or greater, 60-89, 30-59, and less than 30 mL/min/1.73 m(2). Propensity score generation and 1:1 matching of patients were performed in each eGFR subgroup. Incidence of AKI (serum creatinine [SCr] increase of ≥0.5 mg/dL [≥44.2 μmol/L] above baseline) was compared in the matched subgroups by using the Fisher exact test. A total of 12 508 propensity score-matched patients with contrast-enhanced and unenhanced scans met all inclusion criteria. In this predominantly inpatient cohort, the incidence of AKI significantly increased with decreasing baseline eGFR (P < .0001). However, this incidence was not significantly different between contrast material and non-contrast material groups in any eGFR subgroup; for the subgroup with eGFR of 90 or greater (n = 1642), odds ratio (OR) was 0.91 (95% confidence interval [CI]: 0.38, 2.15), P = .82; for the subgroup with eGFR of 60-89 (n = 3870), OR was 1.03 (95% CI: 0.66, 1.60), P = .99; for the subgroup with eGFR of 30-59 (n = 5510), OR was 0.94 (95% CI: 0.76, 1.18), P = .65; and for the subgroup with eGFR of less than 30 mL/min/1.73 m(2) (n = 1486), OR was 0.97 (95% CI: 0.72, 1.30), P = .89. Diminished eGFR is associated with an increased risk of SCr-defined AKI following CT examinations

  5. ECG-based estimation of dispersion of APD restitution as a tool to stratify sotalol-induced arrhythmic risk

    PubMed Central

    Mincholé, A.; Bueno-Orovio, A.; Laguna, P.; Pueyo, E.; Rodriguez, B.

    2015-01-01

    Background Increased spatial dispersion of restitution properties has been associated to arrhythmic risk. An ECG-based index quantifying restitution dispersion, DRest, is evaluated in patients who experienced Torsades de Pointes (TdP) under sotalol challenge and compared with the response in healthy subjects. Methods and Results ECG recordings were analyzed for quantification of DRest and QTc, among others biomarkers. DRest provides improved discrimination following sotalol administration between TdP and healthy subjects ([min–max]: [0.18–0.22] vs [0.02–0.12]), compared to other biomarkers including QTc ([436–548 ms] vs [376–467 ms]). Results in healthy subjects are in agreement with simulations of sotalol effects on a human tissue electrophysiological model. Conclusions This case study supports the potential of DRest for improved arrhythmia risk stratification even with QTc values below 450 ms. PMID:26117457

  6. The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581).

    PubMed

    Foster, Nadine E; Konstantinou, Kika; Lewis, Martyn; Ogollah, Reuben; Dunn, Kate M; van der Windt, Danielle; Beardmore, Ruth; Artus, Majid; Bartlam, Bernadette; Hill, Jonathan C; Jowett, Sue; Kigozi, Jesse; Mallen, Christian; Saunders, Benjamin; Hay, Elaine M

    2017-04-26

    Sciatica has a substantial impact on patients, and is associated with high healthcare and societal costs. Although there is variation in the clinical management of sciatica, the current model of care usually involves an initial period of 'wait and see' for most patients, with simple measures of advice and analgesia, followed by conservative and/or more invasive interventions if symptoms fail to resolve. A model of care is needed that does not over-treat those with a good prognosis yet identifies patients who do need more intensive treatment to help with symptoms, and return to everyday function including work. The aim of the SCOPiC trial (SCiatica Outcomes in Primary Care) is to establish whether stratified care based on subgrouping using a combination of prognostic and clinical information, with matched care pathways, is more effective than non-stratified care, for improving time to symptom resolution in patients consulting with sciatica in primary care. We will also assess the impact of stratified care on service delivery and evaluate its cost-effectiveness compared to non-stratified care. Multicentre, pragmatic, parallel arm randomised trial, with internal pilot, cost-effectiveness analysis and embedded qualitative study. We will recruit 470 adult patients with sciatica from general practices in England and Wales, over 24 months. Patients will be randomised to stratified care or non-stratified care, and treated in physiotherapy and spinal specialist services, in participating NHS services. The primary outcome is time to first resolution of sciatica symptoms, measured on a 6-point ordered categorical scale, collected using text messaging. Secondary outcomes include physical function, pain intensity, quality of life, work loss, healthcare use and satisfaction with treatment, and will be collected using postal questionnaires at 4 and 12-month follow-up. Semi-structured qualitative interviews with a subsample of participants and clinicians will explore the

  7. Stratified analysis of 800 Asian patients after robot-assisted radical prostatectomy with a median 64 months of follow up.

    PubMed

    Abdel Raheem, Ali; Kim, Dae Keun; Santok, Glen Denmer; Alabdulaali, Ibrahim; Chung, Byung Ha; Choi, Young Deuk; Rha, Koon Ho

    2016-09-01

    To report the 5-year oncological outcomes of robot-assisted radical prostatectomy from the largest series ever reported from Asia. A retrospective analysis of 800 Asian patients who were treated with robot-assisted radical prostatectomy from July 2005 to May 2010 in the Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea was carried out. The primary end-point was to evaluate the biochemical recurrence. The secondary end-point was to show the biochemical recurrence-free survival, metastasis-free survival and cancer-specific survival. A total of 197 (24.65%), 218 (27.3%), and 385 (48.1%) patients were classified as low-, intermediate- and high-risk patients according to the D'Amico risk stratification risk criteria, respectively. The median follow-up period was 64 months (interquartile range 28-71 months). The overall incidence of positive surgical margin was 36.6%. There was biochemical recurrence in 183 patients (22.9%), 38 patients (4.8%) developed distant metastasis and 24 patients (3%) died from prostate cancer. Actuarial biochemical recurrence-free survival, metastasis-free survival, and cancer-specific survival rates at 5 years were 76.4%, 94.6% and 96.7%, respectively. Positive lymph node was associated with lower 5-year biochemical recurrence-free survival (9.1%), cancer-specific survival (75.7%) and metastasis-free survival (61.9%) rates (P < 0.001). On multivariable analysis, among all the predictors, positive lymph node was the strongest predictor of biochemical recurrence, cancer-specific survival and metastasis-free survival (P < 0.001). Herein we report the largest robot-assisted radical prostatectomy series from Asia. Robot-assisted radical prostatectomy is confirmed to be an oncologically safe procedure that is able to provide effective 5-year cancer control, even in patients with high-risk disease. © 2016 The Japanese Urological Association.

  8. Two-year clinical outcomes of Absorb bioresorbable vascular scaffold implantation in complex coronary artery disease patients stratified by SYNTAX score and ABSORB II study enrolment criteria.

    PubMed

    Kraak, Robin P; Grundeken, Maik J; Hassell, Mariëlla E; Elias, Joëlle; Koch, Karel T; Henriques, José P; Piek, Jan J; Baan, Jan; Vis, Marije M; Tijssen, Jan G P; de Winter, Robbert J; Wykrzykowska, Joanna J

    2016-08-05

    This study presents the two-year clinical outcomes of the Amsterdam ABSORB registry stratified by lesion and patient characteristics complexity (SYNTAX score and ABSORB II study enrolment criteria). Patients treated with BVS were included in this prospective registry and stratified according to the ABSORB II trial inclusion and exclusion criteria and the SYNTAX score. The registry comprises 135 patients (59±11 years, 73% male, 18% diabetic) with 159 lesions. Median follow-up duration was 774 days (742-829). Median SYNTAX score was 11.5 (Q1-Q3: 6-17.5). Two-year event rates were cardiac death 0.7%, MI 5.3%, TVR 13.6%, TLR 11.4%, definite ST 3.0% and TVF 14.4%, respectively. Stratified analyses showed a significantly higher revascularisation rate in patients not meeting ABSORB II criteria (TVR: 2.3% vs. 19.2%, p=0.010, and TLR: 2.3% vs. 15.8%, p=0.025) and patients with SYNTAX score ≥11.5 (TVR: 4.8% vs. 21.8%, p=0.006, and TLR: 3.2% vs. 17.4%, p=0.007). The use of Absorb BVS in patients meeting the ABSORB II trial inclusion criteria or those with low SYNTAX scores is associated with acceptable clinical outcomes at two-year follow-up. Patients with more complex characteristics have significantly higher revascularisation rates.

  9. Risk-stratified staging in paediatric hepatoblastoma: a unified analysis from the Children's Hepatic tumors International Collaboration.

    PubMed

    Meyers, Rebecka L; Maibach, Rudolf; Hiyama, Eiso; Häberle, Beate; Krailo, Mark; Rangaswami, Arun; Aronson, Daniel C; Malogolowkin, Marcio H; Perilongo, Giorgio; von Schweinitz, Dietrich; Ansari, Marc; Lopez-Terrada, Dolores; Tanaka, Yukichi; Alaggio, Rita; Leuschner, Ivo; Hishiki, Tomoro; Schmid, Irene; Watanabe, Kenichiro; Yoshimura, Kenichi; Feng, Yurong; Rinaldi, Eugenia; Saraceno, Davide; Derosa, Marisa; Czauderna, Piotr

    2017-01-01

    Comparative assessment of treatment results in paediatric hepatoblastoma trials has been hampered by small patient numbers and the use of multiple disparate staging systems by the four major trial groups. To address this challenge, we formed a global coalition, the Children's Hepatic tumors International Collaboration (CHIC), with the aim of creating a common approach to staging and risk stratification in this rare cancer. The CHIC steering committee-consisting of leadership from the four major cooperative trial groups (the International Childhood Liver Tumours Strategy Group, Children's Oncology Group, the German Society for Paediatric Oncology and Haematology, and the Japanese Study Group for Paediatric Liver Tumours)-created a shared international database that includes comprehensive data from 1605 children treated in eight multicentre hepatoblastoma trials over 25 years. Diagnostic factors found to be most prognostic on initial analysis were PRETreatment EXTent of disease (PRETEXT) group; age younger than 3 years, 3-7 years, and 8 years or older; α fetoprotein (AFP) concentration of 100 ng/mL or lower and 101-1000 ng/mL; and the PRETEXT annotation factors metastatic disease (M), macrovascular involvement of all hepatic veins (V) or portal bifurcation (P), contiguous extrahepatic tumour (E), multifocal tumour (F), and spontaneous rupture (R). We defined five clinically relevant backbone groups on the basis of established prognostic factors: PRETEXT I/II, PRETEXT III, PRETEXT IV, metastatic disease, and AFP concentration of 100 ng/mL or lower at diagnosis. We then carried the additional factors into a hierarchical backwards elimination multivariable analysis and used the results to create a new international staging system. Within each backbone group, we identified constellations of factors that were most predictive of outcome in that group. The robustness of candidate models was then interrogated using the bootstrapping procedure. Using the clinically

  10. Economics of stratified medicine in rheumatoid arthritis.

    PubMed

    Gavan, Sean; Harrison, Mark; Iglesias, Cynthia; Barton, Anne; Manca, Andrea; Payne, Katherine

    2014-12-01

    Clinically relevant examples of stratified medicine are available for patients with rheumatoid arthritis (RA). The aim of this study was to understand the current economic evidence for stratified medicine in RA. Two systematic reviews were conducted to identify: (1) all economic evaluations of stratified treatments for rheumatoid arthritis, or those which have used a subgroup analysis, and (2) all stated preference studies of treatments for rheumatoid arthritis. Ten economic evaluations of stratified treatments for RA, 38 economic evaluations including with a subgroup analysis and eight stated preference studies were identified. There was some evidence to support that stratified approaches to treating a patient with RA may be cost-effective. However, there remain key gaps in the economic evidence base needed to support the introduction of stratified medicine in RA into healthcare systems and considerable uncertainty about how proposed stratified approaches will impact future patient preferences, outcomes and costs when used in routine practice.

  11. Genetic Determinants of Parkinson's Disease: Can They Help to Stratify the Patients Based on the Underlying Molecular Defect?

    PubMed Central

    Redenšek, Sara; Trošt, Maja; Dolžan, Vita

    2017-01-01

    Parkinson's disease (PD) is a sporadic progressive neurodegenerative brain disorder with a relatively strong genetic background. We have reviewed the current literature about the genetic factors that could be indicative of pathophysiological pathways of PD and their applications in everyday clinical practice. Information on novel risk genes is coming from several genome-wide association studies (GWASs) and their meta-analyses. GWASs that have been performed so far enabled the identification of 24 loci as PD risk factors. These loci take part in numerous cellular processes that may contribute to PD pathology: protein aggregation, protein, and membrane trafficking, lysosomal autophagy, immune response, synaptic function, endocytosis, inflammation, and metabolic pathways are among the most important ones. The identified single nucleotide polymorphisms are usually located in the non-coding regions and their functionality remains to be determined, although they presumably influence gene expression. It is important to be aware of a very low contribution of a single genetic risk factor to PD development; therefore, novel prognostic indices need to account for the cumulative nature of genetic risk factors. A better understanding of PD pathophysiology and its genetic background will help to elucidate the underlying pathological processes. Such knowledge may help physicians to recognize subjects with the highest risk for the development of PD, and provide an opportunity for the identification of novel potential targets for neuroprotective treatment. Moreover, it may enable stratification of the PD patients according to their genetic fingerprint to properly personalize their treatment as well as supportive measures. PMID:28239348

  12. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient

    PubMed Central

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

    2017-01-01

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

  13. Patients at High-Risk for Surgical Site Infection.

    PubMed

    Mueck, Krislynn M; Kao, Lillian S

    Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes. Review of the pertinent English-language literature. High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications. Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.

  14. A dengue vector surveillance by human population-stratified ovitrap survey for Aedes (Diptera: Culicidae) adult and egg collections in high dengue-risk areas of Taiwan.

    PubMed

    Wu, Huai-Hui; Wang, Chih-Yuan; Teng, Hwa-Jen; Lin, Cheo; Lu, Liang-Chen; Jian, Shu-Wan; Chang, Niann-Tai; Wen, Tzai-Hung; Wu, Jhy-Wen; Liu, Ding-Ping; Lin, Li-Jen; Norris, Douglas E; Wu, Ho-Sheng

    2013-03-01

    Aedes aegypti L. is the primary dengue vector in southern Taiwan. This article is the first report on a large-scale surveillance program to study the spatial-temporal distribution of the local Ae. aegytpi population using ovitraps stratified according to the human population in high dengue-risk areas. The sampling program was conducted for 1 yr and was based on weekly collections of eggs and adults in Kaohsiung City. In total, 10,380 ovitraps were placed in 5,190 households. Paired ovitraps, one indoors and one outdoors were used per 400 people. Three treatments in these ovitraps (paddle-shaped wooden sticks, sticky plastic, or both) were assigned by stratified random sampling to two areas (i.e., metropolitan or rural, respectively). We found that the sticky plastic alone had a higher sensitivity for detecting the occurrence of indigenous dengue cases than other treatments with time lags of up to 14 wk. The wooden paddle alone detected the oviposition of Ae. aegypti throughout the year in this study area. Furthermore, significantly more Ae. aegypti females were collected indoors than outdoors. Therefore, our survey identified the whole year oviposition activity, spatial-temporal distribution of the local Ae. aegypti population and a 14 wk lag correlation with dengue incidence to plan an effectively proactive control.

  15. Age-stratified 5-year risks of cervical precancer among women with enrollment and newly detected HPV infection.

    PubMed

    Gage, Julia C; Katki, Hormuzd A; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas; Cheung, Li C; Castle, Philip E; Kinney, Walter K

    2015-04-01

    It is unclear whether a woman's age influences her risk of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) upon detection of HPV. A large change in risk as women age would influence vaccination and screening policies. Among 972,029 women age 30-64 undergoing screening with Pap and HPV testing (Hybrid Capture 2, Qiagen, Germantown, MD) at Kaiser Permanente Northern California (KPNC), we calculated age-specific 5-year CIN3+ risks among women with HPV infections detected at enrollment, and among women with "newly detected" HPV infections at their second screening visit. Women (57,899, 6.0%) had an enrollment HPV infection. Among the women testing HPV negative at enrollment with a second screening visit, 16,724 (3.3%) had a newly detected HPV infection at their second visit. Both enrollment and newly detected HPV rates declined with age (p < 0.001). Women with enrollment versus newly detected HPV infection had higher 5-year CIN3+ risks: 8.5% versus 3.9%, (p < 0.0001). Risks did not increase with age but declined slightly from 30-34 years to 60-64 years: 9.4% versus 7.4% (p = 0.017) for enrollment HPV and 5.1% versus 3.5% (p = 0.014) for newly detected HPV. Among women age 30-64 in an established screening program, women with newly detected HPV infections were at lower risk than women with enrollment infections, suggesting reduced benefit vaccinating women at older ages. Although the rates of HPV infection declined dramatically with age, the subsequent CIN3+ risks associated with HPV infection declined only slightly. The CIN3+ risks among older women are sufficiently elevated to warrant continued screening through age 65.

  16. Age-Stratified 5-Year Risks of Cervical Precancer among Women with Enrollment and Newly Detected HPV Infection

    PubMed Central

    Gage, Julia C.; Katki, Hormuzd A.; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy E.; Lorey, Thomas; Cheung, Li C.; Castle, Philip E.; Kinney, Walter K.

    2014-01-01

    It is unclear whether a woman's age influences her risk of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) upon detection of HPV. A large change in risk as women age would influence vaccination and screening policies. Among 972,029 women age 30-64 undergoing screening with Pap and HPV testing (Hybrid Capture 2, Qiagen, Germantown, MD, USA) at Kaiser Permanente Northern California (KPNC), we calculated age-specific 5-year CIN3+ risks among women with HPV infections detected at enrollment, and among women with “newly detected” HPV infections at their second screening visit. 57,899 women (6.0%) had an enrollment HPV infection. Among the women testing HPV negative at enrollment with a second screening visit, 16,724 (3.3%) had a newly detected HPV infection at their second visit. Both enrollment and newly detected HPV rates declined with age (p<.001). Women with enrollment vs. newly detected HPV infection had higher 5-year CIN3+ risks: 8.5% vs. 3.9%, (p<.0001). Risks did not increase with age but declined slightly from 30-34 years to 60-64 years: 9.4% vs. 7.4% (p=0.017) for enrollment HPV and 5.1% vs. 3.5% (p=0.014) for newly detected HPV. Among women age 30-64 in an established screening program, women with newly detected HPV infections were at lower risk than women with enrollment infections, suggesting reduced benefit vaccinating women at older ages. Although the rates of HPV infection declined dramatically with age, the subsequent CIN3+ risks associated with HPV infection declined only slightly. The CIN3+ risks among older women are sufficiently elevated to warrant continued screening through age 65. PMID:25136967

  17. Limitations of EuroSCORE for measurement of risk-stratified mortality in aortic arch surgery using selective cerebral perfusion: is advanced age no longer a risk?

    PubMed

    Matsuura, Kaoru; Ogino, Hitoshi; Matsuda, Hitoshi; Minatoya, Kenji; Sasaki, Hiroaki; Yagihara, Toshikatsu; Kitamura, Soichiro

    2006-06-01

    The European system for cardiac operative risk evaluation (EuroSCORE) is a risk stratification tool for perioperative mortality of cardiothoracic surgery that was developed in Europe and validated in North America in more than 500,000 patients. The operative mortality of aortic arch surgery has been improved by various novel operative techniques and adjuncts, whereas the number of such procedures for elderly patients has recently been increasing. The aim of this study was to examine the usefulness of the EuroSCORE, and our modification of it regarding age, in predicting mortality after aortic arch repair performed with selective cerebral perfusion. We reviewed 358 consecutive patients with a mean age of 69 +/- 10 years undergoing aortic arch repair with selective cerebral perfusion between January 1993 and February 2004. Observed in-hospital mortality was compared with predicted mortality as determined by both additive and logistic EuroSCOREs. We also evaluated a version of the EuroSCORE modified for age, which was obtained by subtracting the contribution of age from the original EuroSCORE. Score validities were assessed by calculating the areas under receiver operating characteristic curves. Overall hospital mortality was 6.2% compared with 7.7% (additive EuroSCORE) and 11.8% (logistic EuroSCORE). Area under the receiver operating characteristic curve was 0.58 for the additive EuroSCORE and 0.58 for the logistic EuroSCORE as well. The overall age-unrelated EuroSCOREs were 5.1% (additive) and 5.2% (logistic), respectively, and areas under the receiver operating characteristic curve were 0.70 for additive and 0.69 for logistic. The original additive and logistic EuroSCOREs overpredicted mortality in this patient group, whereas the age-unrelated EuroSCORE was better in predicting mortality.

  18. Identifying patients at risk for recurrent or advanced BCC.

    PubMed

    Hamid, Omid; Goldenberg, Gary

    2013-11-01

    Basal cell carcinoma (BCC) is a common skin cancer and its incidence is on the rise worldwide. Clinical presentation and histologic examination are used for diagnosis and to stratify BCCs as either low- or high-risk for recurrence or development of advanced disease. A number of surgical and nonsurgical options are available for BCC. BCC is most often managed with a surgical approach, but not all tumors and patients are suitable for surgery. Vismodegib is a recently approved first-in-class hedgehog pathway inhibitor that has expanded options for patients who have locally advanced or metastatic BCC.

  19. Risks of general anesthesia for the special needs dental patient.

    PubMed

    Messieha, Zakaria

    2009-01-01

    The risk of dental rehabilitation under general anesthesia has multiple contributing factors. The literature has addressed the general anesthetic risk of dental general anesthesia and sedation in the operating room and the office settings, but more studies are needed to address the special needs population in particular. There is still a great need for more studies to assess the risk versus benefit for special need population as well as to stratify such risk in order to assist care providers in decision making as well as in sharing such risk concerns with patients, caretakers, and guardians. One recommended approach is to conduct a national retrospective study of patients treated under general anesthesia in the past 10 years in all the various settings and assess the associated risks and complications related to their physical status and the underlying physical and mental disabilities. The product of such a study could be a stratification of risk versus benefit as well as some guidelines for decision making as far as which kind of procedures should be conducted under general anesthesia while weighing the level of risk for the particular patient. Although access to care is not a direct risk factor, it can certainly deter timely treatment and intervention for patients with special needs.

  20. Endovascular thrombectomy for acute ischemic stroke in failed intravenous tissue plasminogen activator versus non-intravenous tissue plasminogen activator patients: revascularization and outcomes stratified by the site of arterial occlusions.

    PubMed

    Shi, Zhong-Song; Loh, Yince; Walker, Gary; Duckwiler, Gary R

    2010-06-01

    Intracranial mechanical thrombectomy is a therapeutic option for acute ischemic stroke patients failing intravenous tissue plasminogen activator (IV tPA). We compared patients treated by mechanical embolus removal in cerebral ischemia (MERCI) thrombectomy after failed IV tPA with those treated with thrombectomy alone. We pooled MERCI and Multi MERCI study patients, grouped them either as failed IV tPA or non-IV tPA, and assessed revascularization rates, procedural complications, symptomatic hemorrhage rates, clinical outcomes, and mortality. We also evaluated outcomes stratified by the occlusion site and final revascularization. Among 305 patients, 48 failed, and 257 were ineligible for IV tPA. Nonresponders to IV tPA trended toward a higher revascularization rate (73% versus 63%) and less mortality (27.7% versus 40.1%) and had similar rates of symptomatic hemorrhage and procedural complications. Favorable 90-day outcomes were similar in failed and non-IV tPA patients (38% versus 31%), with no difference according to occlusion site. Among patients failing IV tPA, good outcomes tended to occur more frequently in revascularized patients (47.1% versus 15.4%), although this relationship was attributable solely to middle cerebral artery and not internal carotid artery occlusions, with no difference in mortality. Among IV tPA-ineligible patients, revascularization correlated with good outcome (47.4% versus 4.4%) and less mortality (28.5% versus 59.6%). The risks of hemorrhage and procedure-related complications after mechanical thrombectomy do not differ with respect to previous IV tPA administration. Thrombectomy after IV tPA achieves similar rates of good outcomes, a tendency toward lower mortality, and similar revascularization rates when stratified by clot location. Good outcomes correlate with successful revascularization except with internal carotid artery occlusions in tPA-nonresponders.

  1. Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

    PubMed

    Hewner, Sharon; Wu, Yow-Wu Bill; Castner, Jessica

    2016-01-01

    Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

  2. Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

    PubMed

    Hewner, Sharon; Wu, Yow-Wu Bill; Castner, Jessica

    2015-03-06

    Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

  3. Patient risk from interproximal radiography

    SciTech Connect

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

    1984-09-01

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

  4. Brugada Syndrome: Defining the Risk in Asymptomatic Patients

    PubMed Central

    Brugada, Pedro

    2016-01-01

    Since the first description of the Brugada syndrome (BS) in 1992, scientific progress in the understanding of this disease has been enormous; at the same time more and more individuals with the disease have been diagnosed. The profile of patients with BS has changed with more asymptomatic individuals and less expressive clinical features. Asymptomatic BS individuals are at lower arrhythmic risk than those presenting with syncope or sudden cardiac death (SCD). The event incidence rate is around 0.5 % per year; this figure is relevant due to the fact that individuals have a long life expectancy and are otherwise healthy. As a result of the risk of SCD, risk stratification is of utmost importance. As the implantation of a cardioverter defibrillator is the main treatment for those patients at higher risk, benefits and long-term potential risks have to be adequately considered. Some risk factors, such as spontaneous type 1 electrocardiogram (ECG) pattern, are widely accepted, whilst for others contradictory data are present. Furthermore, novel risk factors are now available that might help in the management of BS. The presence of a spontaneous type 1 ECG pattern, history of sinus node dysfunction and inducible ventricular arrhythmias during programmed electrical stimulation of the heart allow us to risk stratify these patients. PMID:28116080

  5. [Risk management and patient safety].

    PubMed

    Lessing, C

    2009-06-01

    Risk management and patient safety are of indisputable importance for the quality of health care. At the same time they confront all professional groups in the health system with high demands. The Action Alliance for Patient Safety inc. wants to demonstrate ways in which measures for avoiding errors and improving safety can reach the healthcare practice. Interdisciplinary cooperation and the availability of mutually developed materials are the maxims of the work of the society.

  6. 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.

  7. Apparent diffusion coefficient histogram analysis stratifies progression-free and overall survival in patients with recurrent GBM treated with bevacizumab: a multi-center study.

    PubMed

    Pope, Whitney B; Qiao, Xin Joe; Kim, Hyun J; Lai, Albert; Nghiemphu, Phioanh; Xue, Xi; Ellingson, Benjamin M; Schiff, David; Aregawi, Dawit; Cha, Soonmee; Puduvalli, Vinay K; Wu, Jing; Yung, Wai-Kwan A; Young, Geoffrey S; Vredenburgh, James; Barboriak, Dan; Abrey, Lauren E; Mikkelsen, Tom; Jain, Rajan; Paleologos, Nina A; Rn, Patricia Lada; Prados, Michael; Goldin, Jonathan; Wen, Patrick Y; Cloughesy, Timothy

    2012-07-01

    We have tested the predictive value of apparent diffusion coefficient (ADC) histogram analysis in stratifying progression-free survival (PFS) and overall survival (OS) in bevacizumab-treated patients with recurrent glioblastoma multiforme (GBM) from the multi-center BRAIN study. Available MRI's from patients enrolled in the BRAIN study (n = 97) were examined by generating ADC histograms from areas of enhancing tumor on T1 weighted post-contrast images fitted to a two normal distribution mixture curve. ADC classifiers including the mean ADC from the lower curve (ADC-L) and the mean lower curve proportion (LCP) were tested for their ability to stratify PFS and OS by using Cox proportional hazard ratios and the Kaplan-Meier method with log-rank test. Mean ADC-L was 1,209 × 10(-6)mm(2)/s ± 224 (SD), and mean LCP was 0.71 ± 0.23 (SD). Low ADC-L was associated with worse outcome. The hazard ratios for 6-month PFS, overall PFS, and OS in patients with less versus greater than mean ADC-L were 3.1 (95 % confidence interval: 1.6, 6.1; P = 0.001), 2.3 (95 % CI: 1.3, 4.0; P = 0.002), and 2.4 (95 % CI: 1.4, 4.2; P = 0.002), respectively. In patients with ADC-L <1,209 and LCP >0.71 versus ADC-L >1,209 and LCP <0.71, there was a 2.28-fold reduction in the median time to progression, and a 1.42-fold decrease in the median OS. The predictive value of ADC histogram analysis, in which low ADC-L was associated with poor outcome, was confirmed in bevacizumab-treated patients with recurrent GBM in a post hoc analysis from the multi-center (BRAIN) study.

  8. Risk of sudden sensorineural hearing loss in stroke patients

    PubMed Central

    Kuo, Chin-Lung; Shiao, An-Suey; Wang, Shuu-Jiun; Chang, Wei-Pin; Lin, Yung-Yang

    2016-01-01

    Abstract Poststroke sudden sensorineural hearing loss (SSNHL) can hinder communication between patients and healthcare professionals, thereby restricting participation in rehabilitation programs and limiting improvements in physical performance. However, the relationship between stroke and SSNHL remains unclear. This study employed a nationwide population-based dataset to investigate the relationship between stroke and SSNHL. The Taiwan Longitudinal Health Insurance Database was used to compile data from 11,115 stroke patients and a comparison cohort of 33,345 matched nonstroke enrollees. Each patient was followed for 5 years to identify new-onset SSNHL. Stratified Cox proportional-hazard regression analysis was used to examine the association of stroke with subsequent SSNHL. Among the 44,460 patients, 66 patients (55,378 person-years) from the stroke cohort and 105 patients (166,586 person-years) from the comparison cohort were diagnosed with SSNHL. The incidence of SSNHL was approximately twice as high among stroke patients than among nonstroke patients (1.19 and 0.63/1000 person-years, respectively). Stroke patients had a 71% increased risk of SSNHL, compared with nonstroke patients (adjusted hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.24–2.36). We also observed a remarkable increase in risk of SSNHL in stroke patients within 1-year of follow-up (adjusted HR 5.65, 95% CI 3.07–10.41) or under steroid therapy during hospitalization (adjusted HR 5.14, 95% CI 2.08–12.75). Patients with stroke had a higher risk of subsequent SSNHL compared with patients without stroke. In particular, stroke patients within 1-year follow-up and those undergoing steroid therapy during hospitalization should be treated with the utmost caution, considering that the risk of SSNHL increases by more than 5-fold. PMID:27603402

  9. Survival analysis of cervical cancer using stratified Cox regression

    NASA Astrophysics Data System (ADS)

    Purnami, S. W.; Inayati, K. D.; Sari, N. W. Wulan; Chosuvivatwong, V.; Sriplung, H.

    2016-04-01

    Cervical cancer is one of the mostly widely cancer cause of the women death in the world including Indonesia. Most cervical cancer patients come to the hospital already in an advanced stadium. As a result, the treatment of cervical cancer becomes more difficult and even can increase the death's risk. One of parameter that can be used to assess successfully of treatment is the probability of survival. This study raises the issue of cervical cancer survival patients at Dr. Soetomo Hospital using stratified Cox regression based on six factors such as age, stadium, treatment initiation, companion disease, complication, and anemia. Stratified Cox model is used because there is one independent variable that does not satisfy the proportional hazards assumption that is stadium. The results of the stratified Cox model show that the complication variable is significant factor which influent survival probability of cervical cancer patient. The obtained hazard ratio is 7.35. It means that cervical cancer patient who has complication is at risk of dying 7.35 times greater than patient who did not has complication. While the adjusted survival curves showed that stadium IV had the lowest probability of survival.

  10. [Cardiovascular risk factors prevalence among patients with dyslipidemia in Colombia].

    PubMed

    Machado-Alba, Jorge E; Machado-Duque, Manuel E

    2013-04-01

    To determine the prevalence of cardiovascular risk factors and the ten years risk of cardio-cerebrovascular event in patients with dyslipidemia who were affiliated to the Colombian health system. A retrospective study was carried out in a random and stratified sample of 551 patients with dyslipidemia, from a population of 41,201 people with lipid-lowering therapy in ten Colombian cities between January 1, 2010 and June 30, 2011. Sociodemographic, anthropometric and biochemical variables were taken from medical records, as well as risk factors. To establish the 10-year cardiovascular risk was used Framingham algorithm. 311 patients were included, 56.4% of them were women, mean age 64.9 ± 10.8 years. The mean probability of developing a cardiovascular event at 10 years was 14%. Other cardiovascular risk factors found were hypertension (93.2%), male older than 55 years (35.8%), women older than 65 years (28.1%), diabetes mellitus (28.5%), family history of coronary heart disease (17.2%), personal history of heart disease or stroke (16.7%) and smoking (6.4%). The types of dyslipidemia by frequency were: mixed (46.6%), isolated hypercholesterolemia (29.4%) and hypertriglyceridaemia (20.3%). Patients were men and women older than 65 years, mainly suffering mixed dyslipidemia, and have a 14.0% probability of suffering a cardiovascular event in the next 10 years. It should promote healthy public policies to reduce the presence of hypertension and diabetes mellitus.

  11. Systematic review of fall risk screening tools for older patients in acute hospitals.

    PubMed

    Matarese, Maria; Ivziku, Dhurata; Bartolozzi, Francesco; Piredda, Michela; De Marinis, Maria Grazia

    2015-06-01

    To determine the most accurate fall risk screening tools for predicting falls among patients aged 65 years or older admitted to acute care hospitals. Falls represent a serious problem in older inpatients due to the potential physical, social, psychological and economic consequences. Older inpatients present with risk factors associated with age-related physiological and psychological changes as well as multiple morbidities. Thus, fall risk screening tools for older adults should include these specific risk factors. There are no published recommendations addressing what tools are appropriate for older hospitalized adults. Systematic review. MEDLINE, CINAHL and Cochrane electronic databases were searched between January 1981-April 2013. Only prospective validation studies reporting sensitivity and specificity values were included. Recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews have been followed. Three fall risk assessment tools were evaluated in seven articles. Due to the limited number of studies, meta-analysis was carried out only for the STRATIFY and Hendrich Fall Risk Model II. In the combined analysis, the Hendrich Fall Risk Model II demonstrated higher sensitivity than STRATIFY, while the STRATIFY showed higher specificity. In both tools, the Youden index showed low prognostic accuracy. The identified tools do not demonstrate predictive values as high as needed for identifying older inpatients at risk for falls. For this reason, no tool can be recommended for fall detection. More research is needed to evaluate fall risk screening tools for older inpatients. © 2014 John Wiley & Sons Ltd.

  12. A Gender-Stratified Comparative Analysis of Various Definitions of Metabolic Syndrome and Cardiovascular Risk in a Multiethnic U.S. Population

    PubMed Central

    Hari, Pawan; Nerusu, Kamalakar; Veeranna, Vikas; Sudhakar, Rajeev; Zalawadiya, Sandip; Ramesh, Krithi

    2012-01-01

    Abstract Introduction We sought to evaluate the ability of various metabolic syndrome definitions in predicting primary cardiovascular disease (CVD) outcomes in a vast multiethnic U.S. cohort. Methods This study included 6,814 self-identified men and women aged 45–84 years enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA) study. Gender-stratified analyses were performed to calculate hazard ratios of CVD, stroke, and mortality associated with various metabolic syndrome definitions and their individual constructs. Results The hazard ratios [95% confidence interval (CI)] for all-cause CVD in men were 2.90 (2.18–3.85), 2.64 (1.98–3.51), 2.16 (1.62–2.88), 2.56 (1.91–3.44), 1.82 (1.35–2.46), and 2.92 (2.15–3.95) for the National Cholesterol Education Program (NCEP), American Heart Association (AHA), World Health Organization (WHO), International Diabetes Federation (IDF), European Group for the Study of Insulin Resistance (EGIR), and the newly defined consensus criteria. Hazard ratios in women were 2.11 (1.41–3.15), 2.17 (1.45–3.27), 2.04 (1.37–3.06), 1.91 (1.27–2.88), 1.85 (1.23–2.79), and 2.08 (1.37–3.14), respectively. Metabolic syndrome was strongly associated with stroke risk only in males. In men, all constitutive metabolic syndrome components were continuously and strongly associated with CVD. In women, high-density lipoprotein and triglycerides did not appear to be associated with short term CVD risk. Conclusion We found the newly defined consensus criteria for metabolic syndrome to be similarly predictive of cardiovascular events when compared to existing definitions. Significant gender differences exist in the association between metabolic syndrome, its individual components, and CVD. PMID:21999397

  13. Accuracy of diagnoses predicted from a simple patient questionnaire stratified by the duration of general ambulatory training: an observational study.

    PubMed

    Uehara, Takanori; Ikusaka, Masatomi; Ohira, Yoshiyuki; Ohta, Mitsuyasu; Noda, Kazutaka; Tsukamoto, Tomoko; Takada, Toshihiko; Miyahara, Masahito

    2013-01-01

    To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A "correct" diagnosis was one where the predicted disease matched the final diagnosis code. A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, -3.6) (χ (2)=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors' competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct diagnostic outcome may improve and save further

  14. Accuracy of diagnoses predicted from a simple patient questionnaire stratified by the duration of general ambulatory training: an observational study

    PubMed Central

    Uehara, Takanori; Ikusaka, Masatomi; Ohira, Yoshiyuki; Ohta, Mitsuyasu; Noda, Kazutaka; Tsukamoto, Tomoko; Takada, Toshihiko; Miyahara, Masahito

    2014-01-01

    Purpose To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. Participants and methods Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A “correct” diagnosis was one where the predicted disease matched the final diagnosis code. Results A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, −3.6) (χ2=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. Conclusion Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors’ competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct

  15. Safety Profile of Collagenase Clostridium Histolyticum Stratified by Degree of Penile Curvature in Patients With Peyronie Disease.

    PubMed

    Hellstrom, Wayne J G; Tan, Ronny B W; Liu, Genzhou

    2017-08-01

    To examine the safety of collagenase clostridium histolyticum (CCH) in adult men with penile curvature deformity <30°. CCH is indicated for treatment of Peyronie disease in adult men with palpable plaque and a penile curvature deformity ≥30° at start of therapy; however, during treatment, patients may receive CCH injections when penile curvature deformity is <30°. Patients who received ≥2 CCH treatment cycles in 2 phase 3 studies (Investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies I and II) were included. All patients had penile curvature ≥30° at the beginning of treatment and could receive up to 4 treatment cycles. The rate and number of treatment-related adverse events (TRAEs) with CCH treatment were compared between patients with penile curvature deformity ≥30° and penile curvature <30°. The number of CCH treatment cycles included in the current analysis totaled 1204 and 289 cycles in patients with penile curvature deformity ≥30° and <30°, respectively. The incidence of most TRAEs was similar between groups. Rates of penile swelling (21.1% vs 14.5%, P = .007), penile hemorrhage (12.8% vs 8.9%; P = .046), and skin hyperpigmentation (1.0% vs 0.1%; P = .025) were significantly higher in the <30° group. The occurrence of serious TRAEs was similar between groups. No clinically meaningful differences were observed with TRAE rates when CCH injections were administered at penile curvature deformity ≥30° vs CCH injections at penile curvature deformity <30°. These findings highlight the safety of continued CCH injections for patients who have achieved penile curvature deformity <30° after an initial treatment cycle of CCH. Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.

  16. Dental care provided to sickle cell anemia patients stratified by age: A population-based study in Northeastern Brazil

    PubMed Central

    Costa, Cyrene Piazera Silva; Aires, Bárbara Tamires Cruz; Thomaz, Erika Bárbara Abreu Fonseca; Souza, Soraia de Fátima Carvalho

    2016-01-01

    Objective: To assess differences in the dental care provided to sickle cell anemia (SCA) patients depending on age. This retrospective study used secondary data from the dental records of the Center of Hematology and Hemotherapy in Maranhão (HEMOMAR). Materials and Methods: Data were obtained from 574 dental records of patients with SCA treated or under treatment in the Dental Department of HEMOMAR from 2000 to 2011. Data on the gender, age, duration of dental treatment, number of patients submitted to periodontal treatment (PT), number of filled teeth (FT), teeth extracted (EX), endodontically treated teeth (ET), and reason for the dental procedures were collected. The Kruskal–Wallis test together with Dunn's post hoc test, Chi-square test, and Spearman's correlation was used for statistical analysis. An alpha error of 5% was considered acceptable. Results: Significant differences were found for FT, EX (P < 0.05), ET and PT (P < 0.001) between the age groups. There were fewer FT in children compared to other age groups (P < 0.001). The most common reasons for restorations and endodontic treatment were dental caries (100%) and irreversible pulpitis (55.6%), respectively. The main reasons for teeth extractions were residual roots (21.3%), chronic apical periodontitis (19.7%), and crown destruction (19.3%). There were positive correlations between age and EX (r = 0.93; P = 0.025) and ET (r = 0.92; P = 0.028). Conclusions: FT, ET, EX, and PT procedures become more common in older patients. Tooth decay is the main reason for dental treatment in SCA patients. PMID:27403053

  17. Defining drug response for stratified medicine.

    PubMed

    Lonergan, Mike; Senn, Stephen J; McNamee, Christine; Daly, Ann K; Sutton, Robert; Hattersley, Andrew; Pearson, Ewan; Pirmohamed, Munir

    2017-01-01

    The premise for stratified medicine is that drug efficacy, drug safety, or both, vary between groups of patients, and biomarkers can be used to facilitate more targeted prescribing, with the aim of improving the benefit:risk ratio of treatment. However, many factors can contribute to the variability in response to drug treatment. Inadequate characterisation of the nature and degree of variability can lead to the identification of biomarkers that have limited utility in clinical settings. Here, we discuss the complexities associated with the investigation of variability in drug efficacy and drug safety, and how consideration of these issues a priori, together with standardisation of phenotypes, can increase both the efficiency of stratification procedures and identification of biomarkers with the potential for clinical impact.

  18. Differences in Regional Brain Activation Patterns Assessed by Functional Magnetic Resonance Imaging in Patients with Systemic Lupus Erythematosus Stratified by Disease Duration

    PubMed Central

    Mackay, Meggan; Bussa, Mathew P; Aranow, Cynthia; Uluğ, Aziz M; Volpe, Bruce T; Huerta, Patricio T; Argyelan, Miklos; Mandel, Arthur; Hirsch, Joy; Diamond, Betty; Eidelberg, David

    2011-01-01

    The mediators of tissue damage in systemic lupus erythematosus (SLE) such as antibodies, cytokines and activated immune cells have direct access to most organs in the body but must penetrate the blood-brain barrier (BBB) to gain access to brain tissue. We hypothesized that compromise of the BBB occurs episodically such that the brain will acquire tissue damage slowly and not at the same rate as other organs. On the basis of these assumptions, we wished to determine if duration of disease correlated with brain injury, as measured with functional magnetic resonance imaging (fMRI), and if this was independent of degree of tissue damage in other organs. We investigated differences in brain activation patterns using fMRI in 13 SLE patients stratified by disease duration of ≤2 years (short-term [ST]) or ≥10 years (long-term [LT]). Two fMRI paradigms were selected to measure working memory and emotional response (fearful faces task). Performance in the working memory task was significantly better in the ST group for one and two shape recall; however, both groups did poorly with three shape recall. Imaging studies demonstrated significantly increased cortical activation in the ST group in regions associated with cognition during the two shape retention phase of the working memory task (P < 0.001) and increased amygdala (P < 0.05) and superior parietal (P < 0.01) activation in response to the fearful faces paradigm. In conclusion, analysis of activation patterns stratified by performance accuracy, differences in co-morbid disease, corticosteroid doses or disease activity suggests that these observed differences are attributable to SLE effects on the central nervous system exclusive of vascular disease or other confounding influences. Our hypothesis is further supported by the lack of correlation between regional brain abnormalities on fMRI and the Systemic Lupus International Collaborating Clinics (SLICC) damage index. PMID:21953419

  19. microRNA fingerprinting of CLL patients with chromosome 17p deletion identify a miR-21 score that stratifies early survival.

    PubMed

    Rossi, Simona; Shimizu, Masayoshi; Barbarotto, Elisa; Nicoloso, Milena S; Dimitri, Federica; Sampath, Deepa; Fabbri, Muller; Lerner, Susan; Barron, Lynn L; Rassenti, Laura Z; Jiang, Li; Xiao, Lianchun; Hu, Jianhua; Secchiero, Paola; Zauli, Giorgio; Volinia, Stefano; Negrini, Massimo; Wierda, William; Kipps, Thomas J; Plunkett, William; Coombes, Kevin R; Abruzzo, Lynne V; Keating, Michael J; Calin, George A

    2010-08-12

    Aberrant expression of microRNAs (miRNAs) has been associated with clinical outcome in patients with chronic lymphocytic leukemia (CLL). To identify a powerful and easily assessable miRNA bio-marker of prognosis and survival, we performed quantitative reverse-transcription polymerase chain reaction (qRT-PCR) profiling in 104 CLL patients with a well-defined chromosome 17p status, and we validated our findings with miRNA microarray data from an independent cohort of 80 patients. We found that miR-15a, miR-21, miR-34a, miR-155, and miR-181b were differentially expressed between CLLs with chromosome 17p deletion and CLLs with normal 17p and normal karyotype, and that miR-181b was down-regulated in therapy-refractory cases. miR-21 expression levels were significantly higher in patients with poor prognosis and predicted overall survival (OS), and miR-181b expression levels significantly predicted treatment-free survival. We developed a 21FK score (miR-21 qRT-PCR, fluorescence in situ hybridization, Karyotype) to stratify patients according to OS and found that patients with a low score had a significantly longer OS time. When we evaluated the relative power of the 21FK score with the most used prognostic factors, the score was the most significant in both CLL cohorts. We conclude that the 21FK score represents a useful tool for distinguishing between good-prognosis and poor-prognosis CLL patients.

  20. Achieving cholesterol targets by individualizing starting doses of statin according to baseline low-density lipoprotein cholesterol and coronary artery disease risk category: The CANadians Achieve Cholesterol Targets Fast with Atorvastatin Stratified Titration (CanACTFAST) study

    PubMed Central

    Ur, Ehud; Langer, Anatoly; Rabkin, Simon W; Calciu, Cristina-Dana; Leiter, Lawrence A

    2010-01-01

    BACKGROUND: Despite an increasing body of evidence on the benefit of lowering elevated levels of low-density lipoprotein cholesterol (LDL-C), there is still considerable concern that patients are not achieving target LDL-C levels. OBJECTIVE: The CANadians Achieve Cholesterol Targets Fast with Atorvastatin Stratified Titration (CanACTFAST) trial tested whether an algorithm-based statin dosing approach would enable patients to achieve LDL-C and total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio targets quickly. METHODS: Subjects requiring statin therapy, but with an LDL-C level of 5.7 mmol/L or lower, and triglycerides of 6.8 mmol/L or lower at screening participated in the 12-week study, which had two open-label, six-week phases: a treatment period during which patients received 10 mg, 20 mg, 40 mg or 80 mg of atorvastatin based on an algorithm incorporating baseline LDL-C value and cardiovascular risk; and patients who achieved both LDL-C and TC/HDL-C ratio targets at six weeks continued on the same atorvastatin dose. Patients who did not achieve both targets received dose uptitration using a single-step titration regimen. The primary efficacy outcome was the proportion of patients achieving target LDL-C levels after 12 weeks. RESULTS: Of 2016 subjects screened at 88 Canadian sites, 1258 were assigned to a study drug (1101 were statin-free and 157 were statin-treated at baseline). The proportion of subjects who achieved LDL-C targets after 12 weeks of treatment was 86% (95% CI 84% to 88%) for statin-free patients and 54% (95% CI 46% to 61%) for statin-treated patients. Overall, 1003 subjects (80%; 95% CI 78% to 82%) achieved both lipid targets. CONCLUSIONS: Algorithm-based statin dosing enables patients to achieve LDL-C and TC/HDL-C ratio targets quickly, with either no titration or a single titration. PMID:20151053

  1. Enhancing tumor apparent diffusion coefficient histogram skewness stratifies the postoperative survival in recurrent glioblastoma multiforme patients undergoing salvage surgery.

    PubMed

    Zolal, Amir; Juratli, Tareq A; Linn, Jennifer; Podlesek, Dino; Sitoci Ficici, Kerim Hakan; Kitzler, Hagen H; Schackert, Gabriele; Sobottka, Stephan B; Rieger, Bernhard; Krex, Dietmar

    2016-05-01

    Objective To determine the value of apparent diffusion coefficient (ADC) histogram parameters for the prediction of individual survival in patients undergoing surgery for recurrent glioblastoma (GBM) in a retrospective cohort study. Methods Thirty-one patients who underwent surgery for first recurrence of a known GBM between 2008 and 2012 were included. The following parameters were collected: age, sex, enhancing tumor size, mean ADC, median ADC, ADC skewness, ADC kurtosis and fifth percentile of the ADC histogram, initial progression free survival (PFS), extent of second resection and further adjuvant treatment. The association of these parameters with survival and PFS after second surgery was analyzed using log-rank test and Cox regression. Results Using log-rank test, ADC histogram skewness of the enhancing tumor was significantly associated with both survival (p = 0.001) and PFS after second surgery (p = 0.005). Further parameters associated with prolonged survival after second surgery were: gross total resection at second surgery (p = 0.026), tumor size (0.040) and third surgery (p = 0.003). In the multivariate Cox analysis, ADC histogram skewness was shown to be an independent prognostic factor for survival after second surgery. Conclusion ADC histogram skewness of the enhancing lesion, enhancing lesion size, third surgery, as well as gross total resection have been shown to be associated with survival following the second surgery. ADC histogram skewness was an independent prognostic factor for survival in the multivariate analysis.

  2. PSA-Stratified Performance of (18)F- and (68)Ga-PSMA PET in Patients with Biochemical Recurrence of Prostate Cancer.

    PubMed

    Dietlein, Felix; Kobe, Carsten; Neubauer, Stephan; Schmidt, Matthias; Stockter, Simone; Fischer, Thomas; Schomäcker, Klaus; Heidenreich, Axel; Zlatopolskiy, Boris D; Neumaier, Bernd; Drzezga, Alexander; Dietlein, Markus

    2017-06-01

    Several studies outlined the sensitivity of (68)Ga-labeled PET tracers against the prostate-specific membrane antigen (PSMA) for localization of relapsed prostate cancer in patients with renewed increase in the prostate-specific antigen (PSA), commonly referred to as biochemical recurrence. Labeling of PSMA tracers with (18)F offers numerous advantages, including improved image resolution, longer half-life, and increased production yields. The aim of this study was to assess the PSA-stratified performance of the (18)F-labeled PSMA tracer (18)F-DCFPyL and the (68)Ga-labeled reference (68)Ga-PSMA-HBED-CC. Methods: We examined 191 consecutive patients with biochemical recurrence according to standard acquisition protocols using (18)F-DCFPyL (n = 62, 269.8 MBq, PET scan at 120 min after injection) or (68)Ga-PSMA-HBED-CC (n = 129, 158.9 MBq, 60 min after injection). We determined PSA-stratified sensitivity rates for both tracers and corrected our calculations for Gleason scores using iterative matched-pair analyses. As an orthogonal validation, we directly compared tracer distribution patterns in a separate cohort of 25 patients, sequentially examined with both tracers. Results: After prostatectomy (n = 106), the sensitivity of both tracers was significantly associated with absolute PSA levels (P = 4.3 × 10(-3)). Sensitivity increased abruptly, when PSA values exceeded 0.5 μg/L (P = 2.4 × 10(-5)). For a PSA less than 3.5 μg/L, most relapses were diagnosed at a still limited stage (P = 3.4 × 10(-6)). For a PSA of 0.5-3.5 μg/L, PSA-stratified sensitivity was 88% (15/17) for (18)F-DCFPyL and 66% (23/35) for (68)Ga-PSMA-HBED-CC. This significant difference was preserved in the Gleason-matched-pair analysis. Outside of this range, sensitivity was comparably low (PSA < 0.5 μg/L) or high (PSA > 3.5 μg/L). After radiotherapy (n = 85), tracer sensitivity was largely PSA-independent. In the 25 patients examined with both tracers, distribution patterns of (18)F-DCFPyL and

  3. The influence factors of medical professionalism: A stratified-random sampling study based on the physicians and patients in ambulatory care clinics of Chengdu, China.

    PubMed

    Lin, Yifei; Yin, Senlin; Lai, Sike; Tang, Ji; Huang, Jin; Du, Liang

    2016-10-01

    As the relationship between physicians and patients deteriorated in China recently, medical conflicts occurred more frequently now. Physicians, to a certain extent, also take some responsibilities. Awareness of medical professionalism and its influence factors can be helpful to take targeted measures and alleviate the contradiction. Through a combination of physicians' self-assessment and patients' assessment in ambulatory care clinics in Chengdu, this research aims to evaluate the importance of medical professionalism in hospitals and explore the influence factors, hoping to provide decision-making references to improve this grim situation. From February to March, 2013, a cross-sectional study was conducted in 2 tier 3 hospitals, 5 tier 2 hospitals, and 10 community hospitals through a stratified-random sampling method on physicians and patients, at a ratio of 1/5. Questionnaires are adopted from a pilot study. A total of 382 physicians and 1910 patients were matched and surveyed. Regarding the medical professionalism, the scores of the self-assessment for physicians were 85.18 ± 7.267 out of 100 and the scores of patient-assessment were 57.66 ± 7.043 out of 70. The influence factors of self-assessment were physicians' working years (P = 0.003) and patients' complaints (P = 0.006), whereas the influence factors of patient-assessment were patients' ages (P = 0.001) and their physicians' working years (P < 0.01) and satisfaction on the payment mode (P = 0.006). Higher self-assessment on the medical professionalism was in accordance with physicians of more working years and no complaint history. Higher patient-assessment was in line with elder patients, the physicians' more working years, and higher satisfaction on the payment mode. Elder patients, encountering with physicians who worked more years in health care services or with higher satisfaction on the payment mode, contribute to higher scores in patient assessment part. The government should

  4. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies.

    PubMed Central

    Oliver, D.; Britton, M.; Seed, P.; Martin, F. C.; Hopper, A. H.

    1997-01-01

    OBJECTIVES: To identify clinical characteristics of elderly inpatients that predict their chance of falling (phase 1) and to use these characteristics to derive a risk assessment tool and to evaluate its power in predicting falls (phases 2 and 3). DESIGN: Phase 1: a prospective case-control study. Phases 2 and 3: prospective evaluations of the derived risk assessment tool in predicting falls in two cohorts. SETTING: Elderly care units of St Thomas's Hospital (phase 1 and 2) and Kent and Canterbury Hospital (phase 3). SUBJECTS: Elderly hospital inpatients (aged > or = 65 years): 116 cases and 116 controls in phase 1,217 patients in phase 2, and 331 in phase 3. MAIN OUTCOME MEASURES: 21 separate clinical characteristics were assessed in phase 1, including the abbreviated mental test score, modified Barthel index, a transfer and mobility score obtained by combining the transfer and mobility sections of the Barthel index, and several nursing judgements. RESULTS: In phase 1 five factors were independently associated with a higher risk of falls: fall as a presenting complaint (odds ratio 4.64 (95% confidence interval 2.59 to 8.33); a transfer and mobility score of 3 or 4 (2.10 (1.22 to 3.61)); and primary nurses' judgment that a patient was agitated (20.9 (9.62 to 45.62)), needed frequent toileting (2.48 (1.08 to 5.70)), and was visually impaired (3.56 (1.26 to 10.05)). A risk assessment score (range 0-5) was derived by scoring one point for each of these five factors. In phases 2 and 3 a risk assessment score > 2 was used to define high risk: the sensitivity and specificity of the score to predict falls during the following week was 93% and 88% respectively in phase 2 and 92% and 68% respectively in phase 3. CONCLUSION: This simple risk assessment tool predicted with clinically useful sensitivity and specificity a high percentage of falls among elderly hospital inpatients. PMID:9366729

  5. An electronic patient risk communication board.

    PubMed

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

    2012-01-01

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

  6. Cost-effectiveness of a risk-stratified approach to cardiac resynchronisation therapy defibrillators (high versus low) at the time of generator change.

    PubMed

    Claridge, Simon; Sebag, Frederic A; Fearn, Steven; Behar, Jonathan M; Porter, Bradley; Jackson, Tom; Sieniewicz, Benjamin; Gould, Justin; Webb, Jessica; Chen, Zhong; O'Neill, Mark; Gill, Jaswinder; Leclercq, Christophe; Rinaldi, Christopher A

    2017-09-29

    Responders to cardiac resynchronisation therapy whose device has a defibrillator component and who do not receive a therapy in the lifetime of the first generator have a very low incidence of appropriate therapy after box change. We investigated the cost implications of using a risk stratification tool at the time of generator change resulting in these patients being reimplanted with a resynchronisation pacemaker. A decision tree was created using previously published data which had demonstrated an annualised appropriate defibrillator therapy risk of 2.33%. Costs were calculated at National Health Service (NHS) national tariff rates (2016-2017). EQ-5D utility values were applied to device reimplantations, admissions and mortality data, which were then used to estimate quality-adjusted life-years (QALYs) over 5 years. At 5 years, the incremental cost of replacing a resynchronisation defibrillator device with a second resynchronisation defibrillator versus resynchronisation pacemaker was £5045 per patient. Incremental QALY gained was 0.0165 (defibrillator vs pacemaker), resulting in an incremental cost-effectiveness ratio (ICER) of £305 712 per QALYs gained. Probabilistic sensitivity analysis resulted in an ICER of £313 612 (defibrillator vs pacemaker). For reimplantation of all patients with a defibrillator rather than a pacemaker to yield an ICER of less than £30 000 per QALY gained (current NHS cut-off for approval of treatment), the annual arrhythmic event rate would need to be 9.3%. The budget impact of selective replacement was a saving of £2 133 985 per year. Implanting low-risk patients with a resynchronisation defibrillator with the same device at the time of generator change is not cost-effective by current NHS criteria. Further research is required to understand the impact of these findings on individual patients at the time of generator change. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017

  7. Creation of a Prognostic Index for Spine Metastasis to Stratify Survival in Patients Treated With Spinal Stereotactic Radiosurgery: Secondary Analysis of Mature Prospective Trials

    SciTech Connect

    Tang, Chad; Hess, Kenneth; Bishop, Andrew J.; Pan, Hubert Y.; Christensen, Eva N.; Yang, James N.; Tannir, Nizar; Amini, Behrang; Tatsui, Claudio; Rhines, Laurence; Brown, Paul; Ghia, Amol

    2015-09-01

    Purpose: There exists uncertainty in the prognosis of patients following spinal metastasis treatment. We sought to create a scoring system that stratifies patients based on overall survival. Methods and Materials: Patients enrolled in 2 prospective trials investigating stereotactic spine radiation surgery (SSRS) for spinal metastasis with ≥3-year follow-up were analyzed. A multivariate Cox regression model was used to create a survival model. Pretreatment variables included were race, sex, age, performance status, tumor histology, extent of vertebrae involvement, previous therapy at the SSRS site, disease burden, and timing of diagnosis and metastasis. Four survival groups were generated based on the model-derived survival score. Results: Median follow-up in the 206 patients included in this analysis was 70 months (range: 37-133 months). Seven variables were selected: female sex (hazard ratio [HR] = 0.7, P=.02), Karnofsky performance score (HR = 0.8 per 10-point increase above 60, P=.007), previous surgery at the SSRS site (HR = 0.7, P=.02), previous radiation at the SSRS site (HR = 1.8, P=.001), the SSRS site as the only site of metastatic disease (HR = 0.5, P=.01), number of organ systems involved outside of bone (HR = 1.4 per involved system, P<.001), and >5 year interval from initial diagnosis to detection of spine metastasis (HR = 0.5, P<.001). The median survival among all patients was 25.5 months and was significantly different among survival groups (in group 1 [excellent prognosis], median survival was not reached; group 2 reached 32.4 months; group 3 reached 22.2 months; and group 4 [poor prognosis] reached 9.1 months; P<.001). Pretreatment symptom burden was significantly higher in the patient group with poor survival than in the group with excellent survival (all metrics, P<.05). Conclusions: We developed the prognostic index for spinal metastases (PRISM) model, a new model that identified patient subgroups with poor and excellent prognoses.

  8. Decision analysis of allogeneic hematopoietic stem cell transplantation for patients with myelodysplastic syndrome stratified according to the revised international prognostic scoring system (IPSS-R).

    PubMed

    Della Porta, M G; Jackson, C H; Alessandrino, E P; Rossi, M; Bacigalupo, A; van Lint, M T; Bernardi, M; Allione, B; Bosi, A; Guidi, S; Santini, V; Malcovati, L; Ubezio, M; Milanesi, C; Todisco, E; Voso, M T; Musto, P; Onida, F; Iori, A P; Cerretti, R; Grillo, G; Molteni, A; Pioltelli, P; Borin, L; Angelucci, E; Oldani, E; Sica, S; Pascutto, C; Ferretti, V; Santoro, A; Bonifazi, F; Cazzola, M; Rambaldi, A

    2017-03-21

    Allogeneic hematopoietic stem cell transplantation (allo-SCT) represents the only curative treatment for patients with myelodysplastic syndrome (MDS), but involves non-negligible morbidity and mortality. Crucial questions in clinical decision making include the definition of optimal timing of the procedure and the benefit of cytoreduction before transplant in high risk patients. We carried out a decision analysis on 1728 MDS who received supportive care, transplantation or hypomethylating agents (HMAs). Risk assessment was based on the revised International Prognostic Scoring System (IPSS-R). We used a continuous-time multistate Markov model to describe the natural history of disease and evaluate the effect of different treatment policies on survival. Life expectancy increased when transplantation was delayed from the initial stages to intermediate IPSS-R risk (gain of life expectancy 5.3, 4.7 and 2.8 years for patients aged ⩽55, 60 and 65 years, respectively), and then decreased for higher risks. Modelling decision analysis on IPSS-R vs original IPSS changed transplantation policy in 29% of patients, resulting in a 2-year gain in life expectancy. In advanced stages, HMAs given before transplant is associated with a 2-year gain of life expectancy, especially in older patients. These results provide a preliminary evidence to maximize the effectiveness of allo-SCT in MDS.Leukemia accepted article preview online, 21 March 2017. doi:10.1038/leu.2017.88.

  9. The aged cardiovascular risk patient.

    PubMed

    Priebe, H J

    2000-11-01

    factors contribute most of the increased perioperative risk related to advanced age. First, physiological ageing is accompanied by a progressive decline in resting organ function. Consequently, the reserve capacity to compensate for impaired organ function, drug metabolism and added physiological demands is increasingly impaired. Functional disability will occur more quickly and take longer to be cured. Second, ageing is associated with progressive manifestation of chronic disease which further limits baseline function and accelerates loss of functional reserve in the affected organ. Some of the age-related decline in organ function (e.g. impaired pulmonary gas exchange, diminished renal capacity to conserve and eliminate water and salt, or disturbed thermoregulation) will increase cardiovascular risk. The unpredictable interaction between age-related and disease-associated changes in organ functions, and the altered neurohumoral response to various forms of stress in the elderly may result in a rather atypical clinical presentation of a disease. This may, in turn, delay the correct diagnosis and appropriate treatment and, ultimately, worsen outcome. Third, related to the increased intake of medications and altered pharmacokinetics and pharmacodynamics, the incidence of untoward reactions to medications, anaesthetic agents, and medical and surgical interventions increases with advancing age. On the basis of various clinical studies and observations, it must be concluded that advanced age is an independent predictor of adverse perioperative cardiac outcome. It is to be expected that the aged cardiovascular risk patient carries an even higher perioperative cardiac risk than the younger cardiovascular risk patient. Although knowledge of the physiology of ageing should help reduce age-related complications, successful prophylaxis is hindered by the heterogeneity of age-related changes, unpredictable physiological and pharmacological interactions and diagnostic difficultie

  10. Compliance with adjuvant treatment guidelines in endometrial cancer: room for improvement in high risk patients.

    PubMed

    Eggink, F A; Mom, C H; Boll, D; Ezendam, N P M; Kruitwagen, R F P M; Pijnenborg, J M A; van der Aa, M A; Nijman, H W

    2017-08-01

    Compliance of physicians with guidelines has emerged as an important indicator for quality of care. We evaluated compliance of physicians with adjuvant therapy guidelines for endometrial cancer patients in the Netherlands in a population-based cohort over a period of 10years. Data from all patients diagnosed with endometrial cancer between 2005 and 2014, without residual tumor after surgical treatment, were extracted from the Netherlands Cancer Registry (N=14,564). FIGO stage, grade, tumor type and age were used to stratify patients into risk groups. Possible changes in compliance over time and impact of compliance on survival were assessed. Patients were stratified into low/low-intermediate (52%), high-intermediate (21%) and high (20%) risk groups. Overall compliance with adjuvant therapy guidelines was 85%. Compliance was highest in patients with low/low-intermediate risk (98%, no adjuvant therapy indicated). The lowest compliance was determined in patients with high risk (61%, external beam radiotherapy with/without chemotherapy indicated). Within this group compliance decreased from 64% in 2005-2009 to 57% in 2010-2014. In high risk patients with FIGO stage III serous disease compliance was 55% (chemotherapy with/without radiotherapy indicated) and increased from 41% in 2005-2009 to 66% in 2010-2014. While compliance of physicians with adjuvant therapy guidelines is excellent in patients with low and low-intermediate risk, there is room for improvement in high risk endometrial cancer patients. Eagerly awaited results of ongoing randomized clinical trials may provide more definitive guidance regarding adjuvant therapy for high risk endometrial cancer patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  11. Assessment of drug-induced torsade de pointes risk for hospitalized high-risk patients receiving QT-prolonging agents.

    PubMed

    Jardin, Carla G M; Putney, David; Michaud, Stephen

    2014-02-01

    Although risk factors for torsade de pointes (TdP) are known, identifying hospitalized patients at greatest risk for QTcP who should receive cardiac monitoring is poorly defined. Describe the prevalence of risk for TdP in patients and associations between risk factors and QTc prolongation (QTcP) at a tertiary teaching hospital. This retrospective analysis assessed physiological and pharmacological risk factors for TdP of adult patients receiving ≥1 QTc-prolonging medications (QTcMed) during hospitalization. The QTcMeds were stratified by risk for causing TdP (probable, possible, and conditional). Baseline electrocardiograms (ECGs) were assessed for QTcP associated with risk for TdP. During a 6-month period, 12,401 (51%) hospitalizations received ≥1 QTcMed. A baseline ECG was obtained for 2381 (19%) patients. A total of 386 (16%) patients with a baseline ECG were found to have QTcP. Significant associations for QTcP were found with the following physiological risk factors: female (P = .021), left-ventricular ejection fraction <40% (P < .0001), cardiac arrest (P < .0001), and cardioversion (P = .007). Significantly more patients with QTcP (n = 209, 54%) received probable-risk QTcMeds than those without QTcP (n = 542, 27%; P < .0001). Probable-risk QTcMeds administered alone or concomitantly with other QTcMeds were more frequently associated with QTcP. No documented cases of TdP were identified. Of the population receiving QTcMeds, only a small portion had a baseline ECG, identifying a large population at risk of QTcP without appropriate monitoring. Patients with cardiac disease receiving probable-risk QTcMeds were associated with the highest risk of QTcP and should be monitored closely.

  12. Use of minimal disseminated disease and immunity to NPM-ALK antigen to stratify ALK-positive ALCL patients with different prognosis.

    PubMed

    Mussolin, L; Damm-Welk, C; Pillon, M; Zimmermann, M; Franceschetto, G; Pulford, K; Reiter, A; Rosolen, A; Woessmann, W

    2013-02-01

    We studied the prognostic value of minimal disseminated disease (MDD) and anti-ALK immune response in children with NPM-ALK-positive anaplastic-large cell lymphoma (ALCL) and evaluated their potential for risk stratification. NPM-ALK transcripts were analyzed by RT-PCR in bone marrow/peripheral blood of 128 ALCL patients at diagnosis, whereas ALK antibody titers in plasma were assessed using an immunocytochemical approach. MDD was positive in 59% of patients and 96% showed an anti-ALK response. Using MDD and antibody titer results, patients could be divided into three biological risk groups (bRG) with different prognosis: high risk (bHR): MDD-positive and antibody titer ≤ 1/750, 26/128 (20%); low risk (bLR): MDD negative and antibody titer >1/750, 40/128 (31%); intermediate risk (bIR): all remaining patients, 62/128 (48%). Progression-free survival was 28% (s.e., 9%), 68% (s.e., 6%) and 93% (s.e., 4%) for bHR, bIR and bLR, respectively (P<0.0001). Survival was 71% (s.e., 9%), 83% (s.e., 5%) and 98% (s.e., 2%) for bHR, bIR and bLR (P=0.02). Only bHR and histology other than common type were predictive of higher risk of failure (hazard ratio 4.9 and 2.7, respectively) in multivariate analysis. Stratification of ALCL patients based on MDD and anti-ALK titer should be considered in future ALCL trials to optimize treatment.

  13. Patients with rosacea have increased risk of dementia.

    PubMed

    Egeberg, Alexander; Hansen, Peter R; Gislason, Gunnar H; Thyssen, Jacob P

    2016-06-01

    Rosacea is a common chronic inflammatory skin disorder where upregulation of matrix metalloproteinases (MMPs) and antimicrobial peptides (AMPs) is observed. Notably, inflammation, MMPs, and AMPs are also involved in the etiopathogenesis of neurodegenerative disorders including certain forms of dementia such as Alzheimer disease (AD). Based on several clinical observations, we investigated the association between rosacea and dementia, including AD in Danish registers. All Danish citizens aged ≥18 years between January 1, 1997 and December 31, 2012 were linked at the individual level through administrative registers. Cox regression was used to calculate unadjusted and adjusted hazard ratios (HRs). The study comprised a total of 5,591,718 individuals, including 82,439 patients with rosacea. A total of 99,040 individuals developed dementia (any form) in the study period, of whom 29,193 were diagnosed with AD. The adjusted HRs of dementia and AD were 1.07 (95% confidence interval [CI] = 1.01-1.14), and 1.25 (95% CI = 1.14-1.37), respectively, in patients with rosacea. Stratified by sex, the HRs of AD were 1.28 (95% CI = 1.15-1.45) and 1.16 (95% CI = 1.00-1.35) in women and men, respectively. When results were stratified by age at study entry, the risk of AD was only significantly increased in individuals ≥60 years old (adjusted HR = 1.20, 95% CI = 1.08-1.32). When analyses were limited to patients with a hospital dermatologist diagnosis of rosacea only, the adjusted HRs of dementia and AD were 1.42 (95% CI = 1.17-1.72) and 1.92 (95% CI = 1.44-2.58), respectively. Rosacea is significantly associated with dementia, particularly AD. Increased focus on symptoms of cognitive dysfunction in older patients with rosacea may be relevant. Ann Neurol 2016;79:921-928. © 2016 American Neurological Association.

  14. Combined assessment of thrombotic and haemorrhagic risk in acute medical patients.

    PubMed

    La Regina, Micaela; Orlandini, Francesco; Marchini, Francesca; Marinaro, Alessia; Bonacci, Rosanna; Bonanni, Paola; Corsini, Francesca; Ceraudo, Anna Maria; Pacetti, Edoarda; Scuotri, Lucia; Costabile, Davide; Dentali, Francesco

    2016-01-01

    Acute medical patients have a high risk of venous thromboembolic events (VTE). Unfortunately, the fear of bleeding complications limits the use of antithrombotic prophylaxis in this setting. To stratify the VTE and haemorrhagic risk, two clinical scores (PADUA, IMPROVE) have recently been developed. However, it is not clear how many patients have a concomitant high VTE and haemorrhagic risk and what is the use of prophylaxis in this situation. To clarify these issues we performed a prospective cohort study enrolling consecutive patients admitted to internal medicine. Patients admitted to internal medicine (January to December 2013) were included. VTE and haemorrhagic risk were evaluated in all the included patients. Use and type of anti-thrombotic prophylaxis was recorded. A total of 1761 patients (mean age 77.6 years) were enrolled; 76.8% (95% CI 74.7-78.7) were at high VTE risk and 11.9% (95% CI 10.4-13.5) were at high haemorrhagic risk. Anti-thrombotic prophylaxis was used in 80.5% of patients at high VTE risk and in 6.5% at low VTE risk (p<0.001), and in 16.6% at high haemorrhagic risk and in 72.5% at low haemorrhagic risk (p<0.001). Prophylaxis was used in 20.4% at both high VTE and haemorrhagic risk and in 88.9% at high VTE risk but low haemorrhagic risk. At multivariate-analysis, use of prophylaxis appeared highly influenced by the VTE risk (OR 68.2, 95% CI 43.1 - 108.0). In conclusion, many patients admitted to internal medicine were at high risk of VTE. Since almost 90% of them were at low haemorrhagic risk, pharmacological prophylaxis may be safely prescribed in most of these patients.

  15. Stratified vapor generator

    DOEpatents

    Bharathan, Desikan [Lakewood, CO; Hassani, Vahab [Golden, CO

    2008-05-20

    A stratified vapor generator (110) comprises a first heating section (H.sub.1) and a second heating section (H.sub.2). The first and second heating sections (H.sub.1, H.sub.2) are arranged so that the inlet of the second heating section (H.sub.2) is operatively associated with the outlet of the first heating section (H.sub.1). A moisture separator (126) having a vapor outlet (164) and a liquid outlet (144) is operatively associated with the outlet (124) of the second heating section (H.sub.2). A cooling section (C.sub.1) is operatively associated with the liquid outlet (144) of the moisture separator (126) and includes an outlet that is operatively associated with the inlet of the second heating section (H.sub.2).

  16. Venous thromboembolism: a review of risk and prevention in colorectal surgery patients.

    PubMed

    Bergqvist, David

    2006-10-01

    Hospitalization for surgery has a high risk of developing venous thromboembolism, a condition that encompasses both deep-vein thrombosis and its potentially fatal complication, pulmonary embolism. Colorectal surgery implies a specific high risk for postoperative thromboembolic complications relative to other general surgery. This may be a result of pelvic dissection, the perioperative positioning of these patients, or the presence of additional risk factors common to this patient group, such as cancer, advanced age, or inflammatory bowel disease. The potential impact of venous thromboembolism and the need for effective thromboprophylaxis often are underestimated in these patients. Recommendations for thromboprophylaxis in colorectal surgery patients are based on the American College of Chest Physicians guidelines for thrombosis prevention in general surgery patients, with treatment stratified according to the type of surgery and additional venous thromboembolism risk factors present. Prophylaxis with low-molecular-weight heparin or unfractionated heparin is recommended for colorectal surgery patients classified as moderate to high risk. The small number of studies focusing specifically on colorectal patients, or on cancer or abdominal surgery patients with a colorectal subgroup, has shown that both low-molecular-weight heparin and unfractionated heparin can effectively reduce the incidence of venous thromboembolism. Low-molecular-weight heparin has the practical advantage of once-daily administration and shows a lower risk of heparin-induced thrombocytopenia. This review will assess the risk of venous thromboembolism in colorectal surgery patients and discuss current evidence-based guidelines and recommendations for prevention of venous thromboembolism.

  17. The impact of ART on TB case fatality stratified by CD4 count for HIV-positive TB patients in Cape Town, South Africa (2009–2011)

    PubMed Central

    Kaplan, Richard; Caldwell, Judy; Middelkoop, Keren; Bekker, Linda-Gail; MMed, Robin Wood

    2014-01-01

    Objective To identify determinants of TB case fatality including the impact of antiretroviral therapy (ART) at different CD4 thresholds for HIV-positive adult and adolescent TB patients. Methods Through a retrospective analysis of the electronic TB database, we identified the HIV status of newly registered patients ≥15 yrs. Multivariable Cox proportional hazard models were used to determine risk factors for TB case fatality in these patients. Results In 2009, 2010 and 2011, 25,841, 26,104 and 25,554 newly registered adult TB patients were treated in primary health care clinics in Cape Town, of whom 49.7%, 50.4% and 50.9% were HIV-positive. ART uptake increased over the three years from 43% to 64.9% and case fatality of the HIV-positive patients decreased from 7.0% to 5.8% (p<0.001). Female gender, increasing age, retreatment TB, low CD4 counts and extrapulmonary TB (EPTB) were associated with increased case fatality while patients on ART had a substantial decrease in case fatality. The difference in case fatality between patients on ART and not on ART was most pronounced at low CD4 counts with the positive influence of ART noted up to a CD4 count threshold of 350 cells/mm3 (p<0.001). Despite improvements in ART uptake, in 2011, 21% of patients with CD4 counts <350 cells/mm3 did not start ART during TB treatment. Conclusion This study showed a relatively poor uptake of ART among severely immune-compromised TB patients. Patients with CD4 counts <350 cells/mm3 were shown to clearly benefit from ART during TB treatment and ART initiation should be prioritised for this category of patients. PMID:24820105

  18. Cardiovascular risk of patients with gout seen at rheumatology clinics following a structured assessment.

    PubMed

    Andrés, Mariano; Bernal, José Antonio; Sivera, Francisca; Quilis, Neus; Carmona, Loreto; Vela, Paloma; Pascual, Eliseo

    2017-07-01

    Gout-associated cardiovascular (CV) risk relates to comorbidities and crystal-led inflammation. The aim was to estimate the CV risk by prediction tools in new patients with gout and to assess whether ultrasonographic carotid changes are present in patients without high CV risk. Cross-sectional study. Consecutive new patients with crystal-proven gout underwent a structured CV consultation, including CV events, risk factors and two risk prediction tools-the Systematic COronary Evaluation (SCORE) and the Framingham Heart Study (FHS). CV risk was stratified according to current European guidelines. Carotid ultrasound (cUS) was performed in patients with less than very high CV risk. The presence of carotid plaques was studied depending on the SCORE and FHS by the area under the curve (AUC) of receiver operating curves. 237 new patients with gout were recruited. CV stratification by scores showed a predominance of very high (95 patients, 40.1%) and moderate (72 patients, 30.5%) risk levels. cUS was performed in 142 patients, finding atheroma plaques in 66 (46.5%, 95% CI 37.8 to 54.2). Following cUS findings, patients classified as very high risk increased from 40.1% up to 67.9% (161/237 patients). SCORE and FHS predicted moderately (AUC 0.711 and 0.683, respectively) the presence of atheroma plaques at cUS. The majority of patients presenting with gout may be at very high CV risk, indicating the need for initiating optimal prevention strategies at this stage. Risk prediction tools appear to underestimate the presence of carotid plaque in patients with gout. 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/.

  19. Fluttering in Stratified Flows

    NASA Astrophysics Data System (ADS)

    Lam, Try; Vincent, Lionel; Kanso, Eva

    2016-11-01

    The descent motion of heavy objects under the influence of gravitational and aerodynamic forces is relevant to many branches of engineering and science. Examples range from estimating the behavior of re-entry space vehicles to studying the settlement of marine larvae and its influence on underwater ecology. The behavior of regularly shaped objects freely falling in homogeneous fluids is relatively well understood. For example, the complex interaction of a rigid coin with the surrounding fluid will cause it to either fall steadily, flutter, tumble, or be chaotic. Less is known about the effect of density stratification on the descent behavior. Here, we experimentally investigate the descent of discs in both pure water and in a linearly salt-stratified fluids where the density is varied from 1.0 to 1.14 of that of water where the Brunt-Vaisala frequency is 1.7 rad/sec and the Froude number Fr < 1. We found that stratification enhances the radial dispersion of the disc at landing, and simultaneously, decrease the descent speed and the inclination (or nutation) angle while falling. We conclude by commenting on the relevance of these results to the use of unpowered vehicles and robots for space exploration and underwater missions.

  20. Effect of low-dose aspirin on primary prevention of cardiovascular events in Japanese diabetic patients at high risk.

    PubMed

    Okada, Sadanori; Morimoto, Takeshi; Ogawa, Hisao; Sakuma, Mio; Soejima, Hirofumi; Nakayama, Masafumi; Sugiyama, Seigo; Jinnouchi, Hideaki; Waki, Masako; Doi, Naofumi; Horii, Manabu; Kawata, Hiroyuki; Somekawa, Satoshi; Soeda, Tsunenari; Uemura, Shiro; Saito, Yoshihiko

    2013-01-01

    Benefit of low-dose aspirin for primary prevention of cardiovascular events in diabetes remains controversial. The American Diabetes Association (ADA), the American Heart Association (AHA), and the American College of Cardiology Foundation (ACCF) recommend aspirin for high-risk diabetic patients: older patients with additional cardiovascular risk factors. We evaluated aspirin's benefit in Japanese diabetic patients stratified by cardiovascular risk. In the JPAD trial, we enrolled 2,539 Japanese patients with type 2 diabetes and no history of cardiovascular disease. We randomly assigned them to aspirin (81-100 mg daily) or no aspirin groups. The median follow-up period was 4.4 years. We stratified the patients into high-risk or low-risk groups, according to the US recommendation: age (older; younger) and coexisting cardiovascular risk factors. The risk factors included smoking, hypertension, dyslipidemia, family history of coronary artery disease, and proteinuria. Most of the patients were classified into the high-risk group, consisting of older patients with risk factors (n=1,804). The incidence of cardiovascular events was higher in this group, but aspirin did not reduce cardiovascular events (hazard ratio [HR], 0.83; 95% confidence interval [CI]: 0.58-1.17). In the low-risk group, consisting of older patients without risk factors and younger patients (n=728), aspirin did not reduce cardiovascular events (HR, 0.55; 95% CI: 0.23-1.21). These results were unchanged after adjusting for potential confounding factors. Low-dose aspirin is not beneficial in Japanese diabetic patients at high risk.

  1. Stratifying land use/land cover for spatial analysis of disease ecology and risk: an example using object-based classification techniques.

    PubMed

    Koch, David E; Mohler, Rhett L; Goodin, Douglas G

    2007-11-01

    Landscape epidemiology has made significant strides recently, driven in part by increasing availability of land cover data derived from remotely-sensed imagery. Using an example from a study of land cover effects on hantavirus dynamics at an Atlantic Forest site in eastern Paraguay, we demonstrate how automated classification methods can be used to stratify remotely-sensed land cover for studies of infectious disease dynamics. For this application, it was necessary to develop a scheme that could yield both land cover and land use data from the same classification. Hypothesizing that automated discrimination between classes would be more accurate using an object-based method compared to a per-pixel method, we used a single Landsat Enhanced Thematic Mapper+ (ETM+) image to classify land cover into eight classes using both per-pixel and object-based classification algorithms. Our results show that the object-based method achieves 84% overall accuracy, compared to only 43% using the per-pixel method. Producer's and user's accuracies for the object-based map were higher for every class compared to the per-pixel classification. The Kappa statistic was also significantly higher for the object-based classification. These results show the importance of using image information from domains beyond the spectral domain, and also illustrate the importance of object-based techniques for remote sensing applications in epidemiological studies.

  2. An Electronic Patient Risk Communication Board

    PubMed Central

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

    2012-01-01

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

  3. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery.

    PubMed

    Pinzur, Michael S; Gurza, Edward; Kristopaitis, Theresa; Monson, Rebecca; Wall, Michael J; Porter, Anne; Davidson-Bell, Victoria; Rapp, Timothy

    2009-07-01

    The introduction of the hospitalist co-management model represents an opportunity to improve care by changing the system as it applies to a small group of patients. Eighty-six consecutive patients with multiple comorbidities were selectively enrolled in an academic medical center hospitalist-orthopedic surgery co-management patient care program. Patients were stratified by all patient refined diagnosis-related groups, severity of illness, and risk of mortality. Hospital length of stay, cost of care, in-hospital mortality, complications, and intensive care unit admissions were compared with a retrospectively constructed control group of 54 patients undergoing similar surgery during the period immediately preceding initiation of the program. The University Health System Consortium observed-to-expected ratio for hospital length of stay was 0.693 compared to 0.862 for the control group. The severity of illness and risk of mortality scores represented a relatively higher risk stratification in the study group. While the overall observed-to-expected cost of care remained virtually unchanged, the positive impact of the study model revealed an increased positive effect on the more severely affected severity of illness and risk of mortality patients. The results of this study suggest that a proactive, cooperative, co-management model for the perioperative management of high-risk patients undergoing complex surgery can improve the quality and efficiency metrics associated with the delivery of service to patients.

  4. A hydrodynamics-based approach to evaluating the risk of waterborne pathogens entering drinking water intakes in a large, stratified lake.

    PubMed

    Hoyer, Andrea B; Schladow, S Geoffrey; Rueda, Francisco J

    2015-10-15

    Pathogen contamination of drinking water lakes and reservoirs is a severe threat to human health worldwide. A major source of pathogens in surface sources of drinking waters is from body-contact recreation in the water body. However, dispersion pathways of human waterborne pathogens from recreational beaches, where body-contact recreation is known to occur to drinking water intakes, and the associated risk of pathogens entering the drinking water supply remain largely undocumented. A high spatial resolution, three-dimensional hydrodynamic and particle tracking modeling approach has been developed to analyze the risk and mechanisms presented by pathogen dispersion. The pathogen model represents the processes of particle release, transport and survival. Here survival is a function of both water temperature and cumulative exposure to ultraviolet (UV) radiation. Pathogen transport is simulated using a novel and computationally efficient technique of tracking particle trajectories backwards, from a drinking water intake toward their source areas. The model has been applied to a large, alpine lake - Lake Tahoe, CA-NV (USA). The dispersion model results reveal that for this particular lake (1) the risk of human waterborne pathogens to enter drinking water intakes is low, but significant; (2) this risk is strongly related to the depth of the thermocline in relation to the depth of the intake; (3) the risk increases with the seasonal deepening of the surface mixed layer; and (4) the risk increases at night when the surface mixed layer deepens through convective mixing and inactivation by UV radiation is eliminated. While these risk factors will quantitatively vary in different lakes, these same mechanisms will govern the process of transport of pathogens.

  5. Radon: Counseling patients about risk

    SciTech Connect

    Birrer, R.B. )

    1990-09-01

    Exposure to radon and its decay products has increased as the United States has changed from an outdoor society to a largely indoor society. Radon, which is found primarily in the soil, enters houses and buildings through cracks, holes and pipes in foundation walls and floors. Although radon is suspected of being a significant cause of lung cancer, comparisons with other risk factors cannot yet be made. Radon levels in the home can be measured with commercially available kits. Guidelines for reducing the amount of radon in a home are provided by the U.S. Environmental Protection Agency.18 references.

  6. Predicting oncologic outcomes by stratifying mesorectal extension in patients with pT3 rectal cancer: a Japanese multi-institutional study.

    PubMed

    Akagi, Yoshito; Shirouzu, Kazuo; Fujita, Shin; Ueno, Hideki; Takii, Yasumasa; Komori, Koji; Ito, Masaaki; Sugihara, Kenichi

    2012-09-01

    The goal of this study was to clarify the clinical significance of mesorectal extension in pT3 rectal cancer. This currently remains unclear. Data from 975 consecutive patients with pT3 rectal cancer that underwent curative surgery at 28 institutes were reviewed. The distance of the mesorectal extension (DME) was measured histologically. The optimal prognostic cut-off point of the DME for oncologic outcomes was determined using the receiver operating characteristic curve and Cox regression analysis. When patients were subdivided into two groups according to the optimal cut-off point, DME≤4 mm and DME>4 mm, DME was found to be a powerful independent risk factor for postoperative recurrence. A DME>4 mm was significantly correlated with distant and local recurrences at Stage IIA and IIIB diseases. The recurrence-free 5-year-survival rate was significantly higher in patients with a DME≤4 mm [86.6% at Stage IIA (p=0.00015), and 68.7% at Stage IIIB (p<0.0001)] than in patients with a DME>4 mm (71.3% at Stage IIA and 49.1% at Stage IIIB). No significant difference was noted in the oncologic outcomes between the two groups at Stage IIIC. A value of 4 mm provides the best prognostic cut-off point for patient stratification and for the prediction of oncologic outcomes. A subclassification based on a 4-mm cut-off point may improve the utility of the TNM 7th staging system except for Stage IIIC. These findings warrant further prospective studies to determine the reliability and validity of this cut-off point. Copyright © 2011 UICC.

  7. Tumor biology in older breast cancer patients--what is the impact on survival stratified for guideline adherence? A retrospective multi-centre cohort study of 5378 patients.

    PubMed

    Ebner, Florian; van Ewijk, Reyn; Wöckel, Achim; Hancke, Katharina; Schwentner, Lukas; Fink, Visnja; Kreienberg, Rolf; Janni, Wolfgang; Blettner, Maria

    2015-06-01

    The tumor biology of older breast cancer patients (oBCP) is usually less aggressive, however applied adjuvant treatment is often less potent resulting in an impaired disease free survival and overall survival in this group. This study tries to answer the following questions for the biological subtypes of oBCP (70+ y): Between 1992 and 2008 the BRENDA ('BRENDA' = quality of BREast caNcer care unDer evidence-bAsed guidelines) study group recorded medical data of 17 participating certified breast cancer centers in Germany. We performed a retrospective multi-center database analysis of 5632 patient records. Guideline-adherent-treatment (GL+) of oBCP(n = 1918) was compared to GL+ of yBCP(n = 3714). OBCP were more likely to have hormone receptor positive (HR+) and HER2neu negative (HER2-) breast cancer (77.5% vs 74.5%). The rate of GL- was significantly different (p < 0.001) between the age groups and the biological subgroups (yBCP vs oBCP: 21.8%vs38.8% (HR+/HER2-); 30.6%vs49.7% (HR+/HER2+); 23.6%vs69.5% (HR-/HER2+); 31.4%vs67.8% (TNBC)). The survival parameters for HR+/HER2- and TNBC were significantly worse in case of GL- regarding chemotherapy, and if applicable endocrine therapy. A similar association only existed in HR-/HER2+ tumors for GL- for radiotherapy and in HR+/HER2+ tumors for chemotherapy. Beside the significantly different distribution of biological subtypes in the age groups there is an association between biological subtype, and GL+ influencing survival parameters in oBCP. Copyright © 2015 Elsevier Ltd. All rights reserved.

  8. Breast Cancer Risk Among Klinefelter Syndrome Patients

    PubMed Central

    Brinton, Louise A.

    2014-01-01

    Aim To evaluate male breast cancer (MBC) risk among Klinefelter Syndrome (KS) patients and relate this to possible biologic explanations. Methods A literature review was conducted to identify case series and epidemiologic studies that have evaluated MBC risk among KS patients. Results Case reports without expected values have often led to false impressions of risk. Problems include that a diagnosis of cancer can prompt a karyotypic evaluation and that many cases of KS are unrecognized, resulting in incomplete denominators. Few carefully conducted epidemiologic studies have been undertaken given that both KS and male breast cancer are rare events. The largest study found 19.2- and 57.8-fold increases in incidence and mortality, respectively, with particularly high risks among 47,XXY mosaics. These risks were still approximately 30% lower than among females, contradicting case reports that KS patients have breast cancer rates similar to females. Altered hormone levels (especially the ratio of estrogens to androgens), administration of exogenous androgens, gynecomastia, and genetic factors have been offered as possible explanations for the high risks. Conclusions Additional well-designed epidemiologic studies are needed to clarify which KS patients are at a high risk of developing MBC and to distinguish between possible predisposing factors, including altered endogenous hormones. PMID:21241366

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

    NASA Astrophysics Data System (ADS)

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

    2012-11-01

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

  10. Impact of an opioid risk reduction initiative on motor vehicle crash risk among chronic opioid therapy patients.

    PubMed

    Hansen, Ryan N; Walker, Rod L; Shortreed, Susan M; Dublin, Sascha; Saunders, Kathleen; Ludman, Evette J; Von Korff, Michael

    2017-01-01

    Although prescription opioids have been associated with higher motor vehicle crash (MVC) risk, it is unknown whether health system initiatives to better manage chronic opioid therapy (COT) can reduce MVC risk at the population level. We conducted an interrupted time series population-level cohort study at Group Health (GH), between January 2006 and September 2014, comparing MVC risk among COT patients who were GH members receiving care in either group practice or contracted care settings. Group practice COT risk reduction initiatives were implemented in two phases: (1) altered prescribing expectations and (2) multifaceted initiatives. These initiatives did not exist in the contracted care network. We compared the adjusted quarterly rate of MVC between group practice and contracted care patients over time using a modified Poisson regression model for a binary outcome. A total of 32 691 COT patients (27.4% from contracted care) met eligibility criteria and experienced a total of 1956 MVCs during study follow-up (mean, 8.1 quarters per person), of which 810 were serious injury crashes. Crash rates were not significantly different between the patient groups within any of the time periods. Analyses stratified by concurrent prescription of a sedative hypnotic or benzodiazepine found no significant difference between the group practice and contracted care patients. There was a modest elevation of MVC risk for high-dose patients relative to former COT patients who stopped receiving opioids. The risk of MVC was not mitigated in a large cohort of COT patients exposed to a health plan policy initiative that substantially lowered mean opioid dose. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  11. Predicting a clinically important outcome in patients with low back pain following McKenzie therapy or spinal manipulation: a stratified analysis in a randomized controlled trial.

    PubMed

    Petersen, Tom; Christensen, Robin; Juhl, Carsten

    2015-04-01

    Reports vary considerably concerning characteristics of patients who will respond to mobilizing exercises or manipulation. The objective of this prospective cohort study was to identify characteristics of patients with a changeable lumbar condition, i.e. presenting with centralization or peripheralization, that were likely to benefit the most from either the McKenzie method or spinal manipulation. 350 patients with chronic low back pain were randomized to either the McKenzie method or manipulation. The possible effect modifiers were age, severity of leg pain, pain-distribution, nerve root involvement, duration of symptoms, and centralization of symptoms. The primary outcome was the number of patients reporting success at two months follow-up. The values of the dichotomized predictors were tested according to the prespecified analysis plan. No predictors were found to produce a statistically significant interaction effect. The McKenzie method was superior to manipulation across all subgroups, thus the probability of success was consistently in favor of this treatment independent of predictor observed. When the two strongest predictors, nerve root involvement and peripheralization, were combined, the chance of success was relative risk 10.5 (95% CI 0.71-155.43) for the McKenzie method and 1.23 (95% CI 1.03-1.46) for manipulation (P = 0.11 for interaction effect). We did not find any baseline variables which were statistically significant effect modifiers in predicting different response to either McKenzie treatment or spinal manipulation when compared to each other. However, we did identify nerve root involvement and peripheralization to produce differences in response to McKenzie treatment compared to manipulation that appear to be clinically important. These findings need testing in larger studies. Clinicaltrials.gov: NCT00939107.

  12. China's community-based strategy of universal preconception care in rural areas at a population level using a novel risk classification system for stratifying couples´ preconception health status.

    PubMed

    Zhou, Qiongjie; Zhang, Shikun; Wang, Qiaomei; Shen, Haiping; Tian, Weidong; Chen, Jingqi; Acharya, Ganesh; Li, Xiaotian

    2016-12-28

    Preconception care (PCC) is recommended for optimizing a woman's health prior to pregnancy to minimize the risk of adverse pregnancy and birth outcomes. We aimed to evaluate the impact of strategy and a novel risk classification model of China´s "National Preconception Health Care Project" (NPHCP) in identifying risk factors and stratifying couples' preconception health status. We performed a secondary analysis of data collected by NPHCP during April 2010 to December 2012 in 220 selected counties in China. All couples enrolled in the project accepted free preconception health examination, risk evaluation, health education and medical advice. Risk factors were categorized into five preconception risk classes based on their amenability to prevention and treatment: A-avoidable risk factors, B- benefiting from targeted medical intervention, C-controllable but requiring close monitoring and treatment during pregnancy, D-diagnosable prenatally but not modifiable preconceptionally, X-pregnancy not advisable. Information on each couple´s socio-demographic and health status was recorded and further analyzed. Among the 2,142,849 couples who were enrolled to this study, the majority (92.36%) were from rural areas with low education levels (89.2% women and 88.3% men had education below university level). A total of 1463266 (68.29%) couples had one or more preconception risk factors mainly of category A, B and C, among which 46.25% were women and 51.92% were men. Category A risk factors were more common among men compared with women (38.13% versus 11.24%; P = 0.000). This project provided new insights into preconception health of Chinese couples of reproductive age. More than half of the male partners planning to father a child, were exposed to risk factors during the preconception period, suggesting that an integrated approach to PCC including both women and men is justified. Stratification based on the new risk classification model demonstrated that a majority of the

  13. Invasive Stratified Mucin-producing Carcinoma and Stratified Mucin-producing Intraepithelial Lesion (SMILE): 15 Cases Presenting a Spectrum of Cervical Neoplasia With Description of a Distinctive Variant of Invasive Adenocarcinoma.

    PubMed

    Lastra, Ricardo R; Park, Kay J; Schoolmeester, J Kenneth

    2016-02-01

    Stratified mucin-producing intraepithelial lesion (SMILE) is a cervical intraepithelial lesion, distinct from conventional squamous or glandular counterparts, believed to arise from embryonic cells at the transformation zone by transdifferentiation during high-risk HPV-associated carcinogenesis. It is characterized by stratified, immature epithelial cells displaying varying quantities of intracytoplasmic mucin throughout the majority of the lesional epithelium. We identified a distinct form of invasive cervical carcinoma with morphologic features identical to those in SMILE, which we have termed "invasive stratified mucin-producing carcinoma." Fifteen cases from 15 patients (mean 36 y; range, 22 to 64 y) were retrieved from the pathology archives of multiple institutions with a diagnosis of either SMILE or invasive cervical carcinoma with a description or comment about the invasive tumor's resemblance to SMILE. Seven cases had solely intraepithelial disease with a component of SMILE (mean 29 y; range, 22 to 40 y). The 8 other cases had invasive stratified mucin-producing carcinoma (mean 44; range, 34 to 64 y) in which SMILE was identified in 7. All cases of invasive stratified mucin-producing carcinoma demonstrated stratified, immature nuclei with intracytoplasmic mucin, which morphologically varied between cases from "mucin-rich" to "mucin-poor" in a similar manner to SMILE. All cases had mitotic figures and apoptotic debris, and an intralesional neutrophilic infiltrate was seen in the majority of cases. In cases of invasive carcinoma, the depth of invasion ranged from <1 to 19 mm. Follow-up information was available in 8 cases and ranged from 1 to 36 months (mean 11 mo). Three cases of invasive stratified mucin-producing carcinoma had biopsy or resection-proven metastatic carcinoma on follow-up. These 15 cases of cervical stratified mucin-producing lesions show a combination of intraepithelial and invasive growth patterns. Given that SMILE is well rooted as a

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

    PubMed Central

    Grant, Cynthia L; Lusk, Jaimie L

    2015-01-01

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

  15. A cost-effectiveness analysis comparing a clinical decision rule versus usual care to risk stratify children for intraabdominal injury after blunt torso trauma.

    PubMed

    Nishijima, Daniel K; Yang, Zhuo; Clark, John A; Kuppermann, Nathan; Holmes, James F; Melnikow, Joy

    2013-11-01

    Recently a clinical decision rule (CDR) to identify children at very low risk for intraabdominal injury needing acute intervention (IAI) following blunt torso trauma was developed. Potential benefits of a CDR include more appropriate abdominal computed tomography (CT) use and decreased hospital costs. The objective of this study was to compare the cost-effectiveness of implementing the CDR compared to usual care for the evaluation of children with blunt torso trauma. The hypothesis was that compared to usual care, implementation of the CDR would result in lower CT use and hospital costs. A cost-effectiveness decision analytic model was constructed comparing the costs and outcomes of implementation of the CDR to usual care in the evaluation of children with blunt torso trauma. Probabilities from a multicenter cohort study of children with blunt torso trauma were derived; estimated costs were based on those at the study coordinating site. Outcome measures included missed IAI, number of abdominal CT scans, total costs, and incremental cost-effectiveness ratios. Sensitivity analyses varying imputed probabilities, costs, and scenarios were conducted. Using a hypothetical cohort of 1,000 children with blunt torso trauma, the base case model projected that the implementation of the CDR would result in 0.50 additional missed IAIs, a total cost savings of $54,527, and 104 fewer abdominal CT scans compared to usual care. The usual care strategy would cost $108,110 to prevent missing one additional IAI. Findings were robust under multiple sensitivity analyses. Compared to usual care, implementation of the CDR in the evaluation of children with blunt torso trauma would reduce hospital costs and abdominal CT imaging, with a slight increase in the risk of missed intraabdominal IAI. © 2013 by the Society for Academic Emergency Medicine.

  16. Radiation risks for patients having X rays

    SciTech Connect

    Hale, J.; Thomas, J.W.

    1985-12-01

    In addition to radiation from naturally occurring radioactive materials and cosmic rays, individuals in developed countries receive radiation doses to bone marrow and gonads from the medical diagnostic use of X rays. A brief discussion of radiation epidemiology shows that deleterious effects are low even when doses are high. The concept of acceptable risk is introduced to help evaluate the small, but still existent, risks of radiation dose. Examples of bone marrow and gonadal doses for representative X-ray examinations are presented along with the current best estimates, per unit of X-ray dose, of the induction of leukemia or of genetic harm. The risk to the patient from an examination can then be compared with the normal risk of mortality from leukemia or of the occurrence of genetic defects. The risk increase is found to be very low. The risks to unborn children from radiographic examinations are also discussed. The benefit to the patient from information obtained from the examination must be balanced against the small risks.

  17. Telomere stability is frequently impaired in high-risk groups of patients with myelodysplastic syndromes.

    PubMed

    Ohyashiki, J H; Iwama, H; Yahata, N; Ando, K; Hayashi, S; Shay, J W; Ohyashiki, K

    1999-05-01

    Genomic instability induces an accumulation of genetic changes and may play a role in the pathogenesis of myelodysplastic syndromes (MDS). To clarify the possible association between genomic instability and clinical outcome in MDS patients, we compared telomere dynamics to the recently established International Prognostic Scoring System (IPSS) risk groups for MDS. We measured the terminal restriction fragments (TRFs) of 93 patients with MDS at the time of diagnosis, and telomerase activity was analyzed in 62 patients with MDS using the PCR-based telomeric repeat amplification protocol (TRAP) assay. A total of 53 of 93 MDS patients had TRFs within the age-matched normal range, and the remaining patients showed shortened TRFs (35 patients) or elongated TRFs (5 patients). MDS patients with shortened TRFs had a significantly low hemoglobin concentration (P = 0.04), a high percentage of marrow blasts (P = 0.02), and a high incidence of cytogenetic abnormalities (P < 0.05). The incidence of leukemic transformation was significantly high in patients with shortened TRF length (P < 0.05). In addition, patients with shortened TRF length were frequently seen in the IPSS high-risk group (P < 0.01). Most of the MDS patients had normal-to-low levels of telomerase activity, suggesting that changes in TRF length rather than telomerase activity may more accurately reflect the pathophysiology of MDS. MDS patients with shortened TRF length had a very poor prognosis (P < 0.01), suggesting that telomere dynamics may be linked to clinical outcome in MDS patients. Thus, an abnormal mechanism of telomere maintenance in subgroups of MDS patients may be an early indication of genomic instability. This study demonstrates that telomere stability is frequently impaired in a high-risk group of MDS patients and suggests that, in combination with the IPSS classification system, measurement of TRFs may be useful in the future to stratify MDS patients according to risk and manage the care of MDS

  18. Risk of cancer among patients with herpes zoster infection: a population-based study

    PubMed Central

    Wang, Yu-Ping; Liu, Chia-Jen; Hu, Yu-Wen; Chen, Tzeng-Ji; Lin, Yi-Tsung; Fung, Chang-Phone

    2012-01-01

    Background: Whether the risk of cancer is increased among patients with herpes zoster is unclear. We investigated the risk of cancer among patients with herpes zoster using a nationwide health registry in Taiwan. Methods: We identified 35 871 patients with newly diagnosed herpes zoster during 2000–2008 from the National Health Insurance Research Database in Taiwan. We analyzed the standardized incidence ratios for various types of cancer. Results: Among patients with herpes zoster, 895 cases of cancer were reported. Patients with herpes zoster were not at increased risk of cancer (standardized incidence ratio 0.99, 95% confidence interval 0.93–1.06). Among the subgroups stratified by sex, age and years of follow-up, there was also no increased risk of overall cancer. Interpretation: Herpes zoster is not associated with increased risk of cancer in the general population. These findings do not support extensive investigations for occult cancer or enhanced surveillance for cancer in patients with herpes zoster. PMID:22988158

  19. Individual and Combined Risk Factors for Incident Atrial Fibrillation and Incident Stroke: An Analysis of 3 Million At-Risk US Patients

    PubMed Central

    Chyou, Janice Y; Hunter, Tina D; Mollenkopf, Sarah A; Turakhia, Mintu P; Reynolds, Matthew R

    2015-01-01

    Background The incremental effects of risk factor combinations for atrial fibrillation (AF) and stroke are incompletely understood. We sought to quantify the risks of incident AF and stroke for combinations of established risk factors in a large US sample. Methods and Results Patients with no evidence of AF or stroke in 2007 were stratified by combinations of the following risk factors: heart failure, hypertension, diabetes, age 65 to 74, age ≥75, coronary artery disease, and chronic kidney disease. Patients with ≥2 of the first 5 or ≥3 of the first 7, classified as “high-risk,” and an age-matched sample of patients with fewer risk factors, classified as “low-risk,” were followed over 2008–2010 for incident AF and stroke. Annualized incidence rates and risks were quantified for each combination of factors by using Cox regression. Annualized incidence rates for AF, stroke, and both were 3.59%, 3.27%, and 0.62% in 1 851 653 high-risk patients and 1.32%, 1.48%, and 0.18% in 1 156 221 low-risk patients, respectively. Among patients with 1 risk factor, those with age ≥75 had the highest hazards of incident AF and stroke (HR 9.2, 6.9). Among patients with 2 risk factors, those with age ≥75 and heart failure had the highest annualized incidence rates of AF and stroke (10.2%, 5.9%). The combination of age ≥75 and hypertension was prevalent and had the highest incidences of AF and stroke. Conclusions Adults with combinations of known risk factors are at increased risk of incident AF and stroke, but combinations of risk factors are not always additive. PMID:26206736

  20. Prevalence and Risk Factors of Overweight and Obesity among Children Aged 6-59 Months in Cameroon: A Multistage, Stratified Cluster Sampling Nationwide Survey.

    PubMed

    Tchoubi, Sébastien; Sobngwi-Tambekou, Joëlle; Noubiap, Jean Jacques N; Asangbeh, Serra Lem; Nkoum, Benjamin Alexandre; Sobngwi, Eugene

    2015-01-01

    Childhood obesity is one of the most serious public health challenges of the 21st century. The prevalence of overweight and obesity among children (<5 years) in Cameroon, based on weight-for-height index, has doubled between 1991 and 2006. This study aimed to determine the prevalence and risk factors of overweight and obesity among children aged 6 months to 5 years in Cameroon in 2011. Four thousand five hundred and eighteen children (2205 boys and 2313 girls) aged between 6 to 59 months were sampled in the 2011 Demographic Health Survey (DHS) database. Body Mass Index (BMI) z-scores based on WHO 2006 reference population was chosen to estimate overweight (BMI z-score > 2) and obesity (BMI for age > 3). Regression analyses were performed to investigate risk factors of overweight/obesity. The prevalence of overweight and obesity was 8% (1.7% for obesity alone). Boys were more affected by overweight than girls with a prevalence of 9.7% and 6.4% respectively. The highest prevalence of overweight was observed in the Grassfield area (including people living in West and North-West regions) (15.3%). Factors that were independently associated with overweight and obesity included: having overweight mother (adjusted odds ratio (aOR) = 1.51; 95% CI 1.15 to 1.97) and obese mother (aOR = 2.19; 95% CI = 155 to 3.07), compared to having normal weight mother; high birth weight (aOR = 1.69; 95% CI 1.24 to 2.28) compared to normal birth weight; male gender (aOR = 1.56; 95% CI 1.24 to 1.95); low birth rank (aOR = 1.35; 95% CI 1.06 to 1.72); being aged between 13-24 months (aOR = 1.81; 95% CI = 1.21 to 2.66) and 25-36 months (aOR = 2.79; 95% CI 1.93 to 4.13) compared to being aged 45 to 49 months; living in the grassfield area (aOR = 2.65; 95% CI = 1.87 to 3.79) compared to living in Forest area. Muslim appeared as a protective factor (aOR = 0.67; 95% CI 0.46 to 0.95).compared to Christian religion. This study underlines a high prevalence of early childhood overweight with significant

  1. Prevalence and Risk Factors of Overweight and Obesity among Children Aged 6–59 Months in Cameroon: A Multistage, Stratified Cluster Sampling Nationwide Survey

    PubMed Central

    Tchoubi, Sébastien; Sobngwi-Tambekou, Joëlle; Noubiap, Jean Jacques N.; Asangbeh, Serra Lem; Nkoum, Benjamin Alexandre; Sobngwi, Eugene

    2015-01-01

    Background Childhood obesity is one of the most serious public health challenges of the 21st century. The prevalence of overweight and obesity among children (<5 years) in Cameroon, based on weight-for-height index, has doubled between 1991 and 2006. This study aimed to determine the prevalence and risk factors of overweight and obesity among children aged 6 months to 5 years in Cameroon in 2011. Methods Four thousand five hundred and eighteen children (2205 boys and 2313 girls) aged between 6 to 59 months were sampled in the 2011 Demographic Health Survey (DHS) database. Body Mass Index (BMI) z-scores based on WHO 2006 reference population was chosen to estimate overweight (BMI z-score > 2) and obesity (BMI for age > 3). Regression analyses were performed to investigate risk factors of overweight/obesity. Results The prevalence of overweight and obesity was 8% (1.7% for obesity alone). Boys were more affected by overweight than girls with a prevalence of 9.7% and 6.4% respectively. The highest prevalence of overweight was observed in the Grassfield area (including people living in West and North-West regions) (15.3%). Factors that were independently associated with overweight and obesity included: having overweight mother (adjusted odds ratio (aOR) = 1.51; 95% CI 1.15 to 1.97) and obese mother (aOR = 2.19; 95% CI = 155 to 3.07), compared to having normal weight mother; high birth weight (aOR = 1.69; 95% CI 1.24 to 2.28) compared to normal birth weight; male gender (aOR = 1.56; 95% CI 1.24 to 1.95); low birth rank (aOR = 1.35; 95% CI 1.06 to 1.72); being aged between 13–24 months (aOR = 1.81; 95% CI = 1.21 to 2.66) and 25–36 months (aOR = 2.79; 95% CI 1.93 to 4.13) compared to being aged 45 to 49 months; living in the grassfield area (aOR = 2.65; 95% CI = 1.87 to 3.79) compared to living in Forest area. Muslim appeared as a protective factor (aOR = 0.67; 95% CI 0.46 to 0.95).compared to Christian religion. Conclusion This study underlines a high prevalence of

  2. A venous thromboembolism risk assessment model for patients with Cushing's syndrome.

    PubMed

    Zilio, Marialuisa; Mazzai, Linda; Sartori, Maria Teresa; Barbot, Mattia; Ceccato, Filippo; Daidone, Viviana; Casonato, Alessandra; Saggiorato, Graziella; Noventa, Franco; Trementino, Laura; Prandoni, Paolo; Boscaro, Marco; Arnaldi, Giorgio; Scaroni, Carla

    2016-05-01

    Cushing's syndrome (CS) is associated with an incidence of venous thromboembolism (VTE) about ten times higher than in the normal population. The aim of our study was to develop a model for identifying CS patients at higher risk of VTE. We considered clinical, hormonal, and coagulation data from 176 active CS patients and used a forward stepwise logistic multivariate regression analysis to select the major independent risk factors for thrombosis. The risk of VTE was calculated as a 'CS-VTE score' from the sum of points of present risk factors. VTE developed in 20 patients (4 pulmonary embolism). The group of CS patients with VTE were older (p < 0.001) and had more cardiovascular events (p < 0.05), infections and reduced mobility (both p < 0.001), higher midnight plasma cortisol levels (p < 0.05), and shorter APTT (p < 0.01) than those without. We identified six major independent risk factors for VTE: age ≥69 years and reduced mobility were given two points each, whereas acute severe infections, previous cardiovascular events, midnight plasma cortisol level >3.15 times the normality and shortened APTT were given one point each. A CS-VTE score <2 anticipated no risk of VTE; a CS-VTE score of two mild risk (10 %); a CS-VTE score of three moderate risk (46 %); a CS-VTE score ≥4 high risk (85 %). Considering a score ≥3 as predictive of VTE, 94 % of the patients were correctly classified. A simple score helps stratify the VTE risk in CS patients and identify those who could benefit from thromboprophylaxis.

  3. Prevalence and risk of cardiovascular risk factors and events in offspring of patients at high vascular risk and effect of location of parental vascular disease.

    PubMed

    Weijmans, Maaike; van der Graaf, Yolanda; de Borst, Gert Jan; Asselbergs, Folkert W; Cramer, Maarten J; Algra, Ale; Visseren, Frank L J

    2015-09-15

    Offspring of patients with cardiovascular disease are at increased risk of developing cardiovascular events. We evaluated whether prevalence of risk factors in offspring of patients with increased cardiovascular risk is higher compared with the general population and whether the risk of cardiovascular events and prevalence of cardiovascular risk factors in offspring is dependent on parental vascular disease location. Of 4270 patients enrolled in the SMART cohort we assessed after a follow-up of 7 years (IQR 4-8) the presence of cardiovascular risk factors and disease in their 10,572 children by questionnaire. The SMART patients had symptomatic vascular disease (coronary artery disease (CAD) (n = 1826), cerebrovascular disease (CVD) (n = 637), peripheral artery disease (PAD) (n = 275), abdominal aortic aneurysm (AAA) (n = 98), polyvascular disease (≥ 2 vascular manifestations) (n = 371)) or risk factors (hypercholesterolemia, diabetes, hypertension) (n = 1063). The prevalence of risk factors in offspring was compared with the general population and stratified for parental vascular disease location. The relation between parental vascular disease location and cardiovascular events in offspring was determined by Poisson regression. The offspring had higher prevalence of in particular hypercholesterolemia and hypertension compared with the general population, irrespective of the parental vascular disease location. Higher risks of cardiovascular events compared with offspring of patients without manifest vascular disease were observed in offspring of patients with CAD (PR 1.8, 95%CI 0.9-3.4), CVD (PR 2.4, 95%CI 1.2-4.8), PAD (PR 2.8, 95%CI 1.3-6.4), polyvascular disease (PR 2.5, 95%CI 1.2-5.2), but not with AAA (PR 1.7, 95%CI 0.5-6.1). In offspring from patients with cardiovascular disease or risk factors, the prevalence of traditional risk factors was higher compared with the general population, independent of the location of vascular disease of the parent. Offspring

  4. Cancer Risk in Patients With Empyema

    PubMed Central

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

    2016-01-01

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

  5. [Patient safety in antibiotics administration: Risk assessment].

    PubMed

    Maqueda Palau, M; Pérez Juan, E

    To determine the level of risk in the preparation and administration of antibiotics frequently used in the Intensive Care Unit using a risk matrix. A study was conducted using situation analysis and literature review of databases, protocols and good practice guidelines on intravenous therapy, drugs, and their administration routes. The most used antibiotics in the ICU registered in the ENVIN-HELICS program from 1 April to 30 June 2015 were selected. In this period, 257 patients received antimicrobial treatment and 26 antibiotics were evaluated. Variables studied: A risk assessment of each antibiotic using the scale Risk Assessment Tool, of the National Patient Safety Agency, as well as pH, osmolarity, type of catheter recommended for administration, and compatibility and incompatibility with other antibiotics studied. Almost two-thirds (65.3%) of antibiotics had more than 3 risk factors (represented by a yellow stripe), with the remaining 34.7% of antibiotics having between 0 and 2 risk factors (represented by a green stripe). There were no antibiotics with 6 or more risk factors (represented by a red stripe). Most drugs needed reconstitution, additional dilution, and the use of part of the vial to administer the prescribed dose. More than half of the antibiotics studied had a moderate risk level; thus measures should be adopted in order to reduce it. The risk matrix is a useful tool for the assessment and detection of weaknesses associated with the preparation and administration of intravenous antibiotics. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

  6. Effectiveness of Early Preventive Intervention with Semiannual Fluoride Varnish Application in Toddlers Living in High-Risk Areas: A Stratified Cluster-Randomized Controlled Trial.

    PubMed

    Anderson, Maria; Dahllöf, Göran; Twetman, Svante; Jansson, Leif; Bergenlid, Ann-Cathrine; Grindefjord, Margaret

    2016-01-01

    This study evaluated whether toddlers in an extended preventive program of semiannual fluoride varnish applications from 1 year of age had a lower incidence of caries than those undergoing a standard program. A cohort of 1-year-old children (n = 3,403) living in multicultural areas of low socioeconomic standing in Stockholm participated in a cluster-randomized controlled field trial with two parallel arms. The children attended 23 dental clinics. Using the ICDAS II criteria, the examiners recorded caries at baseline and after 1 and 2 years. The children in the reference group received a standardized oral health program once yearly between 1 and 3 years of age. The children in the test group received the same standard program supplemented with topical applications of fluoride varnish every 6 months. We compared the test group and the reference group for the prevalence and increment of caries. At baseline, 5% of the children had already developed caries (ICDAS II 1-6). We reexamined the children after 1 year (n = 2,675) and after 2 years (n = 2,536). Neither prevalence nor caries increment differed between the groups. At 3 years of age, 12% of the children had developed moderate and severe carious lesions (ICDAS II 3-6), with a mean increment of 0.5 (SD 2.4) in the test group and 0.6 (SD 2.2) in the reference group. In conclusion, semiannual professional applications of fluoride varnish, as a supplement to a standard oral health program, failed to reduce caries development in toddlers from high-risk communities. © 2016 S. Karger AG, Basel.

  7. Cancer risks in Crohn disease patients.

    PubMed

    Hemminki, K; Li, X; Sundquist, J; Sundquist, K

    2009-03-01

    Patients diagnosed with Crohn disease (CD) are known to be at an increased risk of bowel cancers and lymphoma. CD is an autoimmune disease and we hypothesize that the patients are predisposed to a wider spectrum of cancers. A CD research database was constructed by identifying hospitalized CD patients from the Hospital Discharge Register and cancer patients from the Swedish Cancer Registry. Follow-up of 21 788 CD patients first hospitalized during the years 1964-2004 identified 1424 cancer cases. Standardized incidence ratios (SIRs) were calculated by comparing cancers in CD patients with subjects without CD. In addition to the known sites, many additional sites were in excess in CD patients. These included liver, pancreatic, lung, prostate, testicular, kidney and skin (squamous cell) cancers; nonthyroid endocrine tumors and leukemia. The previously established sites showed the highest SIRs; however, SIRs >2.0 were noted for the novel sites of the liver, testis and kidney. For testicular cancer, the SIR of seminoma was 2.74. Cancer risks were influences by age at first hospitalization for CD but whether the age effects were increasing or decreasing depending on the cancer type. This large study identified many novel subsequent cancers in CD patients.

  8. Suspected spinal cord compression in cancer patients: a multidisciplinary risk assessment.

    PubMed

    Lu, Charles; Gonzalez, Ramon G; Jolesz, Ferenc A; Wen, Patrick Y; Talcott, James A

    2005-01-01

    Investigators involved in this study sought to identify independent clinical predictors of spinal cord compression (SCC) in cancer patients by analyzing a comprehensive set of potential risk factors based on the results of spine magnetic resonance imaging (MRI). In all, the investigators analyzed 136 episodes of suspected SCC among 134 cancer patients evaluated with spine MRI. Each subject was interviewed within 7 days of the spine MRI to collect accurate self-reported symptom data. Neurologic examination data were detailed by the physician examining the subject prior to the spine MRI; uniform demographic and clinical information regarding the subject's cancer history was abstracted from the medical record. Multivariable logistic regression analysis was used to identify independent predictors of SCC. Clinically significant SCC was defined as thecal sac compression (TSC), which occurred in 50 episodes (37%). Four independent predictors of TSC were identified and included information from the neurologic examination (abnormal neurologic examination), subject-reported symptoms (middle or upper back pain), and the oncologic history (known vertebral metastases and metastatic disease at initial diagnosis). These four predictors stratified patients experiencing episodes into subgroups with varying risks of TSC, ranging from 8% (no risk factors) to 81% (three or four risk factors). These results confirmed earlier retrospective studies indicating that the evaluation of cancer patients with suspected SCC should be based upon clinical information that includes cancer-related history, symptom data,and the presence of pertinent neurologic signs. These predictors may help clinicians to assess risk in this patient population.

  9. Surgical jejunostomy in aspiration risk patients.

    PubMed Central

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

    1992-01-01

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

  10. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient: The Imaging Council of the American College of Cardiology.

    PubMed

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

    2016-02-01

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

  11. Risk Prediction for Acute Hypotensive Patients by Using Gap Constrained Sequential Contrast Patterns

    PubMed Central

    Ghosh, Shameek; Feng, Mengling; Nguyen, Hung; Li, Jinyan

    2014-01-01

    The development of acute hypotension in a critical care patient causes decreased tissue perfusion, which can lead to multiple organ failures. Existing systems that employ population level prognostic scores to stratify the risks of critical care patients based on hypotensive episodes are suboptimal in predicting impending critical conditions, or in directing an effective goal-oriented therapy. In this work, we propose a sequential pattern mining approach which target novel and informative sequential contrast patterns for the detection of hypotension episodes. Our results demonstrate the competitiveness of the approach, in terms of both prediction performance as well as knowledge interpretability. Hence, sequential patterns-based computational biomarkers can help comprehend unusual episodes in critical care patients ahead of time for early warning systems. Sequential patterns can thus aid in the development of a powerful critical care knowledge discovery framework for facilitating novel patient treatment plans. PMID:25954447

  12. Sleep apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk stratification: an exploration of feasibility

    PubMed Central

    Lyons, M Melanie; Bhatt, Nitin Y; Kneeland-Szanto, Elizabeth; Keenan, Brendan T; Pechar, Joanne; Stearns, Branden; Elkassabany, Nabil M; Memtsoudis, Stavros G; Pack, Allan I; Gurubhagavatula, Indira

    2016-01-01

    Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing total joint arthroplasty (TJA) and is a major risk factor for postoperative cardiovascular complications and death. Recognizing this, the American Society of Anesthesiologists urges clinicians to implement special considerations in the perioperative care of OSA patients. However, as the volume of patients presenting for TJA increases, resources to implement these recommendations are limited. This necessitates mechanisms to efficiently risk stratify patients having OSA who may be susceptible to post-TJA cardiovascular complications. We explore the role of perioperative measurement of cardiac troponins (cTns) and brain natriuretic peptides (BNPs) in helping determine which OSA patients are at increased risk for post-TJA cardiovascular-related morbidity. PMID:26925513

  13. Implementing stratified primary care management for low back pain: cost-utility analysis alongside a prospective, population-based, sequential comparison study.

    PubMed

    Whitehurst, David G T; Bryan, Stirling; Lewis, Martyn; Hay, Elaine M; Mullis, Ricky; Foster, Nadine E

    2015-03-15

    Within-study cost-utility analysis. To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain). Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up. Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence. Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean health care cost savings of £124 and an incremental QALY estimate of 0.023. The likelihood that stratified care provides a cost-effective use of resources for patients at low and medium risk is no greater than 60% irrespective of a decision makers' willingness-to-pay for additional QALYs. Patients at medium and high risk of persistent disability in paid employment at 6-month follow-up reported, on average, 6 fewer days of LBP-related work absence in the stratified care cohort compared with usual care (associated societal cost savings per employed patient of £736 and £652, respectively). At the observed level of adherence to screening tool recommendations for matched treatments, stratified care for LBP is cost-effective for patients at high risk of persistent disabling LBP only. 2.

  14. [Draft of the best medical treatment in patients with low-risk thyroid cancer].

    PubMed

    Vlček, Petr; Nováková, Dagmar; Vejvalka, Jan; Zimák, Jaroslav; Křenek, Martin; Vošmiková, Květuše; Smutný, Svatopluk; Bavor, Petr; Astl, Jaromír; Lukáš, Jindřich

    2015-09-01

    and follicular microcarcinoma size 10-15 mm. The histological initial finding captured unifocal type of cancer in 344 patients, multifocality in 123 patients, in 45 cases local metastases and in 3 cases of pulmonary metastases. Group D: 259 patients were monitored in this group with breast size 16-20 mm. At the initial finding was captured one bearing cancer in 188 patients, multifocality in 71 patients, in 24 cases evidence of local metastases and 2 patients had a case of distant lung metastases. In patients in whom risk factors were found, radioiodine treatment was indicated. This included 744 patients. In this group of patients after a year or more, relapse was observed in 74 patients (9.94 %). In 1 236 patients who did not undergo radioiodine treatment, there was a relapse in 49 patients (3.96 %). Based on our analysis, it is necessary to stratify the risk of relapse according to risk factors. In case of missed radioiodine therapy in patients with low-risk cancer without confirmed risk factors, it is also necessary to have regular clinical, laboratory and ultrasound examination. It is important to distinguish patients with risk factors that may contribute to disease recurrence. Only in this way, on one hand we prevent excessive treatment of patients with low-risk thyroid cancer which leads to increased cost of health care, and on the other hand prevent reduced level of care for patients with an increase in relapses.

  15. Exploring Dynamic Risk Prediction for Dialysis Patients

    PubMed Central

    Ganssauge, Malte; Padman, Rema; Teredesai, Pradip; Karambelkar, Ameet

    2016-01-01

    Despite substantial advances in the treatment of end-stage renal disease, mortality of hemodialysis patients remains high. Several models exist that predict mortality for this population and identify patients at risk. However, they mostly focus on patients at a particular stage of dialysis treatment, such as start of dialysis, and only use the most recent patient data. Generalization of such models for predictions in later periods can be challenging since disease characteristics change over time and the evolution of biomarkers is not adequately incorporated. In this research, we explore dynamic methods which allow updates of initial predictions when patients progress in time and new data is observed. We compare a Dynamic Bayesian Network (DBN) to regularized logistic regression models and a Cox model with landmarking. Our preliminary results indicate that the DBN achieves satisfactory performance for short term prediction horizons, but needs further refinement and parameter tuning for longer horizons. PMID:28269937

  16. Sensemaking of Patient Safety Risks and Hazards

    PubMed Central

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

    2006-01-01

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

  17. Increased risk for nonmelanoma skin cancers in patients who receive thiopurines for inflammatory bowel disease.

    PubMed

    Peyrin-Biroulet, Laurent; Khosrotehrani, Kiarash; Carrat, Fabrice; Bouvier, Anne-Marie; Chevaux, Jean-Baptiste; Simon, Tabassome; Carbonnel, Frank; Colombel, Jean-Frédéric; Dupas, Jean-Louis; Godeberge, Philippe; Hugot, Jean-Pierre; Lémann, Marc; Nahon, Stéphane; Sabaté, Jean-Marc; Tucat, Gilbert; Beaugerie, Laurent

    2011-11-01

    Patients with inflammatory bowel disease (IBD) who have been exposed to thiopurines might have an increased risk of skin cancer. We assessed this risk among patients in France. We performed a prospective observational cohort study of 19,486 patients with IBD, enrolled from May 2004 to June 2005, who were followed up until December 31, 2007. The incidence of nonmelanoma skin cancer (NMSC) in the general population, used for reference, was determined from the French Network of Cancer Registries. Before the age of 50 years, the crude incidence rates of NMSC among patients currently receiving or who previously received thiopurines were 0.66/1000 and 0.38/1000 patient-years, respectively; these values were 2.59/1000 and 1.96/1000 patient-years for the age group of 50 to 65 years and 4.04/1000 and 5.70/1000 patient-years for patients older than 65 years. Among patients who had never received thiopurines, the incidence of NMSC was zero before the age of 50 years, 0.60/1000 for the ages of 50 to 65 years, and 0.84/1000 for those older than 65 years. A multivariate Cox regression model stratified by propensity score quintiles showed that ongoing thiopurine treatment (hazard ratio [HR], 5.9; 95% confidence interval [CI], 2.1-16.4; P = .0006) and past thiopurine exposure (HR, 3.9; 95% CI, 1.3-12.1; P = .02) were risk factors for NMSC. They also identified age per 1-year increase as a risk factor for NMSC (HR, 1.08; 95% CI, 1.05-1.11; P < .0001). Ongoing and past exposure to thiopurines significantly increases the risk of NMSC in patients with IBD, even before the age of 50 years. These patients should be protected against UV radiation and receive lifelong dermatologic screening. Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.

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

    PubMed Central

    Andrechuk, Carla Renata Silva; Ceolim, Maria Filomena

    2015-01-01

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

  19. Risk of Premenopausal and Postmenopausal Breast Cancer among Multiple Sclerosis Patients

    PubMed Central

    Montgomery, Scott; Burkill, Sarah; Bahmanyar, Shahram

    2016-01-01

    Objective To investigate risk of premenopausal and postmenopausal breast cancer among Multiple Sclerosis (MS) patients, considering tumor stage. Methods The Swedish Patient Register identified 19,330 women with MS between 1968 and 2012, matched individually with a cohort of 193,458 without MS. Matching variables were year of birth, sex, region of residence and vital status at the time of diagnosis. The cancer register identified 471 and 5,753 breast cancer cases among the MS and non-MS cohorts, respectively. Cox proportional hazard models estimated hazard ratios (HR) and 95% confidence intervals (CI) for premenopausal and postmenopausal breast cancer. Results Overall risk of postmenopausal breast cancer was 13% higher among MS patients compared with women without MS (HR = 1.13, 95% CI 1.02–1.26). Stratified analyses showed that the risk was statistically significantly increased in women diagnosed between 1968 and 1980 and those who were diagnosed at age 65 or older age. We observed a non-statistically significant risk only for stage 0–1 postmenopausal breast cancer (HR = 1.17, 95% CI 0.93–1.48). MS was not associated with premenopausal breast cancer. Conclusion The modest increased risk of postmenopausal breast cancer in women with MS may be due to surveillance bias, where contact with health services for one disease increases the risk of a second diagnosis being recorded. PMID:27776164

  20. [Cardiovascular polypill in high risk patients].

    PubMed

    Lafeber, Melvin; Spiering, Wilko; Bots, Michiel L; de Valk, Vincent; Visseren, Frank L J; Grobbee, Diederick E

    2011-01-01

    The initial theoretical concept of a polypill was a fixed-dosed combination pill containing an antiplatelet agent, a cholesterol-lowering agent and multiple blood pressure-lowering agents aimed at the prevention of atherosclerotic vascular disease in the population aged 55 years and up. The reduction in the risk of cardiovascular disease does not depend on the cholesterol level and blood pressure at the start of treatment. The pharmacological reduction in risk factors in individuals with a high risk of atherosclerotic vascular disease is often suboptimal, partly due to the complexity of the guidelines and low adherence to the therapy. A polypill may offer opportunities for improvement. Research has shown that the use of combination products leads to a greater reduction in risk factors than the use of separate substances, possibly through improved adherence to the therapy. The use of a polypill in the prevention of vascular disease in high-risk patients may lead to a more effective reduction in risk, a decrease in costs and a reduction in pharmacological expenditure.

  1. High risk of developing subsequent epilepsy in patients with sleep-disordered breathing

    PubMed Central

    Harnod, Tomor; Wang, Yu-Chiao; Lin, Cheng-Li; Tseng, Chun-Hung

    2017-01-01

    Purpose Sleep-disordered breathing (SDB) is often associated with other medical disorders. Whether SDB interacts with other factors for developing subsequent epilepsy remains unclear. Methods This population-based cohort study was conducted using the National Health Insurance Research Database of Taiwan. Patients aged >20 years and diagnosed with SDB between 2000 and 2010 comprised the SDB cohort (n = 138,507), and their data were compared with those of the comparison cohort (n = 138,507). The adjusted hazard ratio (aHR) for epilepsy was calculated using a multivariate Cox proportional hazards model. Results The SDB cohort had an increased risk of epilepsy (aHR = 1.50, 95% confidence interval [CI] = 1.36–1.66). The sex-stratified analysis revealed a significant adjusted hazard ratio (aHR) for epilepsy with a 1.51-fold higher risk for female patients, and also a significantly 1.49-fold higher risk for male patients in the SDB cohort. Although epilepsy incidence increased with age in both cohorts, different age groups in the SDB cohort all had a significantly higher risk of developing epilepsy than comparison cohort. Conclusion This population-based cohort study indicates that patients with SDB are at a high risk of developing subsequent epilepsy, in both sexes and all age groups. PMID:28291799

  2. Patients' opinions about knowing their risk for depression and what to do about it. The predictD-qualitative study.

    PubMed

    Bellón, Juan Á; Moreno-Peral, Patricia; Moreno-Küstner, Berta; Motrico, Emma; Aiarzagüena, José M; Fernández, Anna; Fernández-Alonso, Carmen; Montón-Franco, Carmen; Rodríguez-Bayón, Antonina; Ballesta-Rodríguez, María Isabel; Runte-Geidel, Ariadne; Rüntel-Geidel, Ariadne; Payo-Gordón, Janire; Serrano-Blanco, Antoni; Oliván-Blázquez, Bárbara; Araujo, Luz; Muñoz-García, María del Mar; King, Michael; Nazareth, Irwin; Amezcua, Manuel

    2014-01-01

    The predictD study developed and validated a risk algorithm for predicting the onset of major depression in primary care. We aimed to explore the opinion of patients about knowing their risk for depression and the values and criteria upon which these opinions are based. A maximum variation sample of patients was taken, stratified by city, age, gender, immigrant status, socio-economic status and lifetime depression. The study participants were 52 patients belonging to 13 urban health centres in seven different cities around Spain. Seven Focus Groups (FGs) were given held with primary care patients, one for each of the seven participating cities. The results showed that patients generally welcomed knowing their risk for depression. Furthermore, in light of available evidence several patients proposed potential changes in their lifestyles to prevent depression. Patients generally preferred to ask their General Practitioners (GPs) for advice, though mental health specialists were also mentioned. They suggested that GPs undertake interventions tailored to each patient, from a "patient-centred" approach, with certain communication skills, and giving advice to help patients cope with the knowledge that they are at risk of becoming depressed. Patients are pleased to be informed about their risk for depression. We detected certain beliefs, attitudes, values, expectations and behaviour among the patients that were potentially useful for future primary prevention programmes on depression.

  3. [Patient's Risk Factors for Perioperative Aspiration Pneumonia].

    PubMed

    Ishikawa, Teruhiko; Isono, Shiroh

    2016-01-01

    This article reviews patient's own risk factors for perioperative aspiration pneumonia. Maintaining the function of the lower esophageal sphincter (LES), the airway protective reflex, and the oral hygiene are the most important to prevent the pneumonia. The LES is adversely affected by excessive stomach distention, some medication given in perioperative periods, and habitual smoking, as well as pathological status such as esophageal hiatus hernia and achalasia. Postapoplectic patients may have insufficient airway protective reflex including swallowing and laryngeal reflex. It is emphasized that the perioperative oral care is increasing in its importance for the prevention of aspiration pneumonia.

  4. Management of patients with risk factors

    PubMed Central

    Waldfahrer, Frank

    2013-01-01

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

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

    PubMed

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

    2013-01-01

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

  6. [The high risk cardiac patient in anesthesia].

    PubMed

    Francke, A

    1996-01-01

    As a result of more offensive therapeutic measures and the given abilities of modern medicine and the increasing number of geriatric patients who are characterized by multimorbidity, more perioperative complications, in particular those of cardiac origin, can be expected. As in any other medical discipline, the safety of anaesthesiological care of the patient very much depends on the individual professional qualification and competence of the physician. For the field of anaesthesiology it can be concluded that it is necessary to tackle the specific problems of this risk group in order to reduce the rate of complications to a minimum. In line with a number of studies showing equal manifestation of cardiac risk factors during the pre-, intra- and postoperative periods, we should concentrate on the consistent use of all preventive and therapeutic measures available during these three periods. Besides evaluation of the cardiac risk factors and planning of the intra- and postoperative management, premedication is of particular importance in the preoperative period. To avoid sympathicoadrenergic contraregulations, benzodiazepines are particularly recommended because of their anxiolytic and sedative effects. The selection of a special anaesthetic method suitable for the patient with high cardiac risk should be influenced not only by anaesthesiological aspects but also by the complex effects of anaesthetic drugs on the determinants of the myocardial oxygen balance. In this connection, an increased sympathicoadrenergic tonus is of particular importance, i.e. extreme changes in blood pressure or heart rate--compared to preanaesthetic values--and an increase in diastolic wall tension should be avoided. An anaesthetic regime comprising gentle general anaesthesia combined with epidural block and small doses of opioids or local anaesthetics meets these requirements, as does a combination of opioids with low doses of volatile anaesthetics or intravenous hypnotics. The quality of

  7. Risk of disseminated intravascular coagulation in patients with type 2 diabetes mellitus: retrospective cohort study

    PubMed Central

    Nogami, Kenichiro; Muraki, Isao; Imano, Hironori; Iso, Hiroyasu

    2017-01-01

    Objectives To determine quantitatively the association between type 2 diabetes mellitus (T2DM) and disseminated intravascular coagulation (DIC). Design Retrospective cohort study using a claims database. Setting Medical care institutions representing 9% of all secondary hospitals (acute care hospitals) in Japan. Participants In total, 797 324 admissions, comprising 435 354 patients aged 18–79 years at the time of admission, were enrolled between January 2010 and September 2014. All patients were diagnosed with diabetes or admitted to hospitals that provided laboratory data. Main outcome measures Incidence of DIC reported by physicians in claims data. Results Logistic regression analysis found that the risk of DIC was significantly higher in T2DM patients than in non-DM patients (fully adjusted OR: 1.39 (95% CI 1.32 to 1.45)), independent of age, sex, admission year and potential underlying diseases. The higher risk of DIC in T2DM patients was apparent in those who were treated with insulin within the 30-day period prior to admission (1.53 (1.37 to 1.72)). When stratified by the potential underlying diseases, the risk of DIC was higher in T2DM patients with non-septic severe infection (1.67 (1.41 to 1.97)) and with solid tumour (1.59 (1.47 to 1.72)) than in non-DM patients with those underlying diseases. The risk was similar between T2DM and non-DM patients with sepsis (0.98 (0.90 to 1.08)) and lower in T2DM patients with acute leukaemia (0.70 (0.59 to 0.84)). Conclusions T2DM was associated with a higher risk of DIC, particularly when recently treated with insulin, as well as among admissions with solid tumour or non-septic severe infection. PMID:28122835

  8. 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

  9. Surgical risk in patients with cirrhosis.

    PubMed

    Nicoll, Amanda

    2012-10-01

    Surgery in the patient with cirrhosis is problematic, as encephalopathy, ascites, sepsis and bleeding are common in the postoperative period. Accurate preoperative assessment and planning, and careful postoperative management have the potential to reduce the frequency and severity of such complications, and reduce the length of hospital stay, but there is little literature evidence to prove this. Operative mortality and other risks correlate with the severity of the liver disease, co-morbidities and the type of surgery. The Child-Turcott-Pugh (CTP) score or model for end-stage liver disease (MELD) score may be used to determine the severity of the liver disease, but must also take into account recent changes in the patient's condition. Surgery that does not involve opening the peritoneum may have slightly better outcomes, as the risk of ascitic leak, sepsis and difficult fluid management are reduced. Mortality rates range from 10% in CTP-A patients to 82% in CTP-C patients. The presence of portal hypertension is an important negative predictor, especially in abdominal surgery, as refractory ascites may occur. Careful monitoring in the postoperative period and early intervention of complications are essential. Hepatic resections in cirrhosis are associated with other considerations such as leaving sufficient liver tissue to prevent liver failure, and are beyond the scope of this review.

  10. 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.

  11. RADIAL STABILITY IN STRATIFIED STARS

    SciTech Connect

    Pereira, Jonas P.; Rueda, Jorge A. E-mail: jorge.rueda@icra.it

    2015-03-01

    We formulate within a generalized distributional approach the treatment of the stability against radial perturbations for both neutral and charged stratified stars in Newtonian and Einstein's gravity. We obtain from this approach the boundary conditions connecting any two phases within a star and underline its relevance for realistic models of compact stars with phase transitions, owing to the modification of the star's set of eigenmodes with respect to the continuous case.

  12. Risk Assessment Among Prostate Cancer Patients Receiving Primary Androgen Deprivation Therapy

    PubMed Central

    Cooperberg, Matthew R.; Hinotsu, Shiro; Namiki, Mikio; Ito, Kazuto; Broering, Jeanette; Carroll, Peter R.; Akaza, Hideyuki

    2009-01-01

    Purpose Prostate cancer epidemiology has been marked overall by a downward risk migration over time. However, in some populations, both in the United States and abroad, many men are still diagnosed with high-risk and/or advanced disease. Primary androgen deprivation therapy (PADT) is frequently offered to these patients, and disease risk prediction is not well-established in this context. We compared risk features between large disease registries from the United States and Japan, and aimed to build and validate a risk prediction model applicable to PADT patients. Methods Data were analyzed from 13,740 men in the United States community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry and 19,265 men in the Japan Study Group of Prostate Cancer (J-CaP) database, a national Japanese registry of men receiving androgen deprivation therapy. Risk distribution was compared between the two datasets using three well-described multivariable instruments. A novel instrument (Japan Cancer of the Prostate Risk Assessment [J-CAPRA]) was designed and validated to be specifically applicable to PADT patients, and more relevant to high-risk patients than existing instruments. Results J-CaP patients are more likely than CaPSURE patients to be diagnosed with high-risk features; 43% of J-CaP versus 5% of CaPSURE patients had locally advanced or metastatic disease that could not be stratified with the standard risk assessment tools. J-CAPRA—scored 0 to 12 based on Gleason score, prostate-specific antigen level, and clinical stage—predicts progression-free survival among PADT patients in J-CaP with a c-index of 0.71, and cancer-specific survival among PADT patients in CaPSURE with a c-index of 0.84. Conclusion The novel J-CAPRA is the first risk instrument developed and validated for patients undergoing PADT. It is applicable to those with both localized and advanced disease, and performs well in diverse populations. PMID:19667269

  13. Risk of Migraine in Patients With Asthma: A Nationwide Cohort Study.

    PubMed

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

    2016-03-01

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

  14. [Perioperative risk in patients with sleep apnoea].

    PubMed

    Ogonowska-Kobusiewicz, Maria; Rutyna, Rafał; Nestorowicz, Andrzej

    2008-01-01

    Patients with upper airway obstruction during sleep are at constant risk of hypoxic and hypercarbic episodes and are especially vulnerable during anaesthesia and sedation as the abnormal anatomy is compounded by drug-related respiratory depression. Elective procedures in patients with the obstructive sleep apnoea (OSA) should be usually delayed, allowing for the preoperative home treatment (diet, alcohol abstinence, nasal CPAP/BiPAP during night). Respiratory supportive techniques, started at home, should be continued in the hospital, both in preoperative and postoperative periods. Patients with OSA should be also thoroughly examined for possible anatomic abnormalities of the upper airway that may complicate laryngoscopy and/or intubation. Heavy premedication should be avoided; in special cases of very nervous patients oral clonidine may be used. Careful preoxygenation is mandatory, opioids should be used sparingly. Muscle relaxant should be calculated for an ideal body weight. Isoflurane should be avoided. The OPS and obese patients are usually extubated in the sitting or lateral positions to avoid limitation of FRC by elevated diaphragm. In selected cases, prolonged intubation and/or ventilation are recommended. Regional anaesthesia are usually safe in these patients, however, opioids should be used carefully. When sedation is required, ketamine or dexmedetomidine may be used.

  15. Risk of Cerebrovascular Diseases After Uvulopalatopharyngoplasty in Patients With Obstructive Sleep Apnea

    PubMed Central

    Chen, Shin-Yan; Cherng, Yih-Giun; Lee, Fei-Peng; Yeh, Chun-Chieh; Huang, Shih-Yu; Hu, Chaur-Jong; Liao, Chien-Chang; Chen, Ta-Liang

    2015-01-01

    Abstract Little was known about the beneficial effects of uvulopalatopharyngoplasty (UPPP) on the outcomes after obstructive sleep apnea (OSA). The aim of this study is to investigate the effects of UPPP on reducing risk of cerebrovascular diseases in patients with OSA. Using Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study of 10,339 patients with new OSA between January 1, 2004, and December 31, 2009. The incident cerebrovascular disease was identified during the 1-year follow-up period in patients with and without receiving UPPP. The rate ratios (RRs) and 95% confidence intervals (CIs) of cerebrovascular disease associated with receiving UPPP in patients with OSA were calculated in multivariate Poisson regression. The 1-year incidences of cerebrovascular disease for OSA patients with and without UPPP were 1.06% and 5.14%, respectively. Patients with OSA receiving UPPP had lower risk of cerebrovascular disease compared with those without UPPP (RR, 0.45; 95% CI, 0.33–0.61). The decreased risk of cerebrovascular disease following UPPP was observed in both sexes and all age groups. In the stratified analysis of medical conditions, the RR of cerebrovascular disease associated with UPPP for patients with 0, 1, ≥ 2 medical conditions were 0.28 (95% CI 0.12–0.68), 0.39 (95% CI 0.21–0.73), and 0.63 (95% CI 0.43–0.93), respectively. Patients with OSA who received UPPP had lower risk of cerebrovascular disease within 1 year after surgery compared with patients not receiving UPPP. Clinical physicians could have more evidence to persuade patients to receive surgical intervention, especially those who have severe OSA symptoms or do not acquire adequate symptom relief under conservative treatments. PMID:26469923

  16. Personalized Predictive Modeling and Risk Factor Identification using Patient Similarity.

    PubMed

    Ng, Kenney; Sun, Jimeng; Hu, Jianying; Wang, Fei

    2015-01-01

    Personalized predictive models are customized for an individual patient and trained using information from similar patients. Compared to global models trained on all patients, they have the potential to produce more accurate risk scores and capture more relevant risk factors for individual patients. This paper presents an approach for building personalized predictive models and generating personalized risk factor profiles. A locally supervised metric learning (LSML) similarity measure is trained for diabetes onset and used to find clinically similar patients. Personalized risk profiles are created by analyzing the parameters of the trained personalized logistic regression models. A 15,000 patient data set, derived from electronic health records, is used to evaluate the approach. The predictive results show that the personalized models can outperform the global model. Cluster analysis of the risk profiles show groups of patients with similar risk factors, differences in the top risk factors for different groups of patients and differences between the individual and global risk factors.

  17. [Anesthesiological management of the high-risk surgical patient].

    PubMed

    Bertoldi, G; Avalle, M

    1980-03-01

    Evaluation of the anaesthesiological risk in surgical patients is described and an account is given of results obtained with an association of ketamin and NLA II in 57 high-risk patients subjected to general surgical management.

  18. Celiac Disease Does Not Influence Fracture Risk in Young Patients with Type 1 Diabetes

    PubMed Central

    Reilly, Norelle R; Lebwohl, Benjamin; Mollazadegan, Kaziwe; Michaëlsson, Karl; Green, Peter HR; Ludvigsson, Jonas F

    2015-01-01

    Objectives To examine the risk of any fractures in patients with both type 1 diabetes (T1D) and celiac disease (CD) vs patients with T1D only. Study design We performed a population-based cohort study. We defined T1D as individuals aged ≤30 years who had a diagnosis of diabetes recorded in the Swedish National Patient Register between 1964–2009. Individuals with CD were identified through biopsy report data between 1969–2008 from any of Sweden’s 28 pathology departments. Some 958 individuals had both T1D and CD and were matched for sex, age and calendar period with 4,598 reference individuals with T1D only. We then used a stratified Cox regression analysis, where CD was modeled as a time-dependent covariate, to estimate the risk of any fractures and osteoporotic fractures (hip, distal forearm, thoracic and lumbar spine, and proximal humerus) in patients with both T1D and CD compared with that in patients with T1D only. Results During follow-up, 12 patients with T1D and CD had a fracture (1 osteoporotic fracture). CD did not influence the risk of any fracture (adjusted Hazard Ratio=0.77; 95%CI=0.42–1.41) or osteoporotic fractures (adjusted Hazard Ratio=0.46; 95%CI=0.06–3.51) in patients with T1D. Stratification for time since CD diagnosis did not affect risk estimates. Conclusion Having a diagnosis of CD does not seem to influence fracture risk in young patients with T1D. Follow-up in this study was, however, too short to ascertain osteoporotic fractures which traditionally occur in old age. PMID:26589343

  19. Efficacy and safety of ipragliflozin in Japanese patients with type 2 diabetes stratified by body mass index: A subgroup analysis of five randomized clinical trials.

    PubMed

    Kashiwagi, Atsunori; Yoshida, Satoshi; Nakamura, Ichiro; Kazuta, Kenichi; Ueyama, Eiji; Takahashi, Hideyuki; Satomi, Hayato; Kosakai, Yoshinori; Kawamuki, Kosei

    2016-07-01

    The influence of overweight/obesity on the clinical efficacy and safety of sodium-glucose co-transporter 2 inhibitors is unclear. We carried out a pooled analysis to examine the impact of body mass index on the efficacy and safety of ipragliflozin. Patient-level data were pooled for five Japanese double-blind trials (NCT00621868, NCT01057628, NCT01135433, NCT01225081 and NCT01242215) in which patients were randomized to ipragliflozin or a placebo as monotherapy, or in combination with metformin, pioglitazone or a sulfonylurea. Outcomes included the changes in hemoglobin A1c, fasting plasma glucose, bodyweight and treatment-emergent adverse events. Patients were divided into four body mass index categories. Hemoglobin A1c, fasting plasma glucose and bodyweight decreased significantly in the ipragliflozin group compared with the placebo group in all body mass index categories, and in the total cohort (all P < 0.001). Hemoglobin A1c did not improve in 11.2 and 69.2% of patients in the ipragliflozin and placebo groups, respectively. The change in hemoglobin A1c was weakly correlated with the change in bodyweight in all patients (r = 0.136, P = 0.002). Regarding laboratory variables, the placebo-subtracted difference tended to be greater in patients with higher body mass index for aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase and uric acid. The incidences of treatment-emergent adverse events were similar between the ipragliflozin and placebo groups in all patients combined and in the four body mass index categories. These results show that the efficacy and safety of ipragliflozin are not influenced by obesity/overweight in Japanese patients. © 2015 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd.

  20. V-CLIP: Integrating plasma VEGF into a new scoring system to stratify patients with advanced hepatocellular carcinoma for clinical trials

    PubMed Central

    Kaseb, Ahmed O.; Hassan, Manal M.; Lin, E; Xiao, Lianchun; Kumar, Vikas; Pathak, Priyanka; Lozano, Richard; Rashid, Asif; Abbruzzese, James L.; Morris, Jeffrey S.

    2010-01-01

    Background Several staging systems have been proposed for hepatocellular carcinoma (HCC), however, none has incorporated circulating angiogenic biomarkers. This study sought to determine whether vascular endothelial growth factor (VEGF) could independently predict overall survival in patients with HCC, and whether adding VEGF level into the Cancer of the Liver Italian Program (CLIP) score could improve patients stratification and prediction of overall survival. Methods Between 2001 and 2008, baseline plasma VEGF levels were available from 288 patients and multivariate Cox regression models and median survival (95% confidence intervals) were calculated. Recursive partitioning was used to determine the optimal cut point for VEGF, using 10 repeated training/validation samples, each using 2/3 of the data to determine the best cut point and the remaining 1/3 to validate it. Prognostic ability of CLIP and V-CLIP was compared using C-index. Results Plasma VEGF was a significant independent predictor of overall survival, with an optimal VEGF cut point of 450 pg/ml. After CLIP validation in our patients, we added VEGF to the CLIP score and found that the new V-CLIP score better separates patients into homogenous prognostic groups (p-value=0.005). Conclusion The assessment of baseline plasma VEGF levels increases the precision of the CLIP scoring system for predicting HCC prognosis, which may assist in equally randomizing patients with HCC in clinical trials. Prospective validation of the V-CLIP scoring system is warranted. PMID:24048796

  1. Identification of patients at risk for early out-of-hospital mortality after redocoronary artery surgery

    PubMed Central

    van Eck, F.M.; Noyez, L.; Verheugt, F.W.A.; Brouwer, R.M.H.J.

    2003-01-01

    Objective Analyse risk factors and construct a predictive model for identification of patients at risk of early out-of-hospital mortality after coronary reoperations (RECABG). Methods 505 patients, discharged from hospital after a RECABG (1987-1998), were studied by univariate and multivariate analysis. A stepwise selective procedure (p<0.05) was used to identify a subset of variables with prognostic value for early out-of-hospital mortality. This subset was used to calculate a prognostic score 'S' and a predicted probability 'p' for early out-of-hospital mortality, p=1/1+ e-s. Sensitivity analysis was used for evaluation. Results The best predictive variables for early out-of-hospital mortality were diabetes (p=0.002), lung disease (p=0.05), emergency operation (p=0.0001) and a perioperative myocardial infarction (p=0.0001). Emergency operation (p=0.001) and antegrade/retrograde cardioplegia (p<0.0000) were independent predictors of a perioperative myocardial infarction. The prognostic accuracy (ROC area) was 86%. Patients were classified into low risk (5%), intermediate risk (15%), high risk (30%) and very high risk (≥40%). A predicted probability of ≥0.40 was used as cut-off point. The specificity of this test was 99%, sensitivity 33%, predictive value of a positive test 79%, and 95% for a negative test. Conclusion The results show that patients discharged from hospital after RECABG can be stratified according to their early out-of-hospital risk. A perioperative myocardial infarction is the major independent risk factor and can be affected by use of retrograde cardioplegia. PMID:25696148

  2. Risk of Venous Thromboembolism and Operative Duration in Patients Undergoing Neurosurgical Procedures.

    PubMed

    Bekelis, Kimon; Labropoulos, Nicos; Coy, Shannon

    2017-05-01

    The association of operative duration with the risk of venous thromboembolism (VTE) has not been quantified in neurosurgery. To investigate the association of surgical duration for several neurosurgical procedures and the incidence of VTE. We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. In order to control for confounding, we used multivariable regression models, and propensity score conditioning. During the study period, there were 94 747 patients, who underwent neurosurgical procedures, and met the inclusion criteria. Of these, 1358 (1.0%) developed VTE within 30 days postoperatively. Multivariable logistic regression demonstrated an association of longer operative duration with higher 30-day incidence of VTE (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19-1.25). Compared with procedures of moderate duration (third quintile, 40-60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 3.15; 95% CI, 2.49-3.99) of developing VTE. The shortest procedures (<20th percentile) were associated with a decreased incidence of VTE (OR, 0.51; 95% CI, 0.27-0.76) in comparison to those of moderate duration. The same associations were present in propensity score-adjusted models, and models stratified by subgroups of cranial, spinal, peripheral nerve, and carotid procedures. In a cohort of patients from a national prospective surgical registry, increased operative duration was associated with increased incidence of VTE for neurosurgical procedures. These results can be used by neurosurgeons to inform operative management, and to stratify patients with regard to VTE risk.

  3. Identification of plasma protein profiles associated with risk groups of prostate cancer patients

    PubMed Central

    Nordström, Malin; Wingren, Christer; Rose, Carsten; Bjartell, Anders; Becker, Charlotte; Lilja, Hans; Borrebaeck, Carl AK

    2015-01-01

    Purpose Early detection of prostate cancer (PC) using prostate-specific antigen (PSA) in blood reduces PC-death among unscreened men. However, due to modest specificity of PSA at commonly used cut-offs, there are urgent needs for additional biomarkers contributing enhanced risk classification among men with modestly elevated PSA. Experimental design Recombinant antibody microarrays were applied for protein expression profiling of 80 plasma samples from routine PSA-measurements, a priori divided into four risk groups, based on levels of total and %free PSA. Results The results demonstrated that plasma protein profiles could be identified that pinpointed PC (a malignant biomarker signature) and most importantly that showed moderate to high correlation with biochemically defined PC risk groups. Notably, the data also implied that the risk group with mid-range PSA and low %free PSA, a priori known to be heterogeneous, could be further stratified into two subgroups, more resembling the lowest and highest risk groups, respectively. Conclusions and clinical relevance In this pilot study, we have shown that plasma protein biomarker signatures, associated with risk groups of PC, could be identified from crude plasma samples using affinity proteomics. This approach could in the longer perspective provide novel opportunities for improved risk classification of PC patients. PMID:25196118

  4. Dialysis: Hypokalaemia and cardiac risk in peritoneal dialysis patients.

    PubMed

    Kwan, Bonnie Ching-Ha; Szeto, Cheuk-Chun

    2012-09-01

    Dialysis, particularly haemodialysis, is associated with an increased risk of cardiovascular disease. A new study confirms that hypokalaemia confers an excess cardiovascular risk and contributes disproportionately to the high risk of death in patients on peritoneal dialysis, which may partially account for the fact that observed cardiac risk is similar for patients on peritoneal dialysis and haemodialysis.

  5. Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus

    PubMed Central

    Utrera-Lagunas, Marcelo; Orea-Tejeda, Arturo; Castillo-Martínez, Lilia; Balderas-Muñoz, Karla; Keirns-Davis, Candace; Espinoza-Rosas, Sarahi; Sánchez-Ortíz, Néstor Alonso; Olvera-Mayorga, Gabriela

    2013-01-01

    BACKGROUND: Diabetes is a major risk factor for heart failure (HF), although the pathophysiological processes have not been clarified. OBJECTIVE: To determine the prevalence of HF and of abnormal myocardial perfusion in diabetic patients evaluated using technetium (99m) sestamibi single-photon emission computed tomography. METHODS: An observational cross-sectional study was conducted that included patients with type 2 diabetes mellitus who underwent echocardiography to diagnose HF and a pharmacological stress test with intravenous dipyridamole to examine cardiac scintigraphic perfusion abnormalities. Clinical and biochemical data were also collected. RESULTS: Of the 160 diabetic patients included, 92 (57.6%) were in HF and 68 (42.5%) were not. When patients were stratified according to the presence of abnormal myocardial perfusion, those with abnormal perfusion had a higher prevalence of HF (93%) than those with normal perfusion (44.4%) (P<0.0001). Patients with HF weighed more (P=0.03), used insulin less frequently (P=0.01), had lower total cholesterol (P=0.05) and high-density lipoprotein cholesterol concentrations (P=0.002), and a greater number of their myocardial segments showed abnormal perfusion (P≤0.001). More HF patients had a history of myocardial infarction (P<0.001) compared with those without HF. In a logistic regression analysis, the number of segments exhibiting abnormal myocardial perfusion was an independent risk factor for HF. CONCLUSIONS: The prevalence of HF in diabetic patients was high and HF predominantly occured in association with myocardial ischemia. PMID:24294048

  6. Risk of colectomy in patients with ulcerative colitis under thiopurine treatment.

    PubMed

    Cañas-Ventura, Alex; Márquez, Lucia; Ricart, Elena; Domènech, Eugeni; Gisbert, Javier P; García-Sanchez, Valle; Marín-Jiménez, Ignacio; Rodriguez-Moranta, Francisco; Gomollón, Fernando; Calvet, Xavier; Merino, Olga; Garcia-Planella, Esther; Vázquez-Romero, Narcis; Esteve, Maria; Iborra, Marisa; Gutiérrez, Ana; Vera, Maribel; Andreu, Montserrat

    2014-10-01

    Little is known about the risk factors of colectomy in patients with ulcerative colitis (UC) under thiopurine treatment. The aim of the study was to determine the prevalence and the predictive risk factors of colectomy in an extensive cohort of patients with UC treated with thiopurines in Spain. Among 5753 UC patients, we identified those diagnosed between 1980 and 2009 and treated with azathioprine or mercaptopurine (AZA/MP). We analyzed the age at diagnosis, familial history of IBD, extraintestinal manifestations (EIMs), disease extent, smoking status and treatment requirements (AZA/MP, cyclosporine (CsA) or anti-TNFα). Colectomies for dysplasia or cancer were excluded. Survival analysis and Cox proportional hazard regression were performed. Results were reported as hazard ratios (HR) with 95% CI. Among the 1334 cases included, 119 patients (8.9%) required colectomy after a median time of 26 months (IQR 12-42) after AZA/MP initiation. Independent predictors of colectomy were: Extensive UC (HR 1.7, 95% CI: 1.1-2.6), EIMs (HR 1.5, 95% CI: 1.0-2.4), need for antiTNFα (HR 2.3, 95% CI: 1.5-3.4) and need for CsA (HR 2.4, 95% CI: 1.6-3.7). Patients requiring early introduction of AZA/MP had an increased risk of colectomy with a HR of 4.9 (95% CI: 3.2-7.8) when AZA/MP started in the first 33 months after UC diagnosis. Nearly one-tenth of patients with UC under thiopurines require colectomy. Extensive UC, EIMs, need for CsA or anti-TNFα ever and an early need for AZA/MP treatment were associated with a higher risk of colectomy. These risk factors of colectomy could help to stratify risk in further controlled studies in UC. Copyright © 2014 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

  7. Antibiograms in resource limited settings: Are stratified antibiograms better?

    PubMed

    Saxena, S; Ansari, S K; Raza, M W; Dutta, R

    2016-04-01

    Background Antibiograms often act as a reference guide for empirical selection of antibiotics. Hospital-wide antibiograms constructed on the basis of cumulative antimicrobial susceptibility data from diverse patient groups can often be misleading. In order to show the significance of age- and location-stratified antibiograms, this study compared hospital-wide antibiograms with stratified antibiograms for the clinical isolates of Pseudomonas aeruginosa. Methods Stratified antibiograms were created on the basis of patient age (<18 years, 18-50 years, >50 years) and location (inpatient or outpatient) using all 2011, 2012 and 2013 clinical isolates of P. aeruginosa isolates. Susceptibility rates were compared among cumulative and stratified antibiograms using non-parametric inferential statistics. Results The hospital-wide antibiogram under-estimated susceptibility rates in adult patients isolates (age group = 18-50 years) and over-estimated susceptibility rates in isolates from the paediatric patients and elderly. Paediatric isolates were found to be less susceptible to amikacin and imipenem, whereas isolates from elderly patients >50 years were less susceptible to ciprofloxacin. Statistically significant difference was seen in the susceptibility rates of OPD and IPD isolates of P. aeruginosa in the case of the paediatric age group. Susceptibility rates for all drugs were lower for isolates from inpatients than from outpatients. Conclusion Age and location associated differences in susceptibility rates have the potential to influence empirical antibiotic selection, which was shown in stratified antibiograms of P. aeruginosa that is obscured by hospital-wide antibiograms.

  8. Incisional Reinforcement in High-Risk Patients

    PubMed Central

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

    2014-01-01

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

  9. Stratifying diffuse large B-cell lymphoma patients treated with chemoimmunotherapy: GCB/non-GCB by immunohistochemistry is still a robust and feasible marker

    PubMed Central

    Batlle-López, Ana; de Villambrosía, Sonia González; Francisco, Mazorra; Malatxeberria, Sefora; Sáez, Anabel; Montalban, Carlos; Sánchez, Lydia; Garcia, Juan F.; González-Barca, Eva; López-Hernández, Andrés; Ruiz-Marcellan, MC; Mollejo, Manuela; Grande, Carlos; Richards, Kristy L.; Hsi, Eric D.; Tzankov, Alexandar; Visco, Carlo; Xu-Monette, Zijun Y.; Cao, Xin; Young, Ken H.; Piris, Miguel Ángel; Conde, Eulogio; Montes-Moreno, Santiago

    2016-01-01

    Diffuse large B cell lymphoma (DLBCL) is a heterogeneous group of aggressive lymphomas that can be classified into three molecular subtypes by gene expression profiling (GEP): GCB, ABC and unclassified. Immunohistochemistry-based cell of origin (COO) classification, as a surrogate for GEP, using three available immunohistochemical algorithms was evaluated in TMA-arranged tissue samples from 297 patients with de novo DLBCL treated by chemoimmunotherapy (R-CHOP and R-CHOP-like regimens). Additionally, the prognostic impacts of MYC, BCL2, IRF4 and BCL6 abnormalities detected by FISH, the relationship between the immunohistochemical COO classification and the immunohistochemical expression of MYC, BCL2 and pSTAT3 proteins and clinical data were evaluated. In our series, non-GCB DLBCL patients had significantly worse progression-free survival (PFS) and overall survival (OS), as calculated using the Choi, Visco-Young and Hans algorithms, indicating that any of these algorithms would be appropriate for identifying patients who require alternative therapies to R-CHOP. Whilst MYC abnormalities had no impact on clinical outcome in the non-GCB subtype, those patients with isolated MYC rearrangements and a GCB-DLBCL phenotype had worse PFS and therefore might benefit from novel treatment approaches. PMID:26910115

  10. Stratifying diffuse large B-cell lymphoma patients treated with chemoimmunotherapy: GCB/non-GCB by immunohistochemistry is still a robust and feasible marker.

    PubMed

    Batlle-López, Ana; González de Villambrosía, Sonia; Francisco, Mazorra; Malatxeberria, Sefora; Sáez, Anabel; Montalban, Carlos; Sánchez, Lydia; Garcia, Juan; González-Barca, Eva; López-Hernández, Andrés; Ruiz-Marcellan, M C; Mollejo, Manuela; Grande, Carlos; Richards, Kristy L; Hsi, Eric D; Tzankov, Alexandar; Visco, Carlo; Xu-Monette, Zijun Y; Cao, Xin; Young, Ken H; Piris, Miguel Ángel; Conde, Eulogio; Montes-Moreno, Santiago

    2016-04-05

    Diffuse large B cell lymphoma (DLBCL) is a heterogeneous group of aggressive lymphomas that can be classified into three molecular subtypes by gene expression profiling (GEP): GCB, ABC and unclassified. Immunohistochemistry-based cell of origin (COO) classification, as a surrogate for GEP, using three available immunohistochemical algorithms was evaluated in TMA-arranged tissue samples from 297 patients with de novo DLBCL treated by chemoimmunotherapy (R-CHOP and R-CHOP-like regimens). Additionally, the prognostic impacts of MYC, BCL2, IRF4 and BCL6 abnormalities detected by FISH, the relationship between the immunohistochemical COO classification and the immunohistochemical expression of MYC, BCL2 and pSTAT3 proteins and clinical data were evaluated. In our series, non-GCB DLBCL patients had significantly worse progression-free survival (PFS) and overall survival (OS), as calculated using the Choi, Visco-Young and Hans algorithms, indicating that any of these algorithms would be appropriate for identifying patients who require alternative therapies to R-CHOP. Whilst MYC abnormalities had no impact on clinical outcome in the non-GCB subtype, those patients with isolated MYC rearrangements and a GCB-DLBCL phenotype had worse PFS and therefore might benefit from novel treatment approaches.

  11. Symptom profiles in the painDETECT Questionnaire in patients with peripheral neuropathic pain stratified according to sensory loss in quantitative sensory testing.

    PubMed

    Vollert, Jan; Kramer, Martin; Barroso, Alejandro; Freynhagen, Rainer; Haanpää, Maija; Hansson, Per; Jensen, Troels S; Kuehler, Bianca M; Maier, Christoph; Mainka, Tina; Reimer, Maren; Segerdahl, Märta; Serra, Jordi; Solà, Romà; Tölle, Thomas R; Treede, Rolf-Detlef; Baron, Ralf

    2016-08-01

    The painDETECT Questionnaire (PDQ) is commonly used as a screening tool to discriminate between neuropathic pain (NP) and nociceptive pain, based on the self-report of symptoms, including pain qualities, numbness, and pain to touch, cold, or heat. However, there are minimal data about whether the PDQ is differentially sensitive to different sensory phenotypes in NP. The aim of the study was to analyze whether the overall PDQ score or its items reflect phenotypes of sensory loss in NP as determined by quantitative sensory testing. An exploratory analysis in the Innovative Medicines Initiative Europain and Neuropain database was performed. Data records of 336 patients identified with NP were grouped into sensory profiles characterized by (1) no loss of sensation, (2) loss of thermal sensation, (3) loss of mechanical sensation, and (4) loss of thermal and mechanical sensation. painDETECT Questionnaire profiles were analyzed in a 2-factor analysis of variance. Patients with loss of thermal sensation (2 and 4) significantly more often reported pain evoked by light touch, and patients with loss of mechanical sensation (3 and 4) significantly more often reported numbness and significantly less often burning sensations and pain evoked by light touch. Although the PDQ was not designed to assess sensory loss, single items reflect thermal and/or mechanical sensory loss at group level, but because of substantial variability, the PDQ does not allow for individual allocation of patients into sensory profiles. It will be useful to develop screening tools according to the current definition of NP.

  12. 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

  13. Changes in quality of life associated with surgical risk in elderly patients undergoing cardiac surgery.

    PubMed

    Romero, Paola Severo; de Souza, Emiliane Nogueira; Rodrigues, Juliane; Moraes, Maria Antonieta

    2015-10-01

    The study aims to verify quality of life of elderly patients submitted to cardiac surgery, and correlating surgical risk to health-related quality of life instrument domains. Prospective cohort study, performed at a cardiology hospital. It included elderly patients who had undergone elective cardiac surgery. Pre- and postoperative quality of life was evaluated by applying the World Health Organization Quality of Life-Old (WHOQOL-OLD) scale and the Short-Form Health Survey (SF-36) questionnaire. Surgical risk was stratified using the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Fifty-four patients, mostly men (64.8%), were included, with a mean age of 69.3 ± 5.7 years. The eight domains of the SF-36 questionnaire, and the four facets presented for the WHOQOL-OLD scale showed improved quality of life 6 months after surgery (P < 0.001). No difference was found in the association of EuroSCORE with the domains of the health-related quality of life instruments. The data showed improved quality of life of elderly people submitted to cardiac surgery, unrelated to surgical risk. © 2014 Wiley Publishing Asia Pty Ltd.

  14. Assessment of cardiovascular risk in hypertensive patients: a comparison of commonly used risk scoring programs.

    PubMed

    Ulusoy, Sükrü

    2013-12-01

    Several calculation modalities are used today for cardiovascular risk assessment. Cardiovascular risk assessment should be performed in all hypertensive patients. Risk assessment methods being based on the population in which the patient lives and the inclusion of factors such as ethnicity variations, socioeconomic status, and medication use will contribute to improvements in risk assessments. The results should be shared with the patient, and modifiable risk factors must be effectively treated.

  15. Estimation of 10-Year Risk of Coronary Heart Disease in Nepalese Patients with Type 2 Diabetes: Framingham Versus United Kingdom Prospective Diabetes Study.

    PubMed

    Pokharel, Daya Ram; Khadka, Dipendra; Sigdel, Manoj; Yadav, Naval Kishor; Sapkota, Lokendra Bahadur; Kafle, Ramchandra; Nepal, Sarthak; Sapkota, Ravindra Mohan; Choudhary, Niraj

    2015-08-01

    Predicting future coronary heart disease (CHD) risk with the help of a validated risk prediction function helps clinicians identify diabetic patients at high risk and provide them with appropriate preventive medicine. The aim of this study is to estimate and compare 10-year CHD risks of Nepalese diabetic patients using two most common risk prediction functions: The Framingham risk equation and United Kingdom Prospective Diabetes Study (UKPDS) risk engine that are yet to be validated for Nepalese population. We conducted a hospital-based, cross-sectional study on 524 patients with type 2 diabetes. Baseline and biochemical variables of individual patients were recorded and CHD risks were estimated by the Framingham and UKPDS risk prediction functions. Estimated risks were categorized as low, medium, and high. The estimated CHD risks were compared using kappa statistics, Pearson's bivariate correlation, Bland-Altman plots, and multiple regression analysis. The mean 10-year CHD risks estimated by the Framingham and UKPDS risk functions were 17.7 ± 12.1 and 16.8 ± 15 (bias: 0.88, P > 0.05), respectively, and were always higher in males and older age groups (P < 0.001). The two risk functions showed moderate convergent validity in predicting CHD risks, but differed in stratifying them and explaining the patients' risk profile. The Framingham equation predicted higher risk for patients usually below 70 years and showed better association with their current risk profile than the UKPDS risk engine. Based on the predicted risk, Nepalese diabetic patients, particularly those associated with increased numbers of risk factors, bear higher risk of future CHDs. Since this study is a cross-sectional one and uses externally validated risk functions, Nepalese clinicians should use them with caution, and preferably in combination with other guidelines, while making important medical decisions in preventive therapy of CHD.

  16. Pharmacotherapy for alcohol dependence: A stratified approach.

    PubMed

    Thompson, A; Owens, L; Pushpakom, S P; Faizal, M; Pirmohamed, M

    2015-09-01

    Alcohol dependence is a common disorder in many societies worldwide, and remains difficult to identify and treat. It is also a risk factor for many secondary non-communicable diseases. Pharmacotherapy is one available treatment option, but appears to be underutilised in practice. Major barriers to use of medications in this area include lack of clinical guidance and questionable efficacy. However, for each medication there appears to be a subpopulation that responds positively, and understanding the moderating factors to treatment efficacy is an important research goal. Thus, this review provides a narrative regarding potential stratification techniques in pharmacological treatment of alcohol dependence, with a specific focus on typologies and pharmacogenetics. In addition, we discuss the basic background of stratified medicine and recent studies on genetic predisposition to alcohol dependence. A growing repository of data exists for both approved and non-approved pharmacotherapies, but failure to replicate findings, inadequate sample sizes, and insufficient funding has resulted in a translational gap. Implementing evidence-based stratified/personalised therapy and identifying new therapeutic agents may lead to improved clinical outcomes and reduced financial burden. Despite some promising findings to date, much work is still required. Copyright © 2015 Elsevier Inc. All rights reserved.

  17. Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients.

    PubMed

    Karter, Andrew J; Parker, Melissa M; Moffet, Howard H; Ahmed, Ameena T; Ferrara, Assiamira; Liu, Jennifer Y; Selby, Joe V

    2004-02-01

    When patients miss scheduled medical appointments, continuity and effectiveness of healthcare delivery is reduced, appropriate monitoring of health status lapses, and the cost of health services increases. We evaluated the relationship between missed appointments and glycemic control (glycosylated hemoglobin or HbA1c) in a large, managed care population of diabetic patients. Missed appointment rate was related cross-sectionally to glycemic control among 84,040 members of the Kaiser Permanente Northern California Diabetes Registry during 2000. Adjusted least-square mean estimates of HbA1c were derived by level of appointment keeping (none missed, 1-30% missed, and >30% missed appointments for the calendar year) stratified by diabetes therapy. Twelve percent of the subjects missed more than 30% of scheduled appointments during 2000. Greater rates of missed appointments were associated with significantly poorer glycemic control after adjusting for demographic factors (age, sex), clinical status, and health care utilization. The adjusted mean HbA1c among members who missed >30% of scheduled appointments was 0.70 to 0.79 points higher (P <0.0001) relative to those attending all appointments. Patients who missed more than 30% of their appointments were less likely to practice daily self-monitoring of blood glucose and to have poor oral medication refill adherence. Patients who underuse care lack recorded information needed to determine level of risk. Frequently missed appointments were associated with poorer glycemic control and suboptimal diabetes self-management practice, are readily ascertained in clinical settings, and therefore could have clinical utility as a risk-stratifying criterion indicating the need for targeted case management.

  18. Risk factors for treatment-limiting toxicities in patients starting nevirapine-containing antiretroviral therapy.

    PubMed

    Kesselring, Anouk M; Wit, Ferdinand W; Sabin, Caroline A; Lundgren, Jens D; Gill, M John; Gatell, Jose M; Rauch, Andri; Montaner, Julio S; de Wolf, Frank; Reiss, Peter; Mocroft, Amanda

    2009-08-24

    This collaboration of seven observational clinical cohorts investigated risk factors for treatment-limiting toxicities in both antiretroviral-naive and experienced patients starting nevirapine-based combination antiretroviral therapy (NVPc). Patients starting NVPc after 1 January 1998 were included. CD4 cell count at starting NVPc was classified as high (>400/microl/>250/microl for men/women, respectively) or low. Cox models were used to investigate risk factors for discontinuations due to hypersensitivity reactions (HSR, n = 6547) and discontinuation of NVPc due to treatment-limiting toxicities and/or patient/physician choice (TOXPC, n = 10,186). Patients were classified according to prior antiretroviral treatment experience and CD4 cell count/viral load at start NVPc. Models were stratified by cohort and adjusted for age, sex, nadir CD4 cell count, calendar year of starting NVPc and mode of transmission. Median time from starting NVPc to TOXPC and HSR were 162 days [interquartile range (IQR) 31-737] and 30 days (IQR 17-60), respectively. In adjusted Cox analyses, compared to naive patients with a low CD4 cell count, treatment-experienced patients with high CD4 cell count and viral load more than 400 had a significantly increased risk for HSR [hazard ratio 1.45, confidence interval (CI) 1.03-2.03] and TOXPC within 18 weeks (hazard ratio 1.34, CI 1.08-1.67). In contrast, treatment-experienced patients with high CD4 cell count and viral load less than 400 had no increased risk for HSR 1.10 (0.82-1.46) or TOXPC within 18 weeks (hazard ratio 0.94, CI 0.78-1.13). Our results suggest it may be relatively well tolerated to initiate NVPc in antiretroviral-experienced patients with high CD4 cell counts provided there is no detectable viremia.

  19. The extent of patients' understanding of the risk of treatments

    PubMed Central

    Lloyd, A

    2001-01-01

    The scientific understanding of how people perceive and code risks and then use this information in decision making has progressed greatly in the last 20 years. There is considerable evidence that people employ simplifying heuristics in judgement and decision making. These heuristics may lead to bias in how people interpret information. However, much of our understanding of risk perception is based on laboratory studies. It is much less clear whether risk perception in the real world (as in the case of medical treatments) exhibits the same patterns and biases. This paper reviews the published literature on risk perception in patients who face substantial treatment risks. It examines how accurate patients' perception of risk is, what factors affect the perception of risk, and several possible explanations for why patients' risk perception is not always accurate. Key Words: patient preference; risk; informed choice; decision making; patient-caregiver communication PMID:11533432

  20. Apolipoprotein L1 risk variants associate with prevalent atherosclerotic disease in African American systemic lupus erythematosus patients.

    PubMed

    Blazer, Ashira; Wang, Binhuan; Simpson, Danny; Kirchhoff, Tomas; Heffron, Sean; Clancy, Robert M; Heguy, Adriana; Ray, Karina; Snuderl, Matija; Buyon, Jill P

    2017-01-01

    Atherosclerosis is exaggerated in African American (AA) systemic lupus erythematosus (SLE) patients, with doubled cardiovascular disease (CVD) risk compared to White patients. The extent to which common Apolipoprotein L1 (APOL1) risk alleles (RA) contribute to this trend is unknown. This retrospective cohort study assessed prevalent atherosclerotic disease across APOL1 genotypes in AA SLE patients. One hundred thirteen AA SLE subjects were APOL1-genotyped and stratified as having: zero risk alleles, one risk allele, or two risk alleles. Chart review assessed CVD manifestations including abdominal aortic aneurysm, angina, carotid artery disease, coronary artery disease, myocardial infarction, peripheral vascular disease, stroke, and vascular calcifications. Associations between the genotypes and a composite endpoint defined as one or more CVD manifestations were calculated using logistic regression. Symptomatic atherosclerotic disease, excluding incidental vascular calcifications, was also assessed. The 0-risk-allele, 1-risk-allele and 2-risk-allele groups, respectively, comprised 34%, 53%, and 13% of the cohort. Respectively, 13.2%, 41.7%, and 60.0% of the 0-risk allele, 1-risk-allele, and 2-risk-allele groups met the composite endpoint of atherosclerotic CVD (p = 0.001). Adjusting for risk factors-including smoking, ESRD, BMI >25 and hypertension-we observed an association between carrying one or more RA and atherosclerotic CVD (OR = 7.1; p = 0.002). For symptomatic disease, the OR was 3.5 (p = 0.02). In a time-to-event analysis, the proportion of subjects free from the composite primary endpoint, symptomatic atherosclerotic CVD, was higher in the 0-risk-allele group compared to the 1-risk-allele and 2-risk-allele groups (χ2 = 6.5; p = 0.04). Taken together, the APOL1 RAs associate with prevalent atherosclerotic CVD in this cohort of AA SLE patients, perhaps reflecting a potentiating effect of SLE on APOL1-related cardiovascular phenotypes.

  1. Proof-of-concept evaluation of trough airway hyper-responsiveness following regular racemic or levosalbutamol in genotype-stratified steroid-treated persistent asthmatic patients.

    PubMed

    Anderson, William J; Short, Philip M; Williamson, Peter A; Morrison, Ashley E; Palmer, Colin; Tavendale, Roger; Lipworth, Brian J

    2014-01-01

    Asthmatic patients receiving ICSs (inhaled corticosteroids) may take frequent add-on therapy with salbutamol despite on-demand prescription. Frequent salbutamol use can be detrimental in asthma. The isomeric formulation of salbutamol and the B2ADR (β2 adrenoceptor) 16 genotype may also influence this phenomenon. We performed a randomized, double-blind, placebo-controlled, triple crossover, proof of concept trial comparing 2 weeks of regular therapy with inhaled racemic salbutamol [200 μg q.i.d. (four times daily)], levosalbutamol (100 μg q.i.d.) or placebo on trough methacholine PC20 [provocative concentration causing 20% fall in FEV1 (forced expiratory volume in 1 s)] 6 h post-dose (the primary outcome) in 30 persistent asthmatic patients (15 who were Arg16 homozygous and 15 who were Gly16 homozygous) all receiving ICSs. There was no worsening of AHR (airway hyper-responsiveness) at trough to methacholine after 2 weeks regular exposure to either racemic (P=0.53) or levosalbutamol (P=0.84) compared with placebo, nor between genotypes-as dd (doubling dilution) difference in methacholine PC20 from placebo [salbutamol/Arg16=0.36 dd [95% CI (confidence interval), -0.43, 1.15]; salbutamol/Gly16=0.01 dd (95% CI, -0.47, 0.49); levosalbutamol/Arg16=-0.01 dd (95% CI, -0.89, 0.87); and levosalbutamol/Gly16=0.28 dd (95% CI, -0.22, 0.77)]. Both active treatments improved morning PEF (peak expiratory flow) in Gly16 (P=0.04 overall) but not Arg16 (P=0.50 overall) patients, whereas evening PEF improved in both Gly16 (P<0.001 overall) and Arg16 (P=0.006 overall) patients. In conclusion, the regular exposure to either racemic or levosalbutamol for 2 weeks added to ICSs did not cause worsening of AHR at trough compared with placebo; with no difference seen between B2ADR 16 genotypes.

  2. The incidence and risk of osteoporosis in patients with anxiety disorder

    PubMed Central

    Hong-Jhe, Chen; Chin-Yuan, Kuo; Ming-Shium, Tu; Fu-Wei, Wang; Ru-Yih, Chen; Kuang-Chieh, Hsueh; Hsiang-Ju, Pan; Ming-Yueh, Chou; Pan-Ming, Chen; Chih-Chuan, Pan

    2016-01-01

    Abstract The purpose of this study was to investigate the relationship between anxiety disorder (AD) and the subsequent development of osteoporosis. We conducted a population-based retrospective cohort analysis according to the data in the Longitudinal Health Insurance Database 2000 of Taiwan. We included 7098 patients in both the AD and no-anxiety cohort who were matched according to age and sex between January 1, 2000, and December 31, 2013. The incidence rate and the risk ratios (RRs) of subsequent new-onset osteoporosis were calculated for both cohorts. We used Cox proportional hazards models to assess the effect of AD. The Kaplan–Meier method was applied to estimate the cumulative osteoporosis incidence curves. The AD cohort consisted of 7098 patients, and the comparison cohort comprised the same matched control patients without anxiety. The risk of osteoporosis was higher in the AD cohort than in the comparison cohort. In addition, the incidence of newly diagnosed osteoporosis remained significantly increased in all of the stratified follow-up durations (0–1, 1–5, 5–10, ≥10years). Patients with AD were 1.79 times more likely to get osteoporosis than those without AD. We also observed a significant increase in osteoporotic risk in AD patients who are comorbid with hypertension, diabetes mellitus, and chronic liver disease. The incidence of osteoporosis in Taiwan is associated with an a priori AD history. The risk ratios are the highest for osteoporosis within 1 year of AD diagnosis, but the risk remains statistically significant for >1 year. Clinicians should pay particular attention to osteoporotic comorbidities in AD patients. PMID:27661037

  3. 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.

  4. Urinary tract symptoms and erectile function in patients at risk of prostate cancer.

    PubMed

    Ramírez-Backhaus, M; González-Tampán, J; Ortiz-Rodríguez, I M; Gómez-Ferrer, Á; Rubio-Briones, J; Collado-Serra, A; Calatrava, A; Rodríguez-Torreblanca, C; Solsona-Narbón, E

    2015-01-01

    We estimate that more tan 63000 prostate biopsies are performed in our country each year. There are no functional status data of those patients and if there is a relationship between biopsy result and functional status. In order to solve that question we have performed this study. 1,128 prostate biopsies were included. Patients fill in the IPSS, IIEF-5 and ICIQ-SF questionnaires before the prostate biopsy was performed. A prospective data collection of clinical, pathological and questionnaires results was done. A descriptive analysis was carried out. IPSS and IIEF-5 results were categorized. Results were compared depending on the biopsy result. In the subgroup of patients with prostate cancer, questionnaires results were stratify according to the clinical risk group. The mean age of the sample was 65. Prostate cancer detection rate was 32,71%, 52,2% of the sample had mild lower urinary tract symptoms (LUTS) and 13,4% had severe LUTS at the time of the biopsy. Regarding the impact of LUTS on quality of life (QOL), only 12,6% showed a perfect QOL. More than 50 percent of patients suffered from some degree of erectile dysfunction at the time of the biopsy. According to ICIQ-SF, 24% of the sample experienced some kind of urinary incontinence, although it is true that most of them classified it as small amount. Patients with a positive biopsy had a lower IPSS and IIEF-5 average score. There were no differences in the prostate cancer detection rate stratified by the severity of LUTS. Patients undergoing prostate biopsy have, with a high probability, LUTS. Approximately 50% suffer from some degree of erectile dysfunction and 24% had some kind of urinary leakage. Copyright © 2014 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

  5. The DecisionDx-UM Gene Expression Profile Test Provides Risk Stratification and Individualized Patient Care in Uveal Melanoma.

    PubMed

    Harbour, J William; Chen, Royce

    2013-04-09

    Uveal melanoma (UM) is the most common primary cancer of the eye and has a strong propensity for metastasis. Although there have been many recent improvements in the diagnosis and treatment of UM, and only 2-4% of patients present with detectable metastasis, up to half of patients are at risk for dying of metastatic disease. Clinicopathologic factors are not accurate enough for individualized patient care. Chromosomal alterations have been used for prognostic purposes, but the routine clinical use of these methods is limited by their susceptibility to sampling error resulting from tumor heterogeneity, limited clinical validation, lack of standardized testing platforms, and high technical failure rates. In contrast, the DecisionDx-UM gene expression profile test is a stand-alone platform which requires no other information for maximal prognostic accuracy and which circumvents many of the drawbacks of chromosomal methods through the use of a highly sensitive microfluidics, PCR-based platform that simultaneously measures the expression of 15 carefully selected genes from primary uveal melanoma samples obtained by fine needle biopsy. Low metastatic risk is reported as Class 1, and high metastatic risk as Class 2. The test allows patients to be stratified into risk categories such that high-risk patients can be offered intensive metastatic surveillance and adjuvant therapy while low-risk patients can be spared these interventions. This test is now used as part of the standard of care in many ocular oncology centers.

  6. Individualized Venous Thromboembolism Risk Stratification Using the 2005 Caprini Score to Identify the Benefits and Harms of Chemoprophylaxis in Surgical Patients: A Meta-analysis.

    PubMed

    Pannucci, Christopher J; Swistun, Lukasz; MacDonald, John K; Henke, Peter K; Brooke, Benjamin S

    2017-06-01

    We performed a meta-analysis to investigate benefits and harms of chemoprophylaxis among surgical patients individually risk stratified for venous thromboembolism (VTE) using Caprini scores. Individualized VTE risk stratification may identify high risk surgical patients who benefit from peri-operative chemoprophylaxis. MEDLINE, EMBASE, and the Cochrane Library (CENTRAL) databases were queried. Eligible studies contained data on postoperative VTE and/or bleeding events with and without chemoprophylaxis. Primary outcomes included rates of VTE and clinically relevant bleeding after surgical procedures, stratified by Caprini score. A meta-analysis was conducted using a random-effects model. Among 13 included studies, 11 (n = 14,776) contained data for VTE events and 8 (n = 7590) contained data for clinically relevant bleeding with and without chemoprophylaxis. The majority of patients received mechanical prophylaxis. A 14-fold variation in VTE risk (from 0.7% to 10.7%) was identified among surgical patients who did not receive chemoprophylaxis, and patients at increased levels of Caprini risk were significantly more likely to have VTE. Patients with Caprini scores of 7 to 8 [odds ratio (OR) 0.60, 95% confidence interval (95% CI) 0.37-0.97] and >8 (OR 0.41, 95% CI 0.26-0.65) had significant VTE risk reduction after surgery with chemoprophylaxis. Patients with Caprini scores ≤6 comprised 75% of the overall population, and these patients did not have a significant VTE risk reduction with chemoprophylaxis. No association between postoperative bleeding risk and Caprini score was identified. The benefit of peri-operative VTE chemoprophylaxis was only found among surgical patients with Caprini scores ≥7. Precision medicine using individualized VTE risk stratification helps ensure that chemoprophylaxis is used only in appropriate surgical patients and may minimize bleeding complications.

  7. The emerging agenda of stratified medicine in neurology.

    PubMed

    Matthews, Paul M; Edison, Paul; Geraghty, Olivia C; Johnson, Michael R

    2014-01-01

    Stratified medicine can reduce the costs of neurological care, bringing benefits to both patients and physicians. The availability of routine genetic testing, new biomarkers and advanced imaging, as well as new technologies for patient-centred data collection, has expanded the potential for patient stratification. Several neurology subspecialities, including stroke, epilepsy and behavioural neurology, have already applied stratification for disease prognosis, optimization of disease management and reduction of treatment-related adverse events. Stratification approaches could improve the cost-effectiveness of neurological care that involves treatments with high costs or risks of adverse reactions, as well as guide the use of emerging, highly individualized therapies. There are still major challenges in the development of clinically actionable stratification concepts, and practical barriers can limit adoption of these concepts into clinical practice. However, improved technologies and disease understanding are making more precise stratification practical. We believe that neurologists should become leaders in the development and validation of these practices, and that use of these approaches should be part of a broader strategy for addressing both the growing needs of an ageing population and the rising pressures for rapid improvements in the cost-effectiveness of therapeutics.

  8. Methods to assess performance of models estimating risk of death in intensive care patients: a review.

    PubMed

    Cook, D A

    2006-04-01

    Models that estimate the probability of death of intensive care unit patients can be used to stratify patients according to the severity of their condition and to control for casemix and severity of illness. These models have been used for risk adjustment in quality monitoring, administration, management and research and as an aid to clinical decision making. Models such as the Mortality Prediction Model family, SAPS II, APACHE II, APACHE III and the organ system failure models provide estimates of the probability of in-hospital death of ICU patients. This review examines methods to assess the performance of these models. The key attributes of a model are discrimination (the accuracy of the ranking in order of probability of death) and calibration (the extent to which the model's prediction of probability of death reflects the true risk of death). These attributes should be assessed in existing models that predict the probability of patient mortality, and in any subsequent model that is developed for the purposes of estimating these probabilities. The literature contains a range of approaches for assessment which are reviewed and a survey of the methodologies used in studies of intensive care mortality models is presented. The systematic approach used by Standards for Reporting Diagnostic Accuracy provides a framework to incorporate these theoretical considerations of model assessment and recommendations are made for evaluation and presentation of the performance of models that estimate the probability of death of intensive care patients.

  9. Injury Region and Risk of Hospital-Acquired Pneumonia Among Pediatric Trauma Patients.

    PubMed

    Cutler, Gretchen J; Kharbanda, Anupam B; Nowak, Jeffrey; Ortega, Henry W

    2017-03-01

    To describe the relationship between injury region and risk of hospital-acquired pneumonia (HAP) in pediatric trauma patients. Analyses included patients <19 years of age from the National Trauma Data Bank, during 2009-2011. Multivariable logistic regression was used to examine the association between injury region and odds of developing HAP stratified by age group. A total of 71 377 patients were eligible for analysis, and 1818 patients developed pneumonia. In adjusted regression models both younger (11-15 years) and older (16-18 years) adolescents with multisite injuries including the head and neck had higher odds of developing HAP compared with adolescents with isolated head and neck injuries (odds ratio [OR] = 2.04, 95% confidence interval [CI] 1.34-3.10; OR = 1.47, 95% CI 1.14-1.89, respectively), and younger adolescents with multisite injuries not involving the head and neck also had higher odds of developing HAP (OR = 1.97, 95% CI 1.08-3.60). We found no significant association between injury region and risk of HAP in children <11 years of age. Younger and older adolescents with firearm (OR = 1.85, 95% CI 1.00-3.42; OR = 1.39, 95% CI 1.02-1.88, respectively) or pulmonary (OR = 3.78, 95% CI 1.26-11.3; OR = 2.56, 95% CI 1.01-6.51, respectively) injuries had higher odds of developing HAP compared with those with motor vehicle collision injuries. Adolescent trauma patients with multisite injuries including the head and neck have a higher risk of developing HAP compared with those with isolated head and neck injuries. We identified several risk factors that can be used to inform future research focused on identifying subgroups at high risk for the development of HAP. Copyright © 2017 by the American Academy of Pediatrics.

  10. A Simple Risk Model to Predict Survival in Patients With Carcinoma of Unknown Primary Origin.

    PubMed

    Huang, Chen-Yang; Lu, Chang-Hsien; Yang, Chan-Keng; Hsu, Hung-Chih; Kuo, Yung-Chia; Huang, Wen-Kuan; Chen, Jen-Shi; Lin, Yung-Chang; Chia-Yen, Hung; Shen, Wen-Chi; Chang, Pei-Hung; Yeh, Kun-Yun; Hung, Yu-Shin; Chou, Wen-Chi

    2015-11-01

    Carcinoma of unknown primary origin (CUP) is characterized by diverse histological subtypes and clinical presentations, ranging from clinically indolent to frankly aggressive behaviors. This study aimed to identify prognostic factors of CUP and to develop a simple risk model to predict survival in a cohort of Asian patients.We retrospectively reviewed 190 patients diagnosed with CUP between 2007 and 2012 at a single medical center in Taiwan. The clinicopathological parameters and outcomes of our cohort were analyzed. A risk model was developed using multivariate logistic regression and a prognostic score was generated.The prognostic score was calculated based on 3 independent prognostic variables: the Eastern Cooperative Oncology Group (ECOG) scale (0 points if the score was 1, 2 points if it was 2-4), visceral organ involvement (0 points if no involvement, 1 point if involved), and the neutrophil-to-lymphocyte ratio (0 points if ≤3, 1 point if >3). Patients were stratified into good (score 0), intermediate (score 1-2), and poor (score 3-4) prognostic groups based on the risk model. The median survival (95% confidence interval) was 1086 days (500-1617, n = 42), 305 days (237-372, n = 75), and 64 days (44-84, n = 73) for the good, intermediate, and poor prognostic groups, respectively. The c-statistics using the risk model and ECOG scale for the outcome of 1-year mortality were 0.80 and 0.70 (P = 0.038), respectively.In this study, we developed a simple risk model that accurately predicted survival in patients with CUP. This scoring system may be used to help patients and clinicians determine appropriate treatments.

  11. Clinical features and risk of recurrence among patients with vaginal intraepithelial neoplasia.

    PubMed

    Dodge, J A; Eltabbakh, G H; Mount, S L; Walker, R P; Morgan, A

    2001-11-01

    The best treatment modality and factors affecting recurrence among women with vaginal intraepithelial neoplasia (VAIN) are yet to be determined. The aims of the current study were to describe the clinical features, results of treatment, and factors affecting recurrence among patients with VAIN. We conducted a retrospective review of 121 women with VAIN after confirming the histologic diagnosis. Patient demographics, clinical features, and results of therapy were recorded. Factors affecting recurrence were assessed using the odds ratio and the 95% confidence intervals among patients who were followed up for 7 months or more and had at least one posttreatment Papanicolaou smear. Significant univariate odds ratios were assessed jointly in a multivariate model with a stratified analysis. The mean age of the patients was 35.0 (+/-17), 41% of the patients smoked, 39% had a history of human papillomavirus infection, 27% had history of sexually transmitted diseases, 22% had history of surgery for cervical intraepithelial neoplasia (CIN), and 23% had total hysterectomy. The upper third of the vagina was the most common site of VAIN and 61% of the lesions were multifocal. Associated cervical and vulvar intraepithelial neoplasia (VIN) were present in 65 and 10%, respectively. Recurrences of VAIN and progression to invasive vaginal cancer occurred in 33 and 2%, respectively. Recurrences following partial vaginectomy, laser, and 5-fluorouracil were 0, 38, and 59%, respectively (P = 0.0001). Multifocality and method of treatment were significant independent predictors of VAIN recurrences (odds ratio 3.3, 95% CI 1.2, 9.2, P = 0.02, and 22.4, 95% CI 1.3, 393.6, P = 0.001, respectively), with no interaction, based on a stratified analysis. VAIN occurs most often among women with CIN or VIN, commonly involves the upper third of the vagina, and is often multifocal. Partial vaginectomy provides the highest cure rate and multifocality is a risk factor for recurrence. Copyright 2001

  12. 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.

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

    PubMed

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

    2009-01-01

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

  14. Stroke Risk Perception in Atrial Fibrillation Patients is not Associated with Clinical Stroke Risk.

    PubMed

    Fournaise, Anders; Skov, Jane; Bladbjerg, Else-Marie; Leppin, Anja

    2015-11-01

    Clinical risk stratification models, such as the CHA2DS2-VASc, are used to assess stroke risk in atrial fibrillation (AF) patients. No study has yet investigated whether and to which extent these patients have a realistic perception of their personal stroke risk. The purpose of this study was to investigate and describe the association between AF patients' stroke risk perception and clinical stroke risk. In an observational cross-sectional study design, we surveyed 178 AF patients with a mean age of 70.6 years (SD 8.3) in stable anticoagulant treatment (65% treatment duration >12 months). Clinical stroke risk was scored through the CHA2DS2-VASc, and patients rated their perceived personal stroke risk on a 7-point Likert scale. There was no significant association between clinical stroke risk assessment and patients' stroke risk perception (rho = .025; P = .741). Approximately 60% of the high-risk patients had an unrealistic perception of their own stroke risk, and there was no significant increase in risk perception from those with a lower compared with a higher risk factor load (χ(2) = .010; P = .522). Considering possible negative implications in terms of lack of motivation for lifestyle behavior change and adequate adherence to the treatment and monitoring of vitamin K antagonist, the apparent underestimation of risk by large subgroups warrants attention and needs further investigation with regard to possible behavioral consequences. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

  15. AGE-Related Differences of Novel Atherosclerotic Risk Factors and Angiographic Profile Among Gujarati Acute Coronary Syndrome Patients.

    PubMed

    Prajapati, Jayesh; Joshi, Hasit; Sahoo, Sibasis; Virpariya, Kapil; Parmar, Meena; Shah, Komal

    2015-06-01

    Although numerous risk factors have been established to predict the development of acute coronary syndrome (ACS), the risk factor profile may be different between the younger and older individuals. To analyse the frequency and pattern of atherogenic risk factors and angiographic profiles in age-stratified Gujarati patients with ACS. ACS patients undergoing coronary angiography at U.N. Mehta Institute of Cardiology and Research, Gujarat, India between January 2008 and December 2012 were classified in to two age groups with 40y as cut-off. Patients were assessed for conventional risk factors (diabetes mellitus, dyslipidaemia, hypertension, smoking, obesity), novel risk factors (high sensitivity C-reactive protein, lipoprotein (a), homocysteine), and angiographic profiles.The statistical difference between two age groups was determined by Student's t-test for continuous variables and Chi-square or Fisher's exact test for categorical variables. A total of 200 patients, 100 patients ≤40 y of age and 100 patients >40 y of age, were evaluated. Older patients had higher frequency of hypertension (32 vs. 16%, p=0.008), while family history of coronary artery disease was more common among younger patients (19 vs. 9%, p=0.041). The incidence of diabetes, dyslipidaemia, smoking and tobacco chewing did not vary significantly between the two groups. Total cholesterol and low-density lipoprotein cholesterol levels were significantly higher in the younger group (p<0.05). Lipoprotein (a), homocysteine and high-sensitivity C reactive protein levels were comparable between two age groups. Multi-vessel coronary artery disease was more common among older group. The most commonly affected coronary artery was the left anterior descending artery among younger patients (44%) and the left circumflex artery among older patients (38.1%). Young patients with ACS had different atherosclerotic risk profile and less extensive coronary artery disease as compared to older counterparts. Emphasis

  16. Risk of fractures in vitiligo patients treated with phototherapy-A retrospective population-based cohort study.

    PubMed

    Lo, Po-Ching; Li, Cheng-Yuan; Huang, Weng-Foung; Tsai, Yi-Wen; Liu, Han-Nan; Chang, Yun-Ting; Chiu, Hsien-Yi; Tsai, Tsen-Fang

    2016-06-01

    Phototherapy might increase bone mineral density. However, it is unknown whether phototherapy can reduce the risk of fractures in patients with vitiligo. To investigate the effect of phototherapy on fracture risks in vitiligo patients aged 40 or older. This population-based cohort study used the 2000-2010 Taiwan National Health Insurance Research Database (NHIRD) to identify 3863 patients newly diagnosed with vitiligo between 2003 and 2009 at age ≥40 years. Study subjects were classified into three cohorts: (1) frequent phototherapy; (2) infrequent phototherapy; and (3) no phototherapy. Patients were followed until the first hip or vertebral fracture or 31 December 2010. Data were analysed using Cox regression models and also stratified by age and gender. Frequent phototherapy decreased the fracture risks (adjusted hazard ratio (aHR)=0.32, p=0.009) in vitiligo patients. Stratification by age and gender confirmed the fracture prevention effect of frequent phototherapy in patients aged 40-64 years (aHR=0.14, p=0.016) and in female patients (aHR=0.31, p=0.024). This study provides the first evidence that frequent phototherapy can reduce the risk of fractures among middle-aged and among female vitiligo patients. Copyright © 2016. Published by Elsevier Ireland Ltd.

  17. The risks of minor head injury in the warfarinised patient.

    PubMed

    Volans, A P

    1998-05-01

    The risk factors affecting intracranial haemorrhage in warfarinised patients are described and an attempt made to calculate the risk of haemorrhage in warfarinised patients with minor head injuries. Using the data from studies of patients with spontaneous haemorrhage while taking warfarin, guidelines for treatment and given and the likely outcome predicted.

  18. The risks of minor head injury in the warfarinised patient.

    PubMed Central

    Volans, A P

    1998-01-01

    The risk factors affecting intracranial haemorrhage in warfarinised patients are described and an attempt made to calculate the risk of haemorrhage in warfarinised patients with minor head injuries. Using the data from studies of patients with spontaneous haemorrhage while taking warfarin, guidelines for treatment and given and the likely outcome predicted. PMID:9639176

  19. 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.

  20. Endoscopic risk factors for neoplastic progression in patients with Barrett’s oesophagus

    PubMed Central

    Bureo Gonzalez, Angela; Bergman, Jacques JGHM

    2016-01-01

    Barrett’s oesophagus is a precursor lesion for oesophageal adenocarcinoma, which generally has a poor prognosis. Patients diagnosed with Barrett’s oesophagus therefore undergo regular endoscopic surveillance to detect neoplastic lesions at a curable stage. The efficacy of endoscopic surveillance of Barrett’s oesophagus patients is, however, hampered by difficulties to detect early neoplasia endoscopically, biopsy sampling error, inter-observer variability in histological assessment and the relatively low overall progression rate. Efficacy and cost-effectiveness of Barrett’s surveillance may be improved by using endoscopic and clinical characteristics to risk-stratify Barrett’s patients to high- and low-risk categories. Recent national and international surveillance guidelines have incorporated Barrett’s length and presence of low-grade dysplasia in the advised surveillance intervals. In this review we will discuss endoscopic characteristics that may be associated with neoplastic progression in Barrett’s oesophagus and that may be used to tailor surveillance in Barrett’s patients. PMID:27733907

  1. 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

  2. Psychosocial assessment of candidates and risk classification of patients considered for durable mechanical circulatory support.

    PubMed

    Maltby, Megan C; Flattery, Maureen P; Burns, Brigid; Salyer, Jeanne; Weinland, Stephan; Shah, Keyur B

    2014-08-01

    The psychosocial assessment of candidates for transplantation (PACT), developed to assess candidates for heart transplant, has not been routinely used to assess left ventricular assist device (LVAD) candidacy. We examined the efficacy of the PACT to assess psychosocial outcomes in LVAD patients. We reviewed patients who received LVAD implants between June 2006 and April 2011 and retrospectively applied the PACT. We determined the accuracy of identifying social success with the PACT and revised domains to reflect criteria influencing social success for LVAD patients. Forty-eight patients (72% men, 44% non-white, 50.4 years old) were divided into high-scoring and low-scoring groups. Nine patients with low PACT scores were falsely categorized as high-risk, whereas 4 with high scores had poor social outcomes. The score had a high positive-predictive value (0.86) but low negative-predictive value (0.31). The PACT was revised (modified [m]PACT) to measure indicators, such as social support and understanding of care requirements, identified to more closely affect LVAD outcome. The mPACT exhibited improved accuracy. A reclassification table was developed, and the net reclassification index was 0.32. The percentage of patients incorrectly classified for social risk decreased from 27% with the PACT to 8% with the mPACT. Patients with higher mPACT scores had decreased 30-day readmission rates (26% vs 67%, p = 0.045) after device implantation. By emphasizing social support, psychologic health, lifestyle factors, and device understanding, the mPACT showed improved performance in risk-stratifying candidates for LVAD therapy. Prospective validation is warranted. Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

  3. Risk Factors of Preoperative and Early Postoperative Seizures in Patients with Meningioma: A Retrospective Single-Center Cohort Study.

    PubMed

    Skardelly, Marco; Rother, Christian; Noell, Susan; Behling, Felix; Wuttke, Thomas V; Schittenhelm, Jens; Bisdas, Sotirios; Meisner, Christoph; Rona, Sabine; Tabatabai, Ghazaleh; Roser, Florian; Tatagiba, Marcos Soares

    2017-01-01

    Well-defined risk factors for the identification of patients with meningioma who might benefit from preoperative or early postoperative seizure prophylaxis are unknown. We investigated and quantified risk factors to determine individual risks of seizure occurrence in patients with meningioma. A total of 634 adult patients with meningioma were included in this retrospective cohort study. Patient gender and age, tumor location, grade and volume, usage of antiepileptic drugs (AEDs) and extent of resection were determined. Preoperative and early postoperative seizures occurred in 15% (n = 97) and 5% (n = 21) of the patients, respectively. Overall, 502 and 418 patients were eligible for multivariate logistic regression analyses of preoperative and early postoperative seizures, respectively. Male gender (odds ratio [OR], 2.06; P = 0.009), a non-skull base location (OR, 4.43; P < 0.001), and a tumor volume of >8 cm(3) (OR, 3.05; P = 0.002) were associated with a higher risk of preoperative seizures and were used to stratify the patients into 3 prognostic groups. The high-risk subgroup of patients with meningioma showed a seizure rate of >40% (OR, 9.8; P < 0.001). Only a non-skull base tumor location (OR, 2.61; P = 0.046) was identified as a significant risk factor for early postoperative seizures. AEDs did not reduce early postoperative seizure occurrence. Seizure prophylaxis might be considered for patients at high risk of developing seizures who are for other reasons being considered for watchful waiting instead of resection. In contrast, our data do not provide any evidence of the efficacy of perioperative AEDs in patients with meningioma. Copyright © 2016 Elsevier Inc. All rights reserved.

  4. Managing cardiovascular risk in patients with inflammatory arthritis: practical considerations

    PubMed Central

    Tournadre, Anne; Mathieu, Sylvain; Soubrier, Martin

    2016-01-01

    Patients with inflammatory arthritis, such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, have higher rates of cardiovascular mortality. While the increased cardiovascular risk is only explained to some extent, a lot of research is currently conducted to improve our understanding of its pathogenesis, risk stratification, and optimal cardiovascular risk management. This review sought to report epidemiological data pertaining to the cardiovascular disease burden in patients with inflammatory arthritis, underlying mechanisms accounting for excessive cardiovascular risk, along with recommendations regarding risk assessment and management in this patient population. PMID:27721904

  5. Stratified volume diffractive optical elements

    NASA Astrophysics Data System (ADS)

    Chambers, Diana Marie

    2000-11-01

    Gratings with high diffraction efficiency into a single order find use in applications ranging from optical interconnects to beam steering. Such gratings have been realized with volume holographic, blazed, and diffractive optical techniques. However, each of these methods has limitations that restrict the range of applications in which they can be used. In this work an alternate, novel approach and method for creating high efficiency gratings has been developed. These new gratings are named stratified volume diffractive optical elements (SVDOE's). In this approach diffractive optic techniques are used to create an optical structure that emulates volume grating behavior. An SVDOE consists of binary gratings interleaved with homogeneous layers in a multi-layer, stratified grating structure. The ridges of the binary gratings form fringe planes analogous to those of a volume hologram. The modulation and diffraction of an incident beam, which occur concurrently in a volume grating, are achieved sequentially by the grating layers and the homogeneous layers, respectively. The layers in this type of structure must be fabricated individually, which introduces the capability to laterally shift the binary grating layers relative to one another to create a grating with slanted fringe planes. This allows an element to be designed with high diffraction efficiency into the first order for any arbitrary angle of incidence. A systematic design process has been developed for SVDOE's. Optimum modulation depth of the SVDOE is determined analytically and the number of grating layers along with the thickness of homogeneous layers is determined by numerical simulation. A rigorous electromagnetic simulation of the diffraction properties of multi-layer grating structures, based on the Rigorous Coupled-Wave Analysis (RCWA) algorithm, was developed and applied to SVDOE performance prediction. Fabrication of an SVDOE structure presents unique challenges. Microfabrication combined with

  6. Minimally invasive aortic valve replacement in high risk patient groups

    PubMed Central

    Lewis, Harriet; Benedetto, Umberto; Caputo, Massimo; Angelini, Gianni; Vohra, Hunaid A.

    2017-01-01

    Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts. PMID:28740685

  7. Assessing patients' risk of febrile neutropenia: is there a correlation between physician-assessed risk and model-predicted risk?

    PubMed

    Lyman, Gary H; Dale, David C; Legg, Jason C; Abella, Esteban; Morrow, Phuong Khanh; Whittaker, Sadie; Crawford, Jeffrey

    2015-08-01

    This study evaluated the correlation between the risk of febrile neutropenia (FN) estimated by physicians and the risk of severe neutropenia or FN predicted by a validated multivariate model in patients with nonmyeloid malignancies receiving chemotherapy. Before patient enrollment, physician and site characteristics were recorded, and physicians self-reported the FN risk at which they would typically consider granulocyte colony-stimulating factor (G-CSF) primary prophylaxis (FN risk intervention threshold). For each patient, physicians electronically recorded their estimated FN risk, orders for G-CSF primary prophylaxis (yes/no), and patient characteristics for model predictions. Correlations between physician-assessed FN risk and model-predicted risk (primary endpoints) and between physician-assessed FN risk and G-CSF orders were calculated. Overall, 124 community-based oncologists registered; 944 patients initiating chemotherapy with intermediate FN risk enrolled. Median physician-assessed FN risk over all chemotherapy cycles was 20.0%, and median model-predicted risk was 17.9%; the correlation was 0.249 (95% CI, 0.179-0.316). The correlation between physician-assessed FN risk and subsequent orders for G-CSF primary prophylaxis (n = 634) was 0.313 (95% CI, 0.135-0.472). Among patients with a physician-assessed FN risk ≥ 20%, 14% did not receive G-CSF orders. G-CSF was not ordered for 16% of patients at or above their physician's self-reported FN risk intervention threshold (median, 20.0%) and was ordered for 21% below the threshold. Physician-assessed FN risk and model-predicted risk correlated weakly; however, there was moderate correlation between physician-assessed FN risk and orders for G-CSF primary prophylaxis. Further research and education on FN risk factors and appropriate G-CSF use are needed.

  8. Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program.

    PubMed

    Causey, Marlin W; Ahmed, Ayman; Wu, Bian; Gasper, Warren J; Reyzelman, Alex; Vartanian, Shant M; Hiramoto, Jade S; Conte, Michael S

    2016-06-01

    Clinical decision making and accurate outcomes comparisons in advanced limb ischemia require improved staging systems. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (Wound extent, Ischemia, and foot Infection [WIfI]) was designed to stratify limb outcomes based on three major factors-wound extent, ischemia, and foot infection. The Project or Ex-Vivo vein graft Engineering via Transfection III (PREVENT) III (PIII) risk score was developed to stratify patients by expected amputation-free survival (AFS) after surgical revascularization. This study was designed to prospectively assess limb and patient-based staging for predicting outcomes of hospitalized patients in an amputation prevention program. This study undertook a retrospective analysis of prospectively gathered registry data of consecutive patients with limb-threatening conditions admitted to a fully integrated vascular/podiatry service over a 16-month period. Upon admission, limb risk was stratified using the WIfI system and patient risk was categorized using PIII classification. Patients were assessed for perioperative and postdischarge outcomes, and their relationship to staging at admission was analyzed. There were 174 threatened limbs (143 hospitalized patients) stratified by WIfI stage (1%-12%, 2%-28%, 3%-24%, 4%-28%, 5%-3%, unstaged-5%) and PIII risk (34% low, 49% moderate, and 17% high risk). Diabetes and end-stage renal disease were associated with WIfI stage (P = .006 and P = .018) and PIII risk (P = .003 and P < .001). Perioperative (30-day) events included 3% mortality, 8% major adverse cardiovascular events and 2.4% major amputation. There were 119 limbs (71%) that underwent revascularization, including 108 infrainguinal reconstructions (endovascular or open revascularization). Rate of revascularization increased with WIfI stage (P < .001), concomitant with the number of podiatric procedures, minor amputations, and initial hospital duration of stay

  9. Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis

    PubMed Central

    2013-01-01

    Background Falls are a serious problem for hospitalized patients, reducing the duration and quality of life. It is estimated that over 84% of all adverse events in hospitalized patients are related to falls. Some fall risk assessment tools have been developed and tested in environments other than those for which they were developed with serious validity discrepancies. The aim of this review is to determine the accuracy of instruments for detecting fall risk and predicting falls in acute hospitalized patients. Methods Systematic review and meta-analysis. Main databases, related websites and grey literature were searched. Two blinded reviewers evaluated title and abstracts of the selected articles and, if they met inclusion criteria, methodological quality was assessed in a new blinded process. Meta-analyses of diagnostic ORs (DOR) and likelihood (LH) coefficients were performed with the random effects method. Forest plots were calculated for sensitivity and specificity, DOR and LH. Additionally, summary ROC (SROC) curves were calculated for every analysis. Results Fourteen studies were selected for the review. The meta-analysis was performed with the Morse (MFS), STRATIFY and Hendrich II Fall Risk Model scales. The STRATIFY tool provided greater diagnostic validity, with a DOR value of 7.64 (4.86 - 12.00). A meta-regression was performed to assess the effect of average patient age over 65 years and the performance or otherwise of risk reassessments during the patient’s stay. The reassessment showed a significant reduction in the DOR on the MFS (rDOR 0.75, 95% CI: 0.64 - 0.89, p = 0.017). Conclusions The STRATIFY scale was found to be the best tool for assessing the risk of falls by hospitalized acutely-ill adults. However, the behaviour of these instruments varies considerably depending on the population and the environment, and so their operation should be tested prior to implementation. Further studies are needed to investigate the effect of the

  10. PHOTOSPHERIC EMISSION FROM STRATIFIED JETS

    SciTech Connect

    Ito, Hirotaka; Nagataki, Shigehiro; Ono, Masaomi; Lee, Shiu-Hang; Mao, Jirong; Yamada, Shoichi; Pe'er, Asaf; Mizuta, Akira; Harikae, Seiji

    2013-11-01

    We explore photospheric emissions from stratified two-component jets, wherein a highly relativistic spine outflow is surrounded by a wider and less relativistic sheath outflow. Thermal photons are injected in regions of high optical depth and propagated until the photons escape at the photosphere. Because of the presence of shear in velocity (Lorentz factor) at the boundary of the spine and sheath region, a fraction of the injected photons are accelerated using a Fermi-like acceleration mechanism such that a high-energy power-law tail is formed in the resultant spectrum. We show, in particular, that if a velocity shear with a considerable variance in the bulk Lorentz factor is present, the high-energy part of observed gamma-ray bursts (GRBs) photon spectrum can be explained by this photon acceleration mechanism. We also show that the accelerated photons might also account for the origin of the extra-hard power-law component above the bump of the thermal-like peak seen in some peculiar bursts (e.g., GRB 090510, 090902B, 090926A). We demonstrate that time-integrated spectra can also reproduce the low-energy spectrum of GRBs consistently using a multi-temperature effect when time evolution of the outflow is considered. Last, we show that the empirical E{sub p}-L{sub p} relation can be explained by differences in the outflow properties of individual sources.

  11. Xanax, Valium May Boost Pneumonia Risk in Alzheimer's Patients

    MedlinePlus

    ... html Xanax, Valium May Boost Pneumonia Risk in Alzheimer's Patients Researchers suspect people may breathe saliva or ... 10, 2017 MONDAY, April 10, 2017 (HealthDay News) -- Alzheimer's patients given sedatives such as Valium or Xanax ...

  12. High-density lipoprotein cholesterol and the risk of nephropathy in type 2 diabetic patients.

    PubMed

    Chang, Y-H; Chang, D-M; Lin, K-C; Hsieh, C-H; Lee, Y-J

    2013-08-01

    To date, few studies have demonstrated the impact of variations in blood pressure, blood glucose and lipid levels on the progression of diabetic nephropathy (DN) in type 2 diabetic patients. This study aimed to assess the associations of mean values and variability in metabolic parameters with the development of DN in type 2 diabetic patients. A total of 864 patients who had participated in a comprehensive diabetic care program for at least for 3 years were studied. Patients were stratified into progressor (n = 180) and non-progressor groups (n = 684) according to the status of progression of DN during the follow-up period. By Cox regression analysis, a higher mean HDL-C level was observed to be a protective factor against the progression of DN [hazard ratio (95% CI): 0.971(0.953-0.989), P = 0.002] and a higher HDL-C variation was found to be associated with a higher risk [hazard ratio (95% CI): 1.177(1.032-1.341), P = 0.015] of DN progression. By the Kaplan-Meier survival curve, patients with a higher HDL-C level and lower HDL-C variability were found to have the lowest risk of development of nephropathy. Our study demonstrated for the first time that type 2 diabetic patients under a standard disease management program who have a stable and a higher mean HDL-C level were associated with a lower risk of development of DN. Copyright © 2012 Elsevier B.V. All rights reserved.

  13. 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.

  14. Obesity and Risk of Biochemical Failure for Patients Receiving Salvage Radiotherapy After Prostatectomy

    SciTech Connect

    King, Christopher R. Spiotto, Michael T.; Kapp, Daniel S.

    2009-03-15

    Purpose: Obesity has been proposed as an independent risk factor for patients undergoing surgery or radiotherapy (RT) for prostate cancer. Using body mass index (BMI) as a measure of obesity, we tested its role as a risk factor for patients receiving salvage RT after prostatectomy. Methods and Materials: Rates of subsequent biochemical relapse were examined in 90 patients who underwent salvage RT between 1984 and 2004 for biochemical failure after radical prostatectomy. Median follow-up was 3.7 years. The BMI was tested as a continuous and categorical variable (stratified as <25, 25-<30, and {>=}30 kg/m{sup 2}). Univariate and multivariate proportional hazards regression analyses were performed for clinical, pathologic, and treatment factors associated with time to relapse after salvage RT. Results: There were 40 biochemical failures after salvage RT with a median time to failure of 1.2 years. The BMI was not associated with adverse clinical, pathologic, or treatment factors. On multivariate analysis, obesity was independently significant (hazard ratio [HR], 1.2; p = 0.01), along with RT dose (HR, 0.7; p = 0.003) and pre-RT prostate-specific antigen level (HR, 1.2; p = 0.0003). Conclusions: This study is weakly suggestive that obesity may be a risk factor for salvage RT patients. Whether this results from greater biologic aggressiveness or technical inadequacies cannot be answered by this study. Given the very high failure rate observed for severely obese patients, we propose that technical difficulties with RT are at play. This hypothesis is supported by the RT literature and could be prospectively investigated. Techniques that optimize targeting, especially in obese patients, perhaps seem warranted at this time.

  15. Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest pain.

    PubMed

    Halpern, Ethan J; Deutsch, Jacob P; Hannaway, Maria M; Estepa, Adrian T; Kenia, Anand S; Neuburger, Kenneth J; Levin, David C

    2013-10-01

    The objective of the study is to evaluate cardiac risk factors and risk scores for prediction of coronary artery disease (CAD) and adverse outcomes in an emergency department (ED) population judged to be at low to intermediate risk for acute coronary syndrome. Informed consent was obtained from consecutive ED patients who presented with chest pain and were evaluated with coronary computed tomography angiography (cCTA). Cardiac risk factors, clinical presentation, electrocardiogram, and laboratory studies were recorded; the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores were tabulated. Coronary computed tomography angiography findings were rated on a 6-level plaque burden scale and classified for significant CAD (stenosis ≥50%). Adverse cardiovascular outcomes were recorded at 30 days. Among 250 patients evaluated by cCTA, 143 (57%) had no CAD, 64 (26%) demonstrated minimal plaque (<30% stenosis), 26 (10%) demonstrated mild plaque (<50% stenosis), 9 (4%) demonstrated moderate single vessel disease (50%-70% stenosis), 2 (1%) demonstrated moderate multivessel disease, and 6 (2%) demonstrated severe disease (>70% stenosis). Six patients developed adverse cardiovascular outcomes. Among traditional cardiac risk factors, only age (older) and sex (male) were significant independent predictors of CAD. Correlation with CAD was poor for the TIMI (r = 0.12) and GRACE (r = 0.09-0.23) scores. The TIMI and GRACE scores were not useful to predict adverse outcomes. Coronary computed tomography angiography identified severe CAD in all subjects with adverse outcomes. Among ED patients who present with chest pain judged to be at low to intermediate risk for acute coronary syndrome, traditional risk factors are not useful to stratify risk for CAD and adverse outcomes. Coronary computed tomography angiography is an excellent predictor of CAD and outcome. © 2013.

  16. Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage.

    PubMed

    Pfister, David G; Rubin, David M; Elkin, Elena B; Neill, Ushma S; Duck, Elaine; Radzyner, Mark; Bach, Peter B

    2015-12-01

    Instituting widespread measurement of outcomes for cancer hospitals using administrative data is difficult owing to lack of cancer-specific information such as disease stage. To evaluate the performance of hospitals that treat patients with cancer using Medicare data for outcome ascertainment and risk adjustment and to assess whether hospital rankings based on these measures are altered by the addition of cancer-specific information. Risk-adjusted cumulative mortality rates of patients with cancer were captured in Medicare claims data from 2005 through 2009 nationally and assessed at the hospital level. Similar analyses were conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the subset of the United States covered by the SEER program to determine whether the inclusion of cancer-specific information (only available in cancer registries) in risk adjustment altered measured hospital performance. Data were from 729 279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10 or more patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon, and other. An additional sample of 18 677 similar patients were included from the SEER-Medicare administrative data. Risk-adjusted mortality overall and by cancer category, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data. There were large survival differences between different types of hospitals that treat Medicare patients with cancer. At 1 year, mortality for patients treated by hospitals exempt from the Medicare prospective payment system was 10% lower than at community hospitals (18% vs 28%) across all cancers, and the pattern persisted through 5 years of follow-up and within specific cancer categories. Performance ranking of hospitals was consistent with or without SEER-Medicare disease

  17. The Current National Criteria for Carotid Artery Stenting Overestimates Its Efficacy in Patients Who Are Symptomatic and High Risk

    PubMed Central

    Yoshida, Shunsuke; Bensley, Rodney P.; Glaser, Julia D.; Nabzdyk, Christoph S.; Hamdan, Allen D.; Wyers, Mark C.; Chaikof, Elliot L.; Schermerhorn, Marc L.; Boston

    2013-01-01

    Background The Centers for Medicare and Medicaid Services (CMS) have established guidelines that outline patients who are considered “high risk” for complications following CEA for which CAS may provide benefit. The validity of these high risk criteria are yet unproven. In this study, we stratified patients who underwent either CAS or CEA by CMS high risk criteria and symptom status, and examined their 30-day outcomes. Methods A non-randomized, retrospective cohort study was performed by chart review of all patients undergoing CEA or CAS from January 1, 2005 to December 31, 2010 at our institution. Demographic data, as well as data pertaining to the presence or absence of high risk factors were collected. Patients were stratified using symptom status and high risk status as variables and 30-day adverse events (stroke, death, and/or myocardial infarction (MI)) were compared. Results 271 patients underwent CAS with 30-day complication rates of stroke (3.0%), death (1.1%), MI (1.5%), stroke/death (3.7%), and stroke/death/MI (5.2%). 830 patients underwent CEA with 30-day complication rates of stroke (2.0%), death (0.1%), MI (0.6%), stroke/death (1.9%), and stroke/death/MI (2.7%). Among symptomatic patients, physiologic high risk status was associated with increased stroke/death (6/42, 14.3% vs. 2/74, 2.7%, P<0.01), and anatomic high risk status was associated with a trend towards increased stroke/death (5/31, 16.1% vs. 0/20, 0.0%, P=0.14) in patients who underwent CAS compared to CEA. Analysis of asymptomatic patients showed no differences among the two groups overall, except for a trend towards higher rate of MI following CAS compared to CEA (3/71, 4.2% vs. 0/108, 0.0%, P=.06) in those who were physiologically high risk. Among symptomatic patients who underwent CAS, patients with physiologic and anatomic high risk factors had a higher rate of stroke/death compared to non-high risk patients (6/42, 14.3% vs. 0/24, 0.0% and 5/31, 16.1% vs. 0/24, 0.0%, respectively

  18. A prediction rule for estimating the risk of bacteremia in patients with community-acquired pneumonia.

    PubMed

    Falguera, Miquel; Trujillano, Javier; Caro, Sílvia; Menéndez, Rosario; Carratalà, Jordi; Ruiz-González, Agustín; Vilà, Manuel; García, Mercè; Porcel, José Manuel; Torres, Antoni

    2009-08-01

    We endeavored to construct a simple score based entirely on epidemiological and clinical variables that would stratify patients who require hospital admission because of community-acquired pneumonia into groups with a low or high risk of developing bacteremia. Derivation and internal validation cohorts were obtained by retrospective analysis of a database that included 3116 consecutive patients with community-acquired pneumonia from 2 university hospitals. Potential predictive factors were determined by means of a multivariate logistic regression equation applied to a cohort consisting of 60% of the patients. Points were assigned to significant parameters to generate the score. It was then internally validated with the remaining 40% of patients and was externally validated using an independent multicenter cohort of 1369 patients. The overall rates of bacteremia were 12%-16% in the cohorts. The clinical probability estimate of developing bacteremia was based on 6 variables: liver disease, pleuritic pain, tachycardia, tachypnea, systolic hypotension, and absence of prior antibiotic treatment. For the score, 1 point was assigned to each predictive factor. In the derivation cohort, a cutoff score of 2 best identified the risk of bacteremia. In the validation cohorts, rates of bacteremia were <8% for patients with a score 1 (43%-49% of patients), whereas blood culture results were positive in 14%-63% of cases for patients with a score 2. This clinical score, based on readily available and objective variables, provides a useful tool to predict bacteremia. The score has been internally and externally validated and may be useful to guide diagnostic decisions for community-acquired pneumonia.

  19. The Risk of Cancer in Patients With Obsessive-Compulsive Disorder: A Nationwide Population-Based Retrospective Cohort Study.

    PubMed

    Shen, Cheng-Che; Hu, Li-Yu; Hu, Yu-Wen; Chang, Wen-Han; Tang, Pei-Ling; Chen, Pan-Ming; Chen, Tzeng-Ji; Su, Tung-Ping

    2016-03-01

    Previous studies suggest a link between anxiety disorders and cancer. The aim of the study was to evaluate the risk of cancer among patients with obsessive-compulsive disorder (OCD) using a nationwide population-based dataset. We recruited newly diagnosed OCD patients without antecedent cancer from the Taiwan National Health Insurance Research Database between 2002 and 2011. The standardized incidence ratios (SIRs) were estimated for 22 specific cancer types among OCD patients and we determined the SIRs for subgroups according to age and sex group. In addition, because of a potential detection bias, a subgroup analysis stratified with the duration of the OCD diagnosis was carried out. Among the 52,656 OCD patients, who were followed up for 259,945 person-years (median follow-up = 4.9 years), there were 718 cases of cancer. Patients with OCD did not exhibit an increased overall cancer risk relative to the general population (SIR 1.05, 95% confidence interval [CI] 0.98-1.13). An increased SIR was observed among OCD patients only within the first year of OCD diagnosis (SIR 1.21, 95% CI 1.01-1.43).This study indicated that the overall cancer risk was not elevated among OCD patients. An increased SIR observed among OCD patients within the first year of OCD diagnosis may be caused by a surveillance bias, and because paraneoplastic manifestations presented with obsessive-compulsive behaviors. Prospective study is necessary to confirm these findings.

  20. Integrating clinical features and genetic lesions in the risk assessment of patients with chronic myelomonocytic leukemia.

    PubMed

    Elena, Chiara; Gallì, Anna; Such, Esperanza; Meggendorfer, Manja; Germing, Ulrich; Rizzo, Ettore; Cervera, Jose; Molteni, Elisabetta; Fasan, Annette; Schuler, Esther; Ambaglio, Ilaria; Lopez-Pavia, Maria; Zibellini, Silvia; Kuendgen, Andrea; Travaglino, Erica; Sancho-Tello, Reyes; Catricalà, Silvia; Vicente, Ana I; Haferlach, Torsten; Haferlach, Claudia; Sanz, Guillermo F; Malcovati, Luca; Cazzola, Mario

    2016-09-08

    Chronic myelomonocytic leukemia (CMML) is a myelodysplastic/myeloproliferative neoplasm with variable clinical course. To predict the clinical outcome, we previously developed a CMML-specific prognostic scoring system (CPSS) based on clinical parameters and cytogenetics. In this work, we tested the hypothesis that accounting for gene mutations would further improve risk stratification of CMML patients. We therefore sequenced 38 genes to explore the role of somatic mutations in disease phenotype and clinical outcome. Overall, 199 of 214 (93%) CMML patients carried at least 1 somatic mutation. Stepwise linear regression models showed that these mutations accounted for 15% to 24% of variability of clinical phenotype. Based on multivariable Cox regression analyses, cytogenetic abnormalities and mutations in RUNX1, NRAS, SETBP1, and ASXL1 were independently associated with overall survival (OS). Using these parameters, we defined a genetic score that identified 4 categories with significantly different OS and cumulative incidence of leukemic evolution. In multivariable analyses, genetic score, red blood cell transfusion dependency, white blood cell count, and marrow blasts retained independent prognostic value. These parameters were included into a clinical/molecular CPSS (CPSS-Mol) model that identified 4 risk groups with markedly different median OS (from >144 to 18 months, hazard ratio [HR] = 2.69) and cumulative incidence of leukemic evolution (from 0% to 48% at 4 years, HR = 3.84) (P < .001). The CPSS-Mol fully retained its ability to risk stratify in an independent validation cohort of 260 CMML patients. In conclusion, integrating conventional parameters and gene mutations significantly improves risk stratification of CMML patients, providing a robust basis for clinical decision-making and a reliable tool for clinical trials. © 2016 by The American Society of Hematology.

  1. Integrating clinical features and genetic lesions in the risk assessment of patients with chronic myelomonocytic leukemia

    PubMed Central

    Elena, Chiara; Gallì, Anna; Such, Esperanza; Meggendorfer, Manja; Germing, Ulrich; Rizzo, Ettore; Cervera, Jose; Molteni, Elisabetta; Fasan, Annette; Schuler, Esther; Ambaglio, Ilaria; Lopez-Pavia, Maria; Zibellini, Silvia; Kuendgen, Andrea; Travaglino, Erica; Sancho-Tello, Reyes; Catricalà, Silvia; Vicente, Ana I.; Haferlach, Torsten; Haferlach, Claudia; Sanz, Guillermo F.; Cazzola, Mario

    2016-01-01

    Chronic myelomonocytic leukemia (CMML) is a myelodysplastic/myeloproliferative neoplasm with variable clinical course. To predict the clinical outcome, we previously developed a CMML-specific prognostic scoring system (CPSS) based on clinical parameters and cytogenetics. In this work, we tested the hypothesis that accounting for gene mutations would further improve risk stratification of CMML patients. We therefore sequenced 38 genes to explore the role of somatic mutations in disease phenotype and clinical outcome. Overall, 199 of 214 (93%) CMML patients carried at least 1 somatic mutation. Stepwise linear regression models showed that these mutations accounted for 15% to 24% of variability of clinical phenotype. Based on multivariable Cox regression analyses, cytogenetic abnormalities and mutations in RUNX1, NRAS, SETBP1, and ASXL1 were independently associated with overall survival (OS). Using these parameters, we defined a genetic score that identified 4 categories with significantly different OS and cumulative incidence of leukemic evolution. In multivariable analyses, genetic score, red blood cell transfusion dependency, white blood cell count, and marrow blasts retained independent prognostic value. These parameters were included into a clinical/molecular CPSS (CPSS-Mol) model that identified 4 risk groups with markedly different median OS (from >144 to 18 months, hazard ratio [HR] = 2.69) and cumulative incidence of leukemic evolution (from 0% to 48% at 4 years, HR = 3.84) (P < .001). The CPSS-Mol fully retained its ability to risk stratify in an independent validation cohort of 260 CMML patients. In conclusion, integrating conventional parameters and gene mutations significantly improves risk stratification of CMML patients, providing a robust basis for clinical decision-making and a reliable tool for clinical trials. PMID:27385790

  2. External Validation of Pooled Cohort Risk Equations to Predict 1-Year Clinical Outcome in Ischemic Stroke Patients.

    PubMed

    Li, Haiyan; Zhang, Runhua; Liu, Gaifen; Liu, Liping; Wang, Yilong; Wang, Yongjun

    2017-09-13

    BACKGROUND The present study aimed to validate the pooled cohort risk (PCR) equations in a Chinese ischemic stroke population and to explore its prognostic value in predicting stroke recurrence, coronary heart disease, and vascular death. MATERIAL AND METHODS Patients were selected from the China National Stroke Registry. The C statistic was used to examine the clinical prediction of the scores. To analyze the relevant risk factors, univariate and multivariate logistic regressions were performed. RESULTS Out of a total of 22 216 patients, 8287 patients (including 7652 acute ischemic stroke [AIS] and 635 transient ischemic attack [TIA] patients) were selected and enrolled in the study. At 1-year follow-up, for stroke recurrence rate, the C statistic value was 0.584 in AIS patients and 0.573 in all patients. For non-fatal myocardial infarction, the C statistic value was 0.533 in AIS patients and 0.493 in all patients. For vascular death, the C statistic value was 0.592 in AIS patients and 0.592 in all patients. For all events, the C statistic value was 0.582 in AIS patients and 0.575 in all patients. For AIS patients, the 12-month cumulative rates for recurrent stroke, vascular death, and combined vascular events were higher in the high-PCR group (PCR ≥20%). CONCLUSIONS Pooled cohort risk equations may serve as potential tools to predict and stratify the 1-year risk of recurrent stroke and combined vascular events in AIS/TIA patients in China.

  3. Mixing in confined stratified aquifers

    NASA Astrophysics Data System (ADS)

    Bolster, Diogo; Valdés-Parada, Francisco J.; LeBorgne, Tanguy; Dentz, Marco; Carrera, Jesus

    2011-03-01

    Spatial variability in a flow field leads to spreading of a tracer plume. The effect of microdispersion is to smooth concentration gradients that exist in the system. The combined effect of these two phenomena leads to an 'effective' enhanced mixing that can be asymptotically quantified by an effective dispersion coefficient (i.e. Taylor dispersion). Mixing plays a fundamental role in driving chemical reactions. However, at pre-asymptotic times it is considerably more difficult to accurately quantify these effects by an effective dispersion coefficient as spreading and mixing are not the same (but intricately related). In this work we use a volume averaging approach to calculate the concentration distribution of an inert solute release at pre-asymptotic times in a stratified formation. Mixing here is characterized by the scalar dissipation rate, which measures the destruction of concentration variance. As such it is an indicator for the degree of mixing of a system. We study pre-asymptotic solute mixing in terms of explicit analytical expressions for the scalar dissipation rate and numerical random walk simulations. In particular, we divide the concentration field into a mean and deviation component and use dominant balance arguments to write approximate governing equations for each, which we then solve analytically. This allows us to explicitly evaluate the separate contributions to mixing from the mean and the deviation behavior. We find an approximate, but accurate expression (when compared to numerical simulations) to evaluate mixing. Our results shed some new light on the mechanisms that lead to large scale mixing and allow for a distinction between solute spreading, represented by the mean concentration, and mixing, which comes from both the mean and deviation concentrations, at pre-asymptotic times.

  4. [Assessing the cardiovascular risk in patients with systemic lupus erythematosus].

    PubMed

    Arnaud, L; Mathian, A; Bruckert, E; Amoura, Z

    2014-11-01

    Multiple factors contribute to the increased cardiovascular risk observed in patients with systemic lupus erythematosus (SLE). Among these are the so-called classical cardiovascular risk factors, the disease itself through its activity, treatments, and complications, and the thrombotic risk due to antiphospholipid antibodies (aPL). Observational studies suggest that most classical cardiovascular risk factors are observed more frequently in SLE patients than in the general population, and that these are insufficient to explain the increased cardiovascular risk observed in most studies. Given this high risk, adequate management of cardiovascular risk factors should be recommended in SLE patients. Paradoxically, the benefit due to the anti-inflammatory properties of treatments such as corticosteroids may exceed, in certain cases, their pro-atherogenic effect. Importantly, the tools that were developed for the estimation of cardiovascular risk at the individual level among the general population cannot be used reliably in SLE patients, as these tools appear to underestimate the true cardiovascular risk. The adequate indications and targets of cardiovascular treatments are therefore not fully known in SLE. A better understanding of the determinants of the cardiovascular risk in SLE will allow the identification and more tailored management of these high-risk patients.

  5. The Safety of Thoracentesis in Patients with Uncorrected Bleeding Risk

    PubMed Central

    Argento, A. Christine; Murphy, Terrence E.; Araujo, Katy L. B.; Pisani, Margaret A.

    2013-01-01

    Background: Thoracentesis is commonly performed to evaluate pleural effusions. Many medications (warfarin, heparin, clopidogrel) or physiological factors (elevated International Normalized Ratio [INR], thrombocytopenia, uremia) increase the risk for bleeding. Frequently these medications are withheld or transfusions are performed to normalize physiological parameters before a procedure. The safety of performing thoracentesis without correction of these bleeding risks has not been prospectively evaluated. Methods: This prospective observational cohort study enrolled 312 patients who underwent thoracentesis. All patients were evaluated for the presence of risk factors for bleeding. Hematocrit levels were obtained pre- and postprocedure, and the occurrence of postprocedural hemothorax was evaluated. Measurements and Main Results: Thoracenteses were performed in 312 patients, 42% of whom had a risk for bleeding. Elevated INR, secondary to liver disease or warfarin, and renal disease were the two most common etiologies for bleeding risk, although many patients had multiple potential bleeding risks. There was no significant difference in pre- and postprocedural hematocrit levels in patients with a bleeding risk when compared with patients with no bleeding risk. No patient developed a hemothorax as a result of the thoracentesis. Conclusions: This single-center, observational study suggests that thoracentesis may be safely performed without prior correction of coagulopathy, thrombocytopenia, or medication-induced bleeding risk. This may reduce the morbidity associated with transfusions or withholding of medications. PMID:23952852

  6. Comorbidities and cardiovascular risk factors in patients with psoriasis*

    PubMed Central

    Baeta, Isabela Guimarães Ribeiro; Bittencourt, Flávia Vasques; Gontijo, Bernardo; Goulart, Eugênio Marcos Andrade

    2014-01-01

    BACKGROUND Psoriasis is a chronic inflammatory disease and its pathogenesis involves an interaction between genetic, environmental, and immunological factors. Recent studies have suggested that the chronic inflammatory nature of psoriasis may predispose to an association with other inflammatory diseases, especially cardiovascular diseases and metabolic disorders. OBJECTIVES To describe the demographic, clinical, epidemiological, and laboratory characteristics of a sample of psoriasis patients; to assess the prevalence of cardiovascular comorbidities in this group of patients; and to identify the cardiovascular risk profile using the Framingham risk score. METHODS We conducted a cross-sectional study involving the assessment of 190 patients. Participants underwent history and physical examination. They also completed a specific questionnaire about epidemiological data, past medical history, and comorbidities. The cardiovascular risk profile was calculated using the Framingham risk score. RESULTS Patients' mean age was 51.5 ± 14 years, and the predominant clinical presentation was plaque psoriasis (78.4%). We found an increased prevalence of systemic hypertension, type 2 diabetes, metabolic syndrome, and obesity. Increased waist circumference was also found in addition to a considerable prevalence of depression, smoking, and regular alcohol intake. Patients' cardiovascular risk was high according to the Framingham risk score, and 47.2% of patients had moderate or high risk of fatal and non-fatal coronary events in 10 years. CONCLUSIONS Patients had high prevalence of cardiovascular comorbidities, and high cardiovascular risk according to the Framingham risk score. Further epidemiological studies are needed in Brazil for validation of our results. PMID:25184912

  7. [Risk factors for development of hypomagnesemia in the burned patient].

    PubMed

    Durán-Vega, Héctor César; Romero-Aviña, Francisco Javier; Gutiérrez-Salgado, Jorge Eduardo; Silva-Díaz, Teresita; Ramos-Durón, Luis Ernesto; Carrera-Gómez, Francisco Javier

    2004-01-01

    Electrolyte abnormalities are common in the severely burned patient. There is little information with regard to the frequency and magnitude of hypomagnesemia, as well as on risk factors for this condition. We performed an observational, retrospective analysis of 35 burned patients treated at the Plastic and Reconstructive Surgery Service at the Hospital Central Sur PEMEX, Mexico City. We determined serum magnesium behavior and divided patients into two groups: the first included 11 patients with burns and hypomagnesemia, and the second, 24 patients with burns but without hypomagnesemia. Risk factor identification was performed. We found patient at risk was the one with more than 40% of 2nd or 3rd degree total burned body area, in day 4 or 10 after the burn, and with hypokalemia, hypocalcemia, or both, and without intravenous (i.v.) supplementation of magnesium. The best way to prevent or avoid major complications is to identify the high-risk patient, or to diagnose earlier.

  8. Risk adjusting survival outcomes of hospitals that treat cancer patients without information on cancer stage

    PubMed Central

    Pfister, David G.; Rubin, David M.; Elkin, Elena B.; Neill, Ushma S.; Duck, Elaine; Radzyner, Mark; Bach, Peter B.

    2016-01-01

    Importance Instituting widespread measurement of outcomes for cancer hospitals using administrative data is difficult due to the lack of cancer specific information such as disease stage. Objective To evaluate the performance of hospitals that treat cancer patients using Medicare data for outcome ascertainment and risk adjustment, and to assess whether hospital rankings based on these measures are influenced by the addition of cancer-specific information. Design Risk adjusted cumulative mortality of patients with cancer captured in Medicare claims from 2005–2009 nationally were assessed at the hospital level. Similar analyses were conducted in the Surveillance, Epidemiology and End Result (SEER)-Medicare data for the subset of the US covered by the SEER program to determine whether the exclusion of cancer specific information (only available in cancer registries) from risk adjustment altered measured hospital performance. Setting Administrative claims data and SEER cancer registry data Participants Sample of 729,279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10+ patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon. An additional sample of 18,677 similar patients in SEER-Medicare administrative data. Main Outcomes and Measures Risk-adjusted mortality overall and by cancer type, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data. Results There were large outcome differences between different types of hospitals that treat Medicare patients with cancer. At one year, cumulative mortality for Medicare-prospective-payment-system exempt hospitals was 10% lower than at community hospitals (18% versus 28%) across all cancers, the pattern persisted through five years of follow-up and within specific cancer types. Performance ranking of hospitals was

  9. Risk of lymphoma and solid cancer among patients with rheumatoid arthritis in a primary care setting.

    PubMed

    Andersen, Christen Lykkegaard; Lindegaard, Hanne; Vestergaard, Hanne; Siersma, Volkert Dirk; Hasselbalch, Hans Carl; de Fine Olivarius, Niels; Bjerrum, Ole Weis; Junker, Peter

    2014-01-01

    Several studies have demonstrated an association between rheumatoid arthritis (RA) and lymphoproliferative malignancies, but pathogenic mechanisms remain unclear. We investigated 1) the risk of lymphoproliferative malignancies and solid tumors in adults with RA identified in primary care and 2) the possible mediating role of blood eosinophilia in the clonal evolution of cancer in these patients. From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 356,196 individuals with at least one differential cell count (DIFF) encompassing the eosinophil count between 2000-2007. From these, one DIFF was randomly chosen (the index DIFF). By linking to the Danish National Patient Register, we categorized the selected individuals according to known longstanding (≥3 years) or recent onset (<3 years) RA prior to the index DIFF. In addition, the cohort was stratified according to management in primary or secondary care. From the Danish Cancer Registry we ascertained malignancies within four years following the index DIFF. Using multivariable logistic regression, odds ratios (OR) were calculated and adjusted for sex, age, year, month, eosinophilia, comorbid conditions and C-reactive protein (CRP). 921 patients had recent onset RA and 2,578 had longer disease duration. Seventy three percent of RA patients were managed in primary care. After adjustment for sex, age, year, and month, neither recent onset nor long-standing RA was associated with incident lymphoproliferative malignancies or solid cancers. These risk estimates did not change when eosinophilia, CRP, and comorbidities were included in the models. In this large cohort of patients with RA of short or long duration recruited from a primary care resource, RA was not associated with an increased risk of lymphoproliferative or solid cancers during 4 years of follow-up, when the models were adjusted for confounders. Blood eosinophilia could not be identified as a mediator of cancer development in

  10. Risk of Lymphoma and Solid Cancer among Patients with Rheumatoid Arthritis in a Primary Care Setting

    PubMed Central

    Andersen, Christen Lykkegaard; Lindegaard, Hanne; Vestergaard, Hanne; Siersma, Volkert Dirk; Hasselbalch, Hans Carl; de Fine Olivarius, Niels; Bjerrum, Ole Weis; Junker, Peter

    2014-01-01

    Background Several studies have demonstrated an association between rheumatoid arthritis (RA) and lymphoproliferative malignancies, but pathogenic mechanisms remain unclear. We investigated 1) the risk of lymphoproliferative malignancies and solid tumors in adults with RA identified in primary care and 2) the possible mediating role of blood eosinophilia in the clonal evolution of cancer in these patients. Methods From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 356,196 individuals with at least one differential cell count (DIFF) encompassing the eosinophil count between 2000–2007. From these, one DIFF was randomly chosen (the index DIFF). By linking to the Danish National Patient Register, we categorized the selected individuals according to known longstanding (≥3 years) or recent onset (<3 years) RA prior to the index DIFF. In addition, the cohort was stratified according to management in primary or secondary care. From the Danish Cancer Registry we ascertained malignancies within four years following the index DIFF. Using multivariable logistic regression, odds ratios (OR) were calculated and adjusted for sex, age, year, month, eosinophilia, comorbid conditions and C-reactive protein (CRP). Results 921 patients had recent onset RA and 2,578 had longer disease duration. Seventy three percent of RA patients were managed in primary care. After adjustment for sex, age, year, and month, neither recent onset nor long-standing RA was associated with incident lymphoproliferative malignancies or solid cancers. These risk estimates did not change when eosinophilia, CRP, and comorbidities were included in the models. Conclusions In this large cohort of patients with RA of short or long duration recruited from a primary care resource, RA was not associated with an increased risk of lymphoproliferative or solid cancers during 4 years of follow-up, when the models were adjusted for confounders. Blood eosinophilia could not be

  11. Organizational and individual attributes influencing patient risk detection.

    PubMed

    Despins, Laurel A

    2014-10-01

    This study examined organizational and individual variables impacting patient risk detection by Intensive Care Unit nurses and their decision to reduce the risk of failure to rescue. Thirty-four nurses were randomly assigned to two groups. A video of a manager and staff nurse patient safety discussion was used to prime one group to prioritize patient safety. Participants provided demographic information, received end-of-shift report on two fictional patients, experienced 52 alarm trials during a medication preparation scenario, and completed the Safety Attitude Questionnaire. No difference existed in risk detection; however, nurses who perceived their work environment quality to be good correctly ignored a clinically irrelevant alarm more often and were more apt to classify an alarm as irrelevant. They chose to reduce the risk of medication error rather than that of failure to rescue. This information can assist nurses to balance disregarding distractions with responding to potential patient risk signals.

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

    PubMed

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

    2014-05-01

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

  13. [Evaluation of the cardiac risks in non-cardiac surgery in patients with heart failure].

    PubMed

    Pinaud, M

    2002-02-01

    Cardiac insufficiency represents a major risk factor in patients about to undergo non-cardiac surgery. The post-operative mortality is linked to the severity of the pre-operative functional impairment: rising from 4% in NYHA class 1 to 67% in class IV. The operative risk is greater when the cardiac insufficiency is more disabling, the patient is older (> 70 years) and if there is a history of acute pulmonary oedema and a gallop bruit on auscultation. The use of metabolic equivalents (Duke Activity Status Index) is recommended: the functional capacity is defined as excellent if > 7 MET, moderate between 4 and 7, or poor if < 4. A non-invasive evaluation of left ventricular function is necessary in each patient with obvious congestive cardiac insufficiency or poor control under the American consensus, but it is rare that the patient has not already been seen by a cardiologist. The degree of per-operative haemodynamic constraint is linked to the surgical technique and is stratified according to the type of surgical intervention and whether or not it is performed as an emergency. An intervention duration > 5 hours is associated with an increased peri-operative risk of congestive cardiac insufficiency and non-cardiac death. Deaths from a cardiac cause are thus twice as frequent after intra-abdominal, non-cardiac thoracic or aortic surgery and the post-operative cardiac complications are six times more frequent. Numerous studies have attempted to document the impact of different anaesthetic techniques on the prognosis for the population at increased risk of post-operative cardiovascular complications. It is advisable to opt for peripheral nerve blocks. The cardiovascular morbidity and overall mortality do not differ between general anaesthetic, epidural anaesthetic or spinal nerve block. The ASA (American Society of Anesthesiologists) classification is widely used to determine the overall risk. The ASA class and the age are however too coarse as methods of evaluation for

  14. Primary care assessment of patients at risk for suicide.

    PubMed

    Bono, Valerie; Amendola, Christine Lazaros

    2015-12-01

    Primary care providers (PCPs) play a crucial role caring for patients with depression, managing antidepressant therapy, and assessing patients for suicide risk. Ten percent of the more than 20 million primary care visits for depression each year involve mental health issues, and account for 62% of the antidepressants prescribed in the United States. Psychiatric disorders appear to be underrecognized and undertreated in primary care. Suicidal ideation is present in a significant percentage of depressed primary care patients but rarely discussed. This article describes the warning signs and risk factors associated with suicide and recommends screening tools that can help PCPs identify patients at risk.

  15. How stratified is mantle convection?

    NASA Astrophysics Data System (ADS)

    Puster, Peter; Jordan, Thomas H.

    1997-04-01

    due to slabs alone. A stratification index, Sƒ≲0.2, is sufficient to exclude many stratified convection models still under active consideration, including most forms of chemical layering between the upper and lower mantle, as well as the more extreme versions of avalanching convection governed by a strong endothermic phase change.

  16. Coronary risk factors in patients underwent coronary artery bypass grafting.

    PubMed

    Safaei, Nasser; Alikhah, Hossein; Abadan, Younes

    2011-01-01

    Coronary Artery Disease (CAD) risk increases with increasing number of risk factors. This study was aimed to assess different coronary risk factors among Coronary Artery Bypass Grafting (CABG) surgery patients. A total of 700 patients younger than 45 or older than 65 years and underwent CABG in Tabriz Shahid Madani Heart Center since 2003 to 2007 were enrolled. We examined the probable differences of CAD risk factors between male and female groups and age groups. We also assessed the change of risk factors presentation in last 5 years. There was not significant difference between risk factor numbers in <45 and >65 years groups, but smoking and dyslipidemia was more prevalent in patients < 45 than > 65 years old. Hypertension and diabetes mellitus was more prevalent in patients > 65 old than < 45 years old; also differences were found between males and females patients, so that dyslipidemia, diabetes and hypertension were more prevalent in women than men. Some risk factors were recognized as acting more on one gender than the other. Also, the majority of patients have one or more risk factors, but different age and gender groups may have different risk factors that suggest the need for exact programming for appropriate prophylactic and therapeutic interventions in all groups.

  17. Screening for fall risk in patients with haemophilia.

    PubMed

    Flaherty, L M; Josephson, N C

    2013-05-01

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

  18. Risk Assessment of Hepatocellular Carcinoma Using Transient Elastography Vs. Liver Biopsy in Chronic Hepatitis B Patients Receiving Antiviral Therapy

    PubMed Central

    Seo, Yeon Seok; Kim, Mi Na; Kim, Seung Up; Kim, Sang Gyune; Um, Soon Ho; Han, Kwang-Hyub; Kim, Young Seok

    2016-01-01

    Abstract Liver stiffness (LS) assessed using transient elastography (TE) can assess the risk of developing hepatocellular carcinoma (HCC). We evaluated whether TE, when compared with histological data as a reference standard, can predict the risk of HCC development in chronic hepatitis B (CHB) patients starting antiviral therapy. Observational cohort database of 381 patients with CHB who underwent liver biopsy (LB) and TE were reviewed. All patients underwent surveillance for HCC development using ultrasonography and alpha-fetoprotein. During the median follow-up period of 48.1 (interquartile range 30.3–69.3) months, HCC developed in 34 (8.9%) patients. In patients with HCC development, age, proportion of diabetes mellitus, histological fibrosis stage, and LS value were significantly higher than those in patients without (all P <0.05). The cumulative incidence rates of HCC increased significantly in association with elevated LS value in 3 stratified groups (LS value <8, 8–13, and >13 kPa; log-rank test, P <0.001), and with higher histological fibrosis stage in 3 stratified groups (F0–2, F3, and F4; log-rank test, P <0.001). On multivariate analysis, along with age, LS value was an independent predictor of HCC development (hazard ratio 1.041, P <0.001), whereas histological staging was not (P >0.05). TE predicted HCC development independently in patients with CHB starting antiviral therapy. However, further investigation is needed to determine whether the current surveillance strategy can be optimized based on the LS value at the time of starting antiviral therapy. PMID:27015173

  19. Utility of both Carotid Intima-media Thickness and Endothelial Function for Cardiovascular Risk Stratification in Patients with Angina-like Symptoms

    PubMed Central

    Matsuzawa, Yasushi; Svedlund, Sara; Aoki, Tatsuo; Guddeti, Raviteja R.; Kwon, Taek-Geun; Cilluffo, Rebecca; Widmer, R.Jay.; Nelson, Rebecca E.; Lennon, Ryan J.; Lerman, Lilach O.; Gao, Sinsia; Ganz, Peter; Gan, Li-Ming; Lerman, Amir

    2015-01-01

    Background Myocardial perfusion scintigraphy (MPS) is used widely to assess cardiovascular risk in patients with chest pain. The utility of carotid intima-media thickness (CIMT) and endothelial function as assessed by reactive hyperemia-peripheral arterial tonometry index (RHI) in risk stratifying patients with angina-like symptom needs to be defined. We investigated whether addition of CIMT and RHI to Framingham Cardiovascular Risk Score (FCVRS) and MPS improves comprehensive cardiovascular risk prediction in patients presenting with angina-like symptom. Methods We enrolled 343 consecutive patients with angina-like symptom suspected of having stable angina. MPS, CIMT, and RHI were performed and patients were followed for cardiovascular events for a median of 5.3 years (range 4.4-6.2). Patients were stratified by FCVRS and MPS. Results During the follow-up, 57 patients (16.6%) had cardiovascular events. Among patients without perfusion defect, low RHI was significantly associated with cardiovascular events in the intermediate and high FCVRS groups (Hazard ratio (HR) [95% confidence interval (CI)] of RHI≤2.11 was 6.99 [1.34-128] in the intermediate FCVRS group and 6.08 [1.08-114] in the high FCVRS group). Furthermore, although MPS did not predict, only RHI predicted hard cardiovascular events (cardiovascular death, myocardial infarction, and stroke) independent from FCVRS, and adding RHI to FCVRS improved net reclassification index (20.9%, 95% CI 0.8-41.1, p=0.04). Especially, RHI was significantly associated with hard cardiovascular events in the high FCVRS group (HR [95% CI] of RHI≤1.93 was 5.66 [1.54-36.4], p=0.007). Conclusions Peripheral endothelial function may improve discrimination in identifying at-risk patients for future cardiovascular events when added to FCVRS-MPS-based risk stratification. PMID:25918056

  20. Body Mass Index and the Risk of Dementia among Louisiana Low Income Diabetic Patients

    PubMed Central

    Hu, Gang; Horswell, Ronald; Wang, Yujie; Li, Wei; Besse, Jay; Xiao, Ke; Chen, Honglei; Keller, Jeffrey N.; Heymsfield, Steven B.; Ryan, Donna H.; Katzmarzyk, Peter T.

    2012-01-01

    Background The association between obesity and dementia risk remains debatable and no studies have assessed this association among diabetic patients. The aim of our study was to investigate the association between body mass index (BMI) and dementia risk among middle and low income diabetic patients. Methodology/Principal Findings The sample included 44,660 diabetic patients (19,618 white and 25,042 African American) 30 to 96 years of age without a history of dementia in the Louisiana State University Hospital-Based Longitudinal Study. During a mean follow-up period of 3.9 years, 388 subjects developed incident dementia. The age- and sex-adjusted hazards ratios (HRs) for incident dementia at different levels of BMI (≤25, 25–26.9, 27–29.9, 30–34.9, and ≥35 kg/m2) were 1.00, 0.53 (95% CI 0.34–0.83), 0.29 (0.18–0.45), 0.37 (0.25–0.56), and 0.31 (0.21–0.48) (Ptrend<0.001) in white diabetic patients, and 1.00, 1.00 (95% CI 0.62–1.63), 0.62 (0.39–0.98), 0.56 (0.36–0.86), and 0.65 (0.43–1.01) (Ptrend = 0.029) in African American diabetic patients. Further adjustment for other confounding factors affected the results only slightly. There was a significant interaction between race and BMI on dementia risk (χ2 = 5.52, 1df, p<0.025), such that the association was stronger in white patients. In stratified analyses, the multivariate-adjusted inverse association between BMI and risk of dementia was present in subjects aged 55–64 years, 65–74 years, and ≥75 years, in men and women, in non-smokers and smokers, and in subjects with different types of health insurance. Conclusions/Significance Higher baseline BMI was associated with a lower risk of dementia among diabetic patients, and this association was stronger among white than among African American diabetic patients. PMID:22957079

  1. Assessment of cardiovascular risk in patients with rheumatoid arthritis using the SCORE risk index.

    PubMed

    de Campos, Otávio Augusto Martins; Nazário, Nazaré Otília; de Magalhães Souza Fialho, Sônia Cristina; Fialho, Guilherme Loureiro; de Oliveira, Fernando José Savóia; de Castro, Gláucio Ricardo Werner; Pereira, Ivânio Alves

    2016-01-01

    Rheumatoid arthritis is an autoimmune disease that causes systemic involvement and is associated with increased risk of cardiovascular disease. To analyze the prediction index of 10-year risk of a fatal cardiovascular disease event in female RA patients versus controls. Case-control study with analysis of 100 female patients matched for age and gender versus 100 patients in the control group. For the prediction of 10-year risk of a fatal cardiovascular disease event, the SCORE and modified SCORE (mSCORE) risk indexes were used, as suggested by EULAR, in the subgroup with two or more of the following: duration of disease ≥10 years, RF and/or anti-CCP positivity, and extra-articular manifestations. The prevalence of analyzed comorbidities was similar in RA patients compared with the control group (p>0.05). The means of the SCORE risk index in RA patients and in the control group were 1.99 (SD: 1.89) and 1.56 (SD: 1.87) (p=0.06), respectively. The means of mSCORE index in RA patients and in the control group were 2.84 (SD=2.86) and 1.56 (SD=1.87) (p=0.001), respectively. By using the SCORE risk index, 11% of RA patients were classified as of high risk, and with the use of mSCORE risk index, 36% were at high risk (p<0.001). The SCORE risk index is similar in both groups, but with the application of the mSCORE index, we recognized that RA patients have a higher 10-year risk of a fatal cardiovascular disease event, and this reinforces the importance of factors inherent to the disease not measured in the SCORE risk index, but considered in mSCORE risk index. Copyright © 2015 Elsevier Editora Ltda. All rights reserved.

  2. Plasma Leptin in Patients at Intermediate to High Cardiovascular Risk With and Without Type 2 Diabetes Mellitus.

    PubMed

    Montagnana, Martina; Fava, Cristiano; Targher, Giovanni; Franchini, Massimo; Danese, Elisa; Bonafini, Sara; De Cata, Angela; Salvagno, Gian Luca; Ruzzenente, Orazio; Guidi, Gian Cesare; Lippi, Giuseppe

    2017-03-01

    A number of clinical studies have demonstrated that leptin concentrations are related to the metabolic disturbances that constitute the metabolic syndrome (MetS) and to diabetes mellitus (DM). To investigate possible determinants of leptin concentrations in a sample of patients at high cardiovascular (CV) risk carrying two or more features of the MetS and to investigate if any difference exist between at risk patients with or without DM. Serum leptin concentrations were measured in 60 consecutive male patients affected by at least two CV risk factors which belong to the National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III) definition of MetS: 30 patients affected by type 2 DM (T2DM) and 30 nondiabetic patients (non-T2DM). Nineteen healthy subjects were included in the study as a control group (HC). Leptin was significantly higher in patients carrying two or more features of the MetS compared with HC (P = 0.02). Stratifying MetS patients for DM, we found that leptin level was higher in non-T2DM patients (7.8 ng/ml), intermediate in T2DM (6.2 ng/ml), and lower in HC (4.6 ng/ml). In MetS patients, a positive correlation was found between leptin and waist, triglycerides, and number of MetS criteria. After stratification for T2DM, the correlations were still significant in the non-T2DM but not in the T2DM group. In our sample of moderate-to-high-risk patients, leptin level is positively associated with waist circumference and triglycerides but only in non-T2DM patients. Our data suggest that diabetic subjects could modulate leptin production in a different way compared with patients carrying other MetS-related anomalies. © 2016 Wiley Periodicals, Inc.

  3. Relative versus absolute risk of comorbidities in patients with psoriasis.

    PubMed

    Saleem, Mohammed D; Kesty, Chelsea; Feldman, Steven R

    2017-03-01

    Psoriasis is associated with numerous comorbidities, often reported in terms of relative risk. Both doctors and the general population tend to overestimate the effects of exposures when presented in relative terms, leading to anxiety and potentially poor treatment decisions. Absolute risks might provide a better basis for risk assessment. To characterize and compare relative and absolute risks of comorbidities in patients with psoriasis. A systematic review using Medline identified comorbidities associated with psoriasis, their relative risks, and information for calculating absolute risks. The comorbidities associated with psoriasis with the highest relative risk were nonmelanoma skin cancer, melanoma, and lymphoma, with relative risks of 7.5, 6.12, and 3.61, respectively; the attributable risk for these 3 conditions were 0.64, 0.05, and 0.17 per 1000 person-years, respectively. To attribute 1 event of these conditions to psoriasis would require seeing 1551; 20,135; and 5823 patients, respectively. Database studies might not fully account for confounders, resulting in overestimates of the risk impact of comorbidities. Presenting attributable risk in the form of the number needed to harm provides a clearer picture of the magnitude of risk and a basis for wiser medical decision making and patient education. Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

  4. Renal Function and All-Cause Mortality Risk Among Cancer Patients.

    PubMed

    Yang, Yan; Li, Hui-Yan; Zhou, Qian; Peng, Zhen-Wei; An, Xin; Li, Wei; Xiong, Li-Ping; Yu, Xue-Qing; Jiang, Wen-Qi; Mao, Hai-Ping

    2016-05-01

    Renal dysfunction predicts all-cause mortality in general population. However, the prevalence of renal insufficiency and its relationship with mortality in cancer patients are unclear.We retrospectively studied 9465 patients with newly diagnosed cancer from January 2010 to December 2010. Renal insufficiency was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m using the Chronic Kidney Disease Epidemiology Collaboration equation. The hazard ratio (HR) of all-cause mortality associated with baseline eGFR was assessed by Cox regression.Three thousand sixty-nine patients (32.4%) exhibited eGFR <90 mL/min/1.73 m and 3% had abnormal serum creatinine levels at the time of diagnosis. Over a median follow-up of 40.5 months, 2705 patients (28.6%) died. Compared with the reference group (eGFR ≥ 60 mL/min/1.73 m), an elevated all-cause mortality was observed among patients with eGFR < 60 mL/min/1.73 m stratified by cancer stage in the entire cohort, the corresponding hazard ratios were 1.87 (95% CI, 1.41-2.47) and 1.28 (95% CI, 1.01-1.62) for stage I to III and stage IV, respectively. However, this relationship was not observed after multivariate adjustment. Subgroup analysis found that eGFR < 60 mL/min/1.73 m independently predicted death among patients with hematologic (adjusted HR 2.93, 95% CI [1.36-6.31]) and gynecological cancer (adjusted HR 2.82, 95% CI [1.19-6.70]), but not in those with other cancer. Five hundred fifty-seven patients (6%) had proteinuria. When controlled for potential confounding factors, proteinuria was a risk factor for all-cause mortality among patients in the entire cohort, regardless of cancer stage and eGFR values. When patients were categorized by specific cancer type, the risk of all-cause death was only significant in patients with digestive system cancer (adjusted HR, 1.85 [1.48-2.32]).The prevalence of renal dysfunction was common in patients with newly diagnosed cancer. Patients with eGFR < 60 m

  5. Risk factors for developing mineral bone disease in phenylketonuric patients.

    PubMed

    Mirás, Alicia; Bóveda, M Dolores; Leis, María R; Mera, Antonio; Aldámiz-Echevarría, Luís; Fernández-Lorenzo, José R; Fraga, José M; Couce, María L

    2013-03-01

    There is a compromised bone mass in phenylketonuria patients compared with normal population, but the mechanisms responsible are still a matter of investigation. In addition, tetrahydrobiopterin therapy is a new option for a significant proportion of these patients and the prevalence of mineral bone disease (MBD) in these patients is unknown. We conducted a cross-sectional observational study including 43 phenylketonuric patients. Bone densitometry, nutritional assessment, physical activity questionnaire, biochemical parameters, and molecular study were performed in all patients. Patients were stratified by phenotype, age and type of treatment. The MBD prevalence in phenylketonuria was 14%. Osteopenic and osteoporotic (n=6 patients) had an average daily natural protein intake significantly lower than the remaining (n=37) patients with PKU (14.33 ± 8.95 g vs 21.25 ± 20.85 g). Besides, a lower body mass index was found. There were no statistical differences in physical activity level, calcium, phosphorus and fat intake, and in phenylalanine, vitamin D, paratohormone, docosahexaenoic and eicosapentaenoic acid blood levels. Mutational spectrum was found in up to 30 different PAH genotypes and no relationship was established among genotype and development of MBD. None of the twelve phenylketonuric patients treated with tetrahydrobiopterin (27.9%), for an average of 7.1 years, developed MBD. Natural protein intake and blood levels of eicosapentaenoic acid were significantly higher while calcium intake was lower in these patients. This study shows that the decrease in natural protein intake can play an important role in MBD development in phenylketonuric patients. Therapy with tetrahydrobiopterin allows a more relaxed protein diet, which is associated with better bone mass.

  6. Coronary artery calcification scores improve contrast-induced nephropathy risk assessment in chronic kidney disease patients.

    PubMed

    Osugi, Naohiro; Suzuki, Susumu; Shibata, Yohei; Tatami, Yosuke; Harata, Shingo; Ota, Tomoyuki; Hayashi, Mutsuharu; Yasuda, Yoshinari; Ishii, Hideki; Shimizu, Atsuya; Murohara, Toyoaki

    2017-06-01

    Coronary artery calcification (CAC) is an independent predictor of cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients. The aim of the present study was to evaluate the predictive value of CAC scores for the incidence of contrast-induced nephropathy (CIN) after cardiac catheterization in non-dialyzed CKD patients. The present study evaluated a total of 140 CKD patients who underwent cardiac catheterization. Patients were stratified into two groups based on the optimal cut-off value of the CAC score, which was graded by a non-triggered, routine diagnostic chest computed tomography scan: CAC score ≥8 (high CAC group); and CAC score <8 (low CAC group). CIN was defined as an increase of >10 % in the baseline serum cystatin C level at 24 h after contrast administration. The mean estimated glomerular filtration rate levels were 41.1 mL/min/1.73 m(2), and the mean contrast dose administered was 37.5 mL. Patients with high CAC scores exhibited a higher incidence of CIN than patients with low CAC scores (25.5 vs. 3.2 %, p < 0.001). After multivariate adjustment for confounders, the CAC score predicted CIN (odds ratio 1.68, 95 % confidence interval 1.28-2.21, p < 0.001). Moreover, the C-index for CIN prediction significantly increased when the CAC scores were added to the Mehran risk score (0.855 vs. 0.760, p = 0.023). CAC scores, as evaluated using semi-quantitative methods, are a simple and powerful predictor of CIN. Incorporating the CAC score in the Mehran risk score significantly improved the predictive ability to predict CIN incidence.

  7. Cardiovascular risk factors in patients with asymptomatic primary hyperparathyroidism.

    PubMed

    García-Martín, Antonia; Reyes-García, Rebeca; García-Castro, José Miguel; Quesada-Charneco, Miguel; Escobar-Jiménez, Fernando; Muñoz-Torres, Manuel

    2014-12-01

    Patients with primary hyperparathyroidism (PHP), even asymptomatic, have an increased cardiovascular risk. However, data on reversibility or improvement of cardiovascular disorders with surgery are controversial. Our aims were to assess the prevalence of classic cardiovascular risk factors in patients with asymptomatic PHP, to explore their relationship with calcium and PTH levels, and analyze the effect of parathyroidectomy on those cardiovascular risk factors. A retrospective, observational study of two groups of patients with asymptomatic PHP: 40 patients on observation and 33 patients who underwent surgery. Clinical and biochemical data related to PHP and various cardiovascular risk factors were collected from all patients at baseline and one year after surgery in the operated patients. A high prevalence of obesity (59.9%), type 2 diabetes mellitus (25%), high blood pressure (47.2%), and dyslipidemia (44.4%) was found in the total sample, with no difference between the study groups. Serum calcium and PTH levels positively correlated with BMI (r=.568, P=.011, and r=.509, P=.026 respectively) in non-operated patients. One year after parathyroidectomy, no improvement occurred in the cardiovascular risk factors considered. Our results confirm the high prevalence of obesity, type 2 diabetes mellitus, high blood pressure, and dyslipidemia in patients with asymptomatic PHP. However, parathyroidectomy did not improve these cardiovascular risk factors. Copyright © 2014 SEEN. Published by Elsevier Espana. All rights reserved.

  8. Assessing Differences in Mortality Rates and Risk Factors Between Hispanic and Non-Hispanic Patients With Cystic Fibrosis in California.

    PubMed

    Buu, MyMy C; Sanders, Lee M; Mayo, Jonathan A; Milla, Carlos E; Wise, Paul H

    2016-02-01

    Over the past 30 years, therapeutic advances have extended the median lifespan of patients with cystic fibrosis (CF). Hispanic patients are a vulnerable subpopulation with a high prevalence of risk factors for worse health outcomes. The consequences of these differences on health outcomes have not been well described. The objective of this study was to characterize the difference in health outcomes, including mortality rate, between Hispanic and non-Hispanic patients with CF. This study is a retrospective analysis of CF Foundation Patient Registry data of California residents with CF, diagnosed during or after 1991, from 1991 to 2010. Ethnicity was self-reported. The primary outcome was mortality. Hazard ratios were estimated from a Cox regression model, stratified by sex, and adjusted for socioeconomic status, clinical risk factors, and year of diagnosis. Of 1,719 patients, 485 (28.2%) self-identified as Hispanic. Eighty-five deaths occurred, with an overall mortality rate of 4.9%. The unadjusted mortality rate was higher among Hispanic patients than among non-Hispanic patients (9.1% vs 3.3%, P < .0001). Compared with non-Hispanic patients, Hispanic patients had a lower survival rate 18 years after diagnosis (75.9% vs 91.5%, P < .0001). Adjusted for socioeconomic status and clinical risk factors, Hispanic patients had an increased rate of death compared with non-Hispanic patients (hazard ratio, 2.81; 95% CI, 1.70-4.63). Hispanic patients with CF have a higher mortality rate than do non-Hispanic patients, even after adjusting for socioeconomic status and clinical severity. Further investigation into the mechanism for the measured difference in lung function will help inform interventions and improve the health of all patients with CF. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

  9. Identifying Patients at Risk of High Healthcare Utilization

    PubMed Central

    Sheets, Lincoln; Popejoy, Lori; APRN, GCNS-BC; Khalilia, Mohammed; Petroski, Greg; Parker, Jerry C.

    2016-01-01

    Objective. To develop a systematic and reproducible way to identify patients at increased risk for higher healthcare costs. Methods. Medical records were analyzed for 9,581 adults who were primary care patients in the University of Missouri Health System and who were enrolled in Medicare or Medicaid. Patients were categorized into one of four risk tiers as of October 1, 2013, and the four tiers were compared on demographic characteristics, number of healthcare episodes, and healthcare charges in the year before and the year after cohort formation. Results. The mean number of healthcare episodes and the sum of healthcare charges in the year following cohort formation were higher for patients in the higher-risk tiers. Conclusions. Retrospective information that is easily extracted from medical records can be used to create risk tiers that provide highly useful information about the prospective risk of healthcare utilization and costs. PMID:28269910

  10. High Risk of Depressive Disorders in Patients With Gout

    PubMed Central

    Changchien, Te-Chang; Yen, Yung-Chieh; Lin, Cheng-Li; Lin, Ming-Chia; Liang, Ji-An; Kao, Chia-Hung

    2015-01-01

    Abstract Metabolic abnormalities are common in patients with depressive disorders. However, the relationship between gout and depression is unclear. We explored the causal relationship among gout, antigout medication, and the associated risk of incidental depressive disorders. In this nationwide cohort study, we sampled data from the National Health Insurance Research Database to recruit 34,050 patients with gout as the gout cohort and 68,100 controls (without gout) as the nongout cohort. Our primary endpoint was the diagnosis of depressive disorders during follow-up. The overall study population was followed up until depression diagnosis, withdrawal from the NHI program, or the end of the study. The differences in demographic and clinical characteristics between both cohorts were determined using the Chi-square test for categorical variables and the t-test for continuous variables. Cox proportional hazard regression models were used to examine the effect of gout on the risk of depression, represented using the hazard ratio with the 95% confidence interval. Patients with gout exhibited a higher risk of depressive disorders than controls did. The risk of depressive disorders increased with age and was higher in female patients and those with hypertension, stroke, and coronary artery disease. Nonsteroidal antiinflammatory drug and prednisolone use was associated with a reduced risk of depression. Patients with gout who had received antigout medication exhibited a reduced risk of depressive disorders compared with nongout patients. Our findings support that gout increases the risk of depressive disorders, and that antigout medication use reduces the risk. PMID:26717394

  11. Impact of global risk assessment on the evaluation of hypertensive patients treated by primary care physicians in Korea (a Nation-Wide, Multi-Center, Observational, Cross-Sectional, Epidemiologic Study to Evaluate the Proportion of Cardiovascular Risk Factors in Korean hypertensive patients: WONDER study).

    PubMed

    Kim, Kwang-Il; Lee, Yil-Seob; Park, Chang Gyu

    2014-07-01

    Global cardiovascular risk evaluation and stratification is essential to identify high-risk hypertensive patients. However, it is uncertain how often the strategy is executed in real clinical practice. We sought to evaluate whether global risk evaluation might change the risk stratification in Korean hypertensive patients treated by primary care physicians. A total of 3109 hypertensive patients were analyzed. The mean age was 62.3±11.3 years, and 1502 (48.3%) of the participants were male. The global risk evaluation revealed that 1862 patients (59.9%) were classified as having high- or the very high-risk. High-risk patients were older and obese, and had a male predominance, a longer duration of hypertension and a low HDL-cholesterol. The systolic and diastolic blood pressures (BP) were significantly higher in the high-risk group (P<0.0001). However, combination antihypertensive therapy was more common in the low-risk group (P=0.0265). A total of 2155 patients (69.3%) were reclassified into the higher or the lower-risk group by performing additional tests. In a multivariate logistic regression analysis, age, body mass index, BP, metabolic syndrome, left ventricular hypertrophy and chronic kidney disease were independent factors associated with risk reclassification with global risk evaluation. In conclusion, although the majority of hypertensive patients treated by the primary care physicians were in the high- or very high-risk group, their risk levels were not appropriately stratified. However, simple additional tests enhanced the risk evaluation of hypertensive patients. Accordingly, comprehensive cardiovascular risk stratification should be undertaken in all hypertensive patients.

  12. Magnetized stratified rotating shear waves.

    PubMed

    Salhi, A; Lehner, T; Godeferd, F; Cambon, C

    2012-02-01

    stability of the solution at infinite vertical wavelength (k(3) = 0): There is an oscillatory behavior for τ > 1+|K(2)/k(1)|, where τ = St is a dimensionless time and K(2) is the radial component of the wave vector at τ = 0. The model is suitable to describe instabilities leading to turbulence by the bypass mechanism that can be relevant for the analysis of magnetized stratified Keplerian disks with a purely azimuthal field. For initial isotropic conditions, the time evolution of the spectral density of total energy (kinetic + magnetic + potential) is considered. At k(3) = 0, the vertical motion is purely oscillatory, and the sum of the vertical (kinetic + magnetic) energy plus the potential energy does not evolve with time and remains equal to its initial value. The horizontal motion can induce a rapid transient growth provided K(2)/k(1)>1. This rapid growth is due to the aperiodic velocity vortex mode that behaves like K(h)/k(h) where k(h)(τ)=[k(1)(2) + (K(2) - k(1)τ)(2)](1/2) and K(h) =k(h)(0). After the leading phase (τ > K(2)/k(1)>1), the horizontal magnetic energy and the horizontal kinetic energy exhibit a similar (oscillatory) behavior yielding a high level of total energy. The contribution to energies coming from the modes k(1) = 0 and k(3) = 0 is addressed by investigating the one-dimensional spectra for an initial Gaussian dense spectrum. For a magnetized Keplerian disk with a purely vertical field, it is found that an important contribution to magnetic and kinetic energies comes from the region near k(1) = 0. The limit at k(1) = 0 of the streamwise one-dimensional spectra of energies, or equivalently, the streamwise two-dimensional (2D) energy, is then computed. The comparison of the ratios of these 2D quantities with their three-dimensional counterparts provided by previous direct numerical simulations shows a quantitative agreement.

  13. Dry Eye Syndrome Risks in Patients With Fibromyalgia

    PubMed Central

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

    2016-01-01

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

  14. Embedded CMs work with high-risk patients.

    PubMed

    2014-01-01

    Care managers embedded in primary care clinics work with patients with high-risk diagnoses and multiple visits to the emergency department or hospital. Patients are identified though risk assessments, suggestions from inpatient case management, and requests from primary care clinicians. Care managers call patients before their clinic visits, look for gaps in care and find out patients' questions and concerns, sharing the information with the treating clinicians. Care managers follow patients for four weeks after their visit, helping them meet their health care goals and follow their treatment plan.

  15. 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

  16. Increased Risk of Stroke in Patients With Fibromyalgia

    PubMed Central

    Tseng, Chun-Hung; Chen, Jiunn-Horng; Wang, Yu-Chiao; Lin, Ming-Chia; Kao, Chia-Hung

    2016-01-01

    Abstract Neuropsychiatric diseases might enhance stroke development, possibly through inflammation and atherosclerosis. Approximately 25% to 40% of patients with stroke, largely younger patients, are not associated with any conventional stroke risk factors. In this research, we explored whether fibromyalgia (FM), a neuropsychosomatic disorder, increases stroke risk. From a claims dataset with one million enrollees sourced of the Taiwan National Health Insurance database, we selected 47,279 patients with FM and randomly selected 189,112 age- and sex-matched controls within a 3-year period from January 1, 2000 to December 31, 2002. Stroke risk was assessed using Cox proportional hazards regression. Comorbidities associated with increased stroke risk, such as hypertension, diabetes, hyperlipidemia, coronary heart disease, irritable bowel syndrome, and interstitial cystitis, were more prevalent in patients with FM and high stroke risk than in the controls. The overall stroke risk was 1.25-fold (95% confidence interval [CI]: 1.21–1.30) higher in the FM group than in the non-FM group. Even without comorbidities, stroke risk was higher in patients with FM than in the controls (adjusted hazard ratio [aHR] = 1.44, 95% CI: 1.35–1.53, P < 0.001). The relative risk of stroke was 2.26-fold between FM and non-FM groups in younger patients (age <35 years, 95% CI: 1.86–2.75). This is the first investigation associating FM with an increased risk of stroke development. The outcomes imply that FM is a significant risk factor for stroke and that patients with FM, particularly younger patients, require close attention and rigorous measures for preventing stroke. PMID:26937918

  17. Examination of pneumonia risks and risk levels in trauma patients with pulmonary contusion.

    PubMed

    Landeen, Carolina; Smith, Hayden L

    2014-01-01

    Development of pneumonia in patients with pulmonary contusion can result in morbidity and mortality. This study examined the utility of a pneumonia risk tool for pulmonary contusion patients, which was originally developed using national level data. The study found a 21% prevalence of pneumonia diagnosis in pulmonary contusion patients at the examined level I trauma center, with patients in the high-risk group having 8 times greater odds for pneumonia diagnosis. The study also revealed increasing age and the use of mechanical ventilation as being significantly associated with pneumonia status. Early identification of risk factors for pneumonia could help direct clinician care strategies.

  18. The risk of contralateral breast cancer in patients from BRCA1/2 negative high risk families as compared to patients from BRCA1 or BRCA2 positive families: a retrospective cohort study

    PubMed Central

    2012-01-01

    Introduction While it has been reported that the risk of contralateral breast cancer in patients from BRCA1 or BRCA2 positive families is elevated, little is known about contralateral breast cancer risk in patients from high risk families that tested negative for BRCA1/2 mutations. Methods A retrospective, multicenter cohort study was performed from 1996 to 2011 and comprised 6,235 women with unilateral breast cancer from 6,230 high risk families that had tested positive for BRCA1 (n = 1,154) or BRCA2 (n = 575) mutations or tested negative (n = 4,501). Cumulative contralateral breast cancer risks were calculated using the Kaplan-Meier product-limit method and were compared between groups using the log-rank test. Cox regression analysis was applied to assess the impact of the age at first breast cancer and the familial history stratified by mutation status. Results The cumulative risk of contralateral breast cancer 25 years after first breast cancer was 44.1% (95%CI, 37.6% to 50.6%) for patients from BRCA1 positive families, 33.5% (95%CI, 22.4% to 44.7%) for patients from BRCA2 positive families and 17.2% (95%CI, 14.5% to 19.9%) for patients from families that tested negative for BRCA1/2 mutations. Younger age at first breast cancer was associated with a higher risk of contralateral breast cancer. For women who had their first breast cancer before the age of 40 years, the cumulative risk of contralateral breast cancer after 25 years was 55.1% for BRCA1, 38.4% for BRCA2, and 28.4% for patients from BRCA1/2 negative families. If the first breast cancer was diagnosed at the age of 50 or later, 25-year cumulative risks were 21.6% for BRCA1, 15.5% for BRCA2, and 12.9% for BRCA1/2 negative families. Conclusions Contralateral breast cancer risk in patients from high risk families that tested negative for BRCA1/2 mutations is similar to the risk in patients with sporadic breast cancer. Thus, the mutation status should guide decision making for contralateral mastectomy. PMID

  19. Waves in Turbulent Stably Stratified Shear Flow

    NASA Technical Reports Server (NTRS)

    Jacobitz, F. G.; Rogers, M. M.; Ferziger, J. H.; Parks, John W. (Technical Monitor)

    2002-01-01

    Two approaches for the identification of internal gravity waves in sheared and unsheared homogeneous stratified turbulence are investigated. First, the phase angle between the vertical velocity and density fluctuations is considered. It was found, however, that a continuous distribution of the phase angle is present in weakly and strongly stratified flow. Second, a projection onto the solution of the linearized inviscid equations of motion of unsheared stratified flow is investigated. It was found that a solution of the fully nonlinear viscous Navier-Stokes equations can be represented by the linearized inviscid solution. The projection yields a decomposition into vertical wave modes and horizontal vortical modes.

  20. Validation of Gene Expression Signatures to Identify Low-risk Clear-cell Renal Cell Carcinoma Patients at Higher Risk for Disease-related Death.

    PubMed

    Parasramka, Mansi; Serie, Daniel J; Asmann, Yan W; Eckel-Passow, Jeanette E; Castle, Erik P; Stanton, Melissa L; Leibovich, Brad C; Thompson, Robert Houston; Thompson, E Aubrey; Parker, Alexander S; Ho, Thai H; Joseph, Richard W

    2016-12-15

    Approximately 5-10% of patients with "low-risk" clear cell renal cell carcinoma (ccRCC), as stratified by externally validated clinicopathologic prognostic algorithms, eventually have disease relapse and die. Improving prognostic algorithms for these low-risk patients could help to provide improved individualized surveillance recommendations. To identify genes that are differentially expressed in patients with low-risk ccRCC who did and did not die of their disease. Using the Mayo Clinic Renal Registry, we identified formalin-fixed paraffin-embedded samples from patients with low-risk ccRCC, as defined by Mayo Clinic stage, size, grade, and necrosis score of 0-3. We conducted a nested case-control study between patients who did (cases) and did not (controls) have ccRCC relapse and death, using two independent sets (discovery and validation). We performed RNA sequencing of all samples in the discovery set to identify differentially expressed genes. In the independent validation set, we assessed the top 50 expressed genes using the nCounter Analysis System (NanoString Technologies, Seattle, WA, USA). In the discovery set of 24 cases and 24 controls, 92 genes were differentially expressed with p<0.001. The top 50 genes were validated in an independent set of 22 cases and 22 controls using linear mixed models. In the validation set, 10 genes remained differentially expressed between the groups. RNA signatures from formalin-fixed paraffin-embedded blocks can identify patients with low-risk ccRCC who die of their disease. This finding provides an opportunity to help guide improved surveillance in patients with low-risk ccRCC. In the current study we identified RNA signatures from low-risk clear cell renal cell carcinoma patients who died from this disease. Improving prognostic algorithms for these low-risk patients could help to provide improved individualized surveillance recommendations. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All

  1. Risk Factors of Catheter-Related Thrombosis (CRT) in Cancer Patients: A Patient-Level Data (IPD) Meta-Analysis of Clinical Trials and Prospective Studies

    PubMed Central

    Saber, W.; Moua, T.; Williams, E. C.; Verso, M.; Agnelli, G.; Couban, S.; Young, A.; De Cicco, M.; Biffi, R.; van Rooden, C. J.; Huisman, M. V.; Fagnani, D.; Cimminiello, C.; Moia, M.; Magagnoli, M.; Povoski, S. P.; Malak, S. F.; Lee, A. Y.

    2010-01-01

    Background Knowledge of independent, baseline risk factors of catheter-related thrombosis (CRT) may help select adult cancer patients at high risk to receive thromboprophylaxis. Objectives We conducted a meta-analysis of individual patient-level data to identify these baseline risk factors. Patients/Methods MEDLINE, EMBASE, CINAHL, CENTRAL, DARE, Grey literature databases were searched in all languages from 1995-2008. Prospective studies and randomized controlled trials (RCTs) were eligible. Studies were included if original patient-level data were provided by the investigators and if CRT was objectively confirmed with valid imaging. Multivariate logistic regression analysis of 17 prespecified baseline characteristics was conducted. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Results A total sample of 5636 subjects from 5 RCTs and 7 prospective studies was included in the analysis. Among these subjects, 425 CRT events were observed. In multivariate logistic regression, the use of implanted ports as compared with peripherally implanted central venous catheters (PICC), decreased CRT risk (OR = 0.43; 95% CI, 0.23-0.80), whereas past history of deep vein thrombosis (DVT) (OR = 2.03; 95% CI, 1.05-3.92), subclavian venipuncture insertion technique (OR = 2.16; 95% CI, 1.07-4.34), and improper catheter tip location (OR = 1.92; 95% CI, 1.22-3.02), increased CRT risk. Conclusions CRT risk is increased with using PICC catheters, previous history of DVT, subclavian venipuncture insertion technique and improper positioning of the catheter tip. These factors may be useful for risk stratifying patients to select those for thromboprophylaxis. Prospective studies are needed to validate these findings. PMID:21040443

  2. Blood eosinophil count and pneumonia risk in patients with chronic obstructive pulmonary disease: a patient-level meta-analysis.

    PubMed

    Pavord, Ian D; Lettis, Sally; Anzueto, Antonio; Barnes, Neil

    2016-09-01

    Inhaled corticosteroids are important in the management of chronic obstructive pulmonary disease (COPD), but can slightly increase the risk of pneumonia in patients with moderate-to-severe COPD. Patients with circulating eosinophil counts of 2% or more of blood leucocytes respond better to inhaled corticosteroids than do those with counts of less than 2% and it was therefore postulated that blood eosinophil count might also have an effect on the risk of pneumonia in patients with COPD. In this post-hoc meta-analysis, we investigate whether a 2% threshold can identify patients who differ in their risk of pneumonia, irrespective of inhaled corticosteroid treatment. From the GlaxoSmithKline trial registry, we selected randomised, double-blind, clinical trials of patients with COPD that had: inhaled corticosteroid arms (fluticasone propionate and salmeterol or fluticasone furoate and vilanterol); a control arm (not given inhaled fluticasone); and pre-randomisation measurements of blood eosinophil counts and were of at least 24 weeks in duration. With use of specified terms from the Medical Dictionary for Regulatory Activities we identified pneumonia adverse events in patient-level data. We calculated number of patients with pneumonia events, stratified by baseline blood eosinophil count (<2% vs ≥2% of blood leucocytes) and whether or not patients had received inhaled corticosteroids. We identified ten trials (conducted between 1998 and 2011), with eosinophil count data available for 10 861 patients with COPD. 4043 patients had baseline blood eosinophil counts of less than 2% and 6818 patients had baseline blood eosinophil counts of 2% or more. 149 (3·7%) patients with counts less than 2% had one or more pneumonia adverse events compared with 215 (3·2%) with counts of 2% or more (hazard ratio [HR] 1·31; 95% CI 1·06-1·62). In patients not treated with inhaled corticosteroids, 40 (3·8%) patients with less than 2% blood eosinophil counts had a pneumonia event

  3. The Association Between Hospital Length of Stay and 90-Day Readmission Risk for Femoral Neck Fracture Patients: Within a Total Joint Arthroplasty Bundled Payment Initiative.

    PubMed

    Kester, Benjamin S; Williams, Jarrett; Bosco, Joseph A; Slover, James D; Iorio, Richard; Schwarzkopf, Ran

    2016-12-01

    Hip arthroplasty is increasingly performed as a treatment for femoral neck fractures (FNFs). However, these cases have higher complication rates than elective total hip arthroplasties (THAs). The Center for Medicare and Medicaid Services has created the Comprehensive Care for Joint Replacement model to increase the value of patient care. This model risk stratifies FNF patients in an attempt to appropriately allocate resources, but the formula has not been disclosed. The goal of this study was to ascertain if patients with FNFs have different readmission rates compared to patients undergoing elective THA so that the resource utilization can be assessed. We analyzed all patients undergoing THA at our institution during a 21-month period. Patients classified by a diagnosis-related group of 469 or 470 were included. Multivariate and survival analyses were performed to determine risk of 90-day readmission. Patients admitted for FNFs were older, had higher body mass indices, longer lengths of stay, and were more likely to be discharged to inpatient facilities than patients who underwent elective THA. Increased American Society of Anesthesiologists scores and FNF were also independent risk factors for 90-day readmission, and these patient were more likely to be readmitted during the latter 60 days following admission. Results suggest that patients who undergo an arthroplasty following urgent or emergent FNFs have inferior outcomes to those receiving an arthroplasty for a diagnosis of arthritis. Fracture patients should either be risk stratified to allow appropriate resource allocation or be excluded from alternative payment initiatives such as Comprehensive Care for Joint Replacement. Copyright © 2016 Elsevier Inc. All rights reserved.

  4. Significantly Increased Risk of Cardiovascular Disease among Patients with Gallstone Disease: A Population-Based Cohort Study

    PubMed Central

    Olaiya, Muideen Tunbosun; Chiou, Hung-Yi; Jeng, Jiann-Shing; Lien, Li-Ming; Hsieh, Fang-I

    2013-01-01

    Objective To investigate whether gallstone disease (GD) increases the risk of developing cardiovascular disease (CVD) in a large population-based cohort. Methods A study population including 6,981 patients with GD was identified from The Taiwan National Health Insurance Research Database between 2004 and 2005. GD patients were defined as patients with principal discharge diagnoses of cholelithiasis using the ICD-9-CM code 574. 27,924 patients without GD were randomly selected and matched for age and gender. All patients were followed for 6 years or until diagnosis for CVD. Cox proportional hazards regression model was used to assess the risk of developing CVD with adjustment for age, gender and co-morbid conditions. Results During the six years follow-up period, 935 patients with GD and 2,758 patients without GD developed CVD. Patients with GD had an elevated risk of CVD (HR, 1.32; 95% CI, 1.22-1.43) when compared with those without GD. Similar relationship was observed when CVD was categorized i.e. stroke (HR, 1.15; 95% CI, 1.01-1.32), coronary heart disease (HR, 1.42; 95% CI, 1.28-1.58) and heart failure (HR, 1.31; 95% CI, 1.00-1.73). When GD was classified according to the level of severity, using patients without GD as reference, the risks of CVD were elevated in patients with non-severe GD (HR, 1.34; 95% CI, 1.24-1.46) as well as those with severe GD (HR, 1.20, 95% CI, 1.02-1.40), after adjusting for age, gender and comorbidities. In age-stratified analysis, patients aged 18-40 years with GD were at higher risk of developing CVD (HR, 1.42; 95% CI, 1.09-1.84) than older GD patients. Conclusion This study found an increased risk of CVD in patients diagnosed with GD. The excess risk was particularly high in younger GD patients. Prevention of GD could help reduce the risk of developing CVD, and the better effect could be achieved for the younger age groups. PMID:24098504

  5. General Practitioners Views of Implementing a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study.

    PubMed

    Karstens, Sven; Joos, Stefanie; Hill, Jonathan C; Krug, Katja; Szecsenyi, Joachim; Steinhäuser, Jost

    2015-01-01

    The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs). However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP). A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST) and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach. For the three deductively developed main themes, 15 subthemes emerged: (1) application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2) psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3) the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues. The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be addressed by

  6. Inpatient Mortality Risk Scores and Postdischarge Events in Hospitalized Heart Failure Patients: A Community-Based Study.

    PubMed

    Win, Sithu; Hussain, Imad; Hebl, Virginia B; Dunlay, Shannon M; Redfield, Margaret M

    2017-07-01

    The Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines (GWTG) registries have developed simple heart failure (HF) in-hospital mortality risk scores. We hypothesized that HF scores predictive of in-hospital mortality would perform as well for early postdischarge mortality risk stratification. In this single-center, community-based, retrospective study of all consecutive primary HF hospitalizations (6203 hospitalizations in 3745 patients) from 2000 to 2013, the ADHERE and GWTG risk scores were calculated from admission data. There were 176 (3.0%) and 399 (6.7%), 869 (14.7%), and 1272 (21.5%) deaths in-hospital and at 30, 90, and 180 days postdischarge, respectively. The GWTG but not ADHERE risk score was well calibrated for in-hospital mortality. Both the ADHERE (C statistic 0.66 and 0.67, 0.64, and 0.64) and GWTG (C statistic 0.74 and 0.73, 0.71, and 0.70) HF risk scores were similarly predictive of in-hospital and 30-, 90-, and 180-day postdischarge mortality. The ADHERE risk score identified 10% and the GWTG risk score identified 20% of hospitalizations where 180-day postdischarge mortality was 50%, a prognostic bench mark for hospice referral. In contrast, hospitalizations characterized as lowest risk by the ADHERE (57% of hospitalizations; 180-day mortality 16.2%) or GWTG score (20% of hospitalizations; 180-day mortality 8.0%) had substantially lower mortality (odds ratios high versus low risk of 5-8 [ADHERE] and 11-18 [GWTG] across time points; P<0.0001 for all). The simple ADHERE and GWTG scores stratify hospitalized HF patients for both inpatient and early postdischarge mortality risk, allowing comprehensive risk assessment on admission. © 2017 American Heart Association, Inc.

  7. How can we identify the high-risk patient?

    PubMed

    Sankar, Ashwin; Beattie, W Scott; Wijeysundera, Duminda N

    2015-08-01

    Accurate and early identification of high-risk surgical patients allows for targeted use of perioperative monitoring and interventions that may improve their outcomes. This review summarizes current evidence on how information from the preoperative, operative, and immediate postoperative periods can help identify such individuals. Simple risk indices, such as the Revised Cardiac Risk Index or American Society of Anesthesiologists Physical Status scale, and online calculators allow risk to be estimated with moderate accuracy using readily available preoperative clinical information. Both specific specialized tests (i.e., cardiopulmonary exercise testing and cardiac stress testing) and promising novel biomarkers (i.e., troponins and natriuretic peptides) can help refine these risk estimates before surgery. Estimates of perioperative risk can be further informed by information acquired during the operative and immediate postoperative periods, such as risk indices (i.e., surgical Apgar score), individual risk factors (i.e., intraoperative hypotension), or postoperative biomarkers (i.e., troponins and natriuretic peptides). Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Although novel biomarkers, specialized preoperative testing, and immediate postoperative risk indices show promise as methods to refine these risk estimates, more research is needed on how best to integrate risk information from these different sources.

  8. Risk Acceptance in Multiple Sclerosis Patients on Natalizumab Treatment

    PubMed Central

    Tur, Carmen; Tintoré, Mar; Vidal-Jordana, Ángela; Bichuetti, Denis; Nieto González, Pablo; Arévalo, María Jesús; Arrambide, Georgina; Anglada, Elisenda; Galán, Ingrid; Castilló, Joaquín; Nos, Carlos; Río, Jordi; Martín, María Isabel; Comabella, Manuel; Sastre-Garriga, Jaume; Montalban, Xavier

    2013-01-01

    Objective We aimed to investigate the ability of natalizumab (NTZ)-treated patients to assume treatment-associated risks and the factors involved in such risk acceptance. Methods From a total of 185 patients, 114 patients on NTZ as of July 2011 carried out a comprehensive survey. We obtained disease severity perception scores, personality traits’ scores, and risk-acceptance scores (RAS) so that higher RAS indicated higher risk acceptance. We recorded JC virus status (JCV+/-), prior immunosuppression, NTZ treatment duration, and clinical characteristics. NTZ patients were split into subgroups (A-E), depending on their individual PML risk. Some 22 MS patients on first-line drugs (DMD) acted as controls. Results No differences between treatment groups were observed in disease severity perception and personality traits. RAS were higher in NTZ than in DMD patients (p<0.01). Perception of the own disease as a more severe condition tended to predict higher RAS (p=0.07). Higher neuroticism scores predicted higher RAS in the NTZ group as a whole (p=0.04), and in high PML-risk subgroups (A-B) (p=0.02). In low PML-risk subgroups (C-E), higher RAS were associated with a JCV+ status (p=0.01). Neither disability scores nor pre-treatment relapse rate predicted RAS in either group. Conclusions Risk acceptance is a multifactorial phenomenon, which might be partly explained by an adaptive process, in light of the higher risk acceptance amongst NTZ-treated patients and, especially, amongst those who are JCV seropositive but still have low PML risk, but which seems also intimately related to personality traits. PMID:24340060

  9. [Vigilance level for cardiovascular risk factors in schizophrenic patients].

    PubMed

    Rouillon, F; Van Ganse, E; Vekhoff, P; Arnaud, R; Depret-Bixio, L; Dillenschneider, A

    2015-02-01

    Schizophrenic patients have increased cardiovascular risk factors and morbi-mortality as compared with the general population. To assess the level of French psychiatrists vigilance regarding cardiovascular risk factors in schizophrenic patients. Prospective, transverse, multicentric observational study implemented in France in 2007 and conducted by psychiatrists with a liberal activity. The included patients had to meet the following selection criteria: patients ≥ 18 years old, fulfilling the DSM-IV-TR criteria for schizophrenia, treated or not treated for their schizophrenia, with an ambulatory follow-up, without schizophreniform, schizoaffective, or other psychotic disorder. The psychiatrists "vigilance level" for a given cardiovascular risk factor was defined as a systematic investigation of this cardiovascular risk factor for at least 75% of the schizophrenic patients included in the study by the psychiatrist. A total of 382 psychiatrists included 2242 patients, the data collected for 2222 patients were finally analysed. The mean age was 41 years old, 59% were men. The mean BMI was 27 kg/m(2), 34% of the patients were overweight, 23% were obese. The paranoid and residual schizophrenia were the most frequently described subtypes of the disease (41.3 and 25.0% respectively), 58% of the patients were moderately or markedly ill according to the CGI-S scale. Most of the patients were treated with atypical antipsychotics (77%). Only 58% of the psychiatrists were vigilant for the weight of their patients, 38% for the arterial tension, 25% for the family history of premature coronary disease, 14% for the glycemia, 12% for the triglycerides, 10% for HDL cholesterol, 6% for the waist measurement; 35% of the psychiatrists were vigilant for no cardiovascular risk factor. Less than 30% of the psychiatrists recommended their patients to other specialists to manage cardiovascular disorders. Similarly to other countries, French psychiatrists provide insufficient care of

  10. HbA1c and coronary heart disease risk among diabetic patients.

    PubMed

    Zhao, Wenhui; Katzmarzyk, Peter T; Horswell, Ronald; Wang, Yujie; Johnson, Jolene; Hu, Gang

    2014-02-01

    Clinical trials to date have not provided definitive evidence regarding the effects of glucose lowering with coronary heart disease (CHD) risk among diabetic patients. We prospectively investigated the association of HbA1c at baseline and during follow-up with CHD risk among 17,510 African American and 12,592 white patients with type 2 diabetes. During a mean follow-up of 6.0 years, 7,258 incident CHD cases were identified. The multivariable-adjusted hazard ratios of CHD associated with different levels of HbA1c at baseline (<6.0 [reference group], 6.0-6.9, 7.0-7.9, 8.0-8.9, 9.0-9.9, 10.0-10.9, and ≥11.0%) were 1.00, 1.07 (95% CI 0.97-1.18), 1.16 (1.04-1.31), 1.15 (1.01-1.32), 1.26 (1.09-1.45), 1.27 (1.09-1.48), and 1.24 (1.10-1.40) (P trend = 0.002) for African Americans and 1.00, 1.04 (0.94-1.14), 1.15 (1.03-1.28), 1.29 (1.13-1.46), 1.41 (1.22-1.62), 1.34 (1.14-1.57), and 1.44 (1.26-1.65) (P trend <0.001) for white patients, respectively. The graded association of HbA1c during follow-up with CHD risk was observed among both African American and white diabetic patients (all P trend <0.001). Each one percentage increase of HbA1c was associated with a greater increase in CHD risk in white versus African American diabetic patients. When stratified by sex, age, smoking status, use of glucose-lowering agents, and income, this graded association of HbA1c with CHD was still present. The current study in a low-income population suggests a graded positive association between HbA1c at baseline and during follow-up with the risk of CHD among both African American and white diabetic patients with low socioeconomic status.

  11. Lipoprotein (a) For Risk Assessment in Patients with Established Coronary Artery Disease

    PubMed Central

    O’Donoghue, Michelle; Morrow, David A; Tsimikas, Sotirios; Sloan, Sarah; Ren, Angela F.; Hoffman, Elaine B.; Desai, Nihar P.; Solomon, Scott D.; Domanski, Michael; Arai, Kiyohito; Chiuve, Stephanie E.; Cannon, Christopher P.; Sacks, Frank M.; Sabatine, Marc S

    2013-01-01

    Objectives To assess the prognostic utility of lipoprotein (a) [Lp(a)] in individuals with coronary artery disease (CAD). Background Data regarding an association between Lp(a) and cardiovascular (CV) risk in secondary prevention populations are sparse. Methods Plasma Lp(a) was measured in 6762 subjects with CAD from three studies; data were then combined with eight previously published studies for a total of 18,979 subjects. Results Across the three studies, increasing levels of Lp(a) were not associated with the risk of CV events when modeled as a continuous variable (OR 1.03 per log-transformed SD, 95% CI 0.96-1.11) or by quintile (OR Q5:Q1 1.05, 95% CI, 0.83-1.34). When data were combined with previously published studies of Lp(a) in secondary prevention, subjects with Lp(a) levels in the highest quantile were at increased risk of CV events (OR 1.40, 95% CI 1.15-1.71), but with significant between-study heterogeneity (P=0.001). When stratified on the basis of LDL cholesterol, the association between Lp(a) and CV events was significant in studies in which average LDL cholesterol was ≥130 mg/dl (OR 1.46, 95% CI 1.23-1.73, P<0.001), whereas this relationship was not significant for studies with an average LDL cholesterol <130 mg/dl (OR 1.20, 95 CI 0.90-1.60, P=0.21). Conclusions Lp(a) is significantly associated with the risk of CV events in patients with established CAD; however, there exists marked heterogeneity across trials. In particular, the prognostic value of Lp(a) in patients with low cholesterol levels remains unclear. PMID:24161323

  12. Risk factors in young patients of acute myocardial infarction.

    PubMed

    Faisal, Abdul Wajid Khan; Ayub, Mohammad; Waseem, Tariq; Khan, Rao Shahzad Abdul Tawwab; Hasnain, Syed Sibitul

    2011-01-01

    Ischemic heart disease is a leading cause of death throughout the world. CAD has been recognized among younger age group more frequently in recent years. Very limited data is available regarding the prevalence of various risk factors in our younger patients that is why this study was planed. Objectives of the study were to look for the risk factors most prevalent in our young patient of 1st Acute Myocardial Infarction. And to also look for the number of Risk Factors present in each patient. We studied 100 consecutive patients from 16-45 years of age presenting with first acute MI. Twelve risk factors were studied namely, gender, family history of premature CAD, smoking hypertension, diabetes, dyslipidemia, obesity, mental stress (type A personality), alcohol, oral contraceptive pills (OCPs), physical activity, and diet. We divided the patients into two groups. Group A with patients 35 years of age or less and group B with patients 36-45 years of age. All risk factors were compared in both the groups. Smoking, diabetes mellitus, dyslipidemia and hypertension were statistically different between the two groups. Frequency wise risk factors were lined up as male sex (91%) Diet (66%), Dyslipidemia (62%), smoking (46%), Type A personality(46%), family history (32%), diabetes mellitus (28%), sedentary lifestyle (26%), hypertension (22%), obesity (17%), alcohol (3%), and OCPs (0%) Most of the patients that is 94% had 3 or more risk factors. Smoking, hypertension, diabetes and dyslipidemia are the major modifiable risk factors in our young adults. If a young male who is smoker or a young female who is diabetic, presents in emergency room with chest pain, always suspect coronary artery disease. Other conventional risk factors are also prevalent but alcohol and OCPs are not a major health problem for us.

  13. Risk identification in haemodialysis patients by appropriate body composition assessment.

    PubMed

    Castellano, Sandra; Palomares, Inés; Moissl, Ulrich; Chamney, Paul; Carretero, Diana; Crespo, Antonio; Morente, Camilo; Ribera, Laura; Wabel, Peter; Ramos, Rosa; Merello, José Ignacio

    2016-01-01

    Circumstances such as gender, age, diabetes mellitus (DM) and renal failure impact on the body composition of patients. However, we use nutritional parameters such as lean and fat tissue with reference values from healthy subjects to assess the nutritional status of haemodialysis (HD) patients. To analyse body composition by bioimpedance spectroscopy (BIS) of 6395 HD patients in order to obtain reference values of lean tissue index (LTI) and fat tissue index (FTI) from HD patients; and to confirm its validity by showing that those patients with LTI below the 10th percentile calculated for their group have greatest risk of death. We used the BIS to determine the LTI and FTI in our cohort of HD patients in Spain. We calculated the 10th percentile and 90th percentile of LTI and FTI in each age decile for patients grouped by gender and presence of DM. We collected clinical, laboratory and demographic parameters. The LTI/FTI 10 and 90 percentile values varied by group (age, gender and presence of DM) and, after adjusting for other risk factors such as fluid overload, those patients with LTI lower than percentile 10 had a higher relative risk of death (OR 1.57) than those patients with higher values. Monitoring the LTI and FTI of patients on HD using suitable reference values may help to identify risk in this patient population. Copyright © 2016 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

  14. Lipid-lowering treatment patterns among patients with type 2 diabetes mellitus with high cardiovascular disease risk

    PubMed Central

    Quek, Ruben G W; Fox, Kathleen M; Wang, Li; Li, Lu; Gandra, Shravanthi R; Wong, Nathan D

    2015-01-01

    Objective To examine real-world treatment patterns of lipid-lowering treatment and their possible associated intolerance and/or ineffectiveness among patients with type 2 diabetes mellitus initiating statins and/or ezetimibe. Research design and methods Adult (aged ≥18 years) patients diagnosed with type 2 diabetes who initiated statins and/or ezetimibe from January 1, 2007 to June 30, 2011 were retrospectively identified from the IMS LifeLink Pharmetrics Plus commercial claims database. Patients were further classified into 3 high-risk cohorts: (1) history of cardiovascular event (CVE); (2) two risk factors (age and hypertension); (3) aged ≥40 years. Patients had continuous health plan enrolment ≥1 year preindex and postindex date (statin and/or ezetimibe initiation date). Primary outcomes were index statin intensity, treatment modification(s), possible associated statin/non-statin intolerance and/or ineffectiveness issues (based on treatment modification type), and time-to-treatment modification(s). Analyses for each cohort were stratified by age groups (<65 and ≥65 years). Results A total of 9823 (history of CVE), 62 049 (2 risk factors), and 128 691 (aged ≥40 years) patients were included. Among patients aged <65 years, 81.4% and 51.8% of those with history of CVE, 75.6% and 44.4% of those with 2 risk factors, and 77.9% and 47.1% of those aged ≥40 years had ≥1 and 2 treatment modification(s), respectively. Among all patients, 23.2–28.4% had possible statin intolerance and/or ineffectiveness issues after accounting for second treatment modification (if any). Conclusions Among patients with type 2 diabetes with high cardiovascular disease risk, index statin treatment modifications that potentially imply possible statin intolerance and/or ineffectiveness were frequent. PMID:26435839

  15. Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI).

    PubMed

    McCabe, A; Hassan, T; Doyle, M; McCann, B

    2013-06-01

    There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management. To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment. A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI). Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40-68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4-26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9-48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5-18.2) of CTPAs done were positive for PE. This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.

  16. [Coronary surgery without extracorporeal circulation: the short-term results in high-risk patients].

    PubMed

    Pompilio, G; Antona, C; Cannata, A; Lotto, A; Alamanni, F; Gelpi, G; Tartara, P; Biglioli, P

    1999-03-01

    This study was conducted to assess the impact of coronary bypass surgery (CABG) without cardiopulmonary bypass (CPB) on high-risk patients. From February 1997 to July 1998, 71 patients considered at high-risk underwent a CABG off-pump. Using the "Higgins score", eleven preoperative risk factors were identified and stratified in this group of patients. Among 1271 patients who underwent CABG with CPB in the same period, using a computer-based matched comparison, a second identical group of patients was selected according to the 11 risk variables and the number with coronary disease, so that complete preoperative matching included the year of operation, score index and coronary target. Moreover, among seven other preoperative variables that were not included in the matching comparison, the two groups differed only in mean age (64 +/- 10.9 vs 61.6 +/- 7.3 in groups off and on-pump, respectively, p < 0.05). Postoperative outcome and complications and blood requirement were compared. Myocardial cell injury and left ventricular performance were also assessed in the two groups. The global incidence of neurologic complications in the off-pump group was significantly lower (9.8 vs 0%, in on and off-pump groups, respectively; p = 0.02). Patients undergoing CABG off-pump required blood far less often (% of transfused patients: 26.7% for the patients with CPB and 11.2% for the patients without CPB; p = 0.032). Three patients from the on-pump group (4.2%) had a perioperative myocardial infarction (AMI), versus 0% of the off-pump cases (p = ns). Postoperative atrial fibrillation accounted for 14.1% in off-pump patients and 30.9% in on-pump patients (p = 0.027). One patient in both groups (1.4%) suffered from postoperative heart failure. Mean ventilation time and ICU stay did not differ significantly between the two groups. However, hospital discharge occurred earlier in the off-pump group (9.3 +/- 3 vs 12.6 +/- 8, p = 0.007). In-hospital death occurred in one case from the on

  17. Stratified Scaffolds for Osteochondral Tissue Engineering.

    PubMed

    Nooeaid, Patcharakamon; Schulze-Tanzil, Gundula; Boccaccini, Aldo R

    2015-01-01

    Stratified scaffolds are promising devices finding application in the field of osteochondral tissue engineering. In this scaffold type, different biomaterials are chosen to fulfill specific features required to mimic the complex osteochondral tissue interface, including cartilage, interlayer tissue, and subchondral bone. Here, the biomaterials and fabrication methods currently used to manufacture stratified multilayered scaffolds as well as cell seeding techniques for their characterization are presented.

  18. Radiative transfer in a plane stratified dielectric

    NASA Technical Reports Server (NTRS)

    Wilheit, T. T., Jr.

    1975-01-01

    A model is developed for calculating radiative transfer in a stratified dielectric. This model is used to show that the reflectivity of a stratified dielectric is primarily determined by gradients in the real part of the refractive index over distances on the order of 1/10 wavelength in the medium. The effective temperature of the medium is determined by the thermodynamic temperature profile over distances of the order delta T.

  19. Risk of obstructive sleep apnoea in patients with rheumatoid arthritis: a nationwide population-based retrospective cohort study

    PubMed Central

    Shen, Te-Chun; Hang, Liang-Wen; Liang, Shinn-Jye; Huang, Chien-Chung; Lin, Cheng-Li; Tu, Chih-Yen; Hsia, Te-Chun; Shih, Chuen-Ming; Hsu, Wu-Huei; Sung, Fung-Chang

    2016-01-01

    Objective Sleep disorders are prevalent medical disorders in patients with rheumatoid arthritis (RA). However, whether patients with RA are at an increased risk of developing obstructive sleep apnoea (OSA) is unclear. Design Using population-based retrospective cohort study to examine the risk of OSA in patients with RA. Setting We used claims data of the National Health Insurance Research Database (NHIRD) of Taiwan. Participants We identified a RA cohort with 33 418 patients newly diagnosed in 2000–2010 and a randomly selected non-RA comparison cohort with 33 418 individuals frequency matched by sex, age and diagnosis year. Primary and secondary outcome measures Incident OSA was estimated by the end of 2011. The HRs of OSA were calculated using the Cox proportional hazards regression analysis. Results The overall incidence rate of OSA was 75% greater in the RA cohort than in the non-RA cohort (3.04 vs 1.73/10 000 person-years, p<0.001), with an adjusted HR (aHR) of 1.75 (95% CI 1.18 to 2.60). Stratified analyses by sex, age group and comorbidity revealed that the incidence rates of OSA associated with RA were higher in all subgroups. Conclusions This population-based retrospective cohort study suggested that patients with RA should be monitored for the risk of developing OSA. PMID:27895064

  20. Identifying patients at high risk of breast cancer recurrence: strategies to improve patient outcomes

    PubMed Central

    Martei, Yehoda M; Matro, Jennifer M

    2015-01-01

    Identifying patients at high risk of breast cancer recurrence has important implications not only for enabling the ability to provide accurate information to patients but also the potential to improve patient outcomes. Patients at high recurrence risk can be offered appropriate treatment to improve the overall survival. However, the major challenge is identifying patients with early-stage breast cancer at lower risk who may be spared potentially toxic therapy. The successful integration of molecular assays into clinical practice may address the problem of overtreatment and improve overall patient outcomes. PMID:26504408

  1. Perceptions of high-risk patients and their providers on the patient-centered medical home.

    PubMed

    Kangovi, Shreya; Kellom, Katherine; Sha, Christopher; Johnson, Sarah; Chanton, Casey; Carter, Tamala; Long, Judith A; Grande, David

    2015-01-01

    To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room.

  2. Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

    PubMed Central

    Stonelake, Stephen; Thomson, Peter; Suggett, Nigel

    2015-01-01

    Introduction National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk. Methods Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification. Results The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%. Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening). Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01). Discussion Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively. Conclusions In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient. PMID:26468369

  3. Cost-effectiveness of Telemetry for Hospitalized Patients With Low-risk Chest Pain

    PubMed Central

    Ward, Michael J.; Eckman, Mark H.; Schauer, Daniel P.; Raja, Ali S.; Collins, Sean

    2015-01-01

    Background The majority of chest pain admissions originate in the emergency department (ED). Despite a low incidence of cardiac events, limited telemetry availability, and its questionable benefit, these patients are routinely admitted to a monitored setting. Objectives The objectives were to analyze the cost-effectiveness of admission to telemetry versus admission to an unmonitored hospital bed in low-risk chest pain patients and explore when the use of telemetry may be cost-effective. Methods The authors constructed a decision analytic model to evaluate the scenario of an ED admission of an otherwise healthy 55-year-old patient with low-risk chest pain defined as an acute coronary syndrome (ACS) probability of 2%. Costs were estimated from 2009 Medicare data for hospital reimbursement and physician services, as well as published data on disability costs. Published studies were used to estimate the risk of ACS, cardiac arrest, time to defibrillation, survival, long-term disability, and quality of life. Results In the base case, telemetry was more effective (0.0044 quality-adjusted life-years [QALYs]) but more costly ($299.67) than a floor bed, resulting in a high marginal cost-effectiveness ratio (mCER) of $67,484.55 per QALY. In comprehensive sensitivity analyses, the mCER crossed below the willingness-to-pay (WTP) threshold of $50,000 per QALY when the following scenarios were met: the probability of ACS exceeds 3%, the probability of cardiac arrest is greater than 0.4%, the probability of shockable dysrhythmia is above 83%, the probability of delay in telemetry bed availability is below 52%, and the opportunity cost of delay to telemetry bed placement is below $119. Conclusions Telemetry may be a “cost-effective” use of health care resources for chest pain patients when patients have a probability of ACS above 3% or for patients with a minimal delay and cost associated with obtaining a monitored bed. Further research is needed to better stratify low-risk

  4. [Risk management: relationship with the patient's relatives, who does what?].

    PubMed

    Fenizia, E; Colombo, B; Di Gemma, A; Piredda, M

    2007-08-01

    Risk management is the systematic process of identification, evaluation and treatment of current and potential risks. In the last decades it has acquired a significant importance also in the medical field, where it aims to increase patient' safety, to reduce adverse events and costs, thus improving patients' outcomes. Gastrointestinal endoscopy is a clinical field where operative procedures are carried out; some of them may have complications, which can lead to legal cases; among such techniques endoscopic ultrasonography is acceptably safe. The aim of the article is to highlight some aspects of the risk management which are related with the patient's relatives, in the field of endoscopic ultrasonography: from the gathering of the case history to the required information for a safe discharge. Communication skills and attention given to the information process, can allow the reduction of clinical risks for patients undergoing endoscopic procedures.

  5. Patient's Education Level May Be Key to Heart Risk

    MedlinePlus

    ... https://medlineplus.gov/news/fullstory_166508.html Patient's Education Level May Be Key to Heart Risk As ... 59 percent for those with a grade school education, to 42 percent for those who'd earned ...

  6. Treating Patients with High-Risk Smoldering Myeloma

    Cancer.gov

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

  7. Predicting neutropenia risk in patients with cancer using electronic data.

    PubMed

    Pawloski, Pamala A; Thomas, Avis J; Kane, Sheryl; Vazquez-Benitez, Gabriela; Shapiro, Gary R; Lyman, Gary H

    2017-04-01

    Clinical guidelines recommending the use of myeloid growth factors are largely based on the prescribed chemotherapy regimen. The guidelines suggest that oncologists consider patient-specific characteristics when prescribing granulocyte-colony stimulating factor (G-CSF) prophylaxis; however, a mechanism to quantify individual patient risk is lacking. Readily available electronic health record (EHR) data can provide patient-specific information needed for individualized neutropenia risk estimation. An evidence-based, individualized neutropenia risk estimation algorithm has been developed. This study evaluated the automated extraction of EHR chemotherapy treatment data and externally validated the neutropenia risk prediction model. A retrospective cohort of adult patients with newly diagnosed breast, colorectal, lung, lymphoid, or ovarian cancer who received the first cycle of a cytotoxic chemotherapy regimen from 2008 to 2013 were recruited from a single cancer clinic. Electronically extracted EHR chemotherapy treatment data were validated by chart review. Neutropenia risk stratification was conducted and risk model performance was assessed using calibration and discrimination. Chemotherapy treatment data electronically extracted from the EHR were verified by chart review. The neutropenia risk prediction tool classified 126 patients (57%) as being low risk for febrile neutropenia, 44 (20%) as intermediate risk, and 51 (23%) as high risk. The model was well calibrated (Hosmer-Lemeshow goodness-of-fit test = 0.24). Discrimination was adequate and slightly less than in the original internal validation (c-statistic 0.75 vs 0.81). Chemotherapy treatment data were electronically extracted from the EHR successfully. The individualized neutropenia risk prediction model performed well in our retrospective external cohort.

  8. Understanding risk communication through patient narratives about complex antithrombotic therapies.

    PubMed

    Andreas, Dorothy C; Abraham, Neena S; Naik, Aanand D; Street, Richard L; Sharf, Barbara F

    2010-08-01

    The purpose of this study was to explore how patients use narratives to create coherent understandings of risks associated with complex antithrombotic therapies. We led four focus groups consisting of patients older than 65 years of age who had a diagnosis of cardiovascular disease and were using a prescription for cardioprotective agents, such as aspirin, anticoagulants, and/or antiplatelets. The participants' stories were retrospective accounts about physician and patient interactions and adverse events organized in the plot structure of a trial-and-error story. The trial-and-error narrative structure emphasizes patients' idiosyncrasies and reasons why they expect to experience adverse events from changes in treatment. Any fears that they might have had about these risks were mitigated by physician expertise, patient responsibility, and medical technology. Patients who expressed concer