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Sample records for risk stratification strategy

  1. Risk stratification in emergency patients by copeptin

    DEFF Research Database (Denmark)

    Iversen, Kasper; Gøtze, Jens P; Dalsgaard, Morten

    2014-01-01

    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 pre...

  2. Syncope: risk stratification and clinical decision making.

    Science.gov (United States)

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

    2014-04-01

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

  3. Ventricular repolarization measures for arrhythmic risk stratification

    Institute of Scientific and Technical Information of China (English)

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

    2016-01-01

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

  4. Risk stratification in secondary cardiovascular prevention.

    Science.gov (United States)

    Lazzeroni, Davide; Coruzzi, Paolo

    2018-02-19

    Worldwide, more than 7 million people experience acute myocardial infarction (AMI) every year (1), and although substantial reduction in mortality has been obtained in recent decades, one-year mortality rates are still in the range of 10%. Among patients who survive AMI, 20% suffer a second cardiovascular event in the first year and approximately 50% of major coronary events occur in those with a previous hospital discharge diagnosis of AMI (2). Despite the evidence that lifestyle changes and risk factors management strongly improve long-term prognosis, preventive care post-AMI remains sub-optimal. Cross-sectional data from the serially conducted EUROASPIRE surveys in patients with established ischemic heart disease (IHD) and people at high cardiovascular risk have demonstrated a high prevalence of unhealthy lifestyle, modifiable risk factors and inadequate use of drug therapies to achieve blood pressure and lipid goals (3). Secondary prevention programmes, defined as the level of preventive care focusing on early risk stratification, are highly recommended in all IHD patients, to restore quality of life, maintain or improve functional capacity and prevent recurrence.

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

    Science.gov (United States)

    Huang, Zhengxing; Dong, Wei; Duan, Huilong

    2015-12-01

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

  6. The prostate cancer risk stratification (ProCaRS) project: Recursive partitioning risk stratification analysis

    International Nuclear Information System (INIS)

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

    2013-01-01

    Background: The Genitourinary Radiation Oncologists of Canada (GUROC) published a three-group risk stratification (RS) system to assist prostate cancer decision-making in 2001. The objective of this project is to use the ProCaRS database to statistically model the predictive accuracy and clinical utility of a proposed new multi-group RS schema. Methods: The RS analyses utilized the ProCaRS database that consists of 7974 patients from four Canadian institutions. Recursive partitioning analysis (RPA) was utilized to explore the sub-stratification of groups defined by the existing three-group GUROC scheme. 10-fold cross-validated C-indices and the Net Reclassification Index were both used to assess multivariable models and compare the predictive accuracy of existing and proposed RS systems, respectively. Results: The recursive partitioning analysis has suggested that the existing GUROC classification system could be altered to accommodate as many as six separate and statistical unique groups based on differences in BFFS (C-index 0.67 and AUC 0.70). GUROC low-risk patients would be divided into new favorable-low and low-risk groups based on PSA ⩽6 and PSA >6. GUROC intermediate-risk patients can be subclassified into low-intermediate and high-intermediate groups. GUROC high-intermediate-risk is defined as existing GUROC intermediate-risk with PSA >=10 AND either T2b/c disease or T1T2a disease with Gleason 7. GUROC high-risk patients would be subclassified into an additional extreme-risk group (GUROC high-risk AND (positive cores ⩾87.5% OR PSA >30). Conclusions: Proposed RS subcategories have been identified by a RPA of the ProCaRS database

  7. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification

    DEFF Research Database (Denmark)

    Nicolaides, Andrew N; Kakkos, Stavros K; Kyriacou, Efthyvoulos

    2010-01-01

    The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis.......The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis....

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

    NARCIS (Netherlands)

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

    2016-01-01

    Objectives: Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies

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

    NARCIS (Netherlands)

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

    2016-01-01

    OBJECTIVES: Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies

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

    Directory of Open Access Journals (Sweden)

    Gal Omry-Orbach

    2016-01-01

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

  11. Quantitative risk stratification in Markov chains with limiting conditional distributions.

    Science.gov (United States)

    Chan, David C; Pollett, Philip K; Weinstein, Milton C

    2009-01-01

    Many clinical decisions require patient risk stratification. The authors introduce the concept of limiting conditional distributions, which describe the equilibrium proportion of surviving patients occupying each disease state in a Markov chain with death. Such distributions can quantitatively describe risk stratification. The authors first establish conditions for the existence of a positive limiting conditional distribution in a general Markov chain and describe a framework for risk stratification using the limiting conditional distribution. They then apply their framework to a clinical example of a treatment indicated for high-risk patients, first to infer the risk of patients selected for treatment in clinical trials and then to predict the outcomes of expanding treatment to other populations of risk. For the general chain, a positive limiting conditional distribution exists only if patients in the earliest state have the lowest combined risk of progression or death. The authors show that in their general framework, outcomes and population risk are interchangeable. For the clinical example, they estimate that previous clinical trials have selected the upper quintile of patient risk for this treatment, but they also show that expanded treatment would weakly dominate this degree of targeted treatment, and universal treatment may be cost-effective. Limiting conditional distributions exist in most Markov models of progressive diseases and are well suited to represent risk stratification quantitatively. This framework can characterize patient risk in clinical trials and predict outcomes for other populations of risk.

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

    Directory of Open Access Journals (Sweden)

    David Corcoran

    2015-09-01

    Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom, in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment.

  13. Degree of Agreement between Cardiovascular Risk Stratification Tools.

    Science.gov (United States)

    Garcia, Guilherme Thomé; Stamm, Ana Maria Nunes de Faria; Rosa, Ariel Córdova; Marasciulo, Antônio Carlos; Marasciulo, Rodrigo Conill; Battistella, Cristian; Remor, Alexandre Augusto de Costa

    2017-05-01

    Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in Brazil, and primary prevention care may be guided by risk stratification tools. The Framingham (FRS) and QRISK-2 (QRS) risk scores estimate 10-year overall cardiovascular risk in asymptomatic individuals, but the instrument of choice may lead to different therapeutic strategies. To evaluate the degree of agreement between FRS and QRS in 10-year overall cardiovascular risk stratification in disease-free individuals. Cross-sectional, observational, descriptive and analytical study in a convenience sample of 74 individuals attending the outpatient care service of a university hospital in Brazil between January 2014 and January 2015. After application of FRS and QRS, patients were classified in low/moderate risk (Brasil, e a prevenção primária pode ser direcionada com ferramentas que estratificam o risco. Os escores de Framingham (ERF) e QRISK-2 (ERQ) estimam o risco cardiovascular (RCV) global em 10 anos em indivíduos assintomáticos, mas a escolha do instrumento pode implicar em terapêuticas distintas. Observar o grau de concordância entre o ERF e o ERQ, na estratificação do risco cardiovascular global em 10 anos, nos indivíduos livres da doença. Estudo transversal, observacional, descritivo e analítico, com uma amostra de conveniência de 74 indivíduos, atendidos em um ambulatório de ensino de um hospital universitário brasileiro, no sul do país, de janeiro de 2014 a janeiro de 2015. O ERF e o ERQ foram aplicados nos pacientes, que foram classificados em baixo/moderado (superior no ERF que no ERQ (33,7% vs 21,6%), sendo identificado efeito sinérgico do gênero masculino com hipertensão arterial sistêmica nas duas ferramentas, e com faixa etária geriátrica no ERQ (p < 0,05) nesse estrato de risco. O índice de concordância Kappa entre os dois escores foi igual a 0,519 (IC95% = 0,386-0,652; p < 0,001). Houve concordância moderada entre o ERF e o ERQ, na estimativa de

  14. Clinical Studies in Risk Stratification & Therapy of Thoracic Aortic Disease

    NARCIS (Netherlands)

    Kamman, AV

    2017-01-01

    For this thesis we aimed to summarize outcomes and optimal treatment modality for thoracic aortic disease, discuss new imaging techniques and improve the use of current imaging modalities. Furthermore, we aimed to improve risk stratification for uncomplicated type B aortic dissection (TBAD) and

  15. Improving risk stratification for cardiovascular disease

    NARCIS (Netherlands)

    van Wijk, Diederik F.; Boekholdt, S. Matthijs

    2010-01-01

    Evaluation of: Heslop CL, Frohlich JJ, Hill JS. Myeloperoxidase and C-reactive protein have combined utility for long-term prediction of cardiovascular mortality after coronary angiography. J. Am. Coll. Cardiol. 55(11), 1102-1109 (2010). Identifying people at high risk of cardiovascular events is

  16. Prehypertension: risk stratification and management considerations.

    Science.gov (United States)

    Egan, Brent M; Julius, Stevo

    2008-10-01

    Approximately 37% of US adults are prehypertensive; about 31 million have blood pressures in the range of 130-139/85-89 mm Hg. These stage 2 prehypertensives have threefold greater risk for developing hypertension and twofold higher risk for cardiovascular events than normotensives. Lifestyle changes only are recommended for most prehypertensives, but evidence for community-wide effectiveness is limited. Projected numbers needed to treat to prevent a cardiovascular event are similar for stage 2 prehypertension and stage 1 hypertension when both groups are matched for concomitant risk factors. However, no clinical trials document that pharmacotherapy reduces cardiovascular events in stage 2 prehypertension. The Trial of Preventing Hypertension demonstrated that angiotensin receptor blockade safely lowers blood pressure and prevents or delays progression to hypertension in stage 2 prehypertensives. We believe it is reasonable for clinicians to identify stage 2 prehypertensives at high absolute risk for progression to hypertension and cardiovascular events, and to treat them with a renin-angiotensin system blocker when lifestyle changes alone are ineffective.

  17. Rationale and design of three observational, prospective cohort studies including biobanking to evaluate and improve diagnostics, management strategies and risk stratification in venous thromboembolism: the VTEval Project.

    Science.gov (United States)

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

    2015-07-01

    Venous thromboembolism (VTE) with its two manifestations deep vein thrombosis (DVT) and pulmonary embolism (PE) is a major public health problem. The VTEval Project aims to investigate numerous research questions on diagnosis, clinical management, treatment and prognosis of VTE, which have remained uncertain to date. The VTEval Project consists of three observational, prospective cohort studies on VTE comprising cohorts of individuals with a clinical suspicion of acute PE (with or without DVT), with a clinical suspicion of acute DVT (without symptomatic PE) and with an incidental diagnosis of VTE (PE or DVT). The VTEval Project expects to enrol a total of approximately 2000 individuals with subsequent active and passive follow-up investigations over a time period of 5 years per participant. Time points for active follow-up investigations are at months 3, 6, 12, 24 and 36 after diagnosis (depending on the disease cohort); passive follow-up investigations via registry offices and the cancer registry are performed 48 and 60 months after diagnosis for all participants. Primary short-term outcome is defined by overall mortality (PE-related death and all other causes of death), primary long-term outcome by symptomatic VTE (PE-related death, recurrence of non-fatal PE or DVT). The VTEval Project includes three 'all-comer' studies and involves the standardised acquisition of high-quality data, covering the systematic assessment of VTE including symptoms, risk profile, psychosocial, environmental and lifestyle factors as well as clinical and subclinical disease, and it builds up a large state-of-the-art biorepository containing various materials from serial blood samplings. The VTEval Project has been approved by the local data safety commissioner and the responsible ethics committee (reference no. 837.320.12 (8421-F)). Trial results will be published in peer-reviewed journals and presented at national and international scientific meetings. NCT02156401. Published by the

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

    Directory of Open Access Journals (Sweden)

    Benjamin Z Galper

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

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

    Science.gov (United States)

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

    2015-01-01

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

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

    Science.gov (United States)

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

    2016-01-01

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

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

    Science.gov (United States)

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

    2016-04-15

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

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

    Directory of Open Access Journals (Sweden)

    Marjon Kerkhof

    2007-01-01

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

  3. An Interoperable System toward Cardiac Risk Stratification from ECG Monitoring

    Directory of Open Access Journals (Sweden)

    Cristina Soguero-Ruiz

    2018-03-01

    Full Text Available Many indices have been proposed for cardiovascular risk stratification from electrocardiogram signal processing, still with limited use in clinical practice. We created a system integrating the clinical definition of cardiac risk subdomains from ECGs and the use of diverse signal processing techniques. Three subdomains were defined from the joint analysis of the technical and clinical viewpoints. One subdomain was devoted to demographic and clinical data. The other two subdomains were intended to obtain widely defined risk indices from ECG monitoring: a simple-domain (heart rate turbulence (HRT, and a complex-domain (heart rate variability (HRV. Data provided by the three subdomains allowed for the generation of alerts with different intensity and nature, as well as for the grouping and scrutinization of patients according to the established processing and risk-thresholding criteria. The implemented system was tested by connecting data from real-world in-hospital electronic health records and ECG monitoring by considering standards for syntactic (HL7 messages and semantic interoperability (archetypes based on CEN/ISO EN13606 and SNOMED-CT. The system was able to provide risk indices and to generate alerts in the health records to support decision-making. Overall, the system allows for the agile interaction of research and clinical practice in the Holter-ECG-based cardiac risk domain.

  4. An Interoperable System toward Cardiac Risk Stratification from ECG Monitoring

    Science.gov (United States)

    Mora-Jiménez, Inmaculada; Ramos-López, Javier; Quintanilla Fernández, Teresa; García-García, Antonio; Díez-Mazuela, Daniel; García-Alberola, Arcadi

    2018-01-01

    Many indices have been proposed for cardiovascular risk stratification from electrocardiogram signal processing, still with limited use in clinical practice. We created a system integrating the clinical definition of cardiac risk subdomains from ECGs and the use of diverse signal processing techniques. Three subdomains were defined from the joint analysis of the technical and clinical viewpoints. One subdomain was devoted to demographic and clinical data. The other two subdomains were intended to obtain widely defined risk indices from ECG monitoring: a simple-domain (heart rate turbulence (HRT)), and a complex-domain (heart rate variability (HRV)). Data provided by the three subdomains allowed for the generation of alerts with different intensity and nature, as well as for the grouping and scrutinization of patients according to the established processing and risk-thresholding criteria. The implemented system was tested by connecting data from real-world in-hospital electronic health records and ECG monitoring by considering standards for syntactic (HL7 messages) and semantic interoperability (archetypes based on CEN/ISO EN13606 and SNOMED-CT). The system was able to provide risk indices and to generate alerts in the health records to support decision-making. Overall, the system allows for the agile interaction of research and clinical practice in the Holter-ECG-based cardiac risk domain. PMID:29494497

  5. Novel biomarkers for risk stratification in pulmonary arterial hypertension

    Directory of Open Access Journals (Sweden)

    Thomas Zelniker

    2015-10-01

    Full Text Available Risk stratification in pulmonary arterial hypertension (PAH is paramount to identifying individuals at highest risk of death. So far, there are only limited parameters for prognostication in patients with PAH. 95 patients with confirmed PAH were included in the present analysis and followed for a total of 4 years. Blood samples were analysed for serum levels of N-terminal pro-brain natriuretic peptide, high-sensitivity troponin T (hsTnT, pro-atrial natriuretic peptide (proANP, growth differentiation factor 15, soluble fms-like tyrosine kinase 1 and placental growth factor. 27 (28.4% patients died during a follow-up of 4 years. Levels of all tested biomarkers, except for placental growth factor, were significantly elevated in nonsurvivors compared with survivors. Receiver operating characteristic analyses demonstrated that cardiac biomarkers had the highest power in predicting mortality. In particular, proANP exhibited the highest area under the curve, followed by N-terminal pro-brain natriuretic peptide and hsTnT. Furthermore, proANP and hsTnT added significant additive prognostic value to the established markers in categorical and continuous net reclassification index. Moreover, after Cox regression, proANP (hazard ratio (HR 1.91, hsTnT (HR 1.41, echocardiographic right ventricular impairment (HR 1.30 and 6-min walk test (HR 0.97 per 10 m remained the only significant parameters in prognostication of mortality. Our data suggest benefits of the implementation of proANP and hsTnT as additive biomarkers for risk stratification in patients with PAH.

  6. Perceptions of Risk Stratification Workflows in Primary Care

    Directory of Open Access Journals (Sweden)

    Rachel L. Ross

    2017-10-01

    Full Text Available Risk stratification (RS in primary care is frequently used by policy-makers, payers, and health systems; the process requires risk assessment for adverse health outcomes across a population to assign patients into risk tiers and allow care management (CM resources to be targeted effectively. Our objective was to understand the approach to and perception of RS in primary care practices. An online survey was developed, tested, and administered to 148 representatives of 37 primary care practices engaged in RS varying in size, location and ownership. The survey assessed practices’ approach to, perception of, and confidence in RS, and its effect on subsequent CM activities. We examined psychometric properties of the survey to determine validity and conducted chi-square analyses to determine the association between practice characteristics and confidence and agreement with risk scores. The survey yielded a 68% response rate (100 respondents. Overall, participants felt moderately confident in their risk scores (range 41–53.8%, and moderately to highly confident in their subsequent CM workflows (range 46–68%. Respondents from small and independent practices were more likely to have higher confidence and agreement with their RS approaches and scores (p < 0.01. Confidence levels were highest, however, when practices incorporated human review into their RS processes (p < 0.05. This trend was not affected by respondents’ professional roles. Additional work from a broad mixed-methods effort will add to our understanding of RS implementation processes and outcomes.

  7. Pre-treatment risk stratification of prostate cancer patients: A critical review.

    Science.gov (United States)

    Rodrigues, George; Warde, Padraig; Pickles, Tom; Crook, Juanita; Brundage, Michael; Souhami, Luis; Lukka, Himu

    2012-04-01

    The use of accepted prostate cancer risk stratification groups based on prostate-specific antigen, T stage and Gleason score assists in therapeutic treatment decision-making, clinical trial design and outcome reporting. The utility of integrating novel prognostic factors into an updated risk stratification schema is an area of current debate. The purpose of this work is to critically review the available literature on novel pre-treatment prognostic factors and alternative prostate cancer risk stratification schema to assess the feasibility and need for changes to existing risk stratification systems. A systematic literature search was conducted to identify original research publications and review articles on prognostic factors and risk stratification in prostate cancer. Search terms included risk stratification, risk assessment, prostate cancer or neoplasms, and prognostic factors. Abstracted information was assessed to draw conclusions regarding the potential utility of changes to existing risk stratification schema. The critical review identified three specific clinically relevant potential changes to the most commonly used three-group risk stratification system: (1) the creation of a very-low risk category; (2) the splitting of intermediate-risk into a low- and high-intermediate risk groups; and (3) the clarification of the interface between intermediate- and high-risk disease. Novel pathological factors regarding high-grade cancer, subtypes of Gleason score 7 and percentage biopsy cores positive were also identified as potentially important risk-stratification factors. Multiple studies of prognostic factors have been performed to create currently utilized prostate cancer risk stratification systems. We propose potential changes to existing systems.

  8. Clinical outcome and risk stratification in Brugada syndrome

    Directory of Open Access Journals (Sweden)

    Tadashi Wada, MD

    2013-04-01

    Full Text Available Since the first report on Brugada syndrome, various risk markers for the prediction of ventricular fibrillation (VF in patients with Brugada syndrome have been reported. Multicenter trials reported spontaneous type 1 electrocardiogram (ECG and disease symptoms as prognostic predictors. VF induction by programmed electrical stimulation is still controversial, and most of the studies have failed to prove its significance for the prediction of spontaneous VF episodes. In Japan, although most multicenter studies have shown that patients with type 1 ECG were at high risk, it is difficult to determine the indication for implantation of an implantable cardioverter defibrillator only based on the ECG type. Recent studies have added new risk markers, such as inferolateral early repolarization, fragmented QRS, and shorter effective refractory periods of the ventricle, in addition to type 1 ECG and symptoms. Here, we review the clinical outcome and indices reported as reliable prognostic factors of Brugada syndrome with a focus on the clinical and ECG markers for risk stratification.

  9. Advanced colorectal neoplasia risk stratification by penalized logistic regression.

    Science.gov (United States)

    Lin, Yunzhi; Yu, Menggang; Wang, Sijian; Chappell, Richard; Imperiale, Thomas F

    2016-08-01

    Colorectal cancer is the second leading cause of death from cancer in the United States. To facilitate the efficiency of colorectal cancer screening, there is a need to stratify risk for colorectal cancer among the 90% of US residents who are considered "average risk." In this article, we investigate such risk stratification rules for advanced colorectal neoplasia (colorectal cancer and advanced, precancerous polyps). We use a recently completed large cohort study of subjects who underwent a first screening colonoscopy. Logistic regression models have been used in the literature to estimate the risk of advanced colorectal neoplasia based on quantifiable risk factors. However, logistic regression may be prone to overfitting and instability in variable selection. Since most of the risk factors in our study have several categories, it was tempting to collapse these categories into fewer risk groups. We propose a penalized logistic regression method that automatically and simultaneously selects variables, groups categories, and estimates their coefficients by penalizing the [Formula: see text]-norm of both the coefficients and their differences. Hence, it encourages sparsity in the categories, i.e. grouping of the categories, and sparsity in the variables, i.e. variable selection. We apply the penalized logistic regression method to our data. The important variables are selected, with close categories simultaneously grouped, by penalized regression models with and without the interactions terms. The models are validated with 10-fold cross-validation. The receiver operating characteristic curves of the penalized regression models dominate the receiver operating characteristic curve of naive logistic regressions, indicating a superior discriminative performance. © The Author(s) 2013.

  10. Lifetime risks for aneurysmal subarachnoid haemorrhage: multivariable risk stratification.

    Science.gov (United States)

    Vlak, Monique H M; Rinkel, Gabriel J E; Greebe, Paut; Greving, Jacoba P; Algra, Ale

    2013-06-01

    The overall incidence of aneurysmal subarachnoid haemorrhage (aSAH) in western populations is around 9 per 100 000 person-years, which confers to a lifetime risk of around half per cent. Risk factors for aSAH are usually expressed as relative risks and suggest that absolute risks vary considerably according to risk factor profiles, but such estimates are lacking. We aimed to estimate incidence and lifetime risks of aSAH according to risk factor profiles. We used data from 250 patients admitted with aSAH and 574 sex-matched and age-matched controls, who were randomly retrieved from general practitioners files. We determined independent prognostic factors with multivariable logistic regression analyses and assessed discriminatory performance using the area under the receiver operating characteristic curve. Based on the prognostic model we predicted incidences and lifetime risks of aSAH for different risk factor profiles. The four strongest independent predictors for aSAH, namely current smoking (OR 6.0; 95% CI 4.1 to 8.6), a positive family history for aSAH (4.0; 95% CI 2.3 to 7.0), hypertension (2.4; 95% CI 1.5 to 3.8) and hypercholesterolaemia (0.2; 95% CI 0.1 to 0.4), were used in the final prediction model. This model had an area under the receiver operating characteristic curve of 0.73 (95% CI 0.69 to 0.76). Depending on sex, age and the four predictors, the incidence of aSAH ranged from 0.4/100 000 to 298/100 000 person-years and lifetime risk between 0.02% and 7.2%. The incidence and lifetime risk of aSAH in the general population varies widely according to risk factor profiles. Whether persons with high risks benefit from screening should be assessed in cost-effectiveness studies.

  11. Hepatitis B virus reactivation during immunosuppressive therapy: Appropriate risk stratification.

    Science.gov (United States)

    Seto, Wai-Kay

    2015-04-28

    Our understanding of hepatitis B virus (HBV) reactivation during immunosuppresive therapy has increased remarkably during recent years. HBV reactivation in hepatitis B surface antigen (HBsAg)-positive individuals has been well-described in certain immunosuppressive regimens, including therapies containing corticosteroids, anthracyclines, rituximab, antibody to tumor necrosis factor (anti-TNF) and hematopoietic stem cell transplantation (HSCT). HBV reactivation could also occur in HBsAg-negative, antibody to hepatitis B core antigen (anti-HBc) positive individuals during therapies containing rituximab, anti-TNF or HSCT.For HBsAg-positive patients, prophylactic antiviral therapy is proven to the effective in preventing HBV reactivation. Recent evidence also demonstrated entecavir to be more effective than lamivudine in this aspect. For HBsAg-negative, anti-HBc positive individuals, the risk of reactivations differs with the type of immunosuppression. For rituximab, a prospective study demonstrated the 2-year cumulative risk of reactivation to be 41.5%, but prospective data is still lacking for other immunosupressive regimes. The optimal management in preventing HBV reactivation would involve appropriate risk stratification for different immunosuppressive regimes in both HBsAg-positive and HBsAg-negative, anti-HBc positive individuals.

  12. What imaging techniques should be used in primary versus secondary prevention for further risk stratification?

    Science.gov (United States)

    Schiele, François; Navarese, Eliano Pio; Visoná, Adriana; Ray, Kausik

    2017-04-01

    An accurate assessment of the cardiovascular (CV) risk of an individual is key for guiding the appropriate treatment strategy for cardiovascular disease (CVD). Although conventional risk factors for CVD are well established, there can be substantial variation in the extent of atherosclerosis between patients. The use of a variety of imaging modalities can be beneficial in the primary prevention stage and in the classification of an individual's CV risk. Therefore, appropriate implementation of these imaging techniques for risk assessment purposes, in line with clinical guidelines, can influence the outcomes of CVD prevention. The expert working group collaborated to review current invasive and non-invasive imaging techniques available to healthcare practitioners and how they can be used in the measurement of preclinical vascular damage and CV risk assessment. After evaluation of the current guideline recommendations and clinical data available, the expert working group collaborated to produce recommendations regarding the use of imaging in the risk stratification in primary prevention, CV risk in peri-acute coronary syndrome and CV risk assessment in secondary prevention. Overall, a variety of both invasive and non-invasive imaging modalities were highlighted by the expert working group as having the potential to assist in the risk assessments of patients at risk of CVD. These imaging techniques can be utilised in both primary and secondary prevention strategies and have the potential to be important risk modifiers, improving the outcome of CV risk assessment. Copyright © 2017 Elsevier B.V. All rights reserved.

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

    Science.gov (United States)

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

    2017-05-01

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

  14. A three-gene expression signature model for risk stratification of patients with neuroblastoma.

    Science.gov (United States)

    Garcia, Idoia; Mayol, Gemma; Ríos, José; Domenech, Gema; Cheung, Nai-Kong V; Oberthuer, André; Fischer, Matthias; Maris, John M; Brodeur, Garrett M; Hero, Barbara; Rodríguez, Eva; Suñol, Mariona; Galvan, Patricia; de Torres, Carmen; Mora, Jaume; Lavarino, Cinzia

    2012-04-01

    Neuroblastoma is an embryonal tumor with contrasting clinical courses. Despite elaborate stratification strategies, precise clinical risk assessment still remains a challenge. The purpose of this study was to develop a PCR-based predictor model to improve clinical risk assessment of patients with neuroblastoma. The model was developed using real-time PCR gene expression data from 96 samples and tested on separate expression data sets obtained from real-time PCR and microarray studies comprising 362 patients. On the basis of our prior study of differentially expressed genes in favorable and unfavorable neuroblastoma subgroups, we identified three genes, CHD5, PAFAH1B1, and NME1, strongly associated with patient outcome. The expression pattern of these genes was used to develop a PCR-based single-score predictor model. The model discriminated patients into two groups with significantly different clinical outcome [set 1: 5-year overall survival (OS): 0.93 ± 0.03 vs. 0.53 ± 0.06, 5-year event-free survival (EFS): 0.85 ± 0.04 vs. 0.042 ± 0.06, both P model was an independent marker for survival (P model robustly classified patients in the total cohort and in different clinically relevant risk subgroups. We propose for the first time in neuroblastoma, a technically simple PCR-based predictor model that could help refine current risk stratification systems. ©2012 AACR.

  15. Noninvasive non Doses Method for Risk Stratification of Breast Diseases

    Directory of Open Access Journals (Sweden)

    I. A. Apollonova

    2014-01-01

    Full Text Available The article concerns a relevant issue that is a development of noninvasive method for screening diagnostics and risk stratification of breast diseases. The developed method and its embodiment use both the analysis of onco-epidemiologic tests and the iridoglyphical research.Widely used onco-epidemiologic tests only reflect the patient’s subjective perception of her own life history and sickness. Therefore to confirm the revealed factors, modern objective and safe methods are necessary.Iridoglyphical research may be considered as one of those methods, since it allows us to reveal changes in iris’ zones in real time. As these zones are functionally linked with intern organs and systems, in this case mammary glands, changes of iris’ zones may be used to assess risk groups for mammary gland disorders.The article presents results of research conducted using a prototype of the hardwaresoftware complex to provide screening diagnostics and risk stratification of mammary gland disorders.Research has been conducted using verified materials, provided by the Biomedical Engineering Faculty and the Scientific Biometry Research and Development Centre of Bauman Moscow State Technical University, the City of Moscow’s GUZ Clinical and Diagnostic Centre N°4 of the Western Administrative District and the First Mammology (Breast Care Centre of the Russian Federation’s Ministry of Health and Social Development.The information, obtained as a result of onco-epidemiological tests and iridoglyphical research, was used to develop a procedure of quantitative diagnostics aimed to assess mammary gland cancer risk groups. The procedure is based on Bayes conditional probability.The task of quantitative diagnostics may be formally divided into the differential assessment of three states. The first, D1, is the norm, which corresponds to the population group with a lack of risk factors or changes of the mammary glands. The second, D2, is the population group

  16. Arrhythmogenic Right Ventricular Cardiomyopathy: Risk Stratification and Indications for Defibrillator Therapy.

    Science.gov (United States)

    Zorzi, Alessandro; Rigato, Ilaria; Bauce, Barbara; Pilichou, Kalliopi; Basso, Cristina; Thiene, Gaetano; Iliceto, Sabino; Corrado, Domenico

    2016-06-01

    Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically determined disease which predisposes to life-threatening ventricular arrhythmias. The main goal of ARVC therapy is prevention of sudden cardiac death (SCD). Implantable cardioverter defibrillator (ICD) is the most effective therapy for interruption of potentially lethal ventricular tachyarrhythmias. Despite its life-saving potential, ICD implantation is associated with a high rate of complications and significant impact on quality of life. Accurate risk stratification is needed to identify individuals who most benefit from the therapy. While there is general agreement that patients with a history of cardiac arrest or hemodynamically unstable ventricular tachycardia are at high risk of SCD and needs an ICD, indications for primary prevention remain a matter of debate. The article reviews the available scientific evidence and guidelines that may help to stratify the arrhythmic risk of ARVC patients and guide ICD implantation. Other therapeutic strategies, either alternative or additional to ICD, will be also addressed.

  17. Strongly enhanced colorectal cancer risk stratification by combining family history and genetic risk score

    Directory of Open Access Journals (Sweden)

    Weigl K

    2018-01-01

    Full Text Available Korbinian Weigl,1,2 Jenny Chang-Claude,3,4 Phillip Knebel,5 Li Hsu,6 Michael Hoffmeister,1 Hermann Brenner1,2,7 1Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ, Heidelberg, 2German Cancer Consortium (DKTK, German Cancer Research Center (DKFZ, Heidelberg, 3Unit of Genetic Epidemiology, German Cancer Research Center (DKFZ, Heidelberg, 4University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, 5Department for General, Visceral and Transplantation Surgery, University Heidelberg, Heidelberg, Germany; 6Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; 7Division of Preventive Oncology, German Cancer Research Center (DKFZ and National Center for Tumor Diseases (NCT, Heidelberg, Germany Background and aim: Family history (FH and genetic risk scores (GRSs are increasingly used for risk stratification for colorectal cancer (CRC screening. However, they were mostly considered alternatively rather than jointly. The aim of this study was to assess the potential of individual and joint risk stratification for CRC by FH and GRS.Patients and methods: A GRS was built based on the number of risk alleles in 53 previously identified single-nucleotide polymorphisms among 2,363 patients with a first diagnosis of CRC and 2,198 controls in DACHS [colorectal cancer: chances for prevention through screening], a population-based case-control study in Germany. Associations between GRS and FH with CRC risk were quantified by multiple logistic regression.Results: A total of 316 cases (13.4% and 214 controls (9.7% had a first-degree relative (FDR with CRC (adjusted odds ratio [aOR] 1.86, 95% CI 1.52–2.29. A GRS in the highest decile was associated with a 3.0-fold increased risk of CRC (aOR 3.00, 95% CI 2.24–4.02 compared with the lowest decile. This association was tentatively more pronounced in older age groups. FH and GRS were essentially unrelated, and their

  18. Peri-procedural risk stratification and management of patients with Williams syndrome.

    Science.gov (United States)

    Collins Ii, R Thomas; Collins, Margaret G; Schmitz, Michael L; Hamrick, Justin T

    2017-03-01

    Williams syndrome (WS) is a congenital, multisystem disorder affecting the cardiovascular, connective tissue, and central nervous systems in 1 in 10 000 live births. Cardiovascular involvement is the most common cause of morbidity and mortality in patients with WS, and noninvasive and invasive procedures are common. Sudden cardiovascular collapse in patients with WS is a well-known phenomenon, especially in the peri-procedural period. Detailed guidelines for peri-procedural management of patients with WS are limited. The goal of this review is to provide thoughtful, safe and effective management strategies for the peri-procedural care of patients with WS with careful consideration of hemodynamic impacts of anesthetic strategies. In addition, an expanded risk stratification system for anesthetic administration is provided. © 2017 Wiley Periodicals, Inc.

  19. Developing a PTEN-ERG Signature to Improve Molecular Risk Stratification in Prostate Cancer

    Science.gov (United States)

    2017-10-01

    AWARD NUMBER: W81XWH-16-1-0737 TITLE: Developing a PTEN-ERG Signature to Improve Molecular Risk Stratification in Prostate Cancer PRINCIPAL...AND SUBTITLE 5a. CONTRACT NUMBER Developing a PTEN-ERG Signature to Improve Molecular Risk Stratification in Prostate Cancer 5b. GRANT NUMBER W81XWH...that there exist distinctive molecular correlates of PTEN loss in the context of ETS-negative versus ETS-positive human prostate cancers and that

  20. Noninvasive risk stratification for sudden death in asymptomatic patients with Wolff-Parkinson-White syndrome.

    Science.gov (United States)

    Novella, John; DeBiasi, Ralph M; Coplan, Neil L; Suri, Ranji; Keller, Seth

    2014-01-01

    Sudden cardiac death (SCD) as the first clinical manifestation of Wolff-Parkinson-White (WPW) syndrome is a well-documented, although rare occurrence. The incidence of SCD in patients with WPW ranges from 0% to 0.39% annually. Controversy exists regarding risk stratification for patients with preexcitation on surface electrocardiogram (ECG), particularly in those who are asymptomatic. This article focuses on the role of risk stratification using exercise and pharmacologic testing in patients with WPW pattern on ECG.

  1. Predictive features of CT for risk stratifications in patients with primary gastrointestinal stromal tumour

    International Nuclear Information System (INIS)

    Zhou, Cuiping; Zhang, Xiang; Duan, Xiaohui; Hu, Huijun; Wang, Dongye; Shen, Jun

    2016-01-01

    To determine the predictive CT imaging features for risk stratifications in patients with primary gastrointestinal stromal tumours (GISTs). One hundred and twenty-nine patients with histologically confirmed primary GISTs (diameter >2 cm) were enrolled. CT imaging features were reviewed. Tumour risk stratifications were determined according to the 2008 NIH criteria where GISTs were classified into four categories according to the tumour size, location, mitosis count, and tumour rupture. The association between risk stratifications and CT features was analyzed using univariate analysis, followed by multinomial logistic regression and receiver operating characteristic (ROC) curve analysis. CT imaging features including tumour margin, size, shape, tumour growth pattern, direct organ invasion, necrosis, enlarged vessels feeding or draining the mass (EVFDM), lymphadenopathy, and contrast enhancement pattern were associated with the risk stratifications, as determined by univariate analysis (P < 0.05). Only lesion size, growth pattern and EVFDM remained independent risk factors in multinomial logistic regression analysis (OR = 3.480-100.384). ROC curve analysis showed that the area under curve of the obtained multinomial logistic regression model was 0.806 (95 % CI: 0.727-0.885). CT features including lesion size, tumour growth pattern, and EVFDM were predictors of the risk stratifications for GIST. (orig.)

  2. Segmented Poincaré plot analysis for risk stratification in patients with dilated cardiomyopathy.

    Science.gov (United States)

    Voss, A; Fischer, C; Schroeder, R; Figulla, H R; Goernig, M

    2010-01-01

    The prognostic value of heart rate variability in patients with dilated cardiomyopathy (DCM) is limited and does not contribute to risk stratification although the dynamics of ventricular repolarization differs considerably between DCM patients and healthy subjects. Neither linear nor nonlinear methods of heart rate variability analysis could discriminate between patients at high and low risk for sudden cardiac death. The aim of this study was to analyze the suitability of the new developed segmented Poincaré plot analysis (SPPA) to enhance risk stratification in DCM. In contrast to the usual applied Poincaré plot analysis the SPPA retains nonlinear features from investigated beat-to-beat interval time series. Main features of SPPA are the rotation of cloud of points and their succeeded variability depended segmentation. Significant row and column probabilities were calculated from the segments and led to discrimination (up to pplot analysis of heart rate variability was able to contribute to risk stratification in patients suffering from DCM.

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

    International Nuclear Information System (INIS)

    Russ, Gilles

    2016-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

    Russ, Gilles [Thyroid and Endocrine Tumor Unit, Department of Nuclear Medicine, La Pitie Salpetriere Hospital, Pierre and Marie Curie University, Paris (Korea, Republic of)

    2016-01-15

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

  5. An ischemia-guided approach for risk stratification in patients with acute coronary syndromes.

    Science.gov (United States)

    Pepine, C J

    2000-12-28

    The optimal management approach for patients with non-ST-segment elevation acute coronary syndromes continues to be an issue of debate. An ischemia-guided strategy appears to be effective as an alternative to either a very conservative "wait-and-see" approach or a very aggressive routine revascularization approach. The need for another approach is supported by the lack of conclusive evidence-based results favoring an early routine invasive treatment strategy. In the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial, there were no differences in the incidence of death or myocardial infarction (MI) between patients treated with an early invasive approach and those treated with a conservative approach to treatment. Significantly worse outcomes were shown in patients assigned to an early invasive strategy in the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial at 1-year follow-up (111 clinical events in the invasive group vs 85 in the conservative group; p = 0.05). Registry information, including that from the Organization to Assess Strategies for Ischemic Syndromes (OASIS), which included approximately 8,000 patients with unstable angina or suspected MI, has even suggested an excess hazard with a routine invasive approach. Patients with non-ST-segment elevation MI observed in the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO)-IIB and Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trials also fared better with an ischemia-guided strategy. Even the recent FRagmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) trial investigators had to be very selective relative to eliminating high-risk patients in the first week and treating with intense anti-ischemic therapy and 5-7 days of low-molecular-weight heparin therapy to show an advantage for assigned revascularization. A careful clinical evaluation with

  6. Three-tiered risk stratification model to predict progression in Barrett's esophagus using epigenetic and clinical features.

    Directory of Open Access Journals (Sweden)

    Fumiaki Sato

    2008-04-01

    Full Text Available Barrett'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 epigenetic and clinical parameters, to improve Barrett's esophagus surveillance efficiency.We defined high-grade dysplasia as endpoint of progression, and Barrett's esophagus progressor patients as Barrett's esophagus patients with either no dysplasia or low-grade dysplasia who later developed high-grade dysplasia or esophageal adenocarcinoma. We analyzed 4 epigenetic and 3 clinical parameters in 118 Barrett's esophagus tissues obtained from 35 progressor and 27 non-progressor Barrett's esophagus patients from Baltimore Veterans Affairs Maryland Health Care Systems and Mayo Clinic. Based on 2-year and 4-year prediction models using linear discriminant analysis (area under the receiver-operator characteristic (ROC curve: 0.8386 and 0.7910, respectively, Barrett's esophagus specimens were stratified into high-risk (HR, intermediate-risk (IR, or low-risk (LR groups. This 3-tiered stratification method retained both the high specificity of the 2-year model and the high sensitivity of the 4-year model. Progression-free survivals differed significantly among the 3 risk groups, with p = 0.0022 (HR vs. IR and p<0.0001 (HR or IR vs. LR. Incremental value analyses demonstrated that the number of methylated genes contributed most influentially to prediction accuracy.This 3-tiered risk stratification strategy has the potential to exert a profound impact on Barrett's esophagus surveillance accuracy and efficiency.

  7. The Auckland Cataract Study: Assessing Preoperative Risk Stratification Systems for Phacoemulsification Surgery in a Teaching Hospital.

    Science.gov (United States)

    Kim, Bia Z; Patel, Dipika V; Sherwin, Trevor; McGhee, Charles N J

    2016-11-01

    To evaluate 2 preoperative risk stratification systems for assessing the risk of complications in phacoemulsification cataract surgery, performed by residents, fellows, and attending physicians in a public teaching hospital. Cohort study. One observer assessed the clinical data of 500 consecutive cases, prior to phacoemulsification cataract surgery performed between April and June 2015 at Greenlane Clinical Centre, Auckland, New Zealand. Preoperatively 2 risk scores were calculated for each case using the Muhtaseb and Buckinghamshire risk stratification systems. Complications, intraoperative and postoperative, and visual outcomes were analyzed in relation to these risk scores. Intraoperative complication rates increased with higher risk scores using the Muhtaseb or Buckinghamshire stratification system (P = .001 and P = .003, respectively, n = 500). The odds ratios for residents and fellows were not significantly different from attending physicians after case-mix adjustment according to risk scores (P > .05). Postoperative complication rates increased with higher Buckinghamshire risk scores but not with Muhtaseb scores (P = .014 and P = .094, respectively, n = 476). Postoperative corrected-distance visual acuity was poorer with higher risk scores (P < .001 for both, n = 476). This study confirms that the risk of intraoperative complications increases with higher preoperative risk scores. Furthermore, higher risk scores correlate with poorer postoperative visual acuity and the Buckinghamshire risk score also correlates with postoperative complications. Therefore, preoperative assessment using such risk stratification systems could assist individual informed consent, preoperative surgical planning, safe allocation of cases to trainees, and more meaningful analyses of outcomes for individual surgeons and institutions. Copyright © 2016 Elsevier Inc. All rights reserved.

  8. Unification of favourable intermediate-, unfavourable intermediate-, and very high-risk stratification criteria for prostate cancer.

    Science.gov (United States)

    Zumsteg, Zachary S; Zelefsky, Michael J; Woo, Kaitlin M; Spratt, Daniel E; Kollmeier, Marisa A; McBride, Sean; Pei, Xin; Sandler, Howard M; Zhang, Zhigang

    2017-11-01

    To improve on the existing risk-stratification systems for prostate cancer. This was a retrospective investigation including 2 248 patients undergoing dose-escalated external beam radiotherapy (EBRT) at a single institution. We separated National Comprehensive Cancer Network (NCCN) intermediate-risk prostate cancer into 'favourable' and 'unfavourable' groups based on primary Gleason pattern, percentage of positive biopsy cores (PPBC), and number of NCCN intermediate-risk factors. Similarly, NCCN high-risk prostate cancer was stratified into 'standard' and 'very high-risk' groups based on primary Gleason pattern, PPBC, number of NCCN high-risk factors, and stage T3b-T4 disease. Patients with unfavourable-intermediate-risk (UIR) prostate cancer had significantly inferior prostate-specific antigen relapse-free survival (PSA-RFS, P prostate cancer-specific mortality (PCSM, P prostate cancer. Similarly, patients with very high-risk (VHR) prostate cancer had significantly worse PSA-RFS (P prostate cancer. Moreover, patients with FIR and low-risk prostate cancer had similar outcomes, as did patients with UIR and SHR prostate cancer. Consequently, we propose the following risk-stratification system: Group 1, low risk and FIR; Group 2, UIR and SHR; and Group 3, VHR. These groups have markedly different outcomes, with 8-year distant metastasis rates of 3%, 9%, and 29% (P < 0.001) for Groups 1, 2, and 3, respectively, and 8-year PCSM of 1%, 4%, and 13% (P < 0.001) after EBRT. This modified stratification system was significantly more accurate than the three-tiered NCCN system currently in clinical use for all outcomes. Modifying the NCCN risk-stratification system to group FIR with low-risk patients and UIR with SHR patients, results in modestly improved prediction of outcomes, potentially allowing better personalisation of therapeutic recommendations. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

  9. 205_WS: Improving the Delivery of Primary Care Through Risk Stratification

    DEFF Research Database (Denmark)

    Kinder, Karen; Kristensen, Troels; Abrams, Chad

    . Content The workshop will open with an introductory presentation on the numerous applications of risk stratification within the integrated and primary care sectors. The workshop will then focus on individual sessions based on three applications: – Case Management. – Improving Coordination...

  10. Non-muscle invasive bladder cancer risk stratification

    Directory of Open Access Journals (Sweden)

    Sumit Isharwal

    2015-01-01

    Conclusion: EORTC and CUETO risk tables are the two best-established models to predict recurrence and progression in patients with NMIBC though they tend to overestimate risk and have poor discrimination for prognostic outcomes in external validation. Future research should focus on enhancing the predictive accuracy of risk assessment tools by incorporating additional prognostic factors such as depth of lamina propria invasion and molecular biomarkers after rigorous validation in multi-institutional cohorts.

  11. Optimising preoperative risk stratification tools for prostate cancer using mpMRI

    Energy Technology Data Exchange (ETDEWEB)

    Reisaeter, Lars A.R.; Losnegaard, Are; Biermann, Martin; Roervik, Jarle [Haukeland University Hospital, Department of Radiology, Bergen (Norway); University of Bergen, Department of Clinical Medicine, Bergen (Norway); Fuetterer, Jurgen J. [Radboud University Nijmegen Medical Centre, Department of Radiology, Nijmegen (Netherlands); Nygaard, Yngve [Haukeland University Hospital, Department of Urology, Bergen (Norway); Monssen, Jan [Haukeland University Hospital, Department of Radiology, Bergen (Norway); Gravdal, Karsten [Haukeland University Hospital, Department of Pathology, Bergen (Norway); Halvorsen, Ole J.; Akslen, Lars A. [Haukeland University Hospital, Department of Pathology, Bergen (Norway); Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, University of Bergen (Norway); Haukaas, Svein; Beisland, Christian [University of Bergen, Department of Clinical Medicine, Bergen (Norway); Haukeland University Hospital, Department of Urology, Bergen (Norway)

    2018-03-15

    To improve preoperative risk stratification for prostate cancer (PCa) by incorporating multiparametric MRI (mpMRI) features into risk stratification tools for PCa, CAPRA and D'Amico. 807 consecutive patients operated on by robot-assisted radical prostatectomy at our institution during the period 2010-2015 were followed to identify biochemical recurrence (BCR). 591 patients were eligible for final analysis. We employed stepwise backward likelihood methodology and penalised Cox cross-validation to identify the most significant predictors of BCR including mpMRI features. mpMRI features were then integrated into image-adjusted (IA) risk prediction models and the two risk prediction tools were then evaluated both with and without image adjustment using receiver operating characteristics, survival and decision curve analyses. 37 patients suffered BCR. Apparent diffusion coefficient (ADC) and radiological extraprostatic extension (rEPE) from mpMRI were both significant predictors of BCR. Both IA prediction models reallocated more than 20% of intermediate-risk patients to the low-risk group, reducing their estimated cumulative BCR risk from approximately 5% to 1.1%. Both IA models showed improved prognostic performance with a better separation of the survival curves. Integrating ADC and rEPE from mpMRI of the prostate into risk stratification tools improves preoperative risk estimation for BCR. (orig.)

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

    Science.gov (United States)

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

    2016-05-01

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

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

    Science.gov (United States)

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

    2016-01-01

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

  14. Preoperative B-type natriuretic peptide risk stratification: Do ...

    African Journals Online (AJOL)

    Objectives: It is unclear if there is value in measuring postoperative B-type natriuretic peptide (BNP) in patients risk-stratified using preoperative BNP. Design: Prospective observational study. Setting and subjects: Patients undergoing vascular surgery at Inkosi Albert Luthuli Hospital, Durban. Data on intraoperative risk ...

  15. Risk stratification in upper gastrointestinal bleeding; prediction, prevention and prognosis

    NARCIS (Netherlands)

    de Groot, N.L.

    2013-01-01

    In the first part of this thesis we developed a novel prediction score for predicting upper gastrointestinal (GI) bleeding in both NSAID and low-dose aspirin users. Both for NSAIDs and low-dose aspirin use risk scores were developed by identifying the five most dominant predictors. The risk of upper

  16. Risk stratification of patients suspected of coronary artery disease

    DEFF Research Database (Denmark)

    Jensen, Jesper M; Voss, Mette; Hansen, Vibeke Bøgelund

    2012-01-01

    To compare the performance of five risk models (Diamond-Forrester, the updated Diamond-Forrester, Morise, Duke, and a new model designated COronary Risk SCORE (CORSCORE) in predicting significant coronary artery disease (CAD) in patients with chest pain suggestive of stable angina pectoris....

  17. BRAIN NATRIURETIC PEPTIDE (BNP: BIOMARKER FOR RISK STRATIFICATION AND FUNCTIONAL RECOVERY PREDICTION IN ISCHEMIC STROKE

    Directory of Open Access Journals (Sweden)

    STANESCU Ioana

    2015-02-01

    Full Text Available Functional outcome after cardiovascular and cerebrovascular events is traditionally predicted using demographic and clinical variables like age, gender, blood pressure, cholesterol levels, diabetes status, smoking habits or pre-existing morbidity. Identification of new variables will improve the risk stratification of specific categories of patients. Numerous blood-based biomarkers associated with increased cardiovascular risk have been identified; some of them even predict cardiovascular events. Investigators have tried to produce prediction models by incorporating traditional risk factors and biomarkers. (1. Widely-available, rapidly processed and less expensive biomarkers could be used in the future to guide management of complex cerebrovascular patients in order to maximize their recovery (2 Recently, studies have demonstrated that biomarkers can predict not only the risk for a specific clinical event, but also the risk of death of vascular cause and the functional outcome after cardiovascular or cerebrovascular events. Early prediction of fatal outcome after stroke may improve therapeutic strategies (such as the use of more aggressive treatments or inclusion of patients in clinical trials and guide decision-making processes in order to maximize patient’s chances for survival and recovery. (3 Long term functional outcome after stroke is one of the most difficult variables to predict. Elevated serum levels of brain natriuretic peptide (BNP are powerful predictor of outcomes in patients with cardiovascular disease (heart failure, atrial fibrillation. Potential role of BNP in predicting atrial fibrillation occurrence, cardio-embolic stroke and post-stroke mortality have been proved in many studies. However, data concerning the potential role of BNP in predicting short term and long term functional outcomes after stroke remain controversial.

  18. A Personalized Risk Stratification Platform for Population Lifetime Healthcare.

    Science.gov (United States)

    Daowd, Ali; Abidi, Samina Raza; Abusharekh, Ashraf; Abidi, Syed Sibte Raza

    2018-01-01

    Chronic diseases are the leading cause of death worldwide. It is well understood that if modifiable risk factors are targeted, most chronic diseases can be prevented. Lifetime health is an emerging health paradigm that aims to assist individuals to achieve desired health targets, and avoid harmful lifecycle choices to mitigate the risk of chronic diseases. Early risk identification is central to lifetime health. In this paper, we present a digital health-based platform (PRISM) that leverages artificial intelligence, data visualization and mobile health technologies to empower citizens to self-assess, self-monitor and self-manage their overall risk of major chronic diseases and pursue personalized chronic disease prevention programs. PRISM offers risk assessment tools for 5 chronic conditions, 2 psychiatric disorders and 8 different cancers.

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

    Science.gov (United States)

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

    2017-12-01

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

  20. Current Roles and Future Applications of Cardiac CT: Risk Stratification of Coronary Artery Disease

    Energy Technology Data Exchange (ETDEWEB)

    Yoon, Yeonyee Elizabeth [Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam 463-707 (Korea, Republic of); Lim, Tae-Hwan [Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736 (Korea, Republic of)

    2014-07-01

    Cardiac computed tomography (CT) has emerged as a noninvasive modality for the assessment of coronary artery disease (CAD), and has been rapidly integrated into clinical cares. CT has changed the traditional risk stratification based on clinical risk to image-based identification of patient risk. Cardiac CT, including coronary artery calcium score and coronary CT angiography, can provide prognostic information and is expected to improve risk stratification of CAD. Currently used conventional cardiac CT, provides accurate anatomic information but not functional significance of CAD, and it may not be sufficient to guide treatments such as revascularization. Recently, myocardial CT perfusion imaging, intracoronary luminal attenuation gradient, and CT-derived computed fractional flow reserve were developed to combine anatomical and functional data. Although at present, the diagnostic and prognostic value of these novel technologies needs to be evaluated further, it is expected that all-in-one cardiac CT can guide treatment and improve patient outcomes in the near future.

  1. Numerical analysis on hydrogen stratification and post-inerting of hydrogen risk

    International Nuclear Information System (INIS)

    Peng, Cheng; Tong, Lili; Cao, Xuewu

    2016-01-01

    Highlights: • A three-dimensional computational model was built and the applicability was discussed. • The formation of helium stratification was further studied. • Three influencing factors on the post-inerting of hydrogen risk were analyzed. - Abstract: In the case of severe accidents, the risk of hydrogen explosion threatens the integrity of the nuclear reactor containment. According to nuclear regulations, hydrogen control is required to ensure the safe operation of the nuclear reactor. In this study, the method of Computational Fluid Dynamics (CFD) has been applied to analyze process of hydrogen stratification and the post-inerting of hydrogen risk in the Large-Scale Gas Mixing Facility. A three-dimensional computational model was built and the applicability of different turbulence models was discussed. The result shows that the helium concentration calculated by the standard k–ε turbulence model is closest to the experiment data. Through analyzing the formation of helium stratification at different injection velocities, it is found that when the injection mass flow is constant and the injection velocity of helium increases, the mixture of helium and air is enhanced while there is rarely influence on the formation of helium stratification. In addition, the influences of mass flow rate, injection location and direction and inert gas on the post-inerting of hydrogen risk have been analyzed and the results are as follows: with the increasing of mass flow rate, the mitigation effect of nitrogen on hydrogen risk will be further improved; there is an obvious local difference between the mitigation effects of nitrogen on hydrogen risk in different injection directions and locations; when the inert gas is injected at the same mass flow rate, the mitigation effect of steam on hydrogen risk is better than that of nitrogen. This study can provide technical support for the mitigation of hydrogen risk in the small LWR containment.

  2. Segmented Symbolic Dynamics for Risk Stratification in Patients with Ischemic Heart Failure, Cardiovascular Engineering and Technology

    OpenAIRE

    Voss, Andreas; Schroeder, Rico; Caminal Magrans, Pere; Vallverdú Ferrer, Montserrat; Brunel, Helena; Cygankiewicz, I.; Vázquez, Rafael; Bayes de Luna, Antonio

    2010-01-01

    Chronic heart failure (CHF) is recognized as major and escalating public health problem. Approximately 69% of CHF patients suffer from cardiac death within 5 years after the initial diagnosis. Until now, no generally accepted ECG risk predictors in CHF patients are available. The objective of this study was to investigate the suitability of the new developed non-linear method segmented symbolic dynamics (SSD) for risk stratification in patients with ischemic cardiomyop...

  3. Preoperative B-type natriuretic peptide risk stratification: do ...

    African Journals Online (AJOL)

    2012-09-11

    Sep 11, 2012 ... and noncardiac surgery.6,7 An individual patient data meta- analysis of 850 patients undergoing vascular surgery found that preoperative BNP ..... range. BNP: B-type natriuretic peptide, CVA: cerebrovascular accident, RCRI: revised cardiac risk index ... and avoiding the use of blood stored for >14 days.

  4. Blood Pressure Management in Cardiovascular Risk Stratification. Procedure, Progression, Process.

    NARCIS (Netherlands)

    Adiyaman, A.

    2009-01-01

    In this thesis we have explored different aspects of blood pressure measurement and related it to the risk of cardiovascular disease. In the first part we showed that when the arm is positioned under heart level, for example when the arm is placed on a desk or a chair support, the blood pressure and

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

    Science.gov (United States)

    Roca, Josep; Vargas, Claudia; Cano, Isaac; Selivanov, Vitaly; Barreiro, Esther; Maier, Dieter; Falciani, Francesco; Wagner, Peter; Cascante, Marta; Garcia-Aymerich, Judith; Kalko, Susana; De Mas, Igor; Tegnér, Jesper; Escarrabill, Joan; Agustí, Alvar; Gomez-Cabrero, David

    2014-11-28

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

  6. Risk stratification by using non-invasive radionuclide imaging in patients with unstable angina spec tories

    International Nuclear Information System (INIS)

    Saghari, M.

    2002-01-01

    Unstable angina represents a heterogeneous spectrum of clinical entities between chronic stable angina and acute myocardial infraction. Acute ischemic syndromes (including unstable angina) result from abrupt reduction in coronary flow, frequently after atherosclerotic plaque disruption and with or without associated thrombosis or vasospasm. Nuclear cardiology studies and in particular, myocardial perfusion imaging are powerful noninvasive tools for detecting and assessing the severity of acute ischemic syndromes, including unstable angina pec tories. The information derived from a nuclear cardiology study can answer unresolved clinical question and aid in subsequent patient management, specifically jeopardized myocardium detected during spontaneously occurring acute chest pain or controlled stress testing are important determinant of: 1) The need for admission to an intensive care monitoring unit 2) The need for and urgency of coronary angiography 3) The appropriate use of percutaneous or surgical coronary revascularization procedures. Extensive information suggests the stress nuclear perfusion imaging is the best validated technique for predischarge risk stratification with unstable angina patients who have been medically stabilized. Early information suggests avoidance of unecessary coronary angiography or revascularization is the cost effective strategy

  7. A Prediction Rule for Risk Stratification of Incidentally Discovered Gallstones

    DEFF Research Database (Denmark)

    Shabanzadeh, Daniel Mønsted; Sørensen, Lars Tue; Jørgensen, Torben

    2016-01-01

    % confidence interval [CI], 1.45-3.69), acute cholecystitis (HR, 9.49; 95% CI, 2.05-43.92), and uncomplicated events (HR, 2.55; 95% CI, 1.38-4.71), including cholecystectomy (HR, 2.69; 95% CI, 1.29-5.60). Multiple stones were associated with all events (HR, 1.68; 95% CI, 1.00-2.81), complicated events (HR, 2...... the highest risk for events (HR, 11.05; 95% CI, 3.76-32.44; unadjusted absolute risk, 0.0235 events/person-years). CONCLUSIONS: Fewer than 20% of subjects with gallstones develop clinical events. Larger, multiple, and older gallstones are associated with events. Further studies are needed to confirm...

  8. A mathematical model for stratification of LADA risk groups

    Directory of Open Access Journals (Sweden)

    Tatiana Mikhailovna Tikhonova

    2014-03-01

    Full Text Available Aim. To stratify risk groups via discriminant analysis based on the most clinically relevant indications of LADA onset derived from medical history. Materials and Methods. Present study included 141 patients with diabetes mellitus (DM of whom 65 had preliminary diagnosis of LADA, 40 patients were diagnosed with type 1 diabetes mellitus (T1DM and 36 ? with type 2 diabetes mellitus (T2DM. Discriminant analysis was performed to evaluate the differences between the clinical onsets in study groups. Results. Aside from torpid onset with early evidence for insulin resistance, clinical characteristics of LADA included diagnosis during random examination, progressive loss of body mass, hyperglycemia greater than 14 mmol/L at the diagnosis and, possibly, ketonuria without history of acute ketoacidosis. Conclusion. Discriminant analysis is beneficial in stratifying risk groups for the development of LADA.

  9. A mathematical model for stratification of LADA risk groups

    OpenAIRE

    Tat'yana Mikhaylovna Tikhonova

    2014-01-01

    Aim. To stratify risk groups via discriminant analysis based on the most clinically relevant indications of LADA onset derived from medical history.Materials and Methods. Present study included 141 patients with diabetes mellitus (DM) of whom 65 had preliminary diagnosis of LADA, 40 patients were diagnosed with type 1 diabetes mellitus (T1DM) and 36 – with type 2 diabetes mellitus (T2DM). Discriminant analysis was performed to evaluate the differences between the clinical onsets in study grou...

  10. Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic

    DEFF Research Database (Denmark)

    Munch, Lene; Arreskov, Anne B; Sperling, Michael

    2016-01-01

    BACKGROUND: To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance......, the endocrinologists stratified less patients at level 3 compared to objective assessments (p Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out...... contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health...

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

    Science.gov (United States)

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

    2017-03-01

    The aim of this study was to externally validate the four commonly used scoring systems in the risk stratification of patients with upper gastrointestinal bleed (UGIB). Patients of UGIB who underwent endoscopy within 24 h of presentation were stratified prospectively using the pre-endoscopy Rockall score (PRS) >0, complete Rockall score (CRS) >2, Glasgow Blatchford bleeding scores (GBS) >3, and modified GBS (m-GBS) >3 scores. Patients were followed up to 30 days. Prognostic accuracy of the scores was done by comparing areas under curve (AUC) in terms of overall risk stratification, re-bleeding, mortality, need for intervention, and length of hospitalization. One hundred and seventy-five patients were studied. All four scores performed better in the overall risk stratification on AUC [PRS = 0.566 (CI: 0.481-0.651; p-0.043)/CRS = 0.712 (CI: 0.634-0.790); p0.001); m-GBS = 0.802 (CI: 0.734-0.871; pbleed [AUC-0.679 (CI: 0.579-0.780; p = 0.003)]. All the scoring systems except PRS were found to be significantly better in detecting 30-day mortality with a high AUC (CRS = 0.798; p-0.042)/GBS = 0.833; p-0.023); m-GBS = 0.816; p-0.031). All four scores demonstrated significant accuracy in the risk stratification of non-variceal patients; however, only GBS and m-GBS were significant in variceal etiology. Higher cutoff scores achieved better sensitivity/specificity [RS > 0 (50/60.8), CRS > 1 (87.5/50.6), GBS > 7 (88.5/63.3), m-GBS > 7(82.3/72.6)] in the risk stratification. GBS and m-GBS appear to be more valid in risk stratification of UGIB patients in this region. Higher cutoff values achieved better predictive accuracy.

  12. Short-term versus long-term heart rate variability in ischemic cardiomyopathy risk stratification

    Directory of Open Access Journals (Sweden)

    Andreas eVoss

    2013-12-01

    Full Text Available In industrialized countries with aging populations, heart failure affects 0.3%-2% of the general population. The investigation of 24h-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 30min short-term HRV analysis is sufficient for comparable risk stratification in IHF in comparison to 24h-HRV analysis. From 256 IHF patients (221 at low risk (IHFLR and 35 at high risk (IHFHR a 24h beat-to-beat time series b the first 30min segment c the 30min most stationary day segment and d the 30min 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 hours and for each 30min 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

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

    Directory of Open Access Journals (Sweden)

    Vincent J Gnanapragasam

    2016-08-01

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

  14. Preventing tomorrow's sudden cardiac death today: part I: Current data on risk stratification for sudden cardiac death.

    Science.gov (United States)

    Al-Khatib, Sana M; Sanders, Gillian D; Bigger, J Thomas; Buxton, Alfred E; Califf, Robert M; Carlson, Mark; Curtis, Anne; Curtis, Jeptha; Fain, Eric; Gersh, Bernard J; Gold, Michael R; Haghighi-Mood, Ali; Hammill, Stephen C; Healey, Jeff; Hlatky, Mark; Hohnloser, Stefan; Kim, Raymond J; Lee, Kerry; Mark, Daniel; Mianulli, Marcus; Mitchell, Brent; Prystowsky, Eric N; Smith, Joseph; Steinhaus, David; Zareba, Wojciech

    2007-06-01

    Accurate and timely prediction of sudden cardiac death (SCD) is a necessary prerequisite for effective prevention and therapy. Although the largest number of SCD events occurs in patients without overt heart disease, there are currently no tests that are of proven predictive value in this population. Efforts in risk stratification for SCD have focused primarily on predicting SCD in patients with known structural heart disease. Despite the ubiquity of tests that have been purported to predict SCD vulnerability in such patients, there is little consensus on which test, in addition to the left ventricular ejection fraction, should be used to determine which patients will benefit from an implantable cardioverter defibrillator. On July 20 and 21, 2006, a group of experts representing clinical cardiology, cardiac electrophysiology, biostatistics, economics, and health policy were joined by representatives of the US Food and Drug administration, Centers for Medicare Services, Agency for Health Research and Quality, the Heart Rhythm Society, and the device and pharmaceutical industry for a round table meeting to review current data on strategies of risk stratification for SCD, to explore methods to translate these strategies into practice and policy, and to identify areas that need to be addressed by future research studies. The meeting was organized by the Duke Center for the Prevention of SCD at the Duke Clinical Research Institute and was funded by industry participants. This article summarizes the presentations and discussions that occurred at that meeting.

  15. Noninvasive risk stratification of lethal ventricular arrhythmias and sudden cardiac death after myocardial infarction

    Directory of Open Access Journals (Sweden)

    Kenji Yodogawa, MD

    2014-08-01

    Full Text Available Prediction of lethal ventricular arrhythmias leading to sudden cardiac death is one of the most important and challenging problems after myocardial infarction (MI. Identification of MI patients who are prone to ventricular tachyarrhythmias allows for an indication of implantable cardioverter-defibrillator placement. To date, noninvasive techniques such as microvolt T-wave alternans (MTWA, signal-averaged electrocardiography (SAECG, heart rate variability (HRV, and heart rate turbulence (HRT have been developed for this purpose. MTWA is an indicator of repolarization abnormality and is currently the most promising risk-stratification tool for predicting malignant ventricular arrhythmias. Similarly, late potentials detected by SAECG are indices of depolarization abnormality and are useful in risk stratification. However, the role of SAECG is limited because of its low predictive accuracy. Abnormal HRV and HRT patterns reflect autonomic disturbances, which may increase the risk of lethal ventricular arrhythmias, but the existing evidence is insufficient. Further studies of noninvasive assessment may provide a new insight into risk stratification in post-MI patients.

  16. Novel Risk Stratification Assays for Acute Coronary Syndrome.

    Science.gov (United States)

    Ahmed, Haitham M; Hazen, Stanley L

    2017-08-01

    Since identification of aspartate aminotransferase as the first cardiac biomarker in the 1950s, there have been a number of new markers used for myocardial damage detection over the decades. There have also been several generations of troponin assays, each with progressively increasing sensitivity for troponin detection. Accordingly, the "standard of care" for myocardial damage detection continues to change. The purpose of this paper is to review the clinical utility, biological mechanisms, and predictive value of these various biomarkers in contemporary clinical studies. As of this writing, a fifth "next" generation troponin assay has now been cleared by the US Food and Drug Administration for clinical use in the USA for subjects presenting with suspected acute coronary syndromes. Use of these high-sensitivity assays has allowed for earlier detection of myocardial damage as well as greater negative predictive value for infarction after only one or two serial measurements. Recent algorithms utilizing these assays have allowed for more rapid rule-out of myocardial infarction in emergency department settings. In this review, we discuss novel assays available for the risk assessment of subjects presenting with chest pain, including both the "next generation" cardiac troponin assays as well as other novel biomarkers. We review the biological mechanisms for these markers, and explore the positive and negative predictive value of the assays in clinical studies, where reported. We also discuss the potential use of these new markers within the context of future clinical care in the modern era of higher sensitivity troponin testing. Finally, we discuss advances in new platforms (e.g., mass spectrometry) that historically have not been considered for rapid in vitro diagnostic capabilities, but that are taking a larger role in clinical diagnostics, and whose prognostic value and power promise to usher in new markers with potential for future clinical utility in acute coronary

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

    OpenAIRE

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

    2009-01-01

    Introduction: This paper explores the use of machine learning and Bayesian classification models to develop broadly applicable risk stratification models to guide disease management of health plan enrollees with substance use disorder (SUD). While the high costs and morbidities associated with SUD are understood by payers, who manage it through utilization review, acute interventions, coverage and cost limitations, and disease management, the literature shows mixed results for these modalitie...

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

    Science.gov (United States)

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

    2016-01-01

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

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

    Science.gov (United States)

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

    2015-09-01

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

  20. Characteristic and Preferences of Green Consumer Stratification As Bases to Formulating Marketing Strategies of Ecolabel-Certified Furniture

    Directory of Open Access Journals (Sweden)

    Ririn Wulandari

    2012-06-01

    question. The components used were: satisfaction, safety, socialization, and sustainability, as well as government policies which could open markets. The respondents were 408 potential consumers in Jakarta and its surroundings. The method used was purposive and convenience sampling, in which the survey was conducted at exhibitions and showrooms. Ward Method, Stepwise Discriminant Analysis and Biplot Analysis were used to generate consumer stratifications. Before that, reliability tests were conducted using Crombach Alpha method. In addition, data was explored and reduced using Component Principle Analysis. Preference analysis was performed using the method proposed by Thurston Case V. This study results four stratifications of green consumers. There were similarities and differences in preference on each of the stratification of the component of green marketing strategy as well as the marketing strategies of furniture-certified ecolabel for the targeted consumers.

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

    Directory of Open Access Journals (Sweden)

    Ximena Porcasi

    2012-09-01

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

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

    Science.gov (United States)

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

    2015-01-01

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

  3. Diabetes mellitus and bone health: epidemiology, etiology and implications for fracture risk stratification.

    Science.gov (United States)

    Valderrábano, Rodrigo J; Linares, Maria I

    2018-01-01

    Skeletal fractures can result when there are co-morbid conditions that negatively impact bone strength. Fractures represent an important source of morbidity and mortality, especially in older populations. Diabetes mellitus is a metabolic disorder that has reached worldwide epidemic proportions and is increasingly being recognized as a risk factor for fracture. Type 1 and Type 2 diabetes have different effects on bone mineral density but share common pathways, which lead to bone fragility. In this review, we discuss the available data on diabetes and fractures, bone density and the clinical implications for fracture risk stratification in current practice.

  4. Risk stratification of patients with advanced squamous cell carcinoma of cervix treated by radiotherapy alone

    International Nuclear Information System (INIS)

    Hong, J.-H.; Tsai, C.-S.; Lai, C.-H.; Chang, T.-C.; Wang, C.-C.; Chou, H.-H.; Lee, Steve P.; Lee, C.-C.; Tang, Simon G.; Hsueh Swei

    2005-01-01

    Purpose: To identify prognostic factors for local and distant relapse and perform risk stratification for patients with advanced cervical cancer treated with radiotherapy (RT) alone. Methods and Materials: A total of 1031 patients with Stage IB-IVA squamous cell carcinoma of the cervix treated with full-course RT but without any chemotherapy were included for analysis. Of these, 311 patients with nonbulky Stage IB-IIA disease were designated the reference group and the other 720 patients were the study group. The associations of stage, squamous cell carcinoma antigen (SCC-ag) level, hemoglobin level, age, cell differentiation, and pelvic lymph node status with treatment failure were evaluated. The independent prognostic factors were identified by multivariate analysis. The study group was further stratified into subgroups using combinations of these risk factors. Results: In the study group, independent risk factors for local relapse were advanced stage and age 2, and positive pelvic lymph nodes. The 5-year distant relapse-free survival rate was 83% for patients with bulky Stage IB-IIA and IIB disease, SCC-ag level 2, and positive lymph nodes. Conclusion: The risk of treatment failure in advanced-stage cervical cancer patients treated by RT alone can be more precisely predicted by risk stratification. A certain subgroup of patients had better control than the others. The benefit of treating these relatively low-risk patients with additional treatment such as concurrent chemotherapy should be further evaluated in prospective studies or meta-analyses

  5. Application of support vector machine classifiers to preoperative risk stratification with myocardial perfusion scintigraphy

    International Nuclear Information System (INIS)

    Kasamatsu, Tomotaka; Hashimoto, Jun; Nakahara, Tadaki; Bai, Jingming; Kitamura, Naoto; Kubo, Atsushi; Iyatomi, Hitoshi; Ogawa, Koichi

    2008-01-01

    Myocardial perfusion single-photon emission computed tomography (SPECT) has been used for risk stratification before non-cardiac surgery. However, few authors have used mathematical models for evaluating the likelihood of perioperative cardiac events. This retrospective cohort study collected data of 1,351 patients referred for SPECT before non-cardiac surgery. We generated binary classifiers using support vector machine (SVM) and conventional linear models for predicting perioperative cardiac events. We used clinical and surgical risk, and SPECT findings as input data, and the occurrence of all and hard cardiac events as output data. The area under the receiver-operating characteristic curve (AUC) was calculated for assessing the prediction accuracy. The AUC values were 0.884 and 0.748 in the SVM and linear models, respectively in predicting all cardiac events with clinical and surgical risk, and SPECT variables. The values were 0.861 (SVM) and 0.677 (linear) when not using SPECT data as input. In hard events, the AUC values were 0.892 (SVM) and 0.864 (linear) with SPECT, and 0.867 (SVM) and 0.768 (linear) without SPECT. The SVM was superior to the linear model in risk stratification. We also found an incremental prognostic value of SPECT results over information about clinical and surgical risk. (author)

  6. Utility of the exercise electrocardiogram testing in sudden cardiac death risk stratification.

    Science.gov (United States)

    Refaat, Marwan M; Hotait, Mostafa; Tseng, Zian H

    2014-07-01

    Sudden cardiac death (SCD) remains a major public health problem. Current established criteria identifying those at risk of sudden arrhythmic death, and likely to benefit from implantable cardioverter defibrillators (ICDs), are neither sensitive nor specific. Exercise electrocardiogram (ECG) testing was traditionally used for information concerning patients' symptoms, exercise capacity, cardiovascular function, myocardial ischemia detection, and hemodynamic responses during activity in patients with hypertrophic cardiomyopathy. We conducted a systematic review of MEDLINE on the utility of exercise ECG testing in SCD risk stratification. Exercise testing can unmask suspected primary electrical diseases in certain patients (catecholaminergic polymorphic ventricular tachycardia or concealed long QT syndrome) and can be effectively utilized to risk stratify patients at an increased (such as early repolarization syndrome and Brugada syndrome) or decreased risk of SCD, such as the loss of preexcitation on exercise testing in asymptomatic Wolff-Parkinson-White syndrome. Exercise ECG testing helps in SCD risk stratification in patients with and without arrhythmogenic hereditary syndromes. © 2014 Wiley Periodicals, Inc.

  7. [The scoring system for the risk-stratification in patients with the antiphospholipid syndrome].

    Science.gov (United States)

    Oku, Kenji

    2017-01-01

      Antiphospholipid syndrome (APS) is a clinical disorder characterized by thrombosis and/or pregnancy morbidity in the persistence of the pathogenic autoantibodies, the antiphospholipid antibodies (aPL). Recurernt thrombosis is often observed in patients with APS which requires persistent prophylaxis. However, an uniform prophylactic treatment for APS patients is inadequate and stratification of the thrombotic risks is important as aPL are prevalently observed in other various diseases or elderly population. It is previously known that the multiple positivity or high titre of aPL correlate to the thrombotic events. To progress the stratification of the thrombotic risks and to quantitatively analyze them, antiphospholipid score (aPL-S) and the Global Anti-Phospholipid Syndrome Score (GAPSS) were defined as the scoring-systems. Both of these scoring-systems were raised from the large patient cohort data and either aPL profile classified in detail (aPL-S) or simplified aPL profile with classical thrombotic risk factors (GAPSS) were put into scoring system. They have shown a degree of accuracy in identifying high-risk APS patients, especially those at a high risk of thrombosis. However, there are several areas requiring improvement, or at least that clinicians should be aware of, before these instruments are applied in clinical practice. One such issue is standardisation of the aPL tests, including general testing of phosphatidylserine dependent antiprothrombin antibodies (aPS/PT).

  8. Prodromal Parkinsonism and Neurodegenerative Risk Stratification in REM Sleep Behavior Disorder.

    Science.gov (United States)

    Barber, Thomas R; Lawton, Michael; Rolinski, Michal; Evetts, Samuel; Baig, Fahd; Ruffmann, Claudio; Gornall, Aimie; Klein, Johannes C; Lo, Christine; Dennis, Gary; Bandmann, Oliver; Quinnell, Timothy; Zaiwalla, Zenobia; Ben-Shlomo, Yoav; Hu, Michele T M

    2017-08-01

    Rapid eye movement (REM) sleep behavior disorder (RBD) is the most specific marker of prodromal alpha-synucleinopathies. We sought to delineate the baseline clinical characteristics of RBD and evaluate risk stratification models. Clinical assessments were performed in 171 RBD, 296 control, and 119 untreated Parkinson's (PD) participants. Putative risk measures were assessed as predictors of prodromal neurodegeneration, and Movement Disorders Society (MDS) criteria for prodromal PD were applied. Participants were screened for common leucine-rich repeat kinase 2 (LRRK2)/glucocerebrosidase gene (GBA) gene mutations. Compared to controls, participants with RBD had higher rates of solvent exposure, head injury, smoking, obesity, and antidepressant use. GBA mutations were more common in RBD, but no LRRK2 mutations were found. RBD participants performed significantly worse than controls on Unified Parkinson's Disease Rating Scale (UPDRS)-III, timed "get-up-and-go", Flamingo test, Sniffin Sticks, and cognitive tests and had worse measures of constipation, quality of life (QOL), and orthostatic hypotension. For all these measures except UPDRS-III, RBD and PD participants were equally impaired. Depression, anxiety, and apathy were worse in RBD compared to PD participants. Stratification of people with RBD according to antidepressant use, obesity, and age altered the odds ratio (OR) of hyposmia compared to controls from 3.4 to 45.5. 74% (95% confidence interval [CI] 66%, 80%) of RBD participants met the MDS criteria for probable prodromal Parkinson's compared to 0.3% (95% CI 0.009%, 2%) of controls. RBD are impaired across a range of clinical measures consistent with prodromal PD and suggestive of a more severe nonmotor subtype. Clinical risk stratification has the potential to select higher risk patients for neuroprotective interventions. © Sleep Research Society 2017. Published by Oxford University Press [on behalf of the Sleep Research Society].

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

    Science.gov (United States)

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

    2017-06-26

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

  10. Risk stratification using lean body mass in patients undergoing transcatheter aortic valve replacement.

    Science.gov (United States)

    Hioki, Hirofumi; Watanabe, Yusuke; Kozuma, Ken; Yamamoto, Masanori; Naganuma, Toru; Araki, Motoharu; Tada, Norio; Shirai, Shinichi; Yamanaka, Futoshi; Higashimori, Akihiro; Mizutani, Kazuki; Tabata, Minoru; Takagi, Kensuke; Ueno, Hiroshi; Hayashida, Kentaro

    2018-02-22

    The prognostic impact of skeletal muscle mass, assessed using lean body mass (LBM), remain unclear in patients who underwent transcatheter aortic valve replacement (TAVR). The aim of this study to assess prognostic impact of LBM on mortality after TAVR. We assessed 1,613 patients (median age 85 years, 70% female) who underwent TAVI from October 2013 to April 2016 using OCEAN (Optimized transCathEter vAlvular interveNtion)-TAVI registry data. LBM was calculated using the James formula. The primary endpoint was all-cause death after TAVR. Median follow-up period was 287 days (interquartile range 110-462). The Kaplan-Meier analysis demonstrated that patients with low LBM had significantly higher incidence of all-cause death than those with high LBM in male (32.3% vs. 9.9%, log rank P LBM was an independent predictor of all-cause death in male (Hazard ratio [HR] 0.93; 95% confidence interval [CI] 0.89-0.98) and female (HR 0.94; 95% CI 0.89-0.99). Inversely, the assessment using BMI could not identify the high-risk population in a female. The patients with low LBM had the higher incidence of all-cause death after TAVR than those with high LBM, regardless of gender. Thus, the risk stratification using LBM might provide further insight to identify the high-risk TAVR population, compared to conventional risk stratification using BMI. © 2018 Wiley Periodicals, Inc.

  11. [Sports medical aspects in cardiac risk stratification--heart rate variability and exercise capacity].

    Science.gov (United States)

    Banzer, W; Lucki, K; Bürklein, M; Rosenhagen, A; Vogt, L

    2006-12-01

    The present study investigates the association of the predicted CHD-risk (PROCAM) with the individual endurance capacity and heart rate variability (HRV) in a population-based sample of sedentary elderly. After stratification, in 57 men (48.1+/-9.5 yrs.) with an overall PROCAM-risk or =10% (50.8+/-5.6 points) cycle ergometries and short-term HRV analysis of time (RRMEAN, SDNN, RMSSD) and frequency domain parameters (LF, HF, TP, LF/HF) were conducted. Additionally the autonomic stress index (SI) was calculated. Nonparametric tests were used for statistical correlation analysis (Spearman rho) and group comparisons (Mann-Whitney). For endurance capacity [W/kg] (r=-0.469, pHRV analysis in risk stratification and outline the interrelation of a decreased exercise capacity and autonomic function with a raised individual 10-year cardiac risk. As an independent parameter of the vegetative regulatory state the stress index may contribute to an increased practical relevance of short-time HRV analysis.

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

    Directory of Open Access Journals (Sweden)

    Maurício Pimentel

    2014-10-01

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

  13. A risk stratification model for antihypertensive medication non-adherence among Chinese immigrants

    Directory of Open Access Journals (Sweden)

    Wen-Wen Li

    2016-12-01

    Full Text Available The purpose of this study was to establish a risk stratification model for identifying Chinese immigrants at risk for non-adherence to antihypertensive medications. Questionnaires were self-administered to 200 Chinese immigrants in San Francisco, USA. Questionnaires included demographics, culture factors (e.g., Perceived Susceptibility in General, Perceived Benefits of Western Medication, Perceived Benefits of Chinese Herbs, and Health-Related Social Support, and medications adherence. Participants' mean age was 70.6 (±10.3 years. Three stratification factors were identified for non-adherence: Lower Perceived Susceptibility in General, lower Perceived Benefit of Western Medications, and longer Length of Stay in the United States. The probability of non-adherence was 77%, 62%, and 57% for lower perceived susceptibility, longer stay in the United States, and lower perceived benefits of Western medications, respectively. A combination of lower perceived susceptibility and lower perceived benefits of medication predicted 81% non-adherence and lower perceived susceptibility with longer stay in the United States predicted at 84%. All three factors combined predicted nearly 90%. Patients with all three factors had the highest risk for non-adherence. The second priority groups are patients with lower perceived susceptibility and those with lower perceived susceptibility combined with any of the other two factors. In the clinical setting, these three groups are a high priority for education on the importance of medication adherence.

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

    Science.gov (United States)

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

    2012-07-01

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

  15. Early Risk stratification for Arrhythmic death in Patients with ST-Elevation Myocardial Infarction

    Directory of Open Access Journals (Sweden)

    Mohammad Ali Sadr-Ameli

    2007-01-01

    Full Text Available Background: Sudden cardiac death is a leading cause of death in patients with ST-elevation myocardial infarction (MI. According to high cost of modern therapeutic modalities it is of paramount importance to define protocols for risk stratification of post-MI patients before considering expensive devices such as implantable cardioverter-defibrillator.Methods: One hundred and thirty seven patients with acute ST-elevation MI were selected and underwent echocardiographic study, holter monitoring and signal-averaged electrocardiography (SAECG. Then, the patients were followed for 12 ±3 months.Results: During follow-up, 13 deaths (9.5% occurred; nine cases happened as sudden cardiac death (6.6%. The effect of ejection fraction (EF less than 40% on occurrence of arrhythmic events was significant (P<0.001. Sensitivity and positive predictive value of EF<40% was 100% and 76.95% respectively. Although with lesser sensitivity and predictive power than EF<40%, abnormal heart rate variability (HRV and SAECG had also significant effects on occurrence of sudden death (P=0.02 and P=0.003 respectively. Nonsustained ventricular tachycardia was not significantly related to risk of sudden death in this study (P=0.20.Conclusions: This study indicated that EF less than 40% is the most powerful predictor of sudden cardiac death in post MI patients. Abnormal HRV and SAECG are also important predictors and can be added to EF for better risk stratification.

  16. Molecular risk stratification of medulloblastoma patients based on immunohistochemical analysis of MYC, LDHB, and CCNB1 expression

    NARCIS (Netherlands)

    de Haas, Talitha; Hasselt, Nancy; Troost, Dirk; Caron, Huib; Popovic, Mara; Zadravec-Zaletel, Lorna; Grajkowska, Wieslawa; Perek, Marta; Osterheld, Maria-Chiara; Ellison, David; Baas, Frank; Versteeg, Rogier; Kool, Marcel

    2008-01-01

    PURPOSE: Medulloblastoma is the most common malignant embryonal brain tumor in children. The current clinical risk stratification to select treatment modalities is not optimal because it does not identify the standard-risk patients with resistant disease or the unknown number of high-risk patients

  17. Noninvasive Computed Tomography–based Risk Stratification of Lung Adenocarcinomas in the National Lung Screening Trial

    Science.gov (United States)

    Maldonado, Fabien; Duan, Fenghai; Raghunath, Sushravya M.; Rajagopalan, Srinivasan; Karwoski, Ronald A.; Garg, Kavita; Greco, Erin; Nath, Hrudaya; Robb, Richard A.; Bartholmai, Brian J.

    2015-01-01

    Rationale: Screening for lung cancer using low-dose computed tomography (CT) reduces lung cancer mortality. However, in addition to a high rate of benign nodules, lung cancer screening detects a large number of indolent cancers that generally belong to the adenocarcinoma spectrum. Individualized management of screen-detected adenocarcinomas would be facilitated by noninvasive risk stratification. Objectives: To validate that Computer-Aided Nodule Assessment and Risk Yield (CANARY), a novel image analysis software, successfully risk stratifies screen-detected lung adenocarcinomas based on clinical disease outcomes. Methods: We identified retrospective 294 eligible patients diagnosed with lung adenocarcinoma spectrum lesions in the low-dose CT arm of the National Lung Screening Trial. The last low-dose CT scan before the diagnosis of lung adenocarcinoma was analyzed using CANARY blinded to clinical data. Based on their parametric CANARY signatures, all the lung adenocarcinoma nodules were risk stratified into three groups. CANARY risk groups were compared using survival analysis for progression-free survival. Measurements and Main Results: A total of 294 patients were included in the analysis. Kaplan-Meier analysis of all the 294 adenocarcinoma nodules stratified into the Good, Intermediate, and Poor CANARY risk groups yielded distinct progression-free survival curves (P < 0.0001). This observation was confirmed in the unadjusted and adjusted (age, sex, race, and smoking status) progression-free survival analysis of all stage I cases. Conclusions: CANARY allows the noninvasive risk stratification of lung adenocarcinomas into three groups with distinct post-treatment progression-free survival. Our results suggest that CANARY could ultimately facilitate individualized management of incidentally or screen-detected lung adenocarcinomas. PMID:26052977

  18. Noninvasive Computed Tomography-based Risk Stratification of Lung Adenocarcinomas in the National Lung Screening Trial.

    Science.gov (United States)

    Maldonado, Fabien; Duan, Fenghai; Raghunath, Sushravya M; Rajagopalan, Srinivasan; Karwoski, Ronald A; Garg, Kavita; Greco, Erin; Nath, Hrudaya; Robb, Richard A; Bartholmai, Brian J; Peikert, Tobias

    2015-09-15

    Screening for lung cancer using low-dose computed tomography (CT) reduces lung cancer mortality. However, in addition to a high rate of benign nodules, lung cancer screening detects a large number of indolent cancers that generally belong to the adenocarcinoma spectrum. Individualized management of screen-detected adenocarcinomas would be facilitated by noninvasive risk stratification. To validate that Computer-Aided Nodule Assessment and Risk Yield (CANARY), a novel image analysis software, successfully risk stratifies screen-detected lung adenocarcinomas based on clinical disease outcomes. We identified retrospective 294 eligible patients diagnosed with lung adenocarcinoma spectrum lesions in the low-dose CT arm of the National Lung Screening Trial. The last low-dose CT scan before the diagnosis of lung adenocarcinoma was analyzed using CANARY blinded to clinical data. Based on their parametric CANARY signatures, all the lung adenocarcinoma nodules were risk stratified into three groups. CANARY risk groups were compared using survival analysis for progression-free survival. A total of 294 patients were included in the analysis. Kaplan-Meier analysis of all the 294 adenocarcinoma nodules stratified into the Good, Intermediate, and Poor CANARY risk groups yielded distinct progression-free survival curves (P < 0.0001). This observation was confirmed in the unadjusted and adjusted (age, sex, race, and smoking status) progression-free survival analysis of all stage I cases. CANARY allows the noninvasive risk stratification of lung adenocarcinomas into three groups with distinct post-treatment progression-free survival. Our results suggest that CANARY could ultimately facilitate individualized management of incidentally or screen-detected lung adenocarcinomas.

  19. Risk stratification in myelodysplastic syndromes: is there a role for gene expression profiling?

    Science.gov (United States)

    Zeidan, Amer M; Prebet, Thomas; Saad Aldin, Ehab; Gore, Steven David

    2014-04-01

    Evaluation of: Pellagatti A, Benner A, Mills KI et al. Identification of gene expression-based prognostic markers in the hematopoietic stem cells of patients with myelodysplastic syndromes. J. Clin. Oncol. 31(28), 3557-3564 (2013). Patients with myelodysplastic syndromes (MDS) exhibit wide heterogeneity in clinical outcomes making accurate risk-stratification an integral part of the risk-adaptive management paradigm. Current prognostic schemes for MDS rely on clinicopathological parameters. Despite the increasing knowledge of the genetic landscape of MDS and the prognostic impact of many newly discovered molecular aberrations, none to date has been incorporated formally into the major risk models. Efforts are ongoing to use data generated from genome-wide high-throughput techniques to improve the 'individualized' outcome prediction for patients. We here discuss an important paper in which gene expression profiling (GEP) technology was applied to marrow CD34(+) cells from 125 MDS patients to generate and validate a standardized GEP-based prognostic signature.

  20. Risk stratification for progressive multifocal leukoencephalopathy in patients treated with natalizumab

    DEFF Research Database (Denmark)

    Sørensen, Per Soelberg; Bertolotto, Antonio; Edan, Gilles

    2012-01-01

    using or considering natalizumab therapy. Recommendations for clinical management of patients with MS and use of natalizumab are provided based on the presence of these three risk factors. The identification of risk factors that increase the likelihood of PML in natalizumab-treated patients can......Natalizumab is a highly effective immunomodulator in the treatment of multiple sclerosis (MS). Treatment with natalizumab has been associated with progressive multifocal leukoencephalopathy (PML), an infection of the central nervous system (CNS) caused by a pathogenic form of the normally benign JC......-treated patients. With the development of a reliable and validated assay for detection of antibodies in patients with MS directed against JCV, it is now possible to identify persons who are carriers of JCV. The availability of this assay provides an additional option for risk stratification of PML in patients...

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

    Science.gov (United States)

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

    2015-12-01

    High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer. Copyright © 2015. Published by Elsevier Inc.

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

    International Nuclear Information System (INIS)

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

    1991-01-01

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

  3. Coronary Artery Calcium Screening: Does it Perform Better than Other Cardiovascular Risk Stratification Tools?

    Directory of Open Access Journals (Sweden)

    Irfan Zeb

    2015-03-01

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

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

    International Nuclear Information System (INIS)

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

    1985-01-01

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

  5. Treatment of unresectable hepatocellular carcinoma with intrahepatic yttrium 90 microspheres: a risk-stratification analysis.

    Science.gov (United States)

    Goin, James E; Salem, Riad; Carr, Brian I; Dancey, Janet E; Soulen, Michael C; Geschwind, Jean-Francois H; Goin, Kathleen; Van Buskirk, Mark; Thurston, Kenneth

    2005-02-01

    To present the findings of a risk-stratification survival analysis with use of data collected on a heterogeneous group of patients with hepatocellular carcinoma (HCC) treated with TheraSphere. Baseline, treatment, and follow-up data were collected and analyzed from 121 TheraSphere-treated patients. Survival analyses were performed to identify those variables most strongly associated with 3-month mortality. The presence of any of the identified risk variables resulted in the assignment of a patient to the high-risk category. Five liver reserve and two non-liver reserve variables were identified and used to stratify patients into low- or high-risk groups. Sixteen of the 33 patients assigned to the high-risk group (49%) did not survive the first 3 months after treatment, compared with six of the 88 patients assigned to the low-risk group (7%; Fisher exact test, P TheraSpheres should be evaluated for the presence of the risk variables described herein. The absence of these variables is predictive of improved survival (median of 466 days) compared with patients at high risk (median of 108 days).

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

    Science.gov (United States)

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

    2017-07-01

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

  7. Validating a Local Failure Risk Stratification for Use in Prospective Studies of Adjuvant Radiation Therapy for Bladder Cancer

    International Nuclear Information System (INIS)

    Baumann, Brian C.; He, Jiwei; Hwang, Wei-Ting; Tucker, Kai N.; Bekelman, Justin E.; Herr, Harry W.; Lerner, Seth P.; Guzzo, Thomas J.; Malkowicz, S. Bruce; Christodouleas, John P.

    2016-01-01

    Purpose: To inform prospective trials of adjuvant radiation therapy (adj-RT) for bladder cancer after radical cystectomy, a locoregional failure (LF) risk stratification was proposed. This stratification was developed and validated using surgical databases that may not reflect the outcomes expected in prospective trials. Our purpose was to assess sources of bias that may affect the stratification model's validity or alter the LF risk estimates for each subgroup: time bias due to evolving surgical techniques; trial accrual bias due to inclusion of patients who would be ineligible for adj-RT trials because of early disease progression, death, or loss to follow-up shortly after cystectomy; bias due to different statistical methods to estimate LF; and subgrouping bias due to different definitions of the LF subgroups. Methods and Materials: The LF risk stratification was developed using a single-institution cohort (n=442, 1990-2008) and the multi-institutional SWOG 8710 cohort (n=264, 1987-1998) treated with radical cystectomy with or without chemotherapy. We evaluated the sensitivity of the stratification to sources of bias using Fine-Gray regression and Kaplan-Meier analyses. Results: Year of radical cystectomy was not associated with LF risk on univariate or multivariate analysis after controlling for risk group. By use of more stringent inclusion criteria, 26 SWOG patients (10%) and 60 patients from the single-institution cohort (14%) were excluded. Analysis of the remaining patients confirmed 3 subgroups with significantly different LF risks with 3-year rates of 7%, 17%, and 36%, respectively (P<.01), nearly identical to the rates without correcting for trial accrual bias. Kaplan-Meier techniques estimated higher subgroup LF rates than competing risk analysis. The subgroup definitions used in the NRG-GU001 adj-RT trial were validated. Conclusions: These sources of bias did not invalidate the LF risk stratification or substantially change the model's LF estimates.

  8. Characteristic and Preferences of Green Consumer Stratification As Bases to Formulating Marketing Strategies of Ecolabel-Certified Furniture

    OpenAIRE

    Ririn Wulandari; Budi Suharjo; Agus W. Soehadi; Herry Purnomo

    2012-01-01

    International furniture markets certify ecolabel has been growing, but the domestic market has not yet developed. Unfortunate, because these products have two advantages that ensure environmental sustainability and promote a furniture market. This study was expected to open and developed the domestic market for ecolabel-certified furniture. The aim of this study was to develop marketing strategies for ecolabel-certified furniture on each of green consumer stratifications. Consumer stratificat...

  9. Risk stratification and rapid geriatric screening in an emergency department - a quasi-randomised controlled trial.

    Science.gov (United States)

    Foo, Chik Loon; Siu, Vivan Wing Yin; Ang, Hou; Phuah, Madeline Wei Ling; Ooi, Chee Kheong

    2014-08-30

    To determine if risk stratification followed by rapid geriatric screening in an emergency department (ED) reduced functional decline, ED reattendance and hospitalisation. This was a quasi-randomised controlled trial. Patients were randomised by the last digit of their national registration identity card (NRIC). Odd number controls received standard ED care; even number patients received geriatric screening, followed by intervention and/or onward referrals. Patients were followed up for 12 months. There were 500 and 280 patients in the control and intervention groups. The intervention group had higher Triage Risk Screening Tool (TRST) scores (34.3% vs 25.4% TRST ≥3, p = 0.01) and lower baseline Instrumental Activity of Daily Living (IADL) scores (22.84 vs 24.18, p fall risk (65.0%), vision (61.4%), and footwear (58.2%). 28.2% were referred to a geriatric clinic and 11.8% were admitted. 425 (85.0%) controls and 234 (83.6%) in the intervention group completed their follow-up. After adjusting for TRST and baseline IADL, the intervention group had significant preservation in function (Basic ADL -0.99 vs -0.24, p geriatric screening at the request of the ED doctor. A major limitation was that a large proportion of patients who were randomized to the intervention group either refused (18.8%) or left the ED before being approached (32.0%). These two groups were not followed up, and hence were excluded in our analysis. Risk stratification and focused geriatric screening in ED resulted in significant preservation of patients' function at 12 months. National Healthcare Group (NHG) Domain Specific Review Board (DSRB) C/09/023. Registered 5th March 2009.

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

    Science.gov (United States)

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

    2011-01-01

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

  11. Application of multivariate probabilistic (Bayesian) networks to substance use disorder risk stratification and cost estimation.

    Science.gov (United States)

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

    2009-09-16

    This paper explores the use of machine learning and Bayesian classification models to develop broadly applicable risk stratification models to guide disease management of health plan enrollees with substance use disorder (SUD). While the high costs and morbidities associated with SUD are understood by payers, who manage it through utilization review, acute interventions, coverage and cost limitations, and disease management, the literature shows mixed results for these modalities in improving patient outcomes and controlling cost. Our objective is to evaluate the potential of data mining methods to identify novel risk factors for chronic disease and stratification of enrollee utilization, which can be used to develop new methods for targeting disease management services to maximize benefits to both enrollees and payers. For our evaluation, we used DecisionQ machine learning algorithms to build Bayesian network models of a representative sample of data licensed from Thomson-Reuters' MarketScan consisting of 185,322 enrollees with three full-year claim records. Data sets were prepared, and a stepwise learning process was used to train a series of Bayesian belief networks (BBNs). The BBNs were validated using a 10 percent holdout set. The networks were highly predictive, with the risk-stratification BBNs producing area under the curve (AUC) for SUD positive of 0.948 (95 percent confidence interval [CI], 0.944-0.951) and 0.736 (95 percent CI, 0.721-0.752), respectively, and SUD negative of 0.951 (95 percent CI, 0.947-0.954) and 0.738 (95 percent CI, 0.727-0.750), respectively. The cost estimation models produced area under the curve ranging from 0.72 (95 percent CI, 0.708-0.731) to 0.961 (95 percent CI, 0.95-0.971). We were able to successfully model a large, heterogeneous population of commercial enrollees, applying state-of-the-art machine learning technology to develop complex and accurate multivariate models that support near-real-time scoring of novel payer

  12. Customized oligonucleotide microarray gene expression-based classification of neuroblastoma patients outperforms current clinical risk stratification.

    Science.gov (United States)

    Oberthuer, André; Berthold, Frank; Warnat, Patrick; Hero, Barbara; Kahlert, Yvonne; Spitz, Rüdiger; Ernestus, Karen; König, Rainer; Haas, Stefan; Eils, Roland; Schwab, Manfred; Brors, Benedikt; Westermann, Frank; Fischer, Matthias

    2006-11-01

    To develop a gene expression-based classifier for neuroblastoma patients that reliably predicts courses of the disease. Two hundred fifty-one neuroblastoma specimens were analyzed using a customized oligonucleotide microarray comprising 10,163 probes for transcripts with differential expression in clinical subgroups of the disease. Subsequently, the prediction analysis for microarrays (PAM) was applied to a first set of patients with maximally divergent clinical courses (n = 77). The classification accuracy was estimated by a complete 10-times-repeated 10-fold cross validation, and a 144-gene predictor was constructed from this set. This classifier's predictive power was evaluated in an independent second set (n = 174) by comparing results of the gene expression-based classification with those of risk stratification systems of current trials from Germany, Japan, and the United States. The first set of patients was accurately predicted by PAM (cross-validated accuracy, 99%). Within the second set, the PAM classifier significantly separated cohorts with distinct courses (3-year event-free survival [EFS] 0.86 +/- 0.03 [favorable; n = 115] v 0.52 +/- 0.07 [unfavorable; n = 59] and 3-year overall survival 0.99 +/- 0.01 v 0.84 +/- 0.05; both P model, the PAM predictor classified patients of the second set more accurately than risk stratification of current trials from Germany, Japan, and the United States (P < .001; hazard ratio, 4.756 [95% CI, 2.544 to 8.893]). Integration of gene expression-based class prediction of neuroblastoma patients may improve risk estimation of current neuroblastoma trials.

  13. Plaque Tissue Morphology-Based Stroke Risk Stratification Using Carotid Ultrasound: A Polling-Based PCA Learning Paradigm.

    Science.gov (United States)

    Saba, Luca; Jain, Pankaj K; Suri, Harman S; Ikeda, Nobutaka; Araki, Tadashi; Singh, Bikesh K; Nicolaides, Andrew; Shafique, Shoaib; Gupta, Ajay; Laird, John R; Suri, Jasjit S

    2017-06-01

    Severe atherosclerosis disease in carotid arteries causes stenosis which in turn leads to stroke. Machine learning systems have been previously developed for plaque wall risk assessment using morphology-based characterization. The fundamental assumption in such systems is the extraction of the grayscale features of the plaque region. Even though these systems have the ability to perform risk stratification, they lack the ability to achieve higher performance due their inability to select and retain dominant features. This paper introduces a polling-based principal component analysis (PCA) strategy embedded in the machine learning framework to select and retain dominant features, resulting in superior performance. This leads to more stability and reliability. The automated system uses offline image data along with the ground truth labels to generate the parameters, which are then used to transform the online grayscale features to predict the risk of stroke. A set of sixteen grayscale plaque features is computed. Utilizing the cross-validation protocol (K = 10), and the PCA cutoff of 0.995, the machine learning system is able to achieve an accuracy of 98.55 and 98.83%corresponding to the carotidfar wall and near wall plaques, respectively. The corresponding reliability of the system was 94.56 and 95.63%, respectively. The automated system was validated against the manual risk assessment system and the precision of merit for same cross-validation settings and PCA cutoffs are 98.28 and 93.92%for the far and the near wall, respectively.PCA-embedded morphology-based plaque characterization shows a powerful strategy for risk assessment and can be adapted in clinical settings.

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

    Science.gov (United States)

    Goodyear, Stephen J; Yow, Heng; Saedon, Mahmud; Shakespeare, Joanna; Hill, Christopher E; Watson, Duncan; Marshall, Colette; Mahmood, Asif; Higman, Daniel; Imray, Christopher He

    2013-05-19

    In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction.A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison.Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery.

  15. Application of cardiovascular disease risk prediction models and the relevance of novel biomarkers to risk stratification in Asian Indians.

    Science.gov (United States)

    Kanjilal, S; Rao, V S; Mukherjee, M; Natesha, B K; Renuka, K S; Sibi, K; Iyengar, S S; Kakkar, Vijay V

    2008-01-01

    The increasing pressure on health resources has led to the emergence of risk assessment as an essential tool in the management of cardiovascular disease (CVD). Concern exists regarding the validity of their generalization to all populations. Existing risk scoring models do not incorporate emerging 'novel' risk factors. In this context, the aim of the study was to examine the relevance of British, European, and Framingham predictive CVD risk scores to the asymptomatic high risk Indian population. Blood samples drawn from the participants were analyzed for various 'traditional' and 'novel' biomarkers, and their CVD risk factor profiling was also done. The Framingham model defined only 5% of the study cohort to be at high risk, which appears to be an underestimation of CVD risk in this genetically predisposed population. These subjects at high risk had significantly elevated levels of lipid, pro-inflammatory, pro-thrombotic, and serological markers. It is more relevant to develop risk predictive scores for application to the Indian population. This study substantiates the argument that alternative approaches to risk stratification are required in order to make them more adaptable and applicable to different populations with varying risk factor and disease patterns.

  16. The Auckland Cataract Study II: Reducing Complications by Preoperative Risk Stratification and Case Allocation in a Teaching Hospital.

    Science.gov (United States)

    Kim, Bia Z; Patel, Dipika V; McKelvie, James; Sherwin, Trevor; McGhee, Charles N J

    2017-09-01

    To assess the effect of preoperative risk stratification for phacoemulsification surgery on intraoperative complications in a teaching hospital. Prospective cohort study. Prospective assessment of consecutive phacoemulsification cases (N = 500) enabled calculation of a risk score (M-score of 0-8) using a risk stratification system. M-scores of >3 were allocated to senior surgeons. All surgeries were performed in a public teaching hospital setting, Auckland, New Zealand, in early 2016. Postoperatively, data were reviewed for complications and corrected distance visual acuity (CDVA). Results were compared to a prospective study (N = 500, phase 1) performed prior to formal introduction of risk stratification. Intraoperative complications increased with increasing M-scores (P = .044). Median M-score for complicated cases was higher (P = .022). Odds ratio (OR) for a complication increased 1.269 per unit increase in M-score (95% confidence interval [CI] 1.007-1.599, P = .043). Overall rate of any intraoperative complication was 5.0%. Intraoperative complication rates decreased from 8.4% to 5.0% (OR = 0.576, P = .043) comparing phase 1 and phase 2 (formal introduction of risk stratification). The severity of complications also reduced. A significant decrease in complications for M = 0 (ie, minimal risk cases) was also identified comparing the current study (3.1%) to phase 1 (7.2%), P = .034. There was no change in postoperative complication risks (OR 0.812, P = .434) or in mean postoperative CDVA (20/30, P = .484) comparing current with phase 1 outcomes. A simple preoperative risk stratification system, based on standard patient information gathered at preoperative consultation, appears to reduce intraoperative complications and support safer surgical training by appropriate allocation of higher-risk cases. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. Pharmacogenetic Risk Stratification in Angiotensin-Converting Enzyme Inhibitor-Treated Patients with Congestive Heart Failure

    DEFF Research Database (Denmark)

    Nelveg-Kristensen, Karl Emil; Busk Madsen, Majbritt; Torp-Pedersen, Christian

    2015-01-01

    BACKGROUND: Evidence for pharmacogenetic risk stratification of angiotensin-converting enzyme inhibitor (ACEI) treatment is limited. Therefore, in a cohort of ACEI-treated patients with congestive heart failure (CHF), we investigated the predictive value of two pharmacogenetic scores...... SNPs of the angiotensin-converting enzyme gene (rs4343) and ABO blood group genes (rs495828 and rs8176746). METHODS: Danish patients with CHF enrolled in the previously reported Echocardiography and Heart Outcome Study were included. Subjects were genotyped and categorized according to pharmacogenetic.......05 [95% CI 0.79-1.40]), respectively. CONCLUSIONS: We found no association between either of the analyzed pharmacogenetic scores and fatal outcomes in ACEI-treated patients with CHF....

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

    Science.gov (United States)

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

    2016-09-01

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

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

    LENUS (Irish Health Repository)

    Zannad, Faiez

    2012-04-01

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

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

    Science.gov (United States)

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

    2017-03-01

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

  1. Scores for post-myocardial infarction risk stratification in the community.

    Science.gov (United States)

    Singh, Mandeep; Reeder, Guy S; Jacobsen, Steven J; Weston, Susan; Killian, Jill; Roger, Véronique L

    2002-10-29

    Several scores, most of which were derived from clinical trials, have been proposed for stratifying risk after myocardial infarctions (MIs). Little is known about their generalizability to the community, their respective advantages, and whether the ejection fraction (EF) adds prognostic information to the scores. The purpose of this study is to evaluate the Thrombolysis in Myocardial Infarction (TIMI) and Predicting Risk of Death in Cardiac Disease Tool (PREDICT) scores in a geographically defined MI cohort and determine the incremental value of EF for risk stratification. MIs occurring in Olmsted County were validated with the use of standardized criteria and stratified with the ECG into ST-segment elevation (STEMI) and non-ST-segment elevation (NSTEMI) MI. Logistic regression examined the discriminant accuracy of the TIMI and PREDICT scores to predict death and recurrent MI and assessed the incremental value of the EF. After 6.3+/-4.7 years, survival was similar for the 562 STEMIs and 717 NSTEMIs. The discriminant accuracy of the TIMI score was good in STEMI but only fair in NSTEMI. Across time and end points, irrespective of reperfusion therapy, the discriminant accuracy of the PREDICT score was consistently superior to that of the TIMI scores, largely because PREDICT includes comorbidity; EF provided incremental information over that provided by the scores and comorbidity. In the community, comorbidity and EF convey important prognostic information and should be included in approaches for stratifying risk after MI.

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

    Science.gov (United States)

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

    2012-12-01

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

  3. [Comparison of the present and previously used protocol of risk stratification in children with acute lymphoblastic leukemia].

    Science.gov (United States)

    Glodkowska, Eliza; Bialas, Agnieszka; Jackowska, Teresa

    2007-01-01

    Acute lymphoblastic leukaemia (ALL) is one of the most common cancers in children. In Poland, since November 2002 a new protocol of risk stratification has been recommended for assessment of risk factors and for choosing therapy regimens. assessment of accuracy of protocol ALL-IC 2002 in comparison to previously used risk stratification protocols. ALL was diagnosed in 100 children (44 girls, 56 boys; 1-18 years of age) in the Department of Pediatric Hematology and Oncology, Warsaw Medical University, over the period from November 2002 to November 2006. According to the ALL-IC 2002 protocol the patients were divided into three risk groups: SR-standard, IR-intermediate and HR-high. The stratification was by age, leukocyte count, cytogenetic changes, early response to prednisone therapy and bone marrow remission. In the previously used risk stratification protocols-BFM-90, only hepatosplenomegaly and the number of blasts in peripheral blood (PB) were considered, and the patients were divided into three risk groups: low (LRG1.2). out of the 100 patients qualified for treatment regimens according to the ALL-IC 2002 protocol, 97 entered remission, 11 died and 3 had a relapse. Under the ALL-IC 2002 protocol these children were stratified into the following groups: SR-31%, IR-44% and HR-25%. In the previously used stratification, there would be 26% children in low, 46% in the medium and 28% in the high risk group. According to the BFM-90 protocol 18/31 (58%) and 16/44 (36%) patients from the SR and IR groups respectively would be given more intensive treatment. On the other hand 11/44 (25%) and 14/25 (56%) patients from the IR and HR groups respectively would be given less intensive treatment. 1. ALL-IC 2002 protocol in comparison with the previously used protocol BFM-90, changes the qualification of children with ALL for the SR, IR and HR risk groups. This is linked to basic change of treatment protocol, adequate to severity of disease. 2. Children with ALL qualified

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

    Science.gov (United States)

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

    2015-02-01

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

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

    Science.gov (United States)

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

    2017-06-01

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

  6. The emerging role of cardiovascular MRI for risk stratification in hypertrophic cardiomyopathy

    International Nuclear Information System (INIS)

    Hoey, E.T.D.; Teoh, J.K.; Das, I.; Ganeshan, A.; Simpson, H.; Watkin, R.W.

    2014-01-01

    Hypertrophic cardiomyopathy (HCM) is the most common inheritable cardiovascular disorder. Although many HCM patients remain asymptomatic, sudden death (SD) can occur as the initial manifestation of the disease. It has been hypothesized that myocardial architectural disorganization and scarring represent an unstable electrophysiological substrate that creates susceptibility to malignant ventricular arrhythmias. Cardiovascular magnetic resonance imaging (CMR) is widely used for the diagnosis of HCM, especially in patients with an incomplete or inconclusive echocardiography study. CMR can provide precise non-invasive assessment of biventricular function, wall thickness, and assessment of myocardial fibrosis, using inversion recovery gadolinium-enhanced sequences. CMR is also one of the most promising avenues of research in HCM, and in recent years, has provided many new insights and identified a number of potential adverse prognostic indicators for SD. Future work is still needed to integrate CMR findings into traditional risk assessment algorithms. This paper reviews the evolving role of CMR for risk stratification in HCM including assessment of myocardial hypertrophy, fibrosis and ischaemia

  7. A Practical Risk Stratification Approach for Implementing a Primary Care Chronic Disease Management Program in an Underserved Community.

    Science.gov (United States)

    Xu, Junjun; Williams-Livingston, Arletha; Gaglioti, Anne; McAllister, Calvin; Rust, George

    2018-01-01

    The use of value metrics is often dependent on payer-initiated health care management incentives. There is a need for practices to define and manage their own patient panels regardless of payer to participate effectively in population health management. A key step is to define a panel of primary care patients with high comorbidity profiles. Our sample included all patients seen in an urban academic family medicine clinic over a two-year period. The simplified risk stratification was built using internal electronic health record and billing system data based on ICD-9 codes. There were 347 patients classified as high-risk out of the 5,364 patient panel. Average age was 59 years (SD 15). Hypertension (90%), hyperlipidemia (62%), and depression (55%) were the most common conditions among high-risk patients. Simplified risk stratification provides a feasible option for our team to understand and respond to the nuances of population health in our underserved community.

  8. Risk stratification for venous thromboembolism in patients with testicular germ cell tumors.

    Directory of Open Access Journals (Sweden)

    Angelika Bezan

    Full Text Available Patients with testicular germ cell tumors (TGCT have an increased risk for venous thromboembolism (VTE. We identified risk factors for VTE in this patient cohort and developed a clinical risk model.In this retrospective cohort study at the Medical University of Graz we included 657 consecutive TGCT patients across all clinical stages. A predictive model for VTE was developed and externally validated in 349 TGCT patients treated at the University Hospital Zurich.Venous thromboembolic events occurred in 34 (5.2% patients in the Graz cohort. In univariable competing risk analysis, higher clinical stage (cS and a retroperitoneal lymphadenopathy (RPLN were the strongest predictors of VTE (p<0.0001. As the presence of a RPLN with more than 5cm in greatest dimension without coexisting visceral metastases is classified as cS IIC, we constructed an empirical VTE risk model with the following four categories (12-month-cumulative incidence: cS IA-B 8/463 patients (1.7%, cS IS-IIB 5/86 patients (5.9%, cS IIC 3/21 patients (14.3% and cS IIIA-C 15/70 patients (21.4%. This risk model was externally validated in the Zurich cohort (12-month-cumulative incidence: cS IA-B (0.5%, cS IS-IIB (6.0%, cS IIC (11.1% and cS IIIA-C (19.1%. Our model had a significantly higher discriminatory performance than a previously published classifier (RPLN-VTE-risk-classifier which is based on the size of RPLN alone (AUC-ROC: 0.75 vs. 0.63, p = 0.007.According to our risk stratification, TGCT patients with cS IIC and cS III disease have a very high risk of VTE and may benefit from primary thromboprophylaxis for the duration of chemotherapy.

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

    Directory of Open Access Journals (Sweden)

    Elliot B Tapper

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

  10. Role of diastolic function indices in the risk stratification of patients with mixed aortic valve disease.

    Science.gov (United States)

    Egbe, Alexander C; Khan, Arooj R; Boler, Amber; Said, Sameh M; Geske, Jeffrey B; Miranda, William R; Akintoye, Emmanuel; Connolly, Heidi M; Warnes, Carole A; Oh, Jae K

    2018-06-01

    Determine the role of diastolic function indices in pre-operative and post-operative risk stratification in patients with moderate mixed aortic valve disease (MAVD). A retrospective study was conducted of asymptomatic patients with moderate MAVD (a combination of moderate aortic stenosis and moderate aortic regurgitation) and an ejection fraction of 50% or more who were followed up at Mayo Clinic from 1 January 2004, to 31 December 2013. A pre-requisite for inclusion in the study was assessment of diastolic function involving at least three of the following indices: tissue Doppler early diastolic velocity (e'), mitral inflow early velocity (E), tricuspid regurgitation velocity, and left atrial volume index. Primary endpoints were aortic valve replacement (AVR) or cardiac death while secondary endpoints were cardiovascular adverse events (CAEs) after AVR. We defined CAEs as stroke, heart failure hospitalization, severe left ventricular dysfunction, and cardiac death. There were 214 patients (age 61 ± 8 years, men 146 [68%]) followed for 6.1 ± 2.3 years during which 162 (76%) AVRs and 11 (5%) cardiac deaths occurred. The multivariable risk factors for cardiac death or AVR were relative wall thickness (RWT) > 0.42 [hazard ratio (HR), 1.88 [95% CI, 1.28-2.59]; P = 0.001] and average E/e' >14 (HR, 1.94 [95% CI, 1.29-3.01]; P = 0.02). Freedom from CAE after AVR was significantly lower in the patients with baseline RWT >0.42 or mean E/e' >14 than the other patients: 79% (95% CI 74-83%) vs. 94% (95% CI 89-98%) at 3 years (P = 0.03). The presence of RWT >0.42 or E/e' >14 identifies a high-risk patient subset whose risk for cardiovascular morbidities persists even after AVR.

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

    International Nuclear Information System (INIS)

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

    1985-01-01

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

  12. Optimizing risk stratification in heart failure and the selection of candidates for heart transplantation.

    Science.gov (United States)

    Pereira-da-Silva, Tiago; M Soares, Rui; Papoila, Ana Luísa; Pinto, Iola; Feliciano, Joana; Almeida-Morais, Luís; Abreu, Ana; Cruz Ferreira, Rui

    2018-02-01

    Selecting patients for heart transplantation is challenging. We aimed to identify the most important risk predictors in heart failure and an approach to optimize the selection of candidates for heart transplantation. Ambulatory patients followed in our center with symptomatic heart failure and left ventricular ejection fraction ≤40% prospectively underwent a comprehensive baseline assessment including clinical, laboratory, electrocardiographic, echocardiographic, and cardiopulmonary exercise testing parameters. All patients were followed for 60 months. The combined endpoint was cardiac death, urgent heart transplantation or need for mechanical circulatory support, up to 36 months. In the 263 enrolled patients (75% male, age 54±12 years), 54 events occurred. The independent predictors of adverse outcome were ventilatory efficiency (VE/VCO 2 ) slope (HR 1.14, 95% CI 1.11-1.18), creatinine level (HR 2.23, 95% CI 1.14-4.36), and left ventricular ejection fraction (HR 0.96, 95% CI 0.93-0.99). VE/VCO 2 slope was the most accurate risk predictor at any follow-up time analyzed (up to 60 months). The threshold of 39.0 yielded high specificity (97%), discriminated a worse or better prognosis than that reported for post-heart transplantation, and outperformed peak oxygen consumption thresholds of 10.0 or 12.0 ml/kg/min. For low-risk patients (VE/VCO 2 slope <39.0), sodium and creatinine levels and variations in end-tidal carbon dioxide partial pressure on exercise identified those with excellent prognosis. VE/VCO 2 slope was the most accurate parameter for risk stratification in patients with heart failure and reduced ejection fraction. Those with VE/VCO 2 slope ≥39.0 may benefit from heart transplantation. Copyright © 2018 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

  13. Diagnostic performance of an acoustic-based system for coronary artery disease risk stratification.

    Science.gov (United States)

    Winther, Simon; Nissen, Louise; Schmidt, Samuel Emil; Westra, Jelmer Sybren; Rasmussen, Laust Dupont; Knudsen, Lars Lyhne; Madsen, Lene Helleskov; Kirk Johansen, Jane; Larsen, Bjarke Skogstad; Struijk, Johannes Jan; Frost, Lars; Holm, Niels Ramsing; Christiansen, Evald Høj; Botker, Hans Erik; Bøttcher, Morten

    2017-11-09

    Diagnosing coronary artery disease (CAD) continues to require substantial healthcare resources. Acoustic analysis of transcutaneous heart sounds of cardiac movement and intracoronary turbulence due to obstructive coronary disease could potentially change this. The aim of this study was thus to test the diagnostic accuracy of a new portable acoustic device for detection of CAD. We included 1675 patients consecutively with low to intermediate likelihood of CAD who had been referred for cardiac CT angiography. If significant obstruction was suspected in any coronary segment, patients were referred to invasive angiography and fractional flow reserve (FFR) assessment. Heart sound analysis was performed in all patients. A predefined acoustic CAD-score algorithm was evaluated; subsequently, we developed and validated an updated CAD-score algorithm that included both acoustic features and clinical risk factors. Low risk is indicated by a CAD-score value ≤20. Haemodynamically significant CAD assessed from FFR was present in 145 (10.0%) patients. In the entire cohort, the predefined CAD-score had a sensitivity of 63% and a specificity of 44%. In total, 50% had an updated CAD-score value ≤20. At this cut-off, sensitivity was 81% (95% CI 73% to 87%), specificity 53% (95% CI 50% to 56%), positive predictive value 16% (95% CI 13% to 18%) and negative predictive value 96% (95% CI 95% to 98%) for diagnosing haemodynamically significant CAD. Sound-based detection of CAD enables risk stratification superior to clinical risk scores. With a negative predictive value of 96%, this new acoustic rule-out system could potentially supplement clinical assessment to guide decisions on the need for further diagnostic investigation. ClinicalTrials.gov identifier NCT02264717; Results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  14. A clinical risk stratification tool for predicting treatment resistance in major depressive disorder.

    Science.gov (United States)

    Perlis, Roy H

    2013-07-01

    Early identification of depressed individuals at high risk for treatment resistance could be helpful in selecting optimal setting and intensity of care. At present, validated tools to facilitate this risk stratification are rarely used in psychiatric practice. Data were drawn from the first two treatment levels of a multicenter antidepressant effectiveness study in major depressive disorder, the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) cohort. This cohort was divided into training, testing, and validation subsets. Only clinical or sociodemographic variables available by or readily amenable to self-report were considered. Multivariate models were developed to discriminate individuals reaching remission with a first or second pharmacological treatment trial from those not reaching remission despite two trials. A logistic regression model achieved an area under the receiver operating characteristic curve exceeding .71 in training, testing, and validation cohorts and maintained good calibration across cohorts. Performance of three alternative models with machine learning approaches--a naïve Bayes classifier and a support vector machine, and a random forest model--was less consistent. Similar performance was observed between more and less severe depression, men and women, and primary versus specialty care sites. A web-based calculator was developed that implements this tool and provides graphical estimates of risk. Risk for treatment resistance among outpatients with major depressive disorder can be estimated with a simple model incorporating baseline sociodemographic and clinical features. Future studies should examine the performance of this model in other clinical populations and its utility in treatment selection or clinical trial design. Copyright © 2013 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.

  15. Electrophysiologic profile and results of invasive risk stratification in asymptomatic children and adolescents with the Wolff-Parkinson-White electrocardiographic pattern.

    Science.gov (United States)

    Kubuš, Peter; Vít, Pavel; Gebauer, Roman A; Materna, Ondřej; Janoušek, Jan

    2014-04-01

    Data on the results and clinical effect of an invasive risk stratification strategy in asymptomatic young patients with the Wolff-Parkinson-White electrocardiographic pattern are scarce. Eighty-five consecutive patients agedWolff-Parkinson-White pattern and persistent preexcitation at maximum exercise undergoing invasive risk stratification were retrospectively studied. Adverse accessory pathway (AP) properties were defined according to currently consented criteria as any of the following: shortest preexcited RR interval during atrial fibrillation/rapid atrial pacing≤250 ms (or antegrade effective refractory period≤250 ms if shortest preexcited RR interval was not available) or inducible atrioventricular re-entrant tachycardia. Age at evaluation was median 14.9 years. Eighty-two patients had a structurally normal heart and 3 had hypertrophic cardiomyopathy. A single manifest AP was present in 80, 1 manifest and 1 concealed AP in 4, and 2 manifest APs in 1 patient. Adverse AP properties were present in 32 of 85 patients (37.6%) at baseline and in additional 16 of 44 (36.4%) after isoproterenol. Ablation was performed in 41 of these 48 patients. Ablation was deferred in the remaining 7 for pathway proximity to the atrioventricular node. In addition, 18 of the low-risk patients were ablated based on patient/parental decision. Adverse AP properties at baseline were exhibited by 37.6% of the evaluated patients with an asymptomatic Wolff-Parkinson-White preexcitation persisting at peak exercise. Isoproterenol challenge yielded additional 36.4% of those tested at higher risk. Ablation was performed in a total of 69.4% of patients subjected to invasive risk stratification.

  16. Beyond pulmonary edema: diagnostic, risk stratification, and treatment challenges of acute heart failure management in the emergency department.

    Science.gov (United States)

    Collins, Sean; Storrow, Alan B; Kirk, J Douglas; Pang, Peter S; Diercks, Deborah B; Gheorghiade, Mihai

    2008-01-01

    The majority of heart failure hospitalizations in the United States originate in the emergency department (ED). Current strategies for acute heart failure syndromes have largely been tailored after chronic heart failure guidelines and care. Prospective ED-based acute heart failure syndrome trials are lacking, and current guidelines for disposition are based on either little or no evidence. As a result, the majority of ED acute heart failure syndrome patients are admitted to the hospital. Recent registry data suggest there is a significant amount of heterogeneity in acute heart failure syndrome ED presentations, and diagnostics and therapeutics may need to be individualized to the urgency of the presentation, underlying pathophysiology, and acute hemodynamic characteristics. A paradigm shift is necessary in acute heart failure syndrome guidelines and research: prospective trials need to focus on diagnostic, therapeutic, and risk-stratification algorithms that rely on readily available ED data, focusing on outcomes more proximate to the ED visit (5 days). Intermediate outcomes (30 days) are more dependent on inpatient and outpatient care and patient behavior than ED management decisions. Without these changes, the burden of acute heart failure syndrome care is unlikely to change. This article proposes such a paradigm shift in acute heart failure syndrome care and discusses areas of further research that are necessary to promote this change in approach.

  17. Genetic Stratification in Myeloid Diseases: From Risk Assessment to Clinical Decision Support Tool

    Directory of Open Access Journals (Sweden)

    Yishai Ofran

    2014-10-01

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

  18. BRAF mutation in papillary thyroid microcarcinoma – additional marker of risk stratification

    Directory of Open Access Journals (Sweden)

    Dmitriy Yuriyevich Semyonov

    2014-11-01

    Full Text Available BackgroundPapillary thyroid microcarcinoma (PTMC is heterogeneous group of tumor less than 1 cm in the diameter. The volume of surgical treatment stay unstable because unclear biological potential of PTMC.AimThe aim of our study was to assess the utility of BRAF gene mutation as preoperative additional marker of risk stratification.Materials and methodsWe include 44 patient who were operated in general surgery department Pavlov State Medical University from 2001 to 2013. In all 44 cases BRAF gene mutation was detected and compared with clinic-morphological features (multifocality, invasive growth, lymph node metastasis, recurrence retrospectivelyResultsIn our study the frequency of BRAF gene mutation was 68.2%. On multivariate regression analysis the presence of bilateral tumoural foci, lymph node metastasis and the presence of capsular invasion were significantly related to BRAF positive gene status.ConclusionsThus, appropriate volume for the BRAF positive PTMC is thyroidectomy with central compartment lymph node dissection.

  19. Improving risk stratification among veterans diagnosed with prostate cancer: impact of the 17-gene prostate score assay.

    Science.gov (United States)

    Lynch, Julie A; Rothney, Megan P; Salup, Raoul R; Ercole, Cesar E; Mathur, Sharad C; Duchene, David A; Basler, Joseph W; Hernandez, Javier; Liss, Michael A; Porter, Michael P; Wright, Jonathan L; Risk, Michael C; Garzotto, Mark; Efimova, Olga; Barrett, Laurie; Berse, Brygida; Kemeter, Michael J; Febbo, Phillip G; Dash, Atreya

    2018-01-01

    Active surveillance (AS) has been widely implemented within Veterans Affairs' medical centers (VAMCs) as a standard of care for low-risk prostate cancer (PCa). Patient characteristics such as age, race, and Agent Orange (AO) exposure may influence advisability of AS in veterans. The 17-gene assay may improve risk stratification and management selection. To compare management strategies for PCa at 6 VAMCs before and after introduction of the Oncotype DX Genomic Prostate Score (GPS) assay. We reviewed records of patients diagnosed with PCa between 2013 and 2014 to identify management patterns in an untested cohort. From 2015 to 2016, these patients received GPS testing in a prospective study. Charts from 6 months post biopsy were reviewed for both cohorts to compare management received in the untested and tested cohorts. Men who just received their diagnosis and have National Comprehensive Cancer Network (NCCN) very low-, low-, and select cases of intermediate-risk PCa. Patient characteristics were generally similar in the untested and tested cohorts. AS utilization was 12% higher in the tested cohort compared with the untested cohort. In men younger than 60 years, utilization of AS in tested men was 33% higher than in untested men. AS in tested men was higher across all NCCN risk groups and races, particular in low-risk men (72% vs 90% for untested vs tested, respectively). Tested veterans exposed to AO received less AS than untested veterans. Tested nonexposed veterans received 19% more AS than untested veterans. Median GPS results did not significantly differ as a factor of race or AO exposure. Men who receive GPS testing are more likely to utilize AS within the year post diagnosis, regardless of age, race, and NCCN risk group. Median GPS was similar across racial groups and AO exposure groups, suggesting similar biology across these groups. The GPS assay may be a useful tool to refine risk assessment of PCa and increase rates of AS among clinically and

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

    Science.gov (United States)

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

    2013-04-01

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

  1. Simple risk stratification at admission to identify patients with reduced mortality from primary angioplasty

    DEFF Research Database (Denmark)

    Thune, Jens Jakob; Hoefsten, Dan Eik; Lindholm, Matias Greve

    2005-01-01

    BACKGROUND: Randomized trials comparing fibrinolysis with primary angioplasty for acute ST-elevation myocardial infarction have demonstrated a beneficial effect of primary angioplasty on the combined end point of death, reinfarction, and disabling stroke but not on all-cause death. Identifying...... a patient group with reduced mortality from an invasive strategy would be important for early triage. The Thrombolysis in Myocardial Infarction (TIMI) risk score is a simple validated integer score that makes it possible to identify high-risk patients on admission to hospital. We hypothesized that a high...... as high risk. There was a significant interaction between risk status and effect of primary angioplasty (P=0.008). In the low-risk group, there was no difference in mortality (primary angioplasty, 8.0%; fibrinolysis, 5.6%; P=0.11); in the high-risk group, there was a significant reduction in mortality...

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

    Science.gov (United States)

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

    2012-06-01

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

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

    Directory of Open Access Journals (Sweden)

    Ana A. S. Santos

    2016-01-01

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

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

    International Nuclear Information System (INIS)

    Kansal, Rina

    2016-01-01

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

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

    Science.gov (United States)

    Kansal, Rina

    2016-03-01

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

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

    Science.gov (United States)

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

    2014-08-01

    JC virus (JCPyV) has gained novel clinical importance as cause of progressive multifocal leukoencephalopathy (PML), a rare demyelinating disease recently associated to immunomodulatory drugs, such as natalizumab used in multiple sclerosis (MS) cases. Little is known about the mechanisms leading to PML, and this makes the need of PML risk stratification among natalizumab-treated patients very compelling. Clinical and laboratory-based risk-stratification markers have been proposed, one of these is represented by the JCPyV-seropositive status, which includes about 54% of MS patients. We recently proposed to investigate the possible protective role of neutralizing humoral immune response in preventing JCPyV reactivation. In this proof-of-concept study, by cloning the first human monoclonal antibody (GRE1) directed against a neutralizing epitope on JCPyV/VP1, we optimized a robust anti-JCPyV neutralization assay. This allowed us to evaluate the neutralizing activity in JCPyV-positive sera from MS patients, demonstrating the lack of correlation between the level of anti-JCPyV antibody and anti-JCPyV neutralizing activity. Relevant consequences may derive from future clinical studies induced by these findings; indeed the study of the serum anti-JCPyV neutralizing activity could allow not only a better risk stratification of the patients during natalizumab treatment, but also a better understanding of the pathophysiological mechanisms leading to PML, highlighting the contribution of peripheral versus central nervous system JCPyV reactivation. Noteworthy, the availability of GRE1 could allow the design of novel immunoprophylactic strategies during the immunomodulatory treatment. Copyright © 2014 Elsevier B.V. All rights reserved.

  7. Risk Stratification and Effects of Pharmacotherapy in Patients with Acute Myocardial Infarction (AMI) based on data from Pilot AMI Registry

    Czech Academy of Sciences Publication Activity Database

    Peleška, Jan; Grünfeldová, H.; Monhart, Z.; Faltus, Václav; Tomečková, Marie; Ryšavá, D.; Velimský, T.; Ballek, L.; Hubač, J.; Charalampidi, K.; Jánský, P.

    2007-01-01

    Roč. 30 (2007), s. 367-367 ISSN 1420-4096. [Central European Meeting on Hypertension and Cardiovascular Disease Prevention. 11.10.2007-13.10.2007, Kraków] R&D Projects: GA MŠk(CZ) 1M06014 Institutional research plan: CEZ:AV0Z10300504 Keywords : pilot registry of acute myocardial infarction * risk stratification in acute myocardial infarction * effects of pharmacotherapy in acute myocardial infarction Subject RIV: FA - Cardiovascular Disease s incl. Cardiotharic Surgery

  8. Incorporating Stroke and Bleeding Risk Stratification Tools into Atrial Fibrillation Management Making Sense of the Alphabet Soup.

    Science.gov (United States)

    Deering, Thomas F

    2017-01-01

    Atrial fibrillation (AF) is a common arrhythmia managed by many physicians in a variety of clinical settings. One of the most important clinical decisions related to effective AF management centers upon the need to perform accurate thromboembolic risk stratification followed by effective management decisions that align with established guidelines. This manuscript will review the present state of the art and provide guidance to physicians to enhance patient outcomes.

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

    Directory of Open Access Journals (Sweden)

    Taketsugu Tsuchiya

    2016-07-01

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

  10. Risk stratification and detection of new colorectal neoplasms after colorectal cancer screening with faecal occult blood test

    DEFF Research Database (Denmark)

    Bjerrum, Andreas; Milter, Maya Christel; Andersen, Ole

    2015-01-01

    BACKGROUND: Limited data exist on adenoma surveillance as recommended in the European guidelines for quality assurance in colorectal cancer (CRC) screening and diagnosis after faecal occult blood test (FOBT) screening. OBJECTIVE: To assess the European guidelines for adenoma surveillance after CRC...... of CRC was higher in risk group C than A (RR 5.20, 95% confidence interval: 0.63-42.58), but not statistically significant. In risk group C, half of new advanced adenomas were detected within the first year and four of nine CRC were detected within 3 years. CONCLUSION: Risk stratification of adenoma...

  11. Role of late gadolinium enhancement cardiovascular magnetic resonance in the risk stratification of hypertrophic cardiomyopathy.

    Science.gov (United States)

    Ismail, Tevfik F; Jabbour, Andrew; Gulati, Ankur; Mallorie, Amy; Raza, Sadaf; Cowling, Thomas E; Das, Bibek; Khwaja, Jahanzaib; Alpendurada, Francisco D; Wage, Ricardo; Roughton, Michael; McKenna, William J; Moon, James C; Varnava, Amanda; Shakespeare, Carl; Cowie, Martin R; Cook, Stuart A; Elliott, Perry; O'Hanlon, Rory; Pennell, Dudley J; Prasad, Sanjay K

    2014-12-01

    Myocardial fibrosis identified by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM) is associated with adverse cardiovascular events, but its value as an independent risk factor for sudden cardiac death (SCD) is unknown. We investigated the role of LGE-CMR in the risk stratification of HCM. We conducted a prospective cohort study in a tertiary referral centre. Consecutive patients with HCM (n=711, median age 56.3 years, IQR 46.7-66.6; 70.0% male) underwent LGE-CMR and were followed for a median 3.5 years. The primary end point was SCD or aborted SCD. Overall, 471 patients (66.2%) had myocardial fibrosis (median 5.9% of left ventricular mass, IQR: 2.2-13.3). Twenty-two (3.1%) reached the primary end point. The extent but not the presence of fibrosis was a significant univariable predictor of the primary end point (HR per 5% LGE: 1.24, 95% CI 1.06 to 1.45; p=0.007 and HR for LGE: 2.69, 95% CI 0.91 to 7.97; p=0.073, respectively). However, on multivariable analysis, only LV-EF remained statistically significant (HR: 0.92, 95% CI 0.89 to 0.95; p<0.001). For the secondary outcome of cardiovascular mortality/aborted SCD, the presence and the amount of fibrosis were significant predictors on univariable but not multivariable analysis after adjusting for LV-EF and non-sustained ventricular tachycardia. The amount of myocardial fibrosis was a strong univariable predictor of SCD risk. However, this effect was not maintained after adjusting for LV-EF. Further work is required to elucidate the interrelationship between fibrosis and traditional predictors of outcome in HCM. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  12. Risk stratification after paracetamol overdose using mechanistic biomarkers: results from two prospective cohort studies.

    Science.gov (United States)

    Dear, James W; Clarke, Joanna I; Francis, Ben; Allen, Lowri; Wraight, Jonathan; Shen, Jasmine; Dargan, Paul I; Wood, David; Cooper, Jamie; Thomas, Simon H L; Jorgensen, Andrea L; Pirmohamed, Munir; Park, B Kevin; Antoine, Daniel J

    2018-02-01

    Paracetamol overdose is common but patient stratification is suboptimal. We investigated the usefulness of new biomarkers that have either enhanced liver specificity (microRNA-122 [miR-122]) or provide mechanistic insights (keratin-18 [K18], high mobility group box-1 [HMGB1], and glutamate dehydrogenase [GLDH]). The use of these biomarkers could help stratify patients for their risk of liver injury at hospital presentation. Using data from two prospective cohort studies, we assessed the potential for biomarkers to stratify patients who overdose with paracetamol. We completed two independent prospective studies: a derivation study (MAPP) in eight UK hospitals and a validation study (BIOPAR) in ten UK hospitals. Patients in both cohorts were adults (≥18 years in England, ≥16 years in Scotland), were diagnosed with paracetamol overdose, and gave written informed consent. Patients who needed intravenous acetylcysteine treatment for paracetamol overdose had circulating biomarkers measured at hospital presentation. The primary endpoint was acute liver injury indicating need for continued acetylcysteine treatment beyond the standard course (alanine aminotransferase [ALT] activity >100 U/L). Receiver operating characteristic (ROC) curves, category-free net reclassification index (cfNRI), and integrated discrimination index (IDI) were applied to assess endpoint prediction. Between June 2, 2010, and May 29, 2014, 1187 patients who required acetylcysteine treatment for paracetamol overdose were recruited (985 in the MAPP cohort; 202 in the BIOPAR cohort). In the derivation and validation cohorts, acute liver injury was predicted at hospital presentation by miR-122 (derivation cohort ROC-area under the curve [AUC] 0·97 [95% CI 0·95-0·98]), HMGB1 (0·95 [0·93-0·98]), and full-length K18 (0·95 [0·92-0·97]). Results were similar in the validation cohort (miR-122 AUC 0·97 [95% CI 0·95-0·99], HMGB1 0·98 [0·96-0·99], and full-length K18 0·93 [0·86-0·99]). A

  13. [Risk stratification of patients with diabetes mellitus undergoing coronary artery bypass grafting--a comparison of statistical methods].

    Science.gov (United States)

    Arnrich, B; Albert, A; Walter, J

    2006-01-01

    Among the coronary bypass patients from our Datamart database, we found a prevalence of 29.6% of diagnosed diabetics. 5.2% of the patients without a diagnosis of diabetes mellitus and a fasting plasma glucose level > 125 mg/dl were defined as undiagnosed diabetics. The objective of this paper was to compare univariate methods and techniques for risk stratification to determine, whether undiagnosed diabetes is per se a risk factor for increased ventilation time and length of ICU stay, and for increased prevalence of resuscitation, reintubation and 30-d mortality for diabetics in heart surgery. Univariate comparisons reveals that undiagnosed diabetics needed resuscitation significantly more often and had an increased ventilation time, while the length of ICU stay was significantly reduced. The significantly different distribution between the diabetics groups of 11 from 32 attributes examined, demands the use of methods for risk stratification. Both risk adjusted methods regression and matching confirm that undiagnosed diabetics had an increased ventilation time and an increased prevalence of resuscitation, while the length of ICU stay was not significantly reduced. A homogeneous distribution of the patient characteristics in the two diabetics groups could be achieved through a statistical matching method using the propensity score. In contrast to the regression analysis, a significantly increased prevalence of reintubation in undiagnosed diabetics was found. Based on an example of undiagnosed diabetics in heart surgery, the presented study reveals the necessity and the possibilities of techniques for risk stratification in retrospective analysis and shows how the potential of data collection from daily clinical practice can be used in an effective way.

  14. Prognostic factors and risk stratification in patients with castration-resistant prostate cancer receiving docetaxel-based chemotherapy.

    Science.gov (United States)

    Yamashita, Shimpei; Kohjimoto, Yasuo; Iguchi, Takashi; Koike, Hiroyuki; Kusumoto, Hiroki; Iba, Akinori; Kikkawa, Kazuro; Kodama, Yoshiki; Matsumura, Nagahide; Hara, Isao

    2016-03-22

    While novel drugs have been developed, docetaxel remains one of the standard initial systemic therapies for castration-resistant prostate cancer (CRPC) patients. Despite the excellent anti-tumor effect of docetaxel, its severe adverse effects sometimes distress patients. Therefore, it would be very helpful to predict the efficacy of docetaxel before treatment. The aims of this study were to evaluate the potential value of patient characteristics in predicting overall survival (OS) and to develop a risk classification for CRPC patients treated with docetaxel-based chemotherapy. This study included 79 patients with CRPC treated with docetaxel. The variables, including patient characteristics at diagnosis and at the start of chemotherapy, were retrospectively collected. Prognostic factors predicting OS were analyzed using the Cox proportional hazard model. Risk stratification for overall survival was determined based on the results of multivariate analysis. PSA response ≥50 % was observed in 55 (69.6 %) of all patients, and the median OS was 22.5 months. The multivariate analysis showed that age, serum PSA level at the start of chemotherapy, and Hb were independent prognostic factors for OS. In addition, ECOG performance status (PS) and the CRP-to-albumin ratio were not significant but were considered possible predictors for OS. Risk stratification according to the number of these risk factors could effectively stratify CRPC patients treated with docetaxel in terms of OS. Age, serum PSA level at the start of chemotherapy, and Hb were identified as independent prognostic factors of OS. ECOG PS and the CRP-to-albumin ratio were not significant, but were considered possible predictors for OS in Japanese CRPC patients treated with docetaxel. Risk stratification based on these factors could be helpful for estimating overall survival.

  15. Risk stratification of gallbladder polyps (1-2 cm) for surgical intervention with 18F-FDG PET/CT.

    Science.gov (United States)

    Lee, Jaehoon; Yun, Mijin; Kim, Kyoung-Sik; Lee, Jong-Doo; Kim, Chun K

    2012-03-01

    We assessed the value of (18)F-FDG uptake in the gallbladder polyp (GP) in risk stratification for surgical intervention and the optimal cutoff level of the parameters derived from GP (18)F-FDG uptake for differentiating malignant from benign etiologies in a select, homogeneous group of patients with 1- to 2-cm GPs. Fifty patients with 1- to 2-cm GPs incidentally found on the CT portion of PET/CT were retrospectively analyzed. All patients had histologic diagnoses. GP (18)F-FDG activity was visually scored positive (≥liver) or negative (L ratio) were also measured. Univariate and multivariate logistic regression analyses were performed to determine the utility of patient and clinical variables--that is, sex, age, gallstone, polyp size, and three (18)F-FDG-related parameters in risk stratification. Twenty GPs were classified as malignant and 30 as benign. Multivariate analyses showed that the age and all parameters (visual criteria, SUVgp, and GP/L) related to (18)F-FDG uptake were significant risk factors, with the GP/L being the most significant. The sex, size of GPs, and presence of concurrent gallstones were found to be insignificant. (18)F-FDG uptake in a GP is a strong risk factor that can be used to determine the necessity of surgical intervention more effectively than other known risk factors. However, all criteria derived from (18)F-FDG uptake presented in this series may be applicable to the assessment of 1- to 2-cm GPs.

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

    Science.gov (United States)

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

    2015-04-01

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

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

    Science.gov (United States)

    Bourque, Jamieson M; Beller, George A

    2015-11-01

    Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  18. Stratification for smoking in case-cohort studies of genetic polymorphisms and lung cancer

    DEFF Research Database (Denmark)

    Sørensen, Mette; López, Ana García; Andersen, Per Kragh

    2009-01-01

    and adjustment for smoking on the estimated effect of polymorphisms on lung cancer risk was explored in the case-cohort design. We used an empirical and a statistical simulation approach. The stratification strategies were: no smoking stratification, stratification for smoking status and stratification......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...... for smoking duration. The study base was a prospective follow-up study with 57,053 participants. In the simulation approach the glutathione S-transferase T1 null polymorphism, as a model of any polymorphism, was added to simulated data in two different ways, assuming either absence or presence of association...

  19. Power of resting echocardiographic measurements to classify pulmonary hypertension patients according to European society of cardiology exercise testing risk stratification cut-offs.

    Science.gov (United States)

    Rehman, Michaela B; Garcia, Rodrigue; Christiaens, Luc; Larrieu-Ardilouze, Elisa; Howard, Luke S; Nihoyannopoulos, Petros

    2018-04-15

    Right ventricular function is the major determinant of morbidity and mortality in pulmonary arterial hypertension (PAH). The ESC risk assessment strategy for PAH is based on clinical status, exercise testing, NTproBNP, imaging and haemodynamics but does not include right ventricular function. Our aims were to test the power of resting echocardiographic measurements to classify PAH patients according to ESC exercise testing risk stratification cut-offs and to determine if the classification power of echocardiographic parameters varied in chronic thrombo-embolic pulmonary hypertension (CTEPH). We prospectively and consecutively recruited 46 PAH patients and 42 CTEPH patients referred for cardio-pulmonary exercise testing and comprehensive transthoracic echocardiography. Exercise testing parameters analyzed were peak oxygen consumption, percentage of predicted maximal oxygen consumption and the slope of ventilation against carbon dioxide production. Receiver operator characteristic curves were used to determine the optimal diagnostic cut-off values of echocardiographic parameters for classifying the patients in intermediate or high risk category according to exercise testing. Measurements of right ventricular systolic function were the best for classifying in PAH (area under the curve 0.815 to 0.935). Measurements of right ventricular pressure overload (0.810 to 0.909) were optimal for classifying according to exercise testing in CTEPH. Measurements of left ventricular function were of no use in either group. Measurements of right ventricular systolic function can classify according to exercise testing risk stratification cut-offs in PAH. However, this is not the case in CTEPH where pressure overload, rather than right ventricular function seems to be linked to exercise performance. Copyright © 2018 Elsevier B.V. All rights reserved.

  20. Congenital and hereditary causes of sudden cardiac death in young adults: diagnosis, differential diagnosis, and risk stratification.

    Science.gov (United States)

    Stojanovska, Jadranka; Garg, Anubhav; Patel, Smita; Melville, David M; Kazerooni, Ella A; Mueller, Gisela C

    2013-01-01

    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.

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

    Directory of Open Access Journals (Sweden)

    Zhou Yin

    2015-01-01

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

  2. Sudden cardiac arrest in a young patient with hypertrophic cardiomyopathy and zero canonical risk factors: the inherent limitations of risk stratification in hypertrophic cardiomyopathy.

    Science.gov (United States)

    Kohorst, John J; Bos, J Martijn; Hagler, Donald J; Ackerman, Michael J

    2014-01-01

    Hypertrophic cardiomyopathy is the most common heritable cardiovascular disease and a common cause of sudden cardiac death (SCD) in young adolescents and athletes. Clinical risk stratification for SCD is predicated on the presence of established risk factors; however, this assessment is far from perfect. Herein, we present a 16-year-old male who was resuscitated successfully from his sentinel event of out-of-hospital cardiac arrest. Prior to this event, he was asymptomatic and lacked all traditional SCD-predisposing risk factors for hypertrophic cardiomyopathy. © 2013 Wiley Periodicals, Inc.

  3. The HAT Score-A Simple Risk Stratification Score for Coagulopathic Bleeding During Adult Extracorporeal Membrane Oxygenation.

    Science.gov (United States)

    Lonergan, Terence; Herr, Daniel; Kon, Zachary; Menaker, Jay; Rector, Raymond; Tanaka, Kenichi; Mazzeffi, Michael

    2017-06-01

    The study objective was to create an adult extracorporeal membrane oxygenation (ECMO) coagulopathic bleeding risk score. Secondary analysis was performed on an existing retrospective cohort. Pre-ECMO variables were tested for association with coagulopathic bleeding, and those with the strongest association were included in a multivariable model. Using this model, a risk stratification score was created. The score's utility was validated by comparing bleeding and transfusion rates between score levels. Bleeding also was examined after stratifying by nadir platelet count and overanticoagulation. Predictive power of the score was compared against the risk score for major bleeding during anti-coagulation for atrial fibrillation (HAS-BLED). Tertiary care academic medical center. The study comprised patients who received venoarterial or venovenous ECMO over a 3-year period, excluding those with an identified source of surgical bleeding during exploration. None. Fifty-three (47.3%) of 112 patients experienced coagulopathic bleeding. A 3-variable score-hypertension, age greater than 65, and ECMO type (HAT)-had fair predictive value (area under the receiver operating characteristic curve [AUC] = 0.66) and was superior to HAS-BLED (AUC = 0.64). As the HAT score increased from 0 to 3, bleeding rates also increased as follows: 30.8%, 48.7%, 63.0%, and 71.4%, respectively. Platelet and fresh frozen plasma transfusion tended to increase with the HAT score, but red blood cell transfusion did not. Nadir platelet count less than 50×10 3 /µL and overanticoagulation during ECMO increased the AUC for the model to 0.73, suggesting additive risk. The HAT score may allow for bleeding risk stratification in adult ECMO patients. Future studies in larger cohorts are necessary to confirm these findings. Copyright © 2017 Elsevier Inc. All rights reserved.

  4. Value of cyclin A immunohistochemistry for cancer risk stratification in Barrett esophagus surveillance: A multicenter case-control study.

    Science.gov (United States)

    van Olphen, Sophie H; Ten Kate, Fiebo J C; Doukas, Michail; Kastelein, Florine; Steyerberg, Ewout W; Stoop, Hans A; Spaander, Manon C; Looijenga, Leendert H J; Bruno, Marco J; Biermann, Katharina

    2016-11-01

    The value of endoscopic Barrett esophagus (BE) surveillance based on histological diagnosis of low-grade dysplasia (LGD) remains debated given the lack of adequate risk stratification. The aim of this study was to evaluate the predictive value of cyclin A expression and to combine these results with our previously reported immunohistochemical p53, AMACR, and SOX2 data, to identify a panel of biomarkers predicting neoplastic progression in BE.We conducted a case-control study within a prospective cohort of 720 BE patients. BE patients who progressed to high-grade dysplasia (HGD, n = 37) or esophageal adenocarcinoma (EAC, n = 13), defined as neoplastic progression, were classified as cases and patients without neoplastic progression were classified as controls (n = 575). Cyclin A expression was determined by immunohistochemistry in all 625 patients; these results were combined with the histological diagnosis and our previous p53, AMACR, and SOX2 data in loglinear regression models. Differences in discriminatory ability were quantified as changes in area under the ROC curve (AUC) for predicting neoplastic progression.Cyclin A surface positivity significantly increased throughout the metaplasia-dysplasia-carcinoma sequences and was seen in 10% (107/1050) of biopsy series without dysplasia, 33% (109/335) in LGD, and 69% (34/50) in HGD/EAC. Positive cyclin A expression was associated with an increased risk of neoplastic progression (adjusted relative risk (RR) 2.4; 95% CI: 1.7-3.4). Increases in AUC were substantial for P53 (+0.05), smaller for SOX2 (+0.014), minor for cyclin A (+0.003), and none for AMARC (0.00).Cyclin A immunopositivity was associated with an increased progression risk in BE patients. However, compared to p53 and SOX2, the incremental value of cyclin A was limited. The use of biomarkers has the potential to significantly improve risk stratification in BE.

  5. The value of exercise radionuclide ventriculography in risk stratification in patients with known or suspected coronary artery disease

    International Nuclear Information System (INIS)

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

    1985-01-01

    This study examined the value of rest and exercise (EX) radionuclide ventriculography (RNV) in risk stratification in 392 pts with suspected or known coronary artery disease who were being evaluated for anginal symptoms. There were 289 men and 203 women, aged 55 +- 12 years (mean +- SD). There were 20 cardiac events in the followup period of up to 4 years (19 +- 10 months): 14 pts died of cardiac causes and 6 had non-fatal acute myocardial infarctions. The pts with and without events did not differ in age, clinical presentation, risk factors, and rest and EX ECGs. However, pts with events had lower EX systolic blood pressure (p < 0.02); lower EX duration; (5.5 +- 2.5 vs 7.6 +- 3.7 minutes, p < 0.0l), lower resting left ventricular (LV) ejection fraction (EF) (p = 0.001), and lower EX EF (35 +- 17% vs 56 +- 15%, p = 0.0001). The change in EF from rest to EX was not significantly different (-0.1 +- 6.1 vs 3 +- 9.9). Univariate survival analysis (Cox model) showed several descriptors related to prognosis: EX EF, rest EF, wall motion and EX duration. Multivariate analysis, however, identified the EX EF as the only significant predictor (X/sup 2/ = 19.9). None of the other variables added independent information to that provided by the EX EF. Actuarial lie table analysis showed that the risk increased as the EX EF decreased, when pts were grouped into those with EXEF ≥ 50%, 30-49%, and <30%., (p = 0.001, Mantel-Cox). Thus, the EX RNV is useful in risk stratification; the EX EF is the best descriptor that categorizes pts into different risk groups

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

    Science.gov (United States)

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

    2017-09-01

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

  7. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study.

    Science.gov (United States)

    Olesen, Jonas Bjerring; Lip, Gregory Y H; Hansen, Morten Lock; Hansen, Peter Riis; Tolstrup, Janne Schurmann; Lindhardsen, Jesper; Selmer, Christian; Ahlehoff, Ole; Olsen, Anne-Marie Schjerning; Gislason, Gunnar Hilmar; Torp-Pedersen, Christian

    2011-01-31

    To evaluate the individual risk factors composing the CHADS(2) (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke) score and the CHA(2)DS(2)-VASc (CHA(2)DS(2)-Vascular disease, Age 65-74 years, Sex category) score and to calculate the capability of the schemes to predict thromboembolism. Registry based cohort study. Nationwide data on patients admitted to hospital with atrial fibrillation. Population All patients with atrial fibrillation not treated with vitamin K antagonists in Denmark in the period 1997-2006. Stroke and thromboembolism. Of 121,280 patients with non-valvular atrial fibrillation, 73,538 (60.6%) fulfilled the study inclusion criteria. In patients at "low risk" (score = 0), the rate of thromboembolism per 100 person years was 1.67 (95% confidence interval 1.47 to 1.89) with CHADS(2) and 0.78 (0.58 to 1.04) with CHA(2)DS(2)-VASc at one year's follow-up. In patients at "intermediate risk" (score = 1), this rate was 4.75 (4.45 to 5.07) with CHADS(2) and 2.01 (1.70 to 2.36) with CHA(2)DS(2)-VASc. The rate of thromboembolism depended on the individual risk factors composing the scores, and both schemes underestimated the risk associated with previous thromboembolic events. When patients were categorised into low, intermediate, and high risk groups, C statistics at 10 years' follow-up were 0.812 (0.796 to 0.827) with CHADS(2) and 0.888 (0.875 to 0.900) with CHA(2)DS(2)-VASc. The risk associated with a specific risk stratification score depended on the risk factors composing the score. CHA(2)DS(2)-VASc performed better than CHADS(2) in predicting patients at high risk, and those categorised as low risk by CHA(2)DS(2)-VASc were truly at low risk for thromboembolism.

  8. Preoperative risk stratification using metabolic parameters of {sup 18}F-FDG PET/CT in patients with endometrial cancer

    Energy Technology Data Exchange (ETDEWEB)

    Kitajima, Kazuhiro [Kobe University School of Medicine, Department of Radiology, Kobe (Japan); Kobe University Graduate School of Medicine, Department of Radiology, Kobe (Japan); Suenaga, Yuko; Ueno, Yoshiko; Maeda, Tetsuo; Sofue, Keitarou; Sugimura, Kazuro [Kobe University School of Medicine, Department of Radiology, Kobe (Japan); Ebina, Yasuhiko; Yamada, Hideto [Kobe University School of Medicine, Department of Obstetrics and Gynecology, Kobe (Japan); Okunaga, Takashi; Kubo, Kazuhiro [Kobe University Hospital, Department of Radiology Division, Kobe (Japan); Kanda, Tomonori [Teikyo University School of Medicine, Department of Radiology, Tokyo (Japan); Tamaki, Yukihisa [Shimane University School of Medicine, Department of Radiation Oncology, Shimane (Japan)

    2015-07-15

    To evaluate the usefulness of metabolic parameters obtained by {sup 18}F-FDG PET/CT for preoperative stratification of high-risk and low-risk endometrial carcinomas. Preoperative {sup 18}F-FDG PET/CT was performed in 56 women with endometrial cancer. Maximum standardized uptake values (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) of primary tumours were compared with clinicopathological features of surgical specimens. Diagnostic performance in terms of differentiation of low-risk disease (endometrioid histology, histological grade 1 or 2, invasion of less than half of the myometrium, and FIGO stage I) from high-risk disease was assessed. MTV and TLG were significantly higher in patients with higher histological grade (p = 0.0026 and p = 0.034), larger tumour size (p = 0.002 and p = 0.0017), lymphovascular space involvement (LVSI; p = 0.012 and p = 0.0051), myometrial invasion (p = 0.027 and p = 0.031), cervical stromal invasion (p = 0.023 and p = 0.014), ovarian metastasis (p = 0.00022 and p = 0.00034), lymph node metastasis (p < 0.0001 and p < 0.0001), and higher FIGO stage (p = 0.0011 and p = 0.00048). SUVmax was significantly higher in patients with larger tumour size (p = 0.0025), LVSI (p = 0.00023) and myometrial invasion (p < 0.0001). The areas under the ROC curves (AUCs) for distinguishing high-risk from low-risk carcinoma were 0.625, 0.829 and 0.797 for SUVmax, MTV and TLG, respectively. AUCs for both MTV and TLG were significantly larger than that for SUVmax (p = 0.0049 and p = 0.021). The optimal TLG cut-off value of 70.2, determined by ROC analysis, was found to have 72.0 % sensitivity and 74.2 % specificity for risk stratification. MTV and TLG of primary endometrial cancer show better correlations with clinicopathological features and are more useful for differentiating high-risk from low-risk carcinoma than SUVmax. (orig.)

  9. Hodgkin lymphoma: 2018 update on diagnosis, risk-stratification, and management.

    Science.gov (United States)

    Ansell, Stephen M

    2018-05-01

    Hodgkin lymphoma (HL) is an uncommon B-cell lymphoid malignancy affecting 8500 new patients annually and representing approximately 10.2% of all lymphomas in the United States. HL is composed of two distinct disease entities: classical HL and nodular lymphocyte predominant HL. Nodular sclerosis, mixed cellularity, lymphocyte depletion, and lymphocyte-rich HL are subgroups of classical HL. 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. 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 typically treated with combined modality strategies utilizing 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. Newer agents including brentuximab vedotin are now being incorporated into frontline therapy and these new combinations are becoming a standard of care. 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, PD-1 blockade, nonmyeloablative allogeneic transplant or participation in a clinical trial should be considered. © 2018 Wiley Periodicals, Inc.

  10. Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage.

    Science.gov (United States)

    Jensen, Dennis M; Kovacs, Thomas O G; Ohning, Gordon V; Ghassemi, Kevin; Machicado, Gustavo A; Dulai, Gareth S; Sedarat, Alireza; Jutabha, Rome; Gornbein, Jeffrey

    2017-05-01

    For 4 decades, stigmata of recent hemorrhage in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy's lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) (P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143-0.8565) and the number needed to treat was 7. In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F). Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

  11. The risk stratification and prognostic evaluation of soluble programmed death-1 on patients with sepsis in emergency department.

    Science.gov (United States)

    Zhao, Yongzhen; Jia, Yumei; Li, Chunsheng; Fang, Yingying; Shao, Rui

    2018-01-01

    To evaluate the efficacy of soluble programmed death-1 (sPD-1) for risk stratification and prediction of 28-day mortality in patients with sepsis, we compared serum sPD-1 with procalcitonin (PCT), C-reactive protein (CRP), and the Mortality in Emergency Department Sepsis (MEDS) score. A total of 60 healthy volunteers and 595 emergency department (ED) patients were recruited for this prospective cohort study. According to the severity of their condition on ED arrival, the patients were allocated to the systemic inflammatory response syndrome group (130 cases), sepsis group (276 cases), severe sepsis group (121 cases), and septic shock group (68 cases). In addition, all patients with sepsis were also divided into the survivor group (349 cases) and nonsurvivor group (116 cases) according to the 28-day outcomes. When the severity of sepsis increased, the levels of sPD-1 gradually increased. The levels of sPD-1, PCT, CRP and the MEDS score were also higher in the nonsurvivor group compared to the survivor group. Logistic regression suggested that sPD-1, PCT, and the MEDS score were independent risk factors for 28-day mortality of patients with sepsis. Area under the curve (AUC) of sPD-1, PCT and the MEDS score for 28-day mortality was 0.725, 0.693, and 0.767, respectively, and the AUC was improved when all 3 factors were combined (0.843). Serum sPD-1 is positively correlated with the severity of sepsis, and it is valuable for risk stratification of patients and prediction of 28-day mortality. Combining sPD-1 with PCT and the MEDS score improves the prognostic evaluation. Copyright © 2017 Elsevier Inc. All rights reserved.

  12. Clinical risk stratification optimizes value of biomarkers to predict new-onset heart failure in a community-based cohort.

    Science.gov (United States)

    Brouwers, Frank P; van Gilst, Wiek H; Damman, Kevin; van den Berg, Maarten P; Gansevoort, Ron T; Bakker, Stephan J L; Hillege, Hans L; van Veldhuisen, Dirk J; van der Harst, Pim; de Boer, Rudolf A

    2014-09-01

    We aim to identify and quantify the value of biomarkers for incident new-onset heart failure (HF) in a community-based cohort and subgroups based on cardiovascular risk and evaluate the prognostic value of 13 biomarkers for HF with reduced and preserved ejection fraction. Thirteen biomarkers reflecting diverse pathophysiologic domains were examined in 8569 HF-free participants in Prevention of Vascular and Renal Endstage Disease (mean age, 49 years; 50% men). Subjects were categorized in 2 risk groups based on cardiovascular history. Incremental value per biomarker was assessed using Harrell C-indices. One hundred sixty-eight subjects (2.4%) were diagnosed with new-onset HF in the low-risk group (n=6915; Framingham Risk Score, 5.9%) and 206 (12.2%) subjects in the high-risk group (n=1654; Framingham Risk Score, 18.6%). The association of natriuretic peptides, adrenomedullin, endothelin, and galectin-3 with new-onset HF was stronger in the high-risk group (all Prisk for new-onset HF between both risk groups. The best model for new-onset HF included the combination of N-terminal pro-B-type natriuretic peptide, troponin-T, and urinary albumin excretion, increasing model accuracy to 0.81 (9.5%, Prisk group. Except for a modest effect of cystatin-C, no biomarker was associated with increased risk for HF with preserved ejection fraction. Risk stratification increases the incremental value per biomarker to predict new-onset HF, especially HF with reduced ejection fraction. We suggest that routine biomarker testing should be limited to the use of natriuretic peptides and troponin-T in patients with increased cardiovascular risk. © 2014 American Heart Association, Inc.

  13. Stratification devices

    DEFF Research Database (Denmark)

    Andersen, Elsa; Furbo, Simon

    2008-01-01

    Thermal stratification in the storage tank is extremely important in order to achieve high thermal performance of a solar heating system. High temperatures in the top of the storage tank and low temperatures in the bottom of the storage tank lead to the best operation conditions for any solar hea...

  14. Major bleeding and intracranial hemorrhage risk prediction in patients with atrial fibrillation: Attention to modifiable bleeding risk factors or use of a bleeding risk stratification score? A nationwide cohort study.

    Science.gov (United States)

    Chao, Tze-Fan; Lip, Gregory Y H; Lin, Yenn-Jiang; Chang, Shih-Lin; Lo, Li-Wei; Hu, Yu-Feng; Tuan, Ta-Chuan; Liao, Jo-Nan; Chung, Fa-Po; Chen, Tzeng-Ji; Chen, Shih-Ann

    2018-03-01

    While modifiable bleeding risks should be addressed in all patients with atrial fibrillation (AF), use of a bleeding risk score enables clinicians to 'flag up' those at risk of bleeding for more regular patient contact reviews. We compared a risk assessment strategy for major bleeding and intracranial hemorrhage (ICH) based on modifiable bleeding risk factors (referred to as a 'MBR factors' score) against established bleeding risk stratification scores (HEMORR 2 HAGES, HAS-BLED, ATRIA, ORBIT). A nationwide cohort study of 40,450 AF patients who received warfarin for stroke prevention was performed. The clinical endpoints included ICH and major bleeding. Bleeding scores were compared using receiver operating characteristic (ROC) curves (areas under the ROC curves [AUCs], or c-index) and the net reclassification index (NRI). During a follow up of 4.60±3.62years, 1581 (3.91%) patients sustained ICH and 6889 (17.03%) patients sustained major bleeding events. All tested bleeding risk scores at baseline were higher in those sustaining major bleeds. When compared to no ICH, patients sustaining ICH had higher baseline HEMORR 2 HAGES (p=0.003), HAS-BLED (pbleeding scores, c-indexes were significantly higher compared to MBR factors (pbleeding. C-indexes for the MBR factors score was significantly lower compared to all other scores (De long test, all pbleeding risk scores for major bleeding (all pbleeding risk scores had modest predictive value for predicting major bleeding but the best predictive value and NRI was found for the HAS-BLED score. Simply depending on modifiable bleeding risk factors had suboptimal predictive value for the prediction of major bleeding in AF patients, when compared to the HAS-BLED score. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

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

    Directory of Open Access Journals (Sweden)

    Wang J

    2015-09-01

    Full Text Available Jing Wang,* Min Zhou,* Jing-Yan Xu,* Bing Chen, Jian OuyangDepartment of Hematology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, People’s Republic of China*These authors contributed equally to this work and should be considered as cofirst authorsPurpose: To evaluate whether the addition of two biological markers (MYC and BCL-2 protein overexpression improves the stratification of high-risk patients with diffuse large B-cell lymphoma (DLBCL.Method: Seven risk factors were identified at diagnosis, and a maximum of 7 points were assigned to each patient. The patients were classified according to four risk groups: low (0–1, low-intermediate (2–3, high-intermediate (4, and high (5–7. Only high-risk patients with DLBCL were included in this analysis. We retrospectively examined 20 cases from 2008 to 2013 at the Nanjing Drum Tower Hospital.Results: The median expression of MYC protein was 60%, and 17 of 20 (65% evaluable cases overexpressed MYC. The median expression of BCL-2 protein was also 60%. Eighteen of 20 (90% evaluable cases showed BCL-2 overexpression. Additionally, 12 out of 20 cases (60% demonstrated coexpression of MYC and BCL-2 proteins. The percentages of overall survival and progression-free survival at the median follow-up time (36 months were 33.3%±16.1% and 16.9%±13.5%, respectively. By comparison, nine, four, and 20 patients were classified as high risk based on the International Prognostic Index (IPI, National Comprehensive Cancer Network(NCCN-IPI, and revised IPI criteria, respectively. According to the IPI and NCCN-IPI stratification, the risk groups demonstrated closely overlapping survival curves. In addition, four out of 20 cases were identified as low-intermediate risk according to the NCCN-IPI criteria.Conclusion: The addition of MYC and BCL-2 protein expression to the IPI could identify a subset of DLBCL patients with high-risk clinicopathological characteristics and

  16. A novel approach to population-based risk stratification, comprising individualized lifestyle intervention in Danish general practice to prevent chronic diseases

    DEFF Research Database (Denmark)

    Bruun Larsen, Lars; Søndergaard, Jens; Halling, Anders

    2017-01-01

    Early detection of patients at risk seems to be effective for reducing the prevalence of lifestyle-related chronic diseases. We aim to test the feasibility of a novel intervention for early detection of lifestyle-related chronic diseases based on a population-based stratification using a combinat......Early detection of patients at risk seems to be effective for reducing the prevalence of lifestyle-related chronic diseases. We aim to test the feasibility of a novel intervention for early detection of lifestyle-related chronic diseases based on a population-based stratification using...

  17. Developing a risk stratification tool for audit of outcome after surgery for head and neck squamous cell carcinoma.

    Science.gov (United States)

    Tighe, David F; Thomas, Alan J; Sassoon, Isabel; Kinsman, Robin; McGurk, Mark

    2017-07-01

    Patients treated surgically for head and neck squamous cell carcinoma (HNSCC) represent a heterogeneous group. Adjusting for patient case mix and complexity of surgery is essential if reporting outcomes represent surgical performance and quality of care. A case note audit totaling 1075 patients receiving 1218 operations done for HNSCC in 4 cancer networks was completed. Logistic regression, decision tree analysis, an artificial neural network, and Naïve Bayes Classifier were used to adjust for patient case-mix using pertinent preoperative variables. Thirty-day complication rates varied widely (34%-51%; P risk stratification. The artificial neural network demonstrated the best predictive performance (area under the curve [AUC] 0.85). Early postoperative complications are a measurable outcome that can be used to benchmark surgical performance and quality of care. Surgical outcome reporting in national clinical audits should be taking account of the patient case mix. © 2017 Wiley Periodicals, Inc.

  18. Liposarcoma: exploration of clinical prognostic factors for risk based stratification of therapy

    International Nuclear Information System (INIS)

    Kim, Hyo Song; Park, Joon Oh; Kim, Sung Joo; Lee, Jeeyun; Yi, Seong Yoon; Jun, Hyun Jung; Choi, Yoon-La; Ahn, Geung Hwan; Seo, Sung Wook; Lim, Do Hoon; Ahn, Yong Chan

    2009-01-01

    Prognosis and optimal treatment strategies of liposarcoma have not been fully defined. The purpose of this study is to define the distinctive clinical features of liposarcomas by assessing prognostic factors. Between January 1995 and May 2008, 94 liposarcoma patients who underwent surgical resection with curative intent were reviewed. Fifty patients (53.2%) presented with well differentiated, 22 (23.4%) myxoid, 15 (16.0%) dedifferentiated, 5 (5.3%) round cell, and 2 (2.1%) pleomorphic histology. With the median 14 cm sized of tumor burden, about half of the cases were located in the retroperitoneum (46.8%). Seventy two (76.6%) patients remained alive with 78.1%, and 67.5% of the 5- and 10-year overall survival (OS) rates, respectively. Low grade liposarcoma (well differentiated and myxoid) had a significantly prolonged OS and disease free survival (DFS) with adjuvant radiotherapy when compared with those without adjuvant radiotherapy (5-year OS, 100% vs 66.3%, P = 0.03; 1-year DFS, 92.9% vs 50.0%, respectively, P = 0.04). Independent prognostic factors for OS were histologic variant (P = 0.001; HR, 5.1; 95% CI, 2.0 – 12.9), and margin status (P = 0.005; HR, 4.1; 95% CI, 1.6–10.5). We identified three different risk groups: group 1 (n = 66), no adverse factors; group 2, one or two adverse factors (n = 28). The 5-year OS rate for group 1, and 2 were 91.9%, 45.5%, respectively. The histologic subtype, and margin status were independently associated with OS, and adjuvant radiotherapy seems to confer survival benefit in low grade tumors. Our prognostic model for primary liposarcoma demonstrated distinct three groups of patients with good prognostic discrimination

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

    Directory of Open Access Journals (Sweden)

    Marly Uellendahl

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

  20. Cardiac stress test as a risk-stratification tool for posttransplant cardiac outcomes in diabetic kidney transplant recipients.

    Science.gov (United States)

    Singh, Neeraj; Parikh, Samir; Bhatt, Udayan; Vonvisger, Jon; Nori, Uday; Hasan, Ayesha; Samavedi, Srinivas; Andreoni, Kenneth; Henry, Mitchell; Pelletier, Ronald; Rajab, Amer; Elkhammas, Elmahdi; Pesavento, Todd

    2012-12-27

    The utility of cardiac stress testing as a risk-stratification tool before kidney transplantation remains debatable owing to discordance with coronary angiography and outcome yields at different centers. We conducted a retrospective study of 273 diabetic kidney transplant recipients from 2006 to 2010. By protocol, all diabetic patients underwent pharmacological radionucleotide stress test or dobutamine stress echocardiography before transplant. We compared the 1-year cardiac outcomes between those with negative stress test results and those with positive stress test results. Patients with a positive stress test result (n=67) underwent coronary angiogram, and significant coronary artery disease (≥70% coronary stenosis) was found in 35 (52.2%) patients. Of the latter, 32 (91.4%) underwent cardiac revascularization (24 underwent cardiac stenting and 8 underwent coronary artery bypass grafting). The rest (n=35) were treated medically. Within 1 year after transplant, the group with positive stress test results experienced more cardiac events (34.3% vs. 3.9%, P<0.001) including acute myocardial infarction (22.4% vs. 3.4%, P<0.001) and ventricular arrhythmias (8.9% vs. 0.05%, P=0.001), higher all-cause mortality (19.4% vs. 4.8%, P<0.001), and cardiac mortality (17.9% vs. 0.9%, P<0.001) compared with the group with negative stress test results. In this diabetic population, stress testing showed positive and negative predictive values of 34.3% and 96.1%, respectively. Pharmacological cardiac stress testing provided excellent risk stratification in diabetic kidney transplant recipients.

  1. Efficacy of risk stratification in tailoring immunosuppression regimens in kidney transplant patients at the national kidney and transplant institute.

    Science.gov (United States)

    Ledesma-Gumba, M A; Danguilan, R A; Casasola, C C; Ona, E T

    2008-09-01

    To evaluate the efficacy of tailored immunosuppressive regimens prescribed according to a risk stratification scoring system based on the number of HLA mismatches, donor source, panel-reactive antibodies (PRA), and repeat transplant. Patients in a retrospective cohort of 329 kidney transplantations performed from October 2004 to December 2005 were assigned scores of 0, 2, 4, or 6 with higher scores for > or =1 HLA mismatches, PRA > 10%, repeat transplant, and unrelated or deceased donor. Added scores of or = 6 denoted high risk including a CNI-based regimen with an interleukin-2 receptor antibody. The efficacy analysis compared the incidences of biopsy-proven acute rejection episodes (BPAR) at 1 year. Only 227 (69%) of 329 patients had a complete data set and 84 were excluded because they did not follow the prescribed protocol, yielding 113 low- and 30 high-risk patients in the final population. Low-risk patients had a mean PRA of 5.4%, living related donors in 68%, and primary transplants. High-risk patients had a mean PRA of 18.8% (range = 10%-97%), living nonrelated donors in 84%, four deceased donors, and four repeat transplants. The overall 1-year incidence of BPAR was 5.7%. No significant difference (P = .081) was observed in 1-year BPAR between the low- (4.5%) and high-risk (9.8%) groups. Likewise, no significant difference in the 1-year mean serum creatinine was observed according to the CNI. The mean creatinine was 1.12 for cyclosporine and 1.38 for tacrolimus treatment (P = .06) in the low-risk group and 1.08 for cyclosporine and 1.2 for tacrolimus (P = .61) in the high-risk cohort. There was no significant difference in acute rejection rates between the immunologically low- or high-risk patients using tailored immunosuppression, which was effective to minimize its occurrence with good renal function at 1 year.

  2. Novel risk stratification with time course assessment of in-hospital mortality in patients with acute heart failure.

    Directory of Open Access Journals (Sweden)

    Takeshi Yagyu

    Full Text Available Patients with acute heart failure (AHF show various clinical courses during hospitalization. We aimed to identify time course predictors of in-hospital mortality and to establish a sequentially assessable risk model.We enrolled 1,035 consecutive AHF patients into derivation (n = 597 and validation (n = 438 cohorts. For risk assessments at admission, we utilized Get With the Guidelines-Heart Failure (GWTG-HF risk scores. We examined significant predictors of in-hospital mortality from 11 variables obtained during hospitalization and developed a risk stratification model using multiple logistic regression analysis. Across both cohorts, 86 patients (8.3% died during hospitalization. Using backward stepwise selection, we identified five time-course predictors: catecholamine administration, minimum platelet concentration, maximum blood urea nitrogen, total bilirubin, and C-reactive protein levels; and established a time course risk score that could sequentially assess a patient's risk status. The addition of a time course risk score improved the discriminative ability of the GWTG-HF risk score (c-statistics in derivation and validation cohorts: 0.776 to 0.888 [p = 0.002] and 0.806 to 0.902 [p<0.001], respectively. A calibration plot revealed a good relationship between observed and predicted in-hospital mortalities in both cohorts (Hosmer-Lemeshow chi-square statistics: 6.049 [p = 0.642] and 5.993 [p = 0.648], respectively. In each group of initial low-intermediate risk (GWTG-HF risk score <47 and initial high risk (GWTG-HF risk score ≥47, in-hospital mortality was about 6- to 9-fold higher in the high time course risk score group than in the low-intermediate time course risk score group (initial low-intermediate risk group: 20.3% versus 2.2% [p<0.001], initial high risk group: 57.6% versus 8.5% [p<0.001].A time course assessment related to in-hospital mortality during the hospitalization of AHF patients can clearly categorize a patient's on

  3. Usefulness of ST elevation score by using vector-projected virtual 187-channel ECG for risk stratification in patients with Brugada-type ECG pattern

    Directory of Open Access Journals (Sweden)

    Shoko Ishikawa

    2012-08-01

    Conclusion: The ST elevation score in VP-ECG objectively documented the degree of ST elevation in surface ECG in Brugada-type ECG patterns. The ST-elevation score might be useful for risk stratification in patients with asymptomatic Brugada syndrome.

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

    Science.gov (United States)

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

    2013-08-01

    What's known on the subject? and what does the study add?: Previous studies have identified the most important prognostic factors of the likely outcomes of salvage prostate whole-gland ablation, including initial clinical stage, biopsy Gleason score, and PSA (total and doubling time). There is potential for further optimization of candidate selection for salvage cryoablation with curative intent and nadir PSA achieved after whole-gland cryotherapy may provide additional prognostic value. The study shows that the most important prognostic factors of biochemical progression-free survival for patients who have undergone whole-gland salvage prostate cryotherapy are nadir PSA achieved after therapy and pre-therapy biopsy Gleason score. Based on these two prognostic variables, we have identified risk stratification groups (low, intermediate and high) which help predict the expected outcomes of salvage whole-gland prostate cryotherapy in a given patient. This risk stratification constitutes a useful clinical tool in defining which patients maybe best suited for this local salvage treatment method. To assess the prognostic variables predicting the risk of biochemical progression-free survival (bPFS) after salvage prostate whole-gland cryotherapy using the Phoenix definition of bPFS. A total of 132 patients underwent prostate whole-gland salvage cryotherapy with curative intent. No patient underwent neoadjuvant/adjuvant hormonal ablative therapy, and all had extended post-salvage prostate-specific antigen (PSA) follow-up data. Cox univariate and multivariate logistic regression analyses of potential predictors of bPFS were conducted. Kaplan-Meier analyses of bPFS was also performed. At a mean (range) follow-up of 4.3 (0.9-12.7) years, the median (range) post-cryotherapy nadir PSA achieved was 0.17 (0-33.9) ng/mL. On multivariate analysis, predictors of bPFS were nadir PSA post-cryotherapy and pre-salvage biopsy Gleason score (P 2.5 ng/mL or biopsy Gleason score ≥ 7, with

  5. A novel dual-marker expression panel for easy and accurate risk stratification of patients with gastric cancer.

    Science.gov (United States)

    Kanda, Mitsuro; Murotani, Kenta; Tanaka, Haruyoshi; Miwa, Takashi; Umeda, Shinichi; Tanaka, Chie; Kobayashi, Daisuke; Hayashi, Masamichi; Hattori, Norifumi; Suenaga, Masaya; Yamada, Suguru; Nakayama, Goro; Fujiwara, Michitaka; Kodera, Yasuhiro

    2018-05-07

    Development of specific biomarkers is necessary for individualized management of patients with gastric cancer. The aim of this study was to design a simple expression panel comprising novel molecular markers for precise risk stratification. Patients (n = 200) who underwent gastrectomy for gastric cancer were randomly assigned into learning and validation sets. Tissue mRNA expression levels of 15 candidate molecular markers were determined using quantitative PCR analysis. A dual-marker expression panel was created according to concordance index (C-index) values of overall survival for all 105 combinations of two markers in the learning set. The reproducibility and clinical significance of the dual-marker expression panel were evaluated in the validation set. The patient characteristics of the learning and validation sets were well balanced. The C-index values of combinations were significantly higher compared with those of single markers. The panel with the highest C-index (0.718) of the learning set comprised SYT8 and MAGED2, which clearly stratified patients into low-, intermediate-, and high-risk groups. The reproducibility of the panel was demonstrated in the validation set. High expression scores were significantly associated with larger tumor size, vascular invasion, lymph node metastasis, peritoneal metastasis, and advanced disease. The dual-marker expression panel provides a simple tool that clearly stratifies patients with gastric cancer into low-, intermediate-, and high risk after gastrectomy. © 2018 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

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

    Science.gov (United States)

    Edwards, Michelle

    2010-01-01

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

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

    International Nuclear Information System (INIS)

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

    2012-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2012-01-01

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

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

    DEFF Research Database (Denmark)

    Jons, Christian; O-Uchi, Jin; Moss, Arthur J

    2011-01-01

    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...

  10. Risk stratification of aortic aneurysms : Predictors of natural and clinical course

    NARCIS (Netherlands)

    Schlösser, F.J.V.

    2008-01-01

    Rupture of an abdominal aortic aneurysm (AAA) is a dramatic and often fatal process with an overall risk of mortality that ranges from 79 to 94%. The risk of AAA rupture increases strongly with increasing diameter of the AAA. Approximately 14,000 persons die each year due to aortic aneurysm rupture

  11. Risk stratification of patients with combined acute pulmonary embolism and pulmonary hypertension using dynamic and regular pulmonary perfusion imaging

    International Nuclear Information System (INIS)

    Wang Xuemei; Wang Jing; Li Guohua; Wang Xiangcheng; Zhang Kaixiu; Liu Caiping

    2010-01-01

    Objective: To stratify the risks of patients with acute pulmonary embolism (APE) and pulmonary hypertension (PH) by dynamic pulmonary perfusion imaging (DPPI) and pulmonary perfusion imaging (PPI). Methods: From October 2007 to February 2009, 20 healthy volunteers (12 males, 8 females; mean age =48.47±13.47 years) and 31 APE patients (21 males, 10 females; mean age =47.68±18.06 years; from October 2007 to July 2009) were included in the study. DPPI and PPI were performed in all subjects. Percentage of perfusion defect scores (PPDs%) were calculated by semi-quantitative analysis of PPI. Risk levels were defined according to PPDs% calculated from PPI: normal (PPDs% =0); very low risk (0 60%). Lung equilibrium time (LET) was calculated on region of interest (ROI) drawn over DPPI. Clinical risk was scored by Aujesky method.The t-test, ANOVA and correlation analysis were used with SPSS 13.0 software. Results: (1) LET in healthy volunteers and APE patients was (12.18±3.28) and (32.90±14.29) s respectively (t = 6.81, P<0.01). (2) The correlation coefficient, coefficient of determination between LET and PPDs% in APE patients were 0.93 and 0.87, respectively. The correlation coefficient between LET and clinical risk score was 0.86. (3) The mean LET of APE patients in very low risk (n =5), low risk (n = 12), moderate risk (n=9), high risk (n=4) and very high risk groups (n=1) were (19.59 ±0.04), (25.03±0.08), (36.07±0.10), (57.15±0.06) and (70±0.00) s, respectively. There was significant difference among APE patients with different risk levels (F =16.78, P<0.01). Conclusions: (1) DPPI was a reliable, convenient and non-invasive method for the evaluation of PH in APE. (2) Combined LET of DPPI and PPDs% of PPI was valuable for risk stratification and prognosis estimation in APE patients. (authors)

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

    Science.gov (United States)

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

    2017-01-01

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

  13. Ischemic risk stratification by means of multivariate analysis of the heart rate variability

    International Nuclear Information System (INIS)

    Valencia, José F; Vallverdú, Montserrat; Caminal, Pere; Porta, Alberto; Voss, Andreas; Schroeder, Rico; Vázquez, Rafael; Bayés de Luna, Antonio

    2013-01-01

    In this work, a univariate and multivariate statistical analysis of indexes derived from heart rate variability (HRV) was conducted to stratify patients with ischemic dilated cardiomyopathy (IDC) in cardiac risk groups. Indexes conditional entropy, refined multiscale entropy (RMSE), detrended fluctuation analysis, time and frequency analysis, were applied to the RR interval series (beat-to-beat series), for single and multiscale complexity analysis of the HRV in IDC patients. Also, clinical parameters were considered. Two different end-points after a follow-up of three years were considered: (i) analysis A, with 151 survivor patients as a low risk group and 13 patients that suffered sudden cardiac death as a high risk group; (ii) analysis B, with 192 survivor patients as a low risk group and 30 patients that suffered cardiac mortality as a high risk group. A univariate and multivariate linear discriminant analysis was used as a statistical technique for classifying patients in risk groups. Sensitivity (Sen) and specificity (Spe) were calculated as diagnostic criteria in order to evaluate the performance of the indexes and their linear combinations. Sen and Spe values of 80.0% and 72.9%, respectively, were obtained during daytime by combining one clinical parameter and one index from RMSE, and during nighttime Sen = 80% and Spe = 73.4% were attained by combining one clinical factor and two indexes from RMSE. In particular, relatively long time scales were more relevant for classifying patients into risk groups during nighttime, while during daytime shorter scales performed better. The results suggest that the left atrial size, indexed to body surface and RMSE indexes are those that allow enhanced classification of ischemic patients in their respective risk groups, confirming that a single measurement is not enough to fully characterize ischemic risk patients and the clinical relevance of HRV complexity measures. (paper)

  14. National Veterans Health Administration inpatient risk stratification models for hospital-acquired acute kidney injury

    OpenAIRE

    Cronin, Robert M; VanHouten, Jacob P; Siew, Edward D; Eden, Svetlana K; Fihn, Stephan D; Nielson, Christopher D; Peterson, Josh F; Baker, Clifton R; Ikizler, T Alp; Speroff, Theodore; Matheny, Michael E

    2015-01-01

    Objective Hospital-acquired acute kidney injury (HA-AKI) is a potentially preventable cause of morbidity and mortality. Identifying high-risk patients prior to the onset of kidney injury is a key step towards AKI prevention.

  15. Pneumonia Risk Stratification Scores for Children in Low-Resource Settings: A Systematic Literature Review.

    Science.gov (United States)

    Deardorff, Katrina V; McCollum, Eric D; Ginsburg, Amy Sarah

    2017-12-22

    Pneumonia is the leading infectious cause of death among children less than five years of age. Predictive tools, commonly referred to as risk scores, can be employed to identify high-risk children early for targeted management to prevent adverse outcomes. This systematic review was conducted to identify pediatric pneumonia risk scores developed, validated, and implemented in low-resource settings. We searched CAB Direct, Cochrane Reviews, Embase, PubMed, Scopus, and Web of Science for studies that developed formal risk scores to predict treatment failure or mortality among children less than five years of age diagnosed with a respiratory infection or pneumonia in low-resource settings. Data abstracted from articles included location and study design, sample size, age, diagnosis, score features and model discrimination. Three pediatric pneumonia risk scores predicted mortality specifically, and two treatment failure. Scores developed using World Health Organization recommended variables for pneumonia assessment demonstrated better predictive fit than scores developed using alternative features. Scores developed using routinely collected healthcare data performed similarly well as those developed using clinical trial data. No score has been implemented in low-resource settings. While pediatric pneumonia-specific risk scores have been developed and validated, it is yet unclear if implementation is feasible, what impact, if any, implemented scores may have on child outcomes, or how broadly scores may be generalized. To increase the feasibility of implementation, future research should focus on developing scores based on routinely collected data.

  16. Mean platelet volume as a risk stratification tool in the Emergency Department for evaluating patients with ischaemic stroke and TIA

    International Nuclear Information System (INIS)

    Dogan, N.O.; Karakurt, K.

    2013-01-01

    Objective: To investigate the variations of mean platelet volume in patients with ischaemic cerebrovascular complaints, and to find out its diagnostic utility in an acute setting to help risk stratification in patients with ischaemic stroke and transient ischaemic attacks. Methods: The prospective cross-sectional study was conducted at the Gazi University Hospital, Ankara, Turkey, from November 2009 to June 2010. It comprised 143 consecutive patients of acute ischaemic stroke, 39 patients of transient ischaemic attacks and 60 healthy volunteers. SPSS 13 was used for statistical analysis, and so were t-test, one-way analysis of variance test and correlation analysis. Statistical significance was accepted at p <0.05. Results: Mean platelet volume results were significantly higher in patients with cortical infarction and transient ischaemic attack compared to the control group (p <0.001 and p <0.002). A statistically significant increase was also noted in hospitalised patients when compared with discharged patients from the emergency department (p <0.036). A weak positive correlation was identified between the National Institute of Health Stroke Scores and mean platelet volume levels (r=0.207; p <0.001). A significant relationship was identified between mean platelet volume levels and previous stroke (p <0.005). Conclusion: The measurement of mean platelet volume levels may provide useful diagnostic and prognostic information to emergency physicians caring for patients with transient ischaemic attack and ischaemic stroke. In patients with suspected neurological ischaemic symptoms, high levels may be considered as an atherosclerotic risk factor. (author)

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

    Directory of Open Access Journals (Sweden)

    Francisco Javier eGimeno-Blanes

    2016-03-01

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

  18. Novel Two-Step Classifier for Torsades de Pointes Risk Stratification from Direct Features

    Directory of Open Access Journals (Sweden)

    Jaimit Parikh

    2017-11-01

    Full Text Available While pre-clinical Torsades de Pointes (TdP risk classifiers had initially been based on drug-induced block of hERG potassium channels, it is now well established that improved risk prediction can be achieved by considering block of non-hERG ion channels. The current multi-channel TdP classifiers can be categorized into two classes. First, the classifiers that take as input the values of drug-induced block of ion channels (direct features. Second, the classifiers that are built on features extracted from output of the drug-induced multi-channel blockage simulations in the in-silico models (derived features. The classifiers built on derived features have thus far not consistently provided increased prediction accuracies, and hence casts doubt on the value of such approaches given the cost of including biophysical detail. Here, we propose a new two-step method for TdP risk classification, referred to as Multi-Channel Blockage at Early After Depolarization (MCB@EAD. In the first step, we classified the compound that produced insufficient hERG block as non-torsadogenic. In the second step, the role of non-hERG channels to modulate TdP risk are considered by constructing classifiers based on direct or derived features at critical hERG block concentrations that generates EADs in the computational cardiac cell models. MCB@EAD provides comparable or superior TdP risk classification of the drugs from the direct features in tests against published methods. TdP risk for the drugs highly correlated to the propensity to generate EADs in the model. However, the derived features of the biophysical models did not improve the predictive capability for TdP risk assessment.

  19. Coronary risk stratification of patients undergoing surgery for valvular heart disease.

    Science.gov (United States)

    Hasselbalch, Rasmus Bo; Engstrøm, Thomas; Pries-Heje, Mia; Heitmann, Merete; Pedersen, Frants; Schou, Morten; Mickley, Hans; Elming, Hanne; Steffensen, Rolf; Køber, Lars; Iversen, Kasper

    2017-01-15

    Multislice computed tomography (MSCT) is a non-invasive, less expensive, low-radiation alternative to coronary angiography (CAG) prior to valvular heart surgery. MSCT has a high negative predictive value for coronary artery disease (CAD) but previous studies of patients with valvular disease have shown that MSCT, as the primary evaluation technique, lead to re-evaluation with CAG in about a third of cases and it is therefore not recommended. If a subgroup of patients with low- to intermediate risk of CAD could be identified and examined with MSCT, it could be cost-effective, reduce radiation and the risk of complications associated with CAG. The study cohort was derived from a national registry of patients undergoing CAG prior to valvular heart surgery. Using logistic regression, we identified significant risk factors for CAD and developed a risk score (CT-valve score). The score was validated on a similar cohort of patients from another registry. The study cohort consisted of 2221 patients, 521 (23.5%) had CAD. The validation cohort consisted of 2575 patients, 771 (29.9%) had CAD. The identified risk factors were male sex, age, smoking, hyperlipidemia, hypertension, aortic valve disease, extracardiac arteriopathy, ejection fraction <30% and diabetes mellitus. CT-valve score could identify a third of the population with a risk about 10%. A score based on risk factors of CAD can identify patients that might benefit from using MSCT as a gatekeeper to CAG prior to heart valve surgery. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  20. Risk Stratification of iodine-induced thyrotoxicosis before contrast agent application

    International Nuclear Information System (INIS)

    Fricke, E.

    2004-01-01

    Today, examinations using iodine containing contrast media are rather frequent. Even though in modern contrast agents the content of free iodine is low, in vivo deiodination results in a non physiologic high iodine load of the thyroid gland. Whilst in normal thyroid tissue iodine metabolism and hormone production are self-regulating in spite of the variable iodine load, those mechanisms are disturbed in autonomous thyroid tissue. Clinical studies displayed low risk of iodine induced thyrotoxicosis after application of contrast agent. Nonetheless the clinician has to assess the risk of thyrotoxicosis for each individual patient and he has to decide how to cope with this risk. Thyroid scintigraphy using Tc-99m-pertechnetate with quantitative measurement of the thyroidal uptake (TcTU) has been shown to be a useful tool in this question, especially when performed under suppression of the non-autonomous tissue (TcTUs). In particular patients with pre-existing suppression of the TSH secretion should be selected for this investigation. Also at risk are elderly persons and those with diffuse or nodular goitres. In spite of the high frequency of contrast agent applications, data on scintigraphy for risk evaluation of thyrotoxicosis and on efficacy of prophylactic medication are scarce. Based on own results and on a review of literature, the risk of thyrotoxicosis seems to be negligible in patients with a TcTUs of less than 1% even in case of preexistent latent hyperthyroidism. If a suppressed TSH level is known and TcTUs is higher than 1%, prophylactic medication should be given. There is evidence for a combination therapy inhibiting both iodine uptake and metabolism, i.e. with perchlorate and thiamazole, being more efficient than monotherapy, particularly in patients with high risk of thyrotoxicosis. (orig.)

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

    Science.gov (United States)

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

    2017-03-01

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

  2. Risk Stratification of iodine-induced thyrotoxicosis before contrast agent application; Prognosebeurteilung bei geplanter Kontrastmittelexposition

    Energy Technology Data Exchange (ETDEWEB)

    Fricke, E. [Inst. fuer Molekulare Biophysik, Radiochemie und Nuklearmedizin, Herz- und Diabeteszentrum, Nordrheinwestfalen, Bad Oeynhausen (Germany)

    2004-06-01

    Today, examinations using iodine containing contrast media are rather frequent. Even though in modern contrast agents the content of free iodine is low, in vivo deiodination results in a non physiologic high iodine load of the thyroid gland. Whilst in normal thyroid tissue iodine metabolism and hormone production are self-regulating in spite of the variable iodine load, those mechanisms are disturbed in autonomous thyroid tissue. Clinical studies displayed low risk of iodine induced thyrotoxicosis after application of contrast agent. Nonetheless the clinician has to assess the risk of thyrotoxicosis for each individual patient and he has to decide how to cope with this risk. Thyroid scintigraphy using Tc-99m-pertechnetate with quantitative measurement of the thyroidal uptake (TcTU) has been shown to be a useful tool in this question, especially when performed under suppression of the non-autonomous tissue (TcTUs). In particular patients with pre-existing suppression of the TSH secretion should be selected for this investigation. Also at risk are elderly persons and those with diffuse or nodular goitres. In spite of the high frequency of contrast agent applications, data on scintigraphy for risk evaluation of thyrotoxicosis and on efficacy of prophylactic medication are scarce. Based on own results and on a review of literature, the risk of thyrotoxicosis seems to be negligible in patients with a TcTUs of less than 1% even in case of preexistent latent hyperthyroidism. If a suppressed TSH level is known and TcTUs is higher than 1%, prophylactic medication should be given. There is evidence for a combination therapy inhibiting both iodine uptake and metabolism, i.e. with perchlorate and thiamazole, being more efficient than monotherapy, particularly in patients with high risk of thyrotoxicosis. (orig.)

  3. European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults

    DEFF Research Database (Denmark)

    Russ, Gilles; Bonnema, Steen J; Erdogan, Murat Faik

    2017-01-01

    Thyroid ultrasound (US) is a key examination for the management of thyroid nodules. Thyroid US is easily accessible, noninvasive, and cost-effective, and is a mandatory step in the workup of thyroid nodules. The main disadvantage of the method is that it is operator dependent. Thyroid US assessment......, called EU-TIRADS. This comprises a thyroid US lexicon; a standardized report; definitions of benign and low-, intermediate-, and high-risk nodules, with the estimated risks of malignancy in each category; and indications for FNA. Illustrated by numerous US images, the EU-TIRADS aims to serve physicians...

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

    Energy Technology Data Exchange (ETDEWEB)

    Waxweiler, Timothy V., E-mail: timothy.waxweiler@ucdenver.edu [Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado (United States); Rusthoven, Chad G. [Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado (United States); Proper, Michelle S. [Department of Radiation Oncology, Billings Clinic, Billings, Montana (United States); Cost, Carrye R. [Division of Hematology and Oncology, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado (United States); Cost, Nicholas G. [Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado (United States); Donaldson, Nathan [Department of Orthopedics, University of Colorado Denver School of Medicine, Aurora, Colorado (United States); Garrington, Timothy; Greffe, Brian S. [Division of Hematology and Oncology, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado (United States); Heare, Travis [Department of Orthopedics, University of Colorado Denver School of Medicine, Aurora, Colorado (United States); Macy, Margaret E. [Division of Hematology and Oncology, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado (United States); Liu, Arthur K. [Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado (United States)

    2015-06-01

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

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

    International Nuclear Information System (INIS)

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

    1990-01-01

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

  6. Molecular markers of carcinogenesis for risk stratification of individuals with colorectal polyps: a case-control study.

    Science.gov (United States)

    Gupta, Samir; Sun, Han; Yi, Sang; Storm, Joy; Xiao, Guanghua; Balasubramanian, Bijal A; Zhang, Song; Ashfaq, Raheela; Rockey, Don C

    2014-10-01

    Risk stratification using number, size, and histology of colorectal adenomas is currently suboptimal for identifying patients at increased risk for future colorectal cancer. We hypothesized that molecular markers of carcinogenesis in adenomas, measured via immunohistochemistry, may help identify high-risk patients. To test this hypothesis, we conducted a retrospective, 1:1 matched case-control study (n = 216; 46% female) in which cases were patients with colorectal cancer and synchronous adenoma and controls were patients with adenoma but no colorectal cancer at baseline or within 5 years of follow-up. In phase I of analyses, we compared expression of molecular markers of carcinogenesis in case and control adenomas, blind to case status. In phase II of analyses, patients were randomly divided into independent training and validation groups to develop a model for predicting case status. We found that seven markers [p53, p21, Cox-2, β-catenin (BCAT), DNA-dependent protein kinase (DNApkcs), survivin, and O6-methylguanine-DNA methyltransferase (MGMT)] were significantly associated with case status on unadjusted analyses, as well as analyses adjusted for age and advanced adenoma status (P marker component). When applied to the validation set, a predictive model using these seven markers showed substantial accuracy for identifying cases [area under the receiver operation characteristic curve (AUC), 0.83; 95% confidence interval (CI), 0.74-0.92]. A parsimonious model using three markers performed similarly to the seven-marker model (AUC, 0.84). In summary, we found that molecular markers of carcinogenesis distinguished adenomas from patients with and without colorectal cancer. Furthermore, we speculate that prospective studies using molecular markers to identify individuals with polyps at risk for future neoplasia are warranted. ©2014 American Association for Cancer Research.

  7. Does quantifying epicardial and intrathoracic fat with noncontrast computed tomography improve risk stratification beyond calcium scoring alone?

    Science.gov (United States)

    Forouzandeh, Farshad; Chang, Su Min; Muhyieddeen, Kamil; Zaid, Rashid R; Trevino, Alejandro R; Xu, Jiaqiong; Nabi, Faisal; Mahmarian, John J

    2013-01-01

    Noncontrast cardiac computed tomography allows calculation of coronary artery calcium score (CACS) and measurement of epicardial adipose tissue (EATv) and intrathoracic fat (ITFv) volumes. It is unclear whether fat volume information contributes to risk stratification. Cardiac computed tomography was performed in 760 consecutive patients with acute chest pain admitted thorough the emergency department. None had prior coronary artery disease. CACS was calculated using the Agatston method. EATv and ITFv were semiautomatically calculated. Median patient follow-up was 3.3 years. Mean patient age was 54.4±13.7 years and Framingham risk score 8.2±8.2. The 45 patients (5.9%) with major acute cardiac events (MACE) were older (64.8±13.9 versus 53.7±13.4 years), more frequently male (60% versus 40%), and had a higher median Framingham risk score (16 versus 4) and CACS (268 versus 0) versus those without events (all PEATv (154 versus 116 mL) and ITFv (330 versus 223 mL), and a higher prevalence of EATv >125 mL (67% versus 44%) and ITFv >250 mL (64% versus 42%) (all PEATv, and ITFv were all independently associated with MACE. CACS was associated with MACE after adjustment for fat volumes (PEATv and ITFv improved the risk model only in patients with CACS >400. CACS and fat volumes are independently associated with MACE in acute chest pain patients and beyond that provided by clinical information alone. Although fat volumes may add prognostic value in patients with CACS >400, CACS is most strongly correlated with outcome.

  8. Value of Cardiovascular Magnetic Resonance Imaging in Noninvasive Risk Stratification in Tetralogy of Fallot

    NARCIS (Netherlands)

    Bokma, Jouke P.; de Wilde, Koen C.; Vliegen, Hubert W.; van Dijk, Arie P.; van Melle, Joost P.; Meijboom, Folkert J.; Zwinderman, Aeilko H.; Groenink, Maarten; Mulder, Barbara J. M.; Bouma, Berto J.

    IMPORTANCE Adults late after total correction of tetralogy of Fallot (TOF) are at risk for majorcomplications. Cardiovascular magnetic resonance (CMR) imaging is recommended toquantify right ventricular (RV) and left ventricular (LV) function. However, a commonly usedrisk model by Khairy et al

  9. Pulmonary embolism in old age: usefulness of risk stratification in clinical decision-making

    Directory of Open Access Journals (Sweden)

    Carlo Bova

    2016-10-01

    Full Text Available Pulmonary embolism (PE is a common disease with a not negligible short-term risk of death, in particular in the elderly. An adequate evaluation of the prognosis in patients with PE may guide decision-making in terms of the intensity of the initial treatment during the acute phase. Patients with shock or persistent hypotension are at high risk of early mortality and may benefit from immediate reperfusion. Several tools are available to define the short-term prognosis of hemodynamically stable patients. The pulmonary embolism severity index (PESI score, and the simplified PESI score are particularly useful for identifying patients at low risk of early complications who might be safely treated at home. The identification of patients who are hemodynamically stable at diagnosis but are at a high risk of early complications is more challenging. Current guidelines recommend a multi-parametric prognostic algorithm based on the clinical status, biomarkers and imaging tests. However an aggressive treatment in hemodynamically stable patients is still controversial.

  10. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation

    DEFF Research Database (Denmark)

    Olesen, Jonas Bjerring; Lip, Gregory Y H; Hansen, Morten Lock

    2011-01-01

    To evaluate the individual risk factors composing the CHADS(2) (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke) score and the CHA(2)DS(2)-VASc (CHA(2)DS(2)-Vascular disease, Age 65-74 years, Sex category) score and to calculate the capability of the schemes to p...

  11. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation

    DEFF Research Database (Denmark)

    Olesen, Jonas Bjerring; Lip, Gregory Y H; Hansen, Morten Lock

    2011-01-01

    Objectives To evaluate the individual risk factors composing the CHADS2 (Congestive heart failure, Hypertension, Age=75 years, Diabetes, previous Stroke) score and the CHA2DS2-VASc (CHA2DS2-Vascular disease, Age 65-74 years, Sex category) score and to calculate the capability of the schemes to pr...

  12. Programmed Ventricular Stimulation for Risk Stratification in the Brugada Syndrome: A Pooled Analysis

    NARCIS (Netherlands)

    Sroubek, Jakub; Probst, Vincent; Mazzanti, Andrea; Delise, Pietro; Hevia, Jesus Castro; Ohkubo, Kimie; Zorzi, Alessandro; Champagne, Jean; Kostopoulou, Anna; Yin, Xiaoyan; Napolitano, Carlo; Milan, David J.; Wilde, Arthur; Sacher, Frederic; Borggrefe, Martin; Ellinor, Patrick T.; Theodorakis, George; Nault, Isabelle; Corrado, Domenico; Watanabe, Ichiro; Antzelevitch, Charles; Allocca, Giuseppe; Priori, Silvia G.; Lubitz, Steven A.

    2016-01-01

    The role of programmed ventricular stimulation in identifying patients with Brugada syndrome at the highest risk for sudden death is uncertain. We performed a systematic review and pooled analysis of prospective, observational studies of patients with Brugada syndrome without a history of sudden

  13. Risk stratification for healthcare planning in women with gestational diabetes mellitus

    NARCIS (Netherlands)

    Koning, S. H.; Scheuneman, K. A.; Lutgers, H. L.; Korteweg, F. J.; van den Berg, G.; Sollie, K. M.; Roos, A.; van Loon, A. J.; Links, T. P.; van Tol, K. M.; Hoogenberg, K.; Berg, van den Paul; Wolffenbuttel, B. H. R.

    Background: To identify relevant factors predicting the need for insulin therapy in women with gestational diabetes mellitus (GDM) and secondly to determine a potential 'low-risk' diet-treated group who are likely to have good pregnancy outcomes. Methods: A retrospective analysis between 2011-2014.

  14. Time variability of C-reactive protein: implications for clinical risk stratification.

    Directory of Open Access Journals (Sweden)

    Peter Bogaty

    Full Text Available C-reactive protein (CRP is proposed as a screening test for predicting risk and guiding preventive approaches in coronary artery disease (CAD. However, the stability of repeated CRP measurements over time in subjects with and without CAD is not well defined. We sought to determine the stability of serial CRP measurements in stable subjects with distinct CAD manifestations and a group without CAD while carefully controlling for known confounders.We prospectively studied 4 groups of 25 stable subjects each 1 a history of recurrent acute coronary events; 2 a single myocardial infarction ≥7 years ago; 3 longstanding CAD (≥7 years that had never been unstable; 4 no CAD. Fifteen measurements of CRP were obtained to cover 21 time-points: 3 times during one day; 5 consecutive days; 4 consecutive weeks; 4 consecutive months; and every 3 months over the year. CRP risk threshold was set at 2.0 mg/L. We estimated variance across time-points using standard descriptive statistics and Bayesian hierarchical models.Median CRP values of the 4 groups and their pattern of variability did not differ substantially so all subjects were analyzed together. The median individual standard deviation (SD CRP values within-day, within-week, between-weeks and between-months were 0.07, 0.19, 0.36 and 0.63 mg/L, respectively. Forty-six percent of subjects changed CRP risk category at least once and 21% had ≥4 weekly and monthly CRP values in both low and high-risk categories.Considering its large intra-individual variability, it may be problematic to rely on CRP values for CAD risk prediction and therapeutic decision-making in individual subjects.

  15. Diagnostic performance of an acoustic-based system for coronary artery disease risk stratification

    DEFF Research Database (Denmark)

    Winther, Simon; Nissen, Louise; Schmidt, Samuel Emil

    2017-01-01

    CAD-score value ≤20. At this cut-off, sensitivity was 81% (95% CI 73% to 87%), specificity 53% (95% CI 50% to 56%), positive predictive value 16% (95% CI 13% to 18%) and negative predictive value 96% (95% CI 95% to 98%) for diagnosing haemodynamically significant CAD. CONCLUSION: Sound-based detection......OBJECTIVE: Diagnosing coronary artery disease (CAD) continues to require substantial healthcare resources. Acoustic analysis of transcutaneous heart sounds of cardiac movement and intracoronary turbulence due to obstructive coronary disease could potentially change this. The aim of this study...... features and clinical risk factors. Low risk is indicated by a CAD-score value ≤20. RESULTS: Haemodynamically significant CAD assessed from FFR was present in 145 (10.0%) patients. In the entire cohort, the predefined CAD-score had a sensitivity of 63% and a specificity of 44%. In total, 50% had an updated...

  16. Risk stratification and prediction of cancer of focal thyroid fluorodeoxyglucose uptake during cancer evaluation

    International Nuclear Information System (INIS)

    Kim, Bo-Hyun; Na, Min-A.; Kim, In-Joo; Kim, Seong-Jang; Kim, Yong-Ki

    2010-01-01

    Focal thyroid incidentaloma by F-18 2-deoxy-2-F18-fluoro-D-glucose (FDG) positron emission tomography (PET) has been reported 1-4% of cancer patients and normal healthy population, with a risk of cancer ranging 14-50%. The aim of this study was to investigate the prevalence of thyroid incidentaloma in F-18 FDG PET/CT and risk of cancer, usefulness of visual and SUV max and SUV mean differentiating malignant nodules and to define the predictable variables. A total 159 patients with focal thyroid FDG incidentaloma during cancer evaluation with non-thyroid cancer were enrolled. After F-18 PET/CT, we analyzed the image visually and obtained semiquantitative indices. The incidence of focal FDG thyroid incidentaloma is 1.36% and cancer risk is 23.3%. The incidence of focal thyroid FDG uptake was significantly higher in women (2.88 vs. 0.31%; X 2 =136.4, p max (malignant: median 4.53, range 2.1-12.0; benign: median 3.08, range 1.6-35, p=0.0093). However, SUV mean have no statistical differences (malignant: median 2.17, range 1.77-3.19; benign: median 2.05, range 1.15-5.77, p=0.0541). In ROC analyses, the optimal visual grades were >grade 3, and the optimal semiquantitative indices were 4.46 for SUV max , 2.03 for SUV mean . The visual grade was superior to other variables for the differentiation malignant from benign thyroid incidentalomas. The size and visual grade was the potent predictor by logistic regression analysis. Focal thyroid FDG incidentalomas in non-thyroid cancer patients during evaluation have a high risk of malignancy. The size and visual grade are potential predictors for malignant thyroid incidentaloma. (author)

  17. Evaluating the Impact of Prescription Fill Rates on Risk Stratification Model Performance.

    Science.gov (United States)

    Chang, Hsien-Yen; Richards, Thomas M; Shermock, Kenneth M; Elder Dalpoas, Stacy; J Kan, Hong; Alexander, G Caleb; Weiner, Jonathan P; Kharrazi, Hadi

    2017-12-01

    Risk adjustment models are traditionally derived from administrative claims. Prescription fill rates-extracted by comparing electronic health record prescriptions and pharmacy claims fills-represent a novel measure of medication adherence and may improve the performance of risk adjustment models. We evaluated the impact of prescription fill rates on claims-based risk adjustment models in predicting both concurrent and prospective costs and utilization. We conducted a retrospective cohort study of 43,097 primary care patients from HealthPartners network between 2011 and 2012. Diagnosis and/or pharmacy claims of 2011 were used to build 3 base models using the Johns Hopkins ACG system, in addition to demographics. Model performances were compared before and after adding 3 types of prescription fill rates: primary 0-7 days, primary 0-30 days, and overall. Overall fill rates utilized all ordered prescriptions from electronic health record while primary fill rates excluded refill orders. The overall, primary 0-7, and 0-30 days fill rates were 72.30%, 59.82%, and 67.33%. The fill rates were similar between sexes but varied across different medication classifications, whereas the youngest had the highest rate. Adding fill rates modestly improved the performance of all models in explaining medical costs (improving concurrent R by 1.15% to 2.07%), followed by total costs (0.58% to 1.43%), and pharmacy costs (0.07% to 0.65%). The impact was greater for concurrent costs compared with prospective costs. Base models without diagnosis information showed the highest improvement using prescription fill rates. Prescription fill rates can modestly enhance claims-based risk prediction models; however, population-level improvements in predicting utilization are limited.

  18. Risk-adapted stratification and treatment of childhood acute lymphoblastic leukaemia

    International Nuclear Information System (INIS)

    Schrappe, M.

    2008-01-01

    Systematic enrolment of children and adolescents with acute lymphoblastic leukaemia (ALL) into clinical trials has allowed the establishment of prognostic parameters derived from initial diagnostic findings. More important, these trials have significantly contributed to the reduction of disease recurrence as much as to the reduction of acute and late side effects. Some problems that are related to the specificity of the parameters used for risk assessment were not overcome: high tumour load by white blood cell count (WBC), age and (rare) cytogenetic subtypes (e.g. t9;22) may characterise a significant proportion of children and adolescents with high-risk ALL. Most patients who will eventually relapse do not present with characteristic features at initial diagnosis. It appears feasible through careful response assessment to identify these patients at risk of relapse, who present initially without specific features. Earlier trials of the ALL-BFM (Berlin/Frankfurt/Muenster) study group and others have demonstrated that inadequate leukaemic blast reduction in the peripheral blood or bone marrow after the first few days of therapy is highly predictive of treatment failure. Using clone-specific polymerase chain reaction-based detection of minimal residual disease (MRD) as done in trial AIEOP-BFM ALL 2000 allowed a close surveillance of specific treatment elements when applied in MRD positive patients. This may facilitate innovative chemotherapy approaches and a more rational use of allogeneic haematopoietic stem cell transplantation. In addition, genetic signatures of treatment response or failure have been identified. (authors)

  19. Myocardial revascularization with coronary endarterectomy. Stratification of risk factors for early mortality

    Directory of Open Access Journals (Sweden)

    Atik Fernando Antibas

    2000-01-01

    Full Text Available OBJECTIVE: To determine the risk factors for mortality related to myocardial revascularization when performed in association with coronary endarterectomy. METHODS: We assessed retrospectively 353 patients who underwent 373 coronary endarterectomies between January '89 and November '98, representing 3.73% of the myocardial revascularizations in this period of time. The arteries involved were as follows: right coronary artery in 218 patients (58.45%; left anterior descending in 102 patients (27.35%; circumflex artery in 39 patients (10.46%; and diagonal artery in 14 patients (3.74%. We used 320 (85.79% venous grafts and 53 (14.21% arterial grafts. RESULTS: In-hospital mortality among our patients was 9.3% as compared with 5.7% in patients with myocardial revascularizations without endarterectomy (p=0.003. Cause of death was related to acute myocardial infarction in 18 (54.55% patients. The most significant risk factors for mortality identified were as follows: diabetes mellitus (p=0.001; odds ratio =7.168, left main disease (<0.001; 9.283, female sex (0.01; 3.111, acute myocardial infarction (0.02; 3.546, ejection fraction <35% (<0.001; 5.89, and previous myocardial revascularization (<0.001; 4.295. CONCLUSION: Coronary endarterectomy is related to higher mortality, and the risk factors involved are important elements of a poor outcome.

  20. Estratificación de riesgo en pie diabético Risk stratification in diabetic foot

    Directory of Open Access Journals (Sweden)

    Héctor González de la Torre

    2010-12-01

    factors is an essential previous step in nursing. The purpose of this study is to detect the presence of certain risk factors in diabetic foot in the diabetic population of Triana Healthcare Centre to be able to carry out a stratification of the risk. For this research, there was chosen an observational, descriptive and transversal study. The analyzed sample was constituted by 96 diabetic subjects belonging to the Healthcare Centre. For the data collection, we use different systems such as interviews, physical exams and the available records (clinical history of the patients. The information has been recorded in a questionnaire of the diabetic foot. The existence of risk factors was determined by analyzing the relationship between them allowing the risk stratification of the studied sample.

  1. Hyperglycemia, Young Age, Altered Sleep Habits: The Three Shifting Paradigms of Coronary Artery Disease Risk Stratification

    Directory of Open Access Journals (Sweden)

    Irtiza Hasan

    2012-07-01

    Full Text Available The study was undertaken to estimate the risk factors age, gender, race, obesity (BMI, glycemic status (prediabetes, diabetes, exercise and psychosocial factors (sleep, sadness related to coronary artery disease (CAD. The data set for this study is the National Health Interview Survey (NHIS, which is a large scale, cross sectional, voluntary, household interview survey maintaining data on health status, health care access and progress towards achieving the national health objectives in the USA. A total of 26,965 (male/female =55.8/ 44.2% subjects were included in the study. Of them, 79.9% were less than 65 years of age. Regarding obesity, overweight, obese and morbid obese were 34.8, 17.3 and 11.0%, respectively. Sadness of any degree was reported in 28%. Sleep duration was found 9h/d in 9.7%. Heart disease was reported in 4.9%. About 10% were reported to have diabetes and 4.1% prediabetes. 40% of the respondents’ maintained exercise once per week and only 12.8% maintained 10 or more times per week. Logistic regression estimated that compared with the non-diabetics, the subjects with prediabetes (OR 3.27, 95% CI, 2.32-4.59 and diabetes (OR 6.44 95% CI, 5.21-7.96 had excess risk of CAD, more significant in the younger subjects (65y. The risk of CAD was found significant in both prediabetes (OR 2.47, 95% CI, 1.44-4.23 and diabetes (OR 3.03, 95% CI, 2.16-4.24 as compared with non-diabetic group who slept >9h a day. The subjects with prediabetes or diabetes had excess risk for CAD compared with the non-diabetic subjects, which was more marked in the younger people. Again, compared with the non-diabetic people, the subjects with prediabetes or diabetes, having less sleep or excess sleep, had excess risk for CAD. Further study may confirm our findings. Ibrahim Med. Coll. J. 2012; 6(2: 39-45

  2. Understanding PSA and its derivatives in prediction of tumor volume: Addressing health disparities in prostate cancer risk stratification.

    Science.gov (United States)

    Chinea, Felix M; Lyapichev, Kirill; Epstein, Jonathan I; Kwon, Deukwoo; Smith, Paul Taylor; Pollack, Alan; Cote, Richard J; Kryvenko, Oleksandr N

    2017-03-28

    To address health disparities in risk stratification of U.S. Hispanic/Latino men by characterizing influences of prostate weight, body mass index, and race/ethnicity on the correlation of PSA derivatives with Gleason score 6 (Grade Group 1) tumor volume in a diverse cohort. Using published PSA density and PSA mass density cutoff values, men with higher body mass indices and prostate weights were less likely to have a tumor volume PSA derivatives when predicting for tumor volume. In receiver operator characteristic analysis, area under the curve values for all PSA derivatives varied across race/ethnicity with lower optimal cutoff values for Hispanic/Latino (PSA=2.79, PSA density=0.06, PSA mass=0.37, PSA mass density=0.011) and Non-Hispanic Black (PSA=3.75, PSA density=0.07, PSA mass=0.46, PSA mass density=0.008) compared to Non-Hispanic White men (PSA=4.20, PSA density=0.11 PSA mass=0.53, PSA mass density=0.014). We retrospectively analyzed 589 patients with low-risk prostate cancer at radical prostatectomy. Pre-operative PSA, patient height, body weight, and prostate weight were used to calculate all PSA derivatives. Receiver operating characteristic curves were constructed for each PSA derivative per racial/ethnic group to establish optimal cutoff values predicting for tumor volume ≥0.5 cm3. Increasing prostate weight and body mass index negatively influence PSA derivatives for predicting tumor volume. PSA derivatives' ability to predict tumor volume varies significantly across race/ethnicity. Hispanic/Latino and Non-Hispanic Black men have lower optimal cutoff values for all PSA derivatives, which may impact risk assessment for prostate cancer.

  3. Gastrointestinal stromal tumours: Correlation of modified NIH risk stratification with diffusion-weighted MR imaging as an imaging biomarker

    International Nuclear Information System (INIS)

    Kang, Tae Wook; Kim, Seong Hyun; Jang, Kyung Mi; Choi, Dongil; Ha, Sang Yun; Kim, Kyoung-Mee; Kang, Won Ki; Kim, Min Ji

    2015-01-01

    Highlights: • Except size and necrosis, conventional MR findings of GISTs were not significantly different according to the modified NIH criteria. • The ADC values of GISTs were negatively correlated with the modified NIH criteria. • The ADC value can be helpful for the determination of intermediate or high-risk GISTs. - Abstract: Purpose: To evaluate the correlation of risk grade of gastrointestinal stromal tumours (GISTs) based on modified National Institutes of Health (NIH) criteria with conventional magnetic resonance (MR) imaging and diffusion-weighted (DW) imaging. Methods: We included 22 patients with histopathologically proven GISTs in the stomach or small bowel who underwent pre-operative gadoxetic acid-enhanced MR imaging and DW imaging. We retrospectively assessed correlations between morphologic findings, qualitative (signal intensity, consensus from two observers) and quantitative (degree of dynamic enhancement using signal intensity of tumour/muscle ratio and apparent diffusion coefficient [ADC]) values, and the modified NIH criteria for risk stratification. Spearman partial correlation analysis was used to control for tumour size as a confounding factor. The optimal cut-off level of ADC values for intermediate or high risk GISTs was analyzed using a receiver operating characteristic analysis. Results: Except tumour size and necrosis, conventional MR imaging findings, including the degree of dynamic enhancement, were not significantly different according to the modified NIH criteria (p > 0.05). Tumour ADC values were negatively correlated with the modified NIH criteria, before and after adjustment of tumour size (ρ = −0.754; p < 0.001 and ρ = −0.513; p = 0.017, respectively). The optimal cut-off value for the determination of intermediate or high-risk GISTs was 1.279 × 10 −3 mm 2 /s (100% sensitivity, 69.2% specificity, 81.8% accuracy). Conclusion: Except tumour size and necrosis, conventional MR imaging findings did not correlate with

  4. Gastrointestinal stromal tumours: Correlation of modified NIH risk stratification with diffusion-weighted MR imaging as an imaging biomarker

    Energy Technology Data Exchange (ETDEWEB)

    Kang, Tae Wook [Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710 (Korea, Republic of); Kim, Seong Hyun, E-mail: kshyun@skku.edu [Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710 (Korea, Republic of); Jang, Kyung Mi; Choi, Dongil [Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710 (Korea, Republic of); Ha, Sang Yun; Kim, Kyoung-Mee [Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710 (Korea, Republic of); Kang, Won Ki [Division of Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710 (Korea, Republic of); Kim, Min Ji [Biostatics Unit, Samsung Biomedical Research Institute, Samsung Medical Center, Seoul 135-710 (Korea, Republic of)

    2015-01-15

    Highlights: • Except size and necrosis, conventional MR findings of GISTs were not significantly different according to the modified NIH criteria. • The ADC values of GISTs were negatively correlated with the modified NIH criteria. • The ADC value can be helpful for the determination of intermediate or high-risk GISTs. - Abstract: Purpose: To evaluate the correlation of risk grade of gastrointestinal stromal tumours (GISTs) based on modified National Institutes of Health (NIH) criteria with conventional magnetic resonance (MR) imaging and diffusion-weighted (DW) imaging. Methods: We included 22 patients with histopathologically proven GISTs in the stomach or small bowel who underwent pre-operative gadoxetic acid-enhanced MR imaging and DW imaging. We retrospectively assessed correlations between morphologic findings, qualitative (signal intensity, consensus from two observers) and quantitative (degree of dynamic enhancement using signal intensity of tumour/muscle ratio and apparent diffusion coefficient [ADC]) values, and the modified NIH criteria for risk stratification. Spearman partial correlation analysis was used to control for tumour size as a confounding factor. The optimal cut-off level of ADC values for intermediate or high risk GISTs was analyzed using a receiver operating characteristic analysis. Results: Except tumour size and necrosis, conventional MR imaging findings, including the degree of dynamic enhancement, were not significantly different according to the modified NIH criteria (p > 0.05). Tumour ADC values were negatively correlated with the modified NIH criteria, before and after adjustment of tumour size (ρ = −0.754; p < 0.001 and ρ = −0.513; p = 0.017, respectively). The optimal cut-off value for the determination of intermediate or high-risk GISTs was 1.279 × 10{sup −3} mm{sup 2}/s (100% sensitivity, 69.2% specificity, 81.8% accuracy). Conclusion: Except tumour size and necrosis, conventional MR imaging findings did not

  5. Can Ambulatory Blood Pressure Variability Contribute to Individual Cardiovascular Risk Stratification?

    Directory of Open Access Journals (Sweden)

    Annamária Magdás

    2016-01-01

    Full Text Available Objective. The aim of this study is to define the normal range for average real variability (ARV and to establish whether it can be considered as an additional cardiovascular risk factor. Methods. In this observational study, 110 treated hypertensive patients were included and admitted for antihypertensive treatment adjustment. Circadian blood pressure was recorded with validated devices. Blood pressure variability (BPV was assessed according to the ARV definition. Based on their variability, patients were classified into low, medium, and high variability groups using the fuzzy c-means algorithm. To assess cardiovascular risk, blood samples were collected. Characteristics of the groups were compared by ANOVA tests. Results. Low variability was defined as ARV below 9.8 mmHg (32 patients, medium as 9.8–12.8 mmHg (48 patients, and high variability above 12.8 mmHg (30 patients. Mean systolic blood pressure was 131.2 ± 16.7, 135.0 ± 12.1, and 141.5 ± 11.4 mmHg in the low, medium, and high variability groups, respectively (p=0.0113. Glomerular filtration rate was 78.6 ± 29.3, 74.8 ± 26.4, and 62.7±23.2 mL/min/1.73 m2 in the low, medium, and high variability groups, respectively (p=0.0261. Conclusion. Increased values of average real variability represent an additional cardiovascular risk factor. Therefore, reducing BP variability might be as important as achieving optimal BP levels, but there is need for further studies to define a widely acceptable threshold value.

  6. Hemodynamic Based Coronary Artery Aneurysm Thrombosis Risk Stratification in Kawasaki Disease Patients

    Science.gov (United States)

    Grande Gutierrez, Noelia; Mathew, M.; McCrindle, B.; Kahn, A.; Burns, J.; Marsden, A.

    2017-11-01

    Coronary artery aneurysms (CAA) as a result of Kawasaki Disease (KD) put patients at risk for thrombosis and myocardial infarction. Current AHA guidelines recommend CAA diameter >8 mm or Z-score >10 as the criterion for initiating systemic anticoagulation. Our hypothesis is that hemodynamic data derived from computational blood flow simulations is a better predictor of thrombosis than aneurysm diameter alone. Patient-specific coronary models were constructed from CMRI for a cohort of 10 KD patients (5 confirmed thrombosis cases) and simulations with fluid structure interaction were performed using the stabilized finite element Navier-Stokes solver available in SimVascular. We used a closed-loop lumped parameter network (LPN) to model the heart and vascular boundary conditions coupled numerically to the flow solver. An automated parameter estimation method was used to match LPN values to clinical data for each patient. Hemodynamic data analysis resulted in low correlation between Wall Shear Stress (WSS)/ Particle Residence Time (PRT) and CAA diameter but demonstrates the positive correlation between hemodynamics and adverse patient outcomes. Our results suggest that quantifying WSS and PRT should enable identification of regions at higher risk of thrombosis. We propose a quantitative method to non-invasively assess the abnormal flow in CAA following KD that could potentially improve clinical decision-making regarding anticoagulation therapy.

  7. Formalized Search Strategies for Human Risk Contributions

    DEFF Research Database (Denmark)

    Rasmussen, Jens; Pedersen, O. M.

    For risk management, the results of a probabilistic risk analysis (PRA) as well as the underlying assumptions can be used as references in a closed-loop risk control; and the analyses of operational experiences as a means of feedback. In this context, the need for explicit definition...... risk contributions are described on the basis of general plant design features relevant for risk and accident analysis. With this background, search strategies for human risk contributions are treated: Under the designation "work analysis", procedures for the analysis of familiar, well trained, planned...... tasks are proposed. Strategies for identifying human risk contributions outside this category are outlined....

  8. Market transition, educational disparities, and family strategies in rural China: new evidence on gender stratification and development.

    Science.gov (United States)

    Hannum, Emily

    2005-05-01

    Two theoretical perspectives have dominated debates about the impact of development on gender stratification: modernization theory, which argues that gender inequalities decline with economic growth, and the "women in development" perspective, which argues that development may initially widen gender gaps. Analyzing cross-sectional surveys and time-series data from China, this article indicates the relevance of both perspectives: while girls' educational opportunities were clearly more responsive than boys' to better household economic circumstances, the era of market transition in the late 1970s and early 1980s failed to accelerate and, in fact, may have temporarily slowed progress toward gender equity.

  9. Environmental stratification framework and water-quality monitoring design strategy for the Islamic Republic of Mauritania, Africa

    Science.gov (United States)

    Friedel, Michael J.

    2008-01-01

    Mauritania anticipates an increase in mining activities throughout the country and into the foreseeable future. Because mining-induced changes in the landscape are likely to affect their limited ground-water resources and sensitive aquatic ecosystems, a water-quality assessment program was designed for Mauritania that is based on a nationally consistent environmental stratification framework. The primary objectives of this program are to ensure that the environmental monitoring systems can quantify near real-time changes in surface-water chemistry at a local scale, and quantify intermediate- to long-term changes in groundwater and aquatic ecosystems over multiple scales.

  10. Blood pressure load does not add to ambulatory blood pressure level for cardiovascular risk stratification

    DEFF Research Database (Denmark)

    Li, Yan; Thijs, Lutgarde; Boggia, José

    2014-01-01

    Experts proposed blood pressure (BP) load derived from 24-hour ambulatory BP recordings as a more accurate predictor of outcome than level, in particular in normotensive people. We analyzed 8711 subjects (mean age, 54.8 years; 47.0% women) randomly recruited from 10 populations. We expressed BP...... load as percentage (%) of systolic/diastolic readings ≥135/≥85 mm Hg and ≥120/≥70 mm Hg during day and night, respectively, or as the area under the BP curve (mm Hg×h) using the same ceiling values. During a period of 10.7 years (median), 1284 participants died and 1109 experienced a fatal or nonfatal...... cardiovascular end point. In multivariable-adjusted models, the risk of cardiovascular complications gradually increased across deciles of BP level and load (Pbased on 24-hour systolic or diastolic BP level (generalized R(2) statistic ≤0.294%; net...

  11. Role of anti-domain 1-β2 glycoprotein I antibodies in the diagnosis and risk stratification of antiphospholipid syndrome.

    Science.gov (United States)

    De Craemer, A-S; Musial, J; Devreese, K M J

    2016-09-01

    Essentials Antibodies to domain 1 of β2 glycoprotein I (aD1) are a subset of antiphospholipid antibodies. We evaluated the added diagnostic value of an automated aD1 assay in antiphospholipid syndrome. AD1 IgG correctly classifies patients at risk for thrombosis. Agreement between aD1 and aβ2GPI IgG is high, limiting the added value of aD1 in our setting. Click to hear Professor de Groot's perspective on new mechanistic understanding in antiphospholipid syndrome Background Laboratory diagnosis of antiphospholipid syndrome (APS) includes lupus anticoagulant (LAC), anticardiolipin (aCL) or anti-β2 glycoprotein I (aβ2 GPI) antibodies. Antibodies targeting domain 1 of β2 GPI (aD1) constitute a pathogenic subset of autoantibodies. Objectives In this cohort study, we determined the clinical performance characteristics, additional diagnostic value and the contribution to APS risk stratification of an automated aD1 assay. Patients/Methods LAC, aCL, aβ2 GPI and aD1 IgG were measured in 101 APS patients, 123 patients with autoimmune disorders, 82 diseased controls and 120 healthy controls. aD1 antibodies were detected by QUANTA Flash(®) Beta2GPI-Domain 1 chemiluminescence immunoassay. Results With a cut-off value of 20.0 CU, the aD1 IgG assay identifies APS patients in a clinically affected patient cohort with a sensitivity of 53.5% and specificity of 98.8%. It implied a high odds ratio (OR) for clinical events (OR, 17.0; 95% confidence interval [CI], 7.1-40.5). aD1 IgG did not add diagnostic value to the formal aPL panel because aβ2 GPI IgG was nearly as specific but more sensitive for APS (sensitivity 56.4%) with a higher OR for clinical events (36.2; 95% CI, 11.1-117.9). High aD1 titers identify triple-positive patients and patients with thrombosis in a β2 GPI-dependent LAC-positive population. Agreement between aD1 IgG and aβ2 GPI IgG was high (positive and negative agreement 91.7% and 98.4%, respectively). Conclusion Detection of aD1 IgG correctly classifies

  12. Improved cancer risk stratification and diagnosis via quantitative phase microscopy (Conference Presentation)

    Science.gov (United States)

    Liu, Yang; Uttam, Shikhar; Pham, Hoa V.; Hartman, Douglas J.

    2017-02-01

    Pathology remains the gold standard for cancer diagnosis and in some cases prognosis, in which trained pathologists examine abnormality in tissue architecture and cell morphology characteristic of cancer cells with a bright-field microscope. The limited resolution of conventional microscope can result in intra-observer variation, missed early-stage cancers, and indeterminate cases that often result in unnecessary invasive procedures in the absence of cancer. Assessment of nanoscale structural characteristics via quantitative phase represents a promising strategy for identifying pre-cancerous or cancerous cells, due to its nanoscale sensitivity to optical path length, simple sample preparation (i.e., label-free) and low cost. I will present the development of quantitative phase microscopy system in transmission and reflection configuration to detect the structural changes in nuclear architecture, not be easily identifiable by conventional pathology. Specifically, we will present the use of transmission-mode quantitative phase imaging to improve diagnostic accuracy of urine cytology and the nuclear dry mass is progressively correlate with negative, atypical, suspicious and positive cytological diagnosis. In a second application, we will present the use of reflection-mode quantitative phase microscopy for depth-resolved nanoscale nuclear architecture mapping (nanoNAM) of clinically prepared formalin-fixed, paraffin-embedded tissue sections. We demonstrated that the quantitative phase microscopy system detects a gradual increase in the density alteration of nuclear architecture during malignant transformation in animal models of colon carcinogenesis and in human patients with ulcerative colitis, even in tissue that appears histologically normal according to pathologists. We evaluated the ability of nanoNAM to predict "future" cancer progression in patients with ulcerative colitis.

  13. TP53 mutational status is a potential marker for risk stratification in Wilms tumour with diffuse anaplasia.

    Directory of Open Access Journals (Sweden)

    Mariana Maschietto

    Full Text Available The presence of diffuse anaplasia in Wilms tumours (DAWT is associated with TP53 mutations and poor outcome. As patients receive intensified treatment, we sought to identify whether TP53 mutational status confers additional prognostic information.We studied 40 patients with DAWT with anaplasia in the tissue from which DNA was extracted and analysed for TP53 mutations and 17p loss. The majority of cases were profiled by copy number (n = 32 and gene expression (n = 36 arrays. TP53 mutational status was correlated with patient event-free and overall survival, genomic copy number instability and gene expression profiling.From the 40 cases, 22 (55% had TP53 mutations (2 detected only after deep-sequencing, 20 of which also had 17p loss (91%; 18 (45% cases had no detectable mutation but three had 17p loss. Tumours with TP53 mutations and/or 17p loss (n = 25 had an increased risk of recurrence as a first event (p = 0.03, hazard ratio (HR, 3.89; 95% confidence interval (CI, 1.26-16.0 and death (p = 0.04, HR, 4.95; 95% CI, 1.36-31.7 compared to tumours lacking TP53 abnormalities. DAWT carrying TP53 mutations showed increased copy number alterations compared to those with wild-type, suggesting a more unstable genome (p = 0.03. These tumours showed deregulation of genes associated with cell cycle and DNA repair biological processes.This study provides evidence that TP53 mutational analysis improves risk stratification in DAWT. This requires validation in an independent cohort before clinical use as a biomarker.

  14. TP53 mutational status is a potential marker for risk stratification in Wilms tumour with diffuse anaplasia.

    Science.gov (United States)

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

    2014-01-01

    The presence of diffuse anaplasia in Wilms tumours (DAWT) is associated with TP53 mutations and poor outcome. As patients receive intensified treatment, we sought to identify whether TP53 mutational status confers additional prognostic information. We studied 40 patients with DAWT with anaplasia in the tissue from which DNA was extracted and analysed for TP53 mutations and 17p loss. The majority of cases were profiled by copy number (n = 32) and gene expression (n = 36) arrays. TP53 mutational status was correlated with patient event-free and overall survival, genomic copy number instability and gene expression profiling. From the 40 cases, 22 (55%) had TP53 mutations (2 detected only after deep-sequencing), 20 of which also had 17p loss (91%); 18 (45%) cases had no detectable mutation but three had 17p loss. Tumours with TP53 mutations and/or 17p loss (n = 25) had an increased risk of recurrence as a first event (p = 0.03, hazard ratio (HR), 3.89; 95% confidence interval (CI), 1.26-16.0) and death (p = 0.04, HR, 4.95; 95% CI, 1.36-31.7) compared to tumours lacking TP53 abnormalities. DAWT carrying TP53 mutations showed increased copy number alterations compared to those with wild-type, suggesting a more unstable genome (p = 0.03). These tumours showed deregulation of genes associated with cell cycle and DNA repair biological processes. This study provides evidence that TP53 mutational analysis improves risk stratification in DAWT. This requires validation in an independent cohort before clinical use as a biomarker.

  15. 3 for the Price of 1: Teaching Chest Pain Risk Stratification in a Multidisciplinary, Problem-based Learning Workshop

    Directory of Open Access Journals (Sweden)

    Cynthia Burns

    2018-03-01

    Full Text Available Introduction: Chest pain is a common chief complaint among patients presenting to health systems and often leads to complex and intensive evaluations. While these patients are often cared for by a multidisciplinary team (primary care, emergency medicine, and cardiology, medical students usually learn about the care of these patients in a fragmented, single-specialty paradigm. The present and future care of patients with chest pain is multidisciplinary, and the education of medical students on the subject should be as well. Our objective was to evaluate the effectiveness of a multidisciplinary, problem-based learning workshop to teach third-year medical students about risk assessment for patients presenting with chest pain, specifically focusing on acute coronary syndromes. Methods: To create an educational experience consistent with multidisciplinary team-based care, we designed a multidisciplinary, problem-based learning workshop to provide medical students with an understanding of how patients with chest pain are cared for in a systems-based manner to improve outcomes. Participants included third-year medical students (n=219 at a single, tertiary care, academic medical center. Knowledge acquisition was tested in a pre-/post-retention test study design. Results: Following the workshop, students achieved a 19.7% (95% confidence interval [CI] [17.3–22.2%] absolute increase in scores on post-testing as compared to pre-testing. In addition, students maintained an 11.1% (95% CI [7.2–15.0%] increase on a retention test vs. the pre-test. Conclusion: A multidisciplinary, problem-based learning workshop is an effective method of producing lasting gains in student knowledge about chest pain risk stratification.

  16. Validation of a risk stratification tool for fall-related injury in a state-wide cohort.

    Science.gov (United States)

    McCoy, Thomas H; Castro, Victor M; Cagan, Andrew; Roberson, Ashlee M; Perlis, Roy H

    2017-02-06

    A major preventable contributor to healthcare costs among older individuals is fall-related injury. We sought to validate a tool to stratify such risk based on readily available clinical data, including projected medication adverse effects, using state-wide medical claims data. Sociodemographic and clinical features were drawn from health claims paid in the state of Massachusetts for individuals aged 35-65 with a hospital admission for a period spanning January-December 2012. Previously developed logistic regression models of hospital readmission for fall-related injury were refit in a testing set including a randomly selected 70% of individuals, and examined in a training set comprised of the remaining 30%. Medications at admission were summarised based on reported adverse effect frequencies in published medication labelling. The Massachusetts health system. A total of 68 764 hospitalised individuals aged 35-65 years. Hospital readmission for fall-related injury defined by claims code. A total of 2052 individuals (3.0%) were hospitalised for fall-related injury within 90 days of discharge, and 3391 (4.9%) within 180 days. After recalibrating the model in a training data set comprised of 48 136 individuals (70%), model discrimination in the remaining 30% test set yielded an area under the receiver operating characteristic curve (AUC) of 0.74 (95% CI 0.72 to 0.76). AUCs were similar across age decades (0.71 to 0.78) and sex (0.72 male, 0.76 female), and across most common diagnostic categories other than psychiatry. For individuals in the highest risk quartile, 11.4% experienced fall within 180 days versus 1.2% in the lowest risk quartile; 57.6% of falls occurred in the highest risk quartile. This analysis of state-wide claims data demonstrates the feasibility of predicting fall-related injury requiring hospitalisation using readily available sociodemographic and clinical details. This translatable approach to stratification allows for identification of

  17. Cardiac risk stratification with myocardial perfusion imaging in potential renal-pancreas transplant recipients

    International Nuclear Information System (INIS)

    McCarthy, M.C.; Larcos, G.; Chapman, J.

    1998-01-01

    Full text: Combined renal/pancreas transplantation is used in patients with severe type-1 diabetes and renal failure. Many patients have asymptomatic coronary artery disease (CAD). Thus, myocardial perfusion imaging (MPI) is widely used for preoperative risk assessment, however, its value has recently been challenged. The purpose of this study was to determine the predictive value of MPI compared to coronary angiography and/or thirty day perioperative cardiac events (cardiac death, myocardial infarction and unstable angina). We reviewed the MPI in 132 patients that were referred for possible renal pancreas transplantation during the period between 1987 - June 1997. Fifty five patients were excluded because of: still awaiting transplantation (n=19) ongoing medical assessment (n=21), received kidney only transplant (n=6) or other factors (n=9). Thus, 77 patients form the basis of this report. Seventy one patients were transplanted, 5 had coronary angiography and one died before transplantation but with coronary anatomy defined at autopsy. All patients (39 male, 38 female; mean age 37 years) had Tl-201 or Tc-99m MIBI SPECT at Westmead (n=54) or elsewhere (n=23). Patients underwent MPI, a mean of 12.1 months before transplantation and a mean of 6 months before coronary angiography or autopsy. MPI was normal in 64 (83%) and abnormal in 13 (17%) patients. Of the abnormal MPI, 7 patients had CAD and one had unstable angina post-operatively (PPV = 8/13; 61%). One patient had a fixed defect post CABG but proceeded to transplant with-out event; the other 4 patients had normal coronary anatomy. Of the normal MPIs there were no transplant related cardiac events, but one patient required CABG >12 months post MPI and a further patient died >12 months post transplant and was shown to have CAD at autopsy (NPV=62/64;97%). In conclusion we have found an excellent NPV and an acceptable PPV for MPI in potential renal pancreas graft recipients

  18. Cardiac risk stratification with myocardial perfusion imaging in potential renal-pancreas transplant recipients

    Energy Technology Data Exchange (ETDEWEB)

    McCarthy, M.C.; Larcos, G.; Chapman, J. [Westmead Hospital, Westmead, Sydney, NSW (Australia). Departments of Nuclear Medicine and Ultrasound

    1998-06-01

    Full text: Combined renal/pancreas transplantation is used in patients with severe type-1 diabetes and renal failure. Many patients have asymptomatic coronary artery disease (CAD). Thus, myocardial perfusion imaging (MPI) is widely used for preoperative risk assessment, however, its value has recently been challenged. The purpose of this study was to determine the predictive value of MPI compared to coronary angiography and/or thirty day perioperative cardiac events (cardiac death, myocardial infarction and unstable angina). We reviewed the MPI in 132 patients that were referred for possible renal pancreas transplantation during the period between 1987 - June 1997. Fifty five patients were excluded because of: still awaiting transplantation (n=19) ongoing medical assessment (n=21), received kidney only transplant (n=6) or other factors (n=9). Thus, 77 patients form the basis of this report. Seventy one patients were transplanted, 5 had coronary angiography and one died before transplantation but with coronary anatomy defined at autopsy. All patients (39 male, 38 female; mean age 37 years) had Tl-201 or Tc-99m MIBI SPECT at Westmead (n=54) or elsewhere (n=23). Patients underwent MPI, a mean of 12.1 months before transplantation and a mean of 6 months before coronary angiography or autopsy. MPI was normal in 64 (83%) and abnormal in 13 (17%) patients. Of the abnormal MPI, 7 patients had CAD and one had unstable angina post-operatively (PPV = 8/13; 61%). One patient had a fixed defect post CABG but proceeded to transplant with-out event; the other 4 patients had normal coronary anatomy. Of the normal MPIs there were no transplant related cardiac events, but one patient required CABG >12 months post MPI and a further patient died >12 months post transplant and was shown to have CAD at autopsy (NPV=62/64;97%). In conclusion we have found an excellent NPV and an acceptable PPV for MPI in potential renal pancreas graft recipients

  19. Use of and inhospital outcomes after early clopidogrel therapy in patients not undergoing an early invasive strategy for treatment of non-ST-segment elevation myocardial infarction: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines (CRUSADE).

    Science.gov (United States)

    Alexander, Deepu; Ou, Fang-Shu; Roe, Matthew T; Pollack, Charles V; Ohman, E Magnus; Cannon, Christopher P; Gibler, W Brian; Fintel, Dan J; Peterson, Eric D; Brown, David L

    2008-09-01

    Although current guidelines recommend early initiation of clopidogrel in patients with non-ST-segment elevation myocardial infarction (NSTEMI), the degree to which it has been adopted in clinical practice remains unclear. We sought to determine patterns of early (vs 9.5%, P = .90). Until recently, up to 50% of NSTEMI patients in contemporary practice in the United States not undergoing PCI within 24 hours of arrival in the United States are not treated according to guideline recommendations. Among a high-risk NSTEMI population not undergoing PCI within 24 hours of arrival, the nonrandomized short-term use of clopidogrel is associated with a lower risk of inhospital mortality without an increased risk of major bleeding.

  20. Framework for radiation pneumonitis risk stratification based on anatomic and perfused lung dosimetry

    Energy Technology Data Exchange (ETDEWEB)

    Dhami, Gurleen; Zeng, Jing; Patel, Shilpen A.; Rengan, Ramesh [University of Washington School of Medicine, Department of Radiation Oncology, Seattle, WA (United States); Vesselle, Hubert J.; Kinahan, Paul E.; Miyaoka, Robert S. [University of Washington School of Medicine, Department of Radiology, Seattle, WA (United States); Bowen, Stephen R. [University of Washington School of Medicine, Department of Radiation Oncology, Seattle, WA (United States); University of Washington School of Medicine, Department of Radiology, Seattle, WA (United States)

    2017-05-15

    To design and apply a framework for predicting symptomatic radiation pneumonitis in patients undergoing thoracic radiation, using both pretreatment anatomic and perfused lung dose-volume parameters. Radiation treatment planning CT scans were coregistered with pretreatment [{sup 99m}Tc]MAA perfusion SPECT/CT scans of 20 patients who underwent definitive thoracic radiation. Clinical radiation pneumonitis was defined as grade ≥ 2 (CTCAE v4 grading system). Anatomic lung dose-volume parameters were collected from the treatment planning scans. Perfusion dose-volume parameters were calculated from pretreatment SPECT/CT scans. Equivalent doses in 2 Gy per fraction were calculated in the lung to account for differences in treatment regimens and spatial variations in lung dose (EQD2{sub lung}). Anatomic lung dosimetric parameters (MLD) and functional lung dosimetric parameters (pMLD{sub 70%}) were identified as candidate predictors of grade ≥ 2 radiation pneumonitis (AUC > 0.93, p < 0.01). Pairing of an anatomic and functional dosimetric parameter (e.g., MLD and pMLD{sub 70%}) may further improve prediction accuracy. Not all individuals with high anatomic lung dose (MLD > 13.6 GyEQD2{sub lung}, 19.3 Gy for patients receiving 60 Gy in 30 fractions) developed radiation pneumonitis, but all individuals who also had high mean dose to perfused lung (pMLD{sub 70%} > 13.3 GyEQD2) developed radiation pneumonitis. The preliminary application of this framework revealed differences between anatomic and perfused lung dosimetry in this limited patient cohort. The addition of perfused lung parameters may help risk stratify patients for radiation pneumonitis, especially in treatment plans with high anatomic mean lung dose. Further investigations are warranted. (orig.) [German] Erstellung und Anwendung eines Rahmenwerks zur Vorhersage symptomatischer Strahlenpneumonitis bei Patienten mit einer Thorax-Bestrahlung anhand anatomischer und perfundierter Lungendosis-Volumen-Parameter in der

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

    Science.gov (United States)

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

    2015-09-01

    In nondialysis chronic kidney disease, ambulatory blood pressure (ABP) performs better than clinic BP in predicting outcome, but whether repeated assessment of ABP further refines prognosis remains ill-defined. We recruited 182 consecutive hypertensive patients with nondialysis chronic kidney disease who underwent 2 ABPs 12 months apart to evaluate the enhancement in risk stratification provided by a second ABP obtained 1 year after baseline on the risk (hazard ratio and 95% confidence interval) of composite renal end point (death, chronic dialysis, and estimated glomerular filtration rate decline ≥40%). The difference in daytime and nighttime systolic BP between the 2 ABPs (daytime and nighttime bias) was added to a survival model including baseline ABP. Net reclassification improvement was also calculated. Age was 65.6±13.4 years; 36% had diabetes mellitus and 36% had previous cardiovascular event; estimated glomerular filtration rate was 42.2±19.6 mL/min per 1.73 m(2), and clinic BP was 145±18/80±11 mm Hg. Baseline ABP (daytime, 131±16/75±10 and nighttime, 122±18/66±10 mm Hg) and daytime/nighttime BP goals (58.2% and 43.4%) did not change at month 12. Besides baseline ABP values, bias for daytime and nighttime systolic BP linearly associated with renal outcome (1.12, 1.04-1.21 and 1.18, 1.08-1.29 for every 5-mm Hg increase, respectively). Classification of patients at risk improved when considering nighttime systolic level at second ABP (net reclassification improvement, 0.224; 95% confidence interval, 0.005-0.435). Patients with first and second ABPs above target showed greater renal risk (2.15, 1.29-3.59 and 1.71, 1.07-2.72, for daytime and nighttime, respectively). In nondialysis chronic kidney disease, reassessment of ABP at 1 year further refines renal prognosis; such reassessment should specifically be considered in patients with uncontrolled BP at baseline. © 2015 American Heart Association, Inc.

  2. Cattle farmers’ perceptions of risk and risk management strategies

    DEFF Research Database (Denmark)

    Bishu, Kinfe G.; O'Reilly, Seamus; Lahiff, Edward

    2018-01-01

    This study analyzes cattle farmers’ perceptions of risk and risk management strategies in Tigray, Northern Ethiopia. We use survey data from a sample of 356 farmers based on multistage random sampling. Factor analysis is employed to classify scores of risk and management strategies, and multiple...... utilization were perceived as the most important strategies for managing risks. Livestock disease and labor shortage were perceived as less of a risk by farmers who adopted the practice of zero grazing compared to other farmers, pointing to the potential of this practice for risk reduction. We find strong...... evidence that farmers engage in multiple risk management practices in order to reduce losses from cattle morbidity and mortality. The results suggest that government strategies that aim at reducing farmers’ risk need to be tailored to specific farm and farmer characteristics. Findings from this study have...

  3. Effective risk stratification in patients with moderate cardiovascular risk using albuminuria and atherosclerotic plaques in the carotid arteries

    DEFF Research Database (Denmark)

    Greve, Sara V; Blicher, Marie K; Sehestedt, Thomas

    2015-01-01

    , Systematic COronary Risk Evaluation (SCORE), and Framingham risk score (FRS) groups. Subclinical vascular damage was defined as carotid-femoral pulse wave velocity at least 12 m/s, and carotid atherosclerotic plaques or urine albumin/creatinine ratio (UACR) at least 90th percentile of 0.73/1.06 mg...... risk patients and high-intermediate FRS risk patients with high risk (P = 0.04 and P = 0.001, respectively), whereas elevated carotid-femoral pulse wave velocity did not. Elevated UACR or presence of atherosclerotic plaques reclassified patients from moderate to high SCORE risk [net reclassification...... improvement of 6.4%; P = 0.025), or from high intermediate to high FRS risk (net reclassification improvement 8.8%; P = 0.002). Assuming primary prevention could reduce the relative cardiovascular risk by 24-27%, on the basis of actual levels of blood pressure and cholesterol, one composite endpoint could...

  4. Urinary proteomic biomarkers for diagnosis and risk stratification of autosomal dominant polycystic kidney disease: a multicentric study.

    Directory of Open Access Journals (Sweden)

    Andreas D Kistler

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

  5. Cancer risks: Strategies for elimination

    International Nuclear Information System (INIS)

    Bannasch, P.

    1987-01-01

    This book deals with the possibilities for identifying and eliminating cancer risk factors. The current state of knowledge on the detection, assessment and elimination of chemical, physical (radiation), and biological (viruses) risk factors are comprehensively presented in 15 contributions. Chemical risk factors resulting from smoking and environmental contamination are given special attention. The coverage of cancer risks by radiation includes some of the consequences of the Chernobyl disaster. Finally, the discussion of the possible risks that certain viruses hold for cancer in man is intended to further the development of vaccinations against these viral infections. The information is directed not only at specialists, but also at a wider interested audience. Its primary aim is to convey established findings that are already being used for cancer prevention. Furthermore, the book aims to promote more intense research in the field of primary cancer prevention. Contents: General aspects; chemical carcinogens: Risk assessment; chemical carcinogens: Primary prevention; physical carcinogens - Oncogenic viruses and subject index

  6. Does computer-assisted detection of pulmonary emboli enhance severity assessment and risk stratification in acute pulmonary embolism?

    International Nuclear Information System (INIS)

    Engelke, C.; Schmidt, S.; Auer, F.; Rummeny, E.J.; Marten, K.

    2010-01-01

    Aim: To prospectively assess the value of computer-aided detection (CAD) for the computed tomography (CT) severity assessment of acute pulmonary embolism (PE). Materials and methods: CT angiographic scans of 58 PE-positive patients (34-89 years, mean 66 years) were analysed by four observers for PE severity using the Mastora index, and by CAD. Patients were stratified to three PE risk groups and results compared to an independent reference standard. Interobserver agreement was tested by Bland and Altman and extended kappa (Ke) statistics. Mastora index changes after CAD data review were tested by Wilcoxon signed ranks. Results: CAD detected 343 out of 1118 emboli within given arterial segments and a total of 155 out of 218 polysegmental emboli (segmental vessel-based sensitivity = 30.7%, embolus-based sensitivity = 71.2% false-positive rate = 4.1/scan). Interobserver agreement on PE severity [95% limits of agreement (LOA) = -19.7-7.5% and-5.5-3% for reader pairs 1 versus 2 and 3 versus 4, respectively was enhanced by consensus with CAD data (LOA = -6.5-5.4% and-3.7-2% for reader pairs 1 versus 2 and 3 versus 4, respectively). Simultaneously, the percentual scoring errors (PSE) were significantly decreased (PSE = 35.4 ± 31.8% and 5.1 ± 8.9% for readers1/2 and 2/3, respectively, and PSE = 27.6 ± 31% and 3.8 ± 6.2%, respectively, after CAD consensus; p ≤ 0.005). Misclassifications to PE risk groups occurred in 27.6, 24.1, 5.2, and 5.2% of patients for readers 1-4, respectively, (Ke = 0.74) and were corrected by CAD consensus in 56.3, 36, 33.3, and 33.3% of misclassified patients, respectively (Ke = 0.83; p < 0.05). Conclusion: Radiologists may benefit from consensus with CAD data that improve PE severity scores and stratification to PE risk groups.

  7. Evaluation of risk scores for risk stratification of acute coronary syndromes in the Myocardial Infarction National Audit Project (MINAP) database.

    Science.gov (United States)

    Gale, C P; Manda, S O M; Weston, C F; Birkhead, J S; Batin, P D; Hall, A S

    2009-03-01

    To compare the discriminative performance of the PURSUIT, GUSTO-1, GRACE, SRI and EMMACE risk models, assess their performance among risk supergroups and evaluate the EMMACE risk model over the wider spectrum of acute coronary syndrome (ACS). Observational study of a national registry. All acute hospitals in England and Wales. 100 686 cases of ACS between 2003 and 2005. Model performance (C-index) in predicting the likelihood of death over the time period for which they were designed. The C-index, or area under the receiver-operating curve, range 0-1, is a measure of the discriminative performance of a model. The C-indexes were: PURSUIT C-index 0.79 (95% confidence interval 0.78 to 0.80); GUSTO-1 0.80 (0.79 to 0.81); GRACE in-hospital 0.80 (0.80 to 0.81); GRACE 6-month 0.80 (0.79 to 0.80); SRI 0.79 (0.78 to 0.80); and EMMACE 0.78 (0.77 to 0.78). EMMACE maintained its ability to discriminate 30-day mortality throughout different ACS diagnoses. Recalibration of the model offered no notable improvement in performance over the original risk equation. For all models the discriminative performance was reduced in patients with diabetes, chronic renal failure or angina. The five ACS risk models maintained their discriminative performance in a large unselected English and Welsh ACS population, but performed less well in higher-risk supergroups. Simpler risk models had comparable performance to more complex risk models. The EMMACE risk score performed well across the wider spectrum of ACS diagnoses.

  8. Formalized search strategies for human risk contributions

    International Nuclear Information System (INIS)

    Rasmussen, J.; Pedersen, O.M.

    1982-07-01

    For risk management, the results of a probabilistic risk analysis (PRA) as well as the underlying assumptions can be used as references in a closed-loop risk control; and the analyses of operational experiences as a means of feedback. In this context, the need for explicit definition and documentation of the PRA coverage, including the search strategies applied, is discussed and aids are proposed such as plant description in terms of a formal abstraction hierarchy and use of cause-consequence-charts for the documentation of not only the results of PRA but also of its coverage. Typical human risk contributions are described on the basis of general plant design features relevant for risk and accident analysis. With this background, search strategies for human risk contributions are treated: Under the designation ''work analysis'', procedures for the analysis of familiar, well trained, planned tasks are proposed. Strategies for identifying human risk contributions outside this category are outlined. (author)

  9. Risk stratification with the risk chart from the European Society of Hypertension compared with SCORE in the general population

    DEFF Research Database (Denmark)

    Sehestedt, Thomas; Jeppesen, Jørgen; Hansen, Tine W

    2009-01-01

    to higher-risk categories than SCORE (P smokers. However, ESH risk chart agreed with ESC guidelines for antihypertensive treatment using SCORE in 89% (634/713) of the patients recommended treatment and produced...... similar sensitivities (79 vs. 79%), specificities (46 vs. 50%), positive (14 vs. 15%) and negative (95 vs. 96%) predictive values for CEP. CONCLUSION: Although SCORE did not use subclinical organ damage, the guidelines by ESH and ESC using SCORE recommended antihypertensive treatment in almost the same...

  10. Strategies for successful software development risk management

    Directory of Open Access Journals (Sweden)

    Marija Boban

    2003-01-01

    Full Text Available Nowadays, software is becoming a major part of enterprise business. Software development is activity connected with advanced technology and high level of knowledge. Risks on software development projects must be successfully mitigated to produce successful software systems. Lack of a defined approach to risk management is one of the common causes for project failures. To improve project chances for success, this work investigates common risk impact areas to perceive a foundation that can be used to define a common approach to software risk management. Based on typical risk impact areas on software development projects, we propose three risk management strategies suitable for a broad area of enterprises and software development projects with different amounts of connected risks. Proposed strategies define activities that should be performed for successful risk management, the one that will enable software development projects to perceive risks as soon as possible and to solve problems connected with risk materialization. We also propose a risk-based approach to software development planning and risk management as attempts to address and retire the highest impact risks as early as possible in the development process. Proposed strategies should improve risk management on software development projects and help create a successful software solution.

  11. Inhibitor Risk Stratification and Individualized Treatment in Patients With Nonsevere Hemophilia A: A Single-Institution Practice Audit.

    Science.gov (United States)

    Sun, Haowei Linda; Chan, Stella; Yenson, Paul; Jackson, Shannon

    2018-03-01

    Inhibitor risk in nonsevere hemophilia A increases with cumulative factor VIII (FVIII) exposure days and high-risk mutations. A standardized approach to minimize inhibitor risk is warranted. Following establishment of a systematic approach to reduce inhibitor risk in nonsevere hemophilia, we evaluated the uptake of these strategies into clinical practice. All adult males with nonsevere hemophilia A followed by British Columbia Adult Hemophilia Program from 2004 to 2016 were included in this retrospective audit. Quality-of-care indicators on inhibitor prevention were examined. Of 108 patients, 18 patients had high-risk FVIII mutations for inhibitor development. Rates of FVIII genotyping and 1-deamino-8-d-arginine-vasopressin (DDAVP) testing in mild patients without contraindications were both over 90%, although DDAVP was used for surgical prophylaxis in only 70% of procedures. Inhibitor testing and clinic visits occurred at a median interval of 22 months. Over 80% of patients with high-risk mutations had documentation and education on their inhibitor risk. Our practice audit demonstrated a high level of recognition and patient education of individual inhibitor risk. Impact of our standardized approach on the incidence of inhibitor development is yet to be determined.

  12. Anion gap as a prognostic tool for risk stratification in critically ill patients - a systematic review and meta-analysis.

    Science.gov (United States)

    Glasmacher, Stella Andrea; Stones, William

    2016-08-30

    recommended for risk stratification in critically ill patients. The probable influence of intravenous fluids on AG levels renders the AG an impractical tool in clinical practice. Future research should focus on increasing the availability of lactate monitoring in low resource settings. CRD42015015249 . Registered on 4th February 2015.

  13. Risk impact of two accident management strategies

    International Nuclear Information System (INIS)

    Dingman, S.; Camp, A.

    1992-01-01

    This report probabilistic Risk Assessment is used to evaluate two accident management strategies: intentionally depressurizing the reactor coolant system of a pressurized water reactor to prevent containment-pressurization during high pressure melt ejection, and flooding the containment of a boiling water reactor to prevent or delay vessel breach. Sensitivity studies indicated that intentional depressurization would not provide a significant risk reduction at Surry. A preliminary evaluation of the containment flooding strategy indicated that it might prove beneficial for some plants, but that further strategy development would be needed to fully evaluate the strategy-

  14. Evaluating risk management strategies in resource planning

    International Nuclear Information System (INIS)

    Andrews, C.J.

    1995-01-01

    This paper discusses the evaluation of risk management strategies as a part of integrated resource planning. Value- and scope-related uncertainties can be addressed during the process of planning, but uncertainties in the operating environment require technical analysis within planning models. Flexibility and robustness are two key classes of strategies for managing the risk posed by these uncertainties. This paper reviews standard capacity expansion planning models and shows that they are poorly equipped to compare risk management strategies. Those that acknowledge uncertainty are better at evaluating robustness than flexibility, which implies a bias against flexible options. Techniques are available to overcome this bias

  15. Approved Risk Evaluation and Mitigation Strategies

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to...

  16. Noninvasive Assessment of Preload Reserve Enhances Risk Stratification of Patients With Heart Failure With Reduced Ejection Fraction.

    Science.gov (United States)

    Matsumoto, Kensuke; Onishi, Akira; Yamada, Hirotsugu; Kusunose, Kenya; Suto, Makiko; Hatani, Yutaka; Matsuzoe, Hiroki; Tatsumi, Kazuhiro; Tanaka, Hidekazu; Hirata, Ken-Ichi

    2018-05-01

    The leg-positive pressure maneuver can safely and noninvasively apply preload stress without increase in total body fluid volume. The purpose of this study was to determine whether preload stress could be useful for risk stratification of patients with heart failure with reduced ejection fraction. For this study, 120 consecutive patients with heart failure with reduced ejection fraction were prospectively recruited. The stroke work index was estimated as product of stroke volume index and mean blood pressure, and the E/e' ratio was calculated to estimate ventricular filling pressure. The echocardiographic parameters were obtained both at rest and during leg-positive pressure stress. During the median follow-up period of 20 months, 30 patients developed adverse cardiovascular events. During preload stress, stroke work index increased significantly (from 3280±1371 to 3857±1581 mm Hg·mL/m 2 ; P <0.001) along with minimal changes in ventricular filling pressure (E/e', from 16±10 to 17±9; P <0.05) in patients without cardiovascular events. However, patients with cardiovascular events showed impairment of Frank-Starling mechanism (stroke work index, from 2863±969 to 2903±1084 mm Hg·mL/m 2 ; P =0.70) and a serious increase in E/e' ratio (from 19±11 to 25±14; P <0.001). Both the patients without contractile reserve and those without diastolic reserve exhibited worse event-free survival than the others ( P <0.001). In a Cox proportional-hazards analysis, the changes in stroke work index (hazard ratio: 0.44 per 500 mm Hg·mL/m 2 increase; P =0.001) and in E/e' (hazard ratio: 2.58 per 5-U increase; P <0.001) were predictors of cardiovascular events. Contractile reserve and diastolic reserve during leg-positive pressure stress are important determinants of cardiovascular outcomes for patients with heart failure with reduced ejection fraction. © 2018 American Heart Association, Inc.

  17. Risk evaluation of accident management strategies

    International Nuclear Information System (INIS)

    Dingman, S.; Camp, A.

    1992-01-01

    The use of Probabilistic Risk Assessment (PRA) methods to evaluate accident management strategies in nuclear power plants discussed in this paper. The PRA framework allows an integrated evaluation to be performed to give the full implications of a particular strategy. The methodology is demonstrated for a particular accident management strategy, intentional depressurization of the reactor coolant system to avoid containment pressurization during the ejection of molten debris at vessel breach

  18. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1

    DEFF Research Database (Denmark)

    Olesen, Jonas Bjerring; Torp-Pedersen, Christian; Hansen, Morten Lock

    2012-01-01

    associated with increasing CHA2DS2-VASc score was estimated in Cox regression models adjusted for year of inclusion and antiplatelet therapy. The value of adding the extra CHA2DS2-VASc risk factors to the CHADS2 score was evaluated by c-statistics, Net Reclassification Improvement (NRI) and Integrated......DS2-VASc score significantly improved the predictive value of the CHADS2 score alone and a CHA2DS2-VASc score=0 could clearly identify 'truly low risk' subjects. Use of the CHA2DS2-VASc score would significantly improve classification of AF patients at low and intermediate risk of stroke, compared......North American and European guidelines on atrial fibrillation (AF) are conflicting regarding the classification of patients at low/intermediate risk of stroke. We aimed to investigate if the CHA2DS2-VASc score improved risk stratification of AF patients with a CHADS2 score of 0-1. Using individual...

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

    Science.gov (United States)

    Jernberg, Tomas; Stridsberg, Mats; Venge, Per; Lindahl, Bertil

    2002-08-07

    The study evaluated the prognostic value of single measurement of N-terminal pro brain natriuretic peptide (NT-proBNP) obtained on admission in patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation. Patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation constitute a large and heterogeneous population. Early risk stratification has been based on clinical background factors, electrocardiography (ECG) and biochemical markers of myocardial damage. The neurohormonal activation has, so far, received less attention. The NT-proBNP was analyzed on admission in 755 patients admitted because of chest pain and no ST-segment elevation. Patients were followed concerning death for 40 months (median). The median NT-proBNP level was 400 (111 to 1646) ng/l. Compared to the lowest quartile, patients in the second, third and fourth quartiles had a relative risk of subsequent death of 4.2 (1.6 to 11.1), 10.7 (4.2 to 26.8) and 26.6 (10.8 to 65.5), respectively. When NT-proBNP was added to a Cox regression model including clinical background factors, ECG and troponin T, the NT-proBNP levels were independently associated with prognosis. A single measurement of NT-proBNP on admission will substantially improve the early risk stratification of patients with symptoms suggestive of an acute coronary syndrome and no ST-segment elevation. A combination of clinical background factors, ECG, troponin T and NT-proBNP obtained on admission will provide a highly discerning tool for risk stratification and further clinical decisions.

  20. Managing price risk - setting and implementing strategies

    International Nuclear Information System (INIS)

    Haines, D.

    1999-01-01

    The three hedging strategies for price risk management within the natural gas industry are described. The three strategies are: (1) speculative trader (characterized by 'trading for profit, i.e. small margin/large volumes); (2) price optimizer (the objective here is to outperform the market in the establishment of a price); and (3) strategic hedger( the characteristic concern in this strategy is to manage long-term company goals, i.e. balance sheet orientation). The strategies are not mutually exclusive, but overlapping areas can be the source of considerable confusion. Any firm can enter into more than one of these strategies. Integrated companies will adopt very different strategies for upstream versus downstream operations. Details of the three strategies are provided

  1. Risk Stratification of Acute Kidney Injury Using the Blood Urea Nitrogen/Creatinine Ratio in Patients With Acute Decompensated Heart Failure.

    Science.gov (United States)

    Takaya, Yoichi; Yoshihara, Fumiki; Yokoyama, Hiroyuki; Kanzaki, Hideaki; Kitakaze, Masafumi; Goto, Yoichi; Anzai, Toshihisa; Yasuda, Satoshi; Ogawa, Hisao; Kawano, Yuhei

    2015-01-01

    Risk stratification of acute kidney injury (AKI) is important for acute decompensated heart failure (ADHF). The aim of this study was to determine whether clinical markers, such as the blood urea nitrogen/creatinine ratio (BUN/Cr) or BUN or creatinine values alone, stratify the risk of AKI for mortality. In all, 371 consecutive ADHF patients were enrolled in the study. AKI was defined as serum creatinine ≥0.3 mg/dl or a 1.5-fold increase in serum creatinine levels within 48 h. During ADHF therapy, AKI occurred in 99 patients; 55 patients died during the 12-month follow-up period. Grouping patients according to AKI and a median BUN/Cr at admission of 22.1 (non-AKI+low BUN/Cr, non-AKI+high BUN/Cr, AKI+low BUN/Cr, and AKI+high BUN/Cr groups) revealed higher mortality in the AKI+high BUN/Cr group (log-rank test, Phigh BUN/Cr and mortality, whereas the association with AKI+low BUN/Cr did not reach statistical significance. When patients were grouped according to AKI and median BUN or creatinine values at admission, AKI was associated with mortality, regardless of BUN or creatinine. The combination of AKI and elevated BUN/Cr, but not BUN or creatinine individually, is linked with an increased risk of mortality in ADHF patients, suggesting that the BUN/Cr is useful for risk stratification of AKI.

  2. INSURANCE - A RISK COVERING STRATEGY

    Directory of Open Access Journals (Sweden)

    Marius Dan GAVRILETEA

    2014-12-01

    Full Text Available Insurance industry in Romania is facing for a few years a continuous decreasing in Gross Written Premium. The negative trend may be caused by the effects of financial crises for companies and also for individuals. In order to keep theirs market share, insurance companies must identify new opportunities to increase theirs’ GWP. Among these new market niches hospitality industry may represent an option to be followed. In this paper, we will analyze the types of insurance policies available for hospitality industry (except mandatory motors’ third party liability and motors’ own vehicle insurance. The conclusion represents solution both for insurance companies and for hotel as a part of theirs’ risk financing process.

  3. Risk perception influences athletic pacing strategy.

    Science.gov (United States)

    Micklewright, Dominic; Parry, David; Robinson, Tracy; Deacon, Greg; Renfree, Andrew; St Clair Gibson, Alan; Matthews, William J

    2015-05-01

    The objective of this study is to examine risk taking and risk perception associations with perceived exertion, pacing, and performance in athletes. Two experiments were conducted in which risk perception was assessed using the domain-specific risk taking (DOSPERT) scale in 20 novice cyclists (experiment 1) and 32 experienced ultramarathon runners (experiment 2). In experiment 1, participants predicted their pace and then performed a 5-km maximum effort cycling time trial on a calibrated Kingcycle mounted bicycle. Split times and perceived exertion were recorded every kilometer. In experiment 2, each participant predicted their split times before running a 100-km ultramarathon. Split times and perceived exertion were recorded at seven checkpoints. In both experiments, higher and lower risk perception groups were created using median split of DOSPERT scores. In experiment 1, pace during the first kilometer was faster among lower risk perceivers compared with higher risk perceivers (t(18) = 2.0, P = 0.03) and faster among higher risk takers compared with lower risk takers (t(18) = 2.2, P = 0.02). Actual pace was slower than predicted pace during the first kilometer in both the higher risk perceivers (t(9) = -4.2, P = 0.001) and lower risk perceivers (t(9) = -1.8, P = 0.049). In experiment 2, pace during the first 36 km was faster among lower risk perceivers compared with higher risk perceivers (t(16) = 2.0, P = 0.03). Irrespective of risk perception group, actual pace was slower than predicted pace during the first 18 km (t(16) = 8.9, P risk perception groups. Initial pace is associated with an individual's perception of risk, with low perceptions of risk being associated with a faster starting pace. Large differences between predicted and actual pace suggest that the performance template lacks accuracy, perhaps indicating greater reliance on momentary pacing decisions rather than preplanned strategy.

  4. The adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for risk stratification in young APS patients with acute myocardial infarction.

    Science.gov (United States)

    Radin, M; Schreiber, K; Costanzo, P; Cecchi, I; Roccatello, D; Baldovino, S; Bazzan, M; Cuadrado, M J; Sciascia, S

    2017-08-01

    Young adults with acute myocardial infarction are a critical group to examine for the purpose of risk factor stratification and modification. In this study we aimed to assess the clinical utility of the adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for the risk stratification of acute myocardial infarction in a cohort of young patients with antiphospholipid syndrome (APS). The analysis included 83 consecutive APS patients (≤50years old) who presented with arterial or venous thromboembolic events. Data on cardiovascular risk factors and antiphospholipid antibodies (aPL) positivity were retrospectively collected. The aGAPSS was calculated by adding the points corresponding to the risk factors, based on a linear transformation derived from the ß-regression coefficient as follows: 3 for hyperlipidaemia, 1 for arterial hypertension, 5 for aCL IgG/IgM, 4 for anti-b2 glycoprotein I IgG/IgM and 4 for LA. Higher aGAPSS values were observed in patients with acute myocardial infarction when compared to the others [mean aGAPSS 11.9 (S.D. 4.15, range 4-18) Vs. mean aGAPSS 9.2 (S.D. 5.1, range 1-17); T test: psyndrome compared to patients with a history of peripheral or cerebrovascular arterial thrombotic events [mean aGAPSS 11.9 (S.D. 4.15, range 4-18) Vs. mean aGAPSS 6.7 (S.D. 5.7, range 1-17); T test: P<0.005]. The aGAPSS is based upon a quantitative score and could aid risk stratifying APS patients younger than 50years for the likelihood of developing coronary thrombotic events and may guide pharmacological treatment for high-risk patients. Copyright © 2017 Elsevier B.V. All rights reserved.

  5. Adenosine stress and exercise 99Tcm-MIBI myocardial perfusion imaging in the diagnosis and risk stratification of patients with unstable angina

    International Nuclear Information System (INIS)

    Jia Peng; Guo Wanhua; Xu Shoulin; Feng Xuefeng

    2008-01-01

    Objective: The aim of this study was to evaluate the clinical value of adenosine stress or exercise 99 Tc m -methoxyisobutylisonitrile (MIBI) myocardial perfusion imaging in the diagnosis and risk stratification of patients with unstable angina. Methods: Eighty-seven hospitalized patients with unstable angina [54 men and 33 women, aged of (56.5±12.5) years] underwent adenosine stress or exercise myocardial perfusion imaging and coronary angiography. Patients were followed up. Results: Fifty-seven patients had abnormal myocardial perfusion imaging and significant coronary artery stenosis. Ten patients had abnormal myocardial perfusion imaging but normal coronary angiography. Eight patients had normal myocardial perfusion imaging but significant coronary artery stenosis. Twelve patients had normal myocardial perfusion imaging and normal coronary angiography. Patients with abnormal myocardial perfusion imaging had worse prognosis. There was relationship between cardiac events and the extent and severity of myocardial ischemia. Conclusion: Adenosine stress and exercise myocardial perfusion imaging is of important clinical value in the diagnosis and risk stratification of patients with unstable angina. (authors)

  6. Existential risks: exploring a robust risk reduction strategy.

    Science.gov (United States)

    Jebari, Karim

    2015-06-01

    A small but growing number of studies have aimed to understand, assess and reduce existential risks, or risks that threaten the continued existence of mankind. However, most attention has been focused on known and tangible risks. This paper proposes a heuristic for reducing the risk of black swan extinction events. These events are, as the name suggests, stochastic and unforeseen when they happen. Decision theory based on a fixed model of possible outcomes cannot properly deal with this kind of event. Neither can probabilistic risk analysis. This paper will argue that the approach that is referred to as engineering safety could be applied to reducing the risk from black swan extinction events. It will also propose a conceptual sketch of how such a strategy may be implemented: isolated, self-sufficient, and continuously manned underground refuges. Some characteristics of such refuges are also described, in particular the psychosocial aspects. Furthermore, it is argued that this implementation of the engineering safety strategy safety barriers would be effective and plausible and could reduce the risk of an extinction event in a wide range of possible (known and unknown) scenarios. Considering the staggering opportunity cost of an existential catastrophe, such strategies ought to be explored more vigorously.

  7. Síndromes coronarianas agudas: tratamento e estratificação de risco Acute coronary syndromes: treatment and risk stratification

    Directory of Open Access Journals (Sweden)

    Antonio Eduardo Pereira Pesaro

    2008-06-01

    variable degrees of coronary obstruction. Patients with total occlusion may present with acute ST Elevation Myocardial Infarction (STEMI. Partial vessel obstruction may result in Non-ST-Elevation Acute Myocardial Infarction (NSTEMI or unstable angina (UA. Clinical symptoms and electrocardiographic changes are the main components of identification of ACS. The rapid and effective triage of such patients regarding presence or absence of ST-segment elevation is critical to dictate further therapeutic strategies. The objective of this chapter was to review current evidence and recommendations for the evaluation and early treatment of acute coronary syndromes. CONTENTS: We performed a clinical review using the electronic databases MedLine and LILACS from January 1990 to September 2007. CONCLUSIONS: Reperfusion of the infarct-related artery is the cornerstone of therapy for STEMI. Fibrinolysis and percutaneous coronary intervention are both well established as effective options. Management of UA/NSTEMI patients requires early risk stratification. High-risk patients should undergo an early invasive strategy that consists in performance of cardiac catheterization in the first 24 to 48 hours of presentation.

  8. Impact of chromosome alterations, genetic mutations and clonal hematopoiesis of indeterminate potential (CHIP) on the classification and risk stratification of MDS.

    Science.gov (United States)

    Ganguly, Bani Bandana; Banerjee, Debasis; Agarwal, Mohan B

    2018-03-01

    The advent of technological development has undoubtedly advanced biological and molecular inputs for better understanding the heterogeneous hematopoietic pre-malignant disorder of the stem cells known as myelodysplastic syndromes (MDS). Chromosomal rearrangements, including del(3q/5q/7q/11q/12p/20q), loss of 5/7/Y, trisomy 8/19, i(17q), etc. frequently detected in MDS with variable frequencies and combinations, are the integral components of the 5-tier risk-stratification and WHO-2016 classification. Observations on mutations in genes involved in RNA-splicing, DNA methylation, chromatin modification, transcription factor, signal transduction/kinases, RAS pathway, cohesin complex, DNA repair and other pathways have given insights in independent effects and biological interaction of co-occurrence on disease-phenotype and treatment outcome. However, recent concepts of clonal hematopoiesis of indeterminate potential (CHIP) and idiopathic cytopenia of undetermined significance (ICUS) have urged a re-definition of mutational events in non-clonal cytopenia and non-MDS healthy elderly but with a higher risk of overt leukemia. Considering gene mutations, chromosomal alterations, CHIP, ICUS and their significance in classification and risk-scoring certainly presents a comprehensive picture of disease-phenotype towards better understanding of MDS-pathogenesis, its evolution to AML and its response to therapeutic agents. The present review summarizes chromosomal and gene mutations, co-existence of mutational complexity, and WHO-2016 classification and risk-stratifications of MDS to facilitate a better understanding of its pathogenesis. Copyright © 2017 Elsevier Inc. All rights reserved.

  9. Distribution of Cervical Lymph Node Metastases From Squamous Cell Carcinoma of the Oropharynx in the Era of Risk Stratification Using Human Papillomavirus and Smoking Status.

    Science.gov (United States)

    Amsbaugh, Mark J; Yusuf, Mehran; Cash, Elizabeth; Silverman, Craig; Wilson, Elizabeth; Bumpous, Jeffrey; Potts, Kevin; Perez, Cesar; Bert, Robert; Redman, Rebecca; Dunlap, Neal

    2016-10-01

    To investigate the factors contributing to the clinical presentation of oropharyngeal squamous cell carcinoma (OPSCC) in the era of risk stratification using human papilloma virus (HPV) and smoking status. All patients with OPSCC presenting to our institutional multidisciplinary clinic from January 2009 to June 2015 were reviewed from a prospective database. The patients were grouped as being at low risk, intermediate risk, and high risk in the manner described by Ang et al. Variance in clinical presentation was examined using χ(2), Kruskal-Wallis, Mann-Whitney, and logistic regression analyses. The rates of HPV/p16 positivity (Phigh-risk patients presented with tumor stage T4 at a much higher than expected frequency (P=.003). Patients with BOT primary tumors who were never-smokers were less likely to have clinically involved ipsilateral neck disease than were former smokers (odds ratio 1.8; P=.038). The distribution of cervical lymph node metastases was not associated with HPV/p16 positivity, risk group, or subsite. When these data were compared with those in historical series, no significant differences were seen in the patterns of cervical lymph node metastases for patients with OPSCC. For patients with OPSCC differences in HPV status, smoking history and anatomic subsite were associated with differences in clinical presentation but not with distribution of cervical lymph node metastases. Historical series describing the patterns of cervical lymph node metastases in patients with OPSCC remain clinically relevant. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. Risk stratification of cardiovascular events in hypertensive patients with asymptomatic or symptomatic lacunar infarcts by 24-hour ambulatory blood pressure monitoring

    International Nuclear Information System (INIS)

    Shiraishi, Makoto; Watanabe, Hirofumi; Sakurai, Kenzo; Kato, Bunta; Hasegawa, Yasuhiro

    2012-01-01

    Our goal was to investigate the utility of 24-hour ambulatory blood pressure monitoring (ABPM) for the risk stratification of cardiovascular events in hypertensive patients with asymptomatic or symptomatic lacunar infarcts. A total of 175 hypertensive patients with MRI evidence of asymptomatic or symptomatic lacunar infarcts (92 men, mean age of 69±11 years old) were studied. Patients with symptomatic infarctions were included whose events occurred more than 6 months after the onset. ABPM was performed in all patients in the outpatient clinic. Parameters obtained from ABPM were related to the composite outcome which consisted of all death and fatal or non-fatal cardiovascular events by using the Cox proportional hazard model. Mean follow-up period was 4.8 years and the composite outcome was recorded in 38 patients. 34 of them (89%) had recurrence of lacunar infarcts. Significant association between sleep-time lowest systolic blood pressure and composite outcome was demonstrated by multivariate Cox hazard analyses (heart rate (HR) 1.025, 95% confidence interval (CI) 1.011-1.039, p<0.001). The risk for composite outcome in patients with the highest tertile of sleep-time lowest systolic blood pressure (≥133 mmHg) was significantly elevated when compared to the lowest tertile (<132 mmHg, HR 3.93, 95% CI 1.57-9.86, p=0.004). Sleep-time lowest systolic blood pressure in ABPM may be a useful parameter for the risk stratification of future cardiovascular events in hypertensive patients with asymptomatic or symptomatic lacunar infarcts, especially for the recurrence of these events. (author)

  11. Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction

    DEFF Research Database (Denmark)

    Rasmussen, Martin B; Stengaard, Carsten; Sørensen, Jacob T

    2017-01-01

    -of-care cardiac troponin T measurements (11.0%) had a value ≥50 ng/l, including 966 with acute myocardial infarction (sensitivity: 44.2%, specificity: 92.8%). Patients presenting with a prehospital point-of-care cardiac troponin T value ≥50 ng/l had a one-year mortality of 24% compared with 4.8% in those...... with values analysis: point-of-care cardiac troponin T≥50 ng/l (hazard ratio 2.10, 95% confidence interval: 1.90-2.33), congestive heart failure (hazard ratio 1.93, 95% confidence interval: 1......OBJECTIVE: The purpose of this study was to determine the predictive value of routine prehospital point-of-care cardiac troponin T measurement for diagnosis and risk stratification of patients with suspected acute myocardial infarction. METHODS AND RESULTS: All prehospital emergency medical service...

  12. INLET STRATIFICATION DEVICE

    DEFF Research Database (Denmark)

    2006-01-01

    An inlet stratification device (5) for a circuit circulating a fluid through a tank (1 ) and for providing and maintaining stratification of the fluid in the tank (1 ). The stratification de- vice (5) is arranged vertically in the tank (1) and comprises an inlet pipe (6) being at least partially...... formed of a flexible porous material and having an inlet (19) and outlets formed of the pores of the porous material. The stratification device (5) further comprises at least one outer pipe (7) surrounding the inlet pipe (6) in spaced relationship thereto and being at least partially formed of a porous...

  13. AN EVALUATION OF RISK MANAGEMENT STRATEGIES FOR DAIRY FARMS

    OpenAIRE

    Bosch, Darrell J.; Johnson, Christian J.

    1992-01-01

    Variability in feed prices and crop yields are important sources of risk to dairy farmers. A simulation model of a representative dairy farm was used to evaluate crop insurance and hedging as risk management strategies. These strategies lowered expected net returns but also reduced risk. The preferred set of strategies at lower levels of risk aversion included hedging and crop insurance, although a base scenario in which no risk management strategies were employed was also efficient. The pref...

  14. Risk evaluation mitigation strategies: the evolution of risk management policy.

    Science.gov (United States)

    Hollingsworth, Kristen; Toscani, Michael

    2013-04-01

    The United States Food and Drug Administration (FDA) has the primary regulatory responsibility to ensure that medications are safe and effective both prior to drug approval and while the medication is being actively marketed by manufacturers. The responsibility for safe medications prior to marketing was signed into law in 1938 under the Federal Food, Drug, and Cosmetic Act; however, a significant risk management evolution has taken place since 1938. Additional federal rules, entitled the Food and Drug Administration Amendments Act, were established in 2007 and extended the government's oversight through the addition of a Risk Evaluation and Mitigation Strategy (REMS) for certain drugs. REMS is a mandated strategy to manage a known or potentially serious risk associated with a medication or biological product. Reasons for this extension of oversight were driven primarily by the FDA's movement to ensure that patients and providers are better informed of drug therapies and their specific benefits and risks prior to initiation. This article provides an historical perspective of the evolution of medication risk management policy and includes a review of REMS programs, an assessment of the positive and negative aspects of REMS, and provides suggestions for planning and measuring outcomes. In particular, this publication presents an overview of the evolution of the REMS program and its implications.

  15. Performance of the 2015 International Task Force Consensus Statement Risk Stratification Algorithm for Implantable Cardioverter-Defibrillator Placement in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy.

    Science.gov (United States)

    Orgeron, Gabriela M; Te Riele, Anneline; Tichnell, Crystal; Wang, Weijia; Murray, Brittney; Bhonsale, Aditya; Judge, Daniel P; Kamel, Ihab R; Zimmerman, Stephan L; Tandri, Harikrishna; Calkins, Hugh; James, Cynthia A

    2018-02-01

    Ventricular arrhythmias are a feared complication of arrhythmogenic right ventricular dysplasia/cardiomyopathy. In 2015, an International Task Force Consensus Statement proposed a risk stratification algorithm for implantable cardioverter-defibrillator placement in arrhythmogenic right ventricular dysplasia/cardiomyopathy. To evaluate performance of the algorithm, 365 arrhythmogenic right ventricular dysplasia/cardiomyopathy patients were classified as having a Class I, IIa, IIb, or III indication per the algorithm at baseline. Survival free from sustained ventricular arrhythmia (VT/VF) in follow-up was the primary outcome. Incidence of ventricular fibrillation/flutter cycle length the algorithm appropriately differentiated risk of VT/VF, incidence of VT/VF was underestimated (observed versus expected: 29.6 [95% confidence interval, 25.2-34.0] versus >10%/year Class I; 15.5 [confidence interval 11.1-21.6] versus 1% to 10%/year Class IIa). In addition, the algorithm did not differentiate survival free from ventricular fibrillation/flutter between Class I and IIa patients ( P =0.97) or for VT/VF in Class I and IIa primary prevention patients ( P =0.22). Adding Holter results (the algorithm differentiates arrhythmic risk well overall, it did not distinguish ventricular fibrillation/flutter risks of patients with Class I and IIa implantable cardioverter-defibrillator indications. Limited differentiation was seen for primary prevention cases. As these are vital uncertainties in clinical decision-making, refinements to the algorithm are suggested prior to implementation. © 2018 American Heart Association, Inc.

  16. EPA'S strategy to reduce risk of radon

    International Nuclear Information System (INIS)

    Page, S.

    1993-01-01

    The Indoor Radon Abatement Act of 1988 (IRAA) directed EPA to undertake a variety of activities to address the growing public concern over dangers posed by exposure to indoor radon. Among other requirements, the law directed the Agency to study radon levels, evaluate mitigation methods, establish proficiency programs, assist states with program development, develop training centers, and provide public information. EPA has developed and implemented programs to address each of the key provisions of this statute. This paper presents EPA's broad national strategy to reduce radon risks. It combines and reinforces EPA's basic foundation, including its guiding policies and cooperative partnerships, with an overall management approach and focus for the future. The paper starts with an overview that introduces the strategy's four key elements: underlying policies and scientific principles, a decentralized system of states and other partners for targeting the public, multiple strategies for achieving radon risk reduction, and a strong focus on five key program priorities. This paper then discusses each of these elements in more detail and describes how they interact to guide future efforts and directions of the Agency

  17. Risk management: a proposal for communication strategies

    Directory of Open Access Journals (Sweden)

    Michele Fontana

    2012-07-01

    Full Text Available Disasters related to natural hazards have increased in the last few decades. This increment makes it necessary to develop non-structural risk prevention and mitigation measures to improve people’s safety. An effective non-structural measure that can improve the preparedness of the population is a locally adapted communication campaign that is focused on natural hazards. We have developed a hypothetical communication campaign for a specific area in the north of Italy, in which hydro-geological risk is of considerable importance. The content of the campaign is defined by the combination of the requirements of the law with the results of a survey conducted in the study area. The aim of the survey is to evaluate the level of risk perception among the residents, and their attitudes towards prevention activities. The operative procedure of the campaign is modeled on advertising strategies. The campaign is designed to reach each family, and it is aimed at affecting people’s everyday life through a horizontal communication strategy that involves flyers, billboards, umbrellas and a website. The use of umbrellas as a medium for the campaign is the key. People mostly use umbrellas when it rains. Rain is linked with hydrogeological risk. As the content of the campaign is printed on the umbrellas, each time people use these umbrellas, they remember the campaign. The campaign is integrated into a broader communication program that includes meetings with stakeholders, activities in schools, and public conferences. The final goal is to foster the creation of a shared knowledge about risk in the whole population.

  18. Distribution of Cervical Lymph Node Metastases From Squamous Cell Carcinoma of the Oropharynx in the Era of Risk Stratification Using Human Papillomavirus and Smoking Status

    International Nuclear Information System (INIS)

    Amsbaugh, Mark J.; Yusuf, Mehran; Cash, Elizabeth; Silverman, Craig; Wilson, Elizabeth; Bumpous, Jeffrey; Potts, Kevin; Perez, Cesar; Bert, Robert; Redman, Rebecca; Dunlap, Neal

    2016-01-01

    Purpose/Objective(s): To investigate the factors contributing to the clinical presentation of oropharyngeal squamous cell carcinoma (OPSCC) in the era of risk stratification using human papilloma virus (HPV) and smoking status. Methods and Materials: All patients with OPSCC presenting to our institutional multidisciplinary clinic from January 2009 to June 2015 were reviewed from a prospective database. The patients were grouped as being at low risk, intermediate risk, and high risk in the manner described by Ang et al. Variance in clinical presentation was examined using χ"2, Kruskal-Wallis, Mann-Whitney, and logistic regression analyses. Results: The rates of HPV/p16 positivity (P<.001), never-smoking (P=.016), and cervical lymph node metastases (P=.023) were significantly higher for patients with OPSCC of the tonsil, base of tongue (BOT), or vallecula subsites when compared with pharyngeal wall or palate subsites. Low-risk patients with tonsil, base of tongue, or vallecula primary tumors presented with nodal stage N2a at a much higher than expected frequency (P=.007), and high-risk patients presented with tumor stage T4 at a much higher than expected frequency (P=.003). Patients with BOT primary tumors who were never-smokers were less likely to have clinically involved ipsilateral neck disease than were former smokers (odds ratio 1.8; P=.038). The distribution of cervical lymph node metastases was not associated with HPV/p16 positivity, risk group, or subsite. When these data were compared with those in historical series, no significant differences were seen in the patterns of cervical lymph node metastases for patients with OPSCC. Conclusions: For patients with OPSCC differences in HPV status, smoking history and anatomic subsite were associated with differences in clinical presentation but not with distribution of cervical lymph node metastases. Historical series describing the patterns of cervical lymph node metastases in patients with OPSCC remain

  19. Distribution of Cervical Lymph Node Metastases From Squamous Cell Carcinoma of the Oropharynx in the Era of Risk Stratification Using Human Papillomavirus and Smoking Status

    Energy Technology Data Exchange (ETDEWEB)

    Amsbaugh, Mark J., E-mail: mjamsb01@louisville.edu [Department of Radiation Oncology, University of Louisville, Louisville, Kentucky (United States); Yusuf, Mehran [Department of Radiation Oncology, University of Louisville, Louisville, Kentucky (United States); Cash, Elizabeth [Department of Otolaryngology, University of Louisville, Louisville, Kentucky (United States); Silverman, Craig [Department of Radiation Oncology, University of Louisville, Louisville, Kentucky (United States); Wilson, Elizabeth; Bumpous, Jeffrey; Potts, Kevin [Department of Otolaryngology, University of Louisville, Louisville, Kentucky (United States); Perez, Cesar [Division of Medical Oncology, Department of Medicine, University of Louisville, Louisville, Kentucky (United States); Bert, Robert [Department of Diagnostic Radiology, University of Louisville, Louisville, Kentucky (United States); Redman, Rebecca [Division of Medical Oncology, Department of Medicine, University of Louisville, Louisville, Kentucky (United States); Dunlap, Neal [Department of Radiation Oncology, University of Louisville, Louisville, Kentucky (United States)

    2016-10-01

    Purpose/Objective(s): To investigate the factors contributing to the clinical presentation of oropharyngeal squamous cell carcinoma (OPSCC) in the era of risk stratification using human papilloma virus (HPV) and smoking status. Methods and Materials: All patients with OPSCC presenting to our institutional multidisciplinary clinic from January 2009 to June 2015 were reviewed from a prospective database. The patients were grouped as being at low risk, intermediate risk, and high risk in the manner described by Ang et al. Variance in clinical presentation was examined using χ{sup 2}, Kruskal-Wallis, Mann-Whitney, and logistic regression analyses. Results: The rates of HPV/p16 positivity (P<.001), never-smoking (P=.016), and cervical lymph node metastases (P=.023) were significantly higher for patients with OPSCC of the tonsil, base of tongue (BOT), or vallecula subsites when compared with pharyngeal wall or palate subsites. Low-risk patients with tonsil, base of tongue, or vallecula primary tumors presented with nodal stage N2a at a much higher than expected frequency (P=.007), and high-risk patients presented with tumor stage T4 at a much higher than expected frequency (P=.003). Patients with BOT primary tumors who were never-smokers were less likely to have clinically involved ipsilateral neck disease than were former smokers (odds ratio 1.8; P=.038). The distribution of cervical lymph node metastases was not associated with HPV/p16 positivity, risk group, or subsite. When these data were compared with those in historical series, no significant differences were seen in the patterns of cervical lymph node metastases for patients with OPSCC. Conclusions: For patients with OPSCC differences in HPV status, smoking history and anatomic subsite were associated with differences in clinical presentation but not with distribution of cervical lymph node metastases. Historical series describing the patterns of cervical lymph node metastases in patients with OPSCC remain

  20. Software-based risk stratification of pulmonary adenocarcinomas manifesting as pure ground glass nodules on computed tomography

    Energy Technology Data Exchange (ETDEWEB)

    Nemec, Ursula [Vienna General Hospital, Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Vienna (Austria); Heidinger, Benedikt H.; Bankier, Alexander A. [Harvard Medical School, Radiology, Beth Israel Deaconess Medical Center, Boston, MA (United States); Anderson, Kevin R.; VanderLaan, Paul A. [Harvard Medical School, Pathology, Beth Israel Deaconess Medical Center, Boston, MA (United States); Westmore, Michael S. [Imbio, Delafield, WI (United States)

    2018-01-15

    To assess the performance of the ''Computer-Aided Nodule Assessment and Risk Yield'' (CANARY) software in the differentiation and risk assessment of histological subtypes of lung adenocarcinomas manifesting as pure ground glass nodules on computed tomography (CT). 64 surgically resected and histologically proven adenocarcinomas manifesting as pure ground-glass nodules on CT were assessed using CANARY software, which classifies voxel-densities into three risk components (low, intermediate, and high risk). Differences in risk components between histological adenocarcinoma subtypes were analysed. To determine the optimal threshold reflecting the presence of an invasive focus, sensitivity, specificity, negative predictive value, and positive predictive value were calculated. 28/64 (44%) were adenocarcinomas in situ (AIS); 26/64 (41%) were minimally invasive adenocarcinomas (MIA); and 10/64 (16%) were invasive ACs (IAC). The software showed significant differences in risk components between histological subtypes (P<0.001-0.003). A relative volume of 45% or less of low-risk components was associated with histological invasiveness (specificity 100%, positive predictive value 100%). CANARY-based risk assessment of ACs manifesting as pure ground glass nodules on CT allows the differentiation of their histological subtypes. A threshold of 45% of low-risk components reflects invasiveness in these groups. (orig.)

  1. Software-based risk stratification of pulmonary adenocarcinomas manifesting as pure ground glass nodules on computed tomography

    International Nuclear Information System (INIS)

    Nemec, Ursula; Heidinger, Benedikt H.; Bankier, Alexander A.; Anderson, Kevin R.; VanderLaan, Paul A.; Westmore, Michael S.

    2018-01-01

    To assess the performance of the ''Computer-Aided Nodule Assessment and Risk Yield'' (CANARY) software in the differentiation and risk assessment of histological subtypes of lung adenocarcinomas manifesting as pure ground glass nodules on computed tomography (CT). 64 surgically resected and histologically proven adenocarcinomas manifesting as pure ground-glass nodules on CT were assessed using CANARY software, which classifies voxel-densities into three risk components (low, intermediate, and high risk). Differences in risk components between histological adenocarcinoma subtypes were analysed. To determine the optimal threshold reflecting the presence of an invasive focus, sensitivity, specificity, negative predictive value, and positive predictive value were calculated. 28/64 (44%) were adenocarcinomas in situ (AIS); 26/64 (41%) were minimally invasive adenocarcinomas (MIA); and 10/64 (16%) were invasive ACs (IAC). The software showed significant differences in risk components between histological subtypes (P<0.001-0.003). A relative volume of 45% or less of low-risk components was associated with histological invasiveness (specificity 100%, positive predictive value 100%). CANARY-based risk assessment of ACs manifesting as pure ground glass nodules on CT allows the differentiation of their histological subtypes. A threshold of 45% of low-risk components reflects invasiveness in these groups. (orig.)

  2. The Usefulness of the MEESSI Score for Risk Stratification of Patients With Acute Heart Failure at the Emergency Department.

    Science.gov (United States)

    Miró, Òscar; Rosselló, Xavier; Gil, Víctor; Martín-Sánchez, Francisco Javier; Llorens, Pere; Herrero, Pablo; Jacob, Javier; López-Grima, María Luisa; Gil, Cristina; Lucas Imbernón, Francisco Javier; Garrido, José Manuel; Pérez-Durá, María José; López-Díez, María Pilar; Richard, Fernando; Bueno, Héctor; Pocock, Stuart J

    2018-06-11

    The MEESSI scale stratifies acute heart failure (AHF) patients at the emergency department (ED) according to the 30-day mortality risk. We validated the MEESSI risk score in a new cohort of Spanish patients to assess its accuracy in stratifying patients by risk and to compare its performance in different settings. We included consecutive patients diagnosed with AHF in 30 EDs during January and February 2016. The MEESSI score was calculated for each patient. The c-statistic measured the discriminatory capacity to predict 30-day mortality of the full MEESSI model and secondary models. Further comparisons were made among subgroups of patients from university and community hospitals, EDs with high-, medium- or low-activity and EDs that recruited or not patients in the original MEESSI derivation cohort. We analyzed 4711 patients (university/community hospitals: 3811/900; high-/medium-/low-activity EDs: 2695/1479/537; EDs participating/not participating in the previous MEESSI derivation study: 3892/819). The distribution of patients according to the MEESSI risk categories was: 1673 (35.5%) low risk, 2023 (42.9%) intermediate risk, 530 (11.3%) high risk and 485 (10.3%) very high risk, with 30-day mortality of 2.0%, 7.8%, 17.9%, and 41.4%, respectively. The c-statistic for the full model was 0.810 (95%CI, 0.790-0.830), ranging from 0.731 to 0.785 for the subsequent secondary models. The discriminatory capacity of the MEESSI risk score was similar among subgroups of hospital type, ED activity, and original recruiter EDs. The MEESSI risk score successfully stratifies AHF patients at the ED according to the 30-day mortality risk, potentially helping clinicians in the decision-making process for hospitalizing patients. Copyright © 2018. Published by Elsevier España, S.L.U.

  3. Risk Stratification of Patients With Current Generation Continuous-Flow Left Ventricular Assist Devices Being Bridged to Heart Transplantation.

    Science.gov (United States)

    Guha, Ashrith; Nguyen, Duc; Cruz-Solbes, Ana S; Amione-Guerra, Javier; Schutt, Robert C; Bhimaraj, Arvind; Trachtenberg, Barry H; Park, Myung H; Graviss, Edward A; Gaber, Osama; Suarez, Erik; Montane, Eva; Torre-Amione, Guillermo; Estep, Jerry D

    Patients bridged to transplant (BTT) with continuous-flow left ventricular assist devices (CF-LVADs) have increased in the past decade. Decision support tools for these patients are limited. We developed a risk score to estimate prognosis and guide decision-making. We included heart transplant recipients bridged with CF-LVADs from the United Network for Organ Sharing (UNOS) database and divided them into development (2,522 patients) and validation cohorts (1,681 patients). Univariate and multivariate Cox proportional hazards models were performed. Variables that independently predicted outcomes (age, African American race, recipient body mass index [BMI], intravenous [IV] antibiotic use, pretransplant dialysis, and total bilirubin) were assigned weight using linear transformation, and risk scores were derived. Patients were grouped by predicted posttransplant mortality: low risk (≤ 38 points), medium risk (38-41 points), and high risk (≥ 42 points). We performed Cox proportional hazards analysis on wait-listed CF-LVAD patients who were not transplanted. Score significantly discriminated survival among the groups in the development cohort (6.7, 12.9, 20.7; p = 0.001), validation cohort (6.4, 10.1, 13.6; p assist device (LVAD) BTT risk score that effectively identifies CF-LVAD patients who are at higher risk for worse outcomes after heart transplant. This score may help physicians weigh the risks of transplantation in patients with CF-LVAD.

  4. Hot sanitary water production with CO_2 heat pumps: Effect of control strategy on system performance and stratification inside the storage tank

    International Nuclear Information System (INIS)

    Tammaro, M.; Mauro, A.W.; Montagud, C.; Corberán, J.M.; Mastrullo, R.

    2016-01-01

    In this work three different control strategies for the production of sanitary hot water by means of an electric heat pump working with CO_2 are investigated. The heat pump is a prototype, here modelled in the vapour-compression software package IMST-ART. By simulating this model, the performance of the heat pump is correlated to the boundary conditions and is scaled to different sizes, namely 1, 1.5, and 2 times larger than the reference system. After having chosen an application for which the load profile of sanitary hot water during the year is known, these heat pumps are simulated in a TRNSYS16 model where the production of sanitary hot water and the consumption are buffered by the presence of a tank. Key parameter in guaranteeing comfort and good performance of the system is the stratification inside the storage tank. The size of the tank necessary to keep a certain level of comfort at the user is then determined through a parametric analysis for each size of the heat pump. The energetic performance is also evaluated for each system in terms of seasonal performance factor. Then, the results obtained are compared with a different system where the heat pump is equipped with an inverter and the circulation pump follows a different control logic. The size of the tank and the seasonal performance factor are therefore determined in this case too. Moreover, a “night&day” control logic is compared to these first two options to have a baseline of comparison in terms of volume of storage needed to guarantee a same level of comfort and performance. To provide information also on the running costs, a parametric analysis was run varying the type of control, the heat pump and the tank sizes for different load profiles. The results show that the size of the heat pump has a significant effect on the comfort of the user, which usually leads to oversizing of the storage tank when the load profile is unknown. With regard to this, the results obtained for the alternative

  5. Long-Term Non-Invasive ECG-Based Risk Stratification of Sudden Cardiac Death: Extended 5-Year Results

    Directory of Open Access Journals (Sweden)

    Elena Okisheva

    2017-01-01

    Evaluation of HRT, DC and mTWA during 24-hour ECG monitoring may define the high risk of cardiovascular mortality and SCD in post-MI patients especially during the first 12 months after the baseline examination.

  6. Estratificación epidemiológica en el control de los factores de riesgo de la tuberculosis Epidemiological stratification to control the risk factors of tuberculosis

    Directory of Open Access Journals (Sweden)

    Elba Nieves Moreno Díaz

    2011-12-01

    Full Text Available Se realizó un estudio descriptivo longitudinal, con el objetivo de implementar la estratificación epidemiológica en el control de los factores de riesgo de la tuberculosis, provincia Pinar del Río, 2008-2010. El universo de estudio lo constituyó, los habitantes de la provincia en cada uno de los años estudiados. Se revisó el registro de dispensarización y las encuestas epidemiológicas; de ellos se obtuvieron los factores de riesgo: alcoholismo, hábito de fumar, diabetes mellitus, ancianos solos, desnutrición, inmunodeprimidos y casos viviendo con VIH/Sida. Para el procesamiento de la información se trabajó con Microsoft Excel y MapInfo Professional. Se utilizó la metodología estratificación epidemiológica de riesgo hasta nivel municipal; los estratos para los factores de riesgo como para la enfermedad, se clasificaron en: muy alto, alto, mediano y bajo riesgo. Para determinar la significación de cambios se utilizó la prueba Mc Nemar. Los resultados mostraron que en el 2009, el 50% de los municipios que en la estratificación del 2008 estaban en el estrato de muy alto y alto riesgo, el 85,7% cambiaran de estratos, lo que indica un mejor control de los factores de riesgo. El proceso de estratificación en el 2010, no logró cambios favorables en los municipios con mayor riesgo en el 2008, estando el 65% clasificado en estratos de muy alto y alto riesgo, pues el plan de acción previsto, no fue ejecutado con efectividad y seriedad por los jefes de programa, debido a inestabilidad y ausencia de los mismos en los municipios de mayor riesgo.A descriptive, longitudinal study aimed at implementing epidemiological stratification to control the risk factors of tuberculosis in Pinar del Rio province was carried out form 2008 to 2010. The target group was comprised of the inhabitants of the province for each of the years under study. Records and epidemiological survey were revised; taking into account the risk factors of alcoholism

  7. Age-adjusted high-sensitivity troponin T cut-off value for risk stratification of pulmonary embolism.

    Science.gov (United States)

    Kaeberich, Anja; Seeber, Valerie; Jiménez, David; Kostrubiec, Maciej; Dellas, Claudia; Hasenfuß, Gerd; Giannitsis, Evangelos; Pruszczyk, Piotr; Konstantinides, Stavros; Lankeit, Mareike

    2015-05-01

    High-sensitivity troponin T (hsTnT) helps in identifying pulmonary embolism patients at low risk of an adverse outcome. In 682 normotensive pulmonary embolism patients we investigate whether an optimised hsTnT cut-off value and adjustment for age improve the identification of patients at elevated risk. Overall, 25 (3.7%) patients had an adverse 30-day outcome. The established hsTnT cut-off value of 14 pg·mL(-1) retained its high prognostic value (OR (95% CI) 16.64 (2.24-123.74); p=0.006) compared with the cut-off value of 33 pg·mL(-1) calculated by receiver operating characteristic analysis (7.14 (2.64-19.26); pvalue of 45 pg·mL(-1) but not the established cut-off value of 14 pg·mL(-1) predicted an adverse outcome. An age-adjusted hsTnT cut-off value (≥14 pg·mL(-1) for patients aged risk (12.4% adverse outcome). Risk assessment of normotensive pulmonary embolism patients was improved by the introduction of an age-adjusted hsTnT cut-off value. A three-step approach helped identify patients at higher risk of an adverse outcome who might benefit from advanced therapy. Copyright ©ERS 2015.

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

    International Nuclear Information System (INIS)

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

    2013-01-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

    Baumann, Brian C. [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Guzzo, Thomas J. [Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); He Jiwei [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); Tucker, Kai; Bekelman, Justin E. [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); Vaughn, David J. [Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Malkowicz, S. Bruce [Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Christodouleas, John P., E-mail: christojo@uphs.upenn.edu [Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania (United States)

    2013-01-01

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

  10. Transient ischemic attack: reviewing the evolution of the definition, diagnosis, risk stratification, and management for the emergency physician.

    Science.gov (United States)

    Siket, Matthew S; Edlow, Jonathan A

    2012-08-01

    A transient ischemic attack (TIA) is an episode of reversible neurologic deficit caused by temporary focal central nervous system hypoperfusion. TIA is a medical emergency. Because patients with TIA in the emergency department (ED) have a high risk for stroke within the next 48 hours, it is imperative for the clinician to recognize this golden opportunity to prevent a disabling stroke. This article reviews our conceptual understanding of TIA, its definition, diagnosis, ways to stratify stroke risk, the acute management and disposition in the ED, and the potential future role of diagnostic biomarkers. Copyright © 2012 Elsevier Inc. All rights reserved.

  11. Comparison of EHR-based diagnosis documentation locations to a gold standard for risk stratification in patients with multiple chronic conditions.

    Science.gov (United States)

    Martin, Shelby; Wagner, Jesse; Lupulescu-Mann, Nicoleta; Ramsey, Katrina; Cohen, Aaron; Graven, Peter; Weiskopf, Nicole G; Dorr, David A

    2017-08-02

    To measure variation among four different Electronic Health Record (EHR) system documentation locations versus 'gold standard' manual chart review for risk stratification in patients with multiple chronic illnesses. Adults seen in primary care with EHR evidence of at least one of 13 conditions were included. EHRs were manually reviewed to determine presence of active diagnoses, and risk scores were calculated using three different methodologies and five EHR documentation locations. Claims data were used to assess cost and utilization for the following year. Descriptive and diagnostic statistics were calculated for each EHR location. Criterion validity testing compared the gold standard verified diagnoses versus other EHR locations and risk scores in predicting future cost and utilization. Nine hundred patients had 2,179 probable diagnoses. About 70% of the diagnoses from the EHR were verified by gold standard. For a subset of patients having baseline and prediction year data (n=750), modeling showed that the gold standard was the best predictor of outcomes on average for a subset of patients that had these data. However, combining all data sources together had nearly equivalent performance for prediction as the gold standard. EHR data locations were inaccurate 30% of the time, leading to improvement in overall modeling from a gold standard from chart review for individual diagnoses. However, the impact on identification of the highest risk patients was minor, and combining data from different EHR locations was equivalent to gold standard performance. The reviewer's ability to identify a diagnosis as correct was influenced by a variety of factors, including completeness, temporality, and perceived accuracy of chart data.

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

    Science.gov (United States)

    Kones, Richard

    2010-01-01

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

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

    Science.gov (United States)

    Kones, Richard

    2010-08-09

    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

  14. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study

    DEFF Research Database (Denmark)

    Olesen, Jonas Bjerring; Lip, Gregory Y H; Hansen, Morten Lock

    2011-01-01

    To evaluate the individual risk factors composing the CHADS(2) (Congestive heart failure, Hypertension, Age≥75 years, Diabetes, previous Stroke) score and the CHA(2)DS(2)-VASc (CHA(2)DS(2)-Vascular disease, Age 65-74 years, Sex category) score and to calculate the capability of the schemes to pre...

  15. Identifying Unique Versus Shared Pre- and Perinatal Risk Factors for ASD and ADHD Using a Simplex-Multiplex Stratification

    NARCIS (Netherlands)

    Oerlemans, Anoek M.; Burmanje, Marlot J.; Franke, Barbara; Buitelaar, Jan K.; Hartman, Catharina A.; Rommelse, Nanda N. J.

    Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. Besides shared genetic factors, pre- and perinatal risk factors (PPFs) may determine if ASD, ADHD, or the combination of both disorders becomes manifest. This study aimed to test shared and unique

  16. Clinical Risk Stratification Optimizes Value of Biomarkers to Predict New-Onset Heart Failure in a Community-Based Cohort

    NARCIS (Netherlands)

    Brouwers, Frank P.; van Gilst, Wiek H.; Damman, Kevin; van den Berg, Maarten P.; Gansevoort, Ron T.; Bakker, Stephan J. L.; Hillege, Hans L.; van Veldhuisen, Dirk J.; van der Harst, Pim; de Boer, Rudolf A.

    Background-We aim to identify and quantify the value of biomarkers for incident new-onset heart failure (HF) in a community-based cohort and subgroups based on cardiovascular risk and evaluate the prognostic value of 13 biomarkers for HF with reduced and preserved ejection fraction. Methods and

  17. International classification of function, disability and health framework for fall risk stratification in community dwelling older adults

    Directory of Open Access Journals (Sweden)

    Majumi M. Noohu

    2017-05-01

    Full Text Available Falls is an important cause for mortality and morbidity in older adults. The fall risk assessment is an integral component of fall prevention in older adults. The international classification of function, disability and health (ICF can be an ideal comprehensive model for fall risk assessment. There is lack of information relating ICF and fall risk assessment in community dwelling older adults. In this study we tried to assess the fall risk using different domains of ICF using various clinical tools. A total of 255 subjects were recruited through convenient sampling method from geriatric clinic (OPD of All India Institute of Medical Sciences, New Delhi. The study was single session cross-section design. The body mass index (BMI, grip strength, depression score (Geriatric depression scale:short form; GDS-S and co morbidities were used to assess body function and structure domain, timed up and go (TUG, Berg balance scale (BBS and elderly fall screening test (EFST scores were used for activity domain, selfreported cause of fall, medications and uses of assistive device for environmental factors. Then the association of body function and structure, activity and environmental factors were determined with falls. There was an association of fall in analysis in subjects with no fall and one or more falls for, BMI, grip strength (kg, GDS-S score, no. of co morbidities, chronic pain, TUG, BBS, TUG (s, BBS, EFST, slip/trip, walking cane, hypoglycemic and antihypertensives medications (unadjusted and adjusted odds ratio.The diabetes, and hyper tension showed association for adjusted odds ratio only. In subjects with one fall and more than one fall, TUG, BBS, EFST, GDS-S score, NSAIDS and antidepressants use showed a significant association with fall (unadjusted and adjusted odds ratio. The ICF may be used in routine for fall risk assessment in community dwelling older adults.

  18. On Optimum Stratification

    OpenAIRE

    M. G. M. Khan; V. D. Prasad; D. K. Rao

    2014-01-01

    In this manuscript, we discuss the problem of determining the optimum stratification of a study (or main) variable based on the auxiliary variable that follows a uniform distribution. If the stratification of survey variable is made using the auxiliary variable it may lead to substantial gains in precision of the estimates. This problem is formulated as a Nonlinear Programming Problem (NLPP), which turn out to multistage decision problem and is solved using dynamic programming technique.

  19. Cardiovascular Risk Stratification and Statin Eligibility Based on the Brazilian vs. North American Guidelines on Blood Cholesterol Management.

    Science.gov (United States)

    Cesena, Fernando Henpin Yue; Laurinavicius, Antonio Gabriele; Valente, Viviane A; Conceição, Raquel D; Santos, Raul D; Bittencourt, Marcio S

    2017-06-01

    The best way to select individuals for lipid-lowering treatment in the population is controversial. In healthy individuals in primary prevention: to assess the relationship between cardiovascular risk categorized according to the V Brazilian Guideline on Dyslipidemia and the risk calculated by the pooled cohort equations (PCE); to compare the proportion of individuals eligible for statins, according to different criteria. In individuals aged 40-75 years consecutively submitted to routine health assessment at one single center, four criteria of eligibility for statin were defined: BR-1, BR-2 (LDL-c above or at least 30 mg/dL above the goal recommended by the Brazilian Guideline, respectively), USA-1 and USA-2 (10-year risk estimated by the PCE ≥ 5.0% or ≥ 7.5%, respectively). The final sample consisted of 13,947 individuals (48 ± 6 years, 71% men). Most individuals at intermediate or high risk based on the V Brazilian Guideline had a low risk calculated by the PCE, and more than 70% of those who were considered at high risk had this categorization because of the presence of aggravating factors. Among women, 24%, 17%, 4% and 2% were eligible for statin use according to the BR-1, BR-2, USA-1 and USA-2 criteria, respectively (p valores para os homens foram 75%, 58%, 31% e 17% (p < 0,01). Oitenta e cinco por cento das mulheres e 60% dos homens elegíveis para estatina pelo critério BR-1 não seriam candidatos pelo critério EUA-1. Comparada à diretriz norte-americana, a V Diretriz Brasileira considera uma proporção substancialmente maior da população como elegível para estatina em prevenção primária. Isso se relaciona com discrepâncias entre o risco estratificado pela diretriz brasileira e o calculado pelas PCE, particularmente devido à reclassificação de risco baseada em fatores agravantes.

  20. Ventricular arrhythmia risk stratification in patients with tetralogy of Fallot at the time of pulmonary valve replacement.

    Science.gov (United States)

    Sabate Rotes, Anna; Connolly, Heidi M; Warnes, Carole A; Ammash, Naser M; Phillips, Sabrina D; Dearani, Joseph A; Schaff, Hartzell V; Burkhart, Harold M; Hodge, David O; Asirvatham, Samuel J; McLeod, Christopher J

    2015-02-01

    Most patients with repaired tetralogy of Fallot require pulmonary valve replacement (PVR), but the evaluation for and management of ventricular arrhythmia remain unclear. This study is aimed at clarifying the optimal approach to this potentially life-threatening issue at the time of PVR. A retrospective analysis was performed on 205 patients with repaired tetralogy of Fallot undergoing PVR at our institution between 1988 and 2010. Median age was 32.9 (range, 25.6) years. Previous ventricular tachycardia occurred in 16 patients (8%) and 37 (16%) had left ventricular dysfunction, defined as left ventricular ejection fraction tetralogy of Fallot undergoing PVR with history of ventricular tachycardia or left ventricular dysfunction appear to be associated with a higher risk of arrhythmic events after operation. Events in the first year after PVR are rare, and in select high-risk patients, surgical cryoablation does not seem to increase arrhythmic events and may be protective. © 2014 American Heart Association, Inc.

  1. Risk Stratification of Thyroid Incidentalomas Found on PET/CT: The Value of Iodine Content on Noncontrast Computed Tomography.

    Science.gov (United States)

    Kim, Dongwoo; Hwang, Sang Hyun; Cha, Jongtae; Jo, Kwanhyeong; Lee, Narae; Yun, Mijin

    2015-11-01

    The Hounsfield unit (HU) ratio of thyroid nodules was assessed compared to the contralateral thyroid lobe on noncontrast computed tomography (CT) to stratify further the risk of malignancy in thyroid incidentalomas found on 18F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/CT (PET/CT). This retrospective analysis included 82 patients who had thyroid incidentalomas on PET/CT in 2011. On PET/CT, the maximal standardized uptake value ratios of the thyroid nodule compared to liver (T/BSUV) and the HU ratios of the thyroid nodule compared to contralateral thyroid lobe (T/BHU) were calculated. Diagnostic performances of the T/BSUV and T/BHU were compared. The area under the curve of T/BHU was higher than that of T/BSUV (0.941 vs. 0.689, p risk of malignancy was much higher (71.1%) in nodules with a T/BHU cutoff value ≤0.68, whereas it was 0% in nodules with a T/BHU of >0.68. In this study, there were 18 nodules with nondiagnostic (n = 7) or atypia of undetermined significance or follicular lesion of undetermined significance cytologies (n = 11) after fine-needle aspiration biopsy (FNAB). When the T/BHU cutoff value was applied, three (60%) of the five nodules with a T/BHU of ≤0.68 were found to be papillary carcinomas. The remaining 13 nodules with a T/BHU of >0.68 were all benign with a risk of malignancy of 0%. T/BHU is a simple and effective parameter to stratify the risk of malignancy in thyroid incidentalomas found on PET/CT. This may be of clinical relevance in those nodules with nondiagnostic or undetermined significance cytologies upon FNAB in the scheme of current clinical practice.

  2. Risk stratification in patients with advanced heart failure requiring biventricular assist device support as a bridge to cardiac transplantation.

    Science.gov (United States)

    Cheng, Richard K; Deng, Mario C; Tseng, Chi-hong; Shemin, Richard J; Kubak, Bernard M; MacLellan, W Robb

    2012-08-01

    Prior studies have identified risk factors for survival in patients with end-stage heart failure (HF) requiring left ventricular assist device (LVAD) support. However, patients with biventricular HF may represent a unique cohort. We retrospectively evaluated a consecutive cohort of 113 adult, end-stage HF patients at University of California Los Angeles Medical Center who required BIVAD support between 2000 and 2009. Survival to transplant was 66.4%, with 1-year actuarial survival of 62.8%. All patients were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Level 1 or 2 and received Thoratec (Pleasanton, CA) paracorporeal BIVAD as a bridge to transplant. Univariate analyses showed dialysis use, ventilator use, extracorporal membrane oxygenation use, low cardiac output, preserved LV ejection fraction (restrictive physiology), normal-to-high sodium, low platelet count, low total cholesterol, low high-density and high-density lipoprotein, low albumin, and elevated aspartate aminotransferase were associated with increased risk of death. We generated a scoring system for survival to transplant. Our final model, with age, sex, dialysis, cholesterol, ventilator, and albumin, gave a C-statistic of 0.870. A simplified system preserved a C-statistic of 0.844. Patients were divided into high-risk or highest-risk groups (median respective survival, 367 and 17 days), with strong discrimination between groups for death. We have generated a scoring system that offers high prognostic ability for patients requiring BIVAD support and hope that it may assist in clinical decision making. Further studies are needed to prospectively validate our scoring system. Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

  3. At-admission risk stratification for in-hospital life-threatening ventricular arrhythmias and death in non-ST elevation myocardial infarction patients.

    Science.gov (United States)

    Zorzi, Alessandro; Turri, Riccardo; Zilio, Filippo; Spadotto, Veronica; Baritussio, Anna; Peruzza, Francesco; Gasparetto, Nicola; Marra, Martina Perazzolo; Cacciavillani, Luisa; Marzari, Armando; Tarantini, Giuseppe; Iliceto, Sabino; Corrado, Domenico

    2014-12-01

    Identification of patients with non-ST elevation acute myocardial infarction (NSTEMI) at higher risk of in-hospital life-threatening ventricular arrhythmias (LT-VA) and death is crucial for determining appropriate levels of care/monitoring during hospitalisation. We assessed predictors of in-hospital LT-VA and all-cause mortality in a consecutive series of NSTEMI patients. We prospectively studied 1325 consecutive patients (69.7% males, median age 70 (61-79) years) presenting with NSTEMI and undergoing continuous electrocardiographic monitoring. The primary study end-point was the occurrence of spontaneous (unrelated to coronary interventions) in-hospital LT-VA, including sustained ventricular tachycardia and ventricular fibrillation; the secondary end-point was in-hospital mortality from all causes. Of 1325 patients, 21 (1.5%) experienced LT-VA and 62 (4.7%) died from either arrhythmias (n=1) or other causes (n=61). Seven of the 20 patients who survived LT-VA subsequently died of heart failure. Independent predictors of in-hospital LT-VA were the Global Registry of Acute Coronary Events (GRACE) score >140 (odds ratio (OR)=7.5; 95% confidence interval (CI) 1.7-33.3; p=0.008) and left ventricular ejection fraction (LV-EF)140 (OR=14.6; 95% CI 3.4-62) and LV-EF 140 and LV-EF<35%, while it was respectively 0.2% and 0% among the 627 (47.3%) with GRACE score ≤140 and LV-EF ≥35%. Simple risk stratification at admission based on GRACE score and echocardiographic LV-EF allows early identification of NSTEMI patients at higher risk of both in-hospital LT-VA and all-cause mortality. © The European Society of Cardiology 2014.

  4. JCL roundtable: Risk evaluation and mitigation strategy.

    Science.gov (United States)

    Brown, W Virgil; Bramlet, Dean A; Ross, Joyce L; Underberg, James A

    Many factors enter into the decision by the Food and Drug Administration (FDA) to approve a new drug for use by physicians and other health care providers in treating diseases. Initially, the FDA authority was restricted to issues of safety and only later did the documentation of efficacy become part of the review process required for approval. However, all drugs have the potential for causing harm at some dose level to all and at lower doses in certain patients with vulnerability to the particular pharmacology of the agent. As new drugs have been designed to manage disorders that are uncommon, but of significant consequence, they may have adverse effects that are acceptable only because they are so uniquely beneficial to these specific conditions. The risk of these adverse effects may be acceptable since the benefit can outweigh the harm in most patients and the adversity can be predicted and managed. The approval of this category of drugs has grown rapidly since definition of a mechanism of action to manage and modify the risk has been provided by a process known as known as Risk Evaluation and Mitigation Strategy or "REMS." In 2007, the Food and Drug Administration Amendments Act (FDAAA) allowed the FDA to require postmarketing studies and the authority to mandate the implementation of a REMS for drugs with efficacy but documented potential for harm. Two relatively new drugs useful in the management of severe elevations of low-density lipoprotein cholesterol have been approved under a requirement for a REMS. These are lomitapide, an inhibitor of microsomal triglyceride transfer protein and mipomersen, an antisense oligonucleotide which reduces the synthesis of apolipoprotein B. Copyright © 2016 National Lipid Association. Published by Elsevier Inc. All rights reserved.

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

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Kyubo [Department of Radiation Oncology, Seoul National University College of Medicine, Seoul (Korea, Republic of); Chie, Eui Kyu, E-mail: ekchie93@snu.ac.kr [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); 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); Ha, Sung W. [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)

    2012-09-01

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

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

    DEFF Research Database (Denmark)

    Hansen, T W; Thijs, L; Li, Y

    2014-01-01

    or cerebrovascular event. Adjusted for sex and age, low BMI (vs average risk, 1.52; P or = 30.9 kg m(-2)) predicted the cardiovascular end point (HR, 1.27; P=0.006). With adjustments including 24-h systolic BP, these HRs were 1.50 (P....001) and 0.98 (P=0.91), respectively. Across quartiles of the BMI distribution, 24-h and nighttime systolic BP predicted every end point (1.13 or = .22). Excluding smokers removed...

  7. The rate of depression and its risk stratification in patients with differentiated thyroid cancers treated with radioactive iodine

    International Nuclear Information System (INIS)

    Eftekhari, M.; Fallahi, B.; Ansari, S.; Izadian, E.S.; Esfahani, A.F.; Beiki, D.; Saghari, M.

    2005-01-01

    Full text: Depression is a common disease in general population and may be more frequent in the cases of malignant diseases. Diagnosis and treatment of depressions in such patients may improve the quality of life. The aim of this study was to determine the risk of depression in patients diagnosed as differentiated thyroid cancers (DTC) and treated with radioactive iodine ( 131 I). In a historical Cohort study, 390 DTC patients, 312 female and 78 male, 18-68 years with median age of 41 years who were treated with 131 I and 390 control cases selected from the patients' relatives and matched with DTC cases by age, sex, wedding state and socioeconomic status were entered the study. Each patient and his/her control were concurrently assessed with Beck's questionnaire for diagnosis of depression. The data was analyzed to detect the rate, severity and relative risk of depression and the effect of some variables on the severity of depression in these patients. Of 390 patients, 179(45.9%) showed some degree of depression, 20.3% mild, 14.1% moderate, 11% partially severe and 0.5% severe according to Beck score, while the proportional frequency of different grades of depression among the control group was 15.5% and overall relative risk of depression in DTC patients was 2.96. The frequency of depression in female patients, 47.8% was lesser than male, 38.5% (p=0.013) and in married female (46.2%) was greater than single (14.3%) but lesser than divorced or widow female patients (82.4%), (p<0.0001). Depression was more prevalent and more severe in cases of papillary, 47.9% than follicular carcinoma, 33.3% (p=0.014) and also was more predominant in less-educated than in high-educated patients (p<0.0001). In DTC patients with history of radio-iodine therapy, the rate of depression is almost three times of the general population, so screening and treatment of depression especially in high risk patients like married or divorced female and less-educated patients may be of great

  8. Global cardiovascular risk stratification among hypertensive patients treated in a Family Health Unit of Parnaíba, Piauí - doi: 10.5020/18061230.2012.p287

    Directory of Open Access Journals (Sweden)

    Elce de Seixas Nascimento

    2012-11-01

    Full Text Available Objective: To stratify the global cardiovascular risk among hypertensive patients attended in a Family Health Unit (FHU. Methods: A quantitative, cross-sectional and descriptive study with population of hypertensive patients undergoing treatment in a FHU, module 34, in Parnaíba, Piauí, Brazil, in the period from July to August 2011. The sample consisted of 45 volunteers, selected by free demand conglomerate, who filled a form with questions that support the analysis and Global Cardiovascular Risk stratification (GCR, according to the VI Brazilian Guidelines on Hypertension (VI BGH - 2010, The European Society of Cardiology (ESC and European Society of Hypertension (ESH - 2007. The subjects were then submitted to measurement of blood pressure (BP, waist circumference (WC and body mass index (BMI. Results: The most evident risk factor in the sample was overweight/obesity in 75.5% (n=34, followed by sedentary lifestyle in 73.3% (n=33 and hypercholesterolemia in 55.5% (n=25. The data collected resulted in a stratification in which 84.4% (n=38 presented high added risk and 15.5% (n=7 a very high added risk of presenting cardiovascular events in the next 10 years. Conclusion: The stratification in the population studied indicated high incidence of such factors, pointing to the need of interfering in this population segment, in order to promote changes in lifestyle that generate prevention and control of cardiovascular diseases.

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

    Science.gov (United States)

    Wentzensen, Nicolas; Wacholder, Sholom

    2013-02-01

    Researchers developing biomarkers for early detection can determine the potential for clinical benefit at early stages of development. We provide the theoretical background showing the quantitative connection between biomarker levels in cases and controls and clinically meaningful risk measures, as well as a spreadsheet for researchers to use in their own research. We provide researchers with tools to decide whether a test is useful, whether it needs technical improvement, whether it may work only in specific populations, or whether any further development is futile. The methods described here apply to any method that aims to estimate risk of disease based on biomarkers, clinical tests, genetics, environment, or behavior. Many efforts go into futile biomarker development and premature clinical testing. In many instances, predictions for translational success or failure can be made early, simply based on critical analysis of case–control data. Our article presents well-established theory in a form that can be appreciated by biomarker researchers. Furthermore, we provide an interactive spreadsheet that links biomarker performance with specific disease characteristics to evaluate the promise of biomarker candidates at an early stage.

  10. Dobutamine stress MRI. Part II. Risk stratification with dobutamine cardiovascular magnetic resonance in patients suspected of myocardial ischemia

    International Nuclear Information System (INIS)

    Kuijpers, Dirkjan; Dijkman, Paul R.M. van; Janssen, Caroline H.C.; Vliegenthart, Rozemarijn; Zijlstra, Felix; Oudkerk, Matthijs

    2004-01-01

    The aim of this study was to determine the prognostic value of dobutamine cardiovascular magnetic resonance (CMR) in patients suspected of myocardial ischemia. Clinical data and dobutamine-CMR results were analyzed in 299 consecutive patients. Follow-up data were analyzed in categories of risk levels defined by the history of coronary artery disease and presence of rest wall motion abnormalities (RWMA). Major adverse cardiac events (MACE) as evaluated end points included cardiac death, nonfatal myocardial infarction and clinically indicated coronary revascularization. Follow-up was completed in 214 (99%) patients with a negative dobutamine-CMR study (no signs of inducible myocardial ischemia) with an average of 24 months. The patients with a negative dobutamine-CMR study and RWMA showed a significantly higher annual MACE rate (18%) than the patients without RWMA (0.56%) (P<0.001). Patients without RWMA showed an annual MACE rate of 2% when they had a history of coronary artery disease and <0.1% without a previous coronary event (P<0.001). Dobutamine-CMR showed a positive and negative predictive value of 95 and 93%, respectively. The cardiovascular occurrence-free survival rate was 96.2%. In patients suspected of myocardial ischemia, dobutamine-CMR is able to assess risk levels for coronary events with high accuracy. (orig.)

  11. Dobutamine stress MRI. Part II. Risk stratification with dobutamine cardiovascular magnetic resonance in patients suspected of myocardial ischemia

    Energy Technology Data Exchange (ETDEWEB)

    Kuijpers, Dirkjan [State University and Academic Hospital Groningen, Department of Radiology and Cardiology, Groningen (Netherlands); Bronovo Hospital, Department of Radiology and Cardiology, Bronovolaan 1, P.O. Box 96900, The Hague (Netherlands); Dijkman, Paul R.M. van [Bronovo Hospital, Department of Radiology and Cardiology, Bronovolaan 1, P.O. Box 96900, The Hague (Netherlands); Janssen, Caroline H.C.; Vliegenthart, Rozemarijn; Zijlstra, Felix; Oudkerk, Matthijs [State University and Academic Hospital Groningen, Department of Radiology and Cardiology, Groningen (Netherlands)

    2004-11-01

    The aim of this study was to determine the prognostic value of dobutamine cardiovascular magnetic resonance (CMR) in patients suspected of myocardial ischemia. Clinical data and dobutamine-CMR results were analyzed in 299 consecutive patients. Follow-up data were analyzed in categories of risk levels defined by the history of coronary artery disease and presence of rest wall motion abnormalities (RWMA). Major adverse cardiac events (MACE) as evaluated end points included cardiac death, nonfatal myocardial infarction and clinically indicated coronary revascularization. Follow-up was completed in 214 (99%) patients with a negative dobutamine-CMR study (no signs of inducible myocardial ischemia) with an average of 24 months. The patients with a negative dobutamine-CMR study and RWMA showed a significantly higher annual MACE rate (18%) than the patients without RWMA (0.56%) (P<0.001). Patients without RWMA showed an annual MACE rate of 2% when they had a history of coronary artery disease and <0.1% without a previous coronary event (P<0.001). Dobutamine-CMR showed a positive and negative predictive value of 95 and 93%, respectively. The cardiovascular occurrence-free survival rate was 96.2%. In patients suspected of myocardial ischemia, dobutamine-CMR is able to assess risk levels for coronary events with high accuracy. (orig.)

  12. Dobutamine stress MRI. Part II. Risk stratification with dobutamine cardiovascular magnetic resonance in patients suspected of myocardial ischemia.

    Science.gov (United States)

    Kuijpers, Dirkjan; van Dijkman, Paul R M; Janssen, Caroline H C; Vliegenthart, Rozemarijn; Zijlstra, Felix; Oudkerk, Matthijs

    2004-11-01

    The aim of this study was to determine the prognostic value of dobutamine cardiovascular magnetic resonance (CMR) in patients suspected of myocardial ischemia. Clinical data and dobutamine-CMR results were analyzed in 299 consecutive patients. Follow-up data were analyzed in categories of risk levels defined by the history of coronary artery disease and presence of rest wall motion abnormalities (RWMA). Major adverse cardiac events (MACE) as evaluated end points included cardiac death, nonfatal myocardial infarction and clinically indicated coronary revascularization. Follow-up was completed in 214 (99%) patients with a negative dobutamine-CMR study (no signs of inducible myocardial ischemia) with an average of 24 months. The patients with a negative dobutamine-CMR study and RWMA showed a significantly higher annual MACE rate (18%) than the patients without RWMA (0.56%) ( P<0.001). Patients without RWMA showed an annual MACE rate of 2% when they had a history of coronary artery disease and <0.1% without a previous coronary event ( P<0.001). Dobutamine-CMR showed a positive and negative predictive value of 95 and 93%, respectively. The cardiovascular occurrence-free survival rate was 96.2%. In patients suspected of myocardial ischemia, dobutamine-CMR is able to assess risk levels for coronary events with high accuracy.

  13. Diagnosis of myocardial infarction using the new universal definition: is it enough for risk stratification and guiding decision for revascularization?

    Science.gov (United States)

    Calé, Rita; Ferreira, Jorge; Aguiar, Carlos; Santos, Nuno; Carmo, Pedro; Figueira, João; Raposo, Luis; Gonçalves, Pedro; Silva, José Aniceto

    2010-12-01

    Abstract Objectives: Evaluate the new ESC/ACCF/AHA/WHF universal definition of myocardial infarction (MI) in relation to its prognostic implications and the role for guiding decision for revascularization. It was also compared with the multivariable based GRACE Risk Score (GRS). Single centre registry of 389 consecutive patients admitted with non-ST-segment elevation (NSTE) ACS. We calculated the adjusted HR & 95%CI for death/MI at 30-days and one-year follow-up, between the presence or absence of MI using: (1) universal definition: > 99th URL for cTnI (> 0.06 ng/ml) or MBm (> 3.2 ng/ml); (2) MBm > 2 × URL (> 12.2 ng/ml); 3) old WHO: MBact > 2 × URL (> 32U/l). Logistic analysis was performed to test the interaction between tertiles of biomarkers or GRS and the effect of revascularization on the outcome. The universal definition increased the incidence of MI in 3.5-fold for cTnI, but was not an independent predictor of outcome. The GRS was the only independent predictor of prognosis at 30-days and one-year. The interaction with the prognostic impact of revascularization was only present for the GRS categorized by tertiles. In a contemporary unselected population with NSTE-ACS, the universal definition of MI alone was not adequate for risk assessment and revascularization decision making. These purposes were fully addressed with the GRS.

  14. Stratification of risk to the surgical team in removal of small arms ammunition implanted in the craniofacial region: case report.

    Science.gov (United States)

    Forbes, Jonathan A; Laughlin, Ian; Newberry, Shane; Ryhn, Michael; Pasley, Jason; Newberry, Travis

    2016-09-01

    In cases of penetrating injury with implantation of small arms ammunition, it can often be difficult to tell the difference between simple ballistics and ballistics associated with unexploded ordnances (UXOs). In the operative environment, where highly flammable substances are often close to the surgical site, detonation of UXOs could have catastrophic consequences for both the patient and surgical team. There is a paucity of information in the literature regarding how to evaluate whether an implanted munition contains explosive material. This report describes a patient who presented during Operation Enduring Freedom with an implanted munition suspicious for a UXO and the subsequent workup organized by Explosive Ordnance Disposal (EOD) Company prior to surgical removal. Clinical risk factors for UXOs include assassination attempts and/or wartime settings. Specific radiological features suggestive of a UXO include projectile size greater than 7.62-mm caliber, alterations in density of the tip, as well as radiological evidence of a hollowed-out core. If an implanted UXO is suspected, risks to the surgical and anesthesia teams can be minimized by notifying the nearest military installation with EOD capabilities and following clinical practice guidelines set forth by the Joint Theater Trauma System.

  15. Fuel and combustion stratification study of Partially Premixed Combustion

    OpenAIRE

    Izadi Najafabadi, M.; Dam, N.; Somers, B.; Johansson, B.

    2016-01-01

    Relatively high levels of stratification is one of the main advantages of Partially Premixed Combustion (PPC) over the Homogeneous Charge Compression Ignition (HCCI) concept. Fuel stratification smoothens heat release and improves controllability of this kind of combustion. However, the lack of a clear definition of “fuel and combustion stratifications” is obvious in literature. Hence, it is difficult to compare stratification levels of different PPC strategies or other combustion concepts. T...

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

    International Nuclear Information System (INIS)

    Petersen, Johannes; Glodny, Bernhard

    2011-01-01

    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.

  17. Role of quantitative myocardial positron emission tomography for risk stratification in patients with hypertrophic cardiomyopathy: a 2016 reappraisal

    Energy Technology Data Exchange (ETDEWEB)

    Castagnoli, Helga; Passeri, Alessandro; Berti, Valentina; Sciagra, Roberto [University of Florence, Department of Experimental and Clinical Biomedical Sciences - Nuclear Medicine Unit, Firenze (Italy); Ferrantini, Cecilia; Coppini, Raffaele; Baldini, Katia; Cecchi, Franco; Olivotto, Iacopo [Careggi University Hospital, Referral Center for Myocardial Diseases and Genetic Diagnostics Unit, Florence (Italy)

    2016-12-15

    Myocardial blood flow <1.1 mL/min/g following dipyridamole (Dip-MBF) assessed by positron emission tomography (PET) was identified in 2003 as an important outcome predictor in hypertrophic cardiomyopathy (HCM), based on scans performed in the 90s. However, such extreme Dip-MBF impairment is rarely observed in contemporary cohorts. We, therefore, reassessed the Dip-MBF threshold defining high-risk HCM patients. Dip-MBF was measured using {sup 13}N-ammonia in 100 HCM consecutive patients, prospectively enrolled and followed for 4.0 ± 2.2 years. Outcome was assessed based on tertiles of Dip-MBF. The study end-point was a combination of cardiovascular death, progression to severe functional limitation, cardioembolic stroke, life-threatening ventricular arrhythmias. Global Dip-MBF was 1.95 ± 0.85, ranging from 0.7 to 5.9 mL/min/g. Dip-MBF tertile cut-off values were: 0.73 to 1.53 mL/min/g (lowest), 1.54 to 2.13 mL/min/g (middle), and 2.14 to 5.89 mL/min/g (highest). During follow-up, lowest tertile Dip-MBF was associated with sevenfold independent risk of unfavorable outcome compared to the other two tertiles. Dip-MBF 1.35 mL/min/g was identified as the best threshold for outcome prediction. Regional perfusion analysis showed that all cardiac deaths (n = 4) occurred in patients in the lowest tertile of lateral wall Dip-MBF (≤1.72 mL/min/g); septal Dip-MBF was not predictive. Dip-MBF confirms its role as potent predictor of outcome in HCM. However, the threshold for prediction in a contemporary cohort is higher than that reported in earlier studies. Dip-MBF impairment in the lateral wall, possibly reflecting diffuse disease extending to non-hypertrophic regions, is a sensitive predictor of mortality in HCM. (orig.)

  18. Role of quantitative myocardial positron emission tomography for risk stratification in patients with hypertrophic cardiomyopathy: a 2016 reappraisal

    International Nuclear Information System (INIS)

    Castagnoli, Helga; Passeri, Alessandro; Berti, Valentina; Sciagra, Roberto; Ferrantini, Cecilia; Coppini, Raffaele; Baldini, Katia; Cecchi, Franco; Olivotto, Iacopo

    2016-01-01

    Myocardial blood flow <1.1 mL/min/g following dipyridamole (Dip-MBF) assessed by positron emission tomography (PET) was identified in 2003 as an important outcome predictor in hypertrophic cardiomyopathy (HCM), based on scans performed in the 90s. However, such extreme Dip-MBF impairment is rarely observed in contemporary cohorts. We, therefore, reassessed the Dip-MBF threshold defining high-risk HCM patients. Dip-MBF was measured using "1"3N-ammonia in 100 HCM consecutive patients, prospectively enrolled and followed for 4.0 ± 2.2 years. Outcome was assessed based on tertiles of Dip-MBF. The study end-point was a combination of cardiovascular death, progression to severe functional limitation, cardioembolic stroke, life-threatening ventricular arrhythmias. Global Dip-MBF was 1.95 ± 0.85, ranging from 0.7 to 5.9 mL/min/g. Dip-MBF tertile cut-off values were: 0.73 to 1.53 mL/min/g (lowest), 1.54 to 2.13 mL/min/g (middle), and 2.14 to 5.89 mL/min/g (highest). During follow-up, lowest tertile Dip-MBF was associated with sevenfold independent risk of unfavorable outcome compared to the other two tertiles. Dip-MBF 1.35 mL/min/g was identified as the best threshold for outcome prediction. Regional perfusion analysis showed that all cardiac deaths (n = 4) occurred in patients in the lowest tertile of lateral wall Dip-MBF (≤1.72 mL/min/g); septal Dip-MBF was not predictive. Dip-MBF confirms its role as potent predictor of outcome in HCM. However, the threshold for prediction in a contemporary cohort is higher than that reported in earlier studies. Dip-MBF impairment in the lateral wall, possibly reflecting diffuse disease extending to non-hypertrophic regions, is a sensitive predictor of mortality in HCM. (orig.)

  19. Integrating Tenascin-C protein expression and 1q25 copy number status in pediatric intracranial ependymoma prognostication: A new model for risk stratification.

    Science.gov (United States)

    Andreiuolo, Felipe; Le Teuff, Gwénaël; Bayar, Mohamed Amine; Kilday, John-Paul; Pietsch, Torsten; von Bueren, André O; Witt, Hendrik; Korshunov, Andrey; Modena, Piergiorgio; Pfister, Stefan M; Pagès, Mélanie; Castel, David; Giangaspero, Felice; Chimelli, Leila; Varlet, Pascale; Rutkowski, Stefan; Frappaz, Didier; Massimino, Maura; Grundy, Richard; Grill, Jacques

    2017-01-01

    Despite multimodal therapy, prognosis of pediatric intracranial ependymomas remains poor with a 5-year survival rate below 70% and frequent late deaths. This multicentric European study evaluated putative prognostic biomarkers. Tenascin-C (TNC) immunohistochemical expression and copy number status of 1q25 were retained for a pooled analysis of 5 independent cohorts. The prognostic value of TNC and 1q25 on the overall survival (OS) was assessed using a Cox model adjusted to age at diagnosis, tumor location, WHO grade, extent of resection, radiotherapy and stratified by cohort. Stratification on a predictor that did not satisfy the proportional hazards assumption was considered. Model performance was evaluated and an internal-external cross validation was performed. Among complete cases with 5-year median follow-up (n = 470; 131 deaths), TNC and 1q25 gain were significantly associated with age at diagnosis and posterior fossa tumor location. 1q25 status added independent prognostic value for death beyond the classical variables with a hazard ratio (HR) = 2.19 95%CI = [1.29; 3.76] (p = 0.004), while TNC prognostic relation was tumor location-dependent with HR = 2.19 95%CI = [1.29; 3.76] (p = 0.004) in posterior fossa and HR = 0.64 [0.28; 1.48] (p = 0.295) in supratentorial (interaction p value = 0.015). The derived prognostic score identified 3 different robust risk groups. The omission of upfront RT was not associated with OS for good and intermediate prognostic groups while the absence of upfront RT was negatively associated with OS in the poor risk group. Integrated TNC expression and 1q25 status are useful to better stratify patients and to eventually adapt treatment regimens in pediatric intracranial ependymoma.

  20. Integrating Tenascin-C protein expression and 1q25 copy number status in pediatric intracranial ependymoma prognostication: A new model for risk stratification.

    Directory of Open Access Journals (Sweden)

    Felipe Andreiuolo

    Full Text Available Despite multimodal therapy, prognosis of pediatric intracranial ependymomas remains poor with a 5-year survival rate below 70% and frequent late deaths.This multicentric European study evaluated putative prognostic biomarkers. Tenascin-C (TNC immunohistochemical expression and copy number status of 1q25 were retained for a pooled analysis of 5 independent cohorts. The prognostic value of TNC and 1q25 on the overall survival (OS was assessed using a Cox model adjusted to age at diagnosis, tumor location, WHO grade, extent of resection, radiotherapy and stratified by cohort. Stratification on a predictor that did not satisfy the proportional hazards assumption was considered. Model performance was evaluated and an internal-external cross validation was performed.Among complete cases with 5-year median follow-up (n = 470; 131 deaths, TNC and 1q25 gain were significantly associated with age at diagnosis and posterior fossa tumor location. 1q25 status added independent prognostic value for death beyond the classical variables with a hazard ratio (HR = 2.19 95%CI = [1.29; 3.76] (p = 0.004, while TNC prognostic relation was tumor location-dependent with HR = 2.19 95%CI = [1.29; 3.76] (p = 0.004 in posterior fossa and HR = 0.64 [0.28; 1.48] (p = 0.295 in supratentorial (interaction p value = 0.015. The derived prognostic score identified 3 different robust risk groups. The omission of upfront RT was not associated with OS for good and intermediate prognostic groups while the absence of upfront RT was negatively associated with OS in the poor risk group.Integrated TNC expression and 1q25 status are useful to better stratify patients and to eventually adapt treatment regimens in pediatric intracranial ependymoma.

  1. Towards risk stratification in systemic atherosclerosis: value of myocardial function and viability imaging as an adjunct to MR angiography

    Energy Technology Data Exchange (ETDEWEB)

    Seeger, Achim; Fenchel, Michael; Kramer, Ulrich; Bretschneider, Christiane; Grimm, Florian; Klumpp, Bernhard; Claussen, Claus D.; Miller, Stephan [Eberhard Karls University Tuebingen, Department of Diagnostic and Interventional Radiology, Tuebingen (Germany); Scheule, Albertus [Eberhard Karls University Tuebingen, Department for Thorax, Cardiac and Vascular Surgery, Tuebingen (Germany); Balletshofer, Bernd [Eberhard Karls University Tuebingen, Department of Internal Medicine IV, Tuebingen (Germany)

    2010-04-15

    To longitudinally assess the value of cardiac functional and viability imaging as a supplement to MR angiography in patients with atherosclerotic disease. Cardiac MRI was performed in 195 consecutive patients with symptomatic peripheral arterial disease. Of these, 186 patients were followed for 22 {+-} 5 months for the presence of cardiac events (cardiac death, acute coronary syndrome and hospitalisation as a result of congestive heart failure). Myocardial viability imaging showed a high prevalence of known (n = 31) and occult myocardial infarctions (MI) (n = 26). Cardiac events occurred more often in patients with reduced ventricular function (ejection fraction (EF) less than 40%, cardiac event in 4/8 patients; EF 40-55%, cardiac event in 10/40 patients; EF greater than 55%, cardiac event in 15/138 patients) as well as in patients with occult MI (8/25 patients) and known MI (11/30 patients). In patients with normal function, the detection of a previous MI was of high relevance to prognosis. Both reduced EF and the presence of MI influence patients' prognoses. Performing cardiac MRI in this patient population may influence further patient management including intensified risk factor intervention. (orig.)

  2. Towards risk stratification in systemic atherosclerosis: value of myocardial function and viability imaging as an adjunct to MR angiography

    International Nuclear Information System (INIS)

    Seeger, Achim; Fenchel, Michael; Kramer, Ulrich; Bretschneider, Christiane; Grimm, Florian; Klumpp, Bernhard; Claussen, Claus D.; Miller, Stephan; Scheule, Albertus; Balletshofer, Bernd

    2010-01-01

    To longitudinally assess the value of cardiac functional and viability imaging as a supplement to MR angiography in patients with atherosclerotic disease. Cardiac MRI was performed in 195 consecutive patients with symptomatic peripheral arterial disease. Of these, 186 patients were followed for 22 ± 5 months for the presence of cardiac events (cardiac death, acute coronary syndrome and hospitalisation as a result of congestive heart failure). Myocardial viability imaging showed a high prevalence of known (n = 31) and occult myocardial infarctions (MI) (n = 26). Cardiac events occurred more often in patients with reduced ventricular function (ejection fraction (EF) less than 40%, cardiac event in 4/8 patients; EF 40-55%, cardiac event in 10/40 patients; EF greater than 55%, cardiac event in 15/138 patients) as well as in patients with occult MI (8/25 patients) and known MI (11/30 patients). In patients with normal function, the detection of a previous MI was of high relevance to prognosis. Both reduced EF and the presence of MI influence patients' prognoses. Performing cardiac MRI in this patient population may influence further patient management including intensified risk factor intervention. (orig.)

  3. Solid Lymph Nodes as an Imaging Biomarker for Risk Stratification in Human Papillomavirus-Related Oropharyngeal Squamous Cell Carcinoma.

    Science.gov (United States)

    Rath, T J; Narayanan, S; Hughes, M A; Ferris, R L; Chiosea, S I; Branstetter, B F

    2017-07-01

    Human papillomavirus-related oropharyngeal squamous cell carcinoma is associated with cystic lymph nodes on CT and has a favorable prognosis. A subset of patients with aggressive disease experience treatment failure. Our aim was to determine whether the extent of cystic lymph node burden on staging CT can serve as an imaging biomarker to predict treatment failure in human papillomavirus-related oropharyngeal squamous cell carcinoma. We identified patients with human papilloma virus-related oropharyngeal squamous cell carcinoma and staging neck CTs. Demographic and clinical variables were recorded. We retrospectively classified the metastatic lymph node burden on CT as cystic or solid and assessed radiologic extracapsular spread. Biopsy, subsequent imaging, or clinical follow-up was the reference standard for treatment failure. The primary end point was disease-free survival. Cox proportional hazard regression analyses of clinical, demographic, and anatomic variables for treatment failure were performed. One hundred eighty-three patients were included with a mean follow-up of 38 months. In univariate analysis, the following variables had a statistically significant association with treatment failure: solid-versus-cystic lymph nodes, clinical T-stage, clinical N-stage, and radiologic evidence of extracapsular spread. The multivariate Cox proportional hazard model resulted in a model that included solid-versus-cystic lymph nodes, T-stage, and radiologic evidence of extracapsular spread as independent predictors of treatment failure. Patients with cystic nodal metastasis at staging had significantly better disease-free survival than patients with solid lymph nodes. In human papilloma virus-related oropharyngeal squamous cell carcinoma, patients with solid lymph node metastases are at higher risk for treatment failure with worse disease-free survival. Solid lymph nodes may serve as an imaging biomarker to tailor individual treatment regimens. © 2017 by American Journal

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

    Science.gov (United States)

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

    2015-01-01

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

  5. Risk communication strategy development using the aerospace systems engineering process

    Science.gov (United States)

    Dawson, S.; Sklar, M.

    2004-01-01

    This paper explains the goals and challenges of NASA's risk communication efforts and how the Aerospace Systems Engineering Process (ASEP) was used to map the risk communication strategy used at the Jet Propulsion Laboratory to achieve these goals.

  6. Nutritional strategies to reduce falls risk in older people.

    Science.gov (United States)

    Nash, Louise; Bergin, Nick

    2018-03-23

    A literature review found an association between increased falls risk and malnutrition, sarcopenia, vitamin D deficiency and dehydration. Strategies to identify, prevent and treat these conditions can help to reduce falls risk in at-risk groups such as frail, older people. Nurses can reduce falls risk in older people by raising awareness of risk factors and embedding nutritional strategies in local falls reduction strategies. ©2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

  7. Identifying patients at risk of intraoperative and postoperative transfusion in isolated CABG: toward selective conservation strategies.

    Science.gov (United States)

    Arora, Rakesh C; Légaré, Jean-Francois; Buth, Karen J; Sullivan, John A; Hirsch, Gregory M

    2004-11-01

    Allogeneic blood product use during cardiac operation is often reported to exceed 40% despite published guidelines and costly blood conservation strategies. We developed a predictive model, based on eight preoperative risk factors, of allogeneic blood product transfusion rates in patients undergoing a cardiac procedure. All 3,046 consecutive, isolated coronary artery bypass graft (CABG) procedures at a university hospital from 1995 to 1998 were included. A logistic regression model was created to identify independent predictors of allogeneic blood product transfusion. This model was validated using a prospective patient sample. Overall use of allogeneic blood products was 23% with a crude operative mortality of 2.1%. In isolated, elective, first-time CABG cases, 16.9% received allogeneic blood products. Independent predictors of blood product usage in CABG patients were preoperative hemoglobin 12.0 or less, emergent operation, renal failure, female sex, age 70 years or older, left ventricular ejection fraction 0.40 or less, redo procedure, and low body surface area. Prospective validation of this model on 2,117 consecutive isolated CABG patients demonstrated an observed-to-expected allogeneic blood product transfusion rate ratio of 1.06. This internally validated logistic regression risk model is a sensitive and specific predictor of allogeneic blood product use in patients undergoing isolated CABG. Utilization of this model allows for preoperative risk stratification and may allow for more rational resource allocation of costly blood conservation strategies and blood bank resources.

  8. COOPERATION, STRATIFICATION AND RESEARCH DESIGN IN STRATEGY STUDIES IN BRAZIL [doi: 10.5329/RECADM.20100902005] COOPERAÇÃO, ESTRATIFICAÇÃO E PERFIL DA PESQUISA EM ESTRATÉGIA NO BRASIL [doi: 10.5329/RECADM.20100902005

    Directory of Open Access Journals (Sweden)

    José Bonfim Albuquerque Filho

    2010-11-01

    Full Text Available The documentary analysis of publications permits to identify scientific production standards associated with characteristics and tendencies expressed in a certain area of knowledge. Considering the area of Strategy in Organizations and its thematic axes, this study analyzed 765 articles published between 2001 and 2006, in the proceedings of EnAnpad’s and 3Es in order to evaluate quantitatively the research design mostly used throughout the period. Moreover, tendencies expressed in terms of stratification standards and cooperation in the area were also investigated. The data were treated in a descriptive-quantitative way, through statistic procedures and multivariate technique of analysis of multiple correspondence. The findings indicated a predominance of a scientific production focused on empirical articles, mainly case studies and surveys. Additionally, the results revealed the growth of the area concerning the number of articles, authors and institutions, accompanied by greater cooperation in scientific production and changes regarding the regional and institutional stratification standards.   Keywords Strategy; scientific production; methodology; cooperation and academic productivity; management Diego M. Coraiola 12.00 Normal 0 21 false false false PT-BR X-NONE X-NONE RESUMO A análise documental de publicações permite identificar características e tendências expressas em determinada área do conhecimento científico. Tendo em vista a área de Estratégia em Organizações, este estudo analisou 765 artigos, publicados entre 2001 e 2006, nos anais dos EnAnpad e 3Es, objetivando avaliar quantitativamente os delineamentos de pesquisa utilizados e analisar tendências acerca dos padrões de estratificação e cooperação na área. Por meio de procedimentos estatísticos e da técnica multivariada de análise de correspondência múltipla, verificou-se a predominância de uma produção científica voltada para artigos empíricos apoiados

  9. Risk management strategies by Australian farmers: two case studies

    OpenAIRE

    Nguyen, Nam C.; Wegener, Malcolm K.; Russell, Iean W.; Cameron, Donald; Coventry, David; Cooper, Ian M.

    2007-01-01

    Australian farmers operate in one of the most risky farming environments in the world. They have to cope with numerous sources of risk including weather uncertainty, variable market prices, and institutional changes in their business management. This paper reports results from two case studies undertaken to examine the issues of farming risks and risk management strategies in Australia. The first case study found that unpredictable weather, financial risk, marketing risk, and personal risk we...

  10. CONSIDERATIONS REGARDING THE MANAGEMENT STRATEGIES OF BANK RISKS

    Directory of Open Access Journals (Sweden)

    NICOLETA GEORGETA PANAIT

    2015-12-01

    Full Text Available The study summarizes what it means banking risks, the main risk management strategies. The complexity of the business environment, liberalization and internationalization of financial flows, brings rapid innovation, diversified financial markets, new opportunities but multiplied risks. Banks establish the types of risks they are prepared to take and the threshold at which risk is considered significant. The process of determining the risks that are taken includes the nature, the scale and the complexity of banks.

  11. Concepts of investment risks and strategies in electricity generation

    International Nuclear Information System (INIS)

    De Joode, J.; Boots, M.G.

    2005-06-01

    This report deals with the specific investment risks in electricity generation and discusses the problems associated with energy investments in general and focus on the additional or changing risks resulting from electricity market liberalisation. The focus is on (1) risks under the control of the electricity company, and on (2) market risks, such as the risk of price changes. Ultimately, some of the approaches and strategies that enable electricity producers to counter or mitigate these risks are discussed

  12. Cold stratification, but not stratification in salinity, enhances seedling ...

    African Journals Online (AJOL)

    use

    2011-10-26

    Oct 26, 2011 ... Cold stratification was reported to release seed dormancy and enhance plant tolerance to salt stress. ... Key words: Cold stratification, salt stress, seedling emergence, ... methods used to cope with salinity, seed pre-sowing.

  13. Modeling Multimodal Stratification

    DEFF Research Database (Denmark)

    Boeriis, Morten

    2017-01-01

    . The article outlines a theoretical experiment exploring how an alternative way of modeling stratification and instantiation may raise some interesting ideas on the concepts of realization dynamics, system-instance, and the different contexts of the semiotic text. This is elaborated in a discussion of how...

  14. Cold stratification, but not stratification in salinity, enhances seedling ...

    African Journals Online (AJOL)

    Cold stratification, but not stratification in salinity, enhances seedling growth of wheat under salt treatment. L Wang, HL Wang, CH Yin, CY Tian. Abstract. Cold stratification was reported to release seed dormancy and enhance plant tolerance to salt stress. Experiments were conducted to test the hypothesis that cold ...

  15. Benchmarking Outdoor Expeditionary Program Risk Management Strategies

    Science.gov (United States)

    Meerts-Brandsma, Lisa; Furman, Nate; Sibthorp, Jim

    2017-01-01

    In 2003, the University of Utah and the National Outdoor Leadership School (NOLS) completed a study that developed a risk management taxonomy in the outdoor adventure industry and assessed how different outdoor expeditionary programs (OEPs) managed risk (Szolosi, Sibthorp, Paisley, & Gookin, 2003). By unifying the language around risk, the…

  16. National survey of emergency physicians for transient ischemic attack (TIA) risk stratification consensus and appropriate treatment for a given level of risk.

    Science.gov (United States)

    Perry, Jeffrey J; Losier, Justin H; Stiell, Ian G; Sharma, Mukul; Abdulaziz, Kasim

    2016-01-01

    Five percent of transient ischemic attack (TIA) patients have a subsequent stroke within 7 days. The Canadian TIA Score uses clinical findings to calculate the subsequent stroke risk within 7 days. Our objectives were to assess 1) anticipated use; 2) component face validity; 3) risk strata for stroke within 7 days; and 4) actions required, for a given risk for subsequent stroke. After a rigorous development process, a survey questionnaire was administered to a random sample of 300 emergency physicians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique. From a total of 271 eligible surveys, we received 131 (48.3%) completed surveys; 96.2% of emergency physicians would use a validated Canadian TIA Score; 8 of 13 components comprising the Canadian TIA Score were rated as Very Important or Important by survey respondents. Risk categories for subsequent stroke were defined as minimal-risk: 10% risk of subsequent stroke within 7 days. A validated Canadian TIA Score will likely be used by emergency physicians. Most components of the TIA Score have high face validity. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk, in the emergency department.

  17. Diagnostic test strategies in children at increased risk of inflammatory bowel disease in primary care.

    Directory of Open Access Journals (Sweden)

    Gea A Holtman

    Full Text Available In children with symptoms suggestive of inflammatory bowel disease (IBD who present in primary care, the optimal test strategy for identifying those who require specialist care is unclear. We evaluated the following three test strategies to determine which was optimal for referring children with suspected IBD to specialist care: 1 alarm symptoms alone, 2 alarm symptoms plus c-reactive protein, and 3 alarm symptoms plus fecal calprotectin.A prospective cohort study was conducted, including children with chronic gastrointestinal symptoms referred to pediatric gastroenterology. Outcome was defined as IBD confirmed by endoscopy, or IBD ruled out by either endoscopy or unremarkable clinical 12 month follow-up with no indication for endoscopy. Test strategy probabilities were generated by logistic regression analyses and compared by area under the receiver operating characteristic curves (AUC and decision curves.We included 90 children, of whom 17 (19% had IBD (n = 65 from primary care physicians, n = 25 from general pediatricians. Adding fecal calprotectin to alarm symptoms increased the AUC significantly from 0.80 (0.67-0.92 to 0.97 (0.93-1.00, but adding c-reactive protein to alarm symptoms did not increase the AUC significantly (p > 0.05. Decision curves confirmed these patterns, showing that alarm symptoms combined with fecal calprotectin produced the diagnostic test strategy with the highest net benefit at reasonable threshold probabilities.In primary care, when children are identified as being at high risk for IBD, adding fecal calprotectin testing to alarm symptoms was the optimal strategy for improving risk stratification.

  18. Strategy Guideline. Mitigation of Retrofit Risk Factors

    Energy Technology Data Exchange (ETDEWEB)

    Berman, M. [Alliance for Residential Building Innovation (ARBI), Davis, CA (United States); Smith, P. [Alliance for Residential Building Innovation (ARBI), Davis, CA (United States); Porse, E. [Alliance for Residential Building Innovation (ARBI), Davis, CA (United States)

    2012-12-01

    The Alliance for Residential Building Innovation (ARBI) Building America team is currently developing strategies designed to promote and achieve increased energy savings and promote upgrades in the residential retrofit sector. These strategies are targeted to retrofit program managers, retrofit contractors, policy makers, academic researchers, and non-governmental organizations. This report focuses on four key areas to promote home energy upgrades: fostering accurate energy savings projections; understanding consumer perceptions for energy savings; measuring energy savings, and ensuring quality control for retrofit installations.

  19. Strategy Guideline: Mitigation of Retrofit Risk Factors

    Energy Technology Data Exchange (ETDEWEB)

    Berman, M.; Smith, P.; Porse, E.

    2012-12-01

    The Alliance for Residential Building Innovation (ARBI) is currently developing strategies designed to promote and achieve increased energy savings and promote upgrades in the residential retrofit sector. These strategies are targeted to retrofit program managers, retrofit contractors, policy makers, academic researchers, and non-governmental organizations. This report focuses on four key areas to promote home energy upgrades: fostering accurate energy savings projections; understanding consumer perceptions for energy savings; measuring energy savings, and ensuring quality control for retrofit installations.

  20. Precommitted Investment Strategy versus Time-Consistent Investment Strategy for a Dual Risk Model

    Directory of Open Access Journals (Sweden)

    Lidong Zhang

    2014-01-01

    Full Text Available We are concerned with optimal investment strategy for a dual risk model. We assume that the company can invest into a risk-free asset and a risky asset. Short-selling and borrowing money are allowed. Due to lack of iterated-expectation property, the Bellman Optimization Principle does not hold. Thus we investigate the precommitted strategy and time-consistent strategy, respectively. We take three steps to derive the precommitted investment strategy. Furthermore, the time-consistent investment strategy is also obtained by solving the extended Hamilton-Jacobi-Bellman equations. We compare the precommitted strategy with time-consistent strategy and find that these different strategies have different advantages: the former can make value function maximized at the original time t=0 and the latter strategy is time-consistent for the whole time horizon. Finally, numerical analysis is presented for our results.

  1. The predictive value of CHADS₂ risk score in post myocardial infarction arrhythmias - a Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) substudy

    DEFF Research Database (Denmark)

    Ruwald, Anne-Christine Huth; Gang, Uffe; Thomsen, Poul Erik Bloch

    2014-01-01

    BACKGROUND: Previous studies have shown substantially increased risk of cardiac arrhythmias and sudden cardiac death in post-myocardial infarction (MI) patients. However it remains difficult to identify the patients who are at highest risk of arrhythmias in the post-MI setting. The purpose...... of this study was to investigate if CHADS₂ score (congestive heart failure, hypertension, age ≥75 years, diabetes and previous stroke/TCI [doubled]) can be used as a risk tool for predicting cardiac arrhythmias after MI. METHODS: The study included 297 post-MI patients from the CARISMA study with left....... Patients were stratified according to CHADS₂ score at enrollment. Congestive heart failure was defined as LVEF ≤40% and NYHA class II, III or IV. RESULTS: We found significantly increased risk of an arrhythmic event with increasing CHADS₂ score (CHADS₂ score=1-2: HR=2.1 [1.1-3.9], p=0.021, CHADS₂ score ≥ 3...

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

    International Nuclear Information System (INIS)

    Wang, Qing; Ma, Chenming; Kemmner, Wolfgang

    2013-01-01

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

  3. Prognostic study of risk stratification among Japanese patients with ischemic heart disease using gated myocardial perfusion SPECT: J-ACCESS study

    International Nuclear Information System (INIS)

    Nishimura, Tsunehiko; Nakajima, Kenichi; Kusuoka, Hideo; Yamashina, Akira; Nishimura, Shigeyuki

    2008-01-01

    decreased cardiac function, as well as diabetes mellitus, could be predictors of high event rates and, thus, beneficial for risk stratification of Japanese patients with ischemic heart diseases. (orig.)

  4. Prediction of breast cancer risk based on profiling with common genetic variants

    DEFF Research Database (Denmark)

    Mavaddat, Nasim; Pharoah, Paul D P; Michailidou, Kyriaki

    2015-01-01

    BACKGROUND: Data for multiple common susceptibility alleles for breast cancer may be combined to identify women at different levels of breast cancer risk. Such stratification could guide preventive and screening strategies. However, empirical evidence for genetic risk stratification is lacking. M...

  5. Prediction of breast cancer risk based on profiling with common genetic variants

    NARCIS (Netherlands)

    N. Mavaddat (Nasim); P.D.P. Pharoah (Paul); K. Michailidou (Kyriaki); J.P. Tyrer (Jonathan); M.N. Brook (Mark N.); M.K. Bolla (Manjeet); Q. Wang (Qing); J. Dennis (Joe); A.M. Dunning (Alison); M. Shah (Mitul); R.N. Luben (Robert); J. Brown (Judith); S.E. Bojesen (Stig); B.G. Nordestgaard (Børge); S.F. Nielsen (Sune F.); H. Flyger (Henrik); K. Czene (Kamila); H. Darabi (Hatef); M. Eriksson (Mikael); J. Peto (Julian); I. dos Santos Silva (Isabel); F. Dudbridge (Frank); N. Johnson (Nichola); M.K. Schmidt (Marjanka); A. Broeks (Annegien); S. Verhoef; E.J. Rutgers (Emiel J.); A.J. Swerdlow (Anthony ); A. Ashworth (Alan); N. Orr (Nick); M. Schoemaker (Minouk); J.D. Figueroa (Jonine); S.J. Chanock (Stephen); L.A. Brinton (Louise); J. Lissowska (Jolanta); F.J. Couch (Fergus); J.E. Olson (Janet); C. Vachon (Celine); V.S. Pankratz (Shane); D. Lambrechts (Diether); H. Wildiers (Hans); C. van Ongeval (Chantal); E. van Limbergen (Erik); V. Kristensen (Vessela); G. Grenaker Alnæs (Grethe); S. Nord (Silje); A.-L. Borresen-Dale (Anne-Lise); H. Nevanlinna (Heli); T.A. Muranen (Taru); K. Aittomäki (Kristiina); C. Blomqvist (Carl); J. Chang-Claude (Jenny); A. Rudolph (Anja); P. Seibold (Petra); D. Flesch-Janys (Dieter); P.A. Fasching (Peter); L. Haeberle (Lothar); A.B. Ekici (Arif); M.W. Beckmann (Matthias); B. Burwinkel (Barbara); F. Marme (Federick); A. Schneeweiss (Andreas); C. Sohn (Christof); A. Trentham-Dietz (Amy); P. Newcomb (Polly); L. Titus (Linda); K.M. Egan (Kathleen M.); D. Hunter (David); S. Lindstrom (Stephen); R. Tamimi (Rulla); P. Kraft (Peter); N. Rahman (Nazneen); C. Turnbull (Clare); A. Renwick (Anthony); S. Seal (Sheila); J. Li (Jingmei); J. Liu (Jianjun); M.K. Humphreys (Manjeet); J. Benítez (Javier); M.P. Zamora (Pilar); J.I. Arias Pérez (José Ignacio); P. Menéndez (Primitiva); A. Jakubowska (Anna); J. Lubinski (Jan); K. Jaworska-Bieniek (Katarzyna); K. Durda (Katarzyna); N.V. Bogdanova (Natalia); N.N. Antonenkova (Natalia); T. Dörk (Thilo); H. Anton-Culver (Hoda); S.L. Neuhausen (Susan); A. Ziogas (Argyrios); L. Bernstein (Leslie); P. Devilee (Peter); R.A.E.M. Tollenaar (Rob); C.M. Seynaeve (Caroline); C.J. van Asperen (Christi); A. Cox (Angela); S.S. Cross (Simon); M.W.R. Reed (Malcolm); E.K. Khusnutdinova (Elza); M. Bermisheva (Marina); D. Prokofyeva (Darya); Z. Takhirova (Zalina); A. Meindl (Alfons); R.K. Schmutzler (Rita); C. Sutter (Christian); R. Yang (Rongxi); P. Schürmann (Peter); M. Bremer (Michael); H. Christiansen (Hans); T.-W. Park-Simon; P. Hillemanns (Peter); P. Guénel (Pascal); T. Truong (Thérèse); F. Menegaux (Florence); M. Sanchez (Marie); P. Radice (Paolo); P. Peterlongo (Paolo); S. Manoukian (Siranoush); V. Pensotti (Valeria); J. Hopper (John); H. Tsimiklis (Helen); C. Apicella (Carmel); M.C. Southey (Melissa); H. Brauch (Hiltrud); T. Brüning (Thomas); Y.-D. Ko (Yon-Dschun); A.J. Sigurdson (Alice); M.M. Doody (Michele M.); U. Hamann (Ute); D. Torres (Diana); H.U. Ulmer (Hans); A. Försti (Asta); E.J. Sawyer (Elinor); I.P. Tomlinson (Ian); M. Kerin (Michael); N. Miller (Nicola); I.L. Andrulis (Irene); J.A. Knight (Julia); G. Glendon (Gord); A. Marie Mulligan (Anna); G. Chenevix-Trench (Georgia); R. Balleine (Rosemary); G.G. Giles (Graham); R.L. Milne (Roger); C.A. McLean (Catriona Ann); A. Lindblom (Annika); S. Margolin (Sara); C.A. Haiman (Christopher); B.E. Henderson (Brian); F. Schumacher (Fredrick); L. Le Marchand (Loic); U. Eilber (Ursula); S. Wang-Gohrke (Shan); M.J. Hooning (Maartje); A. Hollestelle (Antoinette); A.M.W. van den Ouweland (Ans); L.B. Koppert (Lisa); J. Carpenter (Jane); C. Clarke (Christine); R.J. Scott (Rodney J.); A. Mannermaa (Arto); V. Kataja (Vesa); V-M. Kosma (Veli-Matti); J.M. Hartikainen (J.); H. Brenner (Hermann); V. Arndt (Volker); C. Stegmaier (Christa); A. Karina Dieffenbach (Aida); R. Winqvist (Robert); K. Pykäs (Katri); A. Jukkola-Vuorinen (Arja); M. Grip (Mervi); K. Offit (Kenneth); J. Vijai (Joseph); M. Robson (Mark); R. Rau-Murthy (Rohini); M. Dwek (Miriam); R. Swann (Ruth); K. Annie Perkins (Katherine); M.S. Goldberg (Mark); F. Labrèche (France); M. Dumont (Martine); D. Eccles (Diana); W. Tapper (William); M. Rafiq (Meena); E.M. John (Esther M.); A.S. Whittemore (Alice); S. Slager (Susan); D. Yannoukakos (Drakoulis); A.E. Toland (Amanda); S. Yao (Song); W. Zheng (Wei); S.L. Halverson (Sandra L.); A. González-Neira (Anna); G. Pita (Guillermo); M. Rosario Alonso; N. Álvarez (Nuria); D. Herrero (Daniel); D.C. Tessier (Daniel C.); D. Vincent (Daniel); F. Bacot (Francois); C. Luccarini (Craig); C. Baynes (Caroline); S. Ahmed (Shahana); M. Maranian (Melanie); S. Healey (Sue); J. Simard (Jacques); P. Hall (Per); D.F. Easton (Douglas); M. García-Closas (Montserrat)

    2015-01-01

    textabstractBackground: Data for multiple common susceptibility alleles for breast cancer may be combined to identify women at different levels of breast cancer risk. Such stratification could guide preventive and screening strategies. However, empirical evidence for genetic risk stratification is

  6. TCF7L2 variant genotypes and type 2 diabetes risk in Brazil: significant association, but not a significant tool for risk stratification in the general population

    Directory of Open Access Journals (Sweden)

    Mill JG

    2008-12-01

    Full Text Available Abstract Background Genetic polymorphisms of the TCF7L2 gene are strongly associated with large increments in type 2 diabetes risk in different populations worldwide. In this study, we aimed to confirm the effect of the TCF7L2 polymorphism rs7903146 on diabetes risk in a Brazilian population and to assess the use of this genetic marker in improving diabetes risk prediction in the general population. Methods We genotyped the single nucleotide polymorphisms (SNP rs7903146 of the TCF7L2 gene in 560 patients with known coronary disease enrolled in the MASS II (Medicine, Angioplasty, or Surgery Study Trial and in 1,449 residents of Vitoria, in Southeast Brazil. The associations of this gene variant to diabetes risk and metabolic characteristics in these two different populations were analyzed. To access the potential benefit of using this marker for diabetes risk prediction in the general population we analyzed the impact of this genetic variant on a validated diabetes risk prediction tool based on clinical characteristics developed for the Brazilian general population. Results SNP rs7903146 of the TCF7L2 gene was significantly associated with type 2 diabetes in the MASS-II population (OR = 1.57 per T allele, p = 0.0032, confirming, in the Brazilian population, previous reports of the literature. Addition of this polymorphism to an established clinical risk prediction score did not increased model accuracy (both area under ROC curve equal to 0.776. Conclusion TCF7L2 rs7903146 T allele is associated with a 1.57 increased risk for type 2 diabetes in a Brazilian cohort of patients with known coronary heart disease. However, the inclusion of this polymorphism in a risk prediction tool developed for the general population resulted in no improvement of performance. This is the first study, to our knowledge, that has confirmed this recent association in a South American population and adds to the great consistency of this finding in studies around the world

  7. Correction of population stratification in large multi-ethnic association studies.

    Directory of Open Access Journals (Sweden)

    David Serre

    2008-01-01

    Full Text Available The vast majority of genetic risk factors for complex diseases have, taken individually, a small effect on the end phenotype. Population-based association studies therefore need very large sample sizes to detect significant differences between affected and non-affected individuals. Including thousands of affected individuals in a study requires recruitment in numerous centers, possibly from different geographic regions. Unfortunately such a recruitment strategy is likely to complicate the study design and to generate concerns regarding population stratification.We analyzed 9,751 individuals representing three main ethnic groups - Europeans, Arabs and South Asians - that had been enrolled from 154 centers involving 52 countries for a global case/control study of acute myocardial infarction. All individuals were genotyped at 103 candidate genes using 1,536 SNPs selected with a tagging strategy that captures most of the genetic diversity in different populations. We show that relying solely on self-reported ethnicity is not sufficient to exclude population stratification and we present additional methods to identify and correct for stratification.Our results highlight the importance of carefully addressing population stratification and of carefully "cleaning" the sample prior to analyses to obtain stronger signals of association and to avoid spurious results.

  8. Environmental Risk Assessment Strategy for Nanomaterials

    Directory of Open Access Journals (Sweden)

    Janeck J. Scott‐Fordsmand

    2017-10-01

    Full Text Available An Environmental Risk Assessment (ERA for nanomaterials (NMs is outlined in this paper. Contrary to other recent papers on the subject, the main data requirements, models and advancement within each of the four risk assessment domains are described, i.e., in the: (i materials, (ii release, fate and exposure, (iii hazard and (iv risk characterisation domains. The material, which is obviously the foundation for any risk assessment, should be described according to the legislatively required characterisation data. Characterisation data will also be used at various levels within the ERA, e.g., exposure modelling. The release, fate and exposure data and models cover the input for environmental distribution models in order to identify the potential (PES and relevant exposure scenarios (RES and, subsequently, the possible release routes, both with regard to which compartment(s NMs are distributed in line with the factors determining the fate within environmental compartment. The initial outcome in the risk characterisation will be a generic Predicted Environmental Concentration (PEC, but a refined PEC can be obtained by applying specific exposure models for relevant media. The hazard information covers a variety of representative, relevant and reliable organisms and/or functions, relevant for the RES and enabling a hazard characterisation. The initial outcome will be hazard characterisation in test systems allowing estimating a Predicted No-Effect concentration (PNEC, either based on uncertainty factors or on a NM adapted version of the Species Sensitivity Distributions approach. The risk characterisation will either be based on a deterministic risk ratio approach (i.e., PEC/PNEC or an overlay of probability distributions, i.e., exposure and hazard distributions, using the nano relevant models.

  9. Environmental Risk Assessment Strategy for Nanomaterials.

    Science.gov (United States)

    Scott-Fordsmand, Janeck J; Peijnenburg, Willie J G M; Semenzin, Elena; Nowack, Bernd; Hunt, Neil; Hristozov, Danail; Marcomini, Antonio; Irfan, Muhammad-Adeel; Jiménez, Araceli Sánchez; Landsiedel, Robert; Tran, Lang; Oomen, Agnes G; Bos, Peter M J; Hund-Rinke, Kerstin

    2017-10-19

    An Environmental Risk Assessment (ERA) for nanomaterials (NMs) is outlined in this paper. Contrary to other recent papers on the subject, the main data requirements, models and advancement within each of the four risk assessment domains are described, i.e., in the: (i) materials, (ii) release, fate and exposure, (iii) hazard and (iv) risk characterisation domains. The material, which is obviously the foundation for any risk assessment, should be described according to the legislatively required characterisation data. Characterisation data will also be used at various levels within the ERA, e.g., exposure modelling. The release, fate and exposure data and models cover the input for environmental distribution models in order to identify the potential (PES) and relevant exposure scenarios (RES) and, subsequently, the possible release routes, both with regard to which compartment(s) NMs are distributed in line with the factors determining the fate within environmental compartment. The initial outcome in the risk characterisation will be a generic Predicted Environmental Concentration (PEC), but a refined PEC can be obtained by applying specific exposure models for relevant media. The hazard information covers a variety of representative, relevant and reliable organisms and/or functions, relevant for the RES and enabling a hazard characterisation. The initial outcome will be hazard characterisation in test systems allowing estimating a Predicted No-Effect concentration (PNEC), either based on uncertainty factors or on a NM adapted version of the Species Sensitivity Distributions approach. The risk characterisation will either be based on a deterministic risk ratio approach (i.e., PEC/PNEC) or an overlay of probability distributions, i.e., exposure and hazard distributions, using the nano relevant models.

  10. Aortic pulse wave velocity and HeartSCORE: improving cardiovascular risk stratification. a sub-analysis of the EDIVA (Estudo de DIstensibilidade VAscular) project.

    Science.gov (United States)

    Pereira, T; Maldonado, J; Polónia, J; Silva, J A; Morais, J; Rodrigues, T; Marques, M

    2014-04-01

    HeartSCORE is a tool for assessing cardiovascular risk, basing its estimates on the relative weight of conventional cardiovascular risk factors. However, new markers of cardiovascular risk have been identified, such as aortic pulse wave velocity (PWV). The purpose of this study was to evaluate to what extent the incorporation of PWV in HeartSCORE increases its discriminative power of major cardiovascular events (MACE). This study is a sub-analysis of the EDIVA project, which is a prospective cohort, multicenter and observational study involving 2200 individuals of Portuguese nationality (1290 men and 910 women) aged between 18 and 91 years (mean 46.33 ± 13.76 years), with annual measurements of PWV (Complior). Only participants above 35 years old were included in the present re-analysis, resulting in a population of 1709 participants. All MACE - death, cerebrovascular accident, coronary accidents (coronary heart disease), peripheral arterial disease and renal failure - were recorded. During a mean follow-up period of 21.42 ± 10.76 months, there were 47 non-fatal MACE (2.1% of the sample). Cardiovascular risk was estimated in all patients based on the HeartSCORE risk factors. For the analysis, the refitted HeartSCORE and PWV were divided into three risk categories. The event-free survival at 2 years was 98.6%, 98.0% and 96.1%, respectively in the low-, intermediate- and high-risk categories of HeartSCORE (log-rank p factor model. The C statistics improved from 0.69 to 0.78 (adding PWV, p = 0.005). The net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were also determined, and indicated further evidence of improvements in discrimination of the outcome when including PWV in the risk-factor model (NRI = 0.265; IDI = 0.012). The results clearly illustrate the benefits of integrating PWV in the risk assessment strategies, as advocated by HeartSCORE, insofar as it contributes to a better discriminative capacity of global

  11. An Assessment of risk response strategies practiced in software projects

    Directory of Open Access Journals (Sweden)

    Vanita Bhoola

    2014-11-01

    Full Text Available Risk management and success in projects are highly intertwined – better approaches to project risk management tend to increase chances of project success in terms of achieving scope & quality, schedule and cost targets. The process of responding to risk factors during a project’s life cycle is a crucial aspect of risk management referred to as risk response strategies, in this paper. The current research explores the status of risk response strategies applied in the software development projects in India. India provides a young IT-savvy English-speaking population, which is also cost effective. Other than the workforce, the environment for implementation of software projects in India is different from the matured economies. Risk management process is a commonly discussed theme, though its implementation in practice has a huge scope for improvement in India. The paper talks about four fundamental treatments to risk response – Avoidance, Transference, Mitigation and Acceptance (ATMA. From a primary data of 302 project managers, the paper attempts to address the risk response factors that lead to successful achievement of project scope & quality, schedule and cost targets, by using a series of regressions followed with Seemingly Unrelated Regression Equations (SURE modelling. Mitigation emerged as the most significant risk response strategy to achieve project targets. Acceptance, transference, and avoidance of risk were mostly manifested in the forms of transparency in communication across stakeholders, careful study of the nature of risks and close coordination between project team, customers/end-users and top management.

  12. Forests at risk: integrating risk science into fuel management strategies.

    Science.gov (United States)

    Jonathan. Thompson

    2008-01-01

    The threat from wildland fire continues to grow across many regions of the Western United States. Drought, urbanization, and a buildup of fuels over the last century have contributed to increasing wildfire risk to property and highly valued natural resources. Fuel treatments, including thinning overly dense forests to reduce fuel and lower fire risk, have become a...

  13. Applying risk management strategies to strengthen an IDS's investment policy.

    Science.gov (United States)

    Fine, R P

    1998-11-01

    The increased financial risk that not-for-profit integrated delivery systems have assumed to function under managed care has required them to become increasingly reliant on income and gains from their investment portfolios. This reliance underscores the need for these organizations to take steps to effectively manage their investment risk. Not-for-profit IDSs should establish a systematic approach to investment risk management that is based on maintaining a sound fiduciary infrastructure and having a clear understanding of risk exposures, the most important of which are policy and market risk. Applying reasonable and common-sense risk management strategies to investment policy will enhance an IDS's overall financial and competitive strength.

  14. Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for Advanced Risk Modeling of Prostate Cancer-Patient-tailored Risk Stratification Can Reduce Unnecessary Biopsies.

    Science.gov (United States)

    Radtke, Jan Philipp; Wiesenfarth, Manuel; Kesch, Claudia; Freitag, Martin T; Alt, Celine D; Celik, Kamil; Distler, Florian; Roth, Wilfried; Wieczorek, Kathrin; Stock, Christian; Duensing, Stefan; Roethke, Matthias C; Teber, Dogu; Schlemmer, Heinz-Peter; Hohenfellner, Markus; Bonekamp, David; Hadaschik, Boris A

    2017-12-01

    Multiparametric magnetic resonance imaging (mpMRI) is gaining widespread acceptance in prostate cancer (PC) diagnosis and improves significant PC (sPC; Gleason score≥3+4) detection. Decision making based on European Randomised Study of Screening for PC (ERSPC) risk-calculator (RC) parameters may overcome prostate-specific antigen (PSA) limitations. We added pre-biopsy mpMRI to ERSPC-RC parameters and developed risk models (RMs) to predict individual sPC risk for biopsy-naïve men and men after previous biopsy. We retrospectively analyzed clinical parameters of 1159 men who underwent mpMRI prior to MRI/transrectal ultrasound fusion biopsy between 2012 and 2015. Multivariate regression analyses were used to determine significant sPC predictors for RM development. The prediction performance was compared with ERSPC-RCs, RCs refitted on our cohort, Prostate Imaging Reporting and Data System (PI-RADS) v1.0, and ERSPC-RC plus PI-RADSv1.0 using receiver-operating characteristics (ROCs). Discrimination and calibration of the RM, as well as net decision and reduction curve analyses were evaluated based on resampling methods. PSA, prostate volume, digital-rectal examination, and PI-RADS were significant sPC predictors and included in the RMs together with age. The ROC area under the curve of the RM for biopsy-naïve men was comparable with ERSPC-RC3 plus PI-RADSv1.0 (0.83 vs 0.84) but larger compared with ERSPC-RC3 (0.81), refitted RC3 (0.80), and PI-RADS (0.76). For postbiopsy men, the novel RM's discrimination (0.81) was higher, compared with PI-RADS (0.78), ERSPC-RC4 (0.66), refitted RC4 (0.76), and ERSPC-RC4 plus PI-RADSv1.0 (0.78). Both RM benefits exceeded those of ERSPC-RCs and PI-RADS in the decision regarding which patient to receive biopsy and enabled the highest reduction rate of unnecessary biopsies. Limitations include a monocentric design and a lack of PI-RADSv2.0. The novel RMs, incorporating clinical parameters and PI-RADS, performed significantly better

  15. Volumetry based biomarker speed of growth: Quantifying the change of total tumor volume in whole-body magnetic resonance imaging over time improves risk stratification of smoldering multiple myeloma patients.

    Science.gov (United States)

    Wennmann, Markus; Kintzelé, Laurent; Piraud, Marie; Menze, Bjoern H; Hielscher, Thomas; Hofmanninger, Johannes; Wagner, Barbara; Kauczor, Hans-Ulrich; Merz, Maximilian; Hillengass, Jens; Langs, Georg; Weber, Marc-André

    2018-05-18

    The purpose of this study was to improve risk stratification of smoldering multiple myeloma patients, introducing new 3D-volumetry based imaging biomarkers derived from whole-body MRI. Two-hundred twenty whole-body MRIs from 63 patients with smoldering multiple myeloma were retrospectively analyzed and all focal lesions >5mm were manually segmented for volume quantification. The imaging biomarkers total tumor volume, speed of growth (development of the total tumor volume over time), number of focal lesions, development of the number of focal lesions over time and the recent imaging biomarker '>1 focal lesion' of the International Myeloma Working Group were compared, taking 2-year progression rate, sensitivity and false positive rate into account. Speed of growth, using a cutoff of 114mm 3 /month, was able to isolate a high-risk group with a 2-year progression rate of 82.5%. Additionally, it showed by far the highest sensitivity in this study and in comparison to other biomarkers in the literature, detecting 63.2% of patients who progress within 2 years. Furthermore, its false positive rate (8.7%) was much lower compared to the recent imaging biomarker '>1 focal lesion' of the International Myeloma Working Group. Therefore, speed of growth is the preferable imaging biomarker for risk stratification of smoldering multiple myeloma patients.

  16. Risk management strategies utilized by small scale poultry farmers ...

    African Journals Online (AJOL)

    Birds can only tolerate narrow temperature changes; therefore, poultry flocks are vulnerable to climate induced risk. This study investigated risk management strategies utilized by small scale poultry farmers in Oyo state. A total of 118 respondents were sampled using multi stage sampling procedure. Interview schedule was ...

  17. GFC-Robust Risk Management Strategies under the Basel Accord

    NARCIS (Netherlands)

    M.J. McAleer (Michael); J.A. Jiménez-Martín (Juan-Ángel); T. Pérez-Amaral (Teodosio)

    2010-01-01

    textabstractA risk management strategy is proposed as being robust to the Global Financial Crisis (GFC) by selecting a Value-at-Risk (VaR) forecast that combines the forecasts of different VaR models. The robust forecast is based on the median of the point VaR forecasts of a set of conditional

  18. Role of post-therapy 131Iodine SPECT-CT in risk stratification and management of patients with differentiated thyroid cancer

    International Nuclear Information System (INIS)

    Agarwal, K.; Bhattacharya, A.; Harishankar, C.N.B.; Manohar, K.; Mittal, B.R.

    2010-01-01

    contamination of skin and in 1/13 intermediate risk patient was changed to low risk category (thus changing the post ablation TSH suppression criteria). Conclusion: SPECT/CT data significantly altered the initial risk of recurrence estimates in 4 of 33 patients (12.12%) and changed subsequent patient management in 13 out of 33 patients (39.39%). This study suggests that 131 Iodine SPECT/CT has a significant role in the management strategy of differentiated thyroid cancer

  19. Precommitted Investment Strategy versus Time-Consistent Investment Strategy for a General Risk Model with Diffusion

    Directory of Open Access Journals (Sweden)

    Lidong Zhang

    2014-01-01

    Full Text Available We mainly study a general risk model and investigate the precommitted strategy and the time-consistent strategy under mean-variance criterion, respectively. A lagrange method is proposed to derive the precommitted investment strategy. Meanwhile from the game theoretical perspective, we find the time-consistent investment strategy by solving the extended Hamilton-Jacobi-Bellman equations. By comparing the precommitted strategy with the time-consistent strategy, we find that the company under the time-consistent strategy has to give up the better current utility in order to keep a consistent satisfaction over the whole time horizon. Furthermore, we theoretically and numerically provide the effect of the parameters on these two optimal strategies and the corresponding value functions.

  20. MANAGING RISK BY COORDINATING INVESTMENT, MARKETING, AND PRODUCTION STRATEGIES

    OpenAIRE

    Johnson, Donald A.; Boehlje, Michael

    1983-01-01

    This study of the farm firm integrates long run investment and financial decisions, and short-run production and marketing decisions into a single decision framework that includes both time and risk. The results suggest that the use of various strategies for managing market risks allow the entrepreneur to accept mores risk in investing and producing; and that an integrated analysis of production, marketing and investment-financing alternatives is essential to make accurate recommendations abo...

  1. MITIGATING FINANCIAL RISK BY USING HEDGING STRATEGIES

    Directory of Open Access Journals (Sweden)

    Anca BUTNARIU

    2018-05-01

    Full Text Available Financial derivatives are now widely used by corporations to manage exposure to currency, interest rate, and commodity price risks. The motivation for non-financial firms to engage in corporate hedging is one of the most intensively discussed topics in corporate finance research. Recent financial theory suggests that there are several ways through which corporate hedging can increase firm value in the sense of the maximization of shareholder value. A rich body of literature consists of studies that have empirically investigated the theoretical explanations for corporate hedging, literature that presents rather mixed evidence for the drivers of corporate hedging. This paper investigates the effects of hedging activity on non-financial firm value and how operational hedging is related to and differentiated by financial hedging, by providing an extensive overview and synthesis of the existing literature.

  2. Identification and risk estimation of movement strategies during cutting maneuvers.

    Science.gov (United States)

    David, Sina; Komnik, Igor; Peters, Markus; Funken, Johannes; Potthast, Wolfgang

    2017-12-01

    Approximately 70% of anterior cruciate ligament (ACL) injuries occur in non-contact situations during cutting and landing maneuvers. Parameters such as footstrike patterns and trunk orientation were found to influence ACL relevant knee loading, however, the relationship between the whole body movement and injury risk is debated. This study identifies whole body movement strategies that increase injury risk, and provides training recommendations to reduce this risk or enable a save return to sports after injury. Experimental cross-sectional study design. Three dimensional movement analysis was carried out to investigate 50 participants performing anticipated 90° cutting maneuvers. To identify and characterize movement strategies, footstrike pattern, knee valgus moment, knee internal rotation moment, angle of attack, shoulder and pelvis axis were analyzed using statistical parametric mapping. Three different movement strategies were identified. One strategy included rearfoot striking in combination with a relatively upright body position which generated higher knee joint loads than the second strategy, forefoot striking in combination with more backwards leaning and pre-rotation of the trunk towards the new movement direction. A third strategy combined forefoot striking with less preorientation which increased the ACL relevant knee joint load compared to the second strategy. The identified movement strategies clearly pre-determine the injury risk during non-contact situations with the third strategy as the most unfavorable one. Compared to the study of isolated parameters, the analysis of the whole body movement allowed for detailed separation of more risky from less risky cutting strategies. These results give practical recommendations for the prevention of ACL injury. Copyright © 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

  3. Risk evaluation and mitigation strategies: a focus on belatacept.

    Science.gov (United States)

    Sam, Teena; Gabardi, Steven; Tichy, Eric M

    2013-03-01

    To review the elements and components of the risk evaluation and mitigation strategies (REMS) for the costimulation blocker belatacept and associated implications for health care providers working with transplant recipients. The MEDLINE and EMBASE databases (January 1990 to March 2012) were searched by using risk evaluation and mitigation strategies, REMS, belatacept, and organ transplant as search terms (individual organs were also searched). Retrieved articles were supplemented with analysis of information obtained from the Federal Register, the Food and Drug Administration, and the manufacturer of belatacept. REMS are risk-management strategies implemented to ensure that a product's benefits outweigh its known safety risks. Although belatacept offers a novel strategy in maintenance immunosuppression and was associated with superior renal function compared with cyclosporine in phase 2 and 3 trials, belatacept is also associated with increased risk of posttransplant lymphoproliferative disorder and central nervous system infections. The Food and Drug Administration required development of a REMS program as part of belatacept's approval process to ensure safe and appropriate use of the medication and optimization of its risk-benefit profile. Elements of the belatacept REMS include a medication guide that must be dispensed with each infusion and a communication plan. In the management of a complex population of patients, it is essential that those who care for transplant recipients, and patients, recognize the implications of potential and known risks of belatacept. The REMS program aims to facilitate careful selection and education of patients and vigilant monitoring.

  4. Export strategy risks and governance in the clothing industry

    Directory of Open Access Journals (Sweden)

    Arthur Mapanga

    2016-08-01

    Full Text Available This paper investigates the export strategy implementation risks in Zimbabwe’s clothing sector with a view to build a framework for improving strategy implementation and governance. The government of Zimbabwe has formulated a five year export strategic blue-print to resuscitate the clothing value chain. However, to date, no visible movement towards implementing the export strategy has materialised. The sector is on the brink of collapse putting the welfare and livelihood of over two million people dependent on the sector at risk. A desk research and key informant interviews were conducted to understand the barriers causing inertia in the implementation of the export strategy. Cotton farmers’ unions’ representatives, the cotton ginners association members, the spinning industry members and garment manufacturers representatives, clothing retailers’ representatives, workers’ unions’ members and government officials were important sources of information towards the discovery of the risks. From the research, six of the strategy implementation risks were linked to human elements. Leadership, consensus and commitment deficiencies militated against the implementation of the export strategy in the clothing value chain. There is also a lack of trust among the value chain actors leading to the dislocation of efforts to resuscitate the sector

  5. The MARINA Risk Assessment Strategy: A Flexible Strategy for Efficient Information Collection and Risk Assessment of Nanomaterials.

    Science.gov (United States)

    Bos, Peter M J; Gottardo, Stefania; Scott-Fordsmand, Janeck J; van Tongeren, Martie; Semenzin, Elena; Fernandes, Teresa F; Hristozov, Danail; Hund-Rinke, Kerstin; Hunt, Neil; Irfan, Muhammad-Adeel; Landsiedel, Robert; Peijnenburg, Willie J G M; Sánchez Jiménez, Araceli; van Kesteren, Petra C E; Oomen, Agnes G

    2015-11-27

    An engineered nanomaterial (ENM) may actually consist of a population of primary particles, aggregates and agglomerates of various sizes. Furthermore, their physico-chemical characteristics may change during the various life-cycle stages. It will probably not be feasible to test all varieties of all ENMs for possible health and environmental risks. There is therefore a need to further develop the approaches for risk assessment of ENMs. Within the EU FP7 project Managing Risks of Nanoparticles (MARINA) a two-phase risk assessment strategy has been developed. In Phase 1 (Problem framing) a base set of information is considered, relevant exposure scenarios (RESs) are identified and the scope for Phase 2 (Risk assessment) is established. The relevance of an RES is indicated by information on exposure, fate/kinetics and/or hazard; these three domains are included as separate pillars that contain specific tools. Phase 2 consists of an iterative process of risk characterization, identification of data needs and integrated collection and evaluation of data on the three domains, until sufficient information is obtained to conclude on possible risks in a RES. Only data are generated that are considered to be needed for the purpose of risk assessment. A fourth pillar, risk characterization, is defined and it contains risk assessment tools. This strategy describes a flexible and efficient approach for data collection and risk assessment which is essential to ensure safety of ENMs. Further developments are needed to provide guidance and make the MARINA Risk Assessment Strategy operational. Case studies will be needed to refine the strategy.

  6. The MARINA Risk Assessment Strategy: A Flexible Strategy for Efficient Information Collection and Risk Assessment of Nanomaterials

    Directory of Open Access Journals (Sweden)

    Peter M. J. Bos

    2015-11-01

    Full Text Available An engineered nanomaterial (ENM may actually consist of a population of primary particles, aggregates and agglomerates of various sizes. Furthermore, their physico-chemical characteristics may change during the various life-cycle stages. It will probably not be feasible to test all varieties of all ENMs for possible health and environmental risks. There is therefore a need to further develop the approaches for risk assessment of ENMs. Within the EU FP7 project Managing Risks of Nanoparticles (MARINA a two-phase risk assessment strategy has been developed. In Phase 1 (Problem framing a base set of information is considered, relevant exposure scenarios (RESs are identified and the scope for Phase 2 (Risk assessment is established. The relevance of an RES is indicated by information on exposure, fate/kinetics and/or hazard; these three domains are included as separate pillars that contain specific tools. Phase 2 consists of an iterative process of risk characterization, identification of data needs and integrated collection and evaluation of data on the three domains, until sufficient information is obtained to conclude on possible risks in a RES. Only data are generated that are considered to be needed for the purpose of risk assessment. A fourth pillar, risk characterization, is defined and it contains risk assessment tools. This strategy describes a flexible and efficient approach for data collection and risk assessment which is essential to ensure safety of ENMs. Further developments are needed to provide guidance and make the MARINA Risk Assessment Strategy operational. Case studies will be needed to refine the strategy.

  7. Talent Complementarity and Organizational Stratification

    Science.gov (United States)

    Abrahamson, Mark

    1973-01-01

    Stratification within organizations as produced by the distribution of functional importance among positions is investigated. According to Stinchcombe's hypothesis from the functional theory of stratification, the rewards given to various positions are expected to be less equal when talent is complementary rather than additive. Actual differences…

  8. Strategies and criteria for risk-based configuration control

    International Nuclear Information System (INIS)

    Samanta, P.K.; Kim, I.S.; Vesely, W.E.

    1991-01-01

    A configuration, as used here, is a set of component operability or statuses that define the state of a nuclear power plant. Risk-based configuration control is the management of component configurations using a risk perspective to control risk and assure safety. If the component configurations that have high risk implications do not occur then the risk from the operation of nuclear power plants would be minimal. The control of component configurations, i.e., the management of component statuses, so that the risk from components being unavailable is minimized, becomes difficult because the status of a standby safety system component is often not apparent unless it is tested. In this paper, we discuss the strategies and criteria for risk-based configuration control in nuclear power plants. In developing these strategies and criteria, the primary objective is to obtain more direct risk control but the added benefit is the effective use of plant resources. Implementation of such approaches can result in replacement/modification of parts of Technical Specifications. Specifically, the risk impact or safety impact of a configuration depends upon four factors: (1) The configuration components which are simultaneously down (i.e., inoperable); (2) the backup components which are known to be up (i.e., operable); (3) the duration of time the configuration exists (the outage time); and (4) the frequency at which the configuration occurs. Risk-based configuration control involves managing these factors using risk analyses and risk insights. In this paper, we discuss each of the factors and illustrate how they can be controlled. The information and the tools needed in implementing configuration control are also discussed. The risk-based calculation requirements in achieving the control are also delineated. 4 refs., 4 figs., 1 tab

  9. Risk management - unappreciated instrument of supply chain management strategy

    OpenAIRE

    Wojciech Machowiak

    2012-01-01

    Background: Unlike Enterprise Risk Management, which is certainly quite well rooted in business practice, Supply Chain Risk Management (SCRM) still continues to be dynamically developing subject of academic research, whereas its practical applications are rather scarce. Material and methods: On the basis of broad review of the current state of the art in world literature, significant  relevancies to the core processes and enterprise strategy are discussed.   Results: ...

  10. Fertility drugs, reproductive strategies and ovarian cancer risk

    OpenAIRE

    Tomao, Federica; Lo Russo, Giuseppe; Spinelli, Gian Paolo; Stati, Valeria; Prete, Alessandra Anna; Prinzi, Natalie; Sinjari, Marsela; Vici, Patrizia; Papa, Anselmo; Chiotti, Maria Stefania; Benedetti Panici, Pierluigi; Tomao, Silverio

    2014-01-01

    Several adverse effects have been related to infertility treatments, such as cancer development. In particular, the relationship between infertility, reproductive strategies, and risk of gynecological cancers has aroused much interest in recent years. The evaluation of cancer risk among women treated for infertility is very complex, mainly because of many factors that can contribute to occurrence of cancer in these patients (including parity status). This article addresses the possible associ...

  11. A validation study of the 2003 American College of Cardiology/European Society of Cardiology and 2011 American College of Cardiology Foundation/American Heart Association risk stratification and treatment algorithms for sudden cardiac death in patients with hypertrophic cardiomyopathy.

    Science.gov (United States)

    O'Mahony, Constantinos; Tome-Esteban, Maite; Lambiase, Pier D; Pantazis, Antonios; Dickie, Shaughan; McKenna, William J; Elliott, Perry M

    2013-04-01

    Sudden cardiac death (SCD) is a common mode of death in hypertrophic cardiomyopathy (HCM), but identification of patients who are at a high risk of SCD is challenging as current risk stratification guidelines have never been formally validated. The objective of this study was to assess the power of the 2003 American College of Cardiology (ACC)/European Society of Cardiology (ESC) and 2011 ACC Foundation (ACCF)/American Heart Association (AHA) SCD risk stratification algorithms to distinguish high risk patients who might be eligible for an implantable cardioverter defibrillator (ICD) from low risk individuals. We studied 1606 consecutively evaluated HCM patients in an observational, retrospective cohort study. Five risk factors (RF) for SCD were assessed: non-sustained ventricular tachycardia, severe left ventricular hypertrophy, family history of SCD, unexplained syncope and abnormal blood pressure response to exercise. During a follow-up period of 11 712 patient years (median 6.6 years), SCD/appropriate ICD shock occurred in 20 (3%) of 660 patients without RF (annual rate 0.45%), 31 (4.8%) of 636 patients with 1 RF (annual rate 0.65%), 27 (10.8%) of 249 patients with 2 RF (annual rate 1.3%), 7 (13.7%) of 51 patients with 3 RF (annual rate 1.9%) and 4 (40%) of 10 patients with ≥4 RF (annual rate 5.0%). The risk of SCD increased with multiple RF (2 RF: HR 2.87, p≤0.001; 3 RF: HR 4.32, p=0.001; ≥4 RF: HR 11.37, p<0.0001), but not with a single RF (HR 1.43 p=0.21). The area under time-dependent receiver operating characteristic curves (representing the probability of correctly identifying a patient at risk of SCD on the basis of RF profile) was 0.63 at 1 year and 0.64 at 5 years for the 2003 ACC/ESC algorithm and 0.61 at 1 year and 0.63 at 5 years for the 2011 ACCF/AHA algorithm. The risk of SCD increases with the aggregation of RF. The 2003 ACC/ESC and 2011 ACCF/AHA guidelines distinguish high from low risk individuals with limited power.

  12. Evaluation of test intervals strategies with a risk monitor

    International Nuclear Information System (INIS)

    Soerman, J.

    2005-01-01

    The Swedish nuclear power utility Oskarshamn Power Group (OKG), is investigating how the use of a risk monitor can facilitate and improve risk-informed decision-making at their nuclear power plants. The intent is to evaluate if risk-informed decision-making can be accepted. A pilot project was initiated and carried out in 2004. The project included investigating if a risk monitor can be used for optimising test intervals for diesel- and gas turbine generators with regard to risk level. The Oskarhamn 2 (O2), PSA Level 1 model was converted into a risk monitor using RiskSpectrum RiskWatcher (RSRW) software. The converted PSA model included the complete PSA model for the power operation mode. RSRW then performs a complete requantification for every analysis. Time dependent reliability data are taken into account, i.e. a shorter test interval will increases the components availability (possibility to e.g. start on demand). The converted O2 model was then used to investigate whether it would be possible to balance longer test intervals for diesel generators, gas turbine generators and high pressure injection system with shorter test intervals for the low pressure injection system, while maintaining a low risk level at the plant. The results show that a new mixture of test intervals can be implemented with only marginally changes in the risk calculated with the risk monitor model. The results indicate that the total number of test activities for the systems included in the pilot study could be reduced by 20% with a maintained level of risk. A risk monitor taking into account the impact from test intervals in availability calculations for components is well suited for evaluation of test interval strategies. It also enables the analyst to evaluate the risk level over a period of time including the impact the actual status of the plant may have on the risk level. (author)

  13. Risk Aversion and Public Reporting. Part 2: Mitigation Strategies.

    Science.gov (United States)

    Shahian, David M; Jacobs, Jeffrey P; Badhwar, Vinay; D'Agostino, Richard S; Bavaria, Joseph E; Prager, Richard L

    2017-12-01

    Part 1 of this review summarizes the consequences of risk aversion and the observational studies and surveys relevant to this phenomenon, almost all of which are derived from cardiac surgery and interventional cardiology. In Part 2, we describe the root cause of risk aversion-the belief by providers that current risk adjustment is inadequate to account for the severity of their highest-risk patients, thereby prejudicing their publicly reported performance scores. Evidence supporting the robustness of current risk adjustment is presented, as well as nine potential strategies to further mitigate risk aversion: optimization of data source, risk models, and performance measures; exclusion of high-risk patients; exclusion of non-procedure-related end points; separate reporting of high-risk patients; reporting by condition or diagnosis rather than by procedures; reporting at the hospital or program level rather than the physician level; collaborative, cross-disciplinary decision making; active surveillance for risk aversion; and improved stakeholder education. Of these, the first is most desirable, widely applicable, and resistant to gaming. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  14. Risk Preferences, Probability Weighting, and Strategy Tradeoffs in Wildfire Management.

    Science.gov (United States)

    Hand, Michael S; Wibbenmeyer, Matthew J; Calkin, David E; Thompson, Matthew P

    2015-10-01

    Wildfires present a complex applied risk management environment, but relatively little attention has been paid to behavioral and cognitive responses to risk among public agency wildfire managers. This study investigates responses to risk, including probability weighting and risk aversion, in a wildfire management context using a survey-based experiment administered to federal wildfire managers. Respondents were presented with a multiattribute lottery-choice experiment where each lottery is defined by three outcome attributes: expenditures for fire suppression, damage to private property, and exposure of firefighters to the risk of aviation-related fatalities. Respondents choose one of two strategies, each of which includes "good" (low cost/low damage) and "bad" (high cost/high damage) outcomes that occur with varying probabilities. The choice task also incorporates an information framing experiment to test whether information about fatality risk to firefighters alters managers' responses to risk. Results suggest that managers exhibit risk aversion and nonlinear probability weighting, which can result in choices that do not minimize expected expenditures, property damage, or firefighter exposure. Information framing tends to result in choices that reduce the risk of aviation fatalities, but exacerbates nonlinear probability weighting. © 2015 Society for Risk Analysis.

  15. Fertility drugs, reproductive strategies and ovarian cancer risk.

    Science.gov (United States)

    Tomao, Federica; Lo Russo, Giuseppe; Spinelli, Gian Paolo; Stati, Valeria; Prete, Alessandra Anna; Prinzi, Natalie; Sinjari, Marsela; Vici, Patrizia; Papa, Anselmo; Chiotti, Maria Stefania; Benedetti Panici, Pierluigi; Tomao, Silverio

    2014-01-01

    Several adverse effects have been related to infertility treatments, such as cancer development. In particular, the relationship between infertility, reproductive strategies, and risk of gynecological cancers has aroused much interest in recent years. The evaluation of cancer risk among women treated for infertility is very complex, mainly because of many factors that can contribute to occurrence of cancer in these patients (including parity status). This article addresses the possible association between the use of fertility treatments and the risk of ovarian cancer, through a scrupulous search of the literature published thus far in this field. Our principal objective was to give more conclusive answers on the question whether the use of fertility drug significantly increases ovarian cancer risk. Our analysis focused on the different types of drugs and different treatment schedules used. This study provides additional insights regarding the long-term relationships between fertility drugs and risk of ovarian cancer.

  16. Risk management - unappreciated instrument of supply chain management strategy

    Directory of Open Access Journals (Sweden)

    Wojciech Machowiak

    2012-12-01

    Full Text Available Background: Unlike Enterprise Risk Management, which is certainly quite well rooted in business practice, Supply Chain Risk Management (SCRM still continues to be dynamically developing subject of academic research, whereas its practical applications are rather scarce. Material and methods: On the basis of broad review of the current state of the art in world literature, significant  relevancies to the core processes and enterprise strategy are discussed.   Results: The paper shows some interesting from the enterprise's performance and competitiveness point of view additional benefits, potentially resulting from the proactive, consistent and effective implementation of the SCRM system. Conclusions: Some additional advantages from proactive supply chain risk management account for perceiving SCRM as multifunctional instrument of strategic SC management, exceeding established understanding RM as security and threat-prevention  tool only. Positive influence from SCRM onto SC performance and competitiveness can make reasonable to enhance its position within SCM strategy.

  17. Communicating about risk: strategies for situations where public concern is high but the risk is low

    Directory of Open Access Journals (Sweden)

    Claire Hooker

    2017-02-01

    Full Text Available In this article, we summarise research that identifies best practice for communicating about hazards where the risk is low but public concern is high. We apply Peter Sandman’s ‘risk = hazard + outrage’ formulation to these risks, and review factors associated with the amplification of risk signals. We discuss the structures that determine the success of risk communication strategies, such as the capacity for early communication to ‘capture’ the dominant representation of risk issues, the importance of communicating uncertainty, and the usefulness of engaging with communities. We argue that, when facing trade-offs in probable outcomes from communication, it is always best to choose strategies that maintain or build trust, even at the cost of initial overreactions. We discuss these features of successful risk communication in relation to a range of specific examples, particularly opposition to community water fluoridation, Ebola, and routine childhood immunisation.

  18. Mathematics, Pricing, Market Risk Management and Trading Strategies for Financial Derivatives (2/3)

    CERN Multimedia

    CERN. Geneva; Coffey, Brian

    2009-01-01

    Market Trading and Risk Management of Vanilla FX Options - Measures of Market Risk - Implied Volatility - FX Risk Reversals, FX Strangles - Valuation and Risk Calculations - Risk Management - Market Trading Strategies

  19. Strategies for risk management using the paper markets

    International Nuclear Information System (INIS)

    Annesley, M.

    1992-01-01

    This paper briefly describes the significant milestones in the evolution of the oil markets, with emphasis on the reasons for the changing structures of the markets, and the roles of different types of participant. After explaining the current structure of the oil markets - futures - forwards - options and derivatives the paper then explains some basic strategies. Finally some of the favourite strategies of refiners, producers and end users will be explored. Some cautionary comments on deal tracking, control systems and other associated risk management requirements will round off this paper. (author)

  20. The alignment of organisation strategy and risk appetite in the financial services industry

    OpenAIRE

    2014-01-01

    M.Com. (Business Management) This study concerns itself with the concepts of strategy, risk management and risk appetite. Strategy and risk management playa very important role in any business, but it is very difficult to determine the interrelationship between strategy and risk. There is no scientific/academic proof and there is no model or framework on what the alignment between an organisation's strategy and risk appetite is. Therefore, the purpose of this study is to develop a risk app...

  1. [Strategies for reducing risks in smoking: opportunity or threat].

    Science.gov (United States)

    Córdoba, Rodrigo; Nerín, Isabel

    2009-12-01

    The smoking control policies recommended by the World Health Organisation have achieved a slight decrease in smoking prevalence in the developed countries, although associated mortality is still very high. The use of tobacco products other than cigarettes and even medicinal nicotine (known as nicotine replacement therapy (NRT)) has been proposed as a risk reduction strategy. Among the tobacco products with less individual risk than cigarettes would be any type of tobacco without smoke (smokeless) with a low content in nitrosamines and modified cigarettes; both forms included under the PREP (Potentially Reduced Exposure Products) concept. The idea would be to promote these products among those who cannot quit smoking or wish to reduce their risk without giving up nicotine intake. The possible effects of risk reduction strategies, including PREP, on the decreased prevalence and morbidity and mortality are reviewed, and the possible implications that this measure could have in our country are analysed. Tobacco control measures in Spain are recent and still insufficient. Therefore, the current priority in Spain is the development of policies of control that have shown to more than effective. The marketing and advertising of new tobacco products, even with reduced potential risk, seems more a serious threat than an opportunity for the development of smoking control policies.

  2. Induced seismicity and carbon storage: Risk assessment and mitigation strategies

    Energy Technology Data Exchange (ETDEWEB)

    White, Joshua A. [Lawrence Livermore National Lab. (LLNL), Livermore, CA (United States); Foxall, William [Lawrence Berkeley National Lab. (LBNL), Berkeley, CA (United States); Bachmann, Corinne [Lawrence Berkeley National Lab. (LBNL), Berkeley, CA (United States); Chiaramonte, Laura [Lawrence Livermore National Lab. (LLNL), Livermore, CA (United States); Daley, Thomas M. [Lawrence Berkeley National Lab. (LBNL), Berkeley, CA (United States)

    2016-01-28

    Geologic carbon storage (GCS) is widely recognized as an important strategy to reduce atmospheric carbon dioxide (CO2) emissions. Like all technologies, however, sequestration projects create a number of potential environmental and safety hazards that must be addressed. These include earthquakes—from microseismicity to large, damaging events—that can be triggered by altering pore-pressure conditions in the subsurface. To date, measured seismicity due to CO2 injection has been limited to a few modest events, but the hazard exists and must be considered. There are important similarities between CO2 injection and fluid injection from other applications that have induced significant events—e.g. geothermal systems, waste-fluid injection, hydrocarbon extraction, and others. There are also important distinctions among these technologies that should be considered in a discussion of seismic hazard. This report focuses on strategies for assessing and mitigating risk during each phase of a CO2 storage project. Four key risks related to fault reactivation and induced seismicity were considered. Induced slip on faults could potentially lead to: (1) infrastructure damage, (2) a public nuisance, (3) brine-contaminated drinking water, and (4) CO2-contaminated drinking water. These scenarios lead to different types of damage—to property, to drinking water quality, or to the public welfare. Given these four risks, this report focuses on strategies for assessing (and altering) their likelihoods of occurrence and the damage that may result. This report begins with an overview of the basic physical mechanisms behind induced seismicity. This science basis—and its gaps—is crucial because it forms the foundation for risk assessment and mitigation. Available techniques for characterizing and monitoring seismic behavior are also described. Again, this technical basis—and its limitations—must be factored into the risk

  3. Illness Among Paralympic Athletes: Epidemiology, Risk Markers, and Preventative Strategies.

    Science.gov (United States)

    Janse Van Rensburg, Dina Christina; Schwellnus, Martin; Derman, Wayne; Webborn, Nick

    2018-05-01

    Paralympic athletes have unique preexisting medical conditions that predispose them to increased risk of illness, but data are limited to studies conducted during the last 3 Paralympic Games. This article reviews the epidemiology of illness (risk, patterns, and predictors) in Paralympic athletes and provides practical guidelines for illness prevention. The incidence rate of illness (per 1000 athlete-days) in Paralympic athletes is high in Summer (10.0-13.2) and Winter (18.7) Paralympic Games. The authors propose general and specific guidelines on preventative strategies regarding illness in these athletes. Copyright © 2018 Elsevier Inc. All rights reserved.

  4. Capital Structure, Environmental Dynamism, Innovation Strategy, and Strategic Risk Management

    DEFF Research Database (Denmark)

    Juul Andersen, Torben

    2005-01-01

    Previous research found that capital structure affects performance when it is adapted to the level of environmental dynamism and pursuit of an innovation strategy. The current study reproduces some of these relationships in a more recent dataset but also identifies significant nuances across...... industrial environments. Analyses of a large cross sectional sample and various industry sub-samples suggest that other factors have influenced capital structure effects in recent years including flexibilities in multinational organization and effective strategic risk management capabilities....

  5. On the renewal risk model under a threshold strategy

    Science.gov (United States)

    Dong, Yinghui; Wang, Guojing; Yuen, Kam C.

    2009-08-01

    In this paper, we consider the renewal risk process under a threshold dividend payment strategy. For this model, the expected discounted dividend payments and the Gerber-Shiu expected discounted penalty function are investigated. Integral equations, integro-differential equations and some closed form expressions for them are derived. When the claims are exponentially distributed, it is verified that the expected penalty of the deficit at ruin is proportional to the ruin probability.

  6. Combining standardized uptake value of FDG-PET and apparent diffusion coefficient of DW-MRI improves risk stratification in head and neck squamous cell carcinoma

    Energy Technology Data Exchange (ETDEWEB)

    Preda, Lorenzo; Summers, Paul E. [European Institute of Oncology, Department of Radiology, Milan (Italy); Conte, Giorgio; Bonello, Luke; Giannitto, Caterina; Ruju, Francesca [University of Milan, Specialisation School of Radiology, Milan (Italy); Travaini, Laura L.; Grana, Chiara [European Institute of Oncology, Department of Nuclear Medicine, Milan (Italy); Raimondi, Sara [European Institute of Oncology, Department of Epidemiology and Biostatistics, Milan (Italy); Mohssen, Ansarin [European Institute of Oncology, Department of Head and Neck Surgery, Milan (Italy); Alterio, Daniela [European Institute of Oncology, Department of Radiotherapy, Milan (Italy); Cossu Rocca, Maria [European Institute of Oncology, Department of Urogenital Cancer Medical Treatment, Milan (Italy); Bellomi, Massimo [European Institute of Oncology, Department of Radiology, Milan (Italy); University of Milan, Department of Oncology and Haematology-Oncology, Milan (Italy)

    2016-12-15

    To assess the independent prognostic value of standardized uptake value (SUV) and apparent diffusion coefficient (ADC), separately and combined, in order to evaluate if the combination of these two variables allows further prognostic stratification of patients with head and neck squamous cell carcinomas (HNSCC). Pretreatment SUV and ADC were calculated in 57 patients with HNSCC. Mean follow-up was 21.3 months. Semiquantitative analysis of primary tumours was performed using SUV{sub maxT/B}, ADC{sub mean}, ADC{sub min} and ADC{sub max}. The prognostic value of SUV{sub maxT/B}, ADC{sub mean}, ADC{sub min} and ADC{sub max} in predicting disease-free survival (DFS) was evaluated with log-rank test and Cox regression models. Patients with SUV{sub maxT/B} ≥5.75 had an overall worse prognosis (p = 0.003). After adjusting for lymph node status and diameter, SUV{sub maxT/B} and ADC{sub min} were both significant predictors of DFS with hazard ratio (HR) = 10.37 (95 % CI 1.22-87.95) and 3.26 (95 % CI 1.20-8.85) for SUV{sub maxT/B} ≥5.75 and ADC{sub min} ≥0.58 x 10{sup -3} mm{sup 2}/s, respectively. When the analysis was restricted to subjects with SUV{sub maxT/B} ≥5.75, high ADC{sub min} significantly predicted a worse prognosis, with adjusted HR = 3.11 (95 % CI 1.13-8.55). The combination of SUV{sub maxT/B} and ADC{sub min} improves the prognostic role of the two separate parameters; patients with high SUV{sub maxT/B} and high ADC{sub min} are associated with a poor prognosis. (orig.)

  7. Advances in Risk Classification and Treatment Strategies for Neuroblastoma

    Science.gov (United States)

    Pinto, Navin R.; Applebaum, Mark A.; Volchenboum, Samuel L.; Matthay, Katherine K.; London, Wendy B.; Ambros, Peter F.; Nakagawara, Akira; Berthold, Frank; Schleiermacher, Gudrun; Park, Julie R.; Valteau-Couanet, Dominique; Pearson, Andrew D.J.

    2015-01-01

    Risk-based treatment approaches for neuroblastoma have been ongoing for decades. However, the criteria used to define risk in various institutional and cooperative groups were disparate, limiting the ability to compare clinical trial results. To mitigate this problem and enhance collaborative research, homogenous pretreatment patient cohorts have been defined by the International Neuroblastoma Risk Group classification system. During the past 30 years, increasingly intensive, multimodality approaches have been developed to treat patients who are classified as high risk, whereas patients with low- or intermediate-risk neuroblastoma have received reduced therapy. This treatment approach has resulted in improved outcome, although survival for high-risk patients remains poor, emphasizing the need for more effective treatments. Increased knowledge regarding the biology and genetic basis of neuroblastoma has led to the discovery of druggable targets and promising, new therapeutic approaches. Collaborative efforts of institutions and international cooperative groups have led to advances in our understanding of neuroblastoma biology, refinements in risk classification, and stratified treatment strategies, resulting in improved outcome. International collaboration will be even more critical when evaluating therapies designed to treat small cohorts of patients with rare actionable mutations. PMID:26304901

  8. Diagnosis and Management of Waldenström Macroglobulinemia: Mayo Stratification of Macroglobulinemia and Risk-Adapted Therapy (mSMART) Guidelines 2016.

    Science.gov (United States)

    Kapoor, Prashant; Ansell, Stephen M; Fonseca, Rafael; Chanan-Khan, Asher; Kyle, Robert A; Kumar, Shaji K; Mikhael, Joseph R; Witzig, Thomas E; Mauermann, Michelle; Dispenzieri, Angela; Ailawadhi, Sikander; Stewart, A Keith; Lacy, Martha Q; Thompson, Carrie A; Buadi, Francis K; Dingli, David; Morice, William G; Go, Ronald S; Jevremovic, Dragan; Sher, Taimur; King, Rebecca L; Braggio, Esteban; Novak, Ann; Roy, Vivek; Ketterling, Rhett P; Greipp, Patricia T; Grogan, Martha; Micallef, Ivana N; Bergsagel, P Leif; Colgan, Joseph P; Leung, Nelson; Gonsalves, Wilson I; Lin, Yi; Inwards, David J; Hayman, Suzanne R; Nowakowski, Grzegorz S; Johnston, Patrick B; Russell, Steven J; Markovic, Svetomir N; Zeldenrust, Steven R; Hwa, Yi L; Lust, John A; Porrata, Luis F; Habermann, Thomas M; Rajkumar, S Vincent; Gertz, Morie A; Reeder, Craig B

    2017-09-01

    Waldenström macroglobulinemia (WM), an IgM-associated lymphoplasmacytic lymphoma, has witnessed several practice-altering advances in recent years. With availability of a wider array of therapies, the management strategies have become increasingly complex. Our multidisciplinary team appraised studies published or presented up to December 2015 to provide consensus recommendations for a risk-adapted approach to WM, using a grading system. Waldenström macroglobulinemia remains a rare, incurable cancer, with a heterogeneous disease course. The major classes of effective agents in WM include monoclonal antibodies, alkylating agents, purine analogs, proteasome inhibitors, immunomodulatory drugs, and mammalian target of rapamycin inhibitors. However, the highest-quality evidence from rigorously conducted randomized clinical trials remains scant. Recognizing the paucity of data, we advocate participation in clinical trials, if available, at every stage of WM. Specific indications exist for initiation of therapy. Outside clinical trials, based on the synthesis of available evidence, we recommend bendamustine-rituximab as primary therapy for bulky disease, profound hematologic compromise, or constitutional symptoms attributable to WM. Dexamethasone-rituximab-cyclophosphamide is an alternative, particularly for nonbulky WM. Routine rituximab maintenance should be avoided. Plasma exchange should be promptly initiated before cytoreduction for hyperviscosity-related symptoms. Stem cell harvest for future use may be considered in first remission for patients 70 years or younger who are potential candidates for autologous stem cell transplantation. At relapse, retreatment with the original therapy is reasonable in patients with prior durable responses (time to next therapy ≥3 years) and good tolerability to previous regimen. Ibrutinib is efficacious in patients with relapsed or refractory disease harboring MYD88 L265P mutation. In the absence of neuropathy, a bortezomib

  9. The contracting risks of nuclear power engineering and the risk management strategies

    International Nuclear Information System (INIS)

    Ding Shuying

    2010-01-01

    With the trend of professional operation on the nuclear power engineering (thereafter using NPE for short) construction, the companies specialized on NPE whole-contracting are established one after the other, the mode of NPE whole-contracting has been wide adopted domestically. As people always concern for the safety of nuclear power, the risks exposed to NPE contractors are also concerned with the operator, the NPE corporations and the society. Therefore, it is very meaningful to analyze on the risks exposed to NPE contractors and the strategies they should take, for it not only determines whether the NPE construction will be finished on time, but also related to sustainable development of the NPE contracting corporations. The main content of this paper includes the analysis on the features and advantages of NPE whole contracting, the major NPE contracting risks, such as nuclear safety risks, strategic risks, market risks, legal risks, financial risks and operation risks, and the strategies to prevent or to control these risks. The paper focuses on identifying those business processes which risks may frequently take place, and how to manage them, illustrating practice cases to explain the theory, in order to make reference to NPE corporations. (author)

  10. PORTFOLIO INSURANCE INVESTMENT STRATEGIES: A RISK-MANAGEMENT TOOL

    Directory of Open Access Journals (Sweden)

    Elma Agic-Sabeta

    2017-06-01

    Full Text Available Unsystemic risks in financial markets may be reduced through diversification. Systemic risks relate to the overall economy, cannot be influenced by a single company, and require special attention. Empirical research on return distributions in the long-term shows that investing under the assumption of normal distribution of returns may be dangerous. The main objectives of this article are to describe portfolio insurance strategies and investigate their advantages and disadvantages. Furthermore, their use in financial markets in both developed and emerging markets is explored, with special consideration placed on southeast European markets. Theoretical models are reviewed, including recent research articles in the field. The results are analyzed, summarized, and presented in the form of tables and graphs. The main finding of the article is identification of strategies that could be used in southeast Europe. It concludes that implementation of portfolio insurance strategies by asset managers may reduce financial risks in southeast European markets if implementation is done professionally and, simultaneously, it is monitored during the entire investment horizon.

  11. Nighttime parenting strategies and sleep-related risks to infants.

    Science.gov (United States)

    Volpe, Lane E; Ball, Helen L; McKenna, James J

    2013-02-01

    A large social science and public health literature addresses infant sleep safety, with implications for infant mortality in the context of accidental deaths and Sudden Infant Death Syndrome (SIDS). As part of risk reduction campaigns in the USA, parents are encouraged to place infants supine and to alter infant bedding and elements of the sleep environment, and are discouraged from allowing infants to sleep unsupervised, from bed-sharing either at all or under specific circumstances, or from sofa-sharing. These recommendations are based on findings from large-scale epidemiological studies that generate odds ratios or relative risk statistics for various practices; however, detailed behavioural data on nighttime parenting and infant sleep environments are limited. To address this issue, this paper presents and discusses the implications of four case studies based on overnight observations conducted with first-time mothers and their four-month old infants. These case studies were collected at the Mother-Baby Behavioral Sleep Lab at the University of Notre Dame USA between September 2002 and June 2004. Each case study provides a detailed description based on video analysis of sleep-related risks observed while mother-infant dyads spent the night in a sleep lab. The case studies provide examples of mothers engaged in the strategic management of nighttime parenting for whom sleep-related risks to infants arose as a result of these strategies. Although risk reduction guidelines focus on eliminating potentially risky infant sleep practices as if the probability of death from each were equal, the majority of instances in which these occur are unlikely to result in infant mortality. Therefore, we hypothesise that mothers assess potential costs and benefits within margins of risk which are not acknowledged by risk-reduction campaigns. Exploring why mothers might choose to manage sleep and nighttime parenting in ways that appear to increase potential risks to infants may

  12. Comparison of clinical outcomes and prognostic utility of risk stratification tools in patients with therapy-related vs de novo myelodysplastic syndromes: a report on behalf of the MDS Clinical Research Consortium.

    Science.gov (United States)

    Zeidan, A M; Al Ali, N; Barnard, J; Padron, E; Lancet, J E; Sekeres, M A; Steensma, D P; DeZern, A; Roboz, G; Jabbour, E; Garcia-Manero, G; List, A; Komrokji, R

    2017-06-01

    While therapy-related (t)-myelodysplastic syndromes (MDS) have worse outcomes than de novo MDS (d-MDS), some t-MDS patients have an indolent course. Most MDS prognostic models excluded t-MDS patients during development. The performances of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Global Prognostic System (MPSS), WHO Prognostic Scoring System (WPSS) and t-MDS Prognostic System (TPSS) were compared among patients with t-MDS. Akaike information criteria (AIC) assessed the relative goodness of fit of the models. We identified 370 t-MDS patients (19%) among 1950 MDS patients. Prior therapy included chemotherapy alone (48%), chemoradiation (31%), and radiation alone in 21%. Median survival for t-MDS patients was significantly shorter than for d-MDS (19 vs 46 months, PMDS (PMDS had a significantly higher hazard of death relative to d-MDS in every risk model, and had inferior survival compared to patients with d-MDS within all risk group categories. AIC Scores (lower is better) were 2316 (MPSS), 2343 (TPSS), 2343 (IPSS-R), 2361 (WPSS) and 2364 (IPSS). In conclusion, subsets of t-MDS patients with varying clinical outcomes can be identified using conventional risk stratification models. The MPSS, TPSS and IPSS-R provide the best predictive power.

  13. Thermal stratification in the pressurizer

    International Nuclear Information System (INIS)

    Baik, S.J.; Lee, K.W.; Ro, T.S.

    2001-01-01

    The thermal stratification in the pressurizer due to the insurge from the hot leg to the pressurizer has been studied. The insurge flow of the cold water into the pressurizer takes place during the heatup/cooldown and the normal or abnormal transients during power operation. The pressurizer vessel can undergo significant thermal fatigue usage caused by insurges and outsurges. Two-dimensional axisymmetric transient analysis for the thermal stratification in the pressurizer is performed using the computational fluid dynamics code, FLUENT, to get the velocity and temperature distribution. Parametric study has been carried out to investigate the effect of the inlet velocity and the temperature difference between the hot leg and the pressurizer on the thermal stratification. The results show that the insurge flow of cold water into the pressurizer does not mix well with hot water, and the cold water remains only in the lower portion of the pressurizer, which leads to the thermal stratification in the pressurizer. The thermal load on the pressurizer due to the thermal stratification or the cyclic thermal transient should be examined with respect to the mechanical integrity and this study can serve the design data for the stress analysis. (authors)

  14. BAYESIAN BICLUSTERING FOR PATIENT STRATIFICATION.

    Science.gov (United States)

    Khakabimamaghani, Sahand; Ester, Martin

    2016-01-01

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

  15. Combining standardized uptake value of FDG-PET and apparent diffusion coefficient of DW-MRI improves risk stratification in head and neck squamous cell carcinoma.

    Science.gov (United States)

    Preda, Lorenzo; Conte, Giorgio; Bonello, Luke; Giannitto, Caterina; Travaini, Laura L; Raimondi, Sara; Summers, Paul E; Mohssen, Ansarin; Alterio, Daniela; Cossu Rocca, Maria; Grana, Chiara; Ruju, Francesca; Bellomi, Massimo

    2016-12-01

    To assess the independent prognostic value of standardized uptake value (SUV) and apparent diffusion coefficient (ADC), separately and combined, in order to evaluate if the combination of these two variables allows further prognostic stratification of patients with head and neck squamous cell carcinomas (HNSCC). Pretreatment SUV and ADC were calculated in 57 patients with HNSCC. Mean follow-up was 21.3 months. Semiquantitative analysis of primary tumours was performed using SUV maxT/B , ADC mean , ADC min and ADC max . The prognostic value of SUV maxT/B , ADC mean , ADC min and ADC max in predicting disease-free survival (DFS) was evaluated with log-rank test and Cox regression models. Patients with SUV maxT/B ≥5.75 had an overall worse prognosis (p = 0.003). After adjusting for lymph node status and diameter, SUV maxT/B and ADC min were both significant predictors of DFS with hazard ratio (HR) = 10.37 (95 % CI 1.22-87.95) and 3.26 (95 % CI 1.20-8.85) for SUV maxT/B ≥5.75 and ADC min ≥0.58 × 10 -3 mm 2 /s, respectively. When the analysis was restricted to subjects with SUV maxT/B ≥5.75, high ADC min significantly predicted a worse prognosis, with adjusted HR = 3.11 (95 % CI 1.13-8.55). The combination of SUV maxT/B and ADC min improves the prognostic role of the two separate parameters; patients with high SUV maxT/B and high ADC min are associated with a poor prognosis. • High SUV maxT/B is a poor prognostic factor in HNSCC • High ADC min is a poor prognostic factor in HNSCC • In patients with high SUV maxT/B , high ADC min identified those with worse prognosis.

  16. The place of Political Risk Insurance in the political risk management strategy of multinational corporations

    Directory of Open Access Journals (Sweden)

    Violeta Iftinchi

    2016-06-01

    Full Text Available Confronted with a variety of political risks that affect their international activities, multinational corporations (MNCs can use Political Risk Insurance (PRI as a method to mitigate some of those risks. The aim of this article is to present the main characteristics of the PRI policies and participants, to highlight its benefits and to put forward three limitations that prevent MNCs in using PRI in their political risk management strategy (fluctuating capacity on the market, high premium rates and small compensation value. The recent trend in incorporating corporate social responsibility requirements as a pre-condition for providing PRI can contribute to lowering PRI premium rates.

  17. External Validity of a Risk Stratification Score Predicting Early Distant Brain Failure and Salvage Whole Brain Radiation Therapy After Stereotactic Radiosurgery for Brain Metastases.

    Science.gov (United States)

    Press, Robert H; Boselli, Danielle M; Symanowski, James T; Lankford, Scott P; McCammon, Robert J; Moeller, Benjamin J; Heinzerling, John H; Fasola, Carolina E; Burri, Stuart H; Patel, Kirtesh R; Asher, Anthony L; Sumrall, Ashley L; Curran, Walter J; Shu, Hui-Kuo G; Crocker, Ian R; Prabhu, Roshan S

    2017-07-01

    A scoring system using pretreatment factors was recently published for predicting the risk of early (≤6 months) distant brain failure (DBF) and salvage whole brain radiation therapy (WBRT) after stereotactic radiosurgery (SRS) alone. Four risk factors were identified: (1) lack of prior WBRT; (2) melanoma or breast histologic features; (3) multiple brain metastases; and (4) total volume of brain metastases external patient population. We reviewed the records of 247 patients with 388 brain metastases treated with SRS between 2010 at 2013 at Levine Cancer Institute. The Press (Emory) risk score was calculated and applied to the validation cohort population, and subsequent risk groups were analyzed using cumulative incidence. The low-risk (LR) group had a significantly lower risk of early DBF than did the high-risk (HR) group (22.6% vs 44%, P=.004), but there was no difference between the HR and intermediate-risk (IR) groups (41.2% vs 44%, P=.79). Total lesion volume externally valid, but the model was able to stratify between 2 levels (LR and not-LR [combined IR and HR]) for early (≤6 months) DBF. These results reinforce the importance of validating predictive models in independent cohorts. Further refinement of this scoring system with molecular information and in additional contemporary patient populations is warranted. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Coping strategies, stress and risk perception in a natural and industrial catastrophe risk situation

    International Nuclear Information System (INIS)

    Lopez Vasquez, E.

    1998-01-01

    People are exposed to different environmental risks, their manifestations harm people according to the magnitude, intensity and the number of people concerned. This subject is very ample, therefore we consider only two kinds of risks: the natural risks (especially earthquakes) that have always threatened humanity, and the industrial risks that characterise our modern society. We are interested in risk perception, stress and coping strategies in these two kinds of extreme situations. We concentrate our study on two Mexican events: an industrial explosion accident in 1984 and 1985 (big earthquake, both devastated big urban zones. The consequences were enormous at all levels: personal, psychological, social, political and economical. Facing risk situations people can have stress reactions when a sign of danger appears. According to Jean RIVOLIER (1994), these situations must not be confounded with banal events of everyday life. Stress in those cases is not the stress we confront everyday, so people have to apply other strategies to face she stress and the incidents of the kind of extreme situations. To tackle our subject we are going to review some concepts used in our study: stress, coping strategies and risk perception. (author)

  19. Cornerstones of the Austrian radon risk communication strategy

    International Nuclear Information System (INIS)

    Kunte, A.; Ringer, W.

    2015-01-01

    On behalf of the Federal Ministry of Agriculture, Forestry, Environment and Water Management (BMLFUW), the National Radon Centre of Austria developed the National Radon Risk Communication Strategy. The superior goal is the reduction of the radon exposure of Austrian citizens as well as the reduction of radon-related lung cancer deaths. Austria, like many other countries, follows the approach to raise awareness and to inform the public to achieve this goal. The presented strategy deals with the question of how radon protection issues can be communicated to the public, existing fears can be reduced and affected people can be motivated to take action (perform a radon test, if necessary, mitigate or install preventive measures in new buildings). The cornerstones of the National Radon Risk Communication Strategy can be summarized as follows: - Definition of communication goals - Identification and categorization of target groups - Development of specific key messages for each of the target groups - Determination of communication channels and assessment of their efficiency - Integration of the radon issue in education and training - Cooperation with relevant organizations and platforms. The communication objectives, target groups and communication paths (and their evaluation) will be discussed during the presentation in detail.

  20. The predictive capacity of the Glasgow-Blatchford score for the risk stratification of upper gastrointestinal bleeding in an emergency department

    Directory of Open Access Journals (Sweden)

    José Manuel Recio-Ramírez

    2015-05-01

    Full Text Available Objectives: To assess the ability of the Glasgow Blatchford Score (GBS system to identify the need for urgent upper gastrointestinal endoscopy (UGIE in patients with upper gastrointestinal bleeding (UGIB. Methods: An observational, retrospective study was carried out in all patients attended at the ER for suspected UGIB in one year. Patients were split into two categories -high-risk (>2 and low-risk (≤2- by means of the GBS system. Results: A total of 60 patients were included. Of these, 46 were classified as "high-risk" (> 2 and 14 as "low-risk" (≤ 2 subjects. The characteristics of patients in the low-risk group included: Mean age: 46.6 ± 13.7 (18-88 years. Males/females: 7/7. Urgent endoscopy revealed: normal (50%; n = 7; esophagitis (21.4%; n = 3; gastritis (14.2%; n = 2; Mallory-Weiss syndrome (7.1%; n = 1; non-bleeding varices (7.1%; n = 1. The characteristics of patients in the high-risk group included: Mean age: 68.7 ± 19.8 (31-91 years. Males/females: 30/16. Digestive endoscopy revealed: Gastric/duodenal ulcer (56.52%; n = 26; normal (17.39%; n = 8; esophagitis (8.69%; n = 4; gastritis (8.69%; n = 4; angioectasia (4.34%; n = 2; bleeding varices (4.34%; n = 2. Low-risk patients exhibited no lesions requiring urgent management during endoscopy, and the sensitivity of the GBS scale for high-risk UGIB detection was found to be 100% (95% CI: 86.27%, 99.71%, with a specificity of 48.28% (95% CI: 29.89, 67.1%. Conclusions: The GBS scale seems to accurately identify patients with low-risk UGIB, who may be managed on an outpatient basis and undergo delayed upper GI endoscopy at the outpatient clinic.

  1. ASTARTE: Assessment Strategy and Risk Reduction for Tsunamis in Europe

    Science.gov (United States)

    Baptista, M. A.; Yalciner, A. C.; Canals, M.

    2014-12-01

    Tsunamis are low frequency but high impact natural disasters. In 2004, the Boxing Day tsunami killed hundreds of thousands of people from many nations along the coastlines of the Indian Ocean. Tsunami run-up exceeded 35 m. Seven years later, and in spite of some of the best warning technologies and levels of preparedness in the world, the Tohoku-Oki tsunami in Japan dramatically showed the limitations of scientific knowledge on tsunami sources, coastal impacts and mitigation measures. The experience from Japan raised serious questions on how to improve the resilience of coastal communities, to upgrade the performance of coastal defenses, to adopt a better risk management, and also on the strategies and priorities for the reconstruction of damaged coastal areas. Societal resilience requires the reinforcement of capabilities to manage and reduce risk at national and local scales.ASTARTE (Assessment STrategy And Risk for Tsunami in Europe), a 36-month FP7 project, aims to develop a comprehensive strategy to mitigate tsunami impact in this region. To achieve this goal, an interdisciplinary consortium has been assembled. It includes all CTWPs of NEAM and expert institutions across Europe and worldwide. ASTARTE will improve i) basic knowledge of tsunami generation and recurrence going beyond simple catalogues, with novel empirical data and new statistical analyses for assessing long-term recurrence and hazards of large events in sensitive areas of NEAM, ii) numerical techniques for tsunami simulation, with focus on real-time codes and novel statistical emulation approaches, and iii) methods for assessment of hazard, vulnerability, and risk. ASTARTE will also provide i) guidelines for tsunami Eurocodes, ii) better tools for forecast and warning for CTWPs and NTWCs, and iii) guidelines for decision makers to increase sustainability and resilience of coastal communities. In summary, ASTARTE will develop basic scientific and technical elements allowing for a significant

  2. The adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for risk stratification in young APS patients with acute myocardial infarction

    DEFF Research Database (Denmark)

    Radin, M; Schreiber, K; Costanzo, P

    2017-01-01

    PL) positivity were retrospectively collected. The aGAPSS was calculated by adding the points corresponding to the risk factors, based on a linear transformation derived from the ß-regression coefficient as follows: 3 for hyperlipidaemia, 1 for arterial hypertension, 5 for aCL IgG/IgM, 4 for anti-b2 glycoprotein...... aid risk stratifying APS patients younger than 50years for the likelihood of developing coronary thrombotic events and may guide pharmacological treatment for high-risk patients....

  3. Coopetition as Support Strategy for Supply Chain Risk Management

    Directory of Open Access Journals (Sweden)

    João Batista de Camargo Junior

    2014-06-01

    Full Text Available As supply chain management research and its adoption advance, new challenges are imposed for researchers and managers. Accordingly, the supply chain risk management (SCRM has been a prominent field because it suggests strategies and action plans to mitigate these risks. On the other hand, it is observed that the coopetition concept advocates that two competing organizations can work together in some activities in the form of a strategic alliance, contributing to achieve maximum efficiency. Therefore, the purpose of this paper is to propose the extension of this concept into the activities of SCRM, treating coopetition as an action that can be added to the risk management efforts in order to make supply chains more resilient. Thus, through an exploratory literature search that uses secondary data, we drawn two propositions that deal with the possibility of adding a coopetitor to reduce risks in supply chains and on the feasibility of balanced coopetition changes the profile of a supply chain to a resilient model. Although these propositions require further empirical verification, it is believed that this is a good start for discussions about the benefits and competitive advantages that the adoption of coopetition in risk management activities in supply chains can bring to organizations.

  4. HIV and smoking: associated risks and prevention strategies

    Directory of Open Access Journals (Sweden)

    Kariuki W

    2015-12-01

    Full Text Available Wanjiku Kariuki,1 Jennifer I Manuel,2 Ngaruiya Kariuki,3 Ellen Tuchman,2 Johnnie O'Neal,4 Genevieve A Lalanne2 1University of Texas School of Public Health, Department of Management, Policy, and Community Health, Houston, TX, 2Silver School of Social Work, New York University, New York, 3Internal Medicine Department, Maimonides Medical Center, Brooklyn, 4Department of Social Work, The College of New Rochelle, New Rochelle, NY, USA Abstract: High rates of smoking among persons living with HIV (PLWH may reduce the effectiveness of HIV treatment and contribute to significant morbidity and mortality. Factors associated with smoking in PLWH include mental health comorbidity, alcohol and drug use, health-related quality of life, smoking among social networks and supports, and lack of access to care. PLWH smokers are at a higher risk of numerous HIV-associated infections and non-HIV related morbidity, including a decreased response to antiretroviral treatment, impaired immune functioning, reduced cognitive functioning, decreased lung functioning, and cardiovascular disease. Seventeen smoking cessation interventions were identified, of which seven were randomized controlled trials. The most effective studies combined behavioral and pharmacotherapy treatments that incorporated comprehensive assessments, multiple sessions, and cognitive-behavioral and motivational strategies. Smoking cessation interventions that are tailored to the unique needs of diverse samples and incorporate strategies to reduce the risk of relapse are essential to advancing health outcomes in PLWH. Keywords: HIV, AIDS, smoking, health risks, smoking cessation interventions

  5. Combustion stratification study of partially premixed combustion using Fourier transform analysis of OH* chemiluminescence images

    KAUST Repository

    Izadi Najafabadi, Mohammad

    2017-11-06

    A relatively high level of stratification (qualitatively: lack of homogeneity) is one of the main advantages of partially premixed combustion over the homogeneous charge compression ignition concept. Stratification can smooth the heat release rate and improve the controllability of combustion. In order to compare stratification levels of different partially premixed combustion strategies or other combustion concepts, an objective and meaningful definition of “stratification level” is required. Such a definition is currently lacking; qualitative/quantitative definitions in the literature cannot properly distinguish various levels of stratification. The main purpose of this study is to objectively define combustion stratification (not to be confused with fuel stratification) based on high-speed OH* chemiluminescence imaging, which is assumed to provide spatial information regarding heat release. Stratification essentially being equivalent to spatial structure, we base our definition on two-dimensional Fourier transforms of photographs of OH* chemiluminescence. A light-duty optical diesel engine has been used to perform the OH* bandpass imaging on. Four experimental points are evaluated, with injection timings in the homogeneous regime as well as in the stratified partially premixed combustion regime. Two-dimensional Fourier transforms translate these chemiluminescence images into a range of spatial frequencies. The frequency information is used to define combustion stratification, using a novel normalization procedure. The results indicate that this new definition, based on Fourier analysis of OH* bandpass images, overcomes the drawbacks of previous definitions used in the literature and is a promising method to compare the level of combustion stratification between different experiments.

  6. Usefulness of technetium-99m tetrofosmin single-photon emission computed tomography for short-term risk stratification in patients with acute chest pain in the emergency room

    International Nuclear Information System (INIS)

    Kawahito, Michitomo; Kondo, Makoto; Abe, Yoshiteru

    2003-01-01

    High-risk patients with acute coronary syndrome are difficult to distinguish from low-risk patients with chest pain in the emergency room. Technetium-99 m ( 99m Tc) tetrofosmin single-photon emission computed tomography (SPECT) was investigated to exclude high-risk patients with chest pain in the emergency room. 99m Tc-tetrofosmin SPECT was evaluated using a four-point scoring system in 228 patients (144 men, 84 women, mean age 68±12 years) with chest pain. Negative was defined as the myocardial segments with a defect score (DS) of 99m Tc-tetrofosmin; no significance (NS)), 84.9% (NS) and 60.4% (p 99m Tc-tetrofosmin SPECT is a useful method to exclude high-risk patients among patients with chest pain in the emergency room. (author)

  7. A risk stratification algorithm using non-invasive respiratory volume monitoring to improve safety when using post-operative opioids in the PACU.

    Science.gov (United States)

    Voscopoulos, Christopher; Theos, Kimberly; Tillmann Hein, H A; George, Edward

    2017-04-01

    Late detection of respiratory depression in non-intubated patients compromises patient safety. SpO 2 is a lagging indicator of respiratory depression and EtCO 2 has proven to be unreliable in non-intubated patients. A decline in minute ventilation (MV) is the earliest sign of respiratory depression. A non-invasive respiratory volume monitor (RVM) that provides accurate, continuous MV measurements enables clinicians to predict and quantify respiratory compromise. For this observational study, practitioners were blinded to the RVM measurements and pain management followed the usual routine. Patients were stratified by their MV on PACU admission and classified as "At-Risk" or "Not-At-Risk," with progression to "Low MV" status following opioids assessed for each category. The purpose was to determine if stratifying based on MV on PACU arrival could identify patients at higher risk for respiratory depression. Ability to identify in advance patients at higher risk for respiratory depression following standard opioid dosing would drive changes in pain management and improve patient care. RVM and opioid administration data from 150 PACU patients following elective joint-replacement surgery were collected in an observational study. "Predicted" MV (MV PRED ) and "Percent Predicted" (MV MEASURED /MV PRED  × 100 %) were calculated for each patient using standard formulas. Prior to opioid administration, patients were classified as either "Not-At-Risk" (MV ≥ 80 % MV PRED ) or "At-Risk" (MV safety across the continuum of care.

  8. Reflecting Societal Values in Designing Flood Risk Management Strategies

    Directory of Open Access Journals (Sweden)

    Adamson Mark

    2016-01-01

    Full Text Available In 2006, the Office of Public Works (OPW began the National Catchment-based Flood Risk Assessment and Management (CFRAM Programme through a series of pilot studies. A Multi-Criteria Analysis (MCA Framework was developed through the pilot studies that integrated a number of objectives related to a wide range of potential impacts and benefits into the core of process of appraising and selecting suitable flood risk management measures for a given area or location, and then for prioritising national investments for different schemes and projects. This MCA Framework, that provides a systematic process of developing a non-monetised but numerical indicator of benefit and impact, has since been implemented nationally in the preparation of the Flood Risk Management Plans (FRMPs. A key feature of the MCA is that it should represent societal values. To this end, nationally representative quantitative research was undertaken to determine global weights that reflect the perceived importance of each of the objectives for reducing economic, social and environmental / cultural risks in flood management strategies. Saaty’s Analytical Hierarchy Process (AHP, in conjunction with a pair-wise comparison of criteria relating to these risks, was utilised to determine weights. In excess of 1,000 structured interviews were completed where the relative importance of these objectives were assessed using a seven-point scale. The weighting given to each of the 13 specific objectives identified broadly followed expectations, with risk to people followed by risk to homes and properties being respectively the first and second most important, although some were given greater or less weighting than expected. The national application of the MCA Framework, using the weighted objectives based on this process, through the CFRAM Programme has generally lead to the identification of appropriate and, based on local consultation, acceptable options for each community.

  9. Farmers' motivations, risk perceptions and risk management strategies in a developing economy: Bangladesh experience

    DEFF Research Database (Denmark)

    Ahsan, D. A.

    2011-01-01

    and farm management training are considered among the best methods to manage the risks in the shrimp-farming business. We also observe some disparities in farmers' perceptions. For instance, farmers mentioned that removal of influence of middlemen from supply chain is essential for the betterment......Aquaculture farmers' risk perceptions and risk management strategies have still received little attention in agricultural research. Therefore, an exploratory study has been undertaken to provide empirical insight into Bangladeshi coastal shrimp farmers' risk perceptions and risk management...... and availability of quality shrimp seeds, exploitation by intermediaries and uncertainty about the future demand for shrimp in foreign markets are perceived as the most important sources of risk. On the other hand, prevention of disease, timely supply of shrimp seeds, elimination of middlemen from the supply chain...

  10. 77 FR 26292 - Risk Evaluation and Mitigation Strategy Assessments: Social Science Methodologies to Assess Goals...

    Science.gov (United States)

    2012-05-03

    ...] Risk Evaluation and Mitigation Strategy Assessments: Social Science Methodologies to Assess Goals... announcing a public workshop entitled ``Risk Evaluation and Mitigation Strategy Assessments: Social Science... constructive dialogue and information-sharing among regulators, researchers, the pharmaceutical industry...

  11. The Risk-Stratified Osteoporosis Strategy Evaluation study (ROSE)

    DEFF Research Database (Denmark)

    Rubin, Katrine Hass; Holmberg, Teresa; Rothmann, Mette Juel

    2015-01-01

    The risk-stratified osteoporosis strategy evaluation study (ROSE) is a randomized prospective population-based study investigating the effectiveness of a two-step screening program for osteoporosis in women. This paper reports the study design and baseline characteristics of the study population....... 35,000 women aged 65-80 years were selected at random from the population in the Region of Southern Denmark and-before inclusion-randomized to either a screening group or a control group. As first step, a self-administered questionnaire regarding risk factors for osteoporosis based on FRAX......(®) was issued to both groups. As second step, subjects in the screening group with a 10-year probability of major osteoporotic fractures ≥15 % were offered a DXA scan. Patients diagnosed with osteoporosis from the DXA scan were advised to see their GP and discuss pharmaceutical treatment according to Danish...

  12. [Carotid intima-media thickness distribution according to the stratification of cardiovascular risk by means of Framingham-REGICOR and score function charts].

    Science.gov (United States)

    Hermida-Ameijeiras, Á; López-Paz, J E; Riveiro-Cruz, M A; Calvo-Gómez, C

    2016-01-01

    Carotid intima-media thickness (cIMT) has been suggested as a further tool for risk function charts. The aim of this study was to describethe relationship between cIMT and cardiovascular risk (CVR) estimation according to Framingham-REGICOR and SCORE equations. Observational, cross-sectional cohort study from 362 hypertensive subjects. Demographic and clinical information were collected as well as laboratory, ultrasonographic and CVR estimation by the Framingham-REGICOR and SCORE functions. Statistical analysis was performed using SPSS software (version 20,0). To analyze the data, statistical tests such as Chi-square, T-test, ANOVA, and Pearson correlation coefficient were used. According to both functions, differences on mean cIMT were found between low CVR group and intermediate to high groups. No differences were found between intermediate and high risk groups (cIMT: 0,73mm low risk patients vs. 0,89 or 0,88mm respectively according to SCORE function and cIMT: 0,73 vs. 0,85 or 0,87mm respectively according to Framingham-REGICOR function). cIMT correlated positively with CVR estimation according to both SCORE (r=0,421; P<.01), and Framingham-REGICOR functions (r=0,363; P<.01). cIMT correlates positively with CVR estimated by SCORE and Framingham-REGICOR functions. cIMT in those subjects at intermediate risk is similar to those at high risk. Our findings highlight the importance of carotid ultrasound in identifying silent target-organ damage in those patients at intermediate CVR. Copyright © 2015 SEHLELHA. Published by Elsevier España, S.L.U. All rights reserved.

  13. Understanding risk evaluation and mitigation strategies in organ transplantation.

    Science.gov (United States)

    Gabardi, Steven

    2011-07-01

    The United States Food and Drug Administration (FDA) Amendments Act of 2007 mandated that Risk Evaluation and Mitigation Strategies (REMS) be required of manufacturers. These REMS are strategies implemented to manage known or potential risks associated with drugs and to ensure ongoing pharmacovigilance throughout the life of a pharmaceutical product, including once the product becomes available as generic. The elements of an individual REMS program consist of three levels: medication guide or patient package insert, communication plan, and elements to assure safe use (ETASU). A medication guide or patient package insert is used to help prevent serious adverse events, aid in patient decision making, and enhance drug adherence. Communication plans are used to educate health care providers and to encourage their compliance with REMS. The ETASU is a restrictive process that is implemented when it is deemed necessary to ensure that patients have safe access to products with known serious risks that would otherwise be unavailable. To review the components of REMS and specifically assess their impact on health care providers practicing within the organ transplantation arena, a literature search of the MEDLINE database (January 2007-December 2010) was performed, and published materials from the FDA and its Web site were also reviewed. In transplantation, REMS programs exist for both everolimus (medication guide and communication plan) and sirolimus (medication guide). The FDA has stated that all mycophenolic acid derivatives will be subject to a proposed REMS that has not yet been approved; however, both branded mycophenolic acid agents already have approved medication guides. The REMS are a permanent fixture in the development and marketing of pharmaceutical agents, and their further implementation in solid organ transplantation is inevitable. Transplantation providers should take a proactive role in patient education and implementation of REMS within the therapeutic area

  14. PCA-based polling strategy in machine learning framework for coronary artery disease risk assessment in intravascular ultrasound: A link between carotid and coronary grayscale plaque morphology.

    Science.gov (United States)

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

    2016-05-01

    Percutaneous coronary interventional procedures need advance planning prior to stenting or an endarterectomy. Cardiologists use intravascular ultrasound (IVUS) for screening, risk assessment and stratification of coronary artery disease (CAD). We hypothesize that plaque components are vulnerable to rupture due to plaque progression. Currently, there are no standard grayscale IVUS tools for risk assessment of plaque rupture. This paper presents a novel strategy for risk stratification based on plaque morphology embedded with principal component analysis (PCA) for plaque feature dimensionality reduction and dominant feature selection technique. The risk assessment utilizes 56 grayscale coronary features in a machine learning framework while linking information from carotid and coronary plaque burdens due to their common genetic makeup. This system consists of a machine learning paradigm which uses a support vector machine (SVM) combined with PCA for optimal and dominant coronary artery morphological feature extraction. Carotid artery proven intima-media thickness (cIMT) biomarker is adapted as a gold standard during the training phase of the machine learning system. For the performance evaluation, K-fold cross validation protocol is adapted with 20 trials per fold. For choosing the dominant features out of the 56 grayscale features, a polling strategy of PCA is adapted where the original value of the features is unaltered. Different protocols are designed for establishing the stability and reliability criteria of the coronary risk assessment system (cRAS). Using the PCA-based machine learning paradigm and cross-validation protocol, a classification accuracy of 98.43% (AUC 0.98) with K=10 folds using an SVM radial basis function (RBF) kernel was achieved. A reliability index of 97.32% and machine learning stability criteria of 5% were met for the cRAS. This is the first Computer aided design (CADx) system of its kind that is able to demonstrate the ability of coronary

  15. Ibrutinib-associated bleeding: pathogenesis, management and risk reduction strategies.

    Science.gov (United States)

    Shatzel, J J; Olson, S R; Tao, D L; McCarty, O J T; Danilov, A V; DeLoughery, T G

    2017-05-01

    Ibrutinib is an irreversible inhibitor of Bruton's tyrosine kinase (Btk) that has proven to be an effective therapeutic agent for multiple B-cell-mediated lymphoproliferative disorders. Ibrutinib, however, carries an increased bleeding risk compared with standard chemotherapy. Bleeding events range from minor mucocutaneous bleeding to life-threatening hemorrhage, due in large part to the effects of ibrutinib on several distinct platelet signaling pathways. There is currently a minimal amount of data to guide clinicians regarding the use of ibrutinib in patients at high risk of bleeding or on anticoagulant or antiplatelet therapy. In addition, the potential cardiovascular protective effects of ibrutinib monotherapy in patients at risk of vascular disease are unknown. Patients should be cautioned against using non-steroidal anti-inflammatory drugs, fish oils, vitamin E and aspirin-containing products, and consider replacing ibrutinib with a different agent if dual antiplatelet therapy is indicated. Patients should not take vitamin K antagonists concurrently with ibrutinib; direct oral anticoagulants should be used if extended anticoagulation is strongly indicated. In this review, we describe the pathophysiology of ibrutinib-mediated bleeding and suggest risk reduction strategies for common clinical scenarios associated with ibrutinib. © 2017 International Society on Thrombosis and Haemostasis.

  16. Complications of thoracentesis: incidence, risk factors, and strategies for prevention.

    Science.gov (United States)

    Cantey, Eric P; Walter, James M; Corbridge, Thomas; Barsuk, Jeffrey H

    2016-07-01

    Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema. Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study. Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.

  17. Blood transfusion risks and alternative strategies in pediatric patients.

    Science.gov (United States)

    Lavoie, Josée

    2011-01-01

    Although the safety of the blood supply has been greatly improved, there still remain both infectious and noninfectious risks to the patient. The incidence of noninfectious transfusion reactions is greater than that of infectious complications. Furthermore, the mortality associated with noninfectious risks is significantly higher. In fact, noninfectious risks account for 87-100% of fatal complications of transfusions. It is concerning to note that the majority of pediatric reports relate to human error such as overtransfusion and lack of knowledge of special requirements in the neonatal age group. The second most frequent category is acute transfusion reactions, majority of which are allergic in nature. It is estimated that the incidence of adverse outcome is 18:100,000 red blood cells issued for children aged less than 18 years and 37:100,000 for infants. The comparable adult incidence is 13:100,000. In order to decrease the risks associated with transfusion of blood products, various blood-conservation strategies can be utilized. Modalities such as acute normovolemic hemodilution, hypervolemic hemodilution, deliberate hypotension, antifibrinolytics, intraoperative blood salvage, and autologous blood donation are discussed and the pediatric literature is reviewed. A discussion of transfusion triggers, and algorithms as well as current research into alternatives to blood transfusions concludes this review. © 2010 Blackwell Publishing Ltd.

  18. Mycophenolate fetal toxicity and risk evaluation and mitigation strategies.

    Science.gov (United States)

    Kim, M; Rostas, S; Gabardi, S

    2013-06-01

    The mycophenolic acid (MPA) preparations are one of the most commonly used immunosuppressants in the United States. However, these agents carry a black box warning regarding their use during pregnancy due to an association with increased risk of miscarriage and congenital defects. To ensure that the benefits of MPA outweigh the risks, the Food and Drug Administration (FDA) required all manufacturers of MPA products to propose risk evaluation and mitigation strategies (REMS). Four years after initially calling for proposals, the FDA approved a single shared REMS system in September 2012. The elements of the MPA REMS include a medication guide and elements to assure safe use (ETASU). The medication guide, which was previously FDA-approved in 2008, should continue to be distributed to patients, and the ETASU requires physicians to complete training and obtain patient signatures on the "Patient-Prescriber Acknowledgement Form." A single, national, voluntary pregnancy registry is available, and pregnant patients should be encouraged to participate. Although the impact of the MPA REMS on clinical practice is not clear, it is a step toward increasing the understanding of fetal risks with MPA products among patients and possibly practitioners. © Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.

  19. Risk evaluation and mitigation strategies (REMS): educating the prescriber.

    Science.gov (United States)

    Nicholson, Susan C; Peterson, Janet; Yektashenas, Behin

    2012-02-01

    The US FDA Amendments Act of 2007 was signed into law on 27 September 2007. A provision of this law granted the FDA new powers to enhance drug safety by requiring the pharmaceutical industry to develop Risk Evaluation and Mitigation Strategies (REMS). REMS are deemed necessary when a question exists as to whether the benefits of a drug outweigh its risks. REMS constitute a safety plan with several potential components, including a medication guide, a communication plan, elements to ensure safe use and an implementation system to help guide the prescribers, pharmacists and patients. This applies to existing drugs on the market, new drug applications (NDAs), abbreviated NDAs (generics) and biologics licence applications. REMS represent an 'upgrade' from previously required risk minimization action plans, based on the strengthening of FDA powers of authority and enforceability to incur monetary penalties against individuals representing the pharmaceutical industry who fail to comply. For illustrative purposes, we chose the drug romiplostim (Nplate®) to present an REMS, as all components were utilized to help assuage risks associated with the drug. Romiplostim is an FDA-approved drug used to treat thrombocytopenia in patients with chronic immune (idiopathic) thrombocytopenic purpura that has a significant adverse safety profile based on the risk of changes in bone marrow reticulin formation and bone marrow fibroses, and other associated risks. This review of current REMS policy is intended to provide the prescriber with a better understanding of current modalities in FDA-mandated drug safety programmes, which will impact day-to-day healthcare provider practices.

  20. [The role of biochemical markers of myocardial damage in clinical practice: the diagnosis of infarct and risk stratification. The Intersociety Interdisciplinary Study Group of the ANMCO-SIBioC-SIMeL, Markers of Muocardial Lesions. L'Associazione Nazionale Medici Cardiologi Ospedalieri-Società Italiana di Biochimica Clinica-Società Italiana di Medicina di Laboratorio].

    Science.gov (United States)

    Ottani, F; Galvani, M; Panteghini, M; Dolci, A; Plebani, M; Tubaro, M; Zaninotto, M

    2000-01-01

    For many years creatine kinase (CK) and CK-MB isoenzymes were used together with the ECG to confirm the presence of myocardial infarction. During the last decade newer cardiac markers have been introduced and immunological test systems developed for their quantification. Among these new markers, a prominent role has emerged for cardiac troponins (T or I). These technological advanced assays have shown greater sensitivity compared to "conventional cardiac enzymes;, thereby identifying patients with small--at times, microscopic--infarcts who would not have met defining criteria for myocardial infarction in an earlier era. Another major advantage shown by both cardiac troponins with respect to "conventional cardiac enzymes" is their ability to predict clinical outcome over a short- or long-term follow-up in patients with acute coronary syndromes, and this appears to be particularly relevant in patients with micronecrosis, who constitute a high-risk subgroup of unstable angina patients. Recently, myoglobin has also been widely applied as a marker. Although lacking in myocardial specificity, it is the earliest marker to show an increase after coronary occlusion. Thus, the combined use of myoglobin and a cardiospecific structural protein such as troponin T or I may prove an attractive strategy for biochemical testing in chest pain patients. With the routine use of these novel cardiac markers, fascinating opportunities are now open in the field of diagnostic classification (making the World Health Organization definition of myocardial infarction obsolete) and risk stratification in chest pain patients; opportunities that were unforeseen in the era of cardiac enzymes. However, the use of these markers has also posed some important questions on: a) the best and most cost-effective diagnostic strategy in chest pain patients; b) the remaining role of cardiac enzymes; c) the therapeutic consequences of a positive test result.

  1. Landslide risk reduction strategies: an inventory for the Global South

    Science.gov (United States)

    Maes, Jan; Kervyn, Matthieu; Vranken, Liesbet; Dewitte, Olivier; Vanmaercke, Matthias; Mertens, Kewan; Jacobs, Liesbet; Poesen, Jean

    2015-04-01

    Landslides constitute a serious problem globally. Moreover, landslide impact remains underestimated especially in the Global South. It is precisely there where the largest impact is experienced. An overview of measures taken to reduce risk of landslides in the Global South is however still lacking. Because in many countries of the Global South disaster risk reduction (DRR) is at an emerging stage, it is crucial to monitor the ongoing efforts (e.g. discussions on the Post-2015 Framework for DRR). The first objective of this study is to make an inventory of techniques and strategies that are applied to reduce risk from landslides in tropical countries. The second objective is to investigate what are the main bottlenecks for implementation of DRR strategies. In order to achieve these objectives, a review of both scientific and grey literature was conducted, supplemented with expert knowledge. The compilation of recommended and implemented DRR measures from landslide-prone tropical countries is based on an adapted classification proposed by the SafeLand project. According to Vaciago (2013), landslide risk can be reduced by either reducing the hazard, the vulnerability, the number or value of elements at risk or by sharing the residual risk. In addition, these measures can be combined with education and/or awareness raising and are influenced by governance structures and cultural beliefs. Global landslide datasets have been used to identify landslide-prone countries, augmented with region-specific datasets. Countries located in the tropics were selected in order to include landslide-prone countries with a different Human Development Index (HDI) but with a similar climate. Preliminary results support the statement made by Anderson (2013) that although the importance of shifting from post-disaster emergency actions to pre-disaster mitigation is acknowledged, in practice this paradigm shift seems rather limited. It is expected that this is especially the case in countries

  2. Developing Hydrogeological Site Characterization Strategies based on Human Health Risk

    Science.gov (United States)

    de Barros, F.; Rubin, Y.; Maxwell, R. M.

    2013-12-01

    In order to provide better sustainable groundwater quality management and minimize the impact of contamination in humans, improved understanding and quantification of the interaction between hydrogeological models, geological site information and human health are needed. Considering the joint influence of these components in the overall human health risk assessment and the corresponding sources of uncertainty aid decision makers to better allocate resources in data acquisition campaigns. This is important to (1) achieve remediation goals in a cost-effective manner, (2) protect human health and (3) keep water supplies clean in order to keep with quality standards. Such task is challenging since a full characterization of the subsurface is unfeasible due to financial and technological constraints. In addition, human exposure and physiological response to contamination are subject to uncertainty and variability. Normally, sampling strategies are developed with the goal of reducing uncertainty, but less often they are developed in the context of their impacts on the overall system uncertainty. Therefore, quantifying the impact from each of these components (hydrogeological, behavioral and physiological) in final human health risk prediction can provide guidance for decision makers to best allocate resources towards minimal prediction uncertainty. In this presentation, a multi-component human health risk-based framework is presented which allows decision makers to set priorities through an information entropy-based visualization tool. Results highlight the role of characteristic length-scales characterizing flow and transport in determining data needs within an integrated hydrogeological-health framework. Conditions where uncertainty reduction in human health risk predictions may benefit from better understanding of the health component, as opposed to a more detailed hydrogeological characterization, are also discussed. Finally, results illustrate how different dose

  3. Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis.

    Science.gov (United States)

    Singh, Sukhchain; Sethi, Ankur; Singh, Mukesh; Khosla, Kavia; Grewal, Navsheen; Khosla, Sandeep

    2015-08-01

    Association of inter-arm systolic blood pressure difference (IASBPD) with cardiovascular (CV) morbidity and mortality remains controversial. We aimed to thoroughly examine all available evidence on inter-limb blood pressure (BP) difference and its association with CV risk and outcomes. We searched PubMed, EMBASE, CINAHL, Cochrane library, and Ovid for studies reporting bilateral simultaneous BP measurements in arms or legs and risk of peripheral arterial disease (PAD), coronary artery disease, cerebrovascular disease, subclavian stenosis, or mortality. Random-effect meta-analysis was performed to compare effect estimates. Twenty-seven studies met inclusion criteria, but only 17 studies (18 cohorts) were suitable for analysis. IASBPD of 10 mmHg or more was associated with PAD (risk ratios, 2.22; 1.41-3.5; P = .0006; sensitivity 16.6%; 6.7-35.4; specificity 91.9%; 83.1-96.3; 8 cohorts; 4774 subjects), left ventricular mass index (standardized mean difference 0.21; 0.03-0.39; P = .02; 2 cohort; 1604 subjects), and brachial-ankle pulse wave velocity (PWV) (one cohort). Association of PAD remained significant at cutoff of 15 mmHg (risk ratios, 1.91; 1.28-2.84; P = .001; 5 cohorts; 1914 subjects). We could not find statistically significant direct association of coronary artery disease, cerebrovascular disease, CV, and all-cause mortality in subjects with IASBPD of 10 mmHg or more, 15 mmHg or more, and inter-leg systolic BP difference of 15 mmHg or more. Inter-leg BP difference of 15 mmHg or more was strong predictor of PAD (P = .0001) and brachial-ankle PWV (P = .0001). Two invasive studies showed association of IASBPD and subclavian stenosis (estimates could not be combined). In conclusion, inter-arm and leg BP differences are strong predictors of PAD. IASBPD may be associated with subclavian stenosis, high left ventricular mass effect, and higher brachial-ankle PWVs. Inter-leg BP difference may also be associated with high left ventricular mass effect and higher

  4. Risk Stratification for the Development of Respiratory Adverse Events Following Vascular Surgery Using the Society of Vascular Surgery’s Vascular Quality Initiative

    Science.gov (United States)

    Genovese, Elizabeth A; Fish, Larry; Chaer, Rabih A; Makaroun, Michel S; Baril, Donald T

    2017-01-01

    Objective Post-operative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication and the overall impact of RAEs on patient outcomes. Methods The Vascular Quality Initiative was queried (2003–2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm (AAA) repair, thoracic endovascular aortic repair (TEVAR), suprainguinal bypass or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables and other post-operative adverse events. Results The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (CHF) (9.9%), chronic obstructive pulmonary disease (COPD) requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open AAA repairs (17.6%), in-situ suprainguinal bypasses (9.68%) and TEVARs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, CHF severity, COPD severity, degree of renal insufficiency

  5. Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative.

    Science.gov (United States)

    Genovese, Elizabeth A; Fish, Larry; Chaer, Rabih A; Makaroun, Michel S; Baril, Donald T

    2017-02-01

    Postoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes. The Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events. The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary

  6. Assessment of Risk Evaluation and Mitigation Strategies in Oncology: Summary of the Oncology Risk Evaluation and Mitigation Strategies Workshop

    Science.gov (United States)

    Frame, James N.; Jacobson, Joseph O.; Vogel, Wendy H.; Griffith, Niesha; Wariabharaj, Darshan; Garg, Rekha; Zon, Robin; Stephens, Cyntha L.; Bialecki, Alison M.; Bruinooge, Suanna S.; Allen, Steven L.

    2013-01-01

    To address oncology community stakeholder concerns regarding implementation of the Risk Evaluation and Mitigation Strategies (REMS) program, ASCO sponsored a workshop to gather REMS experiences from representatives of professional societies, patient organizations, pharmaceutical companies, and the US Food and Drug Administration (FDA). Stakeholder presentations and topical panel discussions addressed REMS program development, implementation processes, and practice experiences, as well as oncology drug safety processes. A draft REMS decision tool prepared by the ASCO REMS Steering Committee was presented for group discussion with facilitated, goal-oriented feedback. The workshop identified several unintended consequences resulting from current oncology REMS: (1) the release of personal health information to drug sponsors as a condition for gaining access to a needed drug; (2) risk information that is not tailored—and therefore not accessible—to all literacy levels; (3) exclusive focus on drug risk, thereby affecting patient-provider treatment discussion; (4) REMS elements that do not consider existing, widely practiced oncology safety standards, professional training, and experience; and (5) administrative burdens that divert the health care team from direct patient care activities and, in some cases, could limit patient access to important therapies. Increased provider and professional society participation should form the basis of ongoing and future REMS standardization discussions with the FDA to work toward overall improvement of risk communication. PMID:23814522

  7. Communicating cardiovascular disease risk: an interview study of General Practitioners' use of absolute risk within tailored communication strategies.

    Science.gov (United States)

    Bonner, Carissa; Jansen, Jesse; McKinn, Shannon; Irwig, Les; Doust, Jenny; Glasziou, Paul; McCaffery, Kirsten

    2014-05-29

    Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs' descriptions of their CVD risk communication strategies, including the role of absolute risk. Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour. GPs used absolute CVD risk within three different communication strategies: 'positive', 'scare tactic', and 'indirect'. A 'positive' strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A 'scare tactic' strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to 'scare' them into taking action. An 'indirect' strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations. This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.

  8. Diagnosis and treatment strategies of thrombophilic risk factors

    Directory of Open Access Journals (Sweden)

    Murat Albayrak

    2010-09-01

    Full Text Available Thrombophilia is defined as the general name for a group of genetic and acquired situations, arising from defects of hemostasis mechanism and generating tendency to thrombosis. Examples of the acquired risk factors that increase the tendency to thrombosis are venous catheters, sepsis, surgery, hyperlipidemia, congestive heart disease, increased lipoprotein a, old age, antiphospholipid syndrome, nephrotic syndrome, hyperviscosity, chronic myeloproliferative neoplasms, paroxysmal nocturnal hemoglobinuria, heparin induced thrombocytopenia, vasculitis, immobility, obesity, major surgery, trauma, burns, malignancy, pregnancy and oral contraceptive usage. Genetic tendency to venous thromboembolism in early ages, even without any known cause, is named as thrombophilia. Factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase gene mutations, factor VIII elevation, protein C, protein S and antithrombin deficiency parameters are suggested for evaluation, in patient groups suspected of inherited thrombophilia. Detection of inherited thrombophilic factors in selected patient groups is a guide in developing treatment strategies and in establishing prognosis. Due to the genetic heterogeneities, each society should determine their thrombophilic risk pool. Thus, with the determination of the risk factors, unnecessary assessments will be prevented and a cost-effective approach can be developed.

  9. Multilayer fabric stratification pipes for solar tanks

    DEFF Research Database (Denmark)

    Andersen, Elsa; Furbo, Simon; Fan, Jianhua

    2007-01-01

    The thermal performance of solar heating systems is strongly influenced by the thermal stratification in the heat storage. The higher the degree of thermal stratification is, the higher the thermal performance of the solar heating systems. Thermal stratification in water storages can for instance...

  10. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project).

    Science.gov (United States)

    Goodenough, Christopher J; Ko, Tien C; Kao, Lillian S; Nguyen, Mylan T; Holihan, Julie L; Alawadi, Zeinab; Nguyen, Duyen H; Flores, Juan R; Arita, Nestor T; Roth, J Scott; Liang, Mike K

    2015-04-01

    Ventral incisional hernias (VIH) develop in up to 20% of patients after abdominal surgery. No widely applicable preoperative risk-assessment tool exists. We aimed to develop and validate a risk-assessment tool to predict VIH after abdominal surgery. A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008 to 2010. Variables were defined in accordance with the National Surgical Quality Improvement Project, and VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008 to 2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC). Of 625 patients followed for a median of 41 months (range 0.3 to 64 months), 93 (13.9%) developed a VIH. The training cohort (n = 428, VIH = 70, 16.4%) identified 4 independent predictors: laparotomy (HR 4.77, 95% CI 2.61 to 8.70) or hand-assisted laparoscopy (HAL, HR 4.00, 95% CI 2.08 to 7.70), COPD (HR 2.35; 95% CI 1.44 to 3.83), and BMI ≥ 25 kg/m(2) (HR1.74; 95% CI 1.04 to 2.91). Factors that were not predictive included age, sex, American Society of Anesthesiologists (ASA) score, albumin, immunosuppression, previous surgery, and suture material or technique. The predictive score had an AUC = 0.77 (95% CI 0.68 to 0.86) using the validation cohort (n = 197, VIH = 23, 11.6%). Using the HERNIAscore: HERNIAscore = 4(∗)Laparotomy+3(∗)HAL+1(∗)COPD+1(∗) BMI ≥ 25, 3 classes stratified the risk of VIH: class I (0 to 3 points),5.2%; class II (4 to 5 points),19.6%; and class III (6 points), 55.0%. The HERNIAscore accurately identifies patients at increased risk for VIH. Although external validation is needed, this provides a starting point to counsel patients and guide

  11. Quantitative stratification of diffuse parenchymal lung diseases.

    Directory of Open Access Journals (Sweden)

    Sushravya Raghunath

    Full Text Available 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.

  12. Quantitative Stratification of Diffuse Parenchymal Lung Diseases

    Science.gov (United States)

    Raghunath, Sushravya; Rajagopalan, Srinivasan; Karwoski, Ronald A.; Maldonado, Fabien; Peikert, Tobias; Moua, Teng; Ryu, Jay H.; Bartholmai, Brian J.; Robb, Richard A.

    2014-01-01

    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

  13. The first Latin-American risk stratification system for cardiac surgery: can be used as a graphic pocket-card score.

    Science.gov (United States)

    Carosella, Victorio C; Navia, Jose L; Al-Ruzzeh, Sharif; Grancelli, Hugo; Rodriguez, Walter; Cardenas, Cesar; Bilbao, Jorge; Nojek, Carlos

    2009-08-01

    This study aims to develop the first Latin-American risk model that can be used as a simple, pocket-card graphic score at bedside. The risk model was developed on 2903 patients who underwent cardiac surgery at the Spanish Hospital of Buenos Aires, Argentina, between June 1994 and December 1999. Internal validation was performed on 708 patients between January 2000 and June 2001 at the same center. External validation was performed on 1087 patients between February 2000 and January 2007 at three other centers in Argentina. In the development dataset the area under receiver operating characteristics (ROC) curve was 0.73 and the Hosmer-Lemeshow (HL) test was P=0.88. In the internal validation ROC curve was 0.77. In the external validation ROC curve was 0.81, but imperfect calibration was detected because the observed in-hospital mortality (3.96%) was significantly lower than the development dataset (8.20%) (Pgraphic pocket-card score allows an easy bedside application with acceptable statistic precision.

  14. Educational strategies to reduce risk: a choice of social responsibility

    Directory of Open Access Journals (Sweden)

    Federica La Longa

    2012-07-01

    Full Text Available This study develops the critical reflections of the activities for information, training and education that have been conducted by a group of researchers of the Istituto Nazionale di Geofisica e Vulcanologia in recent years. In particular, from an epistemological point of view, our analysis involves: (i science outreach, the link between science and the world; (ii science teaching and its role in the contact between science and schools; and (iii risk education, seen as a process that can develop a culture of risk in relation to the territory in which we live. These issues are critically analyzed on the basis of experience gained since 1995. The educational methodologies tested in ‘peacetime’ (in the absence of seismic events with the EDURISK Project are compared with those experienced during an emergency in Abruzzo, Italy. Today, we increasingly refer to prevention as the primary strategy of defense against risk. However, very often the responsibility of prevention falls on others, such as the government, institutions and/or local authorities. The citizens then perceive themselves as powerless against the inevitability of natural events, and they refer to these ‘rulers’ for the implementation of effective prevention policies. So, as researchers, what are the most effective actions we can take to influence risk reduction and to motivate the choices of the people? Must the effectiveness of our interventions be based on scientific information or on specific training, or must it be reached through the development of values, actions and awareness? Must our interventions be oriented and developed to inform, to train or to educate?

  15. Risk stratification for avascular necrosis of the femoral head after internal fixation of femoral neck fractures by post-operative SPECT/CT

    Energy Technology Data Exchange (ETDEWEB)

    Han, Sang Won; Oh, Min Young; Yoon, Seok Ho; Kim, Jin Soo; Chang, Jae Suk; Ryu, Jin Sook [Asan Medical CenterUniversity of Ulsan College of Medicine, Seoul (Korea, Republic of); Kim, Ji Wan [Dept. of Orthopedic Surgery, Haeundae Paik Hospital, Inje University, Busan (Korea, Republic of)

    2017-03-15

    Avascular necrosis (AVN) of the femoral head is a major complication after internal fixation of a femoral neck fracture and determines the functional prognosis. We investigated postoperative bone single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing the risk of femoral head AVN. We retrospectively reviewed 53 consecutive patients who underwent bone SPECT/CT within 2 weeks of internal fixation of a femoral neck fracture and follow-up serial hip radiographs over at least 12 months. Nine patients developed femoral head AVN. In 15 patients who showed normal uptake on immediate postoperative SPECT/CT, no AVN occurred, whereas 9 of 38 patients who showed cold defects of the femoral head later developed AVN. The negative predictive value of immediate postoperative SPECT/CT for AVN was 100 %, whereas the positive predictive value was 24 %. Among 38 patients with cold defects, 1 developed AVN 3 months postoperatively. A follow-up bone SPECT/CT was performed in the other 37 patients at 2–10 months postoperatively. The follow-up bone SPECT/CT revealed completely normalized femoral head uptake in 27, partially normalized uptake in 8, and persistent cold defects in 2 patients. AVN developed in 3.7 % (1/27), 62.5 % (5/8), and 100 % (2/2) of each group, respectively. According to the time point of imaging, radiotracer uptake patterns of the femoral head on postoperative bone SPECT/CT indicate the risk of AVN after internal fixation of femoral neck fractures differently. Postoperative bone SPECT/CT may help orthopedic surgeons determine the appropriate follow-up of these patients.

  16. Risk stratification for avascular necrosis of the femoral head after internal fixation of femoral neck fractures by post-operative SPECT/CT

    International Nuclear Information System (INIS)

    Han, Sang Won; Oh, Min Young; Yoon, Seok Ho; Kim, Jin Soo; Chang, Jae Suk; Ryu, Jin Sook; Kim, Ji Wan

    2017-01-01

    Avascular necrosis (AVN) of the femoral head is a major complication after internal fixation of a femoral neck fracture and determines the functional prognosis. We investigated postoperative bone single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing the risk of femoral head AVN. We retrospectively reviewed 53 consecutive patients who underwent bone SPECT/CT within 2 weeks of internal fixation of a femoral neck fracture and follow-up serial hip radiographs over at least 12 months. Nine patients developed femoral head AVN. In 15 patients who showed normal uptake on immediate postoperative SPECT/CT, no AVN occurred, whereas 9 of 38 patients who showed cold defects of the femoral head later developed AVN. The negative predictive value of immediate postoperative SPECT/CT for AVN was 100 %, whereas the positive predictive value was 24 %. Among 38 patients with cold defects, 1 developed AVN 3 months postoperatively. A follow-up bone SPECT/CT was performed in the other 37 patients at 2–10 months postoperatively. The follow-up bone SPECT/CT revealed completely normalized femoral head uptake in 27, partially normalized uptake in 8, and persistent cold defects in 2 patients. AVN developed in 3.7 % (1/27), 62.5 % (5/8), and 100 % (2/2) of each group, respectively. According to the time point of imaging, radiotracer uptake patterns of the femoral head on postoperative bone SPECT/CT indicate the risk of AVN after internal fixation of femoral neck fractures differently. Postoperative bone SPECT/CT may help orthopedic surgeons determine the appropriate follow-up of these patients

  17. European environmental stratifications and typologies

    DEFF Research Database (Denmark)

    Hazeu, G.W,; Metzger, M.J.; Mücher, C.A.

    2011-01-01

    their limitations and challenges. As such, they provide a sound basis for describing the factors affecting the robustness of such datasets. The latter is especially relevant, since there is likely to be further interest in European environmental assessment. In addition, advances in data availability and analysis......A range of new spatial datasets classifying the European environment has been constructed over the last few years. These datasets share the common objective of dividing European environmental gradients into convenient units, within which objects and variables of interest have relatively homogeneous...... scale. This paper provides an overview of five recent European stratifications and typologies, constructed for contrasting objectives, and differing in spatial and thematic detail. These datasets are: the Environmental Stratification (EnS), the European Landscape Classification (LANMAP), the Spatial...

  18. Risk assessment for the intentional depressurization strategy in PWRs

    International Nuclear Information System (INIS)

    Dingman, S.E.

    1994-03-01

    An accident management strategy has been proposed in which the reactor coolant system is intentionally depressurized during an accident. The aim is to reduce the containment pressurization that would result from high pressure ejection of molten debris at vessel breach. Probabilistic risk assessment (PRA) methods were used to evaluate this strategy for the Surry nuclear power plant. Sensitivity studies were conducted using event trees that were developed for the NUREG-1150 study. It was found that depressurization (intentional or unintentional) had minimal impact on the containment failure probability at vessel breach for Surry because the containment loads assessed for NUREG-1150 were not a great threat to the containment survivability. An updated evaluation of the impact of intentional depressurization on the probability of having a high pressure melt ejection was then made that reflected analyses that have been performed since NUREG-1150 was completed. The updated evaluation confirmed the sensitivity study conclusions that intentional depressurization has minimal impact on the probability of a high pressure melt ejection. The updated evaluation did show a slight benefit from depressurization because depressurization delayed core melting, which led to a higher probability of recovering emergency core coolant injection, thereby arresting the core damage

  19. Heterogeneity of PTEN and ERG expression in prostate cancer on core needle biopsies: implications for cancer risk stratification and biomarker sampling.

    Science.gov (United States)

    Shah, Rajal B; Bentley, James; Jeffery, Zach; DeMarzo, Angelo M

    2015-05-01

    ERG and PTEN biomarkers are increasingly being analyzed on prostate core biopsies (NBXs); ERG as a marker of clonality and number of separately arising tumor foci and PTEN for prognostic information. Yet, in patients with multiple biopsy cores positive for cancer (PCa), there is no standardized approach for interrogation of these biomarkers in terms of the number of positive cores to evaluate. A total of 194 NBX cases containing more than one positive core with cancer were evaluated for ERG overexpression and PTEN loss by immunostaining (immunohistochemistry) of all positive cores. ERG overexpression or PTEN loss in at least one cancer core was present in 111 (57%) and 69 (36%) cases respectively. ERG overexpression was significantly associated with PTEN loss (P < .0001), and PTEN loss was associated with a high Gleason score (P < .0001). Inter- and intra-tumor core staining heterogeneity for ERG overexpression occurred in 42% and 5% cases and for PTEN loss both intra- and inter-tumor core heterogeneity was 68%. PTEN staining was highly discordant between PCa sites regardless of laterality. When the Gleason score was non-uniform across PCa sites, the combination of cores showing the highest Gleason score and largest tumor volume provided the best representation of ERG overexpression (92%) and PTEN loss (98%). When grades were uniform across cancer sites, the highest tumor volume core was generally representative of ERG overexpression (90%) but was less representative for PTEN loss (76%). Our results suggest that knowledge of this heterogeneity is critical for developing optimal yet cost-effective strategies to identify these underlying molecular abnormalities. Copyright © 2015 Elsevier Inc. All rights reserved.

  20. Can metabolic tumor parameters on primary staging 18F-FDG PET/CT aid in risk stratification of primary central nervous system lymphomas for patient management as a prognostic model?

    Science.gov (United States)

    Okuyucu, K; Alagoz, E; Ince, S; Ozaydin, S; Arslan, N

    Primary central nervous system (CNS) lymphoma is an aggressive and fatal extranodal non-Hodgkin lymphoma jailed in CNS at initial diagnosis. Its prognosis is poor and the disease has a fatal outcome when compared with systemic non-Hodgkin lymphoma. A few baseline risk stratification scoring systems have been suggested to estimate the prognosis mainly based on serum lactate dehydrogenase level,age, Karnofsky performance score, involvement of deep brain structures and cerebrospinal fluid protein concentration. 18 F-FDG PET/CT has a high prognostic value with respect to overall survival and disease-free survival in many cancers and lymphomas. We aimed to investigate metabolic tumor indexes on primary staging 18 F-FDG PET/CT as prognostic markers in primary CNS lymphoma. Fourteen patients with primary CNS diffuse large B-cell lymphoma (stage i) were enrolled in this retrospective cohort study. Primary staging 18 F-FDG PET/CT was performed and quantitative parameters like maximum standardized uptake value, average standardized uptake value, metabolic tumor volume and total lesion glycolysis (TLG) were calculated for all patients before the treatment. Cox regression models were performed to determine their relation with survival time. In the evaluation of all potential risk factors impacting recurrence/metastases (age, sex, serum lactate dehydrogenase, involvement of deep brain structures, maximum standardized uptake value, average standardized uptake value, metabolic tumor volume, and TLG) with univariate analysis, TLG remained statistically significant (P=.02). Metabolic tumor parameters are useful in prognosis estimation of primary CNS lymphomas, especially TLG, which is the most important one and may play a role in patient management. Copyright © 2017 Elsevier España, S.L.U. y SEMNIM. All rights reserved.

  1. Cancer Stratification by Molecular Imaging

    Directory of Open Access Journals (Sweden)

    Justus Weber

    2015-03-01

    Full Text Available The lack of specificity of traditional cytotoxic drugs has triggered the development of anticancer agents that selectively address specific molecular targets. An intrinsic property of these specialized drugs is their limited applicability for specific patient subgroups. Consequently, the generation of information about tumor characteristics is the key to exploit the potential of these drugs. Currently, cancer stratification relies on three approaches: Gene expression analysis and cancer proteomics, immunohistochemistry and molecular imaging. In order to enable the precise localization of functionally expressed targets, molecular imaging combines highly selective biomarkers and intense signal sources. Thus, cancer stratific