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Risk stratification in emergency patients by copeptin
Background Rapid risk stratification is a core task in emergency medicine. Identifying patients at high and low risk shortly after admission could help clinical decision-making regarding treatment, level of observation, allocation of resources and post discharge follow-up. The purpose of the present study was to determine short-, mid- and long-term mortality by plasma measurement of copeptin in unselected admitted patients. Method Consecutive patients >40-years-old admitted to an inner-city hospital were included. Within the first 24 hours after admission, a structured medical interview was conducted and self-reported medical history was recorded. All patients underwent a clinical examination, an echocardiographic evaluation and collection of blood for later measurement of risk markers. Results Plasma for copeptin measurement was available from 1,320 patients (average age 70.5 years, 59.4% women). Median follow-up time was 11.5 years (range 11.0 to 12.0 years). Copeptin was elevated (that is, above the 97.5 percentile in healthy individuals). Mortality within the first week was 2.7% (17/627) for patients with elevated copeptin (above the 97.5 percentile, that is, >11.3 pmol/L) compared to 0.1% (1/693) for patients with normal copeptin concentrations (that is, ?11.3 pmol/L) (P <0.01). Three-month mortality was 14.5% (91/627) for patients with elevated copeptin compared to 3.2% (22/693) for patients with normal copeptin. Similar figures for one-year mortality and for the entire observation period were 27.6% (173/627) versus 8.7% (60/693) and 82.9% (520/527) versus 57.5% (398/693) (P <0.01 for both), respectively. Using multivariable Cox regression analyses shows that elevated copeptin was significantly and independently related to short-, mid- and long-term mortality. Adjusted hazard ratios were 2.4 for three-month mortality, 1.9 for one-year mortality and 1.4 for mortality in the entire observation period. Conclusions In patients admitted to an inner-city hospital, copeptin was strongly associated with short-, mid- and long-term mortality. The results suggest that rapid copeptin measurement could be a useful tool for both disposition in an emergency department and for mid- and long-term risk assessment.
Natalizumab: risk stratification of individual patients with multiple sclerosis.
At present, three risk factors for the development of progressive multifocal leukoencephalopathy (PML) in natalizumab-treated patients have been identified: the presence of antibodies against JC virus (JCV); the duration of natalizumab treatment, especially if longer than 2Āyears; and the use of immunosuppressants prior to receiving natalizumab. The most commonly used strategy to assess the individual PML risk includes serum anti-JCV antibody testing. Based on the knowledge on all known risk factors, an algorithm for PML risk stratification has been proposed, where patients with the highest PML risk are those with positive anti-JCV antibodies, treatment duration longer than 2Āyears, with or without prior history of immunosuppression. These patients would have an approximate incidence of PML of 11.1 (with prior immunosuppression) or 4.6 (without prior immunosuppression) cases per 1,000 patients treated with natalizumab (and treatment duration longer than 2Āyears). In this review, new data on PML risk factors and possible new strategies for PML risk stratification are discussed. PMID:24942634
Tur, Carmen; Montalban, Xavier
Heart rate variability in risk stratification of cardiac patients.
Heart rate (HR) variability has been extensively studied in cardiac patients, especially in patients surviving an acute myocardial infarction (AMI) and also in patients with congestive heart failure (CHF) or left ventricular (LV) dysfunction. The majority of studies have shown that patients with reduced or abnormal HR variability have an increased risk of mortality within a few years after an AMI or after a diagnosis of CHF/LV dysfunction. Various measures of HR dynamics, such as time-domain, spectral, and non-linear measures of HR variability have been used in risk stratification. The prognostic power of various measures, except of those reflecting rapid R-R interval oscillations, has been almost identical, albeit some non-linear HR variability measures, such as short-term fractal scaling exponent have provided somewhat better prognostic information than the others. Abnormal HR variability predicts both sudden and non-sudden cardiac death. Because of remodeling of the arrhythmia substrate after AMI, early measurement of HR variability to identify those at high risk should likely be repeated later in order to assess the risk of fatal arrhythmia events. Future randomized trials using HR variability/turbulence as one of the pre-defined inclusion criteria will show whether routine measurement of HR variability/turbulence will become a routine clinical tool for risk stratification of cardiac patients. PMID:24215747
Huikuri, Heikki V; Stein, Phyllis K
Apparatus and method for risk stratification of patients with chest pain of suspected cardiac origin
US Patent & Trademark Office Database
The subject invention relates to the detection, diagnosis and risk stratification of clinical events such as acute coronary syndrome, in patients with signs and symptoms of suspected cardiac origin. In one embodiment, a clinical event in a patient is diagnosed by obtaining the patient's ECG, and at least one in vitro diagnostic assay, preferably an assay for a marker of ischemia, and optionally in vitro diagnostic assays for necrotic markers or other cardiac indicators, and combining the foregoing results in an algorithm to provide a diagnosis or a risk stratification of the clinical condition.
ROC optimization may improve risk stratification of prostate cancer patients
Objectives. Rational treatment decision requires accurate projection of the clinical course of a patient. Current methods in clinical outcome analysis mostly focus on population data. We investigated the applicability and optimization of the widely used actuarial method to project individual clinical outcomes.Methods. We designed and implemented a Clinical Outcome Prediction Expert (COPE) that performs, assesses, and optimizes actuarial prediction on
Rex Cheung; Martin D Altschuler; Anthony V DÆAmico; S. Bruce Malkowicz; Alan J Wein; Richard Whittington
Use of mutant-specific ion channel characteristics for risk stratification of long QT syndrome patients.
Inherited long QT syndrome (LQTS) is caused by mutations in ion channels that delay cardiac repolarization, increasing the risk of sudden death from ventricular arrhythmias. Currently, the risk of sudden death in individuals with LQTS is estimated from clinical parameters such as age, gender, and the QT interval, measured from the electrocardiogram. Even though a number of different mutations can cause LQTS, mutation-specific information is rarely used clinically. LQTS type 1 (LQT1), one of the most common forms of LQTS, is caused by mutations in the slow potassium current (I(Ks)) channel ? subunit KCNQ1. We investigated whether mutation-specific changes in I(Ks) function can predict cardiac risk in LQT1. By correlating the clinical phenotype of 387 LQT1 patients with the cellular electrophysiological characteristics caused by an array of mutations in KCNQ1, we found that channels with a decreased rate of current activation are associated with increased risk of cardiac events (hazard ratio=2.02), independent of the clinical parameters usually used for risk stratification. In patients with moderate QT prolongation (a QT interval less than 500 ms), slower activation was an independent predictor for cardiac events (syncope, aborted cardiac arrest, and sudden death) (hazard ratio = 2.10), whereas the length of the QT interval itself was not. Our results indicate that genotype and biophysical phenotype analysis may be useful for risk stratification of LQT1 patients and suggest that slow channel activation is associated with an increased risk of cardiac events. PMID:21451124
Jons, Christian; O-Uchi, Jin; Moss, Arthur J; Reumann, Matthias; Rice, John J; Goldenberg, Ilan; Zareba, Wojciech; Wilde, Arthur A M; Shimizu, Wataru; Kanters, Jorgen K; McNitt, Scott; Hofman, Nynke; Robinson, Jennifer L; Lopes, Coeli M B
Value of planar 201Tl imaging in risk stratification of patients recovering from acute myocardial infarction
Although exercise ECG testing has been shown to have important prognostic value after acute myocardial infarction, exercise 201Tl scintigraphy offers several potential advantages, including: (1) increased sensitivity for detecting residual myocardial ischemia; (2) the ability to localize ischemia to a specific area or areas subtended by a specific coronary artery; (3) the ability to identify exercise-induced left ventricular dysfunction, which is manifested by increased lung uptake or transient left ventricular dilation; and (4) more reliable risk stratification of individual patients. The more optimal prognostic efficiency of 201Tl scintigraphy partially results from the fact that the error rate in falsely classifying patients as low risk is significantly smaller with 201Tl scintigraphy than with stress ECG. Because of these substantial advantages, there seems to be adequate rationale for recommending exercise perfusion imaging rather than exercise ECG alone as the preferred method for evaluating mortality and morbidity risks after acute myocardial infarction.
Gibson, R.S.; Watson, D.D. (Medical Center, University of Virginia Health Sciences Center, Charlottesville (United States))
Clinical Usefulness of Novel Serum and Imaging Biomarkers in Risk Stratification of Patients with Stable Angina
Inflammatory mediators appear to be the most intriguing yet confusing subject, regarding the management of patients with acute coronary syndromes (ACS). The current inflammatory concept of atherosclerotic coronary artery disease (CAD) led many investigators to concentrate on systemic markers of inflammation, as well as imaging techniques, which may be helpful in risk stratification and prognosis assessment for cardiovascular events. In this review, we try to depict many of the recently studied markers regarding stable angina (SA), their clinical usefulness, and possible future applications in the field.
Ikonomidis, Ignatios; Tsantes, Argirios
A comparative analysis of risk stratification tools for emergency department patients with chest pain
Background Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods This prospective observational study evaluated ED patients aged ?30Āyears with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30Ādays. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30Ādays, as analyzed by receiver operator curves (ROC). Results Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3)?=?67.21, N?=?276, p?0.0001]. Conclusion The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.
Genotype-specific risk stratification and management of patients with long QT syndrome.
Long QT syndrome (LQTS) is an inherited disorder associated with life-threatening ventricular arrhythmias. An understanding of the relationship between the genotype and phenotype characteristics of LQTS can lead to improved risk stratification and management of this hereditary arrhythmogenic disorder. Risk stratification in LQTS relies on combined assessment of clinical, electrocardiographic, and mutations-specific factors. Studies have shown that there are genotype-specific risk factors for arrhythmic events including age, gender, resting heart rate, QT corrected for heart rate, prior syncope, the postpartum period, menopause, mutation location, type of mutation, the biophysical function of the mutation, and response to beta-blockers. Importantly, genotype-specific therapeutic options have been suggested. Lifestyle changes are recommended according to the prevalent trigger for cardiac events. Beta-blockers confer greater benefit among patients with LQT1 with the greatest benefit among those with cytoplasmic loops mutations; specific beta-blocker agents may provide greater protection than other agents in specific LQTS genotypes. Potassium supplementation and sex hormone-based therapy may protect patients with LQT2. Sodium channel blockers such as mexiletine, flecainide, and ranolazine could be treatment options in LQT3. PMID:24206565
Barsheshet, Alon; Dotsenko, Olena; Goldenberg, Ilan
Rockall score for risk stratification in adult patients with non-variceal upper gastrointestinal hemorrhage.
The Rockall risk score is a simple, validated predictive index that may serve as a useful clinical decision for assessing the risk of subsequent adverse outcomes in patients with non-variceal upper gastrointestinal hemorrhage (UGIH). The observational study was carried out over a period of 6 months from 10th July, 2012 to 09th January, 2013 in Department of Medicine, Dhaka Medical College Hospital, Dhaka, Bangladesh. A total of 60 patients with non-variceal UGIH were taken for the study during study period to see risk stratification by Rockall score and short term hospital outcome in non-variceal upper GI hemorrhage patients. Categorical variables were reported as percentage and Means and proportions were carried out using the Chi-square test of different variables. Among study population age distribution were 42(70%) <60 years, 16(26.7%) from 60-79 years and 02(3.3%) 80 years or above and sex distribution were 39(65%) male and 21(35%) were female patients. Rockall score of patients 11(18.3%) had score 1, 6(10%) had score 2, 13(21.7%) had score 3, 10(16.7%) had score 4, 6(10%) had score 5, 6(10%) had score 6, 4(6.7%) had score 7, 3(5.0%) had score 8 and 1(1.7%) had score 9. Risk stratification showed 30(50%) had low risk (score 3 or <3), 26(43.3%) had moderate risk (score 4-7) and 4(6.7%) had high risk (score 8 or >8). Outcome after initial Rockall scoring and endoscopy were found that 7(11.7%) died, 46(76.6%) survived and 7(11.7%) patients survived with complication. This study showed that Rockall score of ?3 was predictive of low risk of adverse outcomes, and a score of ?8 was predictive of high mortality and was useful in identifying patients with non-variceal UGIH who had low-risk scores in order to triage appropriately, without affecting patient outcomes. PMID:24292298
Rahman, M W; Sumon, S M; Amin, M R; Kahhar, M A
Risk stratification of mortality in patients with heart failure and left ventricular ejection fraction >35%.
The population of patients with heart failure (HF) and mild to moderate left ventricular (LV) dysfunction is growing, and mortality remains high. There is a need for better risk stratification of patients who might benefit from primary prevention of mortality. This study aimed to evaluate the prognostic value of Holter-based parameters for predicting mortality in patients with HF with LV ejection fraction (EF) >35%. The study involved 294 patients (199 men, mean age 66 years) with HF of ischemic and nonischemic causes, New York Heart Association classes II to III, and LVEF >35%. Surface electrocardiogram and 24-hour Holter monitoring were performed at enrollment to assess traditional electrocardiographic variables, as well as heart rate variability, heart rate turbulence, and repolarization dynamics (QT/RR). Total mortality and sudden death were the primary and secondary end points. During a median 44-month follow-up, there were 43 deaths (15%). None of the traditional electrocardiographic risk parameters significantly predicted mortality. A standard deviation of all normal-to-normal RR intervals < or =86 ms, turbulence slope < or =2.5 ms/RR, and QT end/RR >0.21 at daytime were found to be independent risk predictors of mortality in multivariate analyses. The predictive score based on these 3 variables showed that patients with > or =2 abnormal risk markers were at risk of death (30% 3-year mortality rate) and sudden death (12%), similar to death rates observed in patients with LVEF < or =35%. In conclusion, increased risk of mortality and sudden death could be predicted in patients with HF with LVEF >35% by evaluating the combination of standard deviation of all normal-to-normal RR intervals, turbulence slope, and QT/RR, parameters reflecting autonomic control of the heart, baroreflex sensitivity, and repolarization dynamics. PMID:19327431
Cygankiewicz, Iwona; Zareba, Wojciech; Vazquez, Rafael; Bayes-Genis, Antoni; Pascual, Domingo; Macaya, Carlos; Almendral, Jesus; Fiol, Miquel; Bardaji, Alfredo; Gonzalez-Juanatey, Jose R; Nieto, Vicente; Valdes, Mariano; Cinca, Juan; de Luna, Antoni Bayes
Risk stratification of prostate cancer patients based on EPS-urine zinc content
The early detection of prostate cancer is a life-saving event in patients harboring potentially aggressive disease. With the development of malignancy there is a dramatic reduction in the zinc content of prostate tissue associated with the inability of cancer cells to accumulate the ion. In the current study, we utilized endogenous zinc as a diagnostic biomarker for prostate cancer. We employed a novel fluorescent sensor for mobile zinc (ZPP1) to measure the concentration of zinc in thirty-nine patient samples of expressed prostatic secretion (EPS) in urine. We estimated the probability of classifying a subject as benign, low-risk, or high-risk as functions of the diagnostic test results using a non-informative prior Bayesian approach. Permutation tests and other non-parametric tests were also used. We demonstrated a significant trend in zinc score with disease and with disease risk (P = 0.03), and lack of a significant correlation between zinc score and PSA. We also showed that the proposed diagnostic is potentially superior to PSA for detecting high-risk disease. Considering that risk stratification represents an important unmet need, our method should advance the field of prostate cancer diagnostics and treatment planning.
Medarova, Zdravka; Ghosh, Subrata K; Vangel, Mark; Drake, Richard; Moore, Anna
Risk stratification of patients with syncope in an accident and emergency department
Objectives: This study categorised syncopal patients, in a British accident and emergency (A&E) department, into three prognostic groups, using American College of Physicians (ACP) guidelines. The one year mortality of the three groups was studied to see if risk stratification using these guidelines is applicable to these patients and also whether admission improved outcome. Methods: The records of all syncopal patients presenting to the Leeds General Infirmary A&E department during an eight week period from 2 November 1998 were identified. The cohort was grouped according to ACP guidelines into those who had an absolute indication for admission (group 1), a probable indication for admission (group 2) and no indication for admission (group 3). The actual disposal was recorded and for each patient mortality data were retrieved from general practices or health authorities one year later. The three groups were compared. Results: Two hundred and ten records (1.7% of all new patients aged 16 years or above) were analysed. Forty per cent of the cohort were not assigned a diagnosis after their assessment in A&E. Forty seven (22%) were placed in ACP group 1, 63 (30%) in ACP group 2 and 100 (48%) in ACP group 3. Thirty six per cent of those in group 1 had died within a year, 14% of those in group 2 and none of those in group 3. In neither group 1 patients ("high risk") nor group 2 patients ("moderate risk") did admission to the hospital seem to influence outcome. However, three patients died within a week of their presentation, and two of them had been discharged from A&E. Conclusion: It is possible to stratify syncopal patients presenting acutely to A&E, according to prognosis, using ACP guidelines. Disposal decisions for these patients should be based on their apparent prognosis (as defined in the ACP guidelines) and not on the diagnosis, which is often difficult to make.
Crane, S
Risk stratification for arrhythmic events in patients with idiopathic dilated cardiomyopathy: a review of the literature and current perspectives.
The prognosis for patients with idiopathic dilated cardiomyopathy (DCM) has markedly improved during the last decade, mainly because of advancements in therapeutic strategies. However, sudden death still accounts for a significant part of the total mortality in patients with moderate disease. Recent primary prophylactic trials failed to demonstrate any benefit of cardioverter-defibrillator implantation in an unselected group of idiopathic DCM patients and thus the identification of the subgroup of patients at high arrhythmic risk is crucial. Although different risk stratification methods have been evaluated in risk assessment, the reported clinical value differs in studies, mainly because of differences in either methodology and/or patient selection. The present review focuses on arrhythmic events in idiopathic DCM and on the value of noninvasive methods and electrophysiological study in the risk stratification of this group of patients. PMID:14635374
Cal", Leonardo; Peichl, Petr; Bulava, Alan; Lamberti, Filippo; Loricchio, Maria Luisa; Castro, Antonio; Meo, Antonella; Pandozi, Claudio; Santini, Massimo
Prognostic Factors for Survival in Patients with High-Grade Meningioma and Recurrence-Risk Stratification for Application of Radiotherapy
Background Radiotherapy for high-grade meningioma (HGM) is one of the essential treatment options for disease control. However, appropriate irradiation timing remains under debate. The object of this study is to discern which prognostic factors impact recurrence in HGM patients and to propose a risk-stratification system for the application of postoperative radiotherapy. Methods We retrospectively reviewed 55 adult patients who were diagnosed with Grade II and III intracranial meningioma. Cox regression models were applied to the analysis for impact on early recurrence in HGM patients without postoperative radiotherapy. Results Grade III malignancy (P?=?0.0073) and transformed histology (P?=?0.047) proved to be significantly poor prognostic factors of early recurrence by multivariate analysis. The other candidates for recurrence factors were Simpson Grade 3¢5 resection, preoperative Karnofsky Performance status =?70%, and MIB-1 labeling index >?=?15%. According to these prognostic factors, postoperative HGM patients could be stratified into three recurrence-risk groups. The prognoses were significantly different between each group, as the 3-year actual recurrence-free rates were 90% in low-risk group, 31% in intermediate-risk group, and 15% in high-risk group. Conclusion We propose recurrence-risk stratification for postoperative HGM patients using clinically available factors. Our results suggest that the prognosis for patients with high-risk HGMs is dismal, whereas HGM patients belonging to the low-risk group could have favorable prognoses. This stratification provides us with the criteria necessary to determine whether to apply adjuvant radiotherapy to postoperative HGM patients, and to also help identify potentially curable HGMs without adjuvant radiotherapy.
Yamaguchi, Shigeru; Terasaka, Shunsuke; Kobayashi, Hiroyuki; Asaoka, Katsuyuki; Motegi, Hiroaki; Nishihara, Hiroshi; Kanno, Hiromi; Onimaru, Rikiya; Ito, Yoichi M.; Shirato, Hiroki; Houkin, Kiyohiro
Bone marrow fibrosis in patients with primary myelodysplastic syndromes has prognostic value using current therapies and new risk stratification systems.
Bone marrow fibrosis has recently been recognized as an adverse histological feature in patients with primary myelodysplastic syndromes. In this study, we assessed the prognostic impact of bone marrow fibrosis in patients with primary myelodysplastic syndromes under the recently revised new risk stratification systems: the New Comprehensive Cytogenetic Scoring System and the Revised International Prognostic Scoring System. From 2002 to 2012, a total of 79 (13%) patients with primary myelodysplastic syndromes and moderate/severe bone marrow fibrosis were identified; and these patients were compared with a control group of 166 patients with myelodysplastic syndromes but no significant fibrosis. Bone marrow fibrosis predicted an inferior overall survival and leukemia event-free survival for patients who received no hematopoietic stem cell transplant in univariate and multivariate analysis. Eleven patients with bone marrow fibrosis and 32 control group patients underwent hematopoietic stem cell transplant; and bone marrow fibrosis was an independent risk for an inferior overall survival but not leukemia-free survival. In addition, 17 (4%) patients developed bone marrow fibrosis during the course of myelodysplastic syndromes, which was accompanied by clinical and cytogenetic evidence of disease progression. JAK2 V617F mutations were detected in 6 of the 28 patients with bone marrow fibrosis presenting at the time of diagnosis and 2 of the 7 patients with bone marrow fibrosis developing in the course of disease, significantly higher than the control group patients. We conclude that bone marrow fibrosis is an adverse risk feature in primary myelodysplastic syndromes in the current therapeutic era, and this risk feature is not captured by newly revised risk stratification systems. Inclusion of bone marrow fibrosis in patient assessment may further aid in risk-adapted therapeutic decisions. PMID:24186132
Fu, Bin; Jaso, Jesse M; Sargent, Rachel L; Goswami, Maitrayee; Verstovsek, Srdan; Medeiros, L Jeffrey; Wang, Sa A
The identification of risks associated with sudden cardiac death requires further investigations. The question was addressed whether parameters can be established which not only de- scribe an increased risk for an enhanced electrical instability of the heart but also of inflammatory events underlying plaque rupture. Emphasis is placed on dose-dependent effects of the long-chain omega-(?-)3 fatty acids eicosapentaenoic acid (EPA)
Heinz Rupp; Daniela Wagner; Thomas Rupp; Lisa-Maria Schulte; Bernhard Maisch
Feasibility of an automated quantitative computed tomography angiography-derived risk score for risk stratification of patients with suspected coronary artery disease.
Coronary computed tomography angiography (CTA) has important prognostic value. Additionally, quantitative CTA (QCT) provides a more detailed accurate assessment of coronary artery disease (CAD) on CTA. Potentially, a risk score incorporating all quantitative stenosis parameters allows accurate risk stratification. Therefore, the purpose of this study was to determine if an automatic quantitative assessment of CAD using QCT combined into a CTA risk score allows risk stratification of patients. In 300 patients, QCT was performed to automatically detect and quantify all lesions in the coronary tree. Using QCT, a novel CTA risk score was calculated based on plaque extent, severity, composition, and location on a segment basis. During follow-up, the composite end point of all-cause mortality, revascularization, and nonfatal infarction was recorded. In total, 10% of patients experienced an event during a median follow-up of 2.14Āyears. The CTA risk score was significantly higher in patients with an event (12.5 [interquartile range 8.6 to 16.4] vs 1.7 [interquartile range 0 to 8.4], p <0.001). In 127 patients with obstructive CAD (?50% stenosis), 27 events were recorded, all in patients with a high CTA risk score. In conclusion, the present study demonstrated that a fully automatic QCT analysis of CAD is feasible and can be applied for risk stratification of patients with suspected CAD. Furthermore, a novel CTA risk score incorporating location, severity, and composition of coronary lesion was developed. This score may improve risk stratification but needs to be confirmed in larger studies. PMID:24798123
de Graaf, Michiel A; Broersen, Alexander; Ahmed, Wehab; Kitslaar, Pieter H; Dijkstra, Jouke; Kroft, Lucia J; Delgado, Victoria; Bax, Jeroen J; Reiber, Johan H C; Scholte, Arthur J
Genomic imbalance defines three prognostic groups for risk stratification of patients with chronic lymphocytic leukemia.
Array comparative genomic hybridization (aCGH) has yet to be fully leveraged in a prognostic setting in chronic lymphocytic leukemia (CLL). Genomic imbalance was assessed in 288 CLL specimens using a targeted array. Based on 20 aberrations in a hierarchical manner, all 228 treatment-naive specimens were classified into a group with poor outcome (20.6%) exhibiting at least one aberration that was univariately associated with adverse outcome (gain: 2p, 3q, 8q, 17q, loss: 7q, 8p, 11q, 17p, 18p), good outcome (32.5%) showing 13q14 loss without any of the other 10 aberrations (gain: 1p, 7p, 12, 18p, 18q, 19, loss: 4p, 5p, 6q, 7p) or intermediate outcome (remainder). The three groups were significantly separated with respect to time to first treatment and overall survival (p < 0.001), and validation of the stratification scheme was performed in two independent datasets. Gain of 3q and 8q, and 17p loss were determined to be independent unfavorable prognostic biomarkers. TP53, NOTCH1 and SF3B1 mutations correlated with the presence of one poor outcome aCGH marker, at a considerably higher frequency than when only considering poor risk aberrations routinely detected by fluorescence in situ hybridization (FISH). These data support genomic imbalance evaluation in CLL by aCGH to assist in risk stratification. PMID:24047479
Houldsworth, Jane; Guttapalli, Asha; Thodima, Venkata; Yan, Xiao Jie; Mendiratta, Geetu; Zielonka, Tania; Nanjangud, Gouri; Chen, Weiyi; Patil, Sujata; Mato, Anthony; Brown, Jennifer R; Rai, Kanti; Chiorazzi, Nicholas; Chaganti, R S K
Risk stratification and treatment of brugada syndrome.
The Brugada syndrome (BS) is a hereditary disease characterized by typical electrocardiographic alterations (elevation of the ST segment in right precordial leads) that affects young individuals without structural heart disease, predisposing them to ventricular arrhythmias and sudden death (SD). Several genetic mutations of different subunits of the sodium, calcium and potassium channel have been involved. The majority of patients with BS remain asymptomatic; however, the most frequent symptoms are syncope and/or SD secondary to polymorphic ventricular tachycardia (PVT) or ventricular fibrillation (VF). Electrocardiographic manifestations of the BS are typically dynamic and occasionally only become apparent after the administration of a sodium channel blocker or with fever. Risk stratification is mainly based on symptoms and the surface electrocardiogram. However, in asymptomatic patients, risk evaluation is still controversial and requires further studies. This review provides an updated summary of the BS from the point of view of genetic, clinical manifestations, risk stratification and management. PMID:24893941
Arbelo, Elena; Brugada, Josep
Perioperative cardiovascular risk stratification of patients with diabetes who undergo elective major vascular surgery
Background: The importance of diabetes mellitus (DM) as an independent risk factor for perioperative cardiac morbidity after vascular surgery is controversial. This study examined the impact of DM on perioperative outcomes and length of stay in patients who underwent major vascular surgery. Methods: Patients who underwent elective aortic reconstruction (n = 2792), lower extremity bypass (n = 3838), carotid endarterectomy
David A. Axelrod; Gilbert R. Upchurch Jr; Sonya DeMonner; James C. Stanley; Shukri Khuri; Jennifer Daley; William G. Henderson; Rodney Hayward
The risk stratification in atrial fibrillation.
Atrial fibrillation (AF) is the most common rhythm disorder and represents a major public health problem because it carries an increased risk of arterial thromboembolism and ischemic stroke. Because the absolute benefit of antithrombotic therapy depends on the underlying risk of stroke, an accurate stratification of patients' risk is needed to choose the appropriate antithrombotic strategy. Over the years, several stroke risk stratification models (RSMs) were developed based on the 'classic' risk factors for stroke such as increasing age, hypertension, diabetes mellitus, and left ventricular dysfunction. Among all RSMs, the CHADS(2) score is the most popular and used one thanks to its simplicity and endorsement in several widely promulgated practice guidelines. Despite its validation in large datasets and specific population of AF patients, it has many limitations, especially due to the non-inclusion of several proven risk factors for stroke and to the classification of a large number of patients in the intermediate risk category, so creating ambiguity over the most appropriate antithrombotic therapy. Thus, the CHA(2)DS(2)-VASc score was introduced and was demonstrated to perform better than the CHADS(2), even in a "real world" population of elderly AF patients. Recently, in view of the availability of new oral anticoagulant drugs, that can overcome the limitations of warfarin and allow a more personalized therapy, many efforts are being made to identify other possibilities to assess the thromboembolic risk in AF patients. It has been demonstrated that an increase in C-reactive protein and interleukin-6 and the presence of G20210A factor II gene polymorphism and hyper-homocysteinemia are independent risk factors for ischemic complications in AF patients. Even the presence of chronic renal disease and the daily AF burden, registered with implantable monitors, are associated with an increase risk of stroke. Finally, the assessment of thromboembolic risk should go hand in hand with the consideration of the risk of bleeding. For this purpose, it has been recently developed a practical bleeding risk score, the HAS-BLED, which was included in the last ESC guidelines for the risk stratification of AF patients before starting anticoagulant therapy. PMID:23073863
Prisco, Domenico; Cenci, Caterina; Silvestri, Elena; Emmi, Giacomo; Barnini, Tommaso; Tamburini, Carlo
Risk stratification of patients with familial hypercholesterolemia in a multi-ethnic cohort
Background Heterozygous Familial hypercholesterolemia (FH) is a common autosomal dominant disorder resulting in in very high blood cholesterol levels and premature cardiovascular disease (CVD). However, there is a wide variation in the occurrence of CVD in these patients. The aim of this study is to determine risk factors that are responsible for the variability of CVD events in FH patients. Methods This is a retrospective analysis of a large multiethnic cohort of patients with definite FH attending the Healthy Heart Prevention Clinic in Vancouver, Canada. Cox proportional hazard regression analysis was used to assess the association of the risk factors to the hard cardiovascular outcomes. Results 409 patients were identified as having ōdefiniteö FH, according to the Dutch Lipid Clinic Network Criteria (DLCNC), with 111 (27%) having evidence of CVD. Male sex, family history of premature CVD, diabetes mellitus, low high density lipoprotein cholesterol (HDL-C) and high lipoprotein (a) (Lp (a)) were significant, independent risk factors for CVD. In men, family history, diabetes and low levels of HDL-C were significant risk factors while in women smoking, diabetes mellitus and high Lp (a) were significant risk factors for CVD. There were no significant differences in risk factors between ethnicities. Conclusion In conclusion, men and women differ in the impact of the risk factors on the presence of CVD with family history of CVD and low HDL-C being a significant factor in men while smoking and increased Lp (a) were significant factors in women. Diabetes was a significant factor in both men and women.
Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism
BackgroundŚAssessment of risk and appropriate management of patients with acute pulmonary embolism (PE) remains a challenge. Cardiac troponins I (cTnI) and T (cTnT) are reliable indicators of myocardial injury and may be associated with right ventricular dysfunction in PE. Methods and ResultsŚThe present prospective study included 106 consecutive patients with confirmed acute PE. cTnI was elevated (0.07 ng\\/mL) in 43
Stavros Konstantinides; Annette Geibel; Manfred Olschewski
Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department
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.
Deleger, Louise; Brodzinski, Holly; Zhai, Haijun; Li, Qi; Lingren, Todd; Kirkendall, Eric S; Alessandrini, Evaline; Solti, Imre
Risk stratification after myocardial infarction. Clinical overview
Many patients with an acute myocardial infarction can be stratified into subgroups that are at high risk for morbidity and mortality on the basis of clinical characteristics that indicate recurrent myocardial ischemia, persistent left ventricular dysfunction, and/or recurrent cardiac arrhythmias. In patients with uncomplicated myocardial infarction the assessment of symptoms, physical findings, and ECG changes during predischarge exercise testing often identifies patients at increased risk for further cardiac events. Because of the suboptimum sensitivity and specificity of the exercise ECG for detecting myocardial ischemia, myocardial perfusion imaging with 201Tl and/or assessment of global and segmental ventricular function by two-dimensional echocardiography or radionuclide cineangiography during or immediately after exercise are often added to the predischarge risk stratification.
O'Rourke, R.A. (Department of Medicine, University of Texas Health Science Center, San Antonio (United States))
Risk stratification of patients with pulmonary embolism based on pulse rate and D-dimer concentration.
To enable outpatient treatment of a selected group of patients with pulmonary embolism (PE), insight in the determinants of adverse clinical outcome is warranted. We have identified risk factors for serious adverse events (SAE) within the first 10 days of acute PE. We have retrospectively analysed data of 440 consecutive patients with acute PE. Collected data included age, gender, medical history, blood pressure, pulse rate and D-dimer concentration. The variables associated with SAE in the first 10 days in univariate analysis (p<0.15) have been included in a multivariate logistic regression model (backward conditional, p out >0.10). In 440 patients with acute PE, 20 SAEs occurred in a 10-day follow-up period. Pulse rate > or = 100 beats per minute (bpm) (OR, 6.85; 95%CI 1.43-32.81) and D-dimer concentration > or = 3,000 microg/ml (OR, 5.51; 95%CI 0.68-44.64) were significantly related to the SAEs. All SAEs were predicted by a pulse rate > or = 100 bpm and/or a D-dimer concentration > or = 3,000 microg/ml. Older age, gender, history of venous thromboembolism (VTE), heart failure, chronic obstructive pulmonary disease, cancer or a systolic blood pressure < 90 mm Hg had no significant influence on short term SAEs. Pulse rate and D-dimer concentration can be used to identify patients with acute PE, who are at risk for adverse clinical outcome during the first 10 days of hospitalisation. Outpatient treatment of PE-patients with a pulse rate > or = 100 bpm and/or a D-dimer concentration > or = 3,000 microg/ml has to be discouraged. PMID:19806253
Agterof, Mariette J; van Bladel, Esther R; Schutgens, Roger E G; Snijder, Repke J; Tromp, Ellen A M; Prins, Martin H; Biesma, Douwe H
Free-Breathing, Motion-Corrected Late Gadolinium Enhancement Is Robust and Extends Risk Stratification to Vulnerable Patients
Background Routine clinical use of novel free-breathing, motion-corrected, averaged late gadolinium enhancement (moco-LGE) cardiovascular magnetic resonance may have advantages over conventional breath held LGE (bh-LGE) especially in vulnerable patients. Methods and Results In 390 consecutive patients, we collected bh-LGE and moco-LGE with identical image matrix parameters. In 41 patients, bh-LGE was abandoned due to image quality issues, including 10 with myocardial infarction (MI). When both were acquired, MI detection was similar (McNemar test, p=0.4) with high agreement (kappa statistic 0.95). With artifact-free bh-LGE images, pixelwise MI measures correlated highly (R2=0.96) without bias. Moco-LGE was faster, and image quality and diagnostic confidence were higher on blinded review (p<0.001 for all). Over a median of 1.2 years, 20 heart failure hospitalizations and 18 deaths occurred. For bh-LGE, but not moco-LGE, inferior image quality and bh-LGE non acquisition were linked to patient vulnerability confirmed by adverse outcomes (logrank p<0.001). Moco-LGE significantly stratified risk on the full cohort (logrank p<0.001), but bh-LGE did not (logrank p=0.056) since a significant number of vulnerable patients did not receive bh-LGE (due to arrhythmia or inability to breath hold). Conclusions MI detection and quantification are similar between moco-LGE and bh-LGE when bh-LGE can be acquired well, but bh-LGE quality deteriorates with patient vulnerability. Acquisition time, image quality, diagnostic confidence and the number of successfully scanned patients are superior with moco-LGE which extends LGE-based risk stratification to include patients with vulnerability confirmed by outcomes. Moco-LGE may be suitable for routine clinical use.
Piehler, Kayla M.; Wong, Timothy C.; Puntil, Kathy S.; Zareba, Karolina M.; Lin, Kathie; Harris, David M.; Deible, Christopher R.; Lacomis, Joan M.; Czeyda-Pommersheim, Ferenc; Cook, Stephen C.; Kellman, Peter; Schelbert, Erik B.
Role of computed tomography for diagnosis and risk stratification of patients with suspected or known coronary artery disease.
Cardiac computed tomographic angiography (CCTA) has emerged as a powerful imaging modality for the detection and prognostication of individuals with suspected coronary artery disease. Because calcification of coronary plaque occurs in proportion to the total atheroma volume, the initial diagnostic potential of CCTA focused on the identification and quantification of coronary calcium in low- to intermediate-risk individuals, a finding that tracks precisely with the risk of incident adverse clinical events. Beyond noncontrast detection of coronary calcium, CCTA using iodinated contrast yields incremental information about the degree and distribution of coronary plaques and stenosis, as well as vessel wall morphology and atherosclerotic plaque features. This additive information offers the promise of CCTA to provide a more comprehensive view of total atherosclerotic burden because it relates to myocardial ischemia and future adverse clinical events. Furthermore, emerging data suggest the prognostic and diagnostic importance of stenosis severity detection and atherosclerotic plaque features described by CCTA including positive remodeling, low-attenuation plaque, and spotty calcification, which have been associated with the vulnerability of plaque. We report a summary of the evidence supporting the role of CCTA in the detection of subclinical and clinical coronary artery disease in both asymptomatic and symptomatic patients and discuss the potential of CCTA to augment the identification of at-risk individuals. CCTA and coronary artery calcium scoring offer the ability to improve risk stratification, discrimination, and reclassification of the risk in patients with suspected coronary artery disease and to noninvasively determine the measures of stenosis severity and atherosclerotic plaque features. PMID:24723554
Kalra, Dan K; Heo, Ran; Valenti, Valentina; Nakazato, Ryo; Min, James K
Risk stratification in chronic lymphocytic leukemia.
Chronic lymphocytic leukemia (CLL) follows an extremely variable clinical course with survival ranging from months to decades. Available treatments can often induce remissions, but eventually all patients relapse. Recently, there has been major progress in the identification of molecular and cellular markers that may predict the tendency for disease progression in patients with CLL. Genomic aberrations, the mutational profile of IgVH genes and its surrogate marker ZAP-70 expression, and serum markers like B2-microglobulin (beta2-MG) and thymidine kinase (TK) provide prognostic information for individual patients independently of clinical disease characteristics. These molecular markers are about to enter the stage of risk stratification for individual patients in clinical trials. PMID:16616065
Seiler, Till; D÷hner, Hartmut; Stilgenbauer, Stephan
New biomarkers in the risk stratification of patients with suspected acute myocardial infarction
The acute coronary syndromes (ACS) remain a diagnostic and prognostic challenge for todayÆs physician. Over the past decade,\\u000a studies have identified several serologic biomarkers to aid the clinician in assessing risk and predicting outcomes in ACS.\\u000a Still others are being identified that show promise for increasing the accuracy with which this risk is assessed. However,\\u000a further research remains necessary to
Bret A. Rogers; L. Kristin Newby
Lipoprotein-associated phospholipase A 2 for early risk stratification in patients with suspected acute coronary syndrome: a multi-marker approach
Aims\\u000a ĀĀNumerous markers have been identified as useful predictors of major adverse cardiac events (MACE) in patients with suspected\\u000a acute coronary syndrome (ACS). However, only little is known about the relative benefit of the single markers in risk stratification\\u000a and the best combination for optimising prognostic power.\\u000a \\u000a The aim of the present study was to define the role of the
M. M÷ckel; Reinhold M³ller; J÷rn O. Vollert; Christian M³ller; Oilver Danne; Ragnar Gareis; Thomas St÷rk; Rainer Dietz; Wolfgang Koenig
Usefulness of serum albumin concentration for in-hospital risk stratification in frail, elderly patients with acute heart failure. Insights from a prospective, monocenter study
The present study examined the usefulness of serum albumin concentration measured immediately after clinical stabilization for in-hospital risk stratification in 64 consecutive elderly, institutionalized patients with definite evidence of acute heart failure, of whom 17 died during their in-hospital stay. Serum albumin concentration was a powerful predictor of in-hospital death in this clinical setting (hazard ratio of 0.80 [0.71¢0.89], p<0.001).
Stephane Arques; Emmanuel Roux; Pascal Sbragia; Richard Gelisse; Bertrand Pieri; Pierre Ambrosi
Use of cardiovascular magnetic resonance for risk stratification in chronic heart failure: prognostic value of late gadolinium enhancement in patients with non-ischaemic dilated cardiomyopathy
ObjectiveOwing to its variable clinical course, risk stratification is of paramount importance in non-ischaemic dilated cardiomyopathy (DCM). The goal of this study was to investigate the long-term prognostic significance of late gadolinium enhancement (LGE) as detected by contrast-enhanced cardiovascular magnetic resonance (CE-CMR) in patients with DCM.DesignObservational cohort study.SettingUniversity hospital.Patients184 consecutive patients with DCM.MeasurementsCE-CMR was performed on a 1.5 T clinical
Stephanie Lehrke; Dirk Lossnitzer; Michael Sch÷b; Henning Steen; Constanze Merten; Helmut Kemmling; Regina Pribe; Philipp Ehlermann; Christian Zugck; Grigorios Korosoglou; Evangelos Giannitsis; Hugo A Katus
Membranous nephropathy: Treatment outline and risk stratification
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adult. However, the exact etiology and the best treatment approach are still unclear. It is imperative to understand the nature of and prognosis of MN before initiating treatment which may include disease specific therapy based on a careful risk-stratification approach.
Arabi, Ziad
Genetic Markers Used for Risk Stratification in Multiple Myeloma
While no specific genetic markers are required in the diagnosis of multiple myeloma (MM), multiple genetic abnormalities and gene signatures are used in disease prognostication and risk stratification. This is particularly important for the adequate identification of the high-risk MM group, which does not benefit from any of the current therapies, and novel approaches need to be proposed. Fluorescence in situ hybridization (FISH) has been employed for establishing risk-based stratification and still remains the most used genetic technique in the clinical routine. The incorporation of gene expression profiling (GEP) in the study of MM has shown to be a very powerful test in the patient stratification, but its incorporation in clinical routine depends on some technical and logistic resolutions. Thus, FISH still remains the gold standard test for detecting genomic abnormalities and outcome discrimination in MM.
Segges, Priscilla; Braggio, Esteban
Cardiac risk stratification: Role of the coronary calcium score
Coronary artery calcium (CAC) is an integral part of atherosclerotic coronary heart disease (CHD). CHD is the leading cause of death in industrialized nations and there is a constant effort to develop preventative strategies. The emphasis is on risk stratification and primary risk prevention in asymptomatic patients to decrease cardiovascular mortality and morbidity. The Framingham Risk Score predicts CHD events only moderately well where family history is not included as a risk factor. There has been an exploration for new tests for better risk stratification and risk factor modification. While the Framingham Risk Score, European Systematic Coronary Risk Evaluation Project, and European Prospective Cardiovascular Munster study remain excellent tools for risk factor modification, the CAC score may have additional benefit in risk assessment. There have been several studies supporting the role of CAC score for prediction of myocardial infarction and cardiovascular mortality. It has been shown to have great scope in risk stratification of asymptomatic patients in the emergency room. Additionally, it may help in assessment of progression or regression of coronary artery disease. Furthermore, the CAC score may help differentiate ischemic from nonischemic cardiomyopathy.
Sharma, Rakesh K; Sharma, Rajiv K; Voelker, Donald J; Singh, Vibhuti N; Pahuja, Deepak; Nash, Teresa; Reddy, Hanumanth K
Cloning of the first human anti-JCPyV/VP1 neutralizing monoclonal antibody: Epitope definition and implications in risk stratification of patients under natalizumab therapy.
JC virus (JCPyV) has gained novel clinical importance as cause of progressive multifocal leukoencephalopathy (PML), a rare demyelinating disease recently associated to immunomodulatory drugs, such as natalizumab used in multiple sclerosis (MS) cases. Little is known about the mechanisms leading to PML, and this makes the need of PML risk stratification among natalizumab-treated patients very compelling. Clinical and laboratory-based risk-stratification markers have been proposed, one of these is represented by the JCPyV-seropositive status, which includes about 54% of MS patients. We recently proposed to investigate the possible protective role of neutralizing humoral immune response in preventing JCPyV reactivation. In this proof-of-concept study, by cloning the first human monoclonal antibody (GRE1) directed against a neutralizing epitope on JCPyV/VP1, we optimized a robust anti-JCPyV neutralization assay. This allowed us to evaluate the neutralizing activity in JCPyV-positive sera from MS patients, demonstrating the lack of correlation between the level of anti-JCPyV antibody and anti-JCPyV neutralizing activity. Relevant consequences may derive from future clinical studies induced by these findings; indeed the study of the serum anti-JCPyV neutralizing activity could allow not only a better risk stratification of the patients during natalizumab treatment, but also a better understanding of the pathophysiological mechanisms leading to PML, highlighting the contribution of peripheral versus central nervous system JCPyV reactivation. Noteworthy, the availability of GRE1 could allow the design of novel immunoprophylactic strategies during the immunomodulatory treatment. PMID:24909571
Diotti, Roberta Antonia; Mancini, Nicasio; Clementi, Nicola; Sautto, Giuseppe; Moreno, Guisella Janett; Criscuolo, Elena; Cappelletti, Francesca; Man, Petr; Forest, Eric; Remy, Louise; Giannecchini, Simone; Clementi, Massimo; Burioni, Roberto
Cytogenetic response based on revised IPSS cytogenetic risk stratification and minimal residual disease monitoring by FISH in MDS patients treated with low-dose decitabine.
The features of cytogenetic response have been not well described in myelodysplastic syndrome (MDS) patients receiving low-dose decitabine treatment. In this study, we observed and analyzed the response characteristics based on the revised IPSS (IPSS-R) cytogenetic risk stratification in eighty-seven MDS patients who received low-dose decitabine treatment (15-20 mg/M(2)/dū5/per course). Twenty-seven of 44 patients (61.3%) with abnormal karyotypes achieved a cytogenetic response, including 18 cases with complete cytogenetic response (cCR). The patients carrying poor or very poor karyotypes achieved better clinical and cytogenetic response than those with intermediate or good karyotypes. Among the patients with poor or very poor karyotypes, those carrying chromosome 7 aberrance showed a better treatment response than the other patients. Four patients (22.2%) of the patients who achieved clinical CR presented with a cytogenetic PR (partial response) or NR (no response). Over 5% of the clonal cells determined by FISH analysis were in the two patients who presented cytogenetic CR. Longer median OS (24 months) were observed in the patients who achieved a cytogenetic response than in those who did not (12 months) (P=0.007). The patients with poor or very poor karyotypes could achieve survival comparable to that of the patients with good or very good karyotypes after decitabine treatment (18 vs. 20 months, P=0.365). IPSS-R cytogenetic risk stratification could be used to predict the clinical and cytogenetic response to decitabine treatment in MDS patients, and the predicting effect may be related to chromosome 7 involvement. Analysis with FISH and G-banding should be available in determining the minimal residual disease in MDS patients after treatment. PMID:24084368
Li, Xiao; Chang, Chunkang; He, Qi; Xu, Feng; Zhang, Qingxia; Wu, Lingyun; Su, Jiying; Zhang, Xi; Zhou, Liyu; Wu, Dong; Song, Luxi; Zhang, Zheng
Cardiac troponin risk stratification based on 99th percentile reference cutoffs in patients with ischemic symptoms suggestive of acute coronary syndrome: influence of estimated glomerular filtration rates.
Cardiac troponin (cTn) assays were compared in 490 unselected patients with symptoms suggestive of acute coronary syndrome with varying renal functions for risk stratification. cTnI (Dade, Newark, NJ; Beckman, Chaska, MN; and Tosoh, South San Francisco, CA) and cTnT (Roche, Indianapolis, IN) measurements and estimated glomerular filtration rates (eGFRs) were obtained and classified along sex-derived cutoffs. The cTn levels were increased in 14% to 25% of patients. In 68%, the eGFR was 60 mL/min/1.73 m2 or more; in 17%, it was between 41 and 59; and in 15%, it was 40 or less. There were 36 deaths and 9 cardiac events. Risk stratification was significant at 30 days and 6 months (P < or = .05). Relative risks ranged from 3.1 to 3.7, and cumulative event rates ranged from 22.4% to 24.2% for an increased troponin level compared with 6.7% to 8.9% for a normal level. The 6-month event rate with an eGFR less than 60 mL/min/1.73 m2 and an increased troponin level ranged from 29.9% to 50.8% compared with 4.9% to 6.6% for a normal troponin level and an eGFR greater than 60 mL/min/1.73 m2 (P < .05). The eGFR in combination with an increased cTn level demonstrated the most powerful stratification. PMID:17369136
Apple, Fred S; Pearce, Lesly A; Doyle, Patrick J; Otto, Angela P; Murakami, MaryAnn M
Impact of risk stratification on outcome among patients with multiple myeloma receiving initial therapy with lenalidomide and dexamethasone
The outcome of patients with multiple myeloma is dictated primarily by cytogenetic abnormalities and proliferative capacity of plasma cells. We studied the outcome after initial therapy with lenalidomide-dexamethasone among 100 newly diagnosed patients, risk-stratified by genetic abnormalities and plasma cell labeling index. A total of 16% had high-risk multiple myeloma, defined by the presence of hypodiploidy, del(13q) by metaphase cytogenetics, del(17p), IgH translocations [t(4;14), or t(14;16)] or plasma cell labeling index more than or equal to 3%. Response rates were 81% vs 89% in the high-risk and standard-risk groups, respectively. The median progression-free survival was shorter in the high-risk group (18.5 vs 36.5 months, P < .001), but overall survival was comparable. Because of unavailability of all tests for every patient, we separately analyzed 55 stringently classified patients, and the results were similar. In conclusion, high-risk patients achieve less durable responses with lenalidomide-dexamethasone compared with standard-risk patients; no significant differences in overall survival are apparent so far. These results need confirmation in larger, prospectively designed studies.
Kapoor, Prashant; Kumar, Shaji; Fonseca, Rafael; Lacy, Martha Q.; Witzig, Thomas E.; Hayman, Suzanne R.; Dispenzieri, Angela; Buadi, Francis; Bergsagel, P. Leif; Gertz, Morie A.; Dalton, Robert J.; Mikhael, Joseph R.; Dingli, David; Reeder, Craig B.; Lust, John A.; Russell, Stephen J.; Roy, Vivek; Zeldenrust, Steven R.; Stewart, A. Keith; Kyle, Robert A.; Greipp, Philip R.
PSA density versus risk stratification for lymphadenectomy-making decision in patients with prostate cancer undergoing radical prostatectomy
ObjectivesĀĀTo determine the value of PSA density as independent predictor for lymph node invasion in order to decide lymphadenectomy\\u000a in patients undergoing radical prostatectomy.\\u000a \\u000a \\u000a \\u000a \\u000a Patients and methodsĀĀWe retrospectively analyzed the medical records of 179 patients who undergone radical prostatectomy from January 2001 until\\u000a September 2010. Studied patients divided in groups regarding the preoperative risk for lymph node metastasis (low risk
Stavros Sfoungaristos; Petros Perimenis
Impact of Early Risk Stratification on the Length of Hospitalization in Patients with Acute Q-Wave Myocardial Infarction
An assessment of individual risk factors may identify a subgroup of postinfarction patients at low risk, i.e. patients appropriate for early discharge. Using a large unselected population of the national registry, æThe 60-Minutes Myocardial Infarction ProjectÆ, we (1) attempted to provide a retrospective analysis of clinical factors and in-hospital mortality in a population living on the 6th hospital day following
Stefan Schuster; Armin Koch; Rudolf Schiele; Udo Burczyk; Stefan Wagner; Ralf Zahn; J÷rg Rustige; Peter Limbourg; Hartmut G³lker; Jochen Senges
Life insurance: genomic stratification and risk classification
With the development and increasing accessibility of new genomic tools such as next-generation sequencing, genome-wide association studies, and genomic stratification models, the debate on genetic discrimination in the context of life insurance became even more complex, requiring a review of current practices and the exploration of new scenarios. In this perspective, a multidisciplinary group of international experts representing different interests revisited the genetics and life insurance debate during a 2-day symposium æLife insurance: breast cancer research and genetic risk prediction seminar' held in Quebec City, Canada on 24 and 25 September 2012. Having reviewed the current legal, social, and ethical issues on the use of genomic information in the context of life insurance, the Expert Group identified four main questions: (1) Have recent developments in genomics and related sciences changed the contours of the genetics and life insurance debate? (2) Are genomic results obtained in a research context relevant for life insurance underwriting? (3) Should predictive risk assessment and risk stratification models based on genomic data also be used for life insurance underwriting? (4) What positive actions could stakeholders in the debate take to alleviate concerns over the use of genomic information by life insurance underwriters? This paper presents a summary of the discussions and the specific action items recommended by the Expert Group.
Joly, Yann; Burton, Hilary; Knoppers, Bartha Maria; Feze, Ida Ngueng; Dent, Tom; Pashayan, Nora; Chowdhury, Susmita; Foulkes, William; Hall, Alison; Hamet, Pavel; Kirwan, Nick; Macdonald, Angus; Simard, Jacques; Van Hoyweghen, Ine
Risk stratification and prognostic performance of the predisposition, infection, response, and organ dysfunction (PIRO) scoring system in septic patients in the emergency department: a cohort study
Introduction The predisposition, infection, response and organ dysfunction (PIRO) staging system was designed as a stratification tool to deal with the inherent heterogeneity of septic patients. The present study was conducted to assess the performance of PIRO in predicting multiple organ dysfunction (MOD), intensive care unit (ICU) admission, and 28-day mortality in septic patients in the emergency department (ED), and to compare this scoring system with the Mortality in Emergency Department Sepsis (MEDS) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores. Methods Consecutive septic patients (n?=?680) admitted to the ED of Beijing Chao-Yang Hospital were enrolled. PIRO, MEDS, and APACHE II scores were calculated for each patient on ED arrival. Organ function was reassessed within 3Ādays of enrollment. All patients were followed up for 28Ādays. Outcome criteria were the development of MOD within 3Ādays, ICU admission or death within 28Ādays after enrollment. The predictive ability of the four components of PIRO was analyzed separately. Receiver operating characteristic (ROC) curve and logistic regression analysis were used to assess the prognostic and risk stratification value of the scoring systems. Results Organ dysfunction independently predicted ICU admission, MOD, and 28-day mortality, with areas under the ROC curve (AUC) of 0.888, 0.851, and 0.816, respectively. The predictive value of predisposition, infection, and response was weaker than that of organ dysfunction. A negative correlation was found between the response component and MOD, as well as mortality. PIRO, MEDS, and APACHE II scores significantly differed between patients who did and did not meet the outcome criteria (P?0.001). PIRO and APACHE II independently predicted ICU admission and MOD, but MEDS did not. All three systems were independent predictors of 28-day mortality with similar AUC values. The AUC of PIRO was 0.889 for ICU admission, 0.817 for MOD, and 0.744 for 28-day mortality. The AUCs of PIRO were significantly greater than those of APACHE II and MEDS (P?0.05) in predicting ICU admission and MOD. Conclusions The study indicates that PIRO is helpful for risk stratification and prognostic determinations in septic patients in the ED.
Value of reserve pulse pressure in improving the risk stratification of patients with normal myocardial perfusion imaging
Aims To evaluate the incremental prognostic value of reserve-pulse pressure (reserve-PP: exercise-PP minus rest-PP) to standard risk factors among patients with suspected coronary artery disease (CAD) but normal exercise myocardial perfusion imaging (MPI). Methods and results We studied 4269 consecutive symptomatic patients without known CAD who were referred for exercise MPI but had normal MPI results (mean age 58 ▒ 12 years, 56% females, 84% referred for evaluation of chest pain or dyspnoea, 95% with intermediate pretest likelihood of CAD). There were 202 deaths over 5.1 ▒ 1.4 years of follow-up. Reserve-PP was abnormal (<44 mmHg increase in PP from rest) in 1894 patients (44%). Patients with an abnormal reserve-PP had a higher risk of death compared with patients with normal reserve-PP [hazard ratio (HR): 2.47, 95% CI, 1.8¢3.3]. In multivariable models adjusting for age, sex, ejection fraction, medications, heart rate recovery, Duke treadmill score (DTS), and rest-PP, each 10 mmHg lower reserve-PP was associated with a 20.6% increase in risk-adjusted mortality (adjusted HR 0.83, 95% CI 0.76¢0.91). Models incorporating reserve-PP significantly reclassified risk compared with models without these parameters (net reclassification index 14.3%, P = 0.0007; integrated discrimination index 0.69, P = 0.01). Conclusion In patients without a history of CAD and a normal MPI, an abnormal reserve-PP identified and reclassified those at higher risk of death independent of known risk factors and DTS.
Thomas, Deepak; Al-Mallah, Mouaz; Govindarajulu, Usha; Forman, Daniel E.; Mora, Samia; Di Carli, Marcelo F.; Dorbala, Sharmila
Atrial fibrillation in heart failure: stroke risk stratification and anticoagulation.
For an individual patient with both atrial fibrillation and heart failure, stroke risk is one of the most prominent mitigating factors for subsequent morbidity and mortality. Although the CHADS? stroke risk score is the most widely used score for risk stratification, it does not take into account the risk factors of vascular disease, female gender, or the age group 65-74 years, for which there is increasing evidence. There is also evidence that diastolic heart failure is as much a risk factor for stroke as systolic heart failure. The new oral anticoagulants dabigatran, rivaroxaban and apixaban appear to be appropriate agents in the heart failure population with atrial fibrillation and risk factors for stroke although there are dose-adjustments for renal insufficiency and these medications are contraindicated in advanced renal disease. As with the atrial fibrillation population as a whole, bleeding risk should be considered for every patient with heart failure prior to making recommendations regarding anticoagulation. PMID:24445936
Abraham, JoEllyn M; Connolly, Stuart J
Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography
Stress echocardiography today has matured into a robust and reliable technique not only for the diagnosis of suspected coronary artery disease (CAD) but also for the accurate risk stratification of patients with suspected and established CAD. This is mainly because of rapid advances in image acquisition, digital display, and the development of harmonic and contrast imaging. Stress echocardiography today is also utilised in patients with heart failure both for assessing the cause of heart failure and determining the extent of hibernating myocardium. With advances in myocardial perfusion imaging, stress echocardiography now allows simultaneous assessment of myocardial function and perfusion. Tissue Doppler imaging allows quantitation of wall motion. Ready availability and reliability makes stress echocardiography a cost effective technique for the assessment of CAD.
Senior, R; Monaghan, M; Becher, H; Mayet, J; Nihoyannopoulos, P
Long-Term Absolute Benefit of Lowering Blood Pressure in Hypertensive Patients According to the JNC VI Risk Stratification
Blood pressure (BP) levels alone have been traditionally used to make treatment decisions in patients with hypertension. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) recently recommended that risk strata, in addition to BP levels, be considered in the treatment of hypertension. We estimated the absolute benefit associated
Lorraine G. Ogden; Jiang He; Eva Lydick; Paul K. Whelton
Distant Metastasis Risk Stratification for Patients Undergoing Curative Resection Followed by Adjuvant Chemoradiation for Extrahepatic Bile Duct Cancer
Purpose: To analyze the prognostic factors predicting distant metastasis in patients undergoing adjuvant chemoradiation for extrahepatic bile duct (EHBD) cancer. Methods and Materials: Between January 1995 and August 2006, 166 patients with EHBD cancer underwent resection with curative intent, followed by adjuvant chemoradiation. There were 120 males and 46 females, and median age was 61 years (range, 34-86). Postoperative radiotherapy was delivered to tumor bed and regional lymph nodes (median dose, 40 Gy; range, 34-56 Gy). A total of 157 patients also received fluoropyrimidine chemotherapy as a radiosensitizer, and fluoropyrimidine-based maintenance chemotherapy was administered to 127 patients. Median follow-up duration was 29 months. Results: The treatment failed for 97 patients, and the major pattern of failure was distant metastasis (76 patients, 78.4%). The 5-year distant metastasis-free survival rate was 49.4%. The most common site of distant failure was the liver (n = 36). On multivariate analysis, hilar tumor, tumor size {>=}2 cm, involved lymph node, and poorly differentiated tumor were associated with inferior distant metastasis-free survival (p = 0.0348, 0.0754, 0.0009, and 0.0078, respectively), whereas T stage was not (p = 0.8081). When patients were divided into four groups based on these risk factors, the 5-year distant metastasis-free survival rates for patients with 0, 1, 2, and 3 risk factors were 86.4%, 59.9%, 32.5%, and 0%, respectively (p < 0.0001). Conclusion: Despite maintenance chemotherapy, distant metastasis was the major pattern of failure in patients undergoing adjuvant chemoradiation for EHBD cancer after resection with curative intent. Intensified chemotherapy is warranted to improve the treatment outcome, especially in those with multiple risk factors.
Kim, Kyubo [Department of Radiation Oncology, Seoul National University College of Medicine, Seoul (Korea, Republic of)] [Department of Radiation Oncology, Seoul National University College of Medicine, Seoul (Korea, Republic of); Chie, Eui Kyu, E-mail: firstname.lastname@example.com [Department of Radiation Oncology, Seoul National University College of Medicine, Seoul (Korea, Republic of); Jang, Jin-Young; Kim, Sun Whe [Department of Surgery, Seoul National University College of Medicine, Seoul (Korea, Republic of)] [Department of Surgery, Seoul National University College of Medicine, Seoul (Korea, Republic of); Han, Sae-Won; Oh, Do-Youn; Im, Seock-Ah; Kim, Tae-You; Bang, Yung-Jue [Department of Internal Medicine, Seoul National University College of Medicine, Seoul (Korea, Republic of)] [Department of Internal Medicine, Seoul National University College of Medicine, Seoul (Korea, Republic of); Ha, Sung W. [Department of Radiation Oncology, Seoul National University College of Medicine, Seoul (Korea, Republic of) [Department of Radiation Oncology, Seoul National University College of Medicine, Seoul (Korea, Republic of); Institute of Radiation Medicine, Medical Research Center, Seoul National University (Korea, Republic of)
Oxidative stress assays for disease risk stratification.
Despite the fact that oxidative stress is a significant aetiological factor in several degenerative diseases, its measurement is rarely a part of "routine analyses" performed in hospital clinical chemistry laboratories. This situation is likely to change, as interest in this topic is increasing rapidly. Here we review the pertinent literature, with an assessment of assays for oxidative stress, and categorize them under: (i) assays for monitoring lipid peroxidation, (ii) assays for measuring oxidized amino acids, (iii) assays for measuring oxidized nucleic acids, (iv) assays based on physicochemical and immunological properties of oxidized low-density lipoprotein, and (v) assays for measuring the antioxidant capacity of body fluids and tissues. Our overview should be of help when choosing appropriate laboratory assays for oxidative stress and for routine disease risk stratification. PMID:16613731
Cerne, Darko; Lukac-Bajalo, Jana
Risk stratification for cancer-associated venous thromboembolism.
The risk of venous thromboembolism (VTE) is elevated in cancer, and thrombosis is the second leading cause of death in patients with malignancy. Many risk factors for cancer-associated thrombosis have been identified. These include patient-associated factors such as age, obesity and medical comorbidities; cancer-associated factors such as site and stage of cancer; and treatment-associated factors, particularly chemotherapy and hospitalization. In addition, several candidate biomarkers for cancer-associated thrombosis have been identified recently. Despite the high rate and significant impact of VTE in cancer outpatients, prior attempts at thromboprophylaxis in this population have not consistently demonstrated a benefit. This chapter will focus on risk stratification approaches, including a recently developed predictive model which can be used to identify those patients at highest risk. This model-based approach may have a significant impact on cancer-related morbidity, mortality and cost of care by directing targeted thromboprophylaxis in the future. PMID:19285271
Connolly, Gregory C; Khorana, Alok A
Rearrangements of MYC gene facilitate risk stratification in diffuse large B-cell lymphoma patients treated with rituximab-CHOP.
In order to address the debatable prognostic role of MYC rearrangements in diffuse large B-cell lymphoma patients treated with rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone, we evaluated MYC rearrangements by fluorescence in situ hybridization in 563 cases using break-apart probes and IGH/MYC dual-fusion probes. Concurrent BCL2 and BCL6 aberrations were also assessed. Data were correlated with clinicopathological variables and prognostic parameters. MYC rearrangements were observed in 39/432 evaluable cases (9%), including 4 rearrangements detectable only with the dual-fusion probes, 15 detectable only with the break-apart probes and 20 detectable with both dual-fusion probes and break-apart probes. MYC rearrangements correlated with germinal center B-cell origin (P=0.02), MYC protein expression (P=0.032), and larger tumor mass size (P=0.0003). Patients with MYC rearrangements were more likely to be treatment resistant (P<0.0001). All types of MYC rearrangements were associated with poorer disease-specific survival, that is, 20/39 dead, median disease-specific survival 42 months, compared with 98/393 dead among the non-rearranged cases, median disease-specific survival not reached (P=0.0002). Cases with MYC rearrangements that overexpressed MYC protein were at risk with respect to disease-specific survival independent of the International Prognostic Index (P=0.046 and P<0.001, respectively). Presence of concurrent BCL2 aberrations but not of BCL6 aberrations was prognostically additive. Radiotherapy seemed to diminish the prognostic effects of MYC rearrangements in diffuse large B-cell lymphoma patients since only 2/10 irradiated patients with MYC rearrangements died of/with disease, compared with 16/28 non-irradiated patients with MYC rearrangements. We conclude that MYC rearrangements add prognostic information for individual risk estimation and such cases might represent a distinct, biologically determined disease subgroup. PMID:24336156
Tzankov, Alexandar; Xu-Monette, Zijun Y; Gerhard, Marc; Visco, Carlo; Dirnhofer, Stephan; Gisin, Nora; Dybkaer, Karen; Orazi, Attilio; Bhagat, Govind; Richards, Kristy L; Hsi, Eric D; Choi, William Wl; van Krieken, J Han; Ponzoni, Maurilio; Ferreri, Andrķs Jm; Ye, Qing; Winter, Jane N; Farnen, John P; Piris, Miguel A; M°ller, Michael B; You, M James; McDonnell, Timothy; Medeiros, L Jeffrey; Young, Ken H
Lipoprotein-Associated Phospholipase A 2 and C-Reactive Protein for Risk-Stratification of Patients With TIA
Background and PurposeŚLipoprotein-associated phospholipase A2 (Lp-PLA2) is a marker of unstable atherosclerotic plaque, and is predictive of both primary and secondary stroke in population-based studies. MethodsŚWe conducted a prospective study of patients with acute TIA who presented to the ED. Clinical risk scoring using the ABCD 2 score was determined and Lp-PLA2 mass (LpPLA2-M) and activity (LpPLA2-A) and high-sensitivity C-reactive
Brett L. Cucchiara; Steve R. Messe; Lauren Sansing; Larami MacKenzie; Robert A. Taylor; James Pacelli; Qaisar Shah; Scott E. Kasner
Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Noninvasive Risk Stratification and a Conceptual Framework for the Selection of Noninvasive Imaging Tests in Patients with Known or Suspected Coronary Artery Disease*y
This review deals with noninvasive imaging for risk stratification and with a conceptual approach to the selection of noninvasive tests in patients with suspected or known chronic coronary ar- tery disease (CAD). Already widely acknowledged with SPECT, there is an increasing body of literature data demonstrating thatCTcoronarycalciumassessmentisalsoofprognosticvalue. The amount of coronary atherosclerosis, as can be extrapolated from CT coronary calcium
Daniel S. Berman; Rory Hachamovitch; Leslee J. Shaw; John D. Friedman; Sean W. Hayes; Louise E. J. Thomson; David S. Fieno; Guido Germano; Nathan D. Wong; Xingping Kang; Alan Rozanski
Recent advances in the management of chronic stable angina I: Approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities
The potential importance of both prevention and personal responsibility in controlling heart disease, the leading cause of death in the USA and elsewhere, has attracted renewed attention. Coronary artery disease is preventable, using relatively simple and inexpensive lifestyle changes. The inexorable rise in the prevalence of obesity, diabetes, dyslipidemia, and hypertension, often in the risk cluster known as the metabolic syndrome, drives the ever-increasing incidence of heart disease. Population-wide improvements in personal health habits appear to be a fundamental, evidence based public health measure, yet numerous barriers prevent implementation. A common symptom in patients with coronary artery disease, classical angina refers to the typical chest pressure or discomfort that results when myocardial oxygen demand rises and coronary blood flow is reduced by fixed, atherosclerotic, obstructive lesions. Different forms of angina and diagnosis, with a short description of the significance of pain and silent ischemia, are discussed in this review. The well accepted concept of myocardial oxygen imbalance in the genesis of angina is presented with new data about clinical pathology of stable angina and acute coronary syndromes. The roles of stress electrocardiography and stress myocardial perfusion scintigraphic imaging are reviewed, along with the information these tests provide about risk and prognosis. Finally, the current status of gender disparities in heart disease is summarized. Enhanced risk stratification and identification of patients in whom procedures will meaningfully change management is an ongoing quest. Current guidelines emphasize efficient triage of patients with suspected coronary artery disease. Many experts believe the predictive value of current decision protocols for coronary artery disease still needs improvement in order to optimize outcomes, yet avoid unnecessary coronary angiograms and radiation exposure. Coronary angiography remains the gold standard in the diagnosis of coronary artery obstructive disease. Part II of this two part series will address anti-ischemic therapies, new agents, cardiovascular risk reduction, options to treat refractory angina, and revascularization.
Kones, Richard
The Role of Carotid Ultrasound for Cardiovascular Risk Stratification beyond Traditional Risk Factors
Primary prevention and early detection of cardiovascular disease is important, as it is the leading cause of death throughout world. Risk stratification algorithms, such as Framingham Risk Score and European Systematic Coronary Risk Evaluation, that utilize a combination of various traditional risk factors have been developed to improve primary prevention. However, the accuracy of these algorithms for screening high risk patients is moderate at best. Accordingly, the use of biomarkers or imaging studies may improve risk stratification. Carotid ultrasound, which measures both carotid intima-media thichkness (cIMT) and carotid plaque, is useful in detecting the degree of subclinical carotid atherosclerosis, and has the advantage of being noninvasive and safe. Several large epidemiologic studies have indicated that cIMT and carotid plaque are closely related with other cardiovascular risk factors and may be useful for risk reclassification in subjects deemed to be at intermediate risk by traditional risk scores. Moreover, recent clinical guidelines for management of hypertension or dyslipidemia highlight the usefulness of cIMT in high risk patients. In this article, we review evidence for the usefulness of measurement of cIMT and carotid plaque for cardiovascular risk stratification.
Lee, Chan Joo
Risk stratification in surgically repaired tetralogy of Fallot.
Tetralogy of Fallot is the most common form of congenital heart disease in implantable cardioverter-defibrillator (ICD) recipients. Indeed, sudden death of presumed arrhythmic etiology is the most frequent mode of demise in patients with surgically repaired tetralogy of Fallot, often in early-to-mid adulthood. Nevertheless, the overall annual incidence of sudden death is actually low. Therein lies the major challenge of risk stratification. This review highlights some of the complexities involved in risk stratifying patients with tetralogy of Fallot, underscoring the importance of avoiding oversimplification by means of a rigid algorithm that dictates therapy. To complement sound clinical judgment, a quantitative probabilistic approach is presented, which considers the body of literature from primary prevention ICD trials, risk factors identified by observational studies, the value of programmed ventricular stimulation and insights gleaned from studying ICD recipients with tetralogy of Fallot. PMID:19589112
Khairy, Paul; Dore, Annie; Poirier, Nancy; Marcotte, Franńois; Ibrahim, Reda; Mongeon, Franńois-Pierre; Mercier, Lise-Andrķe
[Ventricular preexcitation: is risk stratification feasible?].
The Wolff-Parkinson-White syndrome is a current debated clinical issue. Although the anatomical characteristics, polymorphic electrocardiographic features, and electrophysiological mechanisms of arrhythmias and sudden cardiac death are well known, the identification of patients at risk of sudden cardiac death remains challenging. Owing to the lack of effective therapeutic strategies, in the pre-ablation era many studies have been conducted to define the prognostic value of clinical and instrumental tests, and to define the actual risk of sudden cardiac death in patients with ventricular preexcitation. Nowadays, radiofrequency transcatheter ablation of anomalous atrioventricular pathways is a strong therapeutic option for all patients, independent of the risk of sudden cardiac death. However, radiofrequency ablation is associated with serious complications, but many studies confirm an overall good prognosis for most of the patients with electrocardiographic pattern of ventricular preexcitation. The aim of this review is to assess the prognostic value of clinical and instrumental tests in patients with ventricular preexcitation, referring to the latest knowledge. PMID:20677574
De Rosa, Francesco; Mancuso, Paola; Chiatto, Mario; Calvelli, Antonio; De Donato, Vincenzo; Mazza, Salvatore; Spadafora, Gabriele
Transient Ischemic Attack Definition, Diagnosis, and Risk Stratification
Transient ischemic attack (TIA) can convey a high imminent risk for the development of a major stroke and is therefore considered to be a medical emergency. Recent evidence indicates that TIA with imaging proof of brain infarction represents an extremely unstable condition with early risk of stroke that is as much as 20 times higher than the risk after TIA without tissue damage. The use of neuroimaging in TIA is therefore critical not only for diagnosis but also for accurate risk-stratification. In this article, we discuss recent advances in diagnostic imaging, categorizations, and risk stratification in TIA.
Sorensen, A. Gregory
New Insights in Risk Stratification of Differentiated Thyroid Cancer
Purpose of review Numerous staging and scoring systems exist for differentiated thyroid cancer (DTC), but all harbor limitations. This has prompted investigation for new factors with prognostic implications for DTC. Recent findings Several new factors that may be involved in DTC risk stratification have emerged, such as thyroid stimulating hormone and molecular markers. In addition, others are controversial and being challenged, such as age, gender and lymph node involvement. Summary The purpose of this review is to present recent updates in the literature on new potential risk stratification predictors for DTC.
Papaleontiou, Maria; Haymart, Megan R.
Risk stratification using data from electronic medical records better predicts suicide risks than clinician assessments
Background To date, our ability to accurately identify patients at high risk from suicidal behaviour, and thus to target interventions, has been fairly limited. This study examined a large pool of factors that are potentially associated with suicide risk from the comprehensive electronic medical record (EMR) and to derive a predictive model for 1¢6Āmonth risk. Methods 7,399 patients undergoing suicide risk assessment were followed up for 180Ādays. The dataset was divided into a derivation and validation cohorts of 4,911 and 2,488 respectively. Clinicians used an 18-point checklist of known risk factors to divide patients into low, medium, or high risk. Their predictive ability was compared with a risk stratification model derived from the EMR data. The model was based on the continuation-ratio ordinal regression method coupled with lasso (which stands for least absolute shrinkage and selection operator). Results In the year prior to suicide assessment, 66.8% of patients attended the emergency department (ED) and 41.8% had at least one hospital admission. Administrative and demographic data, along with information on prior self-harm episodes, as well as mental and physical health diagnoses were predictive of high-risk suicidal behaviour. Clinicians using the 18-point checklist were relatively poor in predicting patients at high-risk in 3Āmonths (AUC 0.58, 95% CIs: 0.50 ¢ 0.66). The model derived EMR was superior (AUC 0.79, 95% CIs: 0.72 ¢ 0.84). At specificity of 0.72 (95% CIs: 0.70-0.73) the EMR model had sensitivity of 0.70 (95% CIs: 0.56-0.83). Conclusion Predictive models applied to data from the EMR could improve risk stratification of patients presenting with potential suicidal behaviour. The predictive factors include known risks for suicide, but also other information relating to general health and health service utilisation.
Genetic Analysis for Stratification of Cancer Risk.
National Technical Information Service (NTIS)
The present invention provides new methods for the assessment of cancer risk in the general population. These methods utilize particular alleles of two or more genes, in combination, to identify individuals with increased or decreased risk of cancer. Exem...
C. E. Aston D. Ralph E. Jupe
Patient stratification for preventive care in dentistry.
Prevention reduces tooth loss, but little evidence supports biannual preventive care for all adults. We used risk-based approaches to test tooth loss association with 1 vs. 2 annual preventive visits in high-risk (HiR) and low-risk (LoR) patients. Insurance claims for 16 years for 5,117 adults were evaluated retrospectively for tooth extraction events. Patients were classified as HiR for progressive periodontitis if they had ? 1 of the risk factors (RFs) smoking, diabetes, interleukin-1 genotype; or as LoR if no RFs. LoR event rates were 13.8% and 16.4% for 2 or 1 annual preventive visits (absolute risk reduction, 2.6%; 95%CI, 0.5% to 5.8%; p = .092). HiR event rates were 16.9% and 22.1% for 2 and 1 preventive visits (absolute risk reduction, 5.2%; 95%CI, 1.8% to 8.4%; p = .002). Increasing RFs increased events (p < .001). Oral health care costs were not increased by any single RF, regardless of prevention frequency (p > .41), but multiple RFs increased costs vs. no (p < .001) or 1 RF (p = .001). For LoR individuals, the association between preventive dental visits and tooth loss was not significantly different whether the frequency was once or twice annually. A personalized medicine approach combining gene biomarkers with conventional risk factors to stratify populations may be useful in resource allocation for preventive dentistry (ClinicalTrials.gov, NCT01584479). PMID:23752171
Giannobile, W V; Braun, T M; Caplis, A K; Doucette-Stamm, L; Duff, G W; Kornman, K S
Cardiovascular risk stratification and management in pre-diabetes.
Prediabetes, covering individuals with impaired fasting glycemia, impaired glucose tolerance, or high-risk HbA1c levels, is associated with a ?20Ā% increased risk of developing cardiovascular disease (CVD) compared with normoglycemic individuals. It is well-known that lifestyle or pharmacologic interventions can prevent diabetes in prediabetic people; however, the evidence is less clear regarding prevention of CVD. Most diabetes prevention trials have failed to show beneficial effects on CVD morbidity and mortality despite significant improvements of CVD risk factors in individuals with prediabetes. Another challenge is how to estimate CVD risk in prediabetic people. In general, prediction models for CVD do not take glucose levels or prediabetes status into account, thereby underestimating CVD risk in these high-risk individuals. More evidence within risk stratification and management of CVD risk in prediabetes is needed in order to recommend useful and effective strategies for early prevention of CVD. PMID:24743942
Fµrch, Kristine; Vistisen, Dorte; Johansen, Nanna Borup; J°rgensen, Marit Eika
Prognostic stratification of colorectal cancer patients: current perspectives
Tumor staging according to the American Joint Committee on Cancer/Union for International Cancer Control tumor, node, metastasis (TNM) system is currently regarded as the standard for staging of patients with colorectal cancer. This system provides the strongest prognostic information for patients with early stage disease and those with advanced disease. For patients with intermediate levels of disease, it is less able to predict disease outcome. Therefore, additional prognostic markers are needed to improve the management of affected patients. Ideal markers are readily assessable on hematoxylin and eosin-stained tumor slides, and in this way are easily applicable worldwide. This review summarizes the histological features of colorectal cancer that can be used for prognostic stratification. Specifically, we refer to the different histological variants of colorectal cancer that have been identified, each of these variants carrying distinct prognostic significance. Established markers of adverse outcomes are lymphatic and venous invasion, as well as perineural invasion, but underreporting still occurs in the routine setting. Tumor budding and tumor necrosis are recent advances that may help to identify patients at high risk for recurrence. The prognostic significance of the antitumor inflammatory response has been known for quite a long time, but a lack of standardization prevented its application in routine pathology. However, scales to assess intra- and peritumoral inflammation have recently emerged, and can be expected to strengthen the prognostic significance of the pathology report.
Schneider, Nora I; Langner, Cord
Analysis of 12Lead T-Wave Morphology for Risk Stratification After Myocardial Infarction
BackgroundŚThe stratification of post-myocardial infarction (MI) patients at risk of sudden cardiac death remains important. The aim of the present study was to assess the prognostic value of novel T-wave morphology descriptors derived from resting 12-lead ECGs. Methods and ResultsŚIn 280 consecutive post-MI patients, a 12-lead ECG was recorded before discharge, optically scanned, and digitized. For the present study, 5
Markus Zabel; Burak Acar; Thomas Klingenheben; Michael R. Franz; Stefan H. Hohnloser; Marek Malik
Prediction of Myocardial Infarction Versus Cardiac Death by Gated Myocardial Perfusion SPECT: Risk Stratification by the Amount of Stress-Induced Ischemia and the Poststress Ejection Fraction
J Nucl Med 2001; 42:831- 837 Stratification of patients into low, intermediate, and high risk of cardiac death (CD) is valuable in deciding on the appropriate treatment modality in patient subsets. Whereas patients at intermediate to high risk of CD benefit from revascularization (1), patients at low risk of CD but at a substantial risk of ischemic events might be
Tali Sharir; Guido Germano; Xingping Kang; Howard C. Lewin; Romalisa Miranda; Ishac Cohen; Raluca D. Agafitei; John D. Friedman; Daniel S. Berman
Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study
Background While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30Ādays. Methods/Design We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness?>?5Āminutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30Ādays of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values ?0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development. Discussion Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety.
Short-term vs. long-term heart rate variability in ischemic cardiomyopathy risk stratification.
In industrialized countries with aging populations, heart failure affects 0.3-2% of the general population. The investigation of 24 h-ECG recordings revealed the potential of nonlinear indices of heart rate variability (HRV) for enhanced risk stratification in patients with ischemic heart failure (IHF). However, long-term analyses are time-consuming, expensive, and delay the initial diagnosis. The objective of this study was to investigate whether 30 min short-term HRV analysis is sufficient for comparable risk stratification in IHF in comparison to 24 h-HRV analysis. From 256 IHF patients [221 at low risk (IHFLR) and 35 at high risk (IHFHR)] (a) 24 h beat-to-beat time series (b) the first 30 min segment (c) the 30 min most stationary day segment and (d) the 30 min most stationary night segment were investigated. We calculated linear (time and frequency domain) and nonlinear HRV analysis indices. Optimal parameter sets for risk stratification in IHF were determined for 24 h and for each 30 min segment by applying discriminant analysis on significant clinical and non-clinical indices. Long- and short-term HRV indices from frequency domain and particularly from nonlinear dynamics revealed high univariate significances (p < 0.01) discriminating between IHFLR and IHFHR. For multivariate risk stratification, optimal mixed parameter sets consisting of 5 indices (clinical and nonlinear) achieved 80.4% AUC (area under the curve of receiver operating characteristics) from 24 h HRV analysis, 84.3% AUC from first 30 min, 82.2 % AUC from daytime 30 min and 81.7% AUC from nighttime 30 min. The optimal parameter set obtained from the first 30 min showed nearly the same classification power when compared to the optimal 24 h-parameter set. As results from stationary daytime and nighttime, 30 min segments indicate that short-term analyses of 30 min may provide at least a comparable risk stratification power in IHF in comparison to a 24 h analysis period. PMID:24379785
Voss, Andreas; Schroeder, Rico; Vallverd·, Montserrat; Schulz, Steffen; Cygankiewicz, Iwona; Vßzquez, Rafael; Bayķs de Luna, Antoni; Caminal, Pere
Short-term vs. long-term heart rate variability in ischemic cardiomyopathy risk stratification
In industrialized countries with aging populations, heart failure affects 0.3¢2% of the general population. The investigation of 24 h-ECG recordings revealed the potential of nonlinear indices of heart rate variability (HRV) for enhanced risk stratification in patients with ischemic heart failure (IHF). However, long-term analyses are time-consuming, expensive, and delay the initial diagnosis. The objective of this study was to investigate whether 30 min short-term HRV analysis is sufficient for comparable risk stratification in IHF in comparison to 24 h-HRV analysis. From 256 IHF patients [221 at low risk (IHFLR) and 35 at high risk (IHFHR)] (a) 24 h beat-to-beat time series (b) the first 30 min segment (c) the 30 min most stationary day segment and (d) the 30 min most stationary night segment were investigated. We calculated linear (time and frequency domain) and nonlinear HRV analysis indices. Optimal parameter sets for risk stratification in IHF were determined for 24 h and for each 30 min segment by applying discriminant analysis on significant clinical and non-clinical indices. Long- and short-term HRV indices from frequency domain and particularly from nonlinear dynamics revealed high univariate significances (p < 0.01) discriminating between IHFLR and IHFHR. For multivariate risk stratification, optimal mixed parameter sets consisting of 5 indices (clinical and nonlinear) achieved 80.4% AUC (area under the curve of receiver operating characteristics) from 24 h HRV analysis, 84.3% AUC from first 30 min, 82.2 % AUC from daytime 30 min and 81.7% AUC from nighttime 30 min. The optimal parameter set obtained from the first 30 min showed nearly the same classification power when compared to the optimal 24 h-parameter set. As results from stationary daytime and nighttime, 30 min segments indicate that short-term analyses of 30 min may provide at least a comparable risk stratification power in IHF in comparison to a 24 h analysis period.
Voss, Andreas; Schroeder, Rico; Vallverdu, Montserrat; Schulz, Steffen; Cygankiewicz, Iwona; Vazquez, Rafael; Bayes de Luna, Antoni; Caminal, Pere
The emergent role of metabolic phenotyping in dynamic patient stratification.
The role that metabolic phenotyping can increasingly play in patient stratification and personalised medicine is discussed. The background to the general approach, comprehensive and simultaneous analysis of small-molecule metabolites in biofluids, tissues and tissue extracts combined with suitable multivariate statistical models, is summarised. The main techniques used (NMR and mass spectrometry) are cited, and the implementation of dedicated phenome centres is explained. Finally, the advantages and limitations, opportunities and drawbacks of the approach are discussed. PMID:24905565
Lindon, John C; Nicholson, Jeremy K
Percentage of Positive Biopsy Cores: A Better Risk Stratification Model for Prostate Cancer?
Purpose: To assess the prognostic value of the percentage of positive biopsy cores (PPC) and perineural invasion in predicting the clinical outcomes after radiotherapy (RT) for prostate cancer and to explore the possibilities to improve on existing risk-stratification models. Methods and Materials: Between 1993 and 2004, 1,056 patients with clinical Stage T1c-T3N0M0 prostate cancer, who had four or more biopsy cores sampled and complete biopsy core data available, were treated with external beam RT, with or without a high-dose-rate brachytherapy boost at William Beaumont Hospital. The median follow-up was 7.6 years. Multivariate Cox regression analysis was performed with PPC, Gleason score, pretreatment prostate-specific antigen, T stage, PNI, radiation dose, androgen deprivation, age, prostate-specific antigen frequency, and follow-up duration. A new risk stratification (PPC classification) was empirically devised to incorporate PPC and replace the T stage. Results: On multivariate Cox regression analysis, the PPC was an independent predictor of distant metastasis, cause-specific survival, and overall survival (all p < .05). A PPC >50% was associated with significantly greater distant metastasis (hazard ratio, 4.01; 95% confidence interval, 1.86-8.61), and its independent predictive value remained significant with or without androgen deprivation therapy (all p < .05). In contrast, PNI and T stage were only predictive for locoregional recurrence. Combining the PPC ({<=}50% vs. >50%) with National Comprehensive Cancer Network risk stratification demonstrated added prognostic value of distant metastasis for the intermediate-risk (hazard ratio, 5.44; 95% confidence interval, 1.78-16.6) and high-risk (hazard ratio, 4.39; 95% confidence interval, 1.70-11.3) groups, regardless of the use of androgen deprivation and high-dose RT (all p < .05). The proposed PPC classification appears to provide improved stratification of the clinical outcomes relative to the National Comprehensive Cancer Network classification. Conclusions: The PPC is an independent and powerful predictor of clinical outcomes of prostate cancer after RT. A risk model replacing T stage with the PPC to reduce subjectivity demonstrated potentially improved stratification.
Huang Jiayi; Vicini, Frank A. [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI (United States); Williams, Scott G. [Peter Maccallum Cancer Centre and University of Melbourne, Melbourne, Victoria (Australia); Ye Hong; McGrath, Samuel; Ghilezan, Mihai; Krauss, Daniel; Martinez, Alvaro A. [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI (United States); Kestin, Larry L., E-mail: firstname.lastname@example.com [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI (United States)
Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction
Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Echocardiography represents the "gold standard" in the assessment of LV systolic dysfunction and in the recognition of systolic heart failure, since dilatation of the LV results in alteration of intracardiac geometry and hemodynamics leading to increased morbidity and mortality. The functional mitral regurgitation is a consequence of adverse LV remodelling that occurs with a structurally normal valve and it is a marker of adverse prognosis. Diastolic dysfunction plays a major role in signs and symptoms of HF and in the risk stratification, and provides prognostic information independently in HF patients and impaired systolic function. Ultrasound lung comets are a simple echographic sign of extravascular lung water, more frequently associated with left ventricular diastolic and/or systolic dysfunction, which can integrate the clinical and pathophysiological information provided by conventional echocardiography and provide a useful information for prognostic stratification of HF patients. Contractile reserve is defined as the difference between values of an index of left ventricular contractility during peak stress and its baseline values and the presence of myocardial viability predicts a favorable outcome. A non-invasive echocardiographic method for the evaluation of force-frequency relationship has been proposed to assess the changes in contractility during stress echo. In conclusion, in HF patients, the evaluation of systolic, diastolic function and myocardial contractile reserve plays a fundamental role in the risk stratification. The highest risk is present in HF patients with a heart that is weak, big, noisy, stiff and wet.
Ciampi, Quirino; Villari, Bruno
A comparison of T-wave alternans, signal averaged electrocardiography and programmed ventricular stimulation for arrhythmia risk stratification
OBJECTIVESThe goal of this study was to compare T-wave alternans (TWA), signal-averaged electrocardiography (SAECG) and programmed ventricular stimulation (EPS) for arrhythmia risk stratification in patients undergoing electrophysiology study.BACKGROUNDAccurate identification of patients at increased risk for sustained ventricular arrhythmias is critical to prevent sudden cardiac death. T-wave alternans is a heart rate dependent measure of repolarization that correlates with arrhythmia vulnerability
Michael R Gold; Daniel M Bloomfield; Kelley P Anderson; Nabil E El-Sherif; David J Wilber; William J Groh; N. A. Mark Estes; Elizabeth S Kaufman; Mark L Greenberg; David S Rosenbaum
Multiple myeloma: 2012 update on diagnosis, risk-stratification, and management
Disease overview Multiple myeloma accounts for ~10% of all hematologic malignancies. Diagnosis The diagnosis requires 10% or more clonal plasma cells on bone marrow examination or a biopsy proven plasmacytoma plus evidence of end-organ damage felt to be related to the underlying plasma-cell disorder. Risk stratification Patients with 17p deletion, t(14;16), t(14;20), or high-risk gene expression profiling signature have high-risk myeloma. Patients with t(4;14) translocation, karyotypic deletion 13, or hypodiploidy are considered to have intermediate-risk disease. All others are considered to have standard-risk myeloma. Risk-adapted therapy Standard-risk patients are treated with nonalkylator-based therapy such as lenalidomide plus low-dose dexamethasone (Rd) followed by autologous stem-cell transplantation (ASCT). An alternative strategy is to continue initial therapy after stem-cell collection, reserving ASCT for first relapse. Intermediate-risk and high-risk patients are treated with a bortezomib-based induction followed by ASCT and then bortezomib-based maintenance. Patients not eligible for ASCT can be treated with Rd for standard risk disease, or with a bortezomib-based regimen if intermediate-risk or high-risk features are present. To reduce toxicity, when using bortezomib, the once-weekly subcutaneous dose is preferred; similarly, when using dexamethasone, the low-dose approach (40 mg once a week) is preferred, unless there is a need for rapid disease control. Management of refractory disease Patients with indolent relapse can be treated first with two-drug or three-drug combinations. Patients with more aggressive relapse often require therapy with a combination of multiple active agents. The most promising new agents in development are pomalidomide and carfilizomib.
Rajkumar, S. Vincent
Consensus recommendations for risk stratification in multiple myeloma: report of the International Myeloma Workshop Consensus Panel 2
A panel of members of the 2009 International Myeloma Workshop developed guidelines for risk stratification in multiple myeloma. The purpose of risk stratification is not to decide time of therapy but to prognosticate. There is general consensus that risk stratification is applicable to newly diagnosed patients; however, some genetic abnormalities characteristic of poor outcome at diagnosis may suggest poor outcome if only detected at the time of relapse. Thus, in good-risk patients, it is necessary to evaluate for high-risk features at relapse. Although detection of any cytogenetic abnormality is considered to suggest higher-risk disease, the specific abnormalities considered as poor risk are cytogenetically detected chromosomal 13 or 13q deletion, t(4;14) and del17p, and detection by fluorescence in situ hybridization of t(4;14), t(14;16), and del17p. Detection of 13q deletion by fluorescence in situ hybridization only, in absence of other abnormalities, is not considered a high-risk feature. High serum ?2-microglobulin level and International Staging System stages II and III, incorporating high ?2-microglobulin and low albumin, are considered to predict higher risk disease. There was a consensus that the high-risk features will change in the future, with introduction of other new agents or possibly new combinations.
Anderson, Kenneth C.; Bergsagel, P. Leif; Shaughnessy, John; Palumbo, Antonio; Durie, Brian; Fonseca, Rafael; Stewart, A. Keith; Harousseau, Jean-Luc; Dimopoulos, Meletios; Jagannath, Sundar; Hajek, Roman; Sezer, Orhan; Kyle, Robert; Sonneveld, Pieter; Cavo, Michele; Rajkumar, S. Vincent; San Miguel, Jesus; Crowley, John
Relative contributions of a single-admission 12-lead electrocardiogram and early 24-hour continuous electrocardiographic monitoring for early risk stratification in patients with unstable coronary artery disease
Patients with unstable coronary syndromes are a heterogeneous group with varying degrees of ischemia and prognosis. The present study compares the prognostic value of a standard electrocardiogram (ECG) obtained at admission to the hospital with the information from 24-hour continuous electrocardiographic monitoring obtained immediately after admission. The admission ECGs and 24 hours of vectorcardiographic (VCG) monitoring from 308 patients admitted
Lene Holmvang; Karl Andersen; Mikael Dellborg; Peter Clemmensen; Galen Wagner; Peer Grande; Putte Abrahamsson
Risk Stratification of In-Hospital Mortality in Patients Hospitalized for Chronic Congestive Heart Failure Secondary to NonIschemic Cardiomyopathy
The study population consisted of 234 consecutive patients hospitalized for acute exacerbation of congestive heart failure secondary to non-ischemic cardiomyopathy. Of the 234 patients, there were 55 in-hospital deaths. Their medical records were deliberatively reviewed and the association of 38 clinical, hemodynamic and biochemical variables with in-hospital mortality was evaluated by multiple stepwise logistic regression analysis. The following variables were
Mien-Cheng Chen; Hsueh-Wen Chang; Cheng-I. Cheng; Yen-Hsun Chen; Han-Tan Chai
[An analysis of the variability of the heart rate and its significance in the risk stratification of patients with unstable angina].
Decreased heart rate variability (HRV) correlates with increased sympathetic or decreased vagal tone. This could contribute to increase local coronary hyperreactivity caused by atherosclerotic plaque disruption, thus facilitating progression from unstable angina to acute myocardial infarction (AMI). To test this hypothesis we studied 92 patients admitted to the coronary care unit for episodes of chest pain at rest associated with transient ST shifts (> 0.15 mV). Patients who developed AMI in the first 24 hours, as well as those with previous AMI, concomitant valvular or myocardial diseases or diabetes mellitus were not enrolled in the study. Thirty age-matched subjects without any evidence of coronary artery disease were chosen as controls. All patients underwent a 2 to 5 day continuous Holter monitoring during full medical treatment (including beta-blockers, heparin and aspirin). Angiography was performed within 1 week in 88 of the 92 patients. During follow-up (mean duration of 16 +/- 5 days), 26 patients (Group I) had a major coronary event (6 deaths, 7 non fatal AMI, 13 urgent revascularizations). The remaining 66 patients (Group II) had a good clinical outcome. ECG recordings during ST shifts were excluded from Holter monitoring analysis. Time domain measurements of HRV predicted mortality and total events. The most powerful predictors was the standard deviation of the means of the 5 min R-R intervals (SDANN index) which was significantly (p < 0.001) lower in Group I than Group II (55 +/- 18 versus 87 +/- 29).(ABSTRACT TRUNCATED AT 250 WORDS) PMID:8087815
Loricchio, M L; Di Clemente, D; Saccone, V; Caccamo, L; Borghi, A; Bugiardini, R
[Risk stratification for thromboembolism and antithrombotic prophylaxis in atrial fibrillation].
Atrial fibrillation (AF) is associated with a significantly high risk of stroke and systemic embolism (4.5%/year). Oral anticoagulant therapy (OAT) with warfarin (INR range 2.0-3.0) significantly reduces thromboembolic risk, whereas aspirin has poor efficacy. In patients with AF, several scoring systems, such as the CHADS2 and CHA2DS2-VASc scores, are currently used to stratify thromboembolic risk. The CHA2DS2-VASc score stratifies patients at intermediate-low thromboembolic risk more accurately than the CHADS2 score. The most recent European and US guidelines on AF have extended the indications for OAT, which is recommended not only for patients at high risk, but also for those at intermediate risk, with CHADS2 score ?1. However, in clinical practice underuse of OAT, suboptimal quality of anticoagulation, and frequent discontinuations of treatment are observed. Therefore, there is a great expectation for the new oral anticoagulants, in particular the direct thrombin inhibitor dabigatran etexilate and the factor Xa inhibitors rivaroxaban and apixaban, which are at least non-inferior to warfarin and safer, and seem to be a suitable therapeutic alternative to the old warfarin. PMID:23160015
Di Pasquale, Giuseppe; Riva, Letizia
Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model
Objective: Our purpose was to compare the performance of risk stratification model between Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patient database. Methods: From August 1994 to December 2000, 803 consecutive patients have undergone heart and thoracic aorta surgery using cardiopulmonary bypass and scored according to Parsonnet and EuroSCORE algorithm. The population was divided into
Yoshito Kawachi; Atsuhiro Nakashima; Yoshihiro Toshima; Kouich Arinaga; Hiroshi Kawano
Standardized reporting guidelines for emergency department syncope risk-stratification research.
There is increasing research interest in the risk stratification of emergency department (ED) syncope patients. A major barrier to comparing and synthesizing existing research is wide variation in the conduct and reporting of studies. The authors wanted to create standardized reporting guidelines for ED syncope risk-stratification research using an expert consensus process. In that pursuit, a panel of syncope researchers was convened and a literature review was performed to identify candidate reporting guideline elements. Candidate elements were grouped into four sections: eligibility criteria, outcomes, electrocardiogram (ECG) findings, and predictors. A two-round, modified Delphi consensus process was conducted using an Internet-based survey application. In the first round, candidate elements were rated on a five-point Likert scale. In the second round, panelists rerated items after receiving information about group ratings from the first round. Items that were rated by >80% of the panelists at the two highest levels of the Likert scale were included in the final guidelines. There were 24 panelists from eight countries who represented five clinical specialties. The panel identified an initial set of 183 candidate elements. After two survey rounds, the final reporting guidelines included 92 items that achieved >80% consensus. These included 10 items for study eligibility, 23 items for outcomes, nine items for ECG abnormalities, and 50 items for candidate predictors. Adherence to these guidelines should facilitate comparison of future research in this area. PMID:22687184
Sun, Benjamin C; Thiruganasambandamoorthy, Venkatesh; Cruz, Jeffrey Dela
Risk Stratification-based Surveillance of Bacterial Contamination in Metropolitan Ambulances
We aimed to know the risk-stratification-based prevalence of bacterial contamination of ambulance vehicle surfaces, equipment, and materials. This study was performed in a metropolitan area with fire-based single-tiered Basic Life Support ambulances. Total 13 out of 117 ambulances (11.1%) were sampled and 33 sites per each ambulance were sampled using a soft rayon swab and aseptic containers. These samples were then plated onto a screening media of blood agar and MacConkey agar. Specific identification with antibiotic susceptibility was performed. We categorized sampling sites into risk stratification-based groups (Critical, Semi-critical, and Non-critical equipment) related to the likelihood of direct contact with patients' mucosa. Total 214 of 429 samples showed positive results (49.9%) for any bacteria. Four of these were pathogenic (0.9%) (MRSA, MRCoNS, and K. pneumoniae), and 210 of these were environmental flora (49.0%). However, the prevalence (positive/number of sample) of bacterial contamination in critical, semi-critical airway, semi-critical breathing apparatus group was as high as 15.4% (4/26), 30.7% (16/52), and 46.2% (48/104), respectively. Despite current formal guidelines, critical and semi-critical equipments were contaminated with pathogens and normal flora. This study suggests the need for strict infection control and prevention for ambulance services.
Noh, Hyun; Kim, Nam Joong; Ro, Young Sun; Oh, Hyang Soon; Joo, Se Ik; Kim, Jung In; Ong, Marcus Eng Hock
IMWG consensus on risk stratification in multiple myeloma.
Multiple myeloma is characterized by underlying clinical and biological heterogeneity, which translates to variable response to treatment and outcome. With the recent increase in treatment armamentarium and the projected further increase in approved therapeutic agents in the coming years, the issue of having some mechanism to dissect this heterogeneity and rationally apply treatment is coming to the fore. A number of robustly validated prognostic markers have been identified and the use of these markers in stratifying patients into different risk groups has been proposed. In this consensus statement, the International Myeloma Working Group propose well-defined and easily applicable risk categories based on current available information and suggests the use of this set of prognostic factors as gold standards in all clinical trials and form the basis of subsequent development of more complex prognostic system or better prognostic factors. At the same time, these risk categories serve as a framework to rationalize the use of therapies. PMID:23974982
Chng, W J; Dispenzieri, A; Chim, C-S; Fonseca, R; Goldschmidt, H; Lentzsch, S; Munshi, N; Palumbo, A; Miguel, J S; Sonneveld, P; Cavo, M; Usmani, S; Durie, B G M; Avet-Loiseau, H
Post-myocardial infarction arrhythmia risk stratification using microvolt T-wave alternans.
Since its initial description, a number of studies have described the use of microvolt T-wave alternans (MTWA) as a predictor of the primary or secondary occurrence of ventricular arrhythmic events. These studies, however, have been limited by small sample sizes and disparate patient populations. Studies of MTWA in post-myocardial infarction (MI) patients are few in number, but hold predictive value for risk of ventricular arrhythmias. We performed a study of MTWA in post-myocardial infarction patients to clarify the predictive accuracy and usefulness of MTWA compared to other invasive and non-invasive techniques. We enrolled 120 patients (74 men, 46 women, mean age 62.3 ▒ 15.2 years in men, and 64.2 ▒ 13.8 years in women) with a history of myocardial infarction but no prior sustained ventricular arrhythmias. Patients were assessed by echocardiography, Holter, signal averaged ECG, MTWA, and electrophysiology study. Mean follow-up was 14 months. The MTWA test had a good negative predictive value for arrhythmic events in post-MI patients and can be used for risk stratification. We consider that in patients with positive MTWA further invasive evaluation, respectively electrophysiology study, is necessary. PMID:24778843
Donoiu, I; Mirea, Oana Cristina; Giuca, Alina; Militaru, C; Ionescu, D D
Heart Rate Variability and Non-Linear Dynamics in Risk Stratification
The time-domain measures and power¢spectral analysis of heart rate variability (HRV) are classic conventional methods to assess the complex regulatory system between autonomic nervous system and heart rate and are most widely used. There are abundant scientific data about the prognostic significance of the conventional measurements of HRV in patients with various conditions, particularly with myocardial infarction. Some studies have suggested that some newer measures describing non-linear dynamics of heart rate, such as fractal measures, may reveal prognostic information beyond that obtained by the conventional measures of HRV. An ideal risk indicator could specifically predict sudden arrhythmic death as the implantable cardioverter-defibrillator (ICD) therapy can prevent such events. There are numerically more sudden deaths among post-infarction patients with better preserved left ventricular function than in those with severe left ventricular dysfunction. Recent data support the concept that HRV measurements, when analyzed several weeks after acute myocardial infarction, predict life-threatening ventricular tachyarrhythmias in patients with moderately depressed left ventricular function. However, well-designed prospective randomized studies are needed to evaluate whether the ICD therapy based on the assessment of HRV alone or with other risk indicators improves the patientsÆ prognosis. Several issues, such as the optimal target population, optimal timing of HRV measurements, optimal methods of HRV analysis, and optimal cutpoints for different HRV parameters, need clarification before the HRV analysis can be a widespread clinical tool in risk stratification.
Perkiomaki, Juha S.
Very early risk stratification after thrombolytic therapy with a bedside myoglobin assay and the 12-lead electrocardiogram
Background Available clinical criteria to estimate prognosis in patients with evolving ST-segment elevation myocardial infarction do not consider the impact of reperfusion therapy and do not incorporate measurement of baseline levels of cardiac serum markers. We evaluated the combination of a baseline myoglobin assay and early (60- to 90-minute) ST resolution for risk stratification after ST-segment elevation myocardial infarction. Methods
James A de Lemos; Elliott M Antman; Robert P Giugliano; David A Morrow; Carolyn H McCabe; Andrew Charlesworth; Rolf Schr÷der; Eugene Braunwald
Risk stratification for implantable cardioverter defibrillator therapy: the role of the wearable cardioverter-defibrillator.
The benefit of implantable cardioverter-defibrillator (ICD) therapy depends upon appropriate evaluation of a persisting risk of sudden death and estimation of the patient's overall survival. Assessment of a stable and unchangeable arrhythmogenic substrate is often difficult. Structural abnormality and ventricular dysfunction, the two major risk parameters, may recover, and heart failure symptoms can improve so that ICD therapy may not be indicated. Risk stratification can take time while the patient continues to be at high risk of arrhythmic death, and patients may need temporary bridging by a defibrillator in cases of interrupted ICD therapy. The wearable cardioverter-defibrillator (WCD) combines a long-term electrocardiogram (ECG)-monitoring system with an external automatic defibrillator. The LIfeVest« (ZOLL, Pittsburgh, PA, USA) is composed of a garment, containing two defibrillation patch electrodes on the back, and an elastic belt with a front-defibrillation patch electrode and four non-adhesive ECG electrodes, connected to a monitoring and defibrillation unit. The WCD is a safe and effective tool to terminate ventricular tachycardia/ventricular fibrillation events, unless a conscious patient withholds shock delivery. It may be used in patients in the early phase after acute myocardial infarction with poor left ventricular function, after acute coronary revascularization procedures (percutaneous coronary intervention or coronary artery bypass grafting) and reduced left ventricular ejection fraction (?35%), in patients with acute heart failure in non-ischaemic cardiomyopathy of uncertain aetiology and prognosis. The WCD may be helpful in subjects with syncope of assumed tachyarrhythmia origin or in patients with inherited arrhythmia syndromes. The WCD may replace ICD implantation in patients waiting for heart transplantation or who need a ventricular-assist device. This review describes the technical details and characteristics of the WCD, discusses its various potential applications, and reports the currently available experience with the wearable defibrillator. PMID:23729691
Klein, Helmut U; Goldenberg, Ilan; Moss, Arthur J
Risk stratification and selection for statin therapy: going beyond framingham.
Decisions for statin therapy in the primary prevention of atherosclerotic cardiovascular disease are generally made using the 10-year Framingham Risk Score (FRS). Even when a family history of premature cardiovascular disease is taken into account, there is often ambiguity about the need for statin therapy for patients with a 10-year FRS of 5%-19% and low-density lipoprotein cholesterol <3.5 mmol/L. Current Canadian dyslipidemia guidelines recommend consideration of a diversity of other factors, including biochemical measurements and imaging studies to help determine whether the calculated FRS might be misleadingly low and whether statin therapy might, therefore, be prudent. However, efficient use of the plethora of secondary factors makes this decision process itself potentially ambiguous. This brief summary provides a practical approach for using clinical information, basic biochemical tests, and more specialized tests, such as carotid ultrasound and coronary artery calcium scoring, to identify groups of patients at greater risk for atherosclerotic cardiovascular disease than suggested by the FRS. PMID:24882539
Fitchett, David H; Mancini, G B John; Gregoire, Jean; Anderson, Todd; McPherson, Ruth
Hodgkin lymphoma: 2014 update on diagnosis, risk-stratification, and management.
Disease overview: Hodgkin lymphoma (HL) is an uncommon B-cell lymphoid malignancy affecting 9,200 new patients annually and representing approximately 11.5% of all lymphomas in the United States. Diagnosis: HL is composed of two distinct disease entities; the more commonly diagnosed classical HL and the rare nodular lymphocyte-predominant HL. Nodular sclerosis, mixed cellularity, lymphocyte depletion, and lymphocyte-rich HL are subgroups under the designation of classical HL. Risk stratification: An accurate assessment of the stage of disease in patients with HL is critical for the selection of the appropriate therapy. Prognostic models that identify patients at low or high risk for recurrence, as well as the response to therapy as determined by positron emission tomography scan, are used to optimize therapy. Risk-adapted therapy: Initial therapy for HL patients is based on the histology of the disease, the anatomical stage, and the presence of poor prognostic features. Patients with early stage disease are treated with combined modality strategies using abbreviated courses of combination chemotherapy followed by involved-field radiation therapy, while those with advanced stage disease receive a longer course of chemotherapy often without radiation therapy. Management of relapsed/refractory disease: High-dose chemotherapy (HDCT) followed by an autologous stem cell transplant (ASCT) is the standard of care for most patients who relapse following initial therapy. For patients who fail HDCT with ASCT, brentuximab vedotin, palliative chemotherapy, nonmyeloablative allogeneic transplant, or participation in a clinical trial should be considered. Am. J. Hematol. 89:772-779, 2014. ® 2014 Wiley Periodicals, Inc. PMID:24953862
Ansell, Stephen M
Modern noninvasive risk stratification in primary prevention of sudden cardiac death
ObjectiveĀĀSince the publication of MADIT II and SCD-HeFT, an implantable cardioverter defibrillator (ICD) for primary prevention represents\\u000a an established, guideline-implemented therapeutic strategy. Facing such an enormous amount of potential ICD recipients, the\\u000a identification of an effective risk stratification remains crucial.\\u000a \\u000a \\u000a \\u000a MethodsĀĀThis article reviews the tools of noninvasive risk stratification which are currently used and defines an optimal test configuration.\\u000a This
J. Kreuz; L. M. Lickfett; J. O. Schwab
Renal disease in scleroderma: an update on evaluation, risk stratification, pathogenesis and management
Purpose of review Renal disease remains an important cause of morbidity and mortality in scleroderma. The spectrum of renal complications in systemic sclerosis includes scleroderma renal crisis (SRC), normotensive renal crisis, antineutrophil cytoplasmic antibodies-associated glomerulonephritis, penacillamine-associated renal disease, and reduced renal functional reserves manifested by proteinuria, microalbuminuria, or isolated reduction in glomerular filtration rate. The purpose of this review is to provide a concise and up-to-date review of the evaluation, risk stratification, pathogenesis, and management of scleroderma-associated renal disease. Recent findings Although SRC survival has significantly improved, mortality of this complication remains high outside of specialized centers. Recent data demonstrate strong associations between anti-RNA polymerase III antibodies and SRC. Subclinical renal impairment affects approximately 50% of scleroderma patients and may be associated with other vascular manifestations. Subclinical renal involvement rarely progresses to end-stage renal failure; however, recent studies suggest it may predict mortality in patients with other vasculopathic manifestations. Summary Testing for anti-RNA polymerase III antibodies should be incorporated into clinical care to identify patients at high risk for SRC. Recommendations from European League Against Rheumatism (EULAR), EULAR Scleroderma Trials and Research, and the Scleroderma Clinical Trials Consortium confirm angiotensin-converting enzyme inhibitors as first-line therapy for SRC, and give recommendations for second-line agents.
Shanmugam, Victoria K.; Steen, Virginia D.
Diagnostic accuracy of dual-source CT angiography and coronary risk stratification
Purpose The aim of this study was to evaluate the diagnostic accuracy of dual-source computed tomography (DSCT) in coronary artery disease, and to test the possibility of using this technique for coronary risk stratification. Background With the advent of DSCT, it is possible to image coronary plaque noninvasively. However, the accuracy of this method in terms of sensitivity and specificity has not been determined. Furthermore, noninvasive determination of plaque composition and plaque burden may be important for improving coronary risk stratification. Methods Forty-six patients with known coronary artery disease underwent DSCT quantitative coronary angiography (QCA), and intravascular ultrasound (IVUS) were included in the study. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DSCT was calculated against QCA and IVUS. Plaque analysis software in a DSCT workstation was used to detect plaque characteristics associated with the Hounsfield unit (Hu) value compared with IVUS. Coronary artery plaques were classified into three types of lesions based on DSCT, and the relationship between different coronary lesions and clinical diagnosis was determined. Results DSCT angiography was performed in 46 patients, and a diagnostic-quality CT image was obtained in 44 patients. Coronary angiography was performed in 138 vessels and IVUS in 102 vessels of all 46 patients. Sensitivity, specificity, PPV, and NPV of DSCT compared with QCA was 100%, 98%, 92%, and 100%, respectively. The same corresponding index of DSCT compared with IVUS was 100%, 99%, 95%, and 100%, respectively. Quantitative coronary stenosis analysis revealed a good correlation between DSCT and QCA (r = 0.85, P < 0.05, 95% confidence interval [CI] 0.60¢0.87). There was also a good correlation between DSCT and IVUS (r = 0.81, P < 0.05, 95% CI 0.56¢0.82). In comparison with IVUS, DSCT predicted plaque characteristics more accurately. The coefficient correlation (r) of luminal cross-sectional area and external elastic membrane cross-sectional area between DSCT and IVUS was 0.82 (P < 0.01, CI 0.67¢0.89) and 0.78 (P < 0.01, CI 0.67¢0.86), respectively. Three different types of plaque were identified on IVUS. Fatty plaque had a 45 ▒ 14 Hu value, fibrous plaque 90 ▒ 20, and calcified plaque 530 ▒ 185, respectively, on DSCT. The relationship between clinical diagnosis and coronary plaque on DSCT indicated that lesions in patients with unstable angina pectoris or ST elevation myocardial infarction were mainly discrete soft plaques, but there was no significant difference in the distributive characteristics of the lesions in patients with non-ST elevation myocardial infarction and stable angina pectoris patients. Conclusions DSCT is a noninvasive tool that allows accurate evaluation of plaque characteristics, diagnosis of coronary artery disease, and stratification of coronary risk according to different coronary plaque type.
Yang, Xia; Gai, Lu-yue; Li, Ping; Chen, Yun-dai; Li, Tao; Yang, Li
Improved risk stratification in myeloma using a microRNA-based classifier.
Multiple myeloma (MM) is a heterogeneous disease. International Staging System/fluorescence hybridization (ISS/FISH)-based model and gene expression profiles (GEP) are effective approaches to define clinical outcome, although yet to be improved. The discovery of a class of small non-coding RNAs (micro RNAs, miRNAs) has revealed a new level of biological complexity underlying the regulation of gene expression. In this work, 163 presenting samples from MM patients were analysed by global miRNA profiling, and distinct miRNA expression characteristics in molecular subgroups with prognostic relevance (4p16, MAF and 11q13 translocations) were identified. Furthermore we developed an "outcome classifier", based on the expression of two miRNAs (MIR17 and MIR886-5p), which is able to stratify patients into three risk groups (median OS 19.4, 40.6 and 65.3 months, P = 0.001). The miRNA-based classifier significantly improved the predictive power of the ISS/FISH approach (P = 0.0004), and was independent of GEP-derived prognostic signatures (P < 0.002). Through integrative genomics analysis, we outlined the potential biological relevance of the miRNAs included in the classifier and their putative roles in regulating a large number of genes involved in MM biology. This is the first report showing that miRNAs can be built into molecular diagnostic strategies for risk stratification in MM. PMID:23718138
Wu, Ping; Agnelli, Luca; Walker, Brian A; Todoerti, Katia; Lionetti, Marta; Johnson, David C; Kaiser, Martin; Mirabella, Fabio; Wardell, Christopher; Gregory, Walter M; Davies, Faith E; Brewer, Daniel; Neri, Antonino; Morgan, Gareth J
What is the utility of preoperative frailty assessment for risk stratification in cardiac surgery?
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether frailty scoring can be used either separately or combined with conventional risk scores to predict survival and complications. Five hundred and thirty-five papers were found using the reported search, of which nine cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There is a paucity of evidence, as advanced age is a criterion for exclusion in most randomized controlled trials. Conventional models of risk following cardiac surgery are not calibrated to accurately predict the outcomes in the elderly and do not currently include frailty parameters. There is no universally accepted definition for frailty, but it is described as a physiological decline in multiple organ systems, decreasing a patient's capacity to withstand the stresses of surgery and disease. Frailty is manifest clinically as deficits in functional capacity, such as slow ambulation and impairments in the activities of daily living (ADL). Analysis of predictive models using area under receiver operating curves (AUC) suggested only a modest benefit by adding gait speed to a Society of Thoracic Surgeons (STS score)-Predicted Risk of Mortality or Major Morbidity (PROM) risk score (AUC 0.04 mean difference). However, a specialist frailty assessment tool named FORECAST was found to be superior at predicting adverse outcomes at 1 year compared with either EuroSCORE or STS score (AUC 0.09 mean difference). However, risk models incorporating frailty parameters require further validation and have not been widely adopted. Routine collection of objective frailty measures such as 5-metre walk time and ADL assessment will help to provide data to develop new risk-assessment models to facilitate risk stratification and clinical decision-making in elderly patients. Based on the best evidence currently available, we conclude that frailty is an independent predictor of adverse outcome following cardiac surgery or transcatheter aortic valve implantation, increasing the risk of mortality 2- to 4-fold compared with non-frail patients. PMID:23667068
Bagnall, Nigel Mark; Faiz, Omar; Darzi, Ara; Athanasiou, Thanos
Arrhythmia risk stratification in idiopathic dilated cardiomyopathy based on echocardiography and 12-lead, signal-averaged, and 24-hour Holter electrocardiography
Background To date, considerable controversy exists regarding noninvasive arrhythmia risk stratification in idiopathic dilated cardiomyopathy (IDC). Methods and Results Between 1992 and 1997, 202 patients with IDC without a history of sustained ventricular tachycardia (VT) underwent echocardiography, signal-averaged electrocardiogram (ECG), and 24-hour Holter ECG in the absence of antiarrhythmic drugs. During 32 ▒ 15 months of prospective follow-up, major arrhythmic
Wolfram Grimm; Christina Glaveris; J³rgen Hoffmann; Volker Menz; Hans-Helge M³ller; G³nther Hufnagel; Bernhard Maisch
Sudden cardiac death in non-ischemic dilated cardiomyopathy: a critical appraisal of existing and potential risk stratification tools.
Non ischemic dilated cardiomyopathy poses a significant risk of malignant ventricular arrhythmias and subsequent sudden cardiac death. The pathologic and electrophysiological substrate implicated to arrhythmogenesis has been quite adequately defined over the last decades and multiple forms of myocardial fibrosis - diffuse, patchy or gross scarring - are being studied regarding their arrhythmogenic potential. Moreover, the recent demonstration and continuous expansion of knowledge regarding causative genes in dilated cardiomyopathy open a new chapter in the field of diagnosis and prognosis of these patients. Numerous noninvasive and invasive methods have been used to stratify patients according to sudden cardiac death level of risk. Severely reduced left ventricular systolic myocardial function, expressed mostly by left ventricular ejection function, NYHA functional class, syncope and invasive electrophysiological study with programmed electrical stimulation have been incorporated into international guidelines, though leaving significant proportions of primary prevention patients out of stratification schemes. Electrocardiographic markers, signal-averaged ECG, heart rate variability, heart rate turbulence, baroreflex sensitivity, heart rate recovery and T-wave alternans have given conflicting results in non ischemic dilated cardiomyopathy. During the last decade, cardiac magnetic resonance, especially with gadolinium enhancement, has made a step forward in defining the fibrotic substrate of such patients. Prospective studies have given promising results, demonstrating correlation between late gadolinium enhancement and ventricular arrhythmogenesis. Identification of patients with genetically caused dilated cardiomyopathy prone to sudden cardiac death and large prospective trials investigating cardiac magnetic resonance and its prognostic potential may be able to establish a new era in stratification schemes. PMID:22889703
Koutalas, Emmanuel; Kanoupakis, Emmanuel; Vardas, Panos
Iodine-123-metaiodobenzylguanidine scintigraphy in risk stratification of sudden death in heart failure.
Metaiodobenzylguanidine (MIBG) is a false neurotransmitter noradrenaline analogue that is taken up by the 'uptake 1' transporter mechanism in the cell membrane of presynaptic adrenergic neurons and accumulates in catecholamine storage vesicles. Since it is practically unmetabolized, it can be labeled with a radioisotope (iodine-123) in scintigraphic exams to noninvasively assess the functional status of the sympathetic innervation of organs with a significant adrenergic component, including the heart. Studies of its application in nuclear cardiology appear to confirm its value in the assessment of conditions such as coronary artery disease, heart failure, arrhythmias and sudden death. Heart failure is a global problem, with an estimated prevalence of 2% in developed countries. Sudden cardiac death is the main cause of its high mortality. The autonomic nervous system dysfunction, including sympathetic hyperactivity, that accompanies chronic heart failure is associated with progressive myocardial remodeling, declining left ventricular function and worsening symptoms, and contributes to the development of ventricular arrhythmias and sudden death. Since 123I-MIBG cardiac scintigraphy can detect changes in the cardiac adrenergic system, there is considerable interest in its role in obtaining diagnostic and prognostic information in patients with heart failure. In this article we present a literature review on the use of 123I-MIBG scintigraphy for risk stratification of sudden death in patients with heart failure. PMID:23731734
Martins da Silva, Marta InĻs; Vidigal Ferreira, Maria JoŃo; MorŃo Moreira, Ana Paula
Adaptive index models for marker-based risk stratification
We use the term ōindex predictorö to denote a score that consists of K binary rules such as ōage > 60ö or ōblood pressure > 120 mm Hg.ö The index predictor is the sum of these binary scores, yielding a value from 0 to K. Such indices as often used in clinical studies to stratify population risk: They are usually derived from subject area considerations. In this paper, we propose a fast data-driven procedure for automatically constructing such indices for linear, logistic, and Cox regression models. We also extend the procedure to create indices for detecting treatment¢marker interactions. The methods are illustrated on a study with protein biomarkers as well as a large microarray gene expression study.
Tian, Lu; Tibshirani, Robert
Clinical and Angiographic Risk Stratification and Differential Impact on Treatment Outcomes in the BARI 2D Trial
Background The BARI 2D trial assigned patients with type 2 diabetes to prompt coronary revascularization (REV) plus intensive medical therapy versus intensive medical therapy (MED) alone and reported no significant difference in mortality. Among patients selected for CABG, REV was associated with a significant reduction in death/MI/stroke compared with MED. We hypothesized that clinical and angiographic risk stratification would impact the effectiveness of the treatments overall and within revascularization strata. Methods and Results An angiographic risk score was developed from variables assessed at randomization; independent prognostic factors were myocardial jeopardy index, total number of coronary lesions, prior coronary revascularization, and left ventricular ejection fraction. The Framingham risk score for patients with coronary disease was used to summarize clinical risk. Cardiovascular event rates were compared by assigned treatment within high-risk and low-risk subgroups. No overall MED versus REV outcome differences were seen in any risk stratum. The five-year risk of death/MI/stroke was 36.8% for MED compared with 24.8% for REV among the 381 CABG-selected patients in the highest angiographic risk tertile (p=0.005); this treatment effect was amplified in patients with both high angiographic and high Framingham risk (47.3% MED versus 27.1% REV, p=0.010; Hazard Ratio=2.10, p=0.009). Treatment group differences were not significant in other clinical-angiographic risk groups within the CABG stratum nor any subgroups within the PCI stratum. Conclusions Among patients with diabetes and stable ischemic heart disease, a strategy of prompt CABG significantly reduces the rate of death/MI/stroke in those with extensive coronary artery disease or impaired left ventricular function. Clinical Trial Registration: ClinicalTrials.gov NCT00006305
Brooks, Maria Mori; Chaitman, Bernard R.; Nesto, Richard W.; Hardison, Regina M.; Feit, Frederick; Gersh, Bernard J.; Krone, Ronald J.; Sako, Edward Y.; Rogers, William J.; Garber, Alan J.; King, Spencer B.; Davidson, Charles J.; Ikeno, Fumiaki; Frye, Robert L.
CT-derived atrial and ventricular septal signs for risk stratification of patients with acute pulmonary embolism: clinical associations of CT-derived signs for prediction of short-term mortality.
A left-bulging atrial septum (AS) is an abnormal sign indicating hemodynamic overloading of the right heart. We tried to evaluate whether computed tomography (CT)-derived AS bulging and ventricular septum (VS) bowing signs would be used to identify patients with acute pulmonary embolism (PE) and significant hemodynamic derangements. In the prospective registry, 208 consecutive patients with a first episode of acute PE diagnosed by chest CT were grouped by clinical hemodynamic assessment: massive or submassive PE (Group 1), and small PE (Group 2). The curvatures of the AS and VS, and the diameters of right ventricle (RV) and left ventricle were measured on chest CT. Group 1 showed higher degrees of echocardiographic RV dysfunction, and abnormal CT-derived VS and AS curvatures versus Group 2. An abnormal VS bowing sign was observed in 32 (32.7Ā%) and 6 (5.5Ā%) patients in Groups 1 and 2, respectively (PĀ<Ā0.001). An abnormal AS bulging sign was observed in 59 (60.2Ā%) and 32 (29.1Ā%) patients in Groups 1 and 2, respectively (PĀ<Ā0.001). An algorithm was designed to predict clinically significant hemodynamic abnormality based on these signs. The patients deemed "higher risk" exhibited higher 90-day all-cause mortality than patients in the lower-risk group (PĀ=Ā0.029). Conventional chest CT-derived hemodynamic findings, including abnormal AS and VS signs, can be used to identify high-risk patients with acute PE and to predict early mortality. PMID:24777628
Kim, Mi-Jeong; Jung, Hae Ok; Jung, Jung Im; Kim, Ki Joon; Jeon, Doo Soo; Youn, Ho-Joong
Evidence for Cytogenetic and Fluorescence In Situ Hybridization Risk Stratification of Newly Diagnosed Multiple Myeloma in the Era of Novel Therapies
Overall survival (OS) has improved with increasing use of novel agents in multiple myeloma (MM). However, the disease course remains highly variable, and the heterogeneity largely reflects different genetic abnormalities. We studied the impact of the Mayo risk-stratification model of MM on patient outcome in the era of novel therapies, evaluating each individual component of the modelŚfluorescence in situ hybridization (FISH), conventional cytogenetics (CG), and the plasma cell labeling indexŚthat segregates patients into high- and standard-risk categories. This report consists of 290 patients with newly diagnosed MM, predominantly treated with novel agents, who were risk-stratified at diagnosis and were followed up for OS. Of these patients, 81% had received primarily thalidomide (n=50), lenalidomide (n=199), or bortezomib (n=79) as frontline or salvage therapies. Our retrospective analysis validates the currently proposed Mayo risk-stratification model (median OS, 37 months vs not reached for high- and standard-risk patients, respectively; P=.003). Although the FISH or CG test identifies a high-risk cohort with hazard ratios of 2.1 (P=.006) and 2.5 (P=.006), respectively, the plasma cell labeling index cutoff of 3% fails to independently prognosticate patient risk (hazard ratio, 1.4; P=.41). In those stratified as standard-risk by one of the 2 tests (FISH or CG), the other test appears to be of additional prognostic significance. This study validates the high-risk features defined by FISH and CG in the Mayo risk-stratification model for patients with MM predominantly treated with novel therapies based on immunomodulatory agents.
Kapoor, Prashant; Fonseca, Rafael; Rajkumar, S. Vincent; Sinha, Shirshendu; Gertz, Morie A.; Stewart, A. Keith; Bergsagel, P. Leif; Lacy, Martha Q.; Dingli, David D.; Ketterling, Rhett P.; Buadi, Francis; Kyle, Robert A.; Witzig, Thomas E.; Greipp, Philip R.; Dispenzieri, Angela; Kumar, Shaji
Rationale, objectives, and design of the EUTrigTreat clinical study: a prospective observational study for arrhythmia risk stratification and assessment of interrelationships among repolarization markers and genotype
Aims The EUTrigTreat clinical study has been designed as a prospective multicentre observational study and aims to (i) risk stratify patients with an implantable cardioverter defibrillator (ICD) for mortality and shock risk using multiple novel and established risk markers, (ii) explore a link between repolarization biomarkers and genetics of ion (Ca2+, Na+, K+) metabolism, (iii) compare the results of invasive and non-invasive electrophysiological (EP) testing, (iv) assess changes of non-invasive risk stratification tests over time, and (v) associate arrythmogenomic risk through 19 candidate genes. Methods and results Patients with clinical ICD indication are eligible for the trial. Upon inclusion, patients will undergo non-invasive risk stratification, including beat-to-beat variability of repolarization (BVR), T-wave alternans, T-wave morphology variables, ambient arrhythmias from Holter, heart rate variability, and heart rate turbulence. Non-invasive or invasive programmed electrical stimulation will assess inducibility of ventricular arrhythmias, with the latter including recordings of monophasic action potentials and assessment of restitution properties. Established candidate genes are screened for variants. The primary endpoint is all-cause mortality, while one of the secondary endpoints is ICD shock risk. A mean follow-up of 3.3 years is anticipated. Non-invasive testing will be repeated annually during follow-up. It has been calculated that 700 patients are required to identify risk predictors of the primary endpoint, with a possible increase to 1000 patients based on interim risk analysis. Conclusion The EUTrigTreat clinical study aims to overcome current shortcomings in sudden cardiac death risk stratification and to answer several related research questions. The initial patient recruitment is expected to be completed in July 2012, and follow-up is expected to end in September 2014. Clinicaltrials.gov identifier: NCT01209494.
Seegers, Joachim; Vos, Marc A.; Flevari, Panagiota; Willems, Rik; Sohns, Christian; Vollmann, Dirk; Luthje, Lars; Kremastinos, Dimitrios T.; Flore, Vincent; Meine, Mathias; Tuinenburg, Anton; Myles, Rachel C.; Simon, Dirk; Brockmoller, Jurgen; Friede, Tim; Hasenfuss, Gerd; Lehnart, Stephan E.; Zabel, Markus
Prognostic stratification of patients with advanced renal cell carcinoma treated with sunitinib: comparison with the Memorial Sloan-Kettering prognostic factors model
BACKGROUND: The treatment paradigm in advanced renal cell carcinoma (RCC) has changed in the recent years. Sunitinib has been established as a new standard for first-line therapy. We studied the prognostic significance of baseline characteristics and we compared the risk stratification with the established Memorial Sloan Kettering Cancer Center (MSKCC) model. METHODS: This is a retrospective analysis of patients treated
Aristotelis Bamias; Alexandra Karadimou; Sofia Lampaki; George Lainakis; Lia Malettou; Eleni Timotheadou; Kostas Papazisis; Charalambos Andreadis; Loukas Kontovinis; Ioannis Anastasiou; Kostas Stravodimos; Ioannis Xanthakis; Andreas Skolarikos; Christos Christodoulou; Kostas Syrigos; Christos Papandreou; Evangelia Razi; Urania Dafni; George Fountzilas; Meletios A Dimopoulos
D'Amico Risk Stratification Correlates with Degree of Suspicion of Prostate Cancer on Multi-Parametric Magnetic Resonance Imaging (MRI)
Objective We sought to determine if there is a correlation between D'Amico risk stratification and degree of suspicion of prostate cancer on multi-parametric MRI, based on targeted biopsies obtained with our electromagnetically (EM) tracked MRI/ultrasound (US) fusion platform. Methods 101 patients underwent 3 Tesla multi-parametric MR imaging of the prostate which consisted of T2, DCE, DWI, and spectroscopy images in patients with a suspicion for, or diagnosis of prostate cancer. All prostate MRI lesions were then identified and graded by the number of modalities positive: low (?2), moderate (3) and high (4) suspicion. Patients and lesions were stratified by D'Amico risk stratification. The biopsy protocol included a standard 12 core biopsy followed by real-time MRI/US fusion-targeted biopsies of the suspicious MR lesions. Results 90.1% of men were clinical T1c with a mean age of 62.7 ▒ 8.3 years and the median PSA was 5.8 ng/ml. 54.5% of the patients were positive for cancer on the protocol biopsy. A Chi-squared analysis resulted in a statistically significant correlation between the MR suspicion and D'Amico risk stratification for patients (p<0.0001). Within-cluster re-sampling technique determined that there was a statistically significant correlation between MR suspicion and D'Amico risk stratification for MR ætargetedÆ core biopsies and MR lesions (p<0.01) Conclusion Our data supports that with multi-parametric MR prostate imaging, one may be able to quantitatively assess the degree of risk associated with MR visible lesions within the prostate.
Rastinehad, Ardeshir R.; Baccala, Angelo A.; Chung, Paul H.; Proano, Juan M.; Kruecker, Jochen; Xu, Sheng; Locklin, Julia K.; Turkbey, Baris; Shih, Joanna; Bratslavsky, Gennady; Linehan, W. Marston; Glossop, Neil D.; Yan, Pingkun; Kadoury, Samuel; Choyke, Peter L.; Wood, Bradford J.; Pinto, Peter A.
Diagnostic evaluation of people with hypertension in low income country: cohort study of "essential" method of risk stratification
Objectives To explore the predictive power of a risk stratification method for people with hypertension based on ōessentialö procedures (that is, available in economically less developed areas of the world), comparing it in the same population with the results given by the method suggested by the 1999 World Health Organization-International Society of Hypertension (WHO-ISH) guidelines. Design Prospective cohort study of outcomes according to cardiovascular risk profile at baseline. Setting Primary care in a poor rural area of the Ecuadorian forest. Participants 504 people with hypertension prospectively monitored for a mean of 6.7 (SD 2.3) years. Interventions Essential data included blood pressure, medical history, smoking, age, sex, and diagnosis of diabetes; the WHO-ISH methods additionally included measurement of fasting blood glucose, total cholesterol, and creatinine, urinalysis, and electrocardiography. Main outcome measures Cardiovascular events and total deaths. Results With both methods there was a highly significant association between the level of predicted risk and the incidence of cardiovascular events and of total deaths: up to three quarters of all cardiovascular events and two thirds of all deaths were reported among people classified as at high or very high risk with either method. The predictive discrimination of the essential method is comparable with the WHO-ISH with C statistics (95% confidence interval) of 0.788 (0.721 to 0.855) and 0.744 (0.673 to 0.815), respectively, for cardiovascular events and 0.747 (0.678 to 0.816) and 0.705 (0.632 to 0.778) for total mortality. Conclusions The risk stratification of patients with hypertension with an essential package of variables (that is, available and practicable even in the economically less developed areas of the world) serves at least as well as the more comprehensive method proposed by WHO-ISH.
Strategies for treating lipids for prevention: risk stratification models with and without imaging.
Cardiovascular disease (CVD) remains the leading cause of mortality both in the United States and worldwide. Traditional risk factors are essential to CVD risk prediction and explain a significant portion of the between-population and between-individual variance in CVD. Nonetheless, due to the large size of the group, a substantial portion of cardiovascular events occur in individuals predicted to be at low risk based on traditional risk factor models such as the Framingham risk score. The problem is that by disregarding this low risk group, a significant proportion of events are ignored and deemed 'unpreventable'. As such, it is imperative to find new ways to improve CVD risk prediction and thereby apply preventive measures to persons more likely to develop 'preventable' disease. Focus has consequently shifted towards identification of novel markers to improve cardiovascular risk prediction. We review the role of various risk stratification models, and assess the incorporation of imaging markers to guide treatment for lipids in prevention of CVD. PMID:24840260
Okwuosa, Tochi M; Mallikethi-Reddy, Sagar; Jones, Donald M Lloyd
The value of exercise radionuclide ventriculography in risk stratification after coronary arterial bypass grafting
Cardiac events after coronary artery bypass surgery (CABG) may be related to left ventricular (LV) function, residual coronary artery diseases (CAD), graft occlusion, and progression of CAD. This study examined the value of rest and exercise (EX) radionuclide ventriculography (RNV) done 3-6 mos after CABG in risk stratification in 212 pts. There were 185 men and 27 women, aged 57 +- 8 years (mean +- SD). During a followup period of up to 4 years, (15 +- 10 months), there were 23 cardiac events; 13 pts died of cardiac causes and 20 had non-fatal acute myocardial infarctions. The pts with and without events did not differ in: clinical presentation after CABG (most were asymptomatic), medications and ECG findings at rest and EX. The pts with events had lower EX systolic blood pressure (p < 0.01); resting LV ejection fraction (EF) (p = 0.002), and EX EF (40 +- 18% vs 54 +- 16%, p = 0.002). The change in EF (rest to EX) was not significantly different (l.6 +- 8.2%, vs 2.1 +- 9.2%). Survival analysis (Cox model) identified the EX EF as the best predictor of death and total events (X/sup 2/ = 4.3 and 2.4, p = 0.04 and 0.07 respectively). Actuarial life table analysis showed that the risk increased as the EX EF decreased when pts were grouped into EX EF greater than or equal to 50, 30-49, and <30%, (p < 0.001, Mantel-Cox). Thus, EX RNA is useful in risk stratification after CABG. The EX LVEF is an important descriptor that categorizes pts into different risks groups. The pts at high risk probably require more aggressive followup and continued medical therapy.
Iskandrian, A.S.; Hakki, A.H.; Goel, I.P.; Mundth, E.D.; Kane, S.; Schenk, C.
Background Quality and benchmarking initiatives highlight the need for accurate stratified risk adjustment. The stratification of trauma patients has relied on scores specific to trauma populations. While the Acute Physiologic and Chronic Health Evaluation (APACHE) II score has been considered "invalid" in the trauma population, we hypothesized that APAHCE II would more accurately predict outcomes in critically injured patients in whom commonly used trauma scores have inherent limitations. Methods A prospective cohort of critically injured patients was enrolled. Severity scores and their sub-components were collected, and in-hospital mortality was assessed. The area under the receiver operating characteristic (AUROC) curve was used to determine the predictive value of each score. Logistic regression estimated the odds of death associated with incremental changes in severity scores and their subcomponents. Results 1,019 patients were available for analysis. APACHE II was the best predictor of mortality (AUROC 0.77 versus AUROC 0.54 for ISS and 0.64 for TRISS). A unit increase in APACHE II was associated with an OR of death of 1.18 (95% CI 1.14 ¢ 1.22). The components of APACHE II that contributed the most to its accuracy included temperature, serum creatinine and the Glasgow Coma Scale (GCS). Conclusion Critically injured patients have physiologic derangements not accurately accounted for by commonly used trauma scores. In this subset a more general ICU scoring system is useful for risk adjustment for research, administrative and quality improvement purposes.
Dossett, Lesly A; Redhage, Leigh Anne; Sawyer, Robert G; May, Addison K
The role of copeptin as a diagnostic and prognostic biomarker for risk stratification in the emergency department
The hypothalamic-pituitary-adrenal axis is activated in response to stress. One of the activated hypothalamic hormones is arginine vasopressin, a hormone involved in hemodynamics and osmoregulation. Copeptin, the C-terminal part of the arginine vasopressin precursor peptide, is a sensitive and stable surrogate marker for arginine vasopressin release. Measurement of copeptin levels has been shown to be useful in a variety of clinical scenarios, particularly as a prognostic marker in patients with acute diseases such as lower respiratory tract infection, heart disease and stroke. The measurement of copeptin levels may provide crucial information for risk stratification in a variety of clinical situations. As such, the emergency department appears to be the ideal setting for its potential use. This review summarizes the recent progress towards determining the prognostic and diagnostic value of copeptin in the emergency department.
BRAF Mutation Testing of Thyroid Fine-Needle Aspiration Biopsy Specimens for Preoperative Risk Stratification in Papillary Thyroid Cancer
Purpose This study investigated the utility of BRAF mutation testing of thyroid fine-needle aspiration biopsy (FNAB) specimens for preoperative risk stratification in papillary thyroid cancer (PTC). Patients and Methods We assessed the T1799A BRAF mutation status in thyroid FNAB specimens obtained from 190 patients before thyroidectomy for PTC and its association with clinicopathologic characteristics of the tumor revealed postoperatively. Results We observed a significant association of BRAF mutation in preoperative FNAB specimens with poorer clinicopathologic outcomes of PTC. In comparison with the wild-type allele, BRAF mutation strongly predicted extrathyroidal extension (23% v 11%; P = .039), thyroid capsular invasion (29% v 16%; P = .045), and lymph node metastasis (38% v 18%; P = .002). During a median follow-up of 3 years (range, 0.6 to 10 years), PTC persistence/recurrence was seen in 36% of BRAF mutation¢positive patients versus 12% of BRAF mutation¢negative patients, with an odds ratio of 4.16 (95% CI, 1.70 to 10.17; P = .002). The positive and negative predictive values for preoperative FNAB-detected BRAF mutation to predict PTC persistence/recurrence were 36% and 88% for overall PTC and 34% and 92% for conventional PTC, respectively. Conclusion Preoperative BRAF mutation testing of FNAB specimens provides a novel tool to preoperatively identify PTC patients at higher risk for extensive disease (extrathyroidal extension and lymph node metastases) and those who are more likely to manifest disease persistence/recurrence. BRAF mutation, as a powerful risk prognostic marker, may therefore be useful in appropriately tailoring the initial surgical extent for patients with PTC.
Xing, Mingzhao; Clark, Douglas; Guan, Haixia; Ji, Meiju; Dackiw, Alan; Carson, Kathryn A.; Kim, Matthew; Tufaro, Anthony; Ladenson, Paul; Zeiger, Martha; Tufano, Ralph
A clinical study of ischaemic strokes with micro-albuminuria for risk stratification, short-term predictive value and outcome.
Stroke results more than 4.3 million deaths worldwide per annum and 85% of all strokes are ischaemic in nature. Besides numerous modifiable and non-modifiable known risk factors, microalbuminuria is thought to be an important marker of global endothelial dysfunction and associated with cardiovascular disease including stroke. Fifty ischaemic stroke cases and 50 (age, sex matched) control subjects were subjected to study to compare and evaluate risk stratification of micro-albuminuria, its predictive value and outcome on day 1 and day 7 among admitted ischaemic stroke cases.The result was found that micro-albuminuria was present in 66% of ischaemic stroke cases compared to only 8% of control group (p < 0.001). Most validated National Institute of Health Stroke Scale (NIHSS) score was used for evaluation and calculation of predictive value and outcome of micro-albuminuria positive patient where higher value indicates poor prognosis, and the result was mean NIHSS score 29.12 versus 18.88 between two groups of strokes ie, with and without micro-albuminuria. Out of 50 ischaemic stroke patients 33 (66%) had micro-albuminuria. Among 11 patients who died, 10 (90.9%) had micro-albuminuria and NIHSS score was 33.64 and 25.0 on day 1 and day 7. Among 39 patients who were discharged, 23 patients (58.97%) were MA positive and NIHSS score was much less than death group ie, 23.38 and 16.38 on day 1 and day 7 respectively. So this study reveals micro-albuminuria itself results higher risk for ischaemic stroke compared to control group and it shows good predictive value for early assessment of clinical severity and subsequent fatal outcome. This is also simple, cost effective and affordable. PMID:23936957
Das, Sukdeb; Yadav, Ujjal; Ghosh, Kartik Chandra; Panchadhyayee, Sujoy; Kundu, Shib Shankar; Ganguly, Prasanta Kumar
Management of newly diagnosed symptomatic multiple myeloma: updated Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) consensus guidelines 2013.
Multiple myeloma remains an incurable neoplasm of plasma cells that affects more than 20,000 people annually in the United States. There has been a veritable revolution in this disease during the past decade, with dramatic improvements in our understanding of its pathogenesis, the development of several novel agents, and a concomitant doubling in overall survival. Because multiple myeloma is a complex and wide-ranging disorder, its management must be guided by disease- and patient-related factors; emerging as one of the most influential factors is risk stratification, primarily based on cytogenetic features. A risk-adapted approach provides optimal therapy to patients, ensuring intense therapy for aggressive disease and minimizing toxic effects, providing sufficient but less intense therapy for low-risk disease. This consensus statement reflects recommendations from more than 20 Mayo Clinic myeloma physicians, providing a practical approach for newly diagnosed patients with myeloma who are not enrolled in a clinical trial. PMID:23541011
Mikhael, Joseph R; Dingli, David; Roy, Vivek; Reeder, Craig B; Buadi, Francis K; Hayman, Suzanne R; Dispenzieri, Angela; Fonseca, Rafael; Sher, Taimur; Kyle, Robert A; Lin, Yi; Russell, Stephen J; Kumar, Shaji; Bergsagel, P Leif; Zeldenrust, Steven R; Leung, Nelson; Drake, Matthew T; Kapoor, Prashant; Ansell, Stephen M; Witzig, Thomas E; Lust, John A; Dalton, Robert J; Gertz, Morie A; Stewart, A Keith; Stewart, Keith; Rajkumar, S Vincent; Chanan-Khan, Asher; Lacy, Martha Q
Three-Tiered Risk Stratification Model to Predict Progression in Barrett's Esophagus Using Epigenetic and Clinical Features
BackgroundBarrett's esophagus predisposes to esophageal adenocarcinoma. However, the value of endoscopic surveillance in Barrett's esophagus has been debated because of the low incidence of esophageal adenocarcinoma in Barrett's esophagus. Moreover, high inter-observer and sampling-dependent variation in the histologic staging of dysplasia make clinical risk assessment problematic. In this study, we developed a 3-tiered risk stratification strategy, based on systematically selected
Fumiaki Sato; Zhe Jin; Karsten Schulmann; Jean Wang; Bruce D. Greenwald; Tetsuo Ito; Takatsugu Kan; James P. Hamilton; Jian Yang; Bogdan Paun; Stefan David; Alexandru Olaru; Yulan Cheng; Yuriko Mori; John M. Abraham; Harris G. Yfantis; Tsung-Teh Wu; Mary B. Fredericksen; Kenneth K. Wang; Marcia Canto; Yvonne Romero; Ziding Feng; Stephen J. Meltzer; J÷rg Hoheisel
Risk stratification with a point-of-care cardiac troponin T test in acute myocardial infarction
Troponin T has been used successfully to risk stratify patients with acute coronary syndromes, but the utility of this approach using a rapid bedside assay in patients undergoing thrombolysis for ST-segment elevation acute myocardial infarction has not been assessed in a large population. We assessed whether a point-of-care, qualitative troponin T test at enrollment could independently risk-stratify patients randomized to
E. Magnus Ohman; Paul W Armstrong; Harvey D White; Christopher B Granger; Robert G Wilcox; W. Douglas Weaver; W. Brian Gibler; Amanda L Stebbins; Cresha Cianciolo; Robert M Califf; Eric J Topol
Erectile dysfunction in primary care: a focus on cardiometabolic risk evaluation and stratification for future cardiovascular events.
An association between erectile dysfunction (ED) and cardiovascular disease has long been recognized, and studies suggest that ED is an independent marker of cardiovascular disease risk and even further, a marker for the burden of both obstructive and non-obstructive coronary artery disease. Therefore, the primary care physician (PCP) must assess the presence or absence of ED in every man > 39 years of age, especially if that man is asymptomatic of signs and symptoms of coronary artery disease. Assessment and management of ED may help identify and reduce the risk of future cardiovascular events, particularly in younger middle-aged men. The initial ED evaluation should distinguish between predominantly vasculogenic ED and ED of other etiologies. For men believed to have predominantly vasculogenic ED, we recommend that initial cardiovascular risk stratification be based on the Framingham Risk Score. Management of men with ED who are at low risk for cardiovascular disease should focus on risk factor control; men at high risk, including those with cardiovascular symptoms, should be referred to a cardiologist. Intermediate risk men should undergo noninvasive evaluation for subclinical atherosclerosis. A growing body of evidence supports the use of selected prognostic markers to further understand cardiovascular risk in men with ED, particularly CT calcium scoring. In conclusion, we support cardiovascular risk stratification and risk factor management in all men with vasculogenic ED. PMID:24978630
Miner, Martin; Rosenberg, Matt T; Barkin, Jack
Electrocardiologic and related methods of non-invasive detection and risk stratification in myocardial ischemia: state of the art and perspectives
Background: Electrocardiographic methods still provide the bulk of cardiovascular diagnostics. Cardiac ischemia is associated with typical alterations in cardiac biosignals that have to be measured, analyzed by mathematical algorithms and allegorized for further clinical diagnostics. The fast growing fields of biomedical engineering and applied sciences are intensely focused on generating new approaches to cardiac biosignal analysis for diagnosis and risk stratification in myocardial ischemia. Objectives: To present and review the state of the art in and new approaches to electrocardiologic methods for non-invasive detection and risk stratification in coronary artery disease (CAD) and myocardial ischemia; secondarily, to explore the future perspectives of these methods. Methods: In follow-up to the Expert Discussion at the 2008 Workshop on "Biosignal Analysis" of the German Society of Biomedical Engineering in Potsdam, Germany, we comprehensively searched the pertinent literature and databases and compiled the results into this review. Then, we categorized the state-of-the-art methods and selected new approaches based on their applications in detection and risk stratification of myocardial ischemia. Finally, we compared the pros and cons of the methods and explored their future potentials for cardiology. Results: Resting ECG, particularly suited for detecting ST-elevation myocardial infarctions, and exercise ECG, for the diagnosis of stable CAD, are state-of-the-art methods. New exercise-free methods for detecting stable CAD include cardiogoniometry (CGM); methods for detecting acute coronary syndrome without ST elevation are Body Surface Potential Mapping, functional imaging and CGM. Heart rate variability and blood pressure variability analyses, microvolt T-wave alternans and signal-averaged ECG mainly serve in detecting and stratifying the risk for lethal arrythmias in patients with myocardial ischemia or previous myocardial infarctions. Telemedicine and ambient-assisted living support the electrocardiological monitoring of at-risk patients. Conclusions: There are many promising methods for the exercise-free, non-invasive detection of CAD and myocardial ischemia in the stable and acute phases. In the coming years, these new methods will help enhance state-of-the-art procedures in routine diagnostics. The future can expect that equally novel methods for risk stratification and telemedicine will transition into clinical routine.
Huebner, Thomas; Goernig, Matthias; Schuepbach, Michael; Sanz, Ernst; Pilgram, Roland; Seeck, Andrea; Voss, Andreas
Noninvasive Arrhythmia Risk Stratification in Idiopathic Dilated Cardiomyopathy Results of the Marburg Cardiomyopathy Study
significant arrhythmia risk predictor in patients with sinus rhythm, with a relative risk of 2.3 per 10% decrease of ejection fraction (95% CI, 1.5 to 3.3; P0.0001). Nonsustained ventricular tachycardia on Holter was associated with a trend toward higher arrhythmia risk (RR, 1.7; 95% CI, 0.9 to 3.3; P0.11), whereas -blocker therapy was associated with a trend toward lower arrhythmia
Wolfram Grimm; Michael Christ; Jennifer Bach; Hans-Helge M³ller; Bernhard Maisch
The incremental value of brachial flow-mediated dilation measurements in risk stratification for incident cardiovascular events: a systematic review.
Abstract Adequate risk assessment for cardiovascular disease (CVD) is essential as a guide to initiate drug treatment. Current methods based on traditional risk factors could be improved considerably. Although brachial flow-mediated dilation (FMD) predicts subsequent cardiovascular events, its predictive value on top of traditional risk factors is unknown. We performed a systematic review to evaluate the incremental predictive value of FMD on top of traditional risk factors in asymptomatic individuals. Using PubMed and reference tracking, three studies were identified that reported on the incremental value of FMD using change in the area under the curve (AUC). Two large cohort studies found no improvement in AUC when FMD was added to traditional risk prediction models, whereas one small case-control study found an improvement. One study used the net reclassification improvement (NRI) to assess whether FMD measurement leads to correct risk stratification in risk categories. Although this study did not find an improvement in AUC, the NRI was statistically significant. Based on the reclassification results of this study, FMD measurement might be helpful in risk prediction. Evidence supporting the use of FMD measurement in clinical practice for risk stratification for CVD on top of traditional risk factors is limited, and future studies are needed. PMID:21585249
Peters, Sanne A E; den Ruijter, Hester M; Bots, Michiel L
Autonomic nervous system in the genesis of arrhythmias in chronic heart failure: implication for risk stratification.
Sudden cardiac death (SCD) is one of a major cause of morbidity and mortality in patients with chronic heart failure (CHF). There is a circadian variation of the frequency of SCD. Beta-blocker therapy significantly reduces the incidence of SCD. These clinical observations suggest a close association between ventricular arrhythmia and sympathetic activity. The identification of patients at risk is a major clinical problem not only for the unpredictability of the event, but also for the continuous growth of patients'number. The implantable cardioverter-defibrillator (ICD) is highly effective at terminating life threatening ventricular tachyarrhythmia At present, 1-2% of the population has heart failure and numbers continue to increase, but the ICD remains expensive. The challenge lies in identifying patients with heart failure who are at significant risk of arrhythmia and who would benefit from an ICD in addition to other anti-arrhythmic strategies. Our power of identifying heart failure patients at risk for arrhythmic death is far from being satisfactory. Heart rate variability and baroreflex sensitivity analysis has been largely utilized to obtain information on autonomic modulation of sinus node as well as to identify patients at risk. It is possible that the combination of results of multiple noninvasive tests such as reduction in ejection fraction and positivity for T wave alternans may not only provide general prognostic information but also facilitate the appropriate identification of patients at risk who may benefit from antiarrhythmic therapy. PMID:17534251
Piepoli, M F; Capucci, A
Subgroup Analyses in Randomized Controlled Trials: the Need for Risk Stratification in Kidney Transplantation
Although randomized controlled trials are the gold standard for establishing causation in clinical research, their aggregated results can be misleading when applied to individual patients. A treatment may be beneficial in some patients, but its harms may outweigh benefits in others. While conventional one-variable-at-a-time subgroup analyses have well-known limitations, multivariable risk-based analyses can help uncover clinically significant heterogeneity in treatment effects that may be otherwise obscured. Trials in kidney transplantation have yielded the finding that a reduction in acute rejection does not translate into a similar benefit in prolonging graft survival and improving graft function. This paradox might be explained by the variation in risk for acute rejection among included kidney transplant recipients varying the likelihood of benefit or harm from intense immunosuppressive regimens. Analyses that stratify patients by their immunological risk may resolve these otherwise puzzling results. Reliable risk models should be developed to investigate benefits and harms in rationally designed risk-based subgroups of patients in existing RCT datasets. These risk strata would need to be validated in future prospective clinical trials examining long term effects on patient and graft survival. This approach may allow better individualized treatment choices for kidney transplant recipients.
Wagner, Martin; Balk, Ethan M.; Kent, David M.; Kasiske, Bertram L.; Ekberg, Henrik
Risk Stratification for Sudden Death: Do We Need Anything More Than Ejection Fraction?
Recent studies have emphasized the prognostic significance of left ventricular ejection fraction in patients with coronary and other types of heart disease. Ejection fraction relates as a continuous variable to mortality risk. In patients with a variety of underlying heart diseases, the lower the ejection fraction, the higher observed mortality. However, while ejection fraction is statistically associated with mortality, it
Alfred E. Buxton
BAALC expression: a suitable marker for prognostic risk stratification and detection of residual disease in cytogenetically normal acute myeloid leukemia.
High brain and acute leukemia, cytoplasmic (BAALC) expression defines an important risk factor in cytogenetically normal acute myeloid leukemia (CN-AML). The prognostic value of BAALC expression in relation to other molecular prognosticators was analyzed in 326 CN-AML patients (<65 years). At diagnosis, high BAALC expression was associated with prognostically adverse mutations: FLT3 internal tandem duplication (FLT3-ITD) with an FLT3-ITD/FLT3 wild-type (wt) ratio of ?0.5 (P=0.001), partial tandem duplications within the MLL gene (MLL-PTD) (P=0.002), RUNX1 mutations (mut) (P<0.001) and WT1mut (P=0.001), while it was negatively associated with NPM1mut (P<0.001). However, high BAALC expression was also associated with prognostically favorable biallelic CEBPA (P=0.001). Survival analysis revealed an independent adverse prognostic impact of high BAALC expression on overall survival (OS) and event-free survival (EFS), and also on OS when eliminating the effect of allogeneic stem cell transplantation (SCT) (OS(TXcens)). Furthermore, we analyzed BAALC expression in 416 diagnostic and follow-up samples of 66 patients. During follow-up, BAALC expression correlated with mutational load or expression levels, respectively, of other minimal residual disease markers: FLT3-ITD (r=0.650, P<0.001), MLL-PTD (r=0.728, P<0.001), NPM1mut (r=0.599, P<0.001) and RUNX1mut (r=0.889, P<0.001). Moreover, a reduction in BAALC expression after the second cycle of induction chemotherapy was associated with improved EFS. Thus, our data underline the utility of BAALC expression as a marker for prognostic risk stratification and detection of residual disease in CN-AML. PMID:24413067
Weber, S; Alpermann, T; Dicker, F; Jeromin, S; Nadarajah, N; Eder, C; Fasan, A; Kohlmann, A; Meggendorfer, M; Haferlach, C; Kern, W; Haferlach, T; Schnittger, S
miRNA Expression Profiling Enables Risk Stratification in Archived and Fresh Neuroblastoma Tumor Samples
Purpose More accurate assessment of prognosis is important to further improve the choice of risk-related therapy in neuroblastoma (NB) patients. In this study, we aimed to establish and validate a prognostic miRNA signature for children with NB and tested it in both fresh frozen and archived formalin-fixed paraffin-embedded (FFPE) samples. Experimental Design Four hundred-thirty human mature miRNAs were profiled in two patient subgroups with maximally divergent clinical courses. Univariate logistic regression analysis was used to select miRNAs correlating with NB patient survival. A 25-miRNA gene signature was built using 51 training samples, tested on 179 test samples, and validated on an independent set of 304 fresh frozen tumor samples and 75 archived FFPE samples. Results The 25-miRNA signature significantly discriminates the test patients with respect to progression-free and overall survival (P < 0.0001), both in the overall population and in the cohort of high-risk patients. Multivariate analysis indicates that the miRNA signature is an independent predictor of patient survival after controlling for current risk factors. The results were confirmed in an external validation set. In contrast to a previously published mRNA classifier, the 25-miRNA signature was found to be predictive for patient survival in a set of 75 FFPE neuroblastoma samples. Conclusions In this study, we present the largest NB miRNA expression study so far, including more than 500 NB patients. We established and validated a robust miRNA classifier, able to identify a cohort of high-risk NB patients at greater risk for adverse outcome using both fresh frozen and archived material.
De Preter, Katleen; Mestdagh, Pieter; Vermeulen, Joelle; Zeka, Fjoralba; Naranjo, Arlene; Bray, Isabella; Castel, Victoria; Chen, Caifu; Drozynska, Elzbieta; Eggert, Angelika; Hogarty, Michael D.; Izycka-Swieszewska, Ewa; London, Wendy B.; Noguera, Rosa; Piqueras, Marta; Bryan, Kenneth; Schowe, Benjamin; van Sluis, Peter; Molenaar, Jan J.; Schramm, Alexander; Schulte, Johannes H.; Stallings, Raymond L.; Versteeg, Rogier; Laureys, Genevieve; Van Roy, Nadine; Speleman, Frank; Vandesompele, Jo
The significance of vasodilator-stimulated phosphoprotein for risk stratification of stent thrombosis.
Low-response to the P2Y12 adenosine diphosphate (ADP)-receptor antagonist clopidogrel was suggested to correspond to a higher incidence of stent thrombosis (ST). This prospective observational study assessed the capability of two platelet function assays, e.g. direct measurement of the phosphorylation status of vasodilator-stimulated phosphoprotein (VASP) and ADP-induced platelet aggregation for definition of the individual risk to develop ST. Ninety-nine patients with an elevated high risk to develop ST were enrolled. All patients received a dual antiplatelet therapy consisting of 100 mg aspirin and 75 mg clopidogrel during an observation period of six months. Flow cytometry of VASP phosphorylation and densitometrically-determined measurement of ADP-induced platelet aggregation was performed 72-96 hours after stent implantation. These data were related to angiographically confirmed ST. Nine patients suffered from angiographically confirmed ST (9.1%). The meanVASP-platelet reactivity indices (VASP-PRI) and values for ADP-induced platelet aggregation in the ST group were significantly higher (60.8 +/- 13.0 and 60.9 +/- 13.1, respectively) compared to patients without ST (41.3 +/- 14.0 and 50.8 +/- 14.4, P < 0.001 vs. 0.048, respectively). There was a fair correlation between both methods using non-linear regression analysis (r = 0.332). In a multivariate analysis, VASP was the only independent predictor of ST and was superior to previously identified angiographic parameters. Receiver- operator characteristic (ROC) curve analysis revealed a cut-off value for VASP-PRI of <48% to be associated with low risk of ST. In conclusion, determination of VASP phosphorylation is superior to conventional platelet aggregometry and angiographic parameters for assessing the risk of ST. Patients with a VASP-PRI >48% seem to have a significantly increased risk. PMID:18064332
Blindt, R³diger; Stellbrink, Katja; de Taeye, Anita; M³ller, Robert; Kiefer, Paul; Yagmur, Eray; Weber, Christian; Kelm, Malte; Hoffmann, Rainer
Quantitative ultrasound criteria for risk stratification in clinical practice: a comparative assessment.
This study aimed to compare two different classifications of the risk of fracture/osteoporosis (OP) based on quantitative ultrasound (QUS). Analyses were based on data from the Epidemiological Study on the Prevalence of Osteoporosis, a cross-sectional study conducted in 2000 aimed at assessing the risk of OP in a representative sample of the Italian population. Subjects were classified into 5 groups considering the cross-classification found in previous studies; logistic regression models were defined separately for women and men to study the fracture risk attributable to groups defined by the cross-classification, adjusting for traditional risk factors. Eight-thousand six-hundred eighty-one subjects were considered in the analyses. Logistic regression models revealed that the two classifications seem to be able to identify a common core of individuals at low and at high risk of fractures, and the importance of a multidimensional assessment in older patients to evaluate clinical risk factors together with a simple, inexpensive, radiation-free device such as QUS. PMID:22542263
Noale, Marianna; Maggi, Stefania; Gonnelli, Stefano; Limongi, Federica; Zanoni, Silvia; Zambon, Sabina; Rozzini, Renzo; Crepaldi, Gaetano
I-CLIP: Improved Stratification of Advanced Hepatocellular Carcinoma Patients by Integrating Plasma IGF-1 into CLIP Score
Objective: Improving the prognostic stratification of unresectable hepatocellular carcinoma (HCC) patients is critically needed. Since patientsÆ survival is closely linked to the severity of the underlying liver disease, and insulin-like growth factor-1 (IGF-1) is produced predominantly in the liver, we hypothesized that IGF-1 may correlate with patientsÆ survival and hence improve the prognostic ability of the Cancer of the Liver
Ahmed O. Kaseb; James L. Abbruzzese; Jean-Nicolas Vauthey; Thomas A. Aloia; Eddie K. Abdalla; Manal M. Hassan; E. Lin; Lianchun Xiao; Adel S. El-Deeb; Asif Rashid; Jeffrey S. Morris
Vagal Reflexes Following an Exercise Stress Test: a Simple Clinical Tool for Gene-Specific Risk Stratification in the Long QT Syndrome
Objectives To assess whether heart rate (HR) reduction following an exercise stress test (ExStrT), an easily quantifiable marker of vagal reflexes, might identify high and low risk long QT syndrome (LQTS) type 1 (LQT1) patients. Background Identification of LQTS patients more likely to be symptomatic remains elusive. We have previously shown that depressed baroreflex sensitivity (BRS), an established marker of reduced vagal reflexes, predicts low probability of symptoms among LQT1. Methods We studied 169 LQTS genotype-positive patients below age 50 who performed an ExStrT with the same protocol, on and off ?-blockers including 47 South African LQT1 patients all harboring the KCNQ1-A341V mutation and 122 Italian LQTS patients with impaired (IKs?, LQT1, n=66) or normal (IKs+, 50 LQT2 and 6 LQT3) IKs current. Results Despite similar maximal HR and workload, by the first minute after cessation of exercise the symptomatic patients in both IKs? groups had a greater HR reduction compared to the asymptomatic (19▒7 vs 13▒5 and 27▒10 vs 20▒8 bpm, both p=0.009). By contrast, there was no difference between the IKs+ symptomatic and asymptomatic patients (23▒9 vs 26▒9 bpm, p=0.47). LQT1 patients in the upper tertile for HR reduction had a higher risk of being symptomatic (OR 3.28, 95% CI 1.3¢8.3, p=0.012). Conclusions HR reduction following exercise identifies LQT1 patients at high or low arrhythmic risk, independently of ?-blocker therapy, and contributes to risk stratification. Exercise training, which potentiates vagal reflexes, should be avoided by LQT1 patients.
Crotti, Lia; Spazzolini, Carla; Porretta, Alessandra P.; Dagradi, Federica; Taravelli, Erika; Petracci, Barbara; Vicentini, Alessandro; Pedrazzini, Matteo; Rovere, Maria Teresa La; Vanoli, Emilio; Goosen, Althea; Heradien, Marshall; Brink, Paul A.; George, Alfred L.; Schwartz, Peter J.
Congenital and hereditary causes of sudden cardiac death in young adults: diagnosis, differential diagnosis, and risk stratification.
Sudden cardiac death is defined as death from unexpected circulatory arrest-usually a result of cardiac arrhythmia-that occurs within 1 hour of the onset of symptoms. Proper and timely identification of individuals at risk for sudden cardiac death and the diagnosis of its predisposing conditions are vital. A careful history and physical examination, in addition to electrocardiography and cardiac imaging, are essential to identify conditions associated with sudden cardiac death. Among young adults (18-35 years), sudden cardiac death most commonly results from a previously undiagnosed congenital or hereditary condition, such as coronary artery anomalies and inherited cardiomyopathies (eg, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy [ARVC], dilated cardiomyopathy, and noncompaction cardiomyopathy). Overall, the most common causes of sudden cardiac death in young adults are, in descending order of frequency, hypertrophic cardiomyopathy, coronary artery anomalies with an interarterial or intramural course, and ARVC. Often, sudden cardiac death is precipitated by ventricular tachycardia or fibrillation and may be prevented with an implantable cardioverter defibrillator (ICD). Risk stratification to determine the need for an ICD is challenging and involves imaging, particularly echocardiography and cardiac magnetic resonance (MR) imaging. Coronary artery anomalies, a diverse group of congenital disorders with a variable manifestation, may be depicted at coronary computed tomographic angiography or MR angiography. A thorough understanding of clinical risk stratification, imaging features, and complementary diagnostic tools for the evaluation of cardiac disorders that may lead to sudden cardiac death is essential to effectively use imaging to guide diagnosis and therapy. PMID:24224591
Stojanovska, Jadranka; Garg, Anubhav; Patel, Smita; Melville, David M; Kazerooni, Ella A; Mueller, Gisela C
Atherosclerotic risk stratification strategy for carotid arteries using texture-based features.
Plaques in the carotid artery result in stenosis, which is one of the main causes for stroke. Patients have to be carefully selected for stenosis treatments as they carry some risk. Since patients with symptomatic plaques have greater risk for strokes, an objective classification technique that classifies the plaques into symptomatic and asymptomatic classes is needed. We present a computer aided diagnostic (CAD) based ultrasound characterization methodology (a class of Atheromatic systems) that classifies the patient into symptomatic and asymptomatic classes using two kinds of datasets: (1) plaque regions in ultrasound carotids segmented semi-automatically and (2) far wall gray-scale intima-media thickness (IMT) regions along the common carotid artery segmented automatically. For both kinds of datasets, the protocol consists of estimating texture-based features in frameworks of local binary patterns (LBP) and Law's texture energy (LTE) and applying these features for obtaining the training parameters, which are then used for classification. Our database consists of 150 asymptomatic and 196 symptomatic plaque regions and 342 IMT wall regions. When using the Atheromatic-based system on semiautomatically determined plaque regions, support vector machine (SVM) classifier was adapted with highest accuracy of 83%. The accuracy registered was 89.5% on the far wall gray-scale IMT regions when using SVM, K-nearest neighbor (KNN) or radial basis probabilistic neural network (RBPNN) classifiers. LBP/LTE-based techniques on both kinds of carotid datasets are noninvasive, fast, objective and cost-effective for plaque characterization and, hence, will add more value to the existing carotid plaque diagnostics protocol. We have also proposed an index for each type of datasets: AtheromaticPi, for carotid plaque region, and AtheromaticWi, for IMT carotid wall region, based on the combination of the respective significant features. These indices show a separation between symptomatic and asymptomatic by 4.53 units and 4.42 units, respectively, thereby supporting the texture hypothesis classification. PMID:22502883
Acharya, U Rajendra; Sree, S Vinitha; Krishnan, M Muthu Rama; Molinari, Filippo; Saba, Luca; Ho, Sin Yee Stella; Ahuja, Anil T; Ho, Suzanne C; Nicolaides, Andrew; Suri, Jasjit S
Integrated e-Health approach based on vascular ultrasound and pulse wave analysis for asymptomatic atherosclerosis detection and cardiovascular risk stratification in the community.
New strategies are urgently needed to identify subjects at increased risk of atherosclerotic cardiovascular disease (ACVD) development or complications. A National Public University Center (CUiiDARTE) was created in Uruguay, based on six main pillars: 1) integration of experts in different disciplines and creation of multidisciplinary teams, 2) incidence in public and professional education programs to give training in the use of new technologies and to shift the focus from ACVD treatment to disease prevention, 3) implementation of free vascular studies in the community (distributed rather than centralized healthcare), 4) innovation and application of e-Health and noninvasive technology and approaches, 5) design and development of a biomedical approach to determine the target population and patient workflow, and 6) improvement in individual risk estimation and differentiation between aging and ACVD-related arterial changes using population-based epidemiological and statistical patient-specific models. This work describes main features of CUiiDARTE project implementation, the scientific and technological steps and innovations done for individual risk stratification, and sub-clinical ACVD diagnosis. PMID:22271835
Santana, Daniel Bia; Z¾calo, Yanina A; Armentano, Ricardo L
Relevance of conventional cardiovascular risk factors for the prediction of coronary artery disease in diabetic patients on renal replacement therapy
in diabetic patients with chronic renal failure. Therefore coronary angiography should be performed Background: Diabetic patients undergoing renal replacement therapy have a high cardiovascular mor- in all diabetic patients prior to renal transplantation. tality. As the rate of patients with diabetic nephropathy rises, adequate risk stratification subsequent to renal Key words: cardiovascular risk factors; coronary angi- transplantation is warranted. It
Michael Koch; Frank Gradaus; Frank-Chris Schoebel; Matthias Leschke; Bernd Grabensee
Cardiac testing to manage cardiovascular risk in cancer patients.
Cardiovascular toxicity is one of the most feared complications of cancer treatment. Recent advances in oncologic therapies have resulted in improved cancer outcomes but also a new set of cardiovascular adverse effects. Common toxicities include left ventricular dysfunction/heart failure, hypertension, and myocardial ischemia. Accurate risk stratification allows avoidance of potentially harmful treatments in those patients at greatest risk while maintaining the ability to deliver high doses of effective therapies to the lower-risk population. Cardiac investigations, including echocardiography, nuclear imaging, magnetic resonance imaging, biomarker measurement, blood pressure monitoring, electrocardiography, stress testing, and invasive angiography, can help to risk-stratify selected patients. In this review, common complications are discussed in terms of the factors used to identify patients with elevated risk, the monitoring strategies available, and selected interventions that have been used to modify outcomes in patients identified as being at high risk for cardiac complications of cancer treatment. PMID:23540740
Davis, Margot; Witteles, Ronald M
Therapeutic risk management of the suicidal patient: safety planning.
This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient. PMID:24847995
Matarazzo, Bridget B; Homaifar, Beeta Y; Wortzel, Hal S
Risk stratification for sudden cardiac death: current status and challenges for the futureå
Sudden cardiac death (SCD) remains a daunting problem. It is a major public health issue for several reasons: from its prevalence (20% of total mortality in the industrialized world) to the devastating psycho-social impact on society and on the families of victims often still in their prime, and it represents a challenge for medicine, and especially for cardiology. This text summarizes the discussions and opinions of a group of investigators with a long-standing interest in this field. We addressed the occurrence of SCD in individuals apparently healthy, in patients with heart disease and mild or severe cardiac dysfunction, and in those with genetically based arrhythmic diseases. Recognizing the need for more accurate registries of the global and regional distribution of SCD in these different categories, we focused on the assessment of risk for SCD in these four groups, looking at the significance of alterations in cardiac function, of signs of electrical instability identified by ECG abnormalities or by autonomic tests, and of the progressive impact of genetic screening. Special attention was given to the identification of areas of research more or less likely to provide useful information, and thereby more or less suitable for the investment of time and of research funds.
Wellens, Hein J.J.; Schwartz, Peter J.; Lindemans, Fred W.; Buxton, Alfred E.; Goldberger, Jeffrey J.; Hohnloser, Stefan H.; Huikuri, Heikki V.; Kaab, Stefan; La Rovere, Maria Teresa; Malik, Marek; Myerburg, Robert J.; Simoons, Maarten L.; Swedberg, Karl; Tijssen, Jan; Voors, Adriaan A.; Wilde, Arthur A.
Risk stratification for sudden cardiac death: current status and challenges for the futureå.
Sudden cardiac death (SCD) remains a daunting problem. It is a major public health issue for several reasons: from its prevalence (20% of total mortality in the industrialized world) to the devastating psycho-social impact on society and on the families of victims often still in their prime, and it represents a challenge for medicine, and especially for cardiology. This text summarizes the discussions and opinions of a group of investigators with a long-standing interest in this field. We addressed the occurrence of SCD in individuals apparently healthy, in patients with heart disease and mild or severe cardiac dysfunction, and in those with genetically based arrhythmic diseases. Recognizing the need for more accurate registries of the global and regional distribution of SCD in these different categories, we focused on the assessment of risk for SCD in these four groups, looking at the significance of alterations in cardiac function, of signs of electrical instability identified by ECG abnormalities or by autonomic tests, and of the progressive impact of genetic screening. Special attention was given to the identification of areas of research more or less likely to provide useful information, and thereby more or less suitable for the investment of time and of research funds. PMID:24801071
Wellens, Hein J J; Schwartz, Peter J; Lindemans, Fred W; Buxton, Alfred E; Goldberger, Jeffrey J; Hohnloser, Stefan H; Huikuri, Heikki V; Kõõb, Stefan; La Rovere, Maria Teresa; Malik, Marek; Myerburg, Robert J; Simoons, Maarten L; Swedberg, Karl; Tijssen, Jan; Voors, Adriaan A; Wilde, Arthur A
Effectiveness of a multidisciplinary chest pain unit for the assessment of coronary syndromes and risk stratification in the Florence area
Background In patients seen at the emergency department (ED) with chest pain (CP), noninvasive diagnostic strategies may differentiate patients at high or intermediate risk from those at low-risk for cardiovascular events and optimize the use of high-cost resources. However, in welfare healthcare systems, the feasibility, accuracy, and potential benefits of such management strategy need further investigation. Methods A total of
Alberto Conti; Barbara Paladini; Simone Toccafondi; Simone Magazzini; Iacopo Olivotto; Ferdinando Galassi; Cesco Pieroni; Gennaro Santoro; David Antoniucci; Giancarlo Berni
Risk Stratification by the ōEPA+DHA Levelö and the ōEPA\\/AA Ratioö
The identification of risks associated with sudden cardiac death requires further investigations. The question was addressed whether parameters can be established which not only describe an increased risk for an enhanced electrical instability of the heart but also of inflammatory events underlying plaque rupture. Emphasis is placed on dose-dependent effects of the long-chain omega-(?-)3 fatty acids eicosapentaenoic acid (EPA) and
Heinz Rupp; Daniela Wagner; Thomas Rupp; Lisa-Maria Schulte; Bernhard Maisch
Time-dependent propensity score and collider-stratification bias: an example of beta2-agonist use and the risk of coronary heart disease.
Stratification and conditioning on time-varying cofounders which are also intermediates can induce collider-stratification bias and adjust-away the (indirect) effect of exposure. Similar bias could be expected when one conditions on time-dependent PS. We explored collider-stratification and confounding bias due to conditioning or stratifying on time-dependent PS using a clinical example on the effect of inhaled short- and long-acting beta2-agonist use (SABA and LABA, respectively) on coronary heart disease (CHD). In an electronic general practice database we selected a cohort of patients with an indication for SABA and/or LABA use and ascertained potential confounders and SABA/LABA use per three month intervals. Hazard ratios (HR) were estimated using PS stratification as well as covariate adjustment and compared with those of Marginal Structural Models (MSMs) in both SABA and LABA use separately. In MSMs, censoring was accounted for by including inverse probability of censoring weights.The crude HR of CHD was 0.90 [95 % CI: 0.63, 1.28] and 1.55 [95 % CI: 1.06, 2.62] in SABA and LABA users respectively. When PS stratification, covariate adjustment using PS, and MSMs were used, the HRs were 1.09 [95 % CI: 0.74, 1.61], 1.07 [95 % CI: 0.72, 1.60], and 0.86 [95 % CI: 0.55, 1.34] for SABA, and 1.09 [95 % CI: 0.74, 1.62], 1.13 [95 % CI: 0.76, 1.67], 0.77 [95 % CI: 0.45, 1.33] for LABA, respectively. Results were similar for different PS methods, but higher than those of MSMs. When treatment and confounders vary during follow-up, conditioning or stratification on time-dependent PS could induce substantial collider-stratification or confounding bias; hence, other methods such as MSMs are recommended. PMID:23354982
Sanni Ali, M; Groenwold, Rolf H H; Pestman, Wiebe R; Belitser, Svetlana V; Hoes, Arno W; de Boer, A; Klungel, Olaf H
Risk Stratification after Biochemical Failure following Curative Treatment of Locally Advanced Prostate Cancer: Data from the TROG 96.01 Trial.
Purpose. Survival following biochemical failure is highly variable. Using a randomized trial dataset, we sought to define a risk stratification scheme in men with locally advanced prostate cancer (LAPC). Methods. The TROG 96.01 trial randomized 802 men with LAPC to radiation?▒?neoadjuvant androgen suppression therapy (AST) between 1996 and 2000. Ten-year follow-up data was used to develop three-tier post-biochemical failure risk stratification schemes based on cutpoints of time to biochemical failure (TTBF) and PSA doubling time (PSADT). Schemes were evaluated in univariable, competing risk models for prostate cancer-specific mortality. The performance was assessed by c-indices and internally validated by the simple bootstrap method. Performance rankings were compared in sensitivity analyses using multivariable models and variations in PSADT calculation. Results. 485 men developed biochemical failure. c-indices ranged between 0.630 and 0.730. The most discriminatory scheme had a high risk category defined by PSADT?4 months or TTBF?1 year and low risk category by PSADT?>?9 months or TTBF?>?3 years. Conclusion. TTBF and PSADT can be combined to define risk stratification schemes after biochemical failure in men with LAPC treated with short-term AST and radiotherapy. External validation, particularly in long-term AST and radiotherapy datasets, is necessary. PMID:23320177
Steigler, Allison; Denham, James W; Lamb, David S; Spry, Nigel A; Joseph, David; Matthews, John; Atkinson, Chris; Turner, Sandra; North, John; Christie, David; Tai, Keen-Hun; Wynne, Chris
ERIC Educational Resources Information Center
According to the author, most grammarians have been writing stratificational grammars without knowing it because they have dealt with units that are related to one another, but not simply as a whole to its parts, or as a class to its members. The question, then, is not whether a grammar is stratified but whether it is explicitly stratified. Thisģ
Algeo, John
Advances in Biophotonics Detection of Field Carcinogenesis for Colon Cancer Risk Stratification
The process of neoplastic transformation of the colon involves a progression through hyperproliferative epithelium through the aberrant crypt foci?small adenoma?large adenoma?invasive cancer?metastatic disease. These are orchestrated by sequential genetic and epigenetic events which provide the underpinnings of cellular alterations such as early induction in proliferation/suppression of apoptosis, along with the late stage increase in invasiveness. Colorectal cancer (CRC) averages 49-111 mutations per tumor encompassing 10-15 critical signaling pathways[1]. Accumulating such a high number of mutations requires a fertile mutational field, which is the hallmark of colon carcinogenesis. While genetic susceptibility to colorectal cancer is well-known, at least half of the risk is believed to be due to exogeneous factors (e.g., obesity, diet, exercise). Understanding these risk factors represents a promising mode of tailoring screening modality and intensity. However, previous attempts using these factors (i.e., NCI risk calculator) have only been modestly successful with an area under receiver operating characteristics (ROC) curve (AUC) of just 0.61. One of the most important concepts is that risk is the interaction between these genetic and environmental components and is driven by the variety of polymorphisms. Thus, predicting risk is difficult given the complexity. On the other hand, the colonic mucosa represents the end product of the complex interplay between these multiple factors. The power of field carcinogenesis is that it reflects this interplay between genetics and environment.
Backman, Vadim; Roy, Hemant K.
Mortality Risk Stratification in Chronic Kidney Disease: One Size for All Ages?
Current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria for chronic kidney disease (CKD) are intended to apply to all age groups. However, it is unclear whether different levels of estimated GFR (eGFR) have the same prognostic significance in older and younger patients. The study cohort was composed of Department of Veterans Affairs (VA) patients who were aged
Ann M. O'Hare; Daniel Bertenthal; Kenneth E. Covinsky; C. Seth Landefeld; Saunak Sen; Kala Mehta; Michael A. Steinman; Ann Borzecki; Louise C. Walter; Bedford VAMC
Project of an expert system supporting risk stratification and therapeutic decision making in acute coronary syndromes.
The aim of the project was to create a computer program--expert system, which will support a doctor when a management for patients with acute coronary syndrome needs to be chosen. The expert system consists of four modules: knowledge base, previous cases database, inference engine and explanation module. Knowledge base was created with support of clinical experts, based on current management standards, guidelines and results of clinical trials according to evidence-based medicine rules. Data from new patient are added to the case database. Inference engine integrates two types of reasoning rule-based and case-based reasoning. Computer expert system gives unambiguous and objective answer. Recommendation given by an expert system can be reliable. At present the system is tested in clinical practice. Strategies recommended by the system are compared to the management applied in patients treated in Cardiology Clinic. PMID:14703289
Grabowski, Marcin; Filipiak, Krzysztof J; Rudowski, Robert; Opolski, Grzegorz
Is Coronary Computed Tomography Angiography a Resource Sparing Strategy in the Risk Stratification and Evaluation of Acute Chest Pain? Results of a Randomized Controlled Trial
Objectives Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. Methods Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. Results The mean (▒ standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ▒ $14,239) versus the SC-only group ($16,579; SD ▒ $19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = ?$1,291; 95% confidence interval [CI] = ?$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = ?33%; 95% CI = ?56% to ?10%; p = 0.007). Conclusions Adding CCTA to the current ED risk stratification of ACPSs resulted in no difference in the quantity of resources utilized, but an increased diagnosis of CAD, and significantly less recidivism and rehospitalization over a 90-day follow-up period.
Miller, Adam H.; Pepe, Paul E.; Peshock, Ron; Bhore, Rafia; Yancy, Clyde C.; Xuan, Lei; Miller, Margarita M.; Huet, Gisselle R.; Trimmer, Clayton; Davis, Rene; Chason, Rebecca; Kashner, Micheal T.
Talking to patients about risk
Doctors talking with patients about alternative treatments for life-threatening disease must be sensitive to the ways in which patients understand and deal with risk. Risk is a combination of chance, measured by some known or estimated probability, and loss, which is a function of magnitude and the subjective value placed upon it by the person at risk. Prospect theory, economics,
Terry L. Deibel; Benjamin D. Sommers; Richard Gilmore; Arthur Sagalowsky; Neal Shore
A GMM-based breast cancer risk stratification using a resonance-frequency electrical impedance spectroscopy
Purpose: The authors developed and tested a multiprobe-based resonance-frequency-based electrical impedance spectroscopy (REIS) system. The purpose of this study was to preliminarily assess the performance of this system in classifying younger women into two groups, those ultimately recommended for biopsy during imaging-based diagnostic workups that followed screening and those rated as negative during mammography. Methods: A seven probe-based REIS system was designed, assembled, and is currently being tested in the breast imaging facility. During an examination, contact is made with the nipple and six concentric points on the breast skin. For each measurement channel between the center probe and one of the six external probes, a set of electrical impedance spectroscopy (EIS) signal sweeps is performed and signal outputs ranging from 200 to 800 kHz at 5 kHz interval are recorded. An initial subset of 174 examinations from an ongoing prospective clinical study was selected for this preliminary analysis. An initial set of 35 features, 33 of which represented the corresponding EIS signal differences between the left and right breasts, was established. A Gaussian mixture model (GMM) classifier was developed to differentiate between ōpositiveö (biopsy recommended) cases and ōnegativeö (nonbiopsy) cases. Selecting an optimal feature set was performed using genetic algorithms with an area under a receiver operating characteristic curve (AUC) as the fitness criterion. Results: The recorded EIS signal sweeps showed that, in general, negative (nonbiopsy) examinations have a higher level of electrical impedance symmetry between the two breasts than positive (biopsy) examinations. Fourteen features were selected by genetic algorithm and used in the optimized GMM classifier. Using a leave-one-case-out test, the GMM classifier yielded a performance level of AUC=0.78, which compared favorably to other three widely used classifiers including support vector machine, classification tree, and linear discriminant analysis. These results also suggest that the REIS signal based GMM classifier could be used as a prescreening tool to correctly identify a fraction of younger women at higher risk of developing breast cancer (i.e., 47% sensitivity at 90% specificity). Conclusions: The study confirms that asymmetry in electrical impedance characteristics between two breasts provides valuable information regarding the presence of a developing breast abnormality; hence, REIS data may be useful in classifying younger women into two groups of ōaverageö and ōsignificantly higher than averageö risk of having or developing a breast abnormality that would ultimately result in a later imaging-based recommendation for biopsy.
Lederman, Dror; Zheng, Bin; Wang, Xingwei; Sumkin, Jules H.; Gur, David
Risk Stratification of Latent Tuberculosis Defined by Combined Interferon Gamma Release Assays
Background Most individuals infected with Mycobacterium tuberculosis develop latent tuberculosis infection (LTBI). Some may progress to active disease and would benefit from preventive treatment yet no means currently exists to predict who will reactivate. Here, we provide an approach to stratify LTBI based on IFN-? responses to two antigens, the recombinant Early-Secreted Antigen Target-6 (rESAT-6) and the latency antigen Heparin-Binding Haemagglutinin (HBHA). Methods We retrospectively analyzed results from in-house IFN-?-release assays with HBHA (HBHA-IGRA) and rESAT-6 (rESAT-6-IGRA) performed during a 12-year period on serial blood samples (3 to 9) collected from 23 LTBI subjects in a low-TB incidence country. Both the kinetics of the absolute IFN-? concentrations secreted in response to each antigen and the dynamics of HBHA/rESAT-6-induced IFN-? concentrations ratios were examined. Results This analysis allowed the identification among the LTBI subjects of three major groups. Group A featured stable HBHA and rESAT-6-IGRA profiles with an HBHA/rESAT-6 ratio persistently higher than 1, and with high HBHA- and usually negative rESAT-6-IGRA responses throughout the study. Group B had changing HBHA/rESAT-6 ratios fluctuating from 0.0001 to 10,000, with both HBHA and rESAT-6 responses varying over time at least once during the follow-up. Group C was characterized by a progressive disappearance of all responses. Conclusions By combining the measures of IFN-? concentrations secreted in response to an early and a latency antigens, LTBI subjects can be stratified into different risk groups. We propose that disappearing responses indicate cure, that persistent responses to HBHA with HBHA/rESAT-6 ratios ?1 represent stable LTBI subjects, whereas subjects with ratios varying from >1 to <1 should be closely monitored as they may represent the highest-risk group, as illustrated by a case report, and should therefore be prioritized for preventive treatment.
Corbiere, Veronique; Pottier, Gaelle; Bonkain, Florence; Schepers, Kinda; Verscheure, Virginie; Lecher, Sophie; Doherty, T. Mark; Locht, Camille; Mascart, Francoise
Short and long-term assessment of heart rate variability for risk stratification after acute myocardial infarction
Depressed heart rate variability (HRV) has been shown to be a powerful and independent risk factor in patients following acute myocardial infarction (AMI). A detailed comparison of the predictive values between short- and long-term HRV has not been made. The predictive value of short-term HRV for 1-year total cardiac mortality was studied in 700 consecutive patients after AMI. All patients
L³ Fei; Xavier Copie; Marek Malik; A. John Camm
Evidence for risk stratification when monitoring for toxicities following initiation of combination antiretroviral therapy
Objective Laboratory monitoring is recommended during combination antiretroviral therapy (cART), but the pattern of detected abnormalities and optimal monitoring are unknown. We assessed laboratory abnormalities during initial cART in 2000¢2010 across the United States. Design Observational study in the Centers for AIDS Research Network of Integrated Clinical Systems Cohort. Methods Among patients with normal results within a year prior to cART initiation, time to first significant abnormality was assessed by Kaplan¢Meier curves stratified by event type, with censoring at first of regimen change, loss to follow-up, or 104 weeks. Incidence rates of first events were estimated using Poisson regression; multivariable analyses identified associated factors. Results were stratified by time (16 weeks) from therapy initiation. Results A total of 3470 individuals contributed 3639 person-years. Median age, pre-cART CD4, and follow-up duration were 40 years, 206 cells/?l, and 51 weeks, respectively. Incidence rates for significant abnormalities (per 100 person-years) in the first 16 weeks post-cART initiation were as follows: lipid 49 [95% confidence interval (CI) 41¢ 58]; hematologic = 44 (40¢49); hepatic = 24 (20¢27); and renal = 9 (7¢11), dropping substantially during weeks 17¢104 of cART to lipid = 23 (18¢29); hematologic = 5 (4¢6); hepatic = 6 (5¢8); and renal = 2 (1¢3) (all P < 0.05). Among patients receiving initial cART with no prior abnormality (N = 1889), strongest associations for hepatic abnormalities after 16 weeks were hepatitis B and C [hazard ratio 2.3 (95% CI 1.2¢4.5) and hazard ratio = 3.0 (1.9¢4.5), respectively]. The strongest association for renal abnormalities was hypertension [hazard ratio = 2.8 (1.4¢5.6)]. Conclusion New abnormalities decreased after week 16 of cART. For abnormalities not present by week 16, subsequent monitoring should be guided by comorbidities.
Taiwo, Babafemi; Yanik, Elizabeth L.; Napravnik, Sonia; Ryscavage, Patrick; Koletar, Susan L.; Moore, Richard; Mathews, W. Christopher; Crane, Heidi M.; Mayer, Kenneth; Zinski, Anne; Kahn, James S.; Eron, Joseph J.
Stroke Prevention in the High-risk Atrial Fibrillation Patient: Medical Management
Medical management of patients with atrial fibrillation (AF) at high risk for stroke is limited by problems of imperfect tools\\u000a for assessment of thromboembolism and bleeding risks. Improved instruments, such as the CHA2DS2VASc and HAS-BLED risk stratification scores, have been incorporated into European practice guidelines. Until recently, the\\u000a most effective therapy for stroke prevention has been anticoagulation with a vitamin
Michael Broukhim; Jonathan L. Halperin
Screening for Abuse Risk in Pain Patients
As opioid prescribing has dramatically expanded over the past decade, so too has the problem of prescription drug abuse. In response to these now two major public health problems ¢ the problem of poorly treated chronic pain and the problem of opioid abuse ¢ a new paradigm has arisen in pain management, namely risk stratification. Once a prescriber has determined
Tara M. Bohn; Lauren B. Levy; Sheyla Celin; Tatiana D. Starr; Steven D. Passik
Biology, Risk Stratification, and Therapy of Pediatric Acute Leukemias: An Update
Purpose We review recent advances in the biologic understanding and treatment of childhood acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML), identify therapeutically challenging subgroups, and suggest future directions of research. Methods A review of English literature on childhood acute leukemias from the past 5 years was performed. Results Contemporary treatments have resulted in 5-year event-free survival rates of approximately 80% for childhood ALL and almost 60% for pediatric AML. The advent of high-resolution genome-wide analyses has provided new insights into leukemogenesis and identified many novel subtypes of leukemia. Virtually all ALL and the vast majority of AML cases can be classified according to specific genetic abnormalities. Cooperative mutations involved in cell differentiation, cell cycle regulation, tumor suppression, drug responsiveness, and apoptosis have also been identified in many cases. The development of new formulations of existing drugs, molecularly targeted therapy, and immunotherapies promises to further advance the cure rates and improve quality of life of patients. Conclusion The application of new high-throughput sequencing techniques to define the complete DNA sequence of leukemia and host normal cells and the development of new agents targeted to leukemogenic pathways promise to further improve outcome in the coming decade.
Pui, Ching-Hon; Carroll, William L.; Meshinchi, Soheil; Arceci, Robert J.
Stratification of the severity of critically ill patients with classification trees
Background Development of three classification trees (CT) based on the CART (Classification and Regression Trees), CHAID (Chi-Square Automatic Interaction Detection) and C4.5 methodologies for the calculation of probability of hospital mortality; the comparison of the results with the APACHE II, SAPS II and MPM II-24 scores, and with a model based on multiple logistic regression (LR). Methods Retrospective study of 2864 patients. Random partition (70:30) into a Development Set (DS) n = 1808 and Validation Set (VS) n = 808. Their properties of discrimination are compared with the ROC curve (AUC CI 95%), Percent of correct classification (PCC CI 95%); and the calibration with the Calibration Curve and the Standardized Mortality Ratio (SMR CI 95%). Results CTs are produced with a different selection of variables and decision rules: CART (5 variables and 8 decision rules), CHAID (7 variables and 15 rules) and C4.5 (6 variables and 10 rules). The common variables were: inotropic therapy, Glasgow, age, (A-a)O2 gradient and antecedent of chronic illness. In VS: all the models achieved acceptable discrimination with AUC above 0.7. CT: CART (0.75(0.71-0.81)), CHAID (0.76(0.72-0.79)) and C4.5 (0.76(0.73-0.80)). PCC: CART (72(69-75)), CHAID (72(69-75)) and C4.5 (76(73-79)). Calibration (SMR) better in the CT: CART (1.04(0.95-1.31)), CHAID (1.06(0.97-1.15) and C4.5 (1.08(0.98-1.16)). Conclusion With different methodologies of CTs, trees are generated with different selection of variables and decision rules. The CTs are easy to interpret, and they stratify the risk of hospital mortality. The CTs should be taken into account for the classification of the prognosis of critically ill patients.
A Novel Risk Stratification to Predict Local-Regional Failures in Urothelial Carcinoma of the Bladder After Radical Cystectomy
Purpose: Local-regional failures (LF) following radical cystectomy (RC) plus pelvic lymph node dissection (PLND) with or without chemotherapy for invasive urothelial bladder carcinoma are more common than previously reported. Adjuvant radiation therapy (RT) could reduce LF but currently has no defined role because of previously reported morbidity. Modern techniques with improved normal tissue sparing have rekindled interest in RT. We assessed the risk of LF and determined those factors that predict recurrence to facilitate patient selection for future adjuvant RT trials. Methods and Materials: From 1990-2008, 442 patients with urothelial bladder carcinoma at University of Pennsylvania were prospectively followed after RC plus PLND with or without chemotherapy with routine pelvic computed tomography (CT) or magnetic resonance imaging (MRI). One hundred thirty (29%) patients received chemotherapy. LF was any pelvic failure detected before or within 3 months of distant failure. Competing risk analyses identified factors predicting increased LF risk. Results: On univariate analysis, pathologic stage {>=}pT3, <10 nodes removed, positive margins, positive nodes, hydronephrosis, lymphovascular invasion, and mixed histology significantly predicted LF; node density was marginally predictive, but use of chemotherapy, number of positive nodes, type of surgical diversion, age, gender, race, smoking history, and body mass index were not. On multivariate analysis, only stage {>=}pT3 and <10 nodes removed were significant independent LF predictors with hazard ratios of 3.17 and 2.37, respectively (P<.01). Analysis identified 3 patient subgroups with significantly different LF risks: low-risk ({<=}pT2), intermediate-risk ({>=}pT3 and {>=}10 nodes removed), and high-risk ({>=}pT3 and <10 nodes) with 5-year LF rates of 8%, 23%, and 42%, respectively (P<.01). Conclusions: This series using routine CT and MRI surveillance to detect LF confirms that such failures are relatively common in cases of locally advanced disease and provides a rubric based on pathological stage and number of nodes removed that stratifies patients into 3 groups with significantly different LF risks to simplify patient selection for future adjuvant radiation therapy trials.
Baumann, Brian C. [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Guzzo, Thomas J. [Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); He Jiwei [Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Keefe, Stephen M. [Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Tucker, Kai; Bekelman, Justin E. [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Hwang, Wei-Ting [Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Vaughn, David J. [Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Malkowicz, S. Bruce [Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)] [Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Christodouleas, John P., E-mail: email@example.com [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)
The promise of pharmacogenetics: assessing the prospects for disease and patient stratification.
Pharmacogenetics is an emerging biotechnology concerned with understanding the genetic basis of drug response, and promises to transform the development, marketing and prescription of medicines. This paper is concerned with analysing the move towards segmented drug markets, which is implicit in the commercial development of pharmacogenetics. It is claimed that in future who gets a particular drug will be determined by their genetic make up. Drawing on ideas from the sociology of expectations we examine how pharmaceutical and biotechnology companies are constructing, responding to and realising particular 'visions' or expectations of pharmacogenetics and market stratification. We argue that the process of market segmentation remains uncertain, but that the outcome will be fashioned according to the convergence and divergence of the interests of key commercial actors. Qualitative data based both on interviews with industry executives and company documentation will be used to explore how different groups of companies are developing pharmacogenetics in distinct ways, and what consequences these different pathways might have for both clinical practice and health policy. In particular, the analysis will show a convergence of interests between biotechnology and pharmaceutical companies for creating segmented markets for new drugs, but a divergence of interest in segmenting established markets. Whilst biotechnology firms have a strong incentive to innovate, the pharmaceutical industry has no commercial interest in segmenting markets for existing products. This has important implications, as many of the claimed public health benefits of pharmacogenetics will derive from changing the prescribing of existing medicines. One significant implication of this is that biotechnology companies who wish to apply pharmacogenetics to existing medicines will have to explore an alternative convergence of interests with healthcare payers and providers (health insurers, HMOs, MCOs and national health systems). Healthcare providers may have a strong incentive to use pharmacogenetics to make the prescribing of existing medicine more cost-effective. However, we conclude by suggesting that a question mark hangs over their ability to provide the necessary economic and structural resources to bring such a vision to fruition. PMID:16980196
Smart, Andrew; Martin, Paul
Effective risk stratification using exercise myocardial perfusion SPECT in women: Gender-related differences in prognostic nuclear testing
Objectives. This study was designed to evaluate the incremental prognostic value over clinical and exercise variables of rest thallium-201\\/exercise technetium-99m sestamibi single-photon emission computed tomography (SPECT) in women compared with men and to determine whether this test can be used to effectively risk stratify patients of both genders.Background. To minimize the previously described gender-related bias in the evaluation of coronary
Rory Hachamovitch; Daniel S. Berman; Hosen Kiat; C. Noel Bairey Merz; Ishac Cohen; J. Arthur Cabico; John Friedman; Guido Germano; Kenneth F. Van Train; George A. Diamond
Clinical Criteria Replenish High-Sensitive Troponin and Inflammatory Markers in the Stratification of Patients with Suspected Acute Coronary Syndrome
Objectives In patients with suspected acute coronary syndrome (ACS), rapid triage is essential. The aim of this study was to establish a tool for risk prediction of 30-day cardiac events (CE) on admission. 30-day cardiac events (CE) were defined as early coronary revascularization, subsequent myocardial infarction, or cardiovascular death within 30 days. Methods and Results This single-centre, prospective cohort study included 377 consecutive patients presenting to the emergency department with suspected ACS and for whom troponin T measurements were requested on clinical grounds. Fifteen biomarkers were analyzed in the admission sample, and clinical parameters were assessed by the TIMI risk score for unstable angina/Non-ST myocardial infarction and the GRACE risk score. Sixty-nine (18%) patients presented with and 308 (82%) without ST-elevations, respectively. Coronary angiography was performed in 165 (44%) patients with subsequent percutaneous coronary intervention ¢ accounting for the majority of CE ¢ in 123 (33%) patients, respectively. Eleven out of 15 biomarkers were elevated in patients with CE compared to those without. High-sensitive troponin T (hs-cTnT) was the best univariate biomarker to predict CE in Non-ST-elevation patients (AUC 0.80), but did not yield incremental information above clinical TIMI risk score (AUC 0.80 vs 0.82, p?=?0.69). Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE. Conclusions In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.
Stahli, Barbara Elisabeth; Yonekawa, Keiko; Altwegg, Lukas Andreas; Wyss, Christophe; Hof, Danielle; Fischbacher, Philipp; Brauchlin, Andreas; Schulthess, Georg; Krayenbuhl, Pierre-Alexandre; von Eckardstein, Arnold; Hersberger, Martin; Neidhart, Michel; Gay, Steffen; Novopashenny, Igor; Wolters, Regine; Frank, Michelle; Wischnewsky, Manfred Bernd; Luscher, Thomas Felix; Maier, Willibald
Traditional Chinese Medicine ZHENG Identification Provides a Novel Stratification Approach in Patients with Allergic Rhinitis
Background. We aimed to apply the ZHENG identification to provide an easy and useful tool to stratify the patients with allergic rhinitis (AR) through exploring the correlation between the quantified scores of AR symptoms and the TCM ZHENGs. Methods. A total of 114 AR patients were enrolled in this observational study. All participants received the examinations of anterior rhinoscopy and acoustic rhinometry. Their blood samples were collected for measurement of total serum immunoglobulin E (IgE), blood eosinophil count (Eos), and serum eosinophil cationic protein (ECP). They also received two questionnaire to assess the severity scores of AR symptoms and quantified TCM ZHENG scores. Multiple linear regression analysis was used to determine explanatory factors for the score of AR manifestations. Results. IgE and ECP level, duration of AR, the 2 derived TCMZHENG scores of ōYin-Xu ? Yang-Xuö, and ōQi-Xu + Blood-Xuö were 5 explanatory variables to predict the severity scores of AR symptoms. The patients who had higher scores of ōYin-Xu ? Yang-Xuö or ōQi-Xu + Blood-Xuö tended to manifest as ōsneezer and runnerö or ōblockers,ö respectively. Conclusions. The TCM ZHENG scores correlated with the severity scores of AR symptoms and provided an easy and useful tool to stratify the AR patients.
Liang, Kai-Li; Jiang, Rong-San; Lee, Chia-Lin; Chiang, Pei-Jung; Lin, Jui-Shan; Su, Yi-Chang
[Comparison of exercise thallium-201 perfusion scintigraphy and coronarography in the prognostic stratification of patients with post-infarction residual ischemia].
The goals of this study were: 1) to determine and compare the prognostic utility of exercise 201Thallium scintigraphy with coronary angiography in patients with residual ischemia at the symptom limited bicycle exercise testing performed at hospital discharge after a first uncomplicated acute myocardial infarction 2) to verify the ability of perfusion scintigraphy to identify better than coronary angiography a subset of these patients at low risk for future events, despite the ischemic response at the exercise stress testing. Accordingly, follow-up data were obtained prospectively for 72 consecutive patients with adequate left ventricular rest systolic function, and with exercise induced greater than or equal to 1 mm ST-segment depression and/or typical angina pectoris. A planar 201Thallium scintigraphy and coronary angiography were performed within 2 months after acute myocardial infarction. By 31 +/- 29 months 38 patients had no events, while 34 experienced a cardiac event: 3 died of cardiac causes, 2 had nonfatal recurrent myocardial infarction, 29 were rehospitalized for severe class III or IV angina pectoris (4 were treated medically, 25 were revascularized: 20 had coronary bypass surgery, 5 coronary angioplasty). Each of the 3 angiographic classification of coronary artery disease (number of vessels with greater than or equal to 70% reduction of luminal diameter, jeopardy score and Gensini score) accurately identified patients with subsequent cardiac event by Mantel and Cox analysis (respectively p = 0.01, p = 0.0000, p = 0.002). Among 201Thallium variables, the number of segments demonstrating redistribution on delayed images (p = 0.0000), the number of segments with persistent defect (p = 0.0003) and increased 201Thallium uptake by the lungs (p = 0.0100) effectively stratified the probability of survival by the same analysis. Furthermore, the number of perfusion defects, either transient or persistent, with exercise 201Thallium scintigraphy provide additive prognostic information to any of the 3 angiographic coronary artery disease classifications considered. On the contrary, when 201Thallium stress findings are known, coronary angiography data in general are not additive in risk stratification. 17 patients with no reversible perfusion defect remained stable at follow up (52 +/- 28 months) despite development of typical angina pectoris (11/17) and/or ischemic ST segment depression (12/17) during exercise testing.(ABSTRACT TRUNCATED AT 400 WORDS) PMID:1790832
Dalle Mule, J; Soravia, G; Da Rold, A; Pellegrini, P; Perelli, R; Martinelli, F; Sponga, B; Burelli, C; Zanuttini, D
The Burden of Hard Atherosclerotic Plaques Does Not Promote Endoleak Development After Endovascular Aortic Aneurysm Repair: A Risk Stratification
Purpose: To objectify the influence of the atherosclerotic burden in the proximal landing zone on the development of endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) using objective aortic calcium scoring (ACS). Materials and Methods: This retrospective observation study included 267 patients who received an aortic endograft between 1997 and 2010 and for whom preoperative computed tomography (CT) was available to perform ACS using the CT-based V600 method. The mean follow-up period was 2 {+-} 2.3 years. Results: Type I endoleaks persisted in 45 patients (16.9%), type II in 34 (12.7%), type III in 8 (3%), and type IV or V in 3 patients, respectively (1.1% each). ACS in patients with type I endoleaks was not increased: 0.029 {+-} 0.061 ml compared with 0.075 {+-} 0.1349 ml in the rest of the patients, (p > 0.05; Whitney-Mann U-Test). There were significantly better results for the indication 'traumatic aortic rupture' than for the other indications (p < 0.05). In multivariate logistic regression analyses, age was an independent risk factor for the development of type I endoleaks in the thoracic aorta (Wald 9.5; p = 0.002), whereas ACS score was an independent protective factor (Wald 6.9; p = 0.009). In the abdominal aorta, neither age nor ACS influenced the development of endoleaks. Conclusion: Contrary to previous assumptions, TEVAR and EVAR can be carried out without increasing the risk of an endoleak of any type, even if there is a high atherosclerotic 'hard-plaque' burden of the aorta. The results are significantly better for traumatic aortic.
Petersen, Johannes, E-mail: email@example.com; Glodny, Bernhard, E-mail: email@example.com [Innsbruck Medical University, Department of Radiology (Austria)
Screening, risk assessment, and the approach to therapy in patients with prostate cancer.
The major challenge in prostate cancer is to identify patients at higher risk of death and to distinguish them from those more likely to die from other causes. Stratification of patients into risk groups can be used to guide management decisions at each disease stage. This review discusses the measures, tools, and nomograms available for risk assessment in prostate cancer. For patients with localized hormone-sensitive disease, the choice is between active surveillance and radical treatment, with focal therapy an emerging option. Current guidelines recommend treatment of patients with a life expectancy ?10 years, although active surveillance is being used with increasing frequency for low-risk patients, even with a long life expectancy. A number of risk stratification methods have been devised to assess the risk of biochemical recurrence (BCR) after treatment, with prostate-specific antigen (PSA) level, Gleason score, clinical stage, and tumor mass/volume all shown to be predictive of BCR. Among men with BCR after treatment, PSA doubling time (PSADT) was the best predictor of further progression. Although studies in patients with castration-resistant prostate cancer have shown that PSA level and PSADT are associated with a risk of developing metastatic disease, there is currently no clear surrogate for disease progression or overall survival for this patient group and no standard second- or third-line therapy after progression on first-line chemotherapy. The use of newly developed risk-stratification models and markers of disease progression should assist in the earlier identification of disease progression, allowing the optimal treatment of such patients. PMID:20960523
Freedland, Stephen J
Classification and risk stratification of invasive breast carcinomas using a real-time quantitative RT-PCR assay
Introduction Predicting the clinical course of breast cancer is often difficult because it is a diverse disease comprised of many biological subtypes. Gene expression profiling by microarray analysis has identified breast cancer signatures that are important for prognosis and treatment. In the current article, we use microarray analysis and a real-time quantitative reverse-transcription (qRT)-PCR assay to risk-stratify breast cancers based on biological 'intrinsic' subtypes and proliferation. Methods Gene sets were selected from microarray data to assess proliferation and to classify breast cancers into four different molecular subtypes, designated Luminal, Normal-like, HER2+/ER-, and Basal-like. One-hundred and twenty-three breast samples (117 invasive carcinomas, one fibroadenoma and five normal tissues) and three breast cancer cell lines were prospectively analyzed using a microarray (Agilent) and a qRT-PCR assay comprised of 53 genes. Biological subtypes were assigned from the microarray and qRT-PCR data by hierarchical clustering. A proliferation signature was used as a single meta-gene (log2 average of 14 genes) to predict outcome within the context of estrogen receptor status and biological 'intrinsic' subtype. Results We found that the qRT-PCR assay could determine the intrinsic subtype (93% concordance with microarray-based assignments) and that the intrinsic subtypes were predictive of outcome. The proliferation meta-gene provided additional prognostic information for patients with the Luminal subtype (P = 0.0012), and for patients with estrogen receptor-positive tumors (P = 3.4 ū 10-6). High proliferation in the Luminal subtype conferred a 19-fold relative risk of relapse (confidence interval = 95%) compared with Luminal tumors with low proliferation. Conclusion A real-time qRT-PCR assay can recapitulate microarray classifications of breast cancer and can risk-stratify patients using the intrinsic subtype and proliferation. The proliferation meta-gene offers an objective and quantitative measurement for grade and adds significant prognostic information to the biological subtypes.
Perreard, Laurent; Fan, Cheng; Quackenbush, John F; Mullins, Michael; Gauthier, Nicholas P; Nelson, Edward; Mone, Mary; Hansen, Heidi; Buys, Saundra S; Rasmussen, Karen; Orrico, Alejandra Ruiz; Dreher, Donna; Walters, Rhonda; Parker, Joel; Hu, Zhiyuan; He, Xiaping; Palazzo, Juan P; Olopade, Olufunmilayo I; Szabo, Aniko; Perou, Charles M; Bernard, Philip S
Clinical Risk Stratification in the Emergency Department Predicts Long-Term Cardiovascular Outcomes in a Population-Based Cohort Presenting with Acute Chest Pain: Primary Results of the Olmsted County Chest Pain Study
The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all Olmsted County EDs. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. Patients with ST elevation myocardial infarction and chest pain of non-cardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and a median follow up of 7.3 years, and mortality through a median of 16.6 years. The 2271 patients were classified: 436 (19.2%) as high-, 1,557 (68.6%) as intermediate- and 278 (12.2%) as low-risk. Thirty-day MACCE occurred in 11.5% in high-risk, 6.2% in intermediate-risk, and 2.5% in the lowrisk group (p<0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate (HR 1.91; 95% CI 1.33¢2.75) and high-risk groups (HR 2.45; 95% CI 1.67¢3.58). Intermediate- and high-risk patients demonstrated a 1.38 fold (95% CI 0.95¢2.01, p=0.09) and a 1.68 fold (95% CI 1.13¢2.50, p = 0.011) higher mortality compared to lowrisk patients at 16.6 years. At 7.3 and 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk. In conclusion, a widely-applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from optimization of their cardiovascular risk management.
Farkouh, Michael E.; Aneja, Ashish; Reeder, Guy S.; Smars, Peter A.; Bansilal, Sameer; Lennon, Ryan J.; Wiste, Heather J.; Razzouk, Louai; Traverse, Kay; Holmes, David R.; Mathew, Verghese
Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial
Objective: To compare in a prospective, randomised, multicentre trial the relative merits of pre-discharge exercise ECG and early pharmacological stress echocardiography concerning risk stratification and costs of treating patients with uncomplicated acute myocardial infarction. Design: 262 patients from six participating centres with a recent uncomplicated myocardial infarction were randomly assigned to early (day 3¢5) pharmacological stress echocardiography (n ?=? 132) or conventional pre-discharge (day 7¢9) maximum symptom limited exercise ECG (n ?=? 130). Results: No complication occurred during either stress echocardiography or exercise ECG. At one year follow up there were 26 events (1 death, 5 non-fatal reinfarctions, 20 patients with unstable angina requiring hospitalisation) in patients randomly assigned to early stress echocardiography and 18 events (2 reinfarctions, 16 unstable angina requiring hospitalisation) in the group randomly assigned to exercise ECG (not significant). The negative predictive value was 92% for stress echocardiography and 88% for exercise ECG (not significant). Total costs of the two strategies were similar (not significant). Conclusion: Early pharmacological stress echocardiography and conventional pre-discharge symptom limited exercise ECG have similar clinical outcome and costs after uncomplicated infarction. Early pharmacological stress echocardiography should be considered a valid alternative even for patients with interpretable baseline ECG who can exercise.
Desideri, A; Fioretti, P M; Cortigiani, L; Trocino, G; Astarita, C; Gregori, D; Bax, J; Velasco, J; Celegon, L; Bigi, R; Pirelli, S; Picano, E
The survival outcomes following liver transplantation (SOFT) score: validation with contemporaneous data and stratification of high-risk cohorts.
Models to project survival after liver transplantation are important to optimize outcomes. We introduced the survival outcomes following liver transplantation (SOFT) score in 2008 (1) and designed to predict survival in liver recipients at three months post-transplant with a C statistic of 0.70. Our objective was to validate the SOFT score, with more contemporaneous data from the OPTN database. We also applied the SOFT score to cohorts of the sickest transplant candidates and the poorest-quality allografts. Analysis included 21 949 patients transplanted from August 1, 2006, to October 1, 2010. Kaplan-Meier survival functions were used for time-to-event analysis. Model discrimination was assessed using the area under the receiver operating characteristic (ROC) curve. We validated the SOFT score in this cohort of 21 949 liver recipients. The C statistic was 0.70 (CI 0.68-0.71), identical to the original analysis. When applied to cohorts of high-risk recipients and poor-quality donor allografts, the SOFT score projected survival with a C statistic between 0.65 and 0.74. In this study, a validated SOFT score was informative among cohorts of the sickest transplant candidates and the poorest-quality allografts. PMID:23808891
Rana, Abbas; Jie, Tun; Porubsky, Marian; Habib, Shahid; Rilo, Horacio; Kaplan, Bruce; Gruessner, Angelika; Gruessner, Rainer
Human CMV-specific T-cell responses in kidney transplantation; toward changing current risk-stratification paradigm.
Despite the great efficacy of current antiviral preventive strategies, hCMV infection is still a major complication after renal transplantation, significantly challenging patient and graft survival. This issue seems to be explained because of the rather poor immunologic monitoring of the antiviral immune response. An important body of evidence has shown that monitoring the hCMV-specific T-cell response, at different time points of the transplant setting, seems to add crucial information for predicting the risk of viral infection, thus potentially helping individualization of therapeutic decision-making in clinical transplantation. While several immune-cellular assays have shown its capability for accurately monitoring hCMV-specific T-cell responses, only few such as the IFN-? ELISPOT and the ELISA based technology assays might be reliable for its application in the clinic. Nonetheless, an important effort has to be made among the transplant community to standardize and validate such immune assays. Noteworthy, large-scale prospective randomized trials are highly warranted to ultimately introduce them in current clinical practice as a part of the highly desired personalized medicine. PMID:24629072
L·cia, Marc; Crespo, Elena; Cruzado, Josep M; Griny¾, Josep M; Bestard, Oriol
Characterization of the novel and specific PI3K? inhibitor NVP-BYL719 and development of the patient stratification strategy for clinical trials.
Somatic PIK3CA mutations are frequently found in solid tumors, raising the hypothesis that selective inhibition of PI3K? may have robust efficacy in PIK3CA-mutant cancers while sparing patients the side-effects associated with broader inhibition of the class I phosphoinositide 3-kinase (PI3K) family. Here, we report the biologic properties of the 2-aminothiazole derivative NVP-BYL719, a selective inhibitor of PI3K? and its most common oncogenic mutant forms. The compound selectivity combined with excellent drug-like properties translates to dose- and time-dependent inhibition of PI3K? signaling in vivo, resulting in robust therapeutic efficacy and tolerability in PIK3CA-dependent tumors. Novel targeted therapeutics such as NVP-BYL719, designed to modulate aberrant functions elicited by cancer-specific genetic alterations upon which the disease depends, require well-defined patient stratification strategies in order to maximize their therapeutic impact and benefit for the patients. Here, we also describe the application of the Cancer Cell Line Encyclopedia as a preclinical platform to refine the patient stratification strategy for NVP-BYL719 and found that PIK3CA mutation was the foremost positive predictor of sensitivity while revealing additional positive and negative associations such as PIK3CA amplification and PTEN mutation, respectively. These patient selection determinants are being assayed in the ongoing NVP-BYL719 clinical trials. PMID:24608574
Fritsch, Christine; Huang, Alan; Chatenay-Rivauday, Christian; Schnell, Christian; Reddy, Anupama; Liu, Manway; Kauffmann, Audrey; Guthy, Daniel; Erdmann, Dirk; De Pover, Alain; Furet, Pascal; Gao, Hui; Ferretti, Stephane; Wang, Youzhen; Trappe, Joerg; Brachmann, Saskia M; Maira, Sauveur-Michel; Wilson, Christopher; Boehm, Markus; Garcia-Echeverria, Carlos; Chene, Patrick; Wiesmann, Marion; Cozens, Robert; Lehar, Joseph; Schlegel, Robert; Caravatti, Giorgio; Hofmann, Francesco; Sellers, William R
Assessing Bleeding Risk in Patients Taking Anticoagulants
Anticoagulant medications are commonly used for the prevention and treatment of thromboembolism. Although highly effective, they are also associated with significant bleeding risks. Numerous individual clinical factors have been linked to an increased risk of hemorrhage, including older age, anemia, and renal disease. To help quantify hemorrhage risk for individual patients, a number of clinical risk prediction tools have been developed. These risk prediction tools differ in how they were derived and how they identify and weight individual risk factors. At present, their ability to effective predict anticoagulant-associated hemorrhage remains modest. Use of risk prediction tools to estimate bleeding in clinical practice is most influential when applied to patients at the lower spectrum of thromboembolic risk, when the risk of hemorrhage will more strongly affect clinical decisions about anticoagulation. Using risk tools may also help counsel and inform patients about their potential risk for hemorrhage while on anticoagulants, and can identify patients who might benefit from more careful management of anticoagulation.
Shoeb, Marwa; Fang, Margaret C.
Risk assessment and patient stratification using implantable medical devices. The funding for personal health programs
Chronic diseases are currently recognized as one of the leading causes of mortality and morbidity worldwide. On top of this, these diseases represent a major burden for the healthcare systems in terms of costs and resources, which is driving them to define and adopt novel programs for prevention and chronic disease management. Still, many aspects of the processes of care
Alejandra Guillen; Javier Colas; German Gutierrez
Role of Coronary Artery Calcium Score and Coronary CT Angiography in the Diagnosis and Risk Stratification of Individuals with Suspected Coronary Artery Disease
Coronary heart disease is the leading cause of death worldwide, and has traditionally been assessed through a patientÆs cardiovascular\\u000a risk profile that is comprised of a combination of genetic, social, physiologic, and environmental factors. A growing discordance\\u000a is being recognized in the ability of current risk estimation tools to predict outcomes versus that of actual measured outcomes.\\u000a Exciting new improvements
Sean R. Wilson; Fay Y. Lin; James K. Min
p16(INK4a) is a useful marker of human papillomavirus integration allowing risk stratification for cervical malignancies.
The present study was conducted to assess utility of p16(INK4a) immunopositivity as a surrogate marker for genomic integration of high-risk human papillomavirus infection (hrHPV). A total of 29 formalin-fixed, paraffin-embedded cervical low-grade squamous intraepithelial lesions (LSILs), 27 high-grade squamous intraepithelial lesions (HSILs) and 53 invasive squamous cell carcinomas (SCCs), histologically-diagnosed between 1st January 2006 to 31st December 2008 at the University of Malaya Medical Centre were stained for p16(INK4a) (CINtec Histology Kit (REF 9511, mtm laboratories AG, Heidelberg, Germany). Immunopositvity was defined as diffuse staining of the squamous cell cytoplasm and or nucleus (involving > 75% of the intraepithelial lesions or SCCs). Staining of basal and parabasal layers of intraepithelial lesions was pre-requisite. One (3.4%) LSIL, 24 (88.9%) HSIL and 46 (86.8%) SCC were p16(INK4a) immunopositive. All normal squamous epithelium did not express p16(INK4). p16(INK4a) expression was significantly lower (p<0.05) in LSIL compared with HSIL and SCC with no difference in expression between HSIL and SCC.The increased p16(INK4a) immunopositivity in HSIL and SCC appears in line with the integrated existence of the hrHPV and may provide more insightful information on risk of malignant transformation of cervical squamous intraepithelial lesions than mere hrHPV detection. PMID:22524808
Cheah, Phaik-Leng; Looi, Lai-Meng; Teoh, Kean-Hooi; Mun, Kein-Seong; Nazarina, Abdul Rahman
Extranodal nasal type NK\\/T-cell Lymphoma: Elucidating clinical prognostic factors for risk-based stratification of therapy
The purpose of this study was to define distinctive clinical features of ōnasalö and ōnasal-typeö NK\\/T cell lymphomas by assessing prognostic factors. The anatomic definition of extranasal NK\\/T cell lymphoma has been vague resulting in variable definitions of extranasal sites by different groups. We analysed the clinical behavior of 90 NK\\/T cell lymphoma patients and attempted to elucidate the prognostic
Jeeyun Lee; Yeon Hee Park; Won Seog Kim; Seung-Sook Lee; Baek-Yeol Ryoo; Sung Hyun Yang; Keon Woo Park; Jung Hoon Kang; Joon Oh Park; Se Hoon Lee; Kihyun Kim; Chul Won Jung; Young Suk Park; Young-Hyuck Im; Won Ki Kang; Mark H. Lee; Young H. Ko; Yong Chan Ahn
Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery
The use of cardiopulmonary exercise testing (CPET) as a preoperative risk stratification tool for a range of non-cardiopulmonary surgery is increasing. The utility of CPET in this role is dependent on the technology being able to identify accurately and reliably those patients at increased risk of perioperative events when compared with existing risk stratification tools. This article identifies and reviews
Philip J Hennis; Paula M Meale; Michael P W Grocott
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).
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. PMID:24739540
Kim, Kwang-Il; Lee, Yil-Seob; Park, Chang Gyu
Germ cell cancer risk in DSD patients.
The risk of germ cell cancer is elevated in many DSD patients, although not to the same extent. A number of risk factors have been identified recently, but their interplay and relative impact is currently not fully clear. Until the advent of reliable screening tools for the detection of pre-invasive cancer lesions, managing germ cell tumour risk focuses on the question if and when to perform biopsy or gonadectomy in most patients and how to interpret the histological findings. PMID:24786700
Cools, Martine
Prognostic significance of the admission plasma B-type natriuretic peptide measurement in patients with first ST-elevation myocardial infarction in comparison with C-reactive protein and TIMI risk score
BackgroundIn ST-elevation myocardial infarction (STEMI) B-type natriuretic peptide (BNP) holds promise for risk stratification. Aim of this study was to assess prognostic value of plasma BNP measurement and to compare with other powerful prognostic markers Ś TIMI Risk Score (TRS) and C-reactive protein (CRP) in patients with first STEMI treated with primary PCI (pPCI).
Agnieszka M. Kuklinska; Bozena Sobkowicz; Barbara Mroczko; Robert Sawicki; Wlodzimierz J. Musial; Malgorzata Knapp; Slawomir Dobrzycki; Maciej Szmitkowski
Managing lung cancer in high-risk patients: what to consider.
Lung cancer patients with medical comorbidity are a challenge for care providers. As with other solid tumors, treatment is stage dependent; but a critical difference is the invasive nature of lung resections and the resulting importance of surgical risk stratification for treatment of early stage disease. External beam radiation was considered the only treatment option for early stage disease in non-operative candidates 10-15 years ago. With recent advances in image-guided technologies, robotics, and the resurgence in interest of sublobar resection there are now numerous treatment options which offer excellent local control and reasonable short and long term survival. Extensive work has been done to clarify interventional risk, and accurately describe anticipated outcomes of these varied treatments in the high risk population. The aim of this article is to review recent literature and provide a better understanding of the considerations used in the management of these patients in the current era. PMID:24905801
Sesti, Joanna; Donington, Jessica S
The lower risk MDS patient at risk of rapid progression
Most patients with myelodysplastic syndrome (MDS) are classified at diagnosis as having a low\\/INT-I or INT-II\\/high risk disease, based on the classical International Prognostic Scoring System (IPSS) criteria. The low\\/INT-I risk patients are usually managed mildly with supportive care, including red blood cell (RBC) transfusions, erythroid stimulating agents (ESAs), other cytokines (G-CSF, platelet stimulating agents), as well as thalidomide and
Moshe Mittelman; Howard S. Oster; Michael Hoffman; Drorit Neumann
Risk assessment in surgical patients: balancing iatrogenic risks and benefits.
Cutaneous procedures are associated with a wide variety of potential risks. This contribution discusses risk-related considerations in the preoperative, intraoperative, and postoperative management of dermatologic surgery patients. In the preoperative setting, major considerations include bleeding risks, the presence of pacemakers or defibrillators, risks of local and systemic infection, and the possibility of adverse reactions to local anesthetics and topical agents used for dermatologic procedures. Risk is minimized intraoperatively through careful attention to sterile technique, maintaining adequate hemostasis, skillful management of emerging complications, and effective closure of surgical defects. To optimize outcomes, postoperative priorities include effective management of postoperative bleeding, appropriate wound care, and prevention and treatment of hypertrophic scars and keloids. Reducing the likelihood of adverse surgical outcomes requires identification of potential risk factors and case-specific approaches to minimize risks while simultaneously preparing for the possibility of complications. PMID:22014989
Pomerantz, Rebecca G; Lee, David A; Siegel, Daniel M
Risk Score and Metastasectomy Independently Impact Prognosis in Patients with Recurrent Renal Cell Carcinoma
Purpose To evaluate the prognostic roles of metastasectomy and an established risk stratification system for patients experiencing a disease recurrence following nephrectomy for non-metastatic renal cell carcinoma (RCC). Methods A retrospective analysis was performed on 129 patients with localized RCC treated by partial or radical nephrectomy and subsequently diagnosed with disease recurrence. At the time of recurrence, a previously validated risk score based on Karnofsky performance status, interval from nephrectomy, and serum hemoglobin, calcium, and lactate dehydrogenase levels was used to categorize patients as favorable, intermediate, or poor-risk. Survival from recurrence was assessed based on risk categorization and metastasectomy Results Median time from nephrectomy to recurrence was 16 months. Median and two-year survival rates were strongly associated with the risk score (favorable-risk: 73 months and 81%; intermediate-risk: 28 months and 54%; poor-risk: 6 months and 11%; log-rank<0.001). Metastasectomy was performed in 44 patients (34%) and found to be of clinical benefit across the various risk categories (interaction analysis, p=0.8). On multivariate analysis, a better risk category (p<0.001) and undergoing a metastasectomy (p<0.001) were each independently associated with a more favorable survival and when combined provided six different risk categories with an estimated two-year survival ranging from 0 ¢ 93%. Conclusions The clinical course for patients with an RCC recurrence following nephrectomy can be variable and is independently impacted by an objectively obtained risk score and whether the patient undergoes a metastasectomy.
Eggener, Scott E; Yossepowitch, Ofer; Kundu, Shilajit; Motzer, Robert J; Russo, Paul
Reducing Vascular Events Risk in Patients with Dyslipidaemia: An Update for Clinicians
Reducing the risk of vascular events in patients with dyslipidaemia requires cardiovascular disease risk stratification and lifestyle/pharmacological intervention on modifiable risk factors. Reduction of low-density lipoprotein cholesterol (LDL-C) with statins is highly effective in reducing cardiovascular disease in patients with and without diabetes, but leaves unaddressed a sizeable residual vascular risk (RvR), which is rarely quantified in routine clinical practice. Such RvR may relate to lack of strict target attainment for all atherogenic variables [LDL-C, non-high-density lipoprotein cholesterol (HDL-C) and/or apolipoprotein B100]. Another substantial lipid-related and modifiable RvR component is related to atherogenic dyslipidaemia, especially as global rates of obesity, type 2 diabetes and metabolic syndrome are increasing. Atherogenic dyslipidaemia is associated with insulin-stimulated very-low-density lipoprotein overproduction and reduced reverse cholesterol transport. The hallmark of atherogenic dyslipidaemia is the coexistence of low HDL-C and elevated triglycerides. Therapeutic lifestyle changes and combination lipid-lowering therapy with drugs targeting atherogenic dyslipidaemia (such as fibrates or innovative drugs targeting atherogenic dyslipidaemia and/or apolipoprotein B100 metabolism) on top of background statins, have a potential to reduce RvR in high-risk groups, as shown in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, in which combination therapy with simvastatin plus fenofibrate decreased macrovascular risk in patients with diabetes and atherogenic dyslipidaemia, and retinopathy risk irrespective of baseline lipids.
Hermans, Michel P.; Fruchart, Jean-Charles
Warm blood cardioplegia in high risk patients
Objective: Despite overall good clinical results, cardiac surgery in high risk patients, such as those with poor left ventricular function or heavily hypertrophied myocardium, is still challenging. This study was designed to assess the efficacy of warm blood cardioplegia (WBC) in these two subgroups of patients. Methods: Fifty-two patients, with an ejection fraction less than 50%, who underwent surgical revascularization,
Alain Bel; Hakim Aznag; Bouchaib Faris
Warm blood cardioplegia in high risk patients
Objective: Despite overall good clinical results, cardiac surgery in high risk patients, such as those with poor left ventricular function or heavily hypertrophied myocardium, is still challenging. This study was designed to assess the efficacy of warm blood cardioplegia (WBC) in these two subgroups of patients. Methods: Fifty-two patients, with an ejection fraction less than 50%, who underwent surgical revascularization,
Alain Bel; Hakim Aznag; Bouchaib Faris; Philippe Menaschķ
Risk stratification for arrhythmic death in an emergency department cohort: a new method of nonlinear PD2i analysis of the ECG
Heart rate variability (HRV) reflects both cardiac autonomic function and risk of sudden arrhythmic death (AD). Indices of HRV based on linear stochastic models are independent risk factors for AD in postmyocardial infarction (MI) cohorts. Indices based on nonlinear deterministic models have a higher sensitivity and specificity for predicting AD in retrospective data. A new nonlinear deterministic model, the automated Point Correlation Dimension (PD2i), was prospectively evaluated for prediction of AD. Patients were enrolled (N = 918) in 6 emergency departments (EDs) upon presentation with chest pain and being determined to be at risk of acute MI (AMI) >7%. Brief digital ECGs (>1000 heartbeats, ?15 min) were recorded and automated PD2i results obtained. Out-of-hospital AD was determined by modified Hinkle-Thaler criteria. All-cause mortality at 1 year was 6.2%, with 3.5% being ADs. Of the AD fatalities, 34% were without previous history of MI or diagnosis of AMI. The PD2i prediction of AD had sensitivity = 96%, specificity = 85%, negative predictive value = 99%, and relative risk >24.2 (p ? 0.001). HRV analysis by the time-dependent nonlinear PD2i algorithm can accurately predict risk of AD in an ED cohort and may have both life-saving and resource-saving implications for individual risk assessment.
Skinner, James E; Meyer, Michael; Dalsey, William C; Nester, Brian A; Ramalanjaona, George; O'Neil, Brian J; Mangione, Antoinette; Terregino, Carol; Moreyra, Abel; Weiss, Daniel N; Anchin, Jerry M; Geary, Una; Taggart, Pamela
Statin use in rheumatoid arthritis in relation to actual cardiovascular risk: evidence for substantial undertreatment of lipid-associated cardiovascular risk?
BackgroundCardiovascular disease (CVD) is partially attributed to traditional cardiovascular risk factors, which can be identified and managed based on risk stratification algorithms (Framingham Risk Score, National Cholesterol Education Program, Systematic Cardiovascular Risk Evaluation and Reynolds Risk Score). We aimed to (a) identify the proportion of at risk patients with rheumatoid arthritis (RA) requiring statin therapy identified by conventional risk calculators,
Tracey E Toms; Vasileios F Panoulas; Karen M J Douglas; Helen Griffiths; Naveed Sattar; Jaqueline P Smith; Deborah P M Symmons; Peter Nightingale; George S Metsios; George D Kitas
Early detection and management of the high-risk patient with elevated blood pressure.
Severe or important blood pressure elevations are associated with the risk of cardiovascular disease. However, a significant proportion of myocardial infarctions and strokes occur in subjects with only slight elevations or even with normal blood pressure. Both the coexistence of other cardiovascular risk factors, such as diabetes or dyslipidemia, or those recently recognized, such as elevations of C-reactive protein or abdominal obesity and metabolic syndrome, or the presence of target organ damage, such as microalbuminuria, left ventricular hypertrophy, mild renal dysfunction or increased intima-media thickness, all indicate the existence of a high cardiovascular risk in mild hypertensives or in subjects with normal or high-normal blood pressure. Unfortunately, these high-risk patients are often not recognized and thus under-treated. The 2003 European Societies of Hypertension and Cardiology guidelines emphasize the importance of a complete risk assessment and stratification in subjects at all blood pressure categories. The search for other cardiovascular risk factors and target organ damage should be encouraged. Identification of these high-risk patients may allow an earlier indication for antihypertensive treatment and for correction of all cardiovascular risk factors. The objective would be to impair the progression or to induce the regression of silent vascular damage before a clinical event develops. PMID:18561504
Sierra, Cristina; de la Sierra, Alejandro
Early detection and management of the high-risk patient with elevated blood pressure
Severe or important blood pressure elevations are associated with the risk of cardiovascular disease. However, a significant proportion of myocardial infarctions and strokes occur in subjects with only slight elevations or even with normal blood pressure. Both the coexistence of other cardiovascular risk factors, such as diabetes or dyslipidemia, or those recently recognized, such as elevations of C-reactive protein or abdominal obesity and metabolic syndrome, or the presence of target organ damage, such as microalbuminuria, left ventricular hypertrophy, mild renal dysfunction or increased intima-media thickness, all indicate the existence of a high cardiovascular risk in mild hypertensives or in subjects with normal or high-normal blood pressure. Unfortunately, these high-risk patients are often not recognized and thus under-treated. The 2003 European Societies of Hypertension and Cardiology guidelines emphasize the importance of a complete risk assessment and stratification in subjects at all blood pressure categories. The search for other cardiovascular risk factors and target organ damage should be encouraged. Identification of these high-risk patients may allow an earlier indication for antihypertensive treatment and for correction of all cardiovascular risk factors. The objective would be to impair the progression or to induce the regression of silent vascular damage before a clinical event develops.
Sierra, Cristina; de la Sierra, Alejandro
Breast Cancer Risk Among Klinefelter Syndrome Patients
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.
Brinton, Louise A.
Screening and follow-up of the patient at high risk for breast cancer.
Accurately defining a patient's risk of developing breast cancer is a challenging endeavor. Many factors have been implicated in the causation of breast cancer and quantifying them is difficult. Risk stratification is performed using population models, such as the Gail model, as well as the patient's personal and family history and genetic testing. The clinician who is facile with these components will not only be able to identify those patients at highest risk for whom heightened surveillance is recommended, but also to allay the fears of the average-risk patient and provide them reassurance. Patients who are at very high risk of developing breast cancer are BRCA1 or BRCA2 gene mutation carriers, those with a personal history of atypical ductal hyperplasia or lobular carcinoma in situ with associated family history, those who have undergone therapeutic or similarly significant radiation exposure, and those with a history of a BRCA1 or BRCA2 gene mutation in the family of an untested individual. Patients with an elevated risk, but not in the very high risk category, are those with a family history of breast cancer, personal history of breast cancer, significantly dense breast tissue, hormone replacement therapy longer than 10 years, and a history of atypical ductal hyperplasia or lobular carcinoma in situ without family history of breast cancer. Risk-reducing strategies include chemoprevention with tamoxifen or raloxifene and surgical prophylaxis with bilateral prophylactic mastectomy and/or bilateral salpingo-oophorectomy. A high-risk surveillance regimen includes annual mammography, annual magnetic resonance imaging in selected individuals, and semiannual clinical breast exams. PMID:18055740
Willey, Shawna C; Cocilovo, Costanza
2012 consensus document of the Italian Society of Hypertension (SIIA): strategies to improve blood pressure control in Italy: from global cardiovascular risk stratification to combination therapy.
Observational clinical studies have demonstrated that only 30-40% of patients with arterial hypertension achieve the recommended blood pressure goals (below 140/90 mmHg). In contrast, interventional trials consistently showed that it is possible to achieve effective blood pressure targets in about 70% of treated hypertensive patients with different cardiovascular risk profiles, especially through the use of rational, effective and well tolerated combination therapies. In order to bridge the gap between current and desired blood pressure control and to achieve more effective prevention of cardiovascular diseases, the Italian Society of Hypertension (SIIA) has developed an interventional strategy aimed at reaching nearly 70% of treated controlled hypertensive patients by 2015. This ambitious goal can be realistically achieved by a more rational use of modern tools and supports, and also through the use of combination therapy in hypertension in daily clinical practice, especially if this approach can be simplified into a single pill (fixed combination therapy), which is a therapeutic option now also available in Italy. Since about 70-80% of treated hypertensive patients require a combination therapy based on at least two classes of drugs in order to achieve the recommended blood pressure goals, it is of key importance to implement this strategy in routine clinical practice. Amongst the various combination therapies currently available for hypertension treatment and control, the use of those strategies based on drugs that antagonize the renin-angiotensin system, such as angiotensin II type 1 receptor antagonists (angiotensin receptor blockers) and ACE inhibitors, in combination with diuretics and/or calcium channel blockers, has been shown to significantly reduce the risk of major cardiovascular events and to improve patient compliance to treatment, resulting in a greater antihypertensive efficacy and better tolerability compared with monotherapy. The present document of the Italian Society of Arterial Hypertension (SIIA) aims to gather the main indications for the implementation of combination therapy in the treatment of hypertension, in order to improve blood pressure control in Italy. PMID:23536324
Volpe, Massimo; Rosei, Enrico Agabiti; Ambrosioni, Ettore; Cottone, Santina; Cuspidi, Cesare; Borghi, Claudio; De Luca, Nicola; Fallo, Francesco; Ferri, Claudio; Morganti, Alberto; Muiesan, Maria Lorenza; Sarzani, Riccardo; Sechi, Leonardo; Virdis, Agostino; Tocci, Giuliano; Trimarco, Bruno; Filippi, Alessandro; Mancia, Giuseppe
The lower risk MDS patient at risk of rapid progression.
Most patients with myelodysplastic syndrome (MDS) are classified at diagnosis as having a low/INT-I or INT-II/high risk disease, based on the classical International Prognostic Scoring System (IPSS) criteria. The low/INT-I risk patients are usually managed mildly with supportive care, including red blood cell (RBC) transfusions, erythroid stimulating agents (ESAs), other cytokines (G-CSF, platelet stimulating agents), as well as thalidomide and lenalidomide. Some patients receive immunosuppressive therapy, and iron chelation is indicated in iron overloaded patients. Aggressive approach (hypomethylating agents, chemotherapy and stem cell transplantation) is usually not applied in such patients. Occasionally, we observe a "low risk" patient with rapid progression of disease and poor outcome. Can we identify demographic, clinical, laboratory, cellular-biological and/or molecular parameters that can predict "poor prognostic features" (PPF) in "low risk" MDS patients? Clinical and laboratory parameters have been reported to be associated with poor prognosis, in addition to the known "classical" IPSS criteria. These include older age, male gender, poor performance status, co-morbidities, degree of anemia, low absolute neutrophile count (ANC) and platelet counts, RBC transfusion requirements, high serum ferritin, high LDH, bone marrow (BM) fibrosis, increased number of BM CD34+ cells and multi-lineage dysplasia. Certain immunophenotypes (low CD11b, high HLA-Dr, CD34, CD13 and CD45), clonal granulocytes, multiple chromosomal abnormalities, chromosomal instability, short telomeres and high telomerase activity were also reported as PPF. Studies of apoptosis identified Bcl-2 expression and high caspase 3 as PPF, while the reports on survivin expression have been confusing. Recent exciting data suggest that methylation of p15 INK4b and of CTNNA1 (in 5q-), high level of methylation of other genes, absence of the TET2 mutation, down regulation of the lymphoid enhancer binding factor 1 (LEF1), mutation of the polycomb-associated gene ASXL1 and a specific 6-gene signature in gene expression profiling - are all associated with poor prognosis in MDS. Do we have data suggesting a different treatment for "low risk" MDS patients displaying PPF? Two teams, the combined Nordic-Italian and the GFM groups have reported an improved survival with ESAs. The GFM has achieved prolonged survival with iron chelation. Recently, encouraging data with survival advantage in azacitidine-treated patients have been published, including a few INT-I patients. Finally, data suggest that low/INT-I MDS patients who undergo stem cell transplantation (SCT0 do better than INT-II/high risk patients). In summary, some patients, classified as "low risk MDS" carry PPF. An appropriate therapeutic approach is indicated. Future updated classifications and prospective trials may lead to a better outcome. PMID:20573398
Mittelman, Moshe; Oster, Howard S; Hoffman, Michael; Neumann, Drorit
Referenceless stratification of parenchymal lung abnormalities.
This paper introduces computational tools that could enable personalized, predictive, preemptive, and participatory (P4) Pulmonary medicine. We demonstrate approaches to (a) stratify lungs from different subjects based on the spatial distribution of parenchymal abnormality and (b) visualize the stratification through glyphs that convey both the grouping efficacy and an iconic overview of an individual's lung wellness. Affinity propagation based on regional parenchymal abnormalities is used in the referenceless stratification. Abnormalities are computed using supervised classification based on Earth Mover's distance. Twenty natural clusters were detected from 372 CT lung scans. The computed clusters correlated with clinical consensus of 9 disease types. The quality of inter- and intra-cluster stratification as assessed by ANOSIM R was 0.887 +/- 0.18 (pval < 0.0005). The proposed tools could serve as biomarkers to objectively diagnose pathology, track progression and assess pharmacologic response within and across patients. PMID:22003703
Raghunath, Sushravya; Rajagopalan, Srinivasan; Karwoski, Ronald A; Bartholmai, Brian J; Robb, Richard A
Radiation risks for patients having X rays
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.
Hale, J.; Thomas, J.W.
Antibiotic Lowers Death Risk for Elderly Patients with Pneumonia
HIV risk factors in dually diagnosed patients.
The authors examined correlates of HIV seropositivity in a sample of dually diagnosed inpatients. The subjects were 147 consecutively admitted patients to a specialized dual-diagnosis unit in a municipal hospital who were given a structured interview and HIV testing. The HIV seroprevalence was 19%, with women having a nearly fourfold increased risk of being HIV seropositive, as compared with men. Cocaine as drug of choice was also highly significant as a risk factor for HIV infection, independent of gender. This finding suggests that targeted prevention and education programs need to be developed for the dually diagnosed patient. PMID:9522009
Krakow, D S; Galanter, M; Dermatis, H; Westreich, L M
First-line natalizumab in multiple sclerosis: rationale, patient selection, benefits and risks.
Natalizumab (NTZ) is a highly effective disease modifying therapy for the treatment of relapsing forms of multiple sclerosis (MS). Despite evidence to support its use as first-line therapy, risk of NTZ-associated progressive multifocal leukoencephalopathy (PML) has largely contributed to it being relegated to a second-line position. Recent preliminary data may allow for a more accurate analysis of JC virus (JCV) risk stratification of a given patient's PML risk. Herein we propose an algorithm to help guide clinicians through this decision-making process. We recommend that NTZ be considered for first-line use in JCV antibody negative MS patients, JCV 'low positive' MS patients without prior exposure to immunosuppression and for a limited period (12-24 months) in JCV 'high positive' MS patients with an aggressive disease course . We caution against first-line use in JCV antibody 'high positive' patients beyond 12-24 months and any JCV antibody positive patient with a history of prior immunosuppression. PMID:24587891
Nicholas, Jacqueline Ann; Racke, Michael Karl; Imitola, Jamie; Boster, Aaron Lee
An alternative approach to selecting patients for high-risk screening with breast MRI.
Current guidelines for adding breast MRI to annual screening mammography are based entirely upon stratification of risk, with a heavy focus on lifetime calculations. This approach is fraught with difficulty due to the reliance on mathematical models that vary widely in their calculations, the inherent age discrimination of using lifetime risks rather than short-term incidence, and the failure to incorporate mammographic density, the latter being an independent risk as well as the greatest predictor of mammographic failure. By utilizing a system of patient selection similar to what was used in the American College of Radiology Imaging Network (ACRIN) 6666 trial for multi-modality imaging, 33 women without a prior diagnosis of breast cancer were found to harbor mammographically occult carcinoma through MRI screening. These 33 patients represent a 2% yield, closely approximating the yields seen in prospective MRI screening trials of women at very high risk of breast cancer. Using the "~20-25%" minimum established by the American Cancer Society and later the National Comprehensive Cancer Network, the Gail model would have prompted the use of MRI in only 9 of 33 (27.3%) patients, the Claus model 1 of 33 (3%), and the Tyrer-Cuzick model 12 of 33 (36.4%). Using all three models and opting for the highest calculated risk, then including BRCA-positivity, still would have identified only 16 of 33 (48.5%) patients with occult breast cancer discovered by MRI. Only one patient was BRCA-positive, and none had lobular carcinoma in situ, while 6 of 33 patients (18.2%) had atypical ductal hyperplasia (ADH). Measures are proposed to refine patient selection for MRI screening through the use of short-term or categorical risks, mammographic density, while maintaining cost-effectiveness through longer MRI screening intervals. PMID:24387050
Hollingsworth, Alan B; Stough, Rebecca G
Identification of the High Risk Angioplasty Patient
\\u000a A recognition and understanding of the factors that make a patient truly at high risk for unsupported coronary angioplasty\\u000a (PTCA) are necessary for the proper implementation of supported PTCA or an avoidance of the technique of PTCA altogether.
Stephen G. Ellis
Colonoscopy Reduces Risk of Death from Colorectal Cancer in High-Risk Patients
Special Report Colonoscopy Reduces Risk of Death from Colorectal Cancer in High-Risk Patients During a colonoscopy, physicians ... for patients at higher-than-average risk of colorectal cancer confirm that removing precancerous adenomas can not only ...
Management of Newly Diagnosed Symptomatic Multiple Myeloma: updated Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Guidelines
Multiple myeloma is a malignant plasma cell neoplasm that affects more than 20,000 people each year and is the second most common hematologic malignancy. It is part of a spectrum of monoclonal plasma cell disorders, many of which do not require active therapy. During the past decade, considerable progress has been made in our understanding of the disease process and factors that influence outcome, along with development of new drugs that are highly effective in controlling the disease and prolonging survival without compromising quality of life. Identification of well-defined and reproducible prognostic factors and introduction of new therapies with unique modes of action and impact on disease outcome have for the first time opened up the opportunity to develop risk-adapted strategies for managing this disease. Although these risk-adapted strategies have not been prospectively validated, enough evidence can be gathered from existing randomized trials, subgroup analyses, and retrospective studies to develop a working framework. This set of recommendations represents such an effortŚthe development of a set of consensus guidelines by a group of experts to manage patients with newly diagnosed disease based on an interpretation of the best available evidence.
Kumar, Shaji K.; Mikhael, Joseph R.; Buadi, Francis K.; Dingli, David; Dispenzieri, Angela; Fonseca, Rafael; Gertz, Morie A.; Greipp, Philip R.; Hayman, Suzanne R.; Kyle, Robert A.; Lacy, Martha Q.; Lust, John A.; Reeder, Craig B.; Roy, Vivek; Russell, Stephen J.; Short, Kristen E. Detweiler; Stewart, A. Keith; Witzig, Thomas E.; Zeldenrust, Steven R.; Dalton, Robert J.; Rajkumar, S. Vincent; Bergsagel, P. Leif
[Strategies for improving blood pressure control in Italy: from global cardiovascular risk stratification to combination therapy. 2012 Position paper of the Italian Society of Hypertension].
Observational studies demonstrate that the proportion of treated hypertensive patients who attain the recommended blood pressure goals (140/90 mmHg) does not exceed 30-40%. Conversely, clinical trials have consistently shown that effective blood pressure control within the recommended targets can be achieved in 70-80% of treated hypertensive patients with different cardiovascular risk profile, especially when appropriate, effective and well tolerated combination therapies are used. In order to bridge the gap between current and optimal blood pressure control rates and to achieve a more effective cardiovascular prevention, the Italian Society of Hypertension has recently developed an interventional strategy that aims to approximate 70% of treated controlled patients by 2015. This ambitious goal can be realistically achieved by the appropriate use of modern aids and tools, also including the implementation of combination therapy, especially if this approach can be simplified into a single pill, now available in Italy. At present, 70-80% of hypertensive patients require combination therapies based on at least two classes of antihypertensive drugs to achieve the recommended blood pressure goals. It is therefore of paramount importance to implement this strategy in routine clinical practice. Among the different combination therapies, the use of combination strategies based on drugs inhibiting the renin-angiotensin system, such as angiotensin receptor blockers and angiotensin-converting enzyme inhibitors, combined with diuretics and/or calcium-channel blockers, have demonstrated to significantly reduce the rates of major cardiovascular events and discontinuations from prescribed therapies, resulting in higher antihypertensive efficacy and better tolerability than monotherapy. The present document of the Italian Society of Hypertension aims to provide main indications for implementing combination therapy in the clinical management of hypertension in order to improve blood pressure control in Italy. PMID:23196689
Volpe, Massimo; Ambrosioni, Ettore; Borghi, Claudio; Cottone, Santina; Cuspidi, Cesare; De Luca, Nicola; Fallo, Francesco; Ferri, Claudio; Morganti, Alberto; Muiesan, Maria Lorenza; Sarzani, Riccardo; Sechi, Leonardo; Virdis, Agostino; Tocci, Giuliano; Agabiti-Rosei, Enrico; Trimarco, Bruno; Filippi, Alessandro; Mancia, Giuseppe
Sensemaking of patient safety risks and hazards.
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
Battles, James B; Dixon, Nancy M; Borotkanics, Robert J; Rabin-Fastmen, Barbara; Kaplan, Harold S
Cancer risks in thyroid cancer patients.
Cancer risks were studied in 834 thyroid cancer patients given 131I (4,551 MBq, average) and in 1,121 patients treated by other means in Sweden between 1950 and 1975. Record-linkage with the Swedish Cancer Register identified 99 new cancers more than 2 years after 131I therapy [standardised incidence ratio (SIR) = 1.43; 95% confidence interval (CI) 1.17-1.75] vs 122 (SIR = 1.19; 95% CI 0.88-1.42) in patients not receiving 131I. In females treated with 131I overall SIR was 1.45 (95% CI 1.14-1.83) and significantly elevated were noted for tumours of the salivary glands, genital organs, kidney and adrenal gland. No elevated risk of a subsequent breast cancer or leukaemia was noted. SIR did not change over time, arguing against a strong radiation effect of 131I. Organs that were estimated to have received more than 1.0 Gy had together a significantly increased risk of a subsequent cancer following 131I treatment (SIR = 2.59; n = 18). A significant trend was seen for increasing activities of 131I with highest risk for patients exposed to greater than or equal to 3,664 MBq (SIR = 1.80; 95% CI 1.20-2.58). No specific cancer or group of cancers could be convincingly linked to high-dose 131I exposures since SIR did not increase after 10 years of observation. However, upper confidence intervals could not exclude levels of risk that would be predicted based on data from the study of atomic bomb survivors. We conclude that the current practice of extrapolating the effects of high-dose exposures to lower-dose situations is unlikely to seriously underestimate radiation hazards for low LET radiation.
Hall, P.; Holm, L. E.; Lundell, G.; Bjelkengren, G.; Larsson, L. G.; Lindberg, S.; Tennvall, J.; Wicklund, H.; Boice, J. D.
FDG-PET SUVmax Combined with IASLC/ATS/ERS Histologic Classification Improves the Prognostic Stratification of Patients with Stage I Lung Adenocarcinoma
Background We investigated the association between the newly proposed International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification and 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET), and whether the combination of these radiologic and pathologic factors can further prognostically stratify patients with stage I lung adenocarcinoma. Methods We retrospectively evaluated 222 patients with pathologic stage I lung adenocarcinoma who underwent FDG-PET scanning before undergoing surgical resection between 1999 and 2005. Patients were classified by histologic grade according to the IASLC/ATS/ERS classification (low, intermediate, or high grade) and by maximum standard uptake value (SUVmax) (low <3.0, high ?3.0). The cumulative incidence of recurrence (CIR) was used to estimate recurrence probabilities. Results Patients with high-grade histology had higher risk of recurrence (5-year CIR, 29 % [n = 25]) than those with intermediate-grade (13 % [n = 181]) or low-grade (11 % [n = 16]) histology (p = 0.046). High SUVmax was associated with high-grade histology (p < 0.001) and with increased risk of recurrence compared to low SUVmax (5-year CIR, 21 % [n = 113] vs. 8 % [n = 109]; p = 0.013). Among patients with intermediate-grade histology, those with high SUVmax had higher risk of recurrence than those with low SUVmax (5-year CIR, 19 % [n = 87] vs. 7 % [n = 94]; p = 0.033). SUVmax was associated with recurrence even after adjusting for pathologic stage (p = 0.037). Conclusions SUVmax on FDG-PET correlates with the IASLC/ATS/ERS classification and can be used to stratify patients with intermediate-grade histology, the predominant histologic subtype, into two prognostic subsets.
Kadota, Kyuichi; Colovos, Christos; Suzuki, Kei; Rizk, Nabil P.; Dunphy, Mark P. S.; Zabor, Emily C.; Sima, Camelia S.; Yoshizawa, Akihiko; Travis, William D.; Rusch, Valerie W.; Adusumilli, Prasad S.
Cancer risk in hospitalised asthma patients.
Asthma is an increasingly common disorder, affecting 5-10% of the population. It involves a dysregulated immune function, which may predispose to subsequent cancer. We examined cancer risk among Swedish subjects who had hospital admission once or multiple times for asthma. An asthma research database was created by identifying asthma patients from the Swedish Hospital Discharge Register and by linking them with the Cancer Registry. A total of 140 425 patients were hospitalised for asthma during 1965-2004, of whom 7421 patients developed cancer, giving an overall standardised incidence ratio (SIR) of 1.36. A significant increase was noted for most sites, with the exception of breast and ovarian cancers and non-Hodgkin's lymphoma and myeloma. Patients with multiple hospital admissions showed a high risk, particularly for stomach (SIR 1.70) and colon (SIR 1.99) cancers. A significant decrease was noted for endometrial cancer and skin melanoma. Oesophageal and lung cancers showed high risks throughout the study period, whereas stomach cancer increased towards the end of the period. The relatively stable temporal trends suggest that the asthmatic condition rather than its medication is responsible for the observed associations. PMID:19174822
Ji, J; Shu, X; Li, X; Sundquist, K; Sundquist, J; Hemminki, K
Risk factors responsible for patients' falls.
The study determined intrinsic factors which contributed to the falls of adults hospitalized in a general hospital during 1987-88. Two hundred and fourteen patients were studied in two groups. Group A consisted of 108 patients who fell during their hospitalization and control Group B consisted of 106 patients with the same characteristics also hospitalized during the same period who did not fall. Of the 23 variables which have been analyzed by the multivariate logistic regression method, seven present statistically significant incidence and increased risk of patients' falls: (1) gender: the number of accidents occurring among male patients was higher than that among females (p = 0.0022); (2) age: the majority of accidents occurred in the 65 greater than or equal to years old age group (p = 0.00426); (3) general pathological conditions: mostly patients with cardiac problems (p = 0.0062); (4) neoplasms (p = 0.0334); (5) anaemias (p = 0.0128); (6) post-operative conditions (p = 0.0063); and the taking of hypnotic/tranquilizer drugs (p = 0.0486). Other significant findings were: the highest incidence of falls occurred during the first 4 days of the patients' admission to hospital and most during the early morning hours (5-6 am). Injuries incurred were bruises (32.4%), minor injuries (24%), major injuries (16.7%) and fractures (10.2%). The high correlation between patients' falls and (1) specific diseases, namely neoplasms, anaemias, cardiac and post-operative conditions and (2) the taking of hypnotic/tranquilizer drugs are risk factors in relation to patients' falls in general hospitals. PMID:1641531
Plati, C; Lanara, V; Mantas, J
Multiparameter flow cytometry for the identification of the Waldenstr÷m's clone in IgM-MGUS and Waldenstr÷m's Macroglobulinemia: new criteria for differential diagnosis and risk stratification.
Although multiparameter flow cytometry (MFC) has demonstrated clinical relevance in monoclonal gammopathy of undetermined significance (MGUS)/myeloma, immunophenotypic studies on the full spectrum of Waldenstr÷m's Macroglobulinemia (WM) remain scanty. Herein, a comprehensive MFC analysis on bone marrow samples from 244 newly diagnosed patients with an immunoglobulin M (IgM) monoclonal protein was performed, including 67 IgM-MGUS, 77 smoldering and 100 symptomatic WM. Our results show a progressive increase on the number and light-chain-isotype-positive B-cells from IgM-MGUS to smoldering and symptomatic WM (P<.001), with only 1% of IgM-MGUS patients showing >10% B cells or 100% light-chain-isotype-positive B-cells (P<.001). Complete light-chain restriction of the B-cell compartment was an independent prognostic factor for time-to progression in smoldering WM (median 26 months; HR: 19.8, P=0.001) and overall survival in symptomatic WM (median 44 months; HR: 2.6, P=0.004). The progressive accumulation of light-chain-isotype-positive B-cells accompanied the emergence of a characteristic Waldenstrom's phenotype (CD22(+dim) / CD25+ /CD27+ / IgM+) that differed from other B-NHL by negative expression of CD5, CD10, CD11c or CD103. In contrast to myeloma, light-chain-isotype-positive plasma cells in IgM monoclonal gammopathies show otherwise normal antigenic expression. Our results highlight the potential value of MFC immunophenotyping for the characterization of the Waldenstr÷m's clone, as well as for the differential diagnosis, risk of progression and survival in WM. PMID:23604227
Paiva, B; Montes, M C; GarcĒa-Sanz, R; Ocio, E M; Alonso, J; de Las Heras, N; Escalante, F; Cuello, R; de Coca, A G; Galende, J; Hernßndez, J; Sierra, M; Martin, A; Pardal, E; Bßrez, A; Alonso, J; Suarez, L; Gonzßlez-L¾pez, T J; Perez, J J; Orfao, A; VidrĒales, M-B; San Miguel, J F
Clinical risk scores to guide perioperative management
Perioperative morbidity is associated with reduced long term survival. Comorbid disease, cardiovascular illness, and functional capacity can predispose patients to adverse surgical outcomes. Accurate risk stratification would facilitate informed patient consent and identify those individuals who may benefit from specific perioperative interventions. The ideal clinical risk scoring system would be objective, accurate, economical, simple to perform, based entirely on information
Sarah Barnett; Suneetha Ramani Moonesinghe
Patient repositioning and pressure ulcer risk--monitoring interface pressures of at-risk patients.
Repositioning patients regularly to prevent pressure ulcers and reduce interface pressures is the standard of care, yet prior work has found that standard repositioning does not relieve all areas of at-risk tissue in nondisabled subjects. To determine whether this holds true for high-risk patients, we assessed the effectiveness of routine repositioning in relieving at-risk tissue of the perisacral area using interface pressure mapping. Bedridden patients at risk for pressure ulcer formation (n = 23, Braden score <18) had their perisacral skin-bed interface pressures recorded every 30 s while they received routine repositioning care for 4-6 h. All participants had specific skin areas (206 +/- 182 cm(2)) that exceeded elevated pressure thresholds for >95% of the observation period. Thirteen participants were observed in three distinct positions (supine, turned left, turned right), and all had specific skin areas (166 +/- 184 cm(2)) that exceeded pressure thresholds for >95% of the observation period. At-risk patients have skin areas that are likely always at risk throughout their hospital stay despite repositioning. Healthcare providers are unaware of the actual tissue-relieving effectiveness (or lack thereof) of their repositioning interventions, which may partially explain why pressure ulcer mitigation strategies are not always successful. Relieving at-risk tissue is a necessary part of pressure ulcer prevention, but the repositioning practice itself needs improvement. PMID:23934869
Peterson, Matthew J; Gravenstein, Nikolaus; Schwab, Wilhelm K; van Oostrom, Johannes H; Caruso, Lawrence J
Network-based stratification of tumor mutations
Many forms of cancer have multiple subtypes with different causes and clinical outcomes. Somatic tumor genomes provide a rich new source of data for uncovering these subtypes but have proven difficult to compare as two tumors rarely share the same mutations. Here, we introduce a method called Network Based Stratification (NBS) which integrates somatic tumor genomes with gene networks. This approach allows for stratification of cancer into informative subtypes by clustering together patients with mutations in similar network regions. We demonstrate NBS in ovarian, uterine and lung cancer cohorts from The Cancer Genome Atlas. For each tissue, NBS identifies clear subtypes that are predictive of clinical outcomes such as patient survival, response to therapy or tumor histology. We identify network regions characteristic of each subtype and show how mutation-derived subtypes can be used to train an mRNA expression signature which provides similar information in the absence of DNA sequence.
Hofree, Matan; Shen, John P.; Carter, Hannah; Gross, Andrew; Ideker, Trey
A Novel Surface Electrocardiogram-Based Marker of Ventricular Arrhythmia Risk in Patients With Ischemic Cardiomyopathy
Background Better sudden cardiac death risk markers are needed in ischemic cardiomyopathy (ICM). Increased heterogeneity of electrical restitution is an important mechanism underlying the risk of ventricular arrhythmia (VA). Our aim was to develop and test a novel quantitative surface electrocardiogram¢based measure of VA risk in patients with ICM: the Regional Restitution Instability Index (R2I2). Methods and Results R2I2, the mean of the standard deviation of residuals from the mean gradient for each ECG lead at a range of diastolic intervals, was measured retrospectively from high-resolution 12-lead ECGs recorded during an electrophysiology study. Patient groups were as follows: Study group, 26 patients with ICM being assessed for implantable defibrillator; Control group, 29 patients with supraventricular tachycardia undergoing electrophysiology study; and Replication group, 40 further patients with ICM. R2I2 was significantly higher in the Study patients than in Controls (mean ▒ standard error of the mean: 1.09▒0.06 versus 0.63▒0.04, P<0.001). Over a median follow-up period of 23 months, 6 of 26 Study group patients had VA or death. R2I2 predicted VA or death independently of demographic factors, electrophysiology study result, left ventricular ejection fraction, or QRS duration (Cox model, P=0.029). R2I2 correlated with peri-infarct zone as assessed by cardiac magnetic resonance imaging (r=0.51, P=0.024). The findings were replicated in the Replication group: R2I2 was significantly higher in 11 of 40 Replication patients experiencing VA (1.18▒0.10 versus 0.92▒0.05, P=0.019). In combined analysis of ICM cohorts, R2I2 ?1.03 identified subjects with significantly higher risk of VA or death (43%) compared with R2I2 <1.03 (11%) (P=0.004). Conclusions In this pilot study, we have developed a novel VA risk marker, R2I2, and have shown that it correlated with a structural measure of arrhythmic risk and predicted risk of VA or death in patients with ICM. R2I2 may improve risk stratification and merits further evaluation. (J Am Heart Assoc. 2012;1:e001552 doi: 10.1161/JAHA.112.001552.)
Nicolson, William B.; McCann, Gerry P.; Brown, Peter D.; Sandilands, Alastair J.; Stafford, Peter J.; Schlindwein, Fernando S.; Samani, Nilesh J.; Ng, G. Andre
Stratification for smoking in case-cohort studies of genetic polymorphisms and lung cancer
The risk estimates obtained in studies of genetic polymorphisms and lung cancer differ markedly between studies, which might be due to chance or differences in study design, in particular the stratification\\/match of comparison group. The effect of different strategies for stratification and adjustment for smoking on the estimated effect of polymorphisms on lung cancer risk was explored in the case-cohort
Mette S°rensen; Ana GarcĒa L¾pez; Per Kragh Andersen; Ulla Vogel; Herman Autrup; Anne Tj°nneland; Kim Overvad; Ole Raaschou-Nielsen
The Effect of a Provider-Enhanced Clinical Decision Support Tool for Guiding Venous Thromboembolism Pharmacoprophylaxis in "Low-Risk" Patients
Background Computer-based tools to assess venous thromboembolism (VTE) risk have been shown to increase VTE pharmacoprophylaxis rates and decrease VTE incidence in high-risk hospitalized patients. However, VTE risk may be underestimated using computer-based tools alone. We tested the effect of a provider-enhanced clinical decision support (CDS) tool on VTE pharmacoprophylaxis and VTE incidence in patients who would have been deemed ōlow-riskö using a computer-based risk assessment tool alone. Methods The study sample was adult patients hospitalized during a 13-month period who were determined to be ōlow-riskö for VTE with a computer-based risk assessment tool. The provider-enhanced CDS tool was implemented 4 months into the study period that required providers to stratify patients as high, moderate, or low-risk for VTE. We compared rates of VTE pharmacoprophylaxis and VTE incidence before and after implementation of the provider-enhanced CDS tool. Results There were 1,322 patients in the 4-month pre-implementation period and 3,347 patients in the 9-month post-implementation period who were deemed ōlow-riskö for VTE based on a computer-based risk assessment tool. Using the provider-enhanced CDS tool, providers stratified 31% of these computer-assigned ōlow-riskö patients as moderate-risk and 7% as high-risk for VTE. The rate of VTE pharmacoprophylaxis increased (27% to 34%, p<0.01). VTE rate decreased from 0.98% to 0.42% after implementation of the provider-enhanced CDS tool (p<0.02). Conclusions Patients identified as ōlow-riskö for VTE solely by computer-based algorithms may include patients that providers determine to be at risk for VTE. Provider-enhanced CDS tools may outperform computer-based VTE risk stratification algorithms.
MaCauley, Michael J.; Showalter, John W.; Beck, Michael J.; Chuang, Cynthia H.
Assessment of cardiovascular risk in hypertensive patients: a comparison of commonly used risk scoring programs
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.
Ulusoy, Sukru
Isolation for high-risk patients
Standard isolation accommodation provides adequate protection against the infectious diseases prevalent in the U.K. but higher standards are necessary for more dangerous infections imported from overseas. These may be provided reasonably cheaply by modifying existing wards but staff are still exposed to risk. By physically separating the patient from the attendants, the Trexler plastic isolator affords a greater degree of protection and is of particular value when dealing with a dangerous infection against which there is no form of immunization. ImagesFig. 3
Emond, Ronald T. D.
Improved coronary risk assessment among intermediate risk patients using a clinical and biomarker based algorithm developed and validated in two population cohorts
Background Many coronary heart disease (CHD) events occur in individuals classified as intermediate risk by commonly used assessment tools. Over half the individuals presenting with a severe cardiac event, such as Myocardial Infarction (MI), have at most one risk factor as included in the widely used Framingham risk assessment. Individuals classified as intermediate risk, who are actually at high risk, may not receive guideline recommended treatments. A clinically useful method for accurately predicting 5-year CHD risk among intermediate risk patients remains an unmet medical need. Objective This study sought to develop a CHD Risk Assessment (CHDRA) model that improves 5-year risk stratification among intermediate risk individuals. Methods Assay panels for biomarkers associated with atherosclerosis biology (inflammation, angiogenesis, apoptosis, chemotaxis, etc.) were optimized for measuring baseline serum samples from 1084 initially CHD-free Marshfield Clinic Personalized Medicine Research Project (PMRP) individuals. A multivariable Cox regression model was fit using the most powerful risk predictors within the clinical and protein variables identified by repeated cross-validation. The resulting CHDRA algorithm was validated in a Multiple-Ethnic Study of Atherosclerosis (MESA) case-cohort sample. Results A CHDRA algorithm of age, sex, diabetes, and family history of MI, combined with serum levels of seven biomarkers (CTACK, Eotaxin, Fas Ligand, HGF, IL-16, MCP-3, and sFas) yielded a clinical net reclassification index of 42.7% (p<0.001) for MESA patients with a recalibrated Framingham 5-year intermediate risk level. Across all patients, the model predicted acute coronary events (hazard ratio=2.17, p<0.001), and remained an independent predictor after Framingham risk factor adjustments. Limitations These include the slightly different event definition with the MESA samples and inability to include PMRP fatal CHD events. Conclusions A novel risk score of serum protein levels plus clinical risk factors, developed and validated in independent cohorts, demonstrated clinical utility for assessing the true risk of CHD events in intermediate risk patients. Improved accuracy in cardiovascular risk classification could lead to improved preventive care and fewer deaths.
Cross, D.S.; McCarty, C.A.; Hytopoulos, E.; Beggs, M.; Nolan, N.; Harrington, D.S.; Hastie, T.; Tibshirani, R.; Tracy, R.P.; Psaty, B.M.; McClelland, R.; Tsao, P.S.; Quertermous, T.
Validation of the Joensuu risk criteria for primary resectable gastrointestinal stromal tumour ¢ The impact of tumour rupture on patient outcomes
BackgroundApproval of imatinib for adjuvant treatment of gastrointestinal stromal tumours (GIST) raised discussion about accuracy of prognostic factors in GIST and the clinical significance of the available risk stratification criteria.
P. Rutkowski; E. Bylina; A. Wozniak; Z. I. Nowecki; C. Osuch; M. Matlok; T. ?witaj; W. Michej; M. Wro?ski; S. G?uszek; J. Kroc; A. Nasierowska-Guttmejer; H. Joensuu
Prevalence of patients at nutritional risk in Danish hospitals
Background & aims: Undernutrition is associated with increased morbidity and mortality and is common in patients admitted to hospital. We examined (1) the prevalence of patients at nutritional risk, (2) whether these patients were identified by the staff, and (3) whether a nutritional plan and monitoring was made for patients at nutritional risk.Methods: A cross-sectional study in 15 randomly selected
Henrik H°jgaard Rasmussen; Jens Kondrup; Michael Staun; Karin Ladefoged; Hanne Kristensen; Anne Wengler
Risk Stratification in Elderly Coronary Artery Disease Patients: Can We Predict Which Seniors Benefit Most from Revascularization Options?
With the increased global burden of an aging population manifesting cardiovascular disease, the decision process for use of\\u000a coronary revascularization options in older adults has gained attention. Assessment of physiologic status has greater bearing\\u000a than chronologic age; items that have proven of particular merit in evaluating comorbidities as they relate to treatment prognosis\\u000a for both PCI and CABG in older
James B. McClurken; Raphael Rosenhek; T. Sloane Guy; Daniel E. Forman
Adjuvant radiotherapy and health-related quality of life of patients at intermediate risk of recurrence following primary surgery for oral squamous cell carcinoma.
Controversy surrounds who should receive adjuvant radiotherapy in patients with intermediate risk of recurrence of oral squamous cell carcinoma following primary surgery. The aim of this study was to compare health-related quality of life (HRQOL) outcomes of those who received adjuvant radiotherapy to those who did not in patients at intermediate-risk of recurrence. A total of 765 oral cancer patients were treated at the Regional Maxillofacial Unit, Liverpool from 1995 to 2007. After excluding 124 patients (87 primary radiotherapy, 23 died within 90 days, 14 had insufficient information for determining risk group status), 169 were low-risk, 271 intermediate-risk and 201 were high-risk. In the intermediate-risk group, 33% had adjuvant radiotherapy. Allowing for attrition, more than 70% had University of Washington quality of life data (UW-QOL). Cumulative survival was similar in those with and without adjuvant radiotherapy in a subset of patients at intermediate risk. There was little difference in overall HRQOL scores and in the socio-emotional subscale scores of the UW-QOL. However, there was a significant difference in physical subscale scores and the issue most affected was saliva. These findings support better stratification of risk in the intermediate group, and the plausibility of withholding radiotherapy without compromising survival. This can have dramatic positive benefits on patient physical outcomes, in particular saliva. Where adjuvant radiotherapy is necessary, it is appropriate to minimise adverse effects through measures such as intensity-modulated radiation therapy. PMID:21827968
Bekiroglu, F; Ghazali, N; Laycock, R; Katre, C; Lowe, D; Rogers, S N
No Increased Risk of Herpes Zoster Found in Cirrhotic Patients: A Nationwide Population-Based Study in Taiwan
Background The association between liver cirrhosis (LC) and herpes zoster has rarely been studied. We investigated the hypothesis that LC, known as an immunodeficiency disease, may increase the risk of herpes zoster using a national health insurance database in Taiwan. Materials and Methods The study cohort included cirrhotic patients between 1998 and 2005 (n?=?4667), and a ratio of 1?5 randomly sampled age- and gender-matched control patients (n?=?23,335). All subjects were followed up for 5 years from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 5-year herpes zoster-free survival rates. Results Of all patients, 523 patients developed herpes zoster during the 5-year follow-up period, among whom 82 were LC patients and 441 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with LC was not higher (AHR: 0.77, 95% confidence interval: 0.59¢1.01, p?=?0.06) than that of the controls during the 5-year follow-up. No increased risk of herpes zoster was found in LC patients after stratification by age, gender, urbanization level, income, geographic region, and all comorbidities. Conclusions This large nationwide population-based cohort study suggests that there is no increased risk for herpes zoster among people who have LC compared to a matching population.
Wu, Ping-Hsun; Lin, Yi-Ting; Kuo, Chun-Nan; Chang, Wei-Chiao; Chang, Wei-Pin
Pillcam ESO« is more accurate than clinical scoring systems in risk stratifying emergency room patients with acute upper gastrointestinal bleeding
Background: Upper gastrointestinal bleeding (UGIB) accounts for 400,000 hospital admissions in the US each year. Despite advances, mortality rates remain high and are estimated to be 5¢10%. Early therapeutic endoscopy is widely recommended as a means of reducing morbidity and mortality. The Rockall and Blatchford scores are clinical scoring systems devised to assist in risk stratifying patients with UGIB. In a prior study we found that rapid live bedside video capsule endoscopy (VCE) utilizing Pillcam ESO« correctly identified patients with high-risk stigmata of bleeding seen on upper endoscopy. In this study, we compare the accuracy of the Rockall and Blatchford scores with Pillcam ESO« in predicting high-risk endoscopic stigmata. Methods: Pre-endoscopy Blatchford and Rockall scores were calculated for 25 patients (14 males, 11 females) presenting to the emergency room with acute UGIB. The average patient was 66 years of age. A total of 24 out of 25 patients underwent upper endoscopy within 24 hours. One patient did not undergo endoscopy due to clinical instability. The timing of endoscopy was based on clinical parameters in 12 patients, and on live view VCE with Pillcam ESO« in the other 13 patients. Positive VCE was defined as red blood, clot or coffee grounds. Mean Rockall and Blatchford scores for all 24 patients were compared to determine potential differences between high- and low-risk patients. Rockall and Blatchford scores were also compared with VCE findings. Results: Of 24 patients, 13 had high-risk stigmata on upper endoscopy. The mean Rockall and Blatchford scores were 3 and 13, respectively. In the 11 patients without stigmata, the mean Rockall and Blatchford scores were 2 and 11, respectively. There was no statistically significant difference between the Blatchford scores of the two groups (95% confidence interval [CI] ?5.1 to 1.3; p = 0.22). There was no statistically significant difference between the Rockall scores of the two groups (95% CI ?2.3 to 0.3; p = 0.11). In the subgroup of 12 patients who underwent VCE prior to endoscopy, 8/12 had positive findings, which were all confirmed at endoscopy. All 4 patients with negative VCE had no high-risk stigmata at endoscopy. Conclusion: In emergency room patients with acute UGIB, neither the Rockall nor the Blatchford scores were able to differentiate high- and low-risk patients identified at endoscopy. Live view VCE, however, was accurate in predicting high-risk endoscopic stigmata, and may be better suited as a risk stratification tool. Additional studies with a larger cohort will be required to validate these findings.
Shalomov, Albert; Hussain, Syed A.; Kim, Sang H.; Cortes, Rafael; Gray, Sondra; Judeh, Hani; Pollack, Simcha; Rubin, Moshe
Quantitative stratification of diffuse parenchymal lung diseases.
Diffuse parenchymal lung diseases (DPLDs) are characterized by widespread pathological changes within the pulmonary tissue that impair the elasticity and gas exchange properties of the lungs. Clinical-radiological diagnosis of these diseases remains challenging and their clinical course is characterized by variable disease progression. These challenges have hindered the introduction of robust objective biomarkers for patient-specific prediction based on specific phenotypes in clinical practice for patients with DPLD. Therefore, strategies facilitating individualized clinical management, staging and identification of specific phenotypes linked to clinical disease outcomes or therapeutic responses are urgently needed. A classification schema consistently reflecting the radiological, clinical (lung function and clinical outcomes) and pathological features of a disease represents a critical need in modern pulmonary medicine. Herein, we report a quantitative stratification paradigm to identify subsets of DPLD patients with characteristic radiologic patterns in an unsupervised manner and demonstrate significant correlation of these self-organized disease groups with clinically accepted surrogate endpoints. The proposed consistent and reproducible technique could potentially transform diagnostic staging, clinical management and prognostication of DPLD patients as well as facilitate patient selection for clinical trials beyond the ability of current radiological tools. In addition, the sequential quantitative stratification of the type and extent of parenchymal process may allow standardized and objective monitoring of disease, early assessment of treatment response and mortality prediction for DPLD patients. PMID:24676019
Raghunath, Sushravya; Rajagopalan, Srinivasan; Karwoski, Ronald A; Maldonado, Fabien; Peikert, Tobias; Moua, Teng; Ryu, Jay H; Bartholmai, Brian J; Robb, Richard A
Increased risk of venous thromboembolism in patients with acute leukaemia
Patients with malignancies have an increased risk for venous thromboembolisms (VTE), but data on patients with acute leukaemia are very limited so far. We found VTE in 12% of 455 patients with acute leukaemia, half of which occurred in association with central venous catheters, with equal risk of ALL and AML.
Mohren, M; Markmann, I; Jentsch-Ullrich, K; Koenigsmann, M; Lutze, G; Franke, A
Increased risk of venous thromboembolism in patients with acute leukaemia.
Patients with malignancies have an increased risk for venous thromboembolisms (VTE), but data on patients with acute leukaemia are very limited so far. We found VTE in 12% of 455 patients with acute leukaemia, half of which occurred in association with central venous catheters, with equal risk of ALL and AML. PMID:16421591
Mohren, M; Markmann, I; Jentsch-Ullrich, K; Koenigsmann, M; Lutze, G; Franke, A
Vascular access and increased risk of death among hemodialysis patients
Vascular access and increased risk of death among hemodialysis patients.BackgroundHemodialysis with a venous catheter increases the risk of infection. The extent to which venous catheters are associated with an increased risk of death among hemodialysis patients has not been extensively studied.MethodsWe conducted a retrospective cohort study of 7497 prevalent hemodialysis patients to assess the association between dialysis with a venous
Stephen Pastan; J Michael Soucie; William M McClellan
Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients
Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients.BackgroundCardiovascular diseases are the most common causes of death among chronic hemodialysis patients, yet the risk factors for these events have not been well established.MethodsIn this cross-sectional study, we examined the relationship between several traditional cardiovascular disease risk factors and the presence or history of cardiovascular events in 936 hemodialysis patients enrolled in
Alfred K. Cheung; Mark J. Sarnak; Guofen Yan; Johanna T. Dwyer; Robert J. Heyka; Michael V. Rocco; Brendan P. Teehan; Andrew S. Levey
Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: A prospective observational study of more than 2000 cases
Background: Conscious sedation is standard for GI endoscopy. Propofol increasingly is used as an alternative drug to avoid unwanted effects of the commonly used benzodiazepines. Although propofol in the hands of nonanesthesiologists is still controversial, this study characterized the safety profile of propofol administered by nurses under supervision of the gastroenterologist. Methods: All patients undergoing any endoscopic procedure between September
Ludwig T. Heuss; Patrizia Schnieper; Juergen Drewe; Eric Pflimlin; Christoph Beglinger
Perioperative care of the older patient
Nearly 60% of the Dutch population undergoing surgery is aged 65Āyears and over. Older patients are at increased risk of developing\\u000a perioperative complications (e.g., myocardial infarction, pneumonia, or delirium), which may lead to a prolonged hospital\\u000a stay or death. Preoperative risk stratification calculates a patientÆs risk by evaluating the presence and extent of frailty,\\u000a pathophysiological risk factors, type of surgery,
E. Blommers; M. Klimek; K. A. Hartholt; T. J. M. van der Cammen; J. Klein; P. G. Noordzij
Transcutaneous computed bioconductance measurement in lung cancer: a treatment enabling technology useful for adjunctive risk stratification in the evaluation of suspicious pulmonary lesions.
Lung cancer is the number one cause of cancer deaths in North America and is rapidly increasing worldwide. Although there are advances being made in the multidisciplinary management and combined-modality therapies of lung cancers, most cases are still diagnosed in later noncurable stages. Early detection has hinged on clinical risk assessment and on the future possibility of screening by low-dose computed tomography of the chest; however, this will only vastly increase the number of indeterminate pulmonary lesions (IPLs) being detected. Given that the majority of radiographically detected lung lesions are benign, and tissue confirmation by various invasive biopsy tests has increased risks and costs, a noninvasive adjunctive test that can stratify likelihood of an indeterminate lung lesion as malignant or benign will be a useful treatment-enabling technology to speed up diagnosis and treatment of lung cancers at a more curable stage and defer unnecessary invasive procedures that have potential for harm. Measurement of transcutaneous bioconductance using the differential conductivity properties of cancerous versus benign tissue has been previously demonstrated on nonlung lesions. Thus, it has the potential of being a noninvasive, simple-to-perform and repeatable test that may be valuable in assessing lung lesions. In this prospective study of subjects with known thoracic malignancies, computed bioconductance measurements discriminated between malignant lesions (29 primary lung cancers) from benign pathology (12) across a range of IPL sizes (0.8 cm and greater) with a sensitivity of 89.7% (positive predictive value 96.3%) and specificity of 91.7% (negative predictive value 78.5%). The technology seems to be effective across a range of tumor thoracic locations, cell types, and stages. Additional cohorts of subjects will be used to validate testing and for refinement of the current algorithm, which at present has a test performance with a receiver operating characteristic of 90.7%. Noninvasive transcutaneous computed bioconductance measurement can become a standard risk assessment and therapy-enabling tool in the evaluation of IPLs. PMID:22425917
Yung, Rex C; Zeng, Ming Ying; Stoddard, Gregory J; Garff, Michael; Callahan, Karleen
Automated detection of dual p16/Ki67 nuclear immunoreactivity in liquid-based Pap tests for improved cervical cancer risk stratification
The Papanicolau (Pap) test is a routine cytological procedure for early detection of dysplastic lesions in cervical epithelium. A reliable screening method is crucial for triage of women at risk; however manual screening and interpretation are associated with relatively low sensitivity and substantial interobserver diagnostic variability. P16 and Ki67 biomarkers have been recently proposed as adjunctive tools in the diagnosis of high-risk human papillomavirus (hrHPV) associated dysplasias to supplement the morphological characteristics of cells by additional colorimetric features. In this study, an automated technique for the evaluation of dual p16/Ki67 immunoreactivity in cervical cell nuclei is introduced. Smears stained with p16 and Ki67 antibodies were digitized, and analyzed by algorithms we developed. Gradient-based radial symmetry operator and adaptive processing of symmetry image were employed to obtain the nuclear mask. This step was followed by the extraction of features including pixel data and immunoreactivity signature from each nucleus. The features were analyzed by two support vector machine classifiers to assign a nucleus into one of four types of immunoreactivity: p16 positive (p16+/Ki67-), Ki67 positive (p16-/Ki67+), dual p16/Ki67 positive (p16+/Ki67+) and negative (p16-/Ki67-) respectively. Results obtained by our method correlated well with readings by two cytopathologists (n=18068 cells); p16+/Ki67+ nuclei were classified with respective precisions of 77.1% and 82.6%. Specificity in identification of p16-/Ki67- nuclei was better than 99.5%, and the sensitivity in detection of all immunopositive nuclei was 86.3% and 89.4% respectively. We found that the quantitative characterization of immunoreactivity provided by the additional highlighting of classified nuclei can positively impact the efficacy and screening outcome of the Pap test.
Gertych, Arkadiusz; Joseph, Anika O.; Walts, Ann E.; Bose, Shikha
Innovative tools for assessing risks for severe adverse events in areas of overlapping Loa loa and other filarial distributions: the application of micro-stratification mapping
Background The wide distribution of Loa loa infection (loiasis) throughout the Democratic Republic of Congo (DRC) is a major obstacle to the plans to eliminate onchocerciasis and lymphatic filariasis (LF) because the standard drug regime is dependent on ivermectin, which cannot be used in co-endemic areas due to the risk of severe adverse events (SAEs). A better understanding of the micro-epidemiology, overlapping low and high risk areas, and how they relate to SAEs is critical to ensure safe and effective treatment. Findings Based on published data from the Bas Congo Province in DRC, this study used geographical information systems (GIS) to re-map and analyse onchocerciasis and loiasis prevalence (<20%, 20 to 40%, >40%) at 144 sites in relation to health district areas reporting SAEs. The new maps highlighted the contrasting patterns of the high prevalence sites, and significant geographical overlap between low onchocerciasis and high loiasis sites. Statistical analyses found that sites with medium to high loiasis prevalence were 10 to 16 times more likely to be in a SAE area than those with low prevalence of loiasis. Sites where both onchocerciasis and loiasis prevalence was >20% were also associated with SAE areas. Conclusions Collaborative efforts between the national onchocerciasis and LF programmes are critical as plans to scale interventions are moving forward and thus, alternative strategies needed in loiasis co-endemic areas which may include the new L. loa test and treat strategy using the Cellscope, or interventions such as integrated vector management, or anti Wolbachia therapy using doxycycline.
Enrichment and Stratification for Predementia Alzheimer Disease Clinical Trials
The tau and amyloid pathobiological processes underlying Alzheimer disease (AD) progresses slowly over periods of decades before clinical manifestation as mild cognitive impairment (MCI), then more rapidly to dementia, and eventually to end-stage organ failure. The failure of clinical trials of candidate disease modifying therapies to slow disease progression in patients already diagnosed with early AD has led to increased interest in exploring the possibility of early intervention and prevention trials, targeting MCI and cognitively healthy (HC) populations. Here, we stratify MCI individuals based on cerebrospinal fluid (CSF) biomarkers and structural atrophy risk factors for the disease. We also stratify HC individuals into risk groups on the basis of CSF biomarkers for the two hallmark AD pathologies. Results show that the broad category of MCI can be decomposed into subsets of individuals with significantly different average regional atrophy rates. By thus selectively identifying individuals, combinations of these biomarkers and risk factors could enable significant reductions in sample size requirements for clinical trials of investigational AD-modifying therapies, and provide stratification mechanisms to more finely assess response to therapy. Power is sufficiently high that detecting efficacy in MCI cohorts should not be a limiting factor in AD therapeutics research. In contrast, we show that sample size estimates for clinical trials aimed at the preclinical stage of the disorder (HCs with evidence of AD pathology) are prohibitively large. Longer natural history studies are needed to inform design of trials aimed at the presymptomatic stage.
Holland, Dominic; McEvoy, Linda K.; Desikan, Rahul S.; Dale, Anders M.
Interventional Fluoroscopy: Reducing Radiation Risks for Patients and Staff
This booklet discusses the value of interventional fluoroscopy as an important tool in patient treatments, the associated radiation risks to patients and staff, and the importance of optimizing radiation dose.
Identification of a 20-Gene Expression-Based Risk Score as a Predictor of Clinical Outcome in Chronic Lymphocytic Leukemia Patients
Despite the improvement in treatment options, chronic lymphocytic leukemia (CLL) remains an incurable disease and patients show a heterogeneous clinical course requiring therapy for many of them. In the current work, we have built a 20-gene expression (GE)-based risk score predictive for patients overall survival and improving risk classification using microarray gene expression data. GE-based risk score allowed identifying a high-risk group associated with a significant shorter overall survival (OS) and time to treatment (TTT) (P ? .01), comprising 19.6% and 13.6% of the patients in two independent cohorts. GE-based risk score, and NRIP1 and TCF7 gene expression remained independent prognostic factors using multivariate Cox analyses and combination of GE-based risk score together with NRIP1 and TCF7 gene expression enabled the identification of three clinically distinct groups of CLL patients. Therefore, this GE-based risk score represents a powerful tool for risk stratification and outcome prediction of CLL patients and could thus be used to guide clinical and therapeutic decisions prospectively.
Bou Samra, Elias; Klein, Bernard; Commes, Therese; Moreaux, Jerome
A Risk Analysis Method to Evaluate the Impact of a Computerized Provider Order Entry System on Patient Safety
Objectives Quantitative evaluation of safety after the implementation of a computerized provider order entry (CPOE) system, stratification of residual risks to drive future developments. Design Comparative risk analysis of the drug prescription process before and after the implementation of CPOE system, according to the Failure Modes, Effects and Criticality Analysis (FMECA) method. Measurements The failure modes were defined and their criticality indices calculated on the basis of the likelihood of occurrence, potential severity for patients, and detection probability. Criticality indices of handwritten and electronic prescriptions were compared, the acceptability of residual risks was discussed. Further developments were proposed and their potential impact on the safety was estimated. Results The sum of criticality indices of 27 identified failure modes was 3813 for the handwritten prescription, 2930 (?23%) for CPOE system, and 1658 (?57%) with 14 enhancements. The major safety improvements were observed for errors due to ambiguous, incomplete or illegible orders (?245 points), wrong dose determination (?217) and interactions (?196). Implementation of targeted pop-ups to remind treatment adaptation (?189), vital signs (?140), and automatic edition of documents needed for the dispensation (?126) were the most promising proposed improvements. Conclusion The impact of a CPOE system on patient safety strongly depends on the implemented functions and their ergonomics. The use of risk analysis helps to quantitatively evaluate the relationship between a system and patient safety and to build a strategy for continuous quality improvement, by selecting the most appropriate improvements to the system.
Bonnabry, Pascal; Despont-Gros, Christelle; Grauser, Damien; Casez, Pierre; Despond, Magali; Pugin, Deborah; Rivara-Mangeat, Claire; Koch, Magali; Vial, Martine; Iten, Anne; Lovis, Christian
A Clinical Prediction Model to Estimate Risk for Thirty Day Adverse Events in Emergency Department Patients with Symptomatic Atrial Fibrillation
Study Objective Atrial fibrillation (AF) affects over 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic AF and admit more than 65%. Our aim was to assess whether data available in the ED management of symptomatic AF can estimate a patient's risk of experiencing a 30-day adverse event. Methods We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic AF between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated using 300 bootstrap replications. Results During the 3-year study period, 914 patients accounted for 1228 ED visits. Eighty patients were excluded for non-AF related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least one of the 30-day adverse events. Increasing age (odds ratio [OR] and [95% CI]: 1.20 per decade [1.06, 1.36]), complaint of dyspnea (OR: 1.57 [1.12, 2.20]), smokers (OR: 2.35 [1.47, 3.76]), inadequate ventricular rate control (OR: 1.58 [1.13, 2.21]), and patients taking beta-blockers (OR: 1.44 [1.02, 2.04]) were independently associated with higher risk for adverse events. C-index was 0.67. Conclusion In ED patients with symptomatic AF, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and beta-blocker treatment were associated with an increased risk of a 30-day adverse event.
Barrett, Tyler W.; Martin, Amy R.; Storrow, Alan B.; Jenkins, Cathy A; Harrell, Frank E.; Russ, Stephan; Roden, Dan M.; Darbar, Dawood
Association of the DNMT3B -579G>T Polymorphism with Risk of Thymomas in Patients with Myasthenia Gravis
Increasing evidence suggests a contribution of epigenetic processes in promoting cancer and autoimmunity. Myasthenia gravis (MG) is an autoimmune disease mediated, in approximately 80% of the patients, by antibodies against the nicotinic acetylcholine receptor (AChR+). Moreover, epithelial tumours (thymomas) are present in about 10-20% of the patients, and there is indication that changes in DNA methylation might contribute to the risk and progression of thymomas. However, the role of epigenetics in MG is still not completely clarified. In the present study we investigated if a common polymorphism (-579G>T: rs1569686) in the promoter of the DNMT3B gene coding for the DNA methyltransferase 3B, an enzyme that mediates DNA methylation, increases the risk to develop MG or MG-associated thymomas. The study polymorphism was selected based on recent reports and a literature meta-analysis suggesting association with increased risk of various types of cancer. We screened 324 AChR+ MG patients (140 males and 184 females, mean age 56.0 ▒ 16.5 years) and 735 healthy matched controls (294 males and 441 females, mean age 57.3 ▒ 15.6 years). 94 of the total MG patients had a thymoma. While there was no association with the whole cohort of MG patients, we found a statistically significant association of the DNMT3B -579T allele (OR = 1.51; 95% CI=1.1-2.1, P = 0.01) and the TT homozygous genotype (OR = 2.59; 95% CI=1.4-4.9, P = 0.006) with the risk of thymoma. No association was observed in MG patients without thymoma, even after stratification into clinical subtypes. Present results suggest that the DNMT3B -579T allele might contribute to the risk of developing thymoma in MG patients, particularly in homozygous TT subjects.
Coppede, Fabio; Ricciardi, Roberta; Denaro, Maria; De Rosa, Anna; Provenzano, Carlo; Bartoccioni, Emanuela; Baggiani, Angelo; Lucchi, Marco; Mussi, Alfredo; Migliore, Lucia
Risk Factors and Biomarkers of Ischemic Stroke in Cancer Patients
Background and Purpose Stroke is common among cancer patients. However, risk factors and biomarkers of stroke in cancer patients are not well established. This study aimed to investigate risk factors and biomarkers as well as etiology of ischemic stroke in cancer patients. Methods A retrospective review was conducted in cancer patients with ischemic stroke who were admitted to a general hospital in Busan, Korea, between January 2003 and December 2012. The risk factors and biomarkers for stroke and stroke subtypes in cancer patients were compared with age- and sex-matched noncancer patients with ischemic stroke who were admitted to the same hospital during the same period. Results One hundred fifty-six cancer patients with ischemic stroke were identified. Cancer patients with ischemic stroke were found to have a significantly lower proportion of hypertension, atrial fibrillation, hyperlipidemia, and ischemic heart disease than noncancer patients with ischemic stroke. However, stroke biomarkers, such as erythrocyte sedimentation rate and high-sensitivity C-reactive protein, fibrinogen, pro-brain natriuretic peptide, and D-dimer levels, were significantly increased in cancer patients with ischemic stroke than in noncancer patients. Large-artery atherosclerosis and stroke of undetermined cause were more common in cancer patients with ischemic stroke than in noncancer patients with ischemic stroke. Conclusions Cancer patients with ischemic stroke showed different risk factors, stroke biomarkers, and stroke etiology compared with noncancer patients with ischemic stroke.
Lee, Ji-Hun
Early recurrence in standard-risk medulloblastoma patients with the common idic(17)(p11.2) rearrangement
Medulloblastoma is diagnosed histologically; treatment depends on staging and age of onset. Whereas clinical factors identify a standard- and a high-risk population, these findings cannot differentiate which standard-risk patients will relapse and die. Outcome is thought to be influenced by tumor subtype and molecular alterations. Poor prognosis has been associated with isochromosome (i)17q in some but not all studies. In most instances, molecular investigations document that i17q is not a true isochromosome but rather an isodicentric chromosome, idic(17)(p11.2), with rearrangement breakpoints mapping within the REPA/REPB region on 17p11.2. This study explores the clinical utility of testing for idic(17)(p11.2) rearrangements using an assay based on fluorescent in situ hybridization (FISH). This test was applied to 58 consecutive standard- and high-risk medulloblastomas with a 5-year minimum of clinical follow-up. The presence of i17q (ie, including cases not involving the common breakpoint), idic(17)(p11.2), and histologic subtype was correlated with clinical outcome. Overall survival (OS) and disease-free survival (DFS) were consistent with literature reports. Fourteen patients (25%) had i17q, with 10 (18%) involving the common isodicentric rearrangement. The presence of i17q was associated with a poor prognosis. OS and DFS were poor in all cases with anaplasia (4), unresectable disease (7), and metastases at presentation (10); however, patients with standard-risk tumors fared better. Of these 44 cases, tumors with idic(17)(p11.2) were associated with significantly worse patient outcomes and shorter mean DFS. FISH detection of idic(17)(p11.2) may be useful for risk stratification in standard-risk patients. The presence of this abnormal chromosome is associated with early recurrence of medulloblastoma.
Bien-Willner, Gabriel A.; Lopez-Terrada, Dolores; Bhattacharjee, Meena B.; Patel, Kayuri U.; Stankiewicz, Pawel; Lupski, James R.; Pfeifer, John D.; Perry, Arie
Anomalous Subjective Experience and Psychosis Risk in Young Depressed Patients
Background: Help-seeking young people often display depressive symptoms. In some patients, these symptoms may co-exist with clinically high-risk mental states for psychosis. The aim of this study was to determine differences in subjective experience and social perception in young depressed patients with and without psychosis risk. Methods: Participants were 68 young persons with major depressive disorder. Twenty-six patients also met
Erika Szily; Szabolcs Kķri
Risk factors for suicidal ideation in psychiatric patients
Sociodemographic and clinical risk factors for suicidal ideation have been less studied than risk factors for parasuicide\\u000a and suicide. No reports on associations between therapy satisfaction and suicidal ideation among psychiatric patients have\\u000a been published. In this study we compared a group of patients with suicidal ideation (n= 84) with a randomly selected group of nonsuicidal patients (n?=?166) in community-based
J. Hintikka; H. Viinamõki; H.-T. Koivumaa-Honkanen; P. Saarinen; A. Tanskanen; J. Lehtonen
Risk of venous thromboembolism in patients with inflammatory bowel disease.
There is ample evidence of an increased risk of venous thromboembolism (VTE) in inflammatory bowel disease (IBD). Recent large studies have quantified this risk showing that IBD patients run a 1.5 to 3.6 higher risk of developing VTE than healthy controls. The development of VTE in IBD seems to be multifactorial, resulting from multiple interactions between acquired and inherited risk factors. The most important independent acquired risk factors include disease activity, hospitalization, colonic localization, and recent surgery. The main genetic defects that have been established as risk factors for VTE in the general population are rather uncommon in IBD, but when present, they increase the risk of VTE. IBD has been demonstrated to represent an independent risk factor for the recurrence of VTE. An increased risk of VTE-related mortality when compared with non-IBD patients has been reported. The guidelines for diagnosis and treatment of IBD patients with VTE are similar to that of thrombotic non-IBD patients. There is a consensus on the use of thromboprophylaxis mainly in hospitalized IBD patients with acute flares, but the prevention strategies need further evaluation in future studies. PMID:23629820
Koutroumpakis, Efstratios I; Tsiolakidou, Georgia; Koutroubakis, Ioannis E
Psoriasis and Cardiovascular Risk: Assessment by CUORE Project Risk Score in Italian Patients
Background. Psoriasis is a common inflammatory and immune-mediated skin disease. There is growing controversy as to whether cardiovascular risk is elevated in psoriasis. A number of studies suggest a high prevalence of cardiovascular risk factors as well as cardiovascular diseases in psoriasis patients. Objective. The objective of this study was to estimate cardiovascular risk score in psoriasis patients and the relation between cardiovascular risk and psoriasis features. Cardiovascular risk was assessed by CUORE project risk score built within the longitudinal study of the Italian CUORE project and suited to populations with a low rate of coronary heart disease. Results. A case-control study in 210 psoriasis outpatients and 111 controls with skin diseases other than psoriasis was performed. CUORE project risk score was higher in patients than controls (6.80 ▒ 6.34 versus 4.48 ▒ 4.38, P < 0.001). Compared to controls, psoriasis patients have higher risk of developing major cardiovascular events. Cardiovascular risk was not related to psoriasis characteristics. Conclusion. Increased focus on identifying cardiovascular risk factors and initiation of preventive lifestyle changes or therapeutic interventions in patients with psoriasis is warranted.
Caputo, Valentina; Bongiorno, Maria Rita
Increased cardiovascular risk in South African patients with Addison's disease.
Patients with Addison's disease (AD) are believed to be at risk for cardiovascular disease (CVD). South Africa, like the rest of the developing world is experiencing an increase in CVD and patients with AD may be at double the risk of their peers. We wished to explore AD patients' CVD risk factors. A cross-sectional nationwide study in South Africa of patients with AD was conducted. A cohort of 147 patients with AD and 147 healthy control subjects were matched by age, gender, ethnicity, and BMI as far as was possible. Lipoproteins and highly-sensitive C-reactive-protein (hs-CRP) were the main outcome measures. AD patients had significantly higher triglycerides; (p=0.001), lower HDLC (p<0.001), higher hs-CRP (p<0.001), and more small dense LDL; (p=0.002) than controls. Nonesterified fatty acids were lower in patients (p<0.001). Approximately 65% [95% confidence interval (CI 55.6-72.4%)] had hypercholesterolaemia, 75% (CI 64.8-81.2%) had low HDLC, and 75% (CI 68.0-84.1%) had a higher LDLC. Thirteen percent of AD patients had diabetes mellitus, but none of the risk factors differed from the nondiabetics. Only HDLC correlated positively with daily hydrocortisone dose (r=0.32; p=0.005). In conclusion dyslipidaemia is common in South African AD patients; CVD risk assessment and intervention are probably warranted in the management of these patients. PMID:23918685
Ross, I L; Bergthorsdottir, R; Levitt, N S; Schatz, D A; Johannsson, G; Marais, A D
Nowadays, increased seroprevalence of hepatitis C virus (HCV) in hemodialysis (HO) patients is an important problem. In this study, it was aimed to investigate the seroprevalence and risk factors leads to spread of HCV in HO and continuous ambulatory peritoneal dialysis (CAPO) patients. 67 HO and 35 CAPO patients were .enrolled in the study, 44 (43.1%) of them were female
Mehmet Emin YILMAZ; H. KARA; Yasin SARI; Suzan DOZEN; Yasemin Usul
Unbiased stratification of left ventricles.
Image based quantitative stratification of the Left Ventricles (LV) across a population helps in unraveling the structure-function symbiosis of the heart. An unbiased, reference less grouping scheme that automatically determines the number of clusters and a physioanatomically relevant strategy that aligns the intra cluster LV shapes would enable the robust construction of pathology stratified cardiac atlas. This paper achieves this hitherto elusive stratification and alignment by adapting the conventional strategies routinely followed by clinicians. The individual LV shape models (N=127) are independently oriented to an "attitudinally consistent orientation" that captures the physioanatomic variations of the LV morphology. Affinity propagation technique based on the automatically identified inter-LV_landmark distances is used to group the LV shapes. The proposed algorithm is computationally efficient and, if the inter cluster variations are linked to pathology, could provide a clinically relevant cardiac atlas. PMID:18979790
Srinivasan, Rajagopalan; Shriram, K S; Suryanarayanan, Srikanth
Coronary calcium screening and coronary risk stratification
Current vital statistics clearly indicate a continuing epidemic of cardiovascular disease in the Western hemisphere and strongly\\u000a suggest that the most desirable approach to this ailment is prevention rather than delayed treatment. Over 7 million people\\u000a in the United States suffer from coronary artery disease and more than 500,000 die from its complications annually. In the\\u000a majority of cases, the
Paolo Raggi; George James
Cardiac biomarkers and risk assessment in patients undergoing major non-cardiac surgery: time to revise the guidelines?
Although the perioperative event rate has declined over the past 30 years, as a consequence of the developments in anesthesiology and surgical techniques, perioperative cardiovascular complications are still a significant clinical problem. At the end of the last century, a pooled analysis of several large studies found a 30-day incidence of cardiac events of 2.5% in unselected patients aged >40 years. The identification of myocardial injury after non-cardiac surgery is a problematic and tough challenge, since up to 50% of cardiac deaths actually occur in patients with no history of overt heart disease. Recently, among novel sensitive and specific cardiovascular risk markers, the European Society of Cardiology and European Society of Anesthesiology guidelines for preoperative cardiac risk assessment have recommended that preoperative brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) measurement should be considered in high-risk patients undergoing non-cardiac surgery. However, several recent studies and meta-analyses, published in the last 5 years, strongly support the use of both assays of cardiac B-type natriuretic peptides and troponins, for risk stratification in patients undergoing non-cardiac surgery, in order to improve operative and postoperative outcome. Indeed, an increase in specific cardiac biomarkers, as it is the case for natriuretic peptides and troponins, always indicates that the heart is under a stress condition or even actually injured, respectively. In conclusion, the authors suggest that future guidelines on cardiovascular risk evaluation in patients undergoing major surgical procedures should take into account the following evidence. PMID:24501160
Clerico, Aldo; Emdin, Michele; Passino, Claudio
Risk Acceptance in Multiple Sclerosis Patients on Natalizumab Treatment
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 traitsÆ 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.
Tur, Carmen; Tintore, Mar; Vidal-Jordana, Angela; Bichuetti, Denis; Nieto Gonzalez, Pablo; Arevalo, Maria Jesus; Arrambide, Georgina; Anglada, Elisenda; Galan, Ingrid; Castillo, Joaquin; Nos, Carlos; Rio, Jordi; Martin, Maria Isabel; Comabella, Manuel; Sastre-Garriga, Jaume; Montalban, Xavier
Risk Profiles and Antithrombotic Treatment of Patients Newly Diagnosed with Atrial Fibrillation at Risk of Stroke: Perspectives from the International, Observational, Prospective GARFIELD Registry
Background Limited data are available on the characteristics, clinical management, and outcomes of patients with atrial fibrillation at risk of stroke, from a worldwide perspective. The aim of this study was to describe the baseline characteristics and initial therapeutic management of patients with non-valvular atrial fibrillation across the spectrum of sites at which these patients are treated. Methods and Findings The Global Anticoagulant Registry in the FIELD (GARFIELD) is an observational study of patients newly diagnosed with non-valvular atrial fibrillation. Enrollment into Cohort 1 (of 5) took place between December 2009 and October 2011 at 540 sites in 19 countries in Europe, Asia-Pacific, Central/South America, and Canada. Investigator sites are representative of the distribution of atrial fibrillation care settings in each country. Cohort 1 comprised 10,614 adults (?18 years) diagnosed with non-valvular atrial fibrillation within the previous 6 weeks, with ?1 investigator-defined stroke risk factor (not limited to those in existing risk-stratification schemes), and regardless of therapy. Data collected at baseline included demographics, medical history, care setting, nature of atrial fibrillation, and treatments initiated at diagnosis. The mean (SD) age of the population was 70.2 (11.2) years; 43.2% were women. Mean▒SD CHADS2 score was 1.9▒1.2, and 57.2% had a score ?2. Mean CHA2DS2-VASc score was 3.2▒1.6, and 8,957 (84.4%) had a score ?2. Overall, 38.0% of patients with a CHADS2 score ?2 did not receive anticoagulant therapy, whereas 42.5% of those at low risk (score 0) received anticoagulant therapy. Conclusions These contemporary observational worldwide data on non-valvular atrial fibrillation, collected at the end of the vitamin K antagonist-only era, indicate that these drugs are frequently not being used according to stroke risk scores and guidelines, with overuse in patients at low risk and underuse in those at high risk of stroke. Trial Registration ClinicalTrials.gov TRI08888
Kakkar, Ajay K.; Mueller, Iris; Bassand, Jean-Pierre; Fitzmaurice, David A.; Goldhaber, Samuel Z.; Goto, Shinya; Haas, Sylvia; Hacke, Werner; Lip, Gregory Y. H.; Mantovani, Lorenzo G.; Turpie, Alexander G. G.; van Eickels, Martin; Misselwitz, Frank; Rushton-Smith, Sophie; Kayani, Gloria; Wilkinson, Peter; Verheugt, Freek W. A.
The Risk of Stroke in Patients with Psoriasis
Psoriasis is a chronic Th-1 and Th-17 inflammatory disease. Chronic inflammation has also been associated with atherosclerosis and thrombosis. The purpose of this study was to determine the risk of stroke in patients with psoriasis. We conducted a population-based cohort study of patients seen by general practitioners participating in the General Practice Research Database in the United Kingdom 1987-2002. Mild psoriasis was defined as any patient with a diagnostic code of psoriasis but no history of systemic therapy. Severe psoriasis was defined as any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. When adjusting for major risk factors for stroke, both mild (HR 1.06, 95% CI 1.0-1.1) and severe (1.43, 95% CI 1.1, 1.9) psoriasis were independent risk factors for stroke. The excess risk of stroke attributable to psoriasis in patients with mild and severe disease was 1 in 4115 per year and 1 in 530 per year, respectively. Patients with psoriasis, particularly if severe, have an increased risk of stroke that is not explained by major stroke risk factors identified in routine medical care.
Gelfand, Joel M.; Dommasch, Erica; Shin, Daniel B; Azfar, Rahat S.; Kurd, Shanu Kohli; Wang, Xingmei; Troxel, Andrea B.
The risk of stroke in patients with psoriasis.
Psoriasis is a chronic Th-1 and Th-17 inflammatory disease. Chronic inflammation has also been associated with atherosclerosis and thrombosis. The purpose of this study was to determine the risk of stroke in patients with psoriasis. We conducted a population-based cohort study of patients seen by general practitioners participating in the General Practice Research Database in the United Kingdom, 1987-2002. Mild psoriasis was defined as any patient with a diagnostic code of psoriasis, but no history of systemic therapy. Severe psoriasis was defined as any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. When adjusting for major risk factors for stroke, both mild (hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.0-1.1) and severe (1.43, 95% CI 1.1-1.9) psoriasis were independent risk factors for stroke. The excess risk of stroke attributable to psoriasis in patients with mild and severe disease was 1 in 4,115 per year and 1 in 530 per year, respectively. Patients with psoriasis, particularly if severe, have an increased risk of stroke that is not explained by major stroke risk factors identified in routine medical care. PMID:19458634
Gelfand, Joel M; Dommasch, Erica D; Shin, Daniel B; Azfar, Rahat S; Kurd, Shanu K; Wang, Xingmei; Troxel, Andrea B
The risk of suicide mortality in chronic pain patients.
Chronic pain has long been considered an important risk factor for suicidal behavior. Less well understood are the factors associated with the increased risk for suicide death within chronic pain populations. The purpose of this review is to examine recent research with regard to rates of and risk factors for suicide mortality in patients with chronic musculoskeletal pain. We conclude that patients with a number of chronic pain states are at increased risk for suicide death, and that this risk appears to be due, at least in part, to other well-known correlates of pain such as depression and substance use disorders. However, in all likelihood, there are aspects of chronic pain itself that add uniquely to an individual's suicide risk profile. Lastly, we address a theoretical perspective and offer recommendations for clinical practice. PMID:24952608
Hassett, Afton L; Aquino, Jordan K; Ilgen, Mark A
COPD Patients Face Greater Risk of Heart Failure, Study Says
[Cardiovascular risk factors on the Framingham Risk Score among hypertensive patients attended by family health teams].
The Framingham Risk Score (FRS) is used to stratify cardiovascular risk. This study sought to identify the prevalence of risk factors used in the FRS and the use of drugs that reduce cardiovascular risk among hypertensive patients attended by the Family Health Strategy (FHS). It is cross-sectional study, which evaluated a random sample of hypertensive patients in the FHS in northern Minas Gerais. Data were collected through interviews and from medical records. 505 hypertensive patients were evaluated in 9 municipalities of the region, with a predominance of women; 325 (64.4%), mean age of 66.4 years. In 90% of hypertensive patients there was at least one associated risk factor. The grouping of three or more factors occurred in 79 (15.7%) patients. Dyslipidemia was found in 188 (37.2%), diabetes in 101 (20%) and smoking in 36 (7.1%). The use of anti-hypertensive drugs was observed in 481 (95.2%) patients. The use of other cardioprotective drugs was higher among patients with 3 or more risk factors: 45.6% used antiplatelet and 27.8% used lipid-lowering drugs. The prevalence of risk factors from the FRS in the population studied was quite high and the use of cardioprotective drugs was seen to be restricted. Strategies to increase the use of FRS may improve the management of hypertension in the FHS. PMID:24897474
Pimenta, Henderson Barbosa; Caldeira, Ant¶nio Prates
Doctors' Skill At Colonoscopy May Affect Patients' Colon Cancer Risk
... JavaScript. Doctors' Skill at Colonoscopy May Affect Patients' Colon Cancer Risk: Study You can ask your physician for ... Wednesday, April 2, 2014 Related MedlinePlus Pages Colonoscopy Colorectal Cancer WEDNESDAY, April 2, 2014 (HealthDay News) -- Your risk ...
Suicide risk in alcohol-dependent patient with depression
Alcohol addiction is the uncontrolled use of alcohol despite its harmful consequences. Depression consists of a long and continuous period of depressed mood with specific symptoms. Treatment for depression comorbidity in alcohol-dependent patients is essential to prevent complications as the suicide risk. Among adolescents and adults with major depression disorder alcohol abuse enhances the risk of suicide. Among alcohol abusers,
Anna Lucia Spear King; Antonio Egidio Nardi; Marcelo Santos Cruz
Behavioral Risk Assessment of the Guarded Suicidal Patient
ERIC Educational Resources Information Center
Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time-limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assistģ
Simon, Robert I.
The risk of thromboembolic events in kidney transplant patients.
Little is known about the risk of venous thrombosis following kidney transplant. To determine this we estimated the risk of thromboembolic events (TEs) in a cohort of consecutive patients who underwent kidney transplantation at a single tertiary care center over an 11-year period and calculated standardized incidence ratios (SIRs) for a first TE in kidney transplant recipients compared with the general population. We then performed a nested case-control study and compared patients with and without TEs to identify risk factors for thrombosis. Among 913 kidney transplant recipients (KTRs), 68 patients developed these events. The SIR for TEs in KTRs compared with the general population was 7.9 over the duration of follow-up. The risk was particularly higher in the first post-transplant year (SIR 26.1) but remained elevated afterward (SIR 5.2). Hospitalization, use of sirolimus, low hemoglobin level, and use of renin-angiotensin system inhibitors were independently associated with these events. When cases of TEs that occurred during hospitalization were excluded, the risk of these events remained elevated. The risk of TEs in KTRs was eightfold higher than in the general population but not fully explained by the increased risk associated with hospitalization. Our results underscore the important risk of thrombosis in patients who received a kidney transplant, making vigilance mandatory especially during hospitalization. PMID:24429408
Verhave, Jacobien C; Tagalakis, Vicky; Suissa, Samy; Madore, Franńois; Hķbert, Marie-Josķe; Cardinal, Hķlo'se
Predictive value of the Essen Stroke Risk Score and Ankle Brachial Index in acute ischaemic stroke patients from 85 German stroke units
Background: Risk stratification can contribute to individualised optimal secondary prevention in patients with cerebrovascular disease. Objective: To prospectively investigate the prediction of the Essen Stroke Risk Score (ESRS) and a pathological Ankle Brachial Index (ABI) in consecutive patients hospitalised with acute ischaemic stroke or transient ischaemic attack (TIA) in 85 neurological stroke units throughout Germany. Methods: 852 patients were prospectively documented on standardised case report forms, including assessment of ESRS and ABI. After 17.5 months, recurrent cerebrovascular events, functional outcome or death could be assessed in 729 patients predominantly via central telephone interview. Results: After discharge from the documenting hospital, recurrent stroke occurred in 41 patients (5.6%) and recurrent TIA in 15 patients (2.1%). 52 patients (7.1%) had died, 33 (4.5%) from cardiovascular causes. Patients with an ESRS ?3 (vs <3) had a significantly higher risk of recurrent stroke or cardiovascular death (9.7% vs 5.1%; odds ratio (OR) 2.00, 95% confidence interval (CI) 1.08 to 3.70) and a higher recurrent stroke risk (6.9% vs 3.7%; OR 1.93, 95% CI 0.95 to 3.94). Patients with an ABI ?0.9 (vs >0.9) had a significantly higher risk of recurrent stroke or cardiovascular death (10.4% vs 5.5%; OR 2.00, 95% CI 1.12 to 3.56) and a higher recurrent stroke risk (6.6% vs 4.6%; OR 1.47, 95% CI 0.76 to 2.83). Conclusion: Our prospective follow-up study shows a significantly higher rate of recurrent stroke or cardiovascular death and a clear trend for a higher rate of recurrent stroke in patients with acute cerebrovascular events classified as high risk by an ESRS ?3 or a pathological ABI.
Weimar, C; Goertler, M; Rother, J; Ringelstein, E B; Darius, H; Nabavi, D G; Kim, In-Ha; Benemann, Jens; Diener, Hans-Christoph
Treatment with Octreotide in Patients with Well-Differentiated Neuroendocrine Tumors of the Ileum: Prognostic Stratification with Ga-68-DOTA-TATE Positron Emission Tomography.
AbstractWe investigated the use of Ga-68-DOTA-Tyr3-octreotate (Ga-68-DOTA-TATE) positron emission tomography (PET) and standardized uptake values (SUVs) to predict the effectiveness of treatment with the somatostatin analogue octreotide acetate (Sandostatin LAR) in patients with neuroendocrine tumors (NETs). Thirty patients with well-differentiated NETs of the ileum (grades G1 and G2) were studied with Ga-68-DOTA-TATE. The average SUV of a 50% isocontour volume of interest covering the lesion with maximum uptake (SUVmean) and the maximum SUV (SUVmax) were determined. Patients were followed up, and the time to progression was recorded. Twenty-one patients showed progressive disease at the end of the study; nine patients had stable disease. The median progression-free survival (PFS) was 51.0 weeks (95% confidence interval [CI] 26.4-75.6). A cutoff for the SUVmax of 29.4 and for the SUVmean of 20.3 could separate between patients with a long PFS (69.0 weeks; 95% CI 9.8-128.2) and a short PFS (26.0 weeks; 95% CI 8.7-43.3) response to octreotide acetate therapy. Patients with high radiotracer uptake had significantly higher PFS with a 2.9-fold higher chance for stable disease after 45 weeks; however, the prognostic performance of SUVmax on an individual basis was poor, with a sensitivity of 75% and a specificity of 64%. SUVmax and SUVmean of NET tumor lesions in Ga-68-DOTA-TATE PET are important prognostic indices for predicting the response to therapy with octreotide acetate. PMID:24742433
Koch, Walter; Auernhammer, Christoph J; Geisler, Julia; Spitzweg, Christine; Cyran, Clemens C; Ilhan, Harun; Bartenstein, Peter; Haug, Alexander R
Treatment with Octreotide in Patients with Well-Differentiated Neuroendocrine Tumors of the Ileum: Prognostic Stratification with Ga-68-DOTA-TATE Positron Emission Tomography.
AbstractWe investigated the use of Ga-68-DOTA-Tyr3-octreotate (Ga-68-DOTA-TATE) positron emission tomography (PET) and standardized uptake values (SUVs) to predict the effectiveness of treatment with the somatostatin analogue octreotide acetate (Sandostatin LAR) in patients with neuroendocrine tumors (NETs). Thirty patients with well-differentiated NETs of the ileum (grades G1 and G2) were studied with Ga-68-DOTA-TATE. The average SUV of a 50% isocontour volume of interest covering the lesion with maximum uptake (SUVmean) and the maximum SUV (SUVmax) were determined. Patients were followed up, and the time to progression was recorded. Twenty-one patients showed progressive disease at the end of the study; nine patients had stable disease. The median progression-free survival (PFS) was 51.0 weeks (95% confidence interval [CI] 26.4-75.6). A cutoff for the SUVmax of 29.4 and for the SUVmean of 20.3 could separate between patients with a long PFS (69.0 weeks; 95% CI 9.8-128.2) and a short PFS (26.0 weeks; 95% CI 8.7-43.3) response to octreotide acetate therapy. Patients with high radiotracer uptake had significantly higher PFS with a 2.9-fold higher chance for stable disease after 45 weeks; however, the prognostic performance of SUVmax on an individual basis was poor, with a sensitivity of 75% and a specificity of 64%. SUVmax and SUVmean of NET tumor lesions in Ga-68-DOTA-TATE PET are important prognostic indices for predicting the response to therapy with octreotide acetate. PMID:24824963
Koch, Walter; Auernhammer, Christoph J; Geisler, Julia; Spitzweg, Christine; Cyran, Clemens C; Ilhan, Harun; Bartenstein, Peter; Haug, Alexander R
Assessing Risk of Venous Thromboembolism in the Patient With Cancer
Purpose Patients with cancer are increasingly at risk for venous thromboembolism (VTE). Rates of VTE, however, vary markedly among patients with cancer. Design This review focuses on recent data derived from population-based, hospital-based, and outpatient cohort studies of patients with cancer that have identified multiple clinical risk factors as well as candidate laboratory biomarkers predictive of VTE. Results Clinical risk factors for cancer-associated VTE include primary tumor site, stage, initial period after diagnosis, presence and number of comorbidities, and treatment modalities including systemic chemotherapy, antiangiogenic therapy, and hospitalization. Candidate predictive biomarkers include elevated platelet or leukocyte counts, tissue factor, soluble P-selectin, and D-dimer. A recently validated risk model, incorporating some of these factors, can help differentiate patients at high or low risk for developing VTE while receiving chemotherapy. Conclusion Identifying patients with cancer who are most at risk for VTE is essential to better target thromboprophylaxis, with the eventual goal of reducing the burden as well as the consequences of VTE for patients with cancer.
Khorana, Alok A.; Connolly, Gregory C.
Cardiovascular risk during hormonal treatment in patients with prostate cancer.
The objective of this review is to provide information on cardiovascular risk following androgen-deprivation therapy (ADT) in prostate cancer patients and to suggest potential prevention and management strategies. Androgen deprivation therapy can cause peripheral insulin resistance, increase fat mass and low-density lipoprotein cholesterol, and induce type 2 diabetes. While recent studies have reported an association in patients with prostate cancer between ADT and increased risk of cardiovascular events, other studies have not detected the association. However, at this time, it is plausible that ADT could increase cardiovascular risk because of the adverse effect of ADT on risk factors for cardiovascular disease. It is advisable that prostate cancer patients in whom ADT is initiated be referred to their physician, who will carefully monitor them for potential metabolic effects. Therefore, physicians should be informed about these potential side effects. This especially applies to men aged >65 years and those with pre-existing cardiovascular comorbidities. Adopting a healthy lifestyle including a balanced diet and regular physical activity is recommended. Patients with cardiovascular disease should receive appropriate preventive therapies, including lipid-lowering, antihypertensive, glucose-lowering, and antiplatelet therapy. ADT should preferably not be unnecessarily administered to prostate cancer patients with pre-existing cardiovascular disease, certainly not to those in whom the risk of prostate cancer-specific mortality is low. The physician should carefully weigh the potential benefits of ADT against the possible risks in individual patients with prostate cancer. PMID:21448299
Van Poppel, Hein; Tombal, Bertrand
Risk-Group Targeted Inferior Vena Cava Filter Placement in Gastric Bypass Patients
BackgroundĀĀDespite a growing body of evidence guiding appropriate perioperative thromboprophylaxis in the general population, few data\\u000a direct strategies to reduce deep venous thrombosis (DVT) and pulmonary embolism (PE) in the morbidly obese. We have implemented\\u000a a novel protocol for venous thromboembolism (VTE) risk stratification in Roux-en-Y gastric bypass (RYGB) candidates at our\\u000a institution, which augments clinical assessment with screening for
D. Wayne Overby; Geoffrey P. Kohn; Mitchell A. Cahan; Robert G. Dixon; Joseph M. Stavas; Stephan Moll; Charles T. Burke; Karen J. Colton; Timothy M. Farrell
Risk of cardiovascular disease? A qualitative study of risk interpretation among patients with high cholesterol
Background Previous studies have shown the importance of paying attention to lay peoplesÆ interpretations of risk of disease, in order to explain health-related behavior. However, risk interpretations interplay with social context in complex ways. The objective was to explore how asymptomatic patients with high cholesterol interpret risk of cardiovascular disease. Methods Fourteen patients with high cholesterol and risk of cardiovascular disease were interviewed, and patterns across patient accounts were identified and analysed from an ethnographic approach. Results Information from the general practitioner about high cholesterol and risk of cardiovascular disease was reinterpreted in everyday social life. The risk associated with fatty foods was weighed against the pleasures of social and cultural events in which this type of food was common and cherished. A positive mindset was applied as a strategy to lower the risk of having high cholesterol, but knowledge about risk was viewed as a cause of anxiety and self-absorption, and this anxiety made the body susceptible to disease, hampering the chances for healthy life. Conclusion Interpretations of high cholesterol and risk of cardiovascular disease are embedded in social relations and everyday life concerns. This should be addressed in general practice in preference-sensitive cases about risk-reducing medication. Trial registration ClinicalTrials.gov: NCT01187056
Organizing patient safety research to identify risks and hazards
Patient safety has become an international priority with major research programmes being carried out in the USA, UK, and elsewhere. The challenge is how to organize research efforts that will produce the greatest yield in making health care safer for patients. Patient safety research initiatives can be considered in three different stages: (1) identification of the risks and hazards; (2) design, implementation, and evaluation of patient safety practices; and (3) maintaining vigilance to ensure that a safe environment continues and patient safety cultures remain in place. Clearly, different research methods and approaches are needed at each of the different stages of the continuum. A number of research approaches can be used at stage 1 to identify risks and hazards including the use of medical records and administrative record review, event reporting, direct observation, process mapping, focus groups, probabilistic risk assessment, and safety culture assessment. No single method can be universally applied to identify risks and hazards in patient safety. Rather, multiple approaches using combinations of these methods should be used to increase identification of risks and hazards of health care associated injury or harm to patients.
Battles, J; Lilford, R
Identifying Subtypes of Civil Psychiatric Patients at High Risk for Violence
Advances in risk assessment have improved the ability to identify psychiatric patients at high risk for violence. Identifying these patients is necessary for developing treatment to address their needs. However, if violence is caused by risk factors that vary across patients, relatively homogeneous subgroups of high-risk patients must be identified and studied to develop effective risk management programs for each.
Jennifer L. Skeem; Edward P. Mulvey; Paul S. Appelbaum; Steven M Banks; Thomas Grisso; Eric Silver; Pamela Clark Robbins
Repositioning the patient: the implications of being 'at risk'.
In the modern era of biomedical practice, genetic knowledge has redefined the idea of 'the patient' to include those who are 'at risk' of disease alongside those who are already sick. For such individuals, it is risk itself that constitutes the raison d'Ļtre of medical intervention. Using data from interviews with 58 users of a UK cancer genetics service together with data derived from clinical consultations, we consider the way such patients or clients make sense of a cancer genetic risk estimate and how they integrate genetic risk information into their lifeworld. In particular, we note that patient-clients who are 'at risk' tend to see themselves in a liminal position betwixt the healthy and the sick, and that such individuals consequently seek recourse to systems of medical surveillance that can continuously monitor their state of health. Our analysis also revealed the fact that many of those deemed by professionals to be at low risk of inheriting cancer-related mutations subsequently strove to be re-categorised as being at moderate or high risk of an adverse outcome. A number of explanations concerning lay health beliefs, lay 'representations' of health and the nature of the patient-client's lifeworld are examined and assessed in order to account for this apparent paradox. PMID:15686817
Scott, S; Prior, L; Wood, F; Gray, J
Increased Risk of Ischemic Stroke in Young Nasopharyngeal Carcinoma Patients
Purpose: Radiation/chemoradiotherapy-induced carotid stenosis and cerebrovascular events in patients with nasopharyngeal carcinoma (NPC) can cause severe disability and even death. This study aimed to estimate the risk of ischemic stroke in this patient population over more than 10 years of follow-up. Methods and Materials: The study cohorts consisted of all patients hospitalized with a principal diagnosis of NPC (n = 1094), whereas patients hospitalized for an appendectomy during 1997 and 1998 (n = 4376) acted as the control group and surrogate for the general population. Cox proportional hazard model was performed as a means of comparing the stroke-free survival rate between the two cohorts after adjusting for possible confounding and risk factors. Results: Of the 292 patients with ischemic strokes, 62 (5.7%) were from the NPC cohort and 230 (5.3%) were from the control group. NPC patients ages 35-54 had a 1.66 times (95% CI, 1.16-2.86; p = 0.009) higher risk of ischemic stroke after adjusting for patient characteristics, comorbidities, geographic region, urbanization level of residence, and socioeconomic status. There was no statistical difference in ischemic stroke risk between the NPC patients and appendectomy patients ages 55-64 years (hazard ratio = 0.87; 95% CI, 0.56-1.33; p = 0.524) after adjusting for other factors. Conclusions: Young NPC patients carry a higher risk for ischemic stroke than the general population. Besides regular examinations of carotid duplex, different irradiation strategies or using new technique of radiotherapy, such as intensity modulated radiation therapy or volumetric modulated arc therapy, should be considered in young NPC patients.
Lee, Ching-Chih [Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan (China); Department of Otolaryngology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); Tumor Center, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); School of Medicine, Tzu Chi University, Hualien, Taiwan (China); Su, Yu-Chieh [Division of Hematology-Oncology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); Tumor Center, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); School of Medicine, Tzu Chi University, Hualien, Taiwan (China); Ho, Hsu-Chueh [Department of Otolaryngology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); Tumor Center, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); School of Medicine, Tzu Chi University, Hualien, Taiwan (China); Hung, Shih-Kai; Lee, Moon-Sing [Department of Radiation Oncology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); Tumor Center, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); School of Medicine, Tzu Chi University, Hualien, Taiwan (China); Chiou, Wen-Yen [Department of Radiation Oncology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); Tumor Center, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China); Chou, Pesus [Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan (China); Huang, Yung-Sung, E-mail: firstname.lastname@example.com [Division of Neurology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan (China)
Clustering of Unconventional Cardiovascular Risk Factors among Taiwanese Hemodialysis Patients
Background: Cardiovascular disease (CAVD) is the most common cause of mortality for chronic hemodialysis (HD) patients, yet the risk factors for the events have not been well established. Methods: We conducted a multicenter cross-sectional survey in 995 chronic HD patients recruited from 12 HD centers in Taiwan to investigate the prevalence of CAVD, including coronary heart disease (CHD), cerebrovascular disease
Shih-Yuan Hung; Hung-Hsiang Liou; Luo-Ping Ger; Liang-Ken Chen; Mei-Chyn Liu; Hsiao-Min Chung; Kang-Ju Chou; Tso-Hsiao Chen; Chih-Kuang Lin; Yu Yang
Risk Factors for Suicide Attempts Among Alcohol Dependent Patients
Suicidal behavior is a common and important problem among alcohol dependent patients. The study was designed to examine risk factors for attempting suicide in 499 alcohol dependent patients. Those who had attempted suicide (NĀ=Ā198) were more likely to be female, report a family history of suicidal behavior, report more childhood trauma, report greater levels of aggressive behavior, began heavy drinking
Alec Roy; Malvin N. Janal
Identification of patients at risk for diabetic foot
The aim of the study was the comparison of a simple standardized noninvasive examination of neuropathy and angiopathy with routine diagnostic practice in community diabetes clinics for the identification of patients at risk of foot ulceration. Consecutive patients (n=322), aged 30 years and more, with a diabetes duration of more than 5 years, were examined by trained podiatric nurses in
Alexandra Jirkovskß; Petr Bou?ek; Veronika Woskovß; Vladim??r BartoÜ; Jelena Skibovß
Elderly patients with a hip fracture: the risk for delirium
This prospective study investigated risk factors for delirium in elderly hip fracture patients that could be recognized by nurses. Data were collected on predisposing and precipitating factors for delirium from 92 elderly patients with a hip fracture. Predisposing factors included age, gender, sensory impairments, functional impairment before the hip fracture, residency before admission, pre-existing cognitive impairment, comorbidities, and medication use.
Marieke J Schuurmans; Sijmen A Duursma; Lillie M Shortridge-Baggett; Gert-Jan Clevers; Ruth Pel-Littel
Intra-hospital transport of critically ill patients: minimising risk
Sir, ōIs your journey really necessary?ö asked a railway poster during the privations of the Second World War. A similar question should be asked of clinicians committing sick patients to a transfer between, or within, hospitals, with the additional question, ōIs this transfer really safe?ö There are many potential risks associated with transporting the critically ill patient, including their greater
Peter J. Shirley; Julian F. Bion
Gun Safety Management with Patients at Risk for Suicide
ERIC Educational Resources Information Center
Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated personģ
Simon, Robert I.
Modifiable Risk Behaviors in Head and Neck Cancer Patients
Background Use of tobacco products, excessive alcohol consumption, and high-risk sexual behaviors increase the risk of developing head and neck cancer and impacts treatment effectiveness after diagnosis. We examined smoking and engagement in other modifiable behavioral risk factors and human papillomavirus (HPV) status in head and neck cancer patients in order to facilitate identification and foster development of targeted interventions in high risk patients. Methods Participants were 102 head and neck cancer patients at a large urban cancer center who completed a self-report background and health questionnaire and provided a saliva sample for determination of the long-acting nicotine metabolite cotinine. Results Compared with former and never smokers, current smokers were less educated, less likely to be married or living with a partner and consumed more alcohol. Cotinine analysis indicated that four of sixteen (25%) patients who denied past-month cigarette use misrepresented their true smoking status. Of patients with oropharyngeal cancer, 74% were confirmed as HPV-positive, and compared with HPV-negative patients, they were younger, more likely to be married/partnered and of Caucasian race, and reported more past vaginal and oral sexual partners. Only one-third of HPV-positive patients were aware of their HPV disease status. Conclusions Cigarette smoking is associated with engagement in other modifiable risk factors in patients with head and neck cancer. Self-report measures of smoking may not accurately depict true smoking status. HPV-positive cancer patients were more likely to endorse a history of multiple sexual partners. Regular screening and targeted interventions for these distinct risk factors are warranted.
Sivasithamparam, Janani; Visk, Carly A.; x Cohen, Ezra E. W. Cohen; King, Andrea C.
Risk factors with intravenous sedation for patients with disabilities.
The purpose of this study was to identify the risk factors associated with low peripheral oxygen saturation (SpO2) and delayed recovery of dental patients with disabilities after intravenous sedation. A total of 1213 patients with disabilities were retrospectively investigated with respect to demographic parameters and sedation conditions. Multivariate logistic analyses were conducted for patients with an SpO2 <90% and a recovery period of >60 minutes to identify the risk factors for poor sedation conditions. A significant odds ratio related to decreased SpO2 was observed for age, sex, midazolam and propofol levels, concurrent use of nitrous oxide, cerebral palsy, Down syndrome, and mental retardation. The most problematic patients were those diagnosed with Down syndrome (odds ratio, 3.003-7.978; 95% confidence interval; P < .001). Decision tree analysis showed an increased risk of decreased SpO2 in males with Down syndrome or after administration of >0.493 mg/kg propofol in combination with midazolam. An increased risk of delayed awakening was seen in patients aged less than 21 years and in males administered >0.032 mg/kg of midazolam. Intravenous sedation for dental patients with disabilities, particularly those with cerebral palsy, Down syndrome, or mental retardation, increases the risk of decreased SpO2. In addition, delayed recovery is expected after midazolam administration. PMID:24423418
Yoshikawa, Fumihiro; Tamaki, Yoh; Okumura, Hisa; Miwa, Zenzo; Ishikawa, Masaaki; Shimoyama, Kazuhiro; Nakamura, Zenkou; Kunimori, Hitomi; Jinno, Shigeharu; Kohase, Hikaru; Fukayama, Haruhisa
Risk Factors With Intravenous Sedation for Patients With Disabilities
The purpose of this study was to identify the risk factors associated with low peripheral oxygen saturation (SpO2) and delayed recovery of dental patients with disabilities after intravenous sedation. A total of 1213 patients with disabilities were retrospectively investigated with respect to demographic parameters and sedation conditions. Multivariate logistic analyses were conducted for patients with an SpO2 <90% and a recovery period of >60 minutes to identify the risk factors for poor sedation conditions. A significant odds ratio related to decreased SpO2 was observed for age, sex, midazolam and propofol levels, concurrent use of nitrous oxide, cerebral palsy, Down syndrome, and mental retardation. The most problematic patients were those diagnosed with Down syndrome (odds ratio, 3.003¢7.978; 95% confidence interval; P < .001). Decision tree analysis showed an increased risk of decreased SpO2 in males with Down syndrome or after administration of >0.493 mg/kg propofol in combination with midazolam. An increased risk of delayed awakening was seen in patients aged less than 21 years and in males administered >0.032 mg/kg of midazolam. Intravenous sedation for dental patients with disabilities, particularly those with cerebral palsy, Down syndrome, or mental retardation, increases the risk of decreased SpO2. In addition, delayed recovery is expected after midazolam administration.
Yoshikawa, Fumihiro; Tamaki, Yoh; Okumura, Hisa; Miwa, Zenzo; Ishikawa, Masaaki; Shimoyama, Kazuhiro; Nakamura, Zenkou; Kunimori, Hitomi; Jinno, Shigeharu; Kohase, Hikaru; Fukayama, Haruhisa
Risk assessment in patients with antiphospholipid antibodies.
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the association of antiphospholipid antibodies (aPL) with thrombosis and/or pregnancy loss: classification criteria were defined in the updated international consensus held in Sidney in 2005. Vascular and obstetric manifestations display partially different pathogenetic mechanisms. Thrombosis develop as a result of local procoagulative changes upon triggers influence (second-hit theory). Pregnancy morbidity is thought to be dependent on placental thrombosis and complement activation. The laboratory tests include Lupus Anticoagulant (LA), a functional assay, and anticardiolipin (aCL) and anti-?2-glycoprotein I antibodies detected by solid phase enzyme-linked immunosorbent assay (ELISA). The LA testing is relatively standardized while there's still significant interlaboratory discrepancy in ELISA tests. Current APS criteria are under discussion: since for vascular and obstetric APS, different pathogenetic mechanisms have been shown, some criteria variation could also be contemplated. What is the weight of aPL antibodies in provoking thrombosis and which contribution could be expected from aPL per se is debated. As thrombosis is generally considered to be multi-factorial, each case needs a risk-stratified approach. Any primary prophylaxis, intensity and duration of secondary prophylaxis should take into account aPL profile, other cardiovascular risk factors and systemic autoimmune diseases associated. We look forward to the publication of recommendations of the leading experts in the field, developed during the recent 14th International Congress in Rio de Janeiro, Brazil. PMID:24316917
Bertero, M; Kuzenko, A
Redo surgery risk in patients with cardiac prosthetic valve dysfunction
Introduction The aim of the study was to analyse the risk factors of early and late mortality in patients undergoing the first reoperation for prosthetic valve dysfunction. Material and methods A retrospective observational study was performed in 194 consecutive patients (M = 75, F = 119; mean age 53.2 ▒11 years) with a mechanical prosthetic valve (n = 103 cases; 53%) or bioprosthesis (91; 47%). Univariate and multivariate Cox statistical analysis was performed to determine risk factors of early and late mortality. Results The overall early mortality was 18.6%: 31.4% in patients with symptoms of NYHA functional class III-IV and 3.4% in pts in NYHA class I-II. Multivariate analysis identified symptoms of NYHA class III-IV and endocarditis as independent predictors of early mortality. The overall late mortality (> 30 days) was 8.2% (0.62% year/patient). Multivariate analysis identified age at the time of reoperation as a strong independent predictor of late mortality. Conclusions Reoperation in patients with prosthetic valves, performed urgently, especially in patients with symptoms of NYHA class III-IV or in the case of endocarditis, bears a high mortality rate. Risk of planned reoperation, mostly in patients with symptoms of NYHA class I-II, does not differ from the risk of the first operation.
Maciejewski, Marek; Piestrzeniewicz, Katarzyna; Bielecka-Dabrowa, Agata; Piechowiak, Monika; Jaszewski, Ryszard
Low risk of colon cancer in patients with celiac disease.
Abstract Objective. Celiac disease (CD) has strongly been established as associated with some site-specific gastrointestinal malignancies. On the contrary, according to the few reports available, the risk of colon carcinoma in CD patients has been described similar to that of general population. In this cohort study, we describe the risk of colon carcinoma in a group of Italian celiac patients. Materials and methods. The study population included all CD patients diagnosed at the Collaborating Centers of the Italian Registry of CD between 1st January 1982 and 31st December 2006. Upon diagnosis of CD and upon at every subsequent clinical control, the Collaborating Centers filled in a validated form for each CD patient reporting information about demographic data, possible occurrence of a neoplasm and adherence to a gluten-free diet. Results. Out of 1757 celiac patients enrolled, 6 developed a colon carcinoma during the follow-up period (mean: 18.1 years). The standardized incidence ratio (SIR) resulted 0.29 (95% CI = 0.07-0.45). Stratifying the risk for the dietary gluten intake, the SIR dropped to 0.07 (95% CI = 0.009-0.27) for CD patients with a strict adherence to a gluten-free diet. Conclusion. We confirm the previous finding that there is low risk to develop a colon cancer in celiac patients. PMID:24621303
Volta, Umberto; Vincentini, Olimpia; Quintarelli, Federica; Felli, Cristina; Silano, Marco
The role of TMPRSS2:ERG in molecular stratification of PCa and its association with tumor aggressiveness: a study in Brazilian patients
Recurrent gene fusions between the genes TMPRSS2 and ERG have been described in prostate cancer (PCa) and are found in 27% to 79% of radical prostatectomy. This fusion transcription results in ERG overexpression, which can be detected by immunohistochemistry (IHC) and provide a potential diagnostic marker for PCa. Three tissue microarrays (TMAs) containing samples from 98 patients with PCa and one TMA of 27 samples from individuals without PCa were tested for ERG immunostaining, and the presence of TMPRSS2:ERG transcripts was confirmed by quantitative real time PCR (qRT-PCR). The results showed that 46.9% of tumors tested positive for ERG immunostaining, and this finding was consistent with the results of qRT-PCR testing (k = 0.694, p < 0.001). IHC had a specificity of 83.3% and a sensitivity of 81% in detecting TMPRSS2:ERG fusion. Patients with PSA < 4.0?ng/mL showed positive immunoreactivity for ERG (p = 0.031). Kaplan-Meier analysis suggested that ERG expression did not influence the time of biochemical recurrence. This study demonstrates that both IHC and qRT-PCR are useful tools in detecting TMPRSS2:ERG fusions. A correlation between ERG expression and clinical and pathological parameters was not found, but the frequency, specificity and recurrence of ERG in PCa suggests that it may be a potential adjunct diagnostic tool.
Eguchi, Flavia C.; Faria, Eliney F.; Neto, Cristovam Scapulatempo; Longatto-Filho, Adhemar; Zanardo-Oliveira, Cleyton; Taboga, Sebastiao R.; Campos, Silvana G. P.
Impact of density of schistosomal antigen expression in urinary bladder tissue on the stratification, cell type, and staging, and prognosis of carcinoma of the bladder in Egyptian patients
Background Infection with urinary schistosomiasis and its severity are oncogenic factors for developing carcinoma of the bladder, whether it is urothelial carcinoma (UC) of a transitional cell type (TCC) or non-urothelial of squamous cell carcinoma (SCC). In UC it is not defined whether it is schistosomal or not. This led to controversial results in expression of tumour markers, tumour prognosis, and response to therapy. Objectives We assessed the application by immunohistochemistry method (IHC) for detection of schistosomal antigen in bladder cancer tissue samples to differentiate UC associated with or without schistosomiasis. Urothelial carcinoma stage, grade, and progression were correlated with the density, intensity, and index of schistosomal antigen expression. Follow up was done for 2-5 years. Design and participants Archival tissue samples of 575 patients were studied: 515 urothelial carcinoma, 30 patients with SCC associated with schistosomiasis, and a control group of 30 patients without schistosomiasis. Measurements Expression of schistosomal antigen in tissue was done by IHC using monoclonal antibodies (MAbs) against schistosomal antigens (SA). Correlation of intensity of antigen expression to clinical and pathological data was analysed. Results and limitations We identified 3 parameters of antigen expression: density, intensity and index with 4 grades for each. SCC-group was 100% positive. UC was positive in 61.4% distributed as follows: Ta: 37.5%, T1: 62%, and muscle invasive T2-4 were 64%. Upstaging, metastases and recurrence were correlated with high index in T1 and T2-4 tumours. Conclusion Urothelial carcinoma associated with schistosomiasis was defined by the positive expression of schistosomal antigens in tissues detected by lHC using MAbs against schistosomal haematobium. Upstaging and progression of T1 and T2-4 were correlated with high density, intensity, and index of antigen expression. Non-schistosomal UC had negative expression for schistosomal antigen, which was detected in 36.5% of cases. These results would be of significance in differentiating schistosomal from non-schistosomal bladder cancer of UC and would predict the prognosis in T1, T2-3 tumours. Implementation of IHC using MAbs against SA in UC would help in planning the proper therapy. Schistosomiasis should be considered as an oncogene for UC in endemic areas.
MGMT expression and promoter methylation status may depend on the site of surgical sample collection within glioblastoma: a possible pitfall in stratification of patients?
We recently described a three-layer concentric model of a glioblastoma (GBM) related to a specific distribution of molecular and phenotypic characteristics driven by the intratumoral hypoxic gradient in which the cancer stem cells niche is located in the hypoxic necrotic core of the tumour. The purpose of this study was to investigate the relationship between O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation status and MGMT expression in GBM samples collected according to the three-layer concentric model. Multiple tissue samples were obtained, by means of image-guided surgery, from the three concentric layers of newly diagnosed GBM. Two samples from each layer were collected from 12 patients (total 72 samples). Immunohistochemical analysis was performed on formalin-fixed paraffin-embedded tissue samples. The methylation status of the MGMT promoter was determined by methylation-specific polymerase-chain-reaction analysis. In all tumours, MGMT protein expression decreased progressively from the inner to the outer layer, and methylation of the MGMT promoter was unrelated to tumour layer. In particular, the MGMT promoter was unmethylated in all layers in 41.7% of tumours, methylated in all layers in 25%, and variably methylated in the three layers in 33.3%. We recorded concordance between MGMT expression and MGMT promoter methylation status within the GBM in only 58.8% of the samples collected. Our data suggest that both MGMT expression and promoter methylation data may be variable throughout GBM and that they may, consequently, depend on the site of surgical sample collection, even in the same patient. However, whereas MGMT expression is pre-operatively predictable when sampling is performed according to the three-layer concentric model, MGMT promoter methylation is not. These results must be considered when sample collection is performed for assessment of MGMT data. PMID:21725802
Della Puppa, Alessandro; Persano, Luca; Masi, Giulia; Rampazzo, Elena; Sinigaglia, Alessandro; Pistollato, Francesca; Denaro, Luca; Barzon, Luisa; Pal∙, Giorgio; Basso, Giuseppe; Scienza, Renato; d'Avella, Domenico
Obesity and Mortality Risk among Younger Dialysis Patients
Summary Background and objectives Many studies show that obesity in dialysis patients is not strongly associated with mortality but not whether this modest association is constant over age. This study investigated the extent to which the relation of body mass index (BMI) and mortality differs between younger and older dialysis patients. Design, setting, participants, & measurements Adult dialysis patients were prospectively followed from their first dialysis treatment for 7 years or until death or transplantation. Patients were stratified by age (<65 or ?65 years) and baseline BMI (<20, 20¢24 [reference], 25¢29, and ?30 kg/m2). Results The study sample included 984 patients younger than 65 years and 765 patients 65 years or older; cumulative survival proportions at end of follow-up were 50% and 16%. Age-standardized mortality rate was 1.7 times higher in obese younger patients than those with normal BMI, corresponding to an excess rate of 5.2 deaths/100 patient-years. Mortality rates were almost equal between obese older patients and those with normal BMI. Excess rates of younger and older patients with low compared with normal BMI were 8.7 and 1.1 deaths/100 patient-years. After adjustment for age, sex, smoking, comorbidity, and treatment modality, hazard ratios by increasing BMI were 2.00, 1, 0.95, and 1.57 for younger patients and 1.07, 1, 0.88, and 0.91 for older patients, implying that obesity is a 1.7-fold (95% confidence interval, 1.1- to 2.9-fold) stronger risk factor in younger than older patients. Conclusions In contrast to older dialysis patients, younger patients with low or very high BMI had a substantially elevated risk for death.
Hoogeveen, Ellen K.; Halbesma, Nynke; Rothman, Kenneth J.; Stijnen, Theo; van Dijk, Sandra; Dekker, Friedo W.; Boeschoten, Elisabeth W.; de Mutsert, Renee
Lipoprotein-Associated Phospholipase A2 and High-Sensitivity C-Reactive Protein Improve the Stratification of Ischemic Stroke Risk in the Atherosclerosis Risk in Communities (ARIC) Study
Background and PurposeŚInflammation plays a critical role in the development of vascular disease, and increased levels of the inflammatory biomarkers, lipoprotein-associated phospholipase A2 (Lp-PLA2), and high-sensitivity C-reactive protein (hs-CRP) have been shown to be associated with an increased risk for ischemic stroke. MethodsŚIn a prospective case-cohort (n949) study in 12 762 apparently healthy, middle-aged men and women in the Atherosclerosis
Vijay Nambi; Ron C. Hoogeveen; Lloyd Chambless; Yijuan Hu; Heejung Bang; Josef Coresh; Hanyu Ni; Eric Boerwinkle; Thomas Mosley; Richey Sharrett; Aaron R. Folsom; Christie M. Ballantyne
World Health Organization classification in combination with cytogenetic markers improves the prognostic stratification of patients with de novo primary myelodysplastic syndromes.
This study correlated chromosomal defects with French-American-British (FAB)/World Health Organization (WHO) classification subtypes, proposed a revised International Prognostic Scoring System (IPSS) cytogenetic grouping; and established which classification, when used with the IPSS cytogenetic categories, best predicted clinical outcome in the myelodysplastic syndromes (MDS). A higher prevalence of chromosomal defects and distinct defects were observed in patients with multi-lineage dysplasia and a blast cell percentage >10%. Abnormalities of the long arm of chromosome 3, del(7)(q31q35), trisomy 8, del(11)(q14q23), del(12p) and 20q- could be segregated from their respective IPSS cytogenetic categories and used to develop new cytogenetic subgroups. Clinical parameters, FAB/WHO classification, IPSS score and standard or revised cytogenetic categories were statistically relevant for overall survival (OS) and progression-free intervals (PFI) and were included within five distinct multivariate models compared by the Akaike Information Criterion. To predict OS, the best models included age, WHO classification and standard or revised IPSS cytogenetic categories; to predict PFI, the best model included the same variables and revised cytogenetic categories. In conclusion, (i) the WHO classification was associated with a more homogeneous cytogenetic pattern than the FAB classification, (ii) WHO classification and standard/revised IPSS cytogenetic categories were much more effective than IPSS for predicting MDS clinical outcome, (iii) revised cytogenetic subgroups predicted PFI more effectively than standard categories. PMID:17408458
Bernasconi, Paolo; Klersy, Catherine; Boni, Marina; Cavigliano, Paola M; Calatroni, Silvia; Giardini, Ilaria; Rocca, Barbara; Zappatore, Rita; Caresana, Marilena; Dambruoso, Irene; Lazzarino, Mario; Bernasconi, Carlo
Colonoscopy-induced ischemic colitis in patients without risk factors
Ischemic colitis is the most common form of intestinal ischemia. It is a condition that is commonly seen in the elderly and among individuals with risk factors for ischemia. Common predisposing conditions for ischemic colitis are major vascular occlusion, small vessel disorder, shock, some medications, colonic obstructions and hematologic disorders. Ischemic colitis following colonoscopy is rare. Here, we report two cases of ischemic colitis after a routine screening colonoscopy in patients without risk factors for ischemia.
Lee, Sang Ok; Kim, Sae Hee; Jung, Sung Hee; Park, Chan Woong; Lee, Min Ji; Lee, Jin A; Koo, Hyun Cheol; Kim, Anna; Han, Hyun-Young; Kang, Dong-Wook
Atherosclerotic risk factors in patients with ischemic cerebrovascular disease
Opinion statementĀĀAggressive treatment of atherosclerotic risk factors can substantially reduce stroke risk in patients with a history of stroke\\u000a or transient ischemic attack. Data from several recent large clinical trials provide convincing evidence of benefit for a\\u000a number of specific therapies directed at this population. The authors recommend treatment with ramipril alone or perindopril\\u000a plus indapamide regardless of blood pressure,
Brett L. Cucchiara; Scott E. Kasner
Colonoscopy-induced ischemic colitis in patients without risk factors.
Ischemic colitis is the most common form of intestinal ischemia. It is a condition that is commonly seen in the elderly and among individuals with risk factors for ischemia. Common predisposing conditions for ischemic colitis are major vascular occlusion, small vessel disorder, shock, some medications, colonic obstructions and hematologic disorders. Ischemic colitis following colonoscopy is rare. Here, we report two cases of ischemic colitis after a routine screening colonoscopy in patients without risk factors for ischemia. PMID:24707156
Lee, Sang Ok; Kim, Sae Hee; Jung, Sung Hee; Park, Chan Woong; Lee, Min Ji; Lee, Jin A; Koo, Hyun Cheol; Kim, Anna; Han, Hyun-Young; Kang, Dong-Wook
Brain Natriuretic Peptide Levels Predict Perioperative Events in Cardiac Patients Undergoing Noncardiac Surgery: A Prospective Study
Objectives: Brain natriuretic peptide (BNP) levels correlate with prognosis in patients with cardiac disease and may be useful in the risk stratification of cardiac patients undergoing noncardiac surgery (NCS). The objective of this study was to examine whether BNP levels predict perioperative events in cardiac patients undergoing NCS. Methods: Patients undergoing NCS with at least 1 of the following criteria
David Leibowitz; David Planer; David Rott; Yair Elitzur; Tova Chajek-Shaul; A. Teddy Weiss
Risk of Tuberculosis in Dialysis Patients: A Nationwide Cohort Study
Background The ability to identify individuals at increased risk of developing tuberculosis (TB) has important implications for public health policy and patient care. We conducted a general population historical cohort study in all Australian States and Territories to establish the risk of TB arising in people on chronic hemo- or peritoneal dialysis. Methodology/Principal Findings Cases of TB disease in patients receiving chronic dialysis were identified by record linkage using the Australia & New Zealand Dialysis and Transplant Registry (ANZDATA) and State and Territory TB notification databases 2001 to 2006. Main outcome measure was the relative risk of TB in people on dialysis, adjusted for TB incidence in country of birth, sex, age and indigenous status. A total of 6,276 cases of active TB were reported among 19,855,283 people living in Australia between 2001 and 2006. Among 14,506 patients on dialysis, 37 had a notification for TB disease after commencing dialysis, of whom 28 were culture positive. The incidence of TB was 66.8/100,000/year (95% CI 47.7 to 93.2) among people on dialysis and 5.7/100,000/year (95% CI 5.5 to 5.8) in the general population. The adjusted relative risk (aRR) of TB in people on dialysis was 7.8 (95% CI 3.3 to 18.7), and the aRR of culture positive TB was 8.6 (95% CI 3.9 to 19.3). Conclusions/Significance Patients on dialysis are at increased risk of TB. The final decision to screen for, and to treat, LTBI in individual dialysis patients will be influenced by a cumulative assessment of the risk of reactivation of TB and by assessment of risk factors for adverse effects of treatment.
Dobler, Claudia C.; McDonald, Stephen P.; Marks, Guy B.
Risk factor assessment of young patients with acute myocardial infarction
The Middle East represents an attractive area for young individuals to seek employment, where they are exposed to numerous environmental conditions. The pursuit of a better standard of living has driven hundreds to the Middle East over the recent decades. This influx has also resulted in a predisposition to premature coronary artery disease (CAD). The aim of this study was to provide an overview of the risk factors in patients younger than 45 years, presenting with acute myocardial infarction (AMI). Out of the 148 patients analyzed, 137 were males and 11 females. 119 were from South Asia and 29 were Arabs. Their mean age was 36 ▒ 4.2 years. Smoking was the most prevalent risk factor in both groups at 67.6%. This was followed by hypertension, family history of CAD, hyperlipidemia and Diabetes mellitus. There was no significant difference in the clinical risk factor profile between these two groups. ST elevation myocardial infarction (STEMI) was noted in 67.6%, while 32.4% patients suffered a Non ST elevation myocardial infarction (NSTEMI). 84.5% received coronary stents, 8.8% had lone thrombus aspiration or balloon angioplasty only, while the rest were treated by conservative medical management or referred for coronary artery bypass surgery. Conclusion: There is no significant difference in the CAD risk profile between young South Asian and Arab patients. Preventive strategies focused on risk factor reduction, especially smoking cessation, should be implemented to protect young adults in the most productive years of their life.
Jamil, Gohar; Jamil, Mujgan; AlKhazraji, Hind; Haque, Amber; Chedid, Fares; Balasubramanian, Manjula; Khairallah, Bahaa; Qureshi, Anwer
The NSAID dilemma: managing osteoarthritis in high-risk patients.
For decades, evidence-based data and reported experience have warned that the common chronic oral nonsteroidal anti-inflammatory drug (NSAID) therapy for osteoarthritis (OA) in elderly patients is ultimately dangerous. Elderly patients with OA are at heightened risk for developing serious gastrointestional and cardiovascular adverse events, including gastrointestinal bleeding, myocardial infarction, and stroke. Prescribing NSAIDs, especially in an elderly population, continues to be discouraged because of these significant risks. A dilemma exists for individuals who need the established efficacy associated with oral NSAIDs but who are at increased risk for serious adverse events associated with these agents. The goal of this clinical review was to evaluate the risks versus benefits of current options in the treatment of OA. This review found that topical NSAIDs seem to be the safest choice among all options to mitigate gastrointestinal and cardiovascular risks and should be considered prior to the initiation of oral nonselective or cyclooxygenase (COX)-2-selective NSAIDs for individuals presenting with a localized expression of OA. Further research is needed to evaluate and compare these therapies in treating both pain and inflammation effectively while mitigating safety risks in high-risk populations. PMID:22030942
Roth, Sanford H; Anderson, Shane
Peripheral blood 8 colour flow cytometry monitoring of hairy cell leukaemia allows detection of high-risk patients.
Although purine analogues have significantly improved the outcome of hairy cell leukaemia (HCL) patients, 30-40% relapse, illustrating the need for minimal residual disease (MRD) markers that can aid personalized therapeutic management. Diagnostic samples from 34 HCL patients were used to design an 8-colour flow cytometry (8-FC) tube for blood MRD (B/RD) analysis (188 samples) which was compared to quantitative IGH polymerase chain reaction (Q-PCR) on 83 samples and to qualitative consensus IGH PCR clonality analysis on 165 samples. Despite heterogeneous HCL phenotypes at diagnosis, discrimination from normal B lymphocytes was possible in all cases using a single 8-FC tube, with a robust sensitivity of detection of 10(-4) , comparable to Q-PCR at this level, but preferable in terms of informativeness, simplicity and cost. B/RD assessment of 15 patients achieving haematological complete remission after purine analogues was predictive of a clinically significant relapse risk: with a median follow-up of 95Āmonths; only one of the nine patients with reproducible 8-FC B/RD levels below 10(-4) (B/RD(neg) ) relapsed, compared to 5/6 in the B/RD(pos) group (PĀ=Ā0Ę003). These data demonstrate the clinical interest of a robust 8-FC HCL B/RD strategy that could become a surrogate biomarker for therapeutic stratification and new drug assessment, which should be evaluated prospectively. PMID:24661013
Garnache Ottou, Francine; Chandesris, Marie-Olivia; Lhermitte, Ludovic; Callens, Cķline; Beldjord, Kheira; Garrido, Marlene; Bedin, Anne-Sophie; Brouzes, Chantal; Villemant, Sarah; Rubio, Marie-ThķrĶse; Belanger, Coralie; Suarez, Felipe; Deau, Bķnķdicte; LefrĶre, Franńois; Hermine, Olivier; Asnafi, Vahid; Varet, Bruno; Macintyre, Elizabeth
Risk of suicide in patients with dementia: a case study.
Evidence indicates that the risk of attempted suicide is a significant issue among people with dementia, however there is a lack of information to guide professional practice. This article uses a case study to reflect on the risk management strategies and ethics of suicide and assisted suicide in relation to a specific patient with dementia. It analyses recommendations aimed at improving the lived experience of people with dementia and those involved in their care, including providing patients with a formal diagnosis as early as possible. PMID:24219483
Nicholson, Linda
Social Stratification (Part I & II)
NSDL National Science Digital Library
This exercise was developed for use in an upper-level sociology course that focuses on race and ethnicity. In this particular exercise, students complete a brief exercise in order to become acquainted with WebCHIP in order to complete the more lengthy Part II of the Social Stratification/Race and Ethnicity activity. This activity uses a customized data set made from the 1990 Census and guides students through data manipulation using WebCHIP software found at DataCounts!. To open WebCHIP with the dataset for the activity, please see instructions and links in the exercise documents under teaching materials. For more information on how to use WebCHIP, see the How To section on DataCounts!
Marshall, Brent
Cancer Risk among Patients with Myotonic Muscular Dystrophy
Context Myotonic muscular dystrophy (MMD) is an autosomal dominant multisystem neuromuscular disorder characterized by unstable nucleotide repeat expansions. Case reports have suggested that MMD patients may be at increased risk of malignancy, putative risks which have never been quantified. Objective To quantitatively evaluate cancer risk in patients with MMD, overall, and by sex and age. Design, Setting, and Participants We identified 1,658 patients with an MMD discharge diagnosis in the Swedish Inpatient Hospital or Danish Patient Discharge Registries between 1977 and 2008. We linked these patients to their corresponding cancer registry. Patients were followed from date of first MMD-related inpatient or outpatient contact, to first cancer diagnosis, death, emigration, or completion of cancer registration. Main Outcome Measures Risks of all cancers combined, and by anatomic site, stratified by sex and age. Results 104 patients with an inpatient or outpatient discharge diagnosis of MMD developed cancer during post-discharge follow-up. This corresponds to an observed cancer rate of 73.4/10,000 person-years in MMD versus an expected rate of 36.9/10,000 in the general Swedish and Danish populations combined (SIR =2.0, 95% CI =1.6¢2.4). Specifically, we observed significant excess risks of cancers of the endometrium (observed rate=16.1/10,000 person-years: SIR=7.6, 95%CI=4.0¢13.2), brain (observed rate=4.9/10,000 person-years: SIR=5.3, 95%CI=2.3¢10.4), ovary (observed rate=10.3/10,000 person-years: SIR=5.2, 95% CI=2.3¢10.2), and colon (observed rate=7.1/10,000 person-years: SIR=2.9, 95%CI=1.5¢5.1). Cancer risks were similar in females and males after excluding genital organ tumors (SIR=1.9, 95% CI=1.4¢2.5 vs. 1.8, 95% CI=1.3¢2.5, respectively, p-heterogeneity=0.81; observed rates=64.5 and 47.7/10,000 person-years in women and men, respectively), The same pattern of cancer excess was observed first in the Swedish, and then in the Danish cohorts, which were studied sequentially and initially analyzed independently. Conclusions MMD patients identified from the Swedish and Danish patient registries were at increased risk of cancer both overall and for selected anatomic sites.
Gadalla, Shahinaz M; Lund, Marie; Pfeiffer, Ruth M; G?rtz, Sanne; Mueller, Christine M; Moxley, Richard T; Kristinsson, Sigurdur Y; Bjorkholm, Magnus; Shebl, Fatma M; Hilbert, James E; Landgren, Ola; Wohlfahrt, Jan; Melbye, Mads; Greene, Mark H
Elderly patients with a hip fracture: the risk for delirium.
This prospective study investigated risk factors for delirium in elderly hip fracture patients that could be recognized by nurses. Data were collected on predisposing and precipitating factors for delirium from 92 elderly patients with a hip fracture. Predisposing factors included age, gender, sensory impairments, functional impairment before the hip fracture, residency before admission, pre-existing cognitive impairment, comorbidities, and medication use. Precipitating factors included factors related to surgery and to the postoperative period. Factors related to surgery included time between admission and surgery, type of surgery, type of anesthesia, duration of surgery and anesthesia, and complications during surgery. Factors studied in the postoperative period were slow recovery, malnutrition, dehydration, addition of three or more medications, introduction of bladder catheter, infections, complications and falls, and use of morphine. Eighteen patients developed delirium, as diagnosed by a geriatrician by using the Diagnostic Statistical Manual-IV criteria. Data on delirious patients were compared with the data on non-delirious patients. The findings confirm that elderly hip fracture patients with premorbid ADL dependency, psychiatric comorbidities (including dementia), and a high number of other comorbid problems are at risk for the development of delirium. Based on these findings, it is recommended that nurses should assess patients' pre-fracture functional and cognitive capacities in an early stage of the hospital stay. Nurses should also be alert to postoperative delirium in "healthy elderly" patients. Monitoring of symptoms postoperatively in all elderly patients is advised. PMID:12764718
Schuurmans, Marieke J; Duursma, Sijmen A; Shortridge-Baggett, Lillie M; Clevers, Gert-Jan; Pel-Littel, Ruth
Cardiovascular risk factors in patients with chronic kidney disease
Patients with chronic kidney disease have a higher burden of cardiovascular disease, which increases in a dose-dependent fashion with worsening kidney function. Traditional cardiovascular risk factors, including advanced age, diabetes mellitus, hypertension and dyslipidemia, have an important role in the progression of cardiovascular disease in patients who have a reduced glomerular filtration rate, especially in those with mild-to-moderate kidney disease.
Sarina van der Zee; Usman Baber; Sammy Elmariah; Jonathan Winston; Valentin Fuster
Atherosclerotic Risk Factors in Patients with Ischemic Cerebrovascular Disease.
Aggressive treatment of atherosclerotic risk factors can substantially reduce stroke risk in patients with a history of stroke or transient ischemic attack. Data from several recent large clinical trials provide convincing evidence of benefit for a number of specific therapies directed at this population. The authors recommend treatment with ramipril alone or perindopril plus indapamide regardless of blood pressure, provided there is no contraindication. For patients already taking a different angiotensin- converting enzyme (ACE) inhibitor, the authors do not routinely switch agents. The authors recommend use of simvastatin 40 mg per day in patients with a total cholesterol level of 135 mg/dL or greater, provided no contraindication exists. The authors also recommend consideration of gemfibrozil in patients with isolated low high- density lipoprotein levels. In patients with diabetes mellitus, tight glycemic control has not been shown to reduce macrovascular complications such as stroke, but does reduce microvascular complications. However, diabetics should receive especially aggressive treatment of other vascular risk factors. There is no role for post-menopausal hormone replacement therapy in prevention of stroke. Weight loss for overweight patients, regular exercise, and a diet rich in fruits, vegetables, cereals, and fish, as well as low in fat and cholesterol, should be a standard recommendation for this group of patients. Treatment with folic acid, B(6), and B(12) for patients with elevated homocysteine appears rational, though this is unproven. However, there is no benefit to vitamin E, vitamin C, or beta-carotene supplementation. Smokers should stop. For every 43 smokers who quit, one stroke is prevented. Moderate consumption of alcohol (one to two drinks a day) may be beneficial, but heavy alcohol use (more than five drinks a day) increases stroke risk. PMID:12354371
Cucchiara, Brett L.; Kasner, Scott E.
Zolpidem Use and Risk of Fracture in Elderly Insomnia Patients
Objectives To evaluate the risk of fractures related with zolpidem in elderly insomnia patients. Methods Health claims data on the entire South Korean elderly population from January 2005 to June 2006 were extracted from the Health Insurance Review and Assessment Service database. We applied a case-crossover design. Cases were defined as insomnia patients who had a fracture diagnosis. We set the hazard period of 1 day length prior to the fracture date and four control periods of the same length at 5, 10, 15, and 20 weeks prior to the fracture date. Time independent confounding factors such as age, gender, lifestyle, cognitive function level, mobility, socioeconomic status, residential environment, and comorbidity could be controlled using the casecrossover design. Time dependent confounding factors, especially co-medication of patients during the study period, were adjusted by conditional logistic regression analysis. The odds ratios and their 95% confidence intervals (CIs) were estimated for the risk of fracture related to zolpidem. Results One thousand five hundred and eight cases of fracture were detected in insomnia patients during the study period. In our data, the use of zolpidem increased the risk of fracture significantly (adjusted odds ratio [aOR], 1.72; 95% CI, 1.37 to 2.16). However, the association between benzodiazepine hypnotics and the risk of fracture was not statistically significant (aOR, 1.00; 95% CI, 0.83 to 1.21). Likewise, the results were not statistically significant in stratified analysis with each benzodiazepine generic subgroup. Conclusions Zolpidem could increase the risk of fracture in elderly insomnia patients. Therefore zolpidem should be prescribed carefully and the elderly should be provided with sufficient patient education.
Kang, Dong-Yoon; Park, Soyoung; Rhee, Chul-Woo; Kim, Ye-Jee; Choi, Nam-Kyong; Lee, Joongyub
Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores in STEMI undergoing primary PCI: insights from a cohort of 1391 patients
Aims: To compare the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION risk models in the ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods: We studied all consecutive patients with STEMI who underwent PPCI at our institution between 2006 and 2010 (n=1391). The CRUSADE, ACUITY-HORIZONS, and ACTION risk scores were calculated based on the patientsÆ clinical characteristics. The occurrence of in-hospital major bleeding (defined as the composite of intracranial or intraocular bleeding, access site haemorrhage requiring intervention, reduction in haemoglobin ?4 g/dl without or ?3g/dl with overt bleeding source, reoperation for bleeding, or blood transfusion) reached 9.8%. Calibration and discrimination of the three risk models were evaluated by the Hosmer?Lemeshow test and the C-statistic, respectively. We compared the predictive accuracy of the risk scores by the DeLong non-parametric test. Results: Calibration of the three risk scores was adequate, given the non-significant results of Hosmer?Lemeshow test for the three risk models. Discrimination of CRUSADE, ACUITY-HORIZONS, and ACTION models was good (C-statistic 0.77, 0.70, and 0.78, respectively). The CRUSADE and ACTION risk scores had a greater predictive accuracy than the ACUITY-HORIZONS risk model (z=3.89, p-value=0.0001 and z=3.51, p-value=0.0004, respectively). There was no significant difference between the CRUSADE and ACTION models (z=0.63, p=0.531). Conclusions: The CRUSADE, ACUITY-HORIZONS, and ACTION scores are useful tools for the risk stratification of bleeding in STEMI treated by PPCI. Our findings favour the CRUSADE and ACTION risk models over the ACUITY-HORIZONS risk score.
Couto-Mallon, D; Rodriguez-Garrido, J; Garcia-Guimaraes, M; Gargallo-Fernandez, P; Pinon-Esteban, P; Aldama-Lopez, G; Salgado-Fernandez, J; Calvino-Santos, R; Vazquez-Gonzalez, N; Castro-Beiras, A
Oral Hypoglycemics: Increased Postoperative Mortality in Coronary Risk Patients
Background: Diabetes mellitus (DM), particularly if insulin-dependent, is a predictor of increased perioperative risk, whereas stringent metabolic control with insulin is beneficial in the critically ill. Methods: The impact of oral hypoglycemics (OH) vs. insulin on outcome was determined as a secondary retrospective analysis of a cohort study in patients with coronary artery disease (CAD) and DM undergoing major non-cardiac
Raban V. Jeger; Manfred D. Seeberger; Ulrich Keller; Matthias E. Pfisterer; Miodrag Filipovic
ICU Patients At Much Greater Risk for PTSD
... JavaScript. ICU Patients at Much Greater Risk for PTSD: Study Stay in intensive care can be traumatic ... May 19, 2014 Related MedlinePlus Pages Critical Care Post-Traumatic Stress Disorder MONDAY, May 19, 2014 (HealthDay News) -- After being ...
Risk factors for bacteremia in patients with limb cellulitis
The aim of this study was to identify the risk factors for bacteremia in patients with limb cellulitis. Using the administrative and microbiology laboratory databases of a community teaching hospital, a review was conducted of all cases of community-acquired limb cellulitis that occurred during the period 1997¢2004 and in which blood cultures had been performed. A comparison of demographical, clinical,
G. Peralta; E. Padr¾n; M. P. Roiz; I. De Benito; J. C. Garrido; F. Talledo; M. J. RodrĒguez-Lera; L. Ansorena; M. B. Sßnchez
Downsizing, reengineering and patient safety: numbers, newness and resultant risk.
Downsizing and reengineering are facts of life in contemporary healthcare organizations. In most instances, these organizational changes are undertaken in an attempt to increase productivity or cut operational costs with results measured in these terms. Less often considered are potential detrimental effects on patient safety or strategies, which might be used to minimize these risks. PMID:10620901
Knox, G E; Kelley, M; Hodgson, S; Simpson, K R; Carrier, L; Berry, D
Behavioral Dimensions of Patients at Risk of Wandering.
ERIC Educational Resources Information Center
Nurses in long-term care settings described behaviors of patients at risk for wandering and rated wanderers (N=59) and nonwanderers (N=41) on these behaviors. Revealed three independent factors of which two differentiated known wanderers from those who had not previously wandered: cognitive deficits and hyperactivity. Dimensions in turn wereģ
Dawson, Pam; Reid, David W.
Mortality Risk Factors in Patients Treated by Chronic Hemodialysis
A survival analysis was applied to 1,453 patients treated between 1972 and 1978 in 33 French dialysis centers and prospectively followed up in the computerized Diaphane Dialysis Registry. 198 deaths (overall mortality = OM) were registered, of which 87 (43%) were secondary to cardiovascular complications (cardiovascular mortality = CVM). Risk factors for OM and CVM (p values < 0.05) were
Patrice Degoulet; Marcel Legrain; Isabelle Rķach; Franńoise Aimķ; Claude DevriĶs; Patricio Rojas; Claude Jacobs
Risk factors for violence among patients with schizophrenia
Studies of birth cohorts show evidence of greater risk of violence among patients with schizophrenia compared to the general population. However, the contribution of schizophrenia to violence is heavily debated and remains unclear. This debate has spurred research whose focus can be associated with one of the following areas: psychotic symptoms, personality disorders (in particular psychopathy), mentalizing abilities, substance abuse
Sune Bo; Ahmad Abu-Akel; Mickey Kongerslev; Ulrik Helt Haahr; Erik Simonsen
A high-risk signature for patients with multiple myeloma established from the molecular classification of human myeloma cell lines
Background Multiple myeloma is a plasma-cell tumor with heterogeneity in molecular abnormalities and treatment response. Design and Methods We have assessed whether human myeloma cell lines have kept patientsÆ heterogeneity using Affymetrix gene expression profiling of 40 human myeloma cell lines obtained with or without IL6 addition and could provide a signature for stratification of patient risk. Results Human myeloma cell lines, especially those derived in the presence of IL6, displayed a heterogeneity that overlaps that of the patients with multiple myeloma. Human myeloma cell lines segregated into 6 groups marked by overexpression of MAF, MMSET, CCND1, FRZB with or without overexpression of cancer testis antigens (CTA). Cell lines of CTA/MAF and MAF groups have a translocation involving C-MAF or MAFB, cell lines of groups CCND1-1 and CCND1-2like have a t(11;14) and cell lines of group MMSET have a t(4;14). The CTA/FRZB group comprises cell lines that had no or no recurrent 14q32 translocation. Expression of 248 genes accounted for human myeloma cell line molecular heterogeneity. Human myeloma cell line heterogeneity genes comprise genes with prognostic value for survival of patients making it possible to build a powerful prognostic score involving a total of 13 genes. Conclusions Human myeloma cell lines derived in the presence of IL6 recapitulate the molecular diversity of multiple myeloma that made it possible to design, using human myeloma cell line heterogeneity genes, a high-risk signature for patients at diagnosis. We propose this classification to be used when addressing the physiopathology of multiple myeloma with human myeloma cell lines.
Moreaux, Jerome; Klein, Bernard; Bataille, Regis; Descamps, Geraldine; Maiga, Sophie; Hose, Dirk; Goldschmidt, Hartmut; Jauch, Anna; Reme, Thierry; Jourdan, Michel; Amiot, Martine; Pellat-Deceunynck, Catherine
Molecular stratification model for prognosis in cytogenetically normal acute myeloid leukemia.
We have evaluated 9 new molecular markers (ERG, EVI1, MLL-PTD, MN1, PRAME, RHAMM, and WT1 gene-expression levels plus FLT3 and NPM1 mutations) in 121 de novo cytogenetically normal acute myeloblastic leukemias. In the multivariate analysis, high ERG or EVI1 and low PRAME expressions were associated with a shorter relapse-free survival (RFS) and overall survival (OS). A 0 to 3 score was given by assigning a value of 0 to favorable parameters (low ERG, low EVI1, and high PRAME) and 1 to adverse parameters. This model distinguished 4 subsets of patients with different OS (2-year OS of 79%, 65%, 46%, and 27%; P = .001) and RFS (2-year RFS of 92%, 65%, 49%, and 43%; P = .005). Furthermore, this score identified patients with different OS (P = .001) and RFS (P = .013), even within the FLT3/NPM1 intermediate-risk/high-risk subgroups. Here we propose a new molecular score for cytogenetically normal acute myeloblastic leukemias, which could improve patient risk-stratification. PMID:19398719
SantamarĒa, Carlos M; Chill¾n, MarĒa C; GarcĒa-Sanz, Ram¾n; Pķrez, Cristina; Caballero, MarĒa D; Ramos, Fernando; de Coca, Alfonso GarcĒa; Alonso, Josķ M; Giraldo, Pilar; Bernal, Teresa; Queizßn, Josķ A; Rodriguez, Juan N; Fernßndez-Abellßn, Pascual; Bßrez, Abelardo; Pe±arrubia, MarĒa J; Balanzategui, Ana; Vidriales, MarĒa B; Sarasquete, MarĒa E; Alcoceba, Miguel; DĒaz-Mediavilla, JoaquĒn; San Miguel, Jes·s F; Gonzalez, Marcos
Metabolomic profiling of schizophrenia patients at risk for metabolic syndrome.
Second-generation antipsychotics (SGAs) are commonly used to treat schizophrenia. However, SGAs cause metabolic disturbances that can manifest as metabolic syndrome (MetS) in a subset of patients. The causes for these metabolic disturbances remain unclear. We performed a comprehensive metabolomic profiling of 60 schizophrenia patients undergoing treatment with SGAs that puts them at high (clozapine, olanzapine), medium (quetiapine, risperidone), or low (ziprasidone, aripiprazole) risk for developing MetS, compared to a cohort of 20 healthy controls. Multiplex immunoassays were used to measure 13 metabolic hormones and adipokines in plasma. Mass spectrometry was used to determine levels of lipids and polar metabolites in 29 patients and 10 controls. We found that levels of insulin and tumor necrosis factor alpha (TNF-?) were significantly higher (pĀ<Ā0.005) in patients at medium and high risk for MetS, compared to controls. These molecules are known to be increased in individuals with high body fat content and obesity. On the other hand, adiponectin, a molecule responsible for control of food intake and body weight, was significantly decreased in patients at medium and high risk for MetS (pĀ<Ā0.005). Further, levels of dyacylglycerides (DG), tryacylglycerides (TG) and cholestenone were increased, whereas ?-Ketoglutarate and malate, important mediators of the tricarboxylic acid (TCA) cycle, were significantly decreased in patients compared to controls. Our studies suggest that high- and medium-risk SGAs are associated with disruption of energy metabolism pathways. These findings may shed light on the molecular underpinnings of antipsychotic-induced MetS and aid in design of novel therapeutic approaches to reduce the side effects associated with these drugs. PMID:24565079
Paredes, R Madelaine; Quinones, Marlon; Marballi, Ketan; Gao, Xiaoli; Valdez, Celina; Ahuja, Seema S; Velligan, Dawn; Walss-Bass, Consuelo
Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke
BACKGROUND: Previous studies have demonstrated poor knowledge of stroke among patients with established risk factors. This study aims to assess the baseline knowledge, among patients with increased risk for stroke in Oman, of warning symptoms of stroke, impending risk factors, treatment, and sources of information. METHODS: In April 2005, trained family practice residents at Sultan Qaboos University Hospital Clinics (cardiology,
Mohammed A Al Shafaee; Shyam S Ganguly; Abdullah R Al Asmi
[Management of vascular risk factors in patients older than 80].
The number of patients older than 80 years is steadily increasing and it represents the main basis for increasing population figures in developed countries. Cardiovascular diseases are the leading causes of mortality and disability causes result in a huge burden of disease in elderly people. However, available scientific evidence to support decision-making on cardiovascular prevention in elderly patients is scarce. Currently available risk assessment scales cannot be applied to elderly people. They are focused on cardiovascular mortality risk and do not provide information on factors with a proven prognostic value in the very old (functioning disability, dementia). Elderly people are a highly heterogeneous population, with a variety of co-morbidities, as well as several functional and cognitive impairment degrees. Furthermore, aging-associated physiological changes and common use of multiple drugs result in an increased risk of adverse drug reactions. Thus, drug use should always be based on a risk/benefit assessment in the elderly. Therefore, therapeutic decision-making in the very old must be an individually tailored and based on an appropriate clinical judgement and a comprehensive geriatric assessment. The current consensus report aims to present a proposal for clinical practices in the primary and secondary cardiovascular prevention in the very old and to provide a number of recommendations on lifestyle changes and drug therapy for the management of major cardiovascular risk factors. PMID:24908624
G¾mez-Huelgas, Ricardo; MartĒnez-Sellķs, Manuel; Formiga, Francesc; Alemßn Sßnchez, Josķ Juan; Camafort, Miguel; Galve, Enrique; Gil, Pedro; Lobos, Josķ MarĒa
Cardiovascular Disease Risk in Schizophrenia Patients: A Case Control Study
Background: The Schizophrenia patients are at higher risk for cardiovascular morbidity and mortality. The aim of this case-control study is to measure Cardiovascular Disease (CVD) risk parameters in patient group and compare it with normal population. Methodology: We recruited 45 cases of Schizophrenia diagnosed by diagnostic and statistical manual of mental disorders (DSM-IV) criteria and 41 healthy controls from general population. The body mass index, metabolic syndrome parameters, lipid parameters and high sensitive C-reactive protein were measured in both groups. Metabolic syndrome and dyslipidemia prevalence were assessed based on National Cholesterol Education Programme (NCEP) Adult Treatment Panel III (ATP III) guidelines. Results: The Schizophrenia subjects showed statistically significant high waist circumference, increased triglycerides and decreased HDL cholesterol values. The subjects also showed statistically significant increased hs-CRP values. The prevalence of metabolic syndrome and laboratory dyslipidemia were 28.8% and 51.1% respectively, which were higher compared to control group. Conclusion: The Schizophrenia subjects are at higher risk for cardiovascular disease events due to high prevalence of metabolic syndrome and dyslipidemia. These patients should be regularly monitored for CVD risk factors and timely referred to physician for further management.
Joshi, Kedar B.; Nillawar, Anup; Thorat, A.P.
Lifetime risk of esophageal adenocarcinoma in patients with Barrett's esophagus
AIM: To investigate the lifetime risk of development of esophageal adenocarcinoma and/or high-grade dysplasia in patients diagnosed with BarrettÆs esophagus. METHODS: Data were extracted from the United Kingdom National BarrettÆs Oesophagus Registry on date of diagnosis, patient age and gender of 7877 patients from who had been registered from 35 United Kingdom centers. Life expectancy was evaluated from United Kingdom National Statistics data based upon gender and age at year at diagnosis. These data were then used with published estimates of annual adenocarcinoma and high-grade dysplasia incidences from meta-analyses and large population-based studies to estimate overall lifetime risk of development of these study endpoints. RESULTS: The mean age at diagnosis of BarrettÆs esophagus was 61.6 years in males and 67.3 years in females. The mean life expectancy at diagnosis was 23.1 years in males, 20.7 years in females and 22.2 years overall. Using data from published meta-analyses, the lifetime risk of development of adenocarcinoma was between 1 in 8 and 1 in 14 and the lifetime risk of high-grade dysplasia or adenocarcinoma was 1 in 5 to 1 in 6. Using data from 3 large recent population-based cohort studies the lifetime risk of adenocarcinoma was between 1 in 10 and 1 in 37 and of the combined end-point of high-grade dysplasia and adenocarcinoma was between 1 in 8 and 1 in 20. Age at BarrettÆs esophagus diagnosis is reducing and life expectancy is increasing, which will partially counter-balance lower annual cancer incidence. CONCLUSION: There is a significant lifetime risk of development of high-grade dysplasia and adenocarcinoma in BarrettÆs esophagus.
Gatenby, Piers; Caygill, Christine; Wall, Christine; Bhatacharjee, Santanu; Ramus, James; Watson, Anthony; Winslet, Marc
Pure variation and organic stratification.
The fundamental problem posed by Darwin distinguishes his theory from any transformism of the past as well as any evolutionism to come: since variation is inherent to the living, it is a question of explaining, not at all why the living varies, but instead why the living does not vary in all directions to the point of constituting a continuum of forms varying ad infinitum. What limits and stabilizes this intrinsically unlimited variation, allowing certain forms to subsist and multiply to the detriment of others, is natural selection. This double principle of intrinsic variation/extrinsic selection constitutes a vector for the unification of reality that underlies Jean-Jacques Kupiec's ontophylogenesis as well as Deleuze and Guattari's global philosophy of Nature. Therefore, everything would potentially tend to incessantly vary. The work of Kupiec and others identifies an intrinsic random variation within ontogenesis itself. For Deleuze and Guattari, it is nothing but the figure, already selected by the organic stratum, of a more fundamental or pure variation. But, in fact, nothing really varies incessantly: everything undergoes a selective pressure according to which nothing subsists as such except what manages to endure through invariance (physical stratum) or reproduction (organic stratum). Thus, organic stratification only retains from variation what ensures and augments this reproduction. In this sense, every organism stratifies, i.e. submits to its imperative of subsistence and reproduction, a body without organs that varies in itself and always tends to escape the organism, for better (intensifications of life) or worse (cancerous pathologies). PMID:22884711
Rosanvallon, Jķr¶me
Risk Factors for Mortality in Patients with Acinetobacter baumannii Bacteremia
Background Acinetobacter baumannii, an opportunistic nosocomial pathogen that can cause significant morbidity and mortality, has emerged as a worldwide problem. The aim of this study was to evaluate the risk factors for mortality in patients with A. baumannii bacteremia. Materials and Methods We retrospectively evaluated 118 patients who had A. baumannii bacteremia between July 2003 and December 2011. The aim of this study was to identify the 30-day mortality in patients with A. baumannii bacteremia and relevant risk factors. Results The bacteremia-related 30-day mortality rate was 34.1%. Univariate analysis revealed that the risk factors for mortality included malignancy, longer hospital stay before bacteremia, intensive care unit (ICU) stay at the time of bacteremia, mechanical ventilation, use of a central venous catheter, unknown origin of bacteremia, bacteremia due to pneumonia, antimicrobial resistance to carbapenems, and elevated Acute Physiology and Chronic Health Evaluation II and Pitt bacteremia scores. Multivariate logistic regression analysis revealed that resistance to carbapenems (odds ratio [OR]: 4.01, 95% confidence interval [CI]: 1.51 to 0.68, P = 0.005), need for mechanical ventilation (OR: 3.97, 95% CI: 1.41 to 11.13, P = 0.005), and presence of malignancy (OR: 4.40, 95% CI: 1.60 to 12.08, P = 0.004) were significantly related to mortality risk. Conclusions Risk factors such as resistance to carbapenems, mechanical ventilation, and presence of malignancy were found to be associated with high mortality rates in the patients with A. baumannii bacteremia.
Park, Se Yoon; Choo, Jin Woo; Kwon, Soon Ha; Yu, Shi Nae; Kim, Tae Hyong; Choo, Eun Ju; Jeon, Min Huok
Cancer risks for relatives of patients with serrated polyposis
OBJECTIVES Serrated polyposis (hyperplastic polyposis) is characterized by multiple polyps with serrated architecture in the colorectum. While patients with serrated polyposis are known to be at increased risk of colorectal cancer (CRC) and possibly extracolonic cancers, cancer risk for their relatives has not been widely explored. The aim of this study was to estimate the risks of CRC and extracolonic cancers for relatives of patients with serrated polyposis. METHODS A cohort of the 1,639 first- and second-degree relatives of 100 index patients with serrated polyposis recruited regardless of a family history of polyps or cancer from genetic clinics in Australia, New Zealand, Canada and the USA, were retrospectively analysed to estimate the country-, age- and sex-specific standardized incidence ratios (SIRs) for relatives compared with the general population. RESULTS A total of 102 CRCs were observed in first- and second-relatives (SIR 2.25, 95% confidence interval, CI 1.75-2.93; P<0.001), with 54 in first-degree relatives (SIR 5.16, 95% CI 3.70-7.30; P<0.001) and 48 in second-degree relatives (SIR 1.38, 95% CI 1.01-1.91; P=0.04). Six pancreatic cancers were observed in first-degree relatives (SIR 3.64, 95% CI 1.70-9.21; P=0.003). There was no statistical evidence of increased risk for cancer of the stomach, brain, breast or prostate. CONCLUSIONS Our finding that relatives of serrated polyposis patients are at significantly increased risk of colorectal and pancreatic cancer, adds to the accumulating evidence that serrated polyposis has an inherited component.
Win, Aung Ko; Walters, Rhiannon J.; Buchanan, Daniel D.; Jenkins, Mark A.; Sweet, Kevin; Frankel, Wendy L.; de la Chapelle, Albert; McKeone, Diane M.; Walsh, Michael D.; Clendenning, Mark; Pearson, Sally-Ann; Pavluk, Erika; Nagler, Belinda; Hopper, John L.; Gattas, Michael R.; Goldblatt, Jack; George, Jill; Suthers, Graeme K.; Phillips, Kerry D.; Woodall, Sonja; Arnold, Julie; Tucker, Kathy; Field, Michael; Greening, Sian; Gallinger, Steve; Aronson, Melyssa; Perrier, Renee; Woods, Michael O.; Green, Jane S.; Walker, Neal; Rosty, Christophe; Parry, Susan; Young, Joanne P.
Identifying patients at risk of type 2 diabetes.
At present there are nearly 3 million people with diabetes in the UK. It is predicted that this number will almost double by 2025. Nine out of ten of these individuals will have type 2 diabetes. It is estimated that one in seven adults have impaired glucose regulation and up to 12% of these will develop type 2 diabetes each year. The impact of obesity on the development of type 2 diabetes cannot be overemphasised, with a 1 kg/m2 increase in BMI raising the risk of impaired fasting glycaemia by 9.5% and of developing new-onset type 2 diabetes by 8.4%. A 1 cm increase in waist circumference increases the risks by 3.2% and 3.5% respectively. NICE advises using a validated risk assessment tool to identify patients at risk of diabetes. Risk factors used by such tools include: age; ethnicity; weight; first-degree relative with type 2 diabetes; low birthweight and sedentary lifestyle. Certain comorbidities increase the risk of type 2 diabetes, these include: cardiovascular and cerebrovascular disease; polycystic ovary syndrome; a history of gestational diabetes; and mental health problems. The initial screening blood test could be a fasting plasma glucose, HbA1c, or an oral glucose tolerance test, according to WHO criteria. NICE recommends that high-risk patients should be offered a programme encouraging them to undertake a minimum of 150 minutes of moderate intensity physical activity a week, gradually lose weight to reach and maintain a BMI within the healthy range, increase consumption of whole grains, vegetables, and other foods that are high in dietary fibre, reduce the total amount of fat in their diet and eat less saturated fat. PMID:22988703
Savill, Peter
Complications of coeliac disease: are all patients at risk?
Coeliac disease is a common condition that is increasingly being recognised as a result of the development of sensitive and specific serology. The diagnosis of coeliac disease and its subsequent treatment with a gluten?free diet have implications for the patient, not just for symptom control but also for the possible effect on quality of life and risk of complications. Whether the mode of presentation of coeliac disease has an effect on survival or risk of complication is yet unclear. This article reviews the available evidence regarding these issues.
Goddard, C J R; Gillett, H R
Prognostic value of exercise echocardiography in diabetic patients
BACKGROUND: Coronary artery disease (CAD) is the leading cause of death in diabetic patients. Although exercise echocardiography (EE) is established as a useful method for diagnosis and stratification of risk for CAD in the general population, there are few studies on its value as a prognostic tool in diabetic patients. The purpose of this investigation was to evaluate the value
Joselina LM Oliveira; Josķ AS Barreto-Filho; Carla RP Oliveira; Thaiana A Santana; Fernando D Anjos-Andrade; ╔rica O Alves; AdŃo C Nascimento-Junior; Thiago JS G¾es; Nathalie O Santana; Francis L Vasconcelos; Martha A Barreto; Argemiro D'Oliveira Junior; Roberto Salvatori; Manuel H Aguiar-Oliveira; Ant¶nio CS Sousa
Using Simulated Patients to Train Physicians in Sexual Risk Assessment and Risk Reduction.
ERIC Educational Resources Information Center
The objectives of this preliminary study were to evaluate the feasibility and acceptability of using trained simulated patient instructors (N=6) as an office-based continuing medical education method and to assess the current sexually transmitted diseases/human immunodeficiency virus risk assessment and counseling practices of primary careģ
Gonzalez-Willis, Angela; And Others
Risk and potential risk reduction in diabetes type 2 patients in Germany
Avoiding serious complications such as stroke, myocardial infarction, and amputations in diabetes patients is the main interest of long-term treatment. Given the considerable prevalence of diabetes type 2 in industrialized countries this is a major public health concern as well as a burden to health care systems. The present study estimated the current risk of major complications occurring in the
Bertram Hõussler; Ursula Berger; Oliver Mast; Wolfgang Thefeld
Atorvastatin and cardiovascular risk in the elderly - patient considerations
Elderly individuals are at increased risk of coronary heart disease (CHD) and account for a majority of CHD deaths. Several clinical trials have assessed the beneficial effects of statins in individuals with, or at risk of developing, CHD. These trials provide evidence that statins reduce risk and improve clinical outcomes even in older patients; however, statin therapy remains under-utilized among the aged. Atorvastatin has been widely investigated among the older subjects and has the greatest magnitude of favorable effects on clinical outcomes of CHD. The pharmacokinetic properties of atorvastatin allow it to be used every other day, a factor which may decrease adverse events and be especially important in the elderly. The purpose of this article is to review the evidence available from randomized clinical trials regarding the safety and efficacy of atorvastatin in primary and secondary prevention of CHD and stroke in older patients and to discuss issues such as drug interactions, patient compliance and cost-effectiveness, which affect prescription of lipid-lowering therapy among older patients.
Acharjee, Subroto; Welty, Francine K
Risk Factors of Treatment Failure in Diabetic Foot Ulcer Patients
Background Some diabetic feet heal without complication, but others undergo amputation due to progressive wounds. This study investigates the risk factors for amputation of diabetic feet. Methods A total of 55 patients who visited our institution from 2008 to 2012 were included in the study. The patients with abnormal fasting blood sugar levels, lower leg vascularity, and poor nutrition were excluded from the study group, and the wound states were unified. The patients were categorized into a treatment success group (n=47) and a treatment failure group (n=8), and their hemoglobin A1C (HgA1C), C-reactive protein (CRP), white blood cell count (WBC), and serum creatinine levels were analyzed. Results The initial CRP, WBC, and serum creatinine levels in the treatment failure group were significantly higher than that of the treatment success group, and the initial HgA1C level was significantly higher in the treatment success group. The CRP and WBC levels of both groups changed significantly as time passed, but their serum creatinine levels did not. Conclusions The initial CRP, WBC, and serum creatinine levels were considered to be risk factors for amputation. Among them, the serum creatinine level was found to be the most important predictive risk factor. Because serum creatinine represents the renal function, thorough care is needed for the feet of diabetic patients with renal impairment.
Lee, Kyung Mook; Kim, Woon Hoe; Choi, Matthew Seung Suk
Dialysis Patients and Cardiovascular Problems: Can Technology Help Solve the Complex Equation?
Patients with end-stage kidney disease undergoing chronic hemodialysis (HD) present higher mortality rates compared with the general population. Once patients are on HD, the risk of cardiovascular death is approximately 30 times higher than in the general population and remains 10¢20 times higher after stratification for age, gender, and the presence of diabetes. About half the deaths of patients on
Claudio Ronco; Sudhi Bowry; Ciro Tetta
Prognostic significance of renal function in patients undergoing dobutamine stress echocardiography
Background. Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings. Methods. We studied 2292 patients, divided into 729 (32%) patients with normal
Stefanos E. Karagiannis; Harm H. H. Feringa; Abdou Elhendy; Domburg van R. T; Michel Chonchol; Radosav Vidakovic; Jeroen J. Bax; George Karatasakis; George Athanasopoulos; Dennis V. Cokkinos; Don Poldermans
Risk factors for brain relapse in patients with metastatic breast cancer
Background: The occurrence of brain metastases is an emerging problem in patients with metastatic breast cancer. In the present study, we looked at risk factors for brain metastasis among patients with metastatic breast cancer. Patients and methods: The risk factors for brain metastasis were first determined in a series of 215 patients with metastatic breast cancer. Risk factors identified in
K. Slimane; F. Andre; S. Delaloge; A. Dunant; A. Perez; J. Grenier; C. Massard; M. Spielmann
Risk of Vancomycin?Resistant Enterococcus (VRE) Bloodstream Infection Among Patients Colonized With VRE
background. Colonization with vancomycin-resistant Enterococcus (VRE) is a risk factor for subsequent VRE bloodstream infection (BSI); however, risk factors for BSI among colonized patients have not been adequately described. We sought to determine the proportion of VRE-colonized patients who subsequently develop VRE BSI and to identify risk factors for VRE BSI among these patients. methods. Records of 768 patients colonized
Thermal Stratification Enhancement for Solar Energy Applications.
National Technical Information Service (NTIS)
A study is presented that shows methods to enhance stratification in liquid storage tanks. The report focusses on the development of a passive inlet distributor which minimizes mixing between incoming and stored fluids at unlike temperatures. Theoretical ...
H. N. Gari M. K. Sharp R. D. Haberstroh R. I. Loehrke
Phase stratification in disordered metallic systems
NASA Astrophysics Data System (ADS)
Phase stratification in a series of binary melts (AlBi, AlCd, AlIn, AlPb, CdGa, CrSn, and CuTl) and an amorphous NiZr alloy was studied. Equations describing the main stratification parameters in the liquid phase (the enthalpy ? H, the relative volume change of melt formation ? V/ V 0, and the highest temperature T k at which phase stratification occurs) were obtained. An equation describing the concentration dependence of the relative integral Gibbs energy in the amorphous (liquid) phase was found. This equation took into account the influence of volume changes caused by melt formation on its entropy. The equations obtained were shown to qualitatively correctly describe phase stratification and the subsequent growth of crystalline phases in NiZr system alloys.
Lysov, V. I.; Tsaregradskaya, T. L.; Turkov, O. V.; Saenko, G. A.; Yarysh, V. V.
Arthroprosthetic cobaltism: identification of the at-risk patient.
MoM hip bearings are being scrutinized due to high early failure rates and concerns that the results of the revision surgeries will be poor. However, orthopedic surgeons and the general medical community are unaware that patients with MoM bearings are also at risk for cobaltism. Medical providers need to know that hip arthroplasty implantees that present with symptom complexes that include tinnitus, deafness, vertigo, visual changes, rashes, hypothyroidism, tremor, dyspnea on exertion, mood disorders, dementia, heart failure, and peripheral neuropathy may be presenting arthroprosthetic cobaltism. These patients need to be asked if they have had a hip replacement and if so what type. For those patients implanted with a MoM bearing or those with a history of hip revision for a failed ceramic bearing obtaining a [Co] is indicated. MoM implantees with renal failure are a particularly high risk for cobaltism. A [Co] can be measured by many reference laboratories from royal blue top trace elements tube of venous blood. Venipuncture with a standard needle is adequate as long as a red stoppered tube is drawn first. The radiographic appearance of a MoM bearing is readily apparent to an orthopedic surgeon. The patient's operative report will usually specify the bearing type. Given that the publicity of the recent ASR bearing recall medical providers will be contacted by worried patients concerned about their hip implants. Most patients with hip replacements will not know the brand or material of their bearings. Providing patients with copies of their hip implant inventory might avoid worry by the majority of patients with hip arthroplasties that are not at risk. Patients with a cobalt levels of greater than 7 mcg/l bear observation of neurologic and cardiac function. Those patients with levels greater than 20 should be advised to have revision of their hip arthroplasty to a bearing that eliminates cobalt. Most patients implanted with MoM bearing have cobalt levels greater than those allowed in industry and cobalt exposed workers may have an increased incidence of subclinical cognitive and cardiac impairments. This association merits further study. Table 1 is a summation of the previously referenced data of this paper that might assist the clinician in interpreting a [Co]. PMID:21066926
Tower, Stephen
Are tuberculous patients at a great risk from hypercalcemia?
The risk of tuberculous patients to develop hypercalcemia was investigated in 33 patients aged 19 to 80. Twenty-two of the 33 received no vitamin D supplements. Before antituberculous chemotherapy serum calcium corrected for albumin and urinary calcium levels were normal, serum 25-hydroxyvitamin D (25(OH)D) levels were low, but serum 1,25(OH)2D levels, oral calcium load test and intestinal 47Ca absorption were normal. After 17 to 34 days of chemotherapy serum calcium corrected for albumin and 1,25(OH)2D levels were lower without change in serum D-binding protein. In 11 patients 25(OH)D, 50 micrograms/day, was given orally for two months. 25(OH)D given three days before chemotherapy in five patients induced an increase of levels of 1,25(OH)2D which was greater than in 10 control patients with similar serum levels of 25(OH)D. When chemotherapy was added to 25(OH)D, the five patients showed high normal 1,25(OH)2D levels. The last six patients received 25(OH)D together with or after starting chemotherapy. None of the 33 patients developed hypercalcemia, even when supplemented with 25(OH)D for two months. It appears that hypercalcemia is uncommon in tuberculosis. PMID:3271334
Fuss, M; Karmali, R; Pepersack, T; Bergans, A; Dierckx, P; Prigogine, T; Bergmann, P; Corvilain, J
Adjuvant therapy for patients with high-risk malignant melanoma.
The role of adjuvant therapy in the treatment of patients with high-risk malignant melanoma remains an area of intense investigation. The initial enthusiasm for high-dose interferon has been tempered by the results of more recent studies that allow for conflicting interpretations. Vaccine therapy trials have failed to clearly demonstrate a survival benefit, although several trials are currently ongoing. Recent studies of the role of chemotherapy suggest there may be combinations that have a survival benefit which deserve further study. This article will address patient selection and staging workup, and review options for treatment. PMID:12170442
McClay, Edward F
Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysiså
OBJECTIVES Prior studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality and morbidity following surgery. It is not clear whether this increased risk occurs across all haematocrit (HCT) levels. The goal of this study was to compare operative mortality in propensity-matched cardiac surgery patients based on stratification of the preoperative HCT levels. METHODS Between 1 August 2004 and 30 June 2011, 3516 patients had cardiac surgery. One thousand nine hundred and twenty-two (54.5%) required blood transfusion during or after surgery. A propensity score for transfusion was developed based on 22 baseline variables. One thousand seven hundred and fourteen patients were matched: 857 in the transfusion group (TG) and 857 in the non-transfused control group (CG). Univariate analyses demonstrated that, after propensity matching, the groups did not differ on any baseline factors included in the propensity model. Operative mortality was defined as death within 30 days of surgery. Preoperative HCT was stratified into four groups: <36, 36¢39, 40¢42 and ?43. RESULTS For HCT <36%, 30-day mortality was higher in the TG than that in the CG (3.0 vs 0.0%). For HCT 36¢39, operative mortality was similar between TG (1.1%, N = 180) and CG (0.8%, N = 361; P = 0.748). For HCT 40¢42, operative mortality was significantly higher in the TG compared with that in the CG (1.9 vs 0%, N = 108 and 218, respectively; P = 0.044). For HCT of ?43, there was a trend towards higher operative mortality in the TG vs the CG (2.0 vs 0%, N = 102 and 152, respectively; P = 0.083). Other surgical complications followed the same pattern with higher rates found in the transfused group at higher presurgery HCT levels. HCT at discharge for the eight groups were similar, with an average of 29.1 ▒ 1.1% (P = 0.117). CONCLUSIONS Our study indicates that a broad application of blood products shows no discernible benefits. Furthermore, patients who receive blood at all HCT levels may be placed at an increased risk of operative mortality and/or other surgical complications. Paradoxically, even though patients with low HCTs theoretically should benefit the most, transfusion was still associated with a higher complication and mortality rate in these patients. Our results indicate that blood transfusion should be used judiciously in cardiac surgery patients.
Shaw, Richard E.; Johnson, Christopher K.; Ferrari, Giovanni; Zapolanski, Alex; Brizzio, Mariano; Rioux, Nancy; Edara, Srinivasa; Sperling, Jason; Grau, Juan B.
Geographic Tongue and Associated Risk Factors among Iranian Dental Patients
Background Geographic Tongue is a benign disorder involving the dorsal surface of the tongue characterized by depapillated areas with leading and folded edges in yellowish or grayish white color and sometimes with unclear borders. Many studies have reported a relationship between such condition and different risk factors. This study aimed to investigate the prevalence rate and the risk factors of geographic tongue in the patients referring to the Department of Oral Medicine of Zahedan Dental School, in 2012. Methods: Using Poisson regression model, 2000 patients referred to the Department were selected for this cross-sectional study. Data collection method included an investigation into the medical history as well as doing intraoral examinations. Using SPSS 17 software and Chi-square statistical test, the collected data were analyzed. Result: Among the 2000 patients selected, 7.8% (156 persons) suffered from geographic tongue. The results of our study show that there is a significant relationship between the occurrence of geographic tongue and a history of allergy and fissured tongue (P<0.001). There was no significant statistical relationship between the occurrence of geographic tongue and gender, smoking and medication. Conclusion: The geographic tongue is more frequently in the patients suffering from atopy or allergy as well as the patients with fissured tongue.
HONARMAND, Marieh; FARHAD MOLLASHAHI, Leila; SHIRZAIY, Masomeh; SEHHATPOUR, Marziye
Does Pomegranate intake attenuate cardiovascular risk factors in hemodialysis patients?
Background Atherosclerotic cardiovascular disease (CVD) is the most common cause of morbidity and mortality among hemodialysis (HD) patients. It has been attributed, among other causes, to hypertension and dyslipidemia. The aim of the present study was to investigate the effect of a year-long consumption of Pomegranate juice (PJ), on two traditional cardiovascular (CV) risk factors: hypertension and lipid profile, as well as on cardiovascular events. Methods 101 HD patients were randomized to receive 100Ācc of PJ (0.7ĀmM polyphenols) or matching placebo juice, three times a week for one year. The primary endpoints were traditional CV risk factors; blood pressure and lipid profile. Systolic, diastolic and pulse pressure, plasma levels of triglycerides (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) and total cholesterol were monitored quarterly during the study year. Secondary endpoint was incidence of cardiovascular events. Results PJ consumption yielded a significant time response improvement in systolic blood pressure, pulse pressure, triglycerides and HDL level; an improvement that was not observed in the placebo intake group. These beneficial outcomes were more pronounced among patients with hypertension, high level of triglycerides and low levels of HDL. Conclusion Regular PJ consumption by HD patients reduced systolic blood pressure and improved lipid profile. These favorable changes may reduce the accelerated atherosclerosis and high incidence of CVD among HD patients. Trial registration ClinicalTrials.gov registry, Identifier number: NCT00727519
Risk of subsequent primary tumor development in melanoma patients.
Incidence of subsequent malignant tumor development in 740 patients with primary cutaneous melanoma verified between 2006 and 2010 at the Semmelweis University was studied retrospectively and was compared to data of sex and age matched Hungarian population. The follow-up period was 1499 person-years for the whole group from the diagnosis of index melanoma with an average of 2 years. Standardized incidence rate (SIR) was established as the ratio of observed and expected values. The risk of all subsequent malignancies was 15- and 10-fold higher in males (SIR: 15.42) and in females (SIR: 10.55) with melanoma, than in the general population. The increased cancer risk resulted mainly from the significantly higher skin tumor development: SIR values were 160.39 and 92.64 for additional invasive melanoma and 342.28 and 77.04 for subsequent in situ melanoma in males and females, respectively. Non-melanoma skin cancers also notably contributed to the higher risk, the SIR was elevated in both genders to the same extent (males: 17.12, females: 17.55). The risk was also significantly higher for extracutaneous tumor development like chronic lymphocytic leukemia, colon and kidney cancer (both genders), non-Hodgkin's lymphoma, cervical cancer (females), and bladder carcinoma (males). These data underline the importance of patient education and the necessity of frequent medical follow up, including a close-up dermatological screening of melanoma survivors for further malignancies. PMID:23681370
T¾th, Veronika; Hatvani, Zs¾fia; Somlai, Beßta; Hßrsing, Judit; Lßszl¾, Jßnos F; Kßrpßti, Sarolta
Patient-specific radiation dose and cancer risk estimation in CT: Part II. Application to patients
Purpose: Current methods for estimating and reporting radiation dose from CT examinations are largely patient-generic; the body size and hence dose variation from patient to patient is not reflected. Furthermore, the current protocol designs rely on dose as a surrogate for the risk of cancer incidence, neglecting the strong dependence of risk on age and gender. The purpose of this study was to develop a method for estimating patient-specific radiation dose and cancer risk from CT examinations. Methods: The study included two patients (a 5-week-old female patient and a 12-year-old male patient), who underwent 64-slice CT examinations (LightSpeed VCT, GE Healthcare) of the chest, abdomen, and pelvis at our institution in 2006. For each patient, a nonuniform rational B-spine (NURBS) based full-body computer model was created based on the patient's clinical CT data. Large organs and structures inside the image volume were individually segmented and modeled. Other organs were created by transforming an existing adult male or female full-body computer model (developed from visible human data) to match the framework defined by the segmented organs, referencing the organ volume and anthropometry data in ICRP Publication 89. A Monte Carlo program previously developed and validated for dose simulation on the LightSpeed VCT scanner was used to estimate patient-specific organ dose, from which effective dose and risks of cancer incidence were derived. Patient-specific organ dose and effective dose were compared with patient-generic CT dose quantities in current clinical use: the volume-weighted CT dose index (CTDI{sub vol}) and the effective dose derived from the dose-length product (DLP). Results: The effective dose for the CT examination of the newborn patient (5.7 mSv) was higher but comparable to that for the CT examination of the teenager patient (4.9 mSv) due to the size-based clinical CT protocols at our institution, which employ lower scan techniques for smaller patients. However, the overall risk of cancer incidence attributable to the CT examination was much higher for the newborn (2.4 in 1000) than for the teenager (0.7 in 1000). For the two pediatric-aged patients in our study, CTDI{sub vol} underestimated dose to large organs in the scan coverage by 30%-48%. The effective dose derived from DLP using published conversion coefficients differed from that calculated using patient-specific organ dose values by -57% to 13%, when the tissue weighting factors of ICRP 60 were used, and by -63% to 28%, when the tissue weighting factors of ICRP 103 were used. Conclusions: It is possible to estimate patient-specific radiation dose and cancer risk from CT examinations by combining a validated Monte Carlo program with patient-specific anatomical models that are derived from the patients' clinical CT data and supplemented by transformed models of reference adults. With the construction of a large library of patient-specific computer models encompassing patients of all ages and weight percentiles, dose and risk can be estimated for any patient prior to or after a CT examination. Such information may aid in decisions for image utilization and can further guide the design and optimization of CT technologies and scan protocols.
Li Xiang; Samei, Ehsan; Segars, W. Paul; Sturgeon, Gregory M.; Colsher, James G.; Toncheva, Greta; Yoshizumi, Terry T.; Frush, Donald P. [Medical Physics Graduate Program, Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States); Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Medical Physics Graduate Program, Department of Physics, and Department of Biomedical Engineering, Duke University Medical Center, Durham, North Carolina 27705 (United States); Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Medical Physics Graduate Program, Duke University Medical Center, Durham, North Carolina 27705 (United States); Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 and Department of Biomedical Engineering, University of North Carolina, Chapel Hill, North Carolina 27599 (United States); Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States); Duke Radiation Dosimetry Laboratory, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States); Duke Radiation Dosimetry Laboratory, Department of Radiology, Medical Physics Graduate Program, Duke University Medical Center, Durham, North Carolina 27705 (United States); Division of Pediatric Radiology, Department of Radiology, Medical Physics Graduate Program, Duke University Medical Center, Durham, North Carolina 27710 (United States)
Hyperuricemia and transesophageal echocardiographic thromboembolic risk in patients with atrial fibrillation at clinically low-intermediate risk.
Background:?There is no clear consensus on thromboprophylaxis in patients with nonvalvular atrial fibrillation (AF) at low-intermediate thromboembolic risk. Although hyperuricemia is a risk factor for cardiovascular diseases, the relationship between serum uric acid (UA) levels and thromboembolic risk has not been fully elucidated in patients with AF. Methods and Results:?Serum UA levels and the score for congestive heart failure, hypertension, age, diabetes mellitus, prior stroke/transient ischemic attack, vascular disease and sex (ie, CHA2DS2-VASc score) were determined in 470 patients with nonvalvular AF who underwent transesophageal echocardiography (TEE) to evaluate their risk of thromboembolism. Serum UA levels were similar between the low-intermediate risk (CHA2DS2-VASc score=0 or 1) and high-risk (?2) groups, although serum D-dimer levels were lower in the low-intermediate risk than in the high-risk group. Among patients at low-intermediate risk, serum UA levels were higher in those with TEE thromboembolic risk (TEE risk: low left atrial appendage flow, spontaneous echo contrast, thrombi, or aortic atherosclerosis) than in those without TEE risk. On multivariate analysis, the serum UA level was an independent predictor of TEE risk in AF patients at low-intermediate risk (odds ratio, 1.45; 95% confidence interval 1.09-2.00; P=0.016). Conclusions:?The serum UA level was associated with thromboembolic risk on TEE in patients with nonvalvular AF at low-intermediate risk stratified by clinical risk factors.??(Circ J?2014; 78: 1600-1605). PMID:24805815
Numa, Satoshi; Hirai, Tadakazu; Nakagawa, Keiko; Ohara, Kazumasa; Fukuda, Nobuyuki; Nozawa, Takashi; Inoue, Hiroshi
[Mortality risk in polytrauma patients with pelvic injury].
The aim of the study is to present results showing whether a pelvic injury in polytrauma patients means a high risk of mortality. The retrospective study (January 2001 - December 2006) included 453 polytrauma patients (130 women, 323 men) with ISS exceeding 16 points, hospitalized at the authors' department (Traumacentre Level I). The age of patients ranged between 13-93 years, the mean age of the whole group was 41 years (43 years in women, 40 years in men). The highest percentage of the deceased was recorded in the subgroup with abdominal injury (35%) and in the subgroup with pelvic injury (31%), the lowest in the subgroup without abdominal injury (20%). A significant difference was recorded between the numbers of deceased patients with and without abdominal trauma (p < 0.001), and between the numbers of patients with and without pelvic injury (p = 0.046). The results of the study have demonstrated a significantly higher rate of mortality in polytrauma patients with ISS > 16 points, with a simultaneous pelvic injury as compared to the patients without pelvic injury. PMID:19413264
Grill, R; Waldauf, P; Dzupa, V; Wendsche, P; Fric, M; Bßca, V; Skßla-Rosenbaum, J
Socioeconomic status in HCV infected patients - risk and prognosis
Background and aims It is unknown whether socioeconomic status (SES) is a risk factor for hepatitis C virus (HCV) infection or a prognostic factor following infection. Methods From Danish nationwide registries, we obtained information on three markers of SES: employment, income, and education. In a case control design, we examined HCV infected patients and controls; conditional logistic regression was employed to obtain odds ratios (ORs) for HCV infection for each of the three SES markers, adjusting for the other two SES markers, comorbidity, and substance abuse. In a cohort design, we used Cox regression analysis to compute mortality rate ratios (MRRs) for each of the three SES markers, adjusting for the other two SES markers, comorbidity level, age, substance abuse, and gender. Results When compared to employed persons, ORs for HCV infection were 2.71 (95% confidence interval [CI]: 2.24¢3.26) for disability pensioners and 2.24 (95% CI: 1.83¢2.72) for the unemployed. When compared to persons with a high income, ORs were 1.64 (95% CI: 1.34¢2.01) for low income persons and 1.19 (95% CI: 1.02¢1.40) for medium income persons. The OR was 1.35 (95% CI: 1.20¢1.52) for low education (no more than basic schooling). When compared to employed patients, MRRs were 1.71 (95% CI: 1.22¢2.40) for unemployed patients and 2.24 (95% CI: 1.63¢3.08) for disability pensioners. When compared to high income patients, MRRs were 1.47 (95% CI: 1.05¢2.05) for medium income patients and 1.64 (95% CI: 1.13¢2.34) for low income patients. Educational status was not associated with mortality. Conclusion Low SES was associated with an increased risk of HCV infection and with poor prognosis in HCV infected patients.
Omland, Lars Haukali; Osler, Merete; Jepsen, Peter; Krarup, Henrik; Weis, Nina; Christensen, Peer Brehm; Roed, Casper; S?rensen, Henrik Toft; Obel, Niels
Impact of a genomic classifier of metastatic risk on postoperative treatment recommendations for prostate cancer patients: a report from the DECIDE study group
Background Only a minority of prostate cancer patients with adverse pathology and biochemical recurrence (BCR) post radical prostatectomy (RP) experience metastasis and die from prostate cancer. Improved risk prediction models using genomic information may enable clinicians to better weigh the risk of metastasis and the morbidity and costs of treatment in a clinically heterogeneous population. Purpose We present a clinical utility study that evaluates the influence on urologist treatment recommendations for patients at risk of metastasis using a genomic-based prediction model (DecipherTM). Methods A prospective, pre-post design was used to assess urologist treatment recommendations following RP in both the adjuvant (without any evidence of PSA rise) and salvage (BCR) settings. Urologists were presented de-identified pathology reports and genomic classifier (GC) test results for 24 patients from a previously conducted GC validation study in high-risk post-RP men. Participants were fellowship trained, high-volume urologic oncologists (n=21) from 18 US institutions. Treatment recommendations for secondary therapy were made based solely on clinical information (pre-GC) and then with genomic biomarker information (post-GC). This study was approved by an independent IRB. Results Treatment recommendations changed from pre-GC to post-GC in 43% of adjuvant, and in 53% of salvage setting case evaluations. In the adjuvant setting, urologists changed their treatment recommendations from treatment (i.e. radiation and/or hormones) to close observation post-GC in 27% of cases. For cases with low GC risk (<3% risk of metastasis), observation was recommended for 79% of the case evaluations post-GC. Consistent trends were observed in the salvage setting. Conclusion These results indicate that urologists across a range of practice settings are likely to change treatment decisions when presented with genomic biomarker information following RP. Implementation of genomic risk stratification into routine clinical practice may better direct treatment decision-making post-RP.
Badani, Ketan; Thompson, Darby J. S.; Buerki, Christine; Davicioni, Elai; Garrison, Jill; Ghadessi, Mercedeh; Mitra, Anirban P.; Wood, Penelope J.; Hornberger, John
Gly82Ser polymorphism of the receptor for advanced glycation end-product (RAGE) potential high risk in patients with colorectal cancer.
The receptor for advanced glycation end products (RAGE) has previously been suggested to stimulate the growth, survival, and metastatic spread of colorectal cancers (CRC). The genetic variant Gly82Ser of RAGE influences its function and is associated with an increased risk of gastric cancer and multiple sclerosis. To investigate the association between the Gly82Ser polymorphisms of RAGE and the risk of CRC, 90 CRC patients and 78 control subjects with benign polyps were genotyped and the results were analyzed using the SPSS statistical software.In comparing with the control group, the CRC group has a higher ratio in the Gly82Ser polymorphism. The odds ratio (OR) for heterozygous GS is 2.037 (95Ā% CI 1.207-3.438); the OR for carriers with the S allele (SS) is 3.32 (95Ā% CI 0.94-11.65). Further stratification analysis of the correlation of the Gly82Ser polymorphism with tumor stages and differentiation indicated that CRC patients with TNM (III + IV) and/or patients with poorly differentiated colorectal cancer have an elevated Gly82Ser polymorphism. The OR for TNM (III + IV) is 3.575, 95Ā% CI 1.495-8.550, and the OR for poorly differentiated is 3.580, 95Ā% CI 1.390-9.217. In conclusion, the RAGE gene Gly82Ser polymorphism may confer not only an increased risk of CRC but also an increased invasion of CRC in the Chinese population. PMID:24248547
Qian, Fei; Sun, Bao-Lan; Zhang, Wen-Yi; Ke, Jing; Zhu, Jianwei
Cancer Risk in Nontransplanted and Transplanted Cystic Fibrosis Patients: A 10Year Study
Background: Cancer in patients with cystic fibrosis (CF), the most common genetic disorder in Caucasians, has been a rare event. However, more patients now reach adulthood, and more patients undergo organ transplantationŚfactors associated with an increased cancer risk. Our aim was to assess the risk of cancer in nontransplanted and trans- planted CF patients. Methods: We followed 28 858 patients
Patrick Maisonneuve; Stacey C. FitzSimmons; Joseph P. Neglia; Preston W. Campbell; Albert B. Lowenfels
Acquired risk factors of venous thromboembolism in medical patients.
Acute venous thromboembolism (VTE) is a serious and potentially fatal disorder, which often complicates the course of hospitalized patients, but may also affect ambulatory and otherwise healthy people. While the introduction of thromboprophylactic measures has most likely affected the present occurrence of postoperative VTE, there is an increasing awareness of the importance of medical conditions in determining thromboembolic events. Among the conditions that predispose patients to VTE are increasing age, cancer and its treatment, prolonged immobility, stroke or paralysis, previous VTE, congestive heart failure,acute infection, pregnancy or puerperium, dehydration, hormonal treatment, varicose veins, long air travel, acute inflammatory bowel disease, rheumatologic disease, and nephrotic syndrome. Other factors that have recently been associated with an increased risk of VTE disorders include persistent elevation of D-dimer and atherosclerotic disease. Recognition of the incidence and clinical importance of thrombosis will most likely encourage more widespread use of antithrombotic prophylaxis in medical patients. PMID:16855357
Prandoni, Paolo
Risk of glaucoma among patients with benign essential blepharospasm
Purpose Debate exists whether intraocular pressure (IOP) fluctuation is a risk factor for glaucoma. Patients with benign essential blepharospasm (BEB) experience intermittent, ultra-short term IOP elevations from frequent blinking and spastic eyelid closure. This paper explores the development of incident glaucoma after BEB diagnosis. Methods Medicare claims files were used to identify patients with a diagnosis of BEB from 1994¢2000. An equal size control group without BEB was created using one-to-one propensity score matching. BEB patients and controls were followed for the development of one of the following main outcome measures: primary open angle glaucoma (POAG), closed angle glaucoma (CAG), or other glaucoma (besides POAG and CAG) over the following 2,190 days. Results There were 1350 persons in each group, consisting of 29% men, 94% of whom were white, with a mean age of 76 years. In the unadjusted model, BEB patients did not develop POAG (HR:1.159; 95% CI:0.876,1.534), CAG (HR:1.477; 95% CI:0.711,3.066), or other glaucoma (HR:1.306; 95% CI: 0.904,1.886) more often than controls. Adjusting for age, gender, race, number of visits to the ophthalmologist and other eye disease, a diagnosis of BEB did not affect the risk of POAG (HR:1.152; 95% CI:0.870,1.525), CAG (HR:1.448; 95% CI:0.696,3.015), or other glaucoma (HR:1.296; 95% CI:0.896,1.873). Conclusions Benign essential blepharospasm is not a risk indicator for POAG, CAG, or other forms of glaucoma.
Lee, Michael S; Harrison, Andrew R; Grossman, Daniel S; Sloan, Frank A
Cancer incidence risks to patients due to hysterosalpingography
Cancer incidence estimates and dosimetry of 120 patients undergoing hysterosalpingography (HSG) without screening at five rural hospitals and with screening using image intensifier-TV at an urban hospital have been studied. Free in air kerma measurements were taken for patient dosimetry. Using PCXMC version 1.5, organ and effective doses to patients were estimated. Incidence of cancer of the ovary, colon, bladder and uterus due to radiation exposure were estimated using biological effects of ionising radiation committee VII excess relative risk models. The effective dose to patients was estimated to be 0.20 ▒ 0.03 mSv and 0.06 ▒ 0.01 mSv for procedures with and without screening, respectively. The average number of exposures for both procedures, 2.5, and screening time of 48.1 s were recorded. Screening time contributed majority of the patient doses due to HSG; therefore, it should be optimised as much as possible. Of all the cancers considered, the incidence of cancer of the bladder for patients undergoing HSG procedures is more probable.
Gyekye, Prince K.; Emi-Reynolds, Geoffrey; Boadu, Mary; Darko, Emmanuel O.; Yeboah, Johnson; Inkoom, Stephen; Mensah, Cynthia K.
Thyroid Cancer Risk Is Not Increased in Diabetic Patients
Objective This study evaluated thyroid cancer risk with regards to diabetes status and diabetes duration, and with the use of anti-diabetic drugs including sulfonylurea, metformin, insulin, acarbose, pioglitazone and rosiglitazone, by using a population-based reimbursement database in Taiwan. Methods A random sample of 1,000,000 subjects covered by the National Health Insurance was recruited. After excluding patients with type 1 diabetes, 999730 subjects (495673 men and 504057 women) were recruited into the analyses. Logistic regression estimated the odds ratios (OR) and their 95% confidence intervals (CI) for independent variables including age, sex, diabetes status/duration, anti-diabetic drugs, other medications, comorbidities, living regions, occupation and examinations that might potentially lead to the diagnosis of thyroid cancer in various models. Results The diabetic patients had a significantly higher probability of receiving potential detection examinations (6.38% vs. 5.83%, P<0.0001). After multivariable-adjustment, the OR (95% CI) for diabetes status was 0.816 (0.652¢1.021); and for diabetes duration <1 year, 1¢3 years, 3¢5 years and ?5 years vs. non-diabetes was 0.071 (0.010¢0.507), 0.450 (0.250¢0.813), 0.374 (0.203¢0.689) and 1.159 (0.914¢1.470), respectively. Among the anti-diabetic agents, only sulfonylurea was significantly associated with thyroid cancer, OR (95% CI): 1.882 (1.202¢2.947). The OR (95% CI) for insulin, metformin, acarbose, pioglitazone and rosiglitazone was 1.701 (0.860¢3.364), 0.696 (0.419¢1.155), 0.581 (0.202¢1.674), 0.522 (0.069¢3.926) and 0.669 (0.230¢1.948), respectively. Furthermore, patients with benign thyroid disease or other cancer, living in Kao-Ping/Eastern regions, or receiving potential detection examinations might have a significantly higher risk; and male sex, hypertension, dyslipidemia, chronic obstructive pulmonary disease, vascular complications or use of statin, aspirin or non-steroidal anti-inflammatory drugs might be associated with a significantly lower risk. Conclusions There is a lack of an overall association between diabetes and thyroid cancer, but patients with diabetes duration <5 years have a significantly lower risk. Sulfonylurea may increase the risk of thyroid cancer.
Tseng, Chin-Hsiao
Risks of myeloid malignancies in patients with autoimmune conditions
Autoimmune conditions are associated with an elevated risk of lymphoproliferative malignancies, but few studies have investigated the risk of myeloid malignancies. From the US Surveillance Epidemiology and End Results (SEER)-Medicare database, 13?486 myeloid malignancy patients (aged 67+ years) and 160?086 population-based controls were selected. Logistic regression models adjusted for gender, age, race, calendar year and number of physician claims were used to estimate odds ratios (ORs) for myeloid malignancies in relation to autoimmune conditions. Multiple comparisons were controlled for using the Bonferroni correction (P<0.0005). Autoimmune conditions, overall, were associated with an increased risk of acute myeloid leukaemia (AML) (OR 1.29) and myelodysplastic syndrome (MDS, OR 1.50). Specifically, AML was associated with rheumatoid arthritis (OR 1.28), systemic lupus erythematosus (OR 1.92), polymyalgia rheumatica (OR 1.73), autoimmune haemolytic anaemia (OR 3.74), systemic vasculitis (OR 6.23), ulcerative colitis (OR 1.72) and pernicious anaemia (OR 1.57). Myelodysplastic syndrome was associated with rheumatoid arthritis (OR1.52) and pernicious anaemia (OR 2.38). Overall, autoimmune conditions were not associated with chronic myeloid leukaemia (OR 1.09) or chronic myeloproliferative disorders (OR 1.15). Medications used to treat autoimmune conditions, shared genetic predisposition and/or direct infiltration of bone marrow by autoimmune conditions, could explain these excess risks of myeloid malignancies.
Anderson, L A; Pfeiffer, R M; Landgren, O; Gadalla, S; Berndt, S I; Engels, E A
Ovarian stimulation in patients in risk of OHSS.
Ovarian hyperstimulation syndrome (OHSS) represents an exaggerated response to controlled ovarian stimulation (COS) that in some cases could be life-threatening. Assuming that complete prevention of OHSS is not possible, several strategies could be carried out to reduce the risk and early identification of risk factors represents the first step of a multi-stage process. Some well-established risk factors that could rise the risk of OHSS include young age, polycystic ovary syndrome, prior hyper-response/OHSS. In recent years research has focus on identifying biomarkers/hormonal markers that could represent potential predictors of OHSS (anti-Mullerian hormone and antral follicle count). The possible prevention strategies available for the clinician could be divided into primary and secondary. Primary prevention includes personalized stimulation protocols in order to suit patients' characteristics (individually tailored COS, use of GnRH antagonist stimulation protocols, in vitro maturation). Secondary prevention includes all strategies directed to counteract an excessive ovarian response (cycle cancellation, coasting, trigger ovulation by low doses of hCG or by alternative agents, cryopreservation of oocytes/embryos, adequate luteal phase support). So far, the combined use of a GnRH antagonist protocol with GnRH agonist triggering and oocyte and embryo freezing could not be recommended as a standard preventive measure, but it surely represents a promising one. PMID:24848075
Soave, I; Marci, R
Uric Acid: A Novel Risk Factor for Acute Kidney Injury in High-Risk Cardiac Surgery Patients?
Background: Uric acid has been reported to be a risk factor for the development of chronic kidney disease; however, no study has examined whether uric acid may confer a risk for acute kidney injury. Methods: We investigated the relation between serum uric acid and the incidence of postoperative acute kidney injury in patients undergoing high-risk cardiovascular surgery (cardiac valve and
A. Ahsan Ejaz; Thomas M. Beaver; Michiko Shimada; Puneet Sood; Vijaykumar Lingegowda; Jesse D. Schold; Tad Kim; Richard J. Johnson
Risk Factors of Lymph Edema in Breast Cancer Patients
Background. Lymphedema secondary to breast cancer treatment is a common and serious problem for disease survivors. The objective of the current study was to identify the risk factors of secondary lymphedema after breast carcinoma treatment. Materials & Methods. The breast cancer patients who were followed up in three centers in Tehran and Mashhad in 2010 were recruited in the study. The circumference measurement was used for defining lymphedema. Results. Among 410 breast cancer patients, 123 cases (30%) developed lymphedema. Variables such as low educational level, body mass index (BMI), higher stage of disease, number of involved lymph nodes, comorbid diseases, trauma, infection, and the time after surgery showed significant correlation with the development of lymphedema. In logistic regression analysis, increase of 1?kg/m2 in BMI (OR?=?1.09; 95%??CI 1.05¢1.15), each number increase in lymph node involvement (OR?=?1.15; 95%??CI 1.08¢1.21) and the increase of every 1 month after surgery (OR?=?1.01; 95%??CI 1.01¢1.02) significantly increased the risk of lymphedema. Conclusion. The results of this study demonstrated that preserving a fitted BMI, emphasis on self-care, and educating preventive activities may have important roles in decreasing the lymphedema incidence and improving the patients' quality of life.
Shahpar, Haghighat; Atieh, Akbari; Maryam, Ansari; Fatemeh, Homaei Shandiz; Massoome, Najafi; Mandana, Ebrahimi; Masud, Yunesian; Hamid Reza, Mirzaei; Mohammad Esmaeil, Akbari