Borderline Risk Research Articles

Abstract P2-05-10: UCBG 2-14: A prospective multicenter non-randomized trial evaluating the effect of EndoPredict® (EPclin®) clinico-genomic test on treatment decision making among patients with intermediate clinical risk

Abstract Background: Genomic tests can identify ER-positive Her2-negative localized breast cancer (BC) patients (pts) who may not drive any benefit from adjuvant chemotherapy (CT). Several genomic tests have reached a high level of analytical and clinical validity, as well as clinical utility in such situation. Recent results suggest that the safe de–escalation of adjuvant chemotherapy may be most beneficial in pts with clinical high or indetermediate risk, as assessed by classical variables or online tools, through the use of a genomic test. The clinical risk though remains quite uncertain with variable definition and grey zones. The present study aimed at determining if EPclin clinico-genomic test had a significant impact on treatment decision making among pts with predefined intermediate /borderline clinical risk. Patients and methods: Women were eligible for the present study if they had complete surgical removal of a localized ER+ Her2- pN0 or pN1mi BC, and were considered by the multidisciplinary team meeting (MTM) of the center as being in a "grey zone" of uncertain CT benefit based on classical clinic-pathological assessment. The MTM1 proposed a decision (chemo/no chemo). After informed consent, an EPclin signature classified the tumor as low risk (EPclin Score < 3.3, no chemo advised) or high risk (> 3.3, a theoretical indication for adjuvant chemo). Primary end point was the proportion of change between initial adjuvant CT decision at MTM1 and final administration of CT (yes/no). A 5 steps Fleming design was planned, considering that a change rate of 15% or less was not acceptable (low clinical utility). A one-step design was used (unilateral α = 2.5% and β = 1%). Results: 203 pts were included, of whom 198 are evaluable for the main end point. 74% of the tumors were grade 2, 72% T1 , 25% T2, 3% T3; 16% were pN1mi and 84% pN0. Median age was 57. EpClin® was low risk in 67% and high risk in 33% of the cases. The global rate of decision change between MTM1 and final administration of CT was 70/198 (35.4% IC-95% = [28.7-42.1]), with 55 (27.7%) decreases and 15 (7.6%) increases in CT indication. 27% instead of 47% of all pts finally received CT (43% decrease in CT prescription). In the multivariate analysis, the factors associated to decrease for less CT were EPclin score (OR 0.11 [0.03-0.35]), proliferation (OR 1.08 [1.03-1.13]) and higher grades (OR 5.22 [1.04-26.08]); while EPclin score was positively (OR 76.6 [7.11-824.8]), but higher grades inversely (OR 0.06 [0-0.86]) associated to an increase in CT administration. Of note, the change in final decision occurred after the MTM2 and after report of the results and discussion with the patient in 9 of the 70 cases (12% of changes; 4.5% of the whole population)(8 decreases and 1 increase in CT administration). Conclusion: Adendom met its primary objective, with 35% of intermediate clinico-pathological risk pts getting significant therapeutic changes upon the receipt of an EPclin gene expression profile. 43% of these "intermediate risk" pts planned for CT avoided it. 12% of the changes were discrepant with the test's results and occurred after discussion with the patient. Citation Format: Penault-Llorca F, Kwiatkovski F, Grenier J, Levy C, Leheurteur M, Uwer L, Derbel O, Le Rol A, Jacquin J-P, Jouannaud C, Quenel-Tueux N, Girre V, Foa C, Guardiola E, Lortholary A, Catala S, Lemonnier J, Delaloge S. UCBG 2-14: A prospective multicenter non-randomized trial evaluating the effect of EndoPredict® (EPclin®) clinico-genomic test on treatment decision making among patients with intermediate clinical risk [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-10.

The Refinement of Risk Stratification for Atrial Thrombus or Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation.

As for nonvalvular atrial fibrillation (NVAF) patients with left atrial thrombus or spontaneous echo contrast (LAT/SEC), we evaluated the additional predictive value of serum uric acid (SUA) and Left atrial diameter (LAD) for CHADS2 and CHA2DS2-VASc, and explored the influence from the level of SUA and LAD to LAT/SEC in moderate risk group. Thus, we put forward the concept of a borderline high risk group to guide clinical anticoagulant therapy in patients with NVAF.A total of 284 NVAF patients without the history of anticoagulant prior to hospitalization were enrolled. They were divided into LAT/SEC group or No LAT/SEC group according to transesophageal echocardiography (TEE). Then, we explored and compared the additional predictive value of serological and ultrasonic indexes after combining them to CHADS2/CHA2DS2-VASc.61 patients (21.48%) had LAT/SEC. SUA and LAD were the independent risk factors of LAT/SEC. After being added with LAD and SUA, the predictive value of CHADS2 and CHA2DS2-VASc were increased much more than others. In the moderate risk group, the incidence of LAT/SEC rose significantly when SUA or LAD was higher than cut-off values.SUA and LAD enhanced the predictive ability of CHADS2 and CHA2DS2-VASc for LAT/SEC as additional factors. For patients in moderate risk group, if SUA or LAD was higher than cut-off values, the risk of thromboembolism events would rise accompanied by the elevated risk of LAT/SEC.

Clinical Prognosis of Nonmassive Central and Noncentral Pulmonary Embolism: A Registry-Based Cohort Study

Whether the localization of nonmassive pulmonary embolism (PE) is associated with the short-term and long-term prognosis of patients remains unknown. Our aim was to characterize associations of nonmassive PE localization with risks of recurrent VTE, major bleeding, and mortality during and after anticoagulation. Among participants of the Registro Informatizado de la Enfermedad ThromboEmbòlica (RIETE) registry with incident symptomatic nonmassive PE diagnosed by CT scan, we compared risks of recurrent VTE, major bleeding, and mortality during and after anticoagulation between central PE (main pulmonary artery) and noncentral PE (more peripheral arteries) using Cox proportional hazard-adjusted models. Of the 6,674 participants, patients with central PE (40.5%) had age (mean 66 years), sex (46.9%male sex), and proportion of idiopathic (45.0%) and cancer-related (22.3%) PE that were similar to those of patients with noncentral PE. During anticoagulation (5,256.1 patient-years), the risk of recurrent VTE was similar between the two groups (2.5 vs2.1 per 100 patient-years; adjusted hazard ratio [aHR], 1.32; 95%CI, 0.91-1.90), as were risks of major bleeding and mortality. After anticoagulation was discontinued (2,175.4 patient-years), participants with central PE had a borderline greater risk of recurrent VTE than did participants with noncentral PE (11.0 vs8.0 per 100 patient-years; aHR, 1.34; 95%CI, 1.01-1.78) but not when restricted to participants after unprovoked PE (13.8 vs11.9 per 100 patient-years; aHR, 1.15; 95%CI, 0.79-1.68; P= .48). Risks of major bleeding and mortality were similar. In nonmassive PE, central localization of PE is associated with greater risk of recurrent VTE after anticoagulation cessation. However, the low magnitude of this association and the absence of association after unprovoked PE suggest that the clinical relevance of this finding is limited and that the duration of anticoagulation should not be tailored to PE localization after nonmassive unprovoked PE.

Pre- and postdiagnostic diet in relation to mortality among breast cancer survivors in the CPS-II Nutrition Cohort.

Due to the limited evidence on the role of diet and cause-specific mortality among breast cancer survivors, current nutrition guidelines for this population are consistent with those for cancer prevention. We evaluated whether diets consistent with the American Cancer Society recommendations for cancer prevention were associated with risk of death in breast cancer survivors. Participants reported information on diet and other factors at baseline in 1992-1993 and twice during follow-up. A nine-point score reflecting concordance with diet recommendations was calculated. Multivariable-adjusted relative risks (RR) and 95% confidence intervals (CI) for diet score in relation to overall and cause-specific mortality were computed using Cox proportional hazards regression methods. Among 4,452 women diagnosed with locally and regionally staged breast cancer after baseline and until 2011, 1,204 died during follow-up through 2012 (398 from breast cancer). Prediagnostic diet score was not associated with mortality from any cause. Postdiagnostic diet score was associated with neither breast cancer-specific mortality (RR 1.44, 95% CI 0.90-2.30 for scores 6-9 vs 0-2) nor cardiovascular disease mortality (RR 0.81, 95% CI 0.47-1.39), but compared to a score of 0-2, a score of 6-9 was associated with a borderline lower risk of other causes of death (RR 0.78, 95% CI 0.56-1.07, p trend=0.03; per two-point increase in score RR 0.88, 95% CI 0.79-0.99). Of diet score components, only limiting red and processed meat consumption was associated with statistically significantly lower risk of total, CVD, and other non-breast cancer mortality. Diets consistent with guidelines for cancer prevention were not associated with breast cancer-specific mortality. However, their association with other causes of mortality underscores the importance of consuming a healthy diet in this population.

In search of best practice for postpartum depression screening: is once enough?

BackgroundPostpartum depression (PPD) causes significant morbidity in postpartum women and their newborns. Universal screening is mandated in many states despite little information on optimal interval and frequency of screening. ObjectiveThe objective of this study was to determine whether the early Edinburgh Postnatal Depression Scale (EPDS) score (done within 96h after delivery) is predictive of the late EPDS score (done at outpatient postpartum visit). Study designThis retrospective cohort study selected 256 women delivered at Cooper University Hospital in Camden, NJ in 2013. All patients who presented to the office during the postpartum period completed the EPDS questionnaire, in accordance to our usual practice. The delivery and outpatient records were reviewed for demographic data, EPDS scores and outcomes. Three groups of EPDS scoring were analyzed: <10 (low risk for PPD), 10–13 (borderline risk for PPD), and ≥14 (high risk for PPD). Early and late EPDS scores were compared using Pearson Chi Square test. The relationship between scores was calculated using the Spearman Rho Correlation test. Assuming the EPDS groups would not change, a sample of 200 was needed with 80% power and 5% α-error. ResultsEPDS scores remained the same or improved in 92.2% (189/205) of women. The 16 women whose scores worsened were more likely to have had a diagnosis of prior psychiatric illness (50% vs 16.4%, p=0.003) and/or a diagnosis of fetal anomaly (12.5 vs 1.6%, p=0.05). An early EPDS score of <10 had a 92.7% probability of maintaining low risk screening (EPDS <10) at a later time. ConclusionsIn low risk women, there is good correlation between early and late EPDS scores and so these women may not need to be rescreened. Therefore, we should redirect the limited available resources from screening low risk women multiple times, towards provision of follow-up care for the smaller number of women at highest risk. We propose that “women know your number” (EPDS prior to discharge); and providers re-screen only those women who score positive on PAP10, which stands for Psychiatry history, Anomaly, Preterm delivery, and EPDS score of 10 or more.

Maintenance therapy of childhood acute lymphoblastic leukemia revisited-Should drug doses be adjusted by white blood cell, neutrophil, or lymphocyte counts?

6-Mercaptopurine (6MP) and methotrexate (MTX) based maintenance therapy is a critical phase of childhood acute lymphoblastic leukemia treatment. Wide interindividual variations in drug disposition warrant frequent doses adjustments, but there is a lack of international consensus on dose adjustment guidelines. To identify relapse predictors, we collected 28,255 data sets on drug doses and blood counts (median: 47/patient) and analyzed erythrocyte (Ery) levels of cytotoxic 6MP/MTX metabolites in 9,182 blood samples (median: 14 samples/patient) from 532 children on MTX/6MP maintenance therapy targeted to a white blood cell count (WBC) of 1.5-3.5 × 109 /l. After a median follow-up of 13.8 years for patients in remission, stepwise Cox regression analysis did not find age, average doses of 6MP and MTX, hemoglobin, absolute lymphocyte counts, thrombocyte counts, or Ery levels of 6-thioguanine nucleotides or MTX (including its polyglutamates) to be significant relapse predictors. The parameters significantly associated with risk of relapse (N=83) were male sex (hazard ratio [HR] 2.0 [1.3-3.1], P=0.003), WBC at diagnosis (HR=1.04 per 10 × 109 /l rise [1.00-1.09], P=0.048), the absolute neutrophil count (ANC; HR=1.7 per 109 /l rise [1.3-2.4], P=0.0007), and Ery thiopurine methyltransferase activity (HR=2.7 per IU/ml rise [1.1-6.7], P=0.03). WBC was significantly related to ANC (Spearman correlation coefficient, rs =0.77; P<0.001), and only a borderline significant risk factor for relapse (HR=1.28 [95% CI: 1.00-1.64], P=0.046) when ANC was excluded from the Cox model. This study indicates that a low neutrophil count is likely to be the best hematological target for dose adjustments of maintenance therapy.

Metformin, other antidiabetic drugs, and endometrial cancer risk: a nested case-control study within Italian healthcare utilization databases.

Metformin may reduce the risk of endometrial cancer whereas other drugs for the treatment of type 2 diabetes mellitus appear to increase it, although the evidence is still limited. We investigated this issue using data from a nested case-control study within the healthcare utilization databases of the Lombardy Region, Italy. This study included 376 diabetic women with endometrial cancer and 7485 diabetic controls matched for cases on age, date at cohort entry, and duration of follow-up. We used conditional logistic regression models to estimate the odds ratio (OR) of endometrial cancer in relation to use of antidiabetic drugs, adjusted for the Charlson's comorbidity index, selected medical conditions, prescription of selected drugs, and concomitant use of other antidiabetic drugs. At cohort entry, no significant associations were observed for metformin [OR=0.99, 95% confidence interval (CI) 0.80-1.23], sulfonylureas (OR=1.14, 95% CI 0.91-1.42), insulin (OR=0.72, 95% CI 0.34-1.56), and other antidiabetic drugs (OR=1.21, 95% CI 0.75-1.95). When we considered use during follow-up, a borderline significant excess risk was found for metformin (OR=1.30, 95% CI 1.00-1.70). However, this estimate decreased to 1.07 (95% CI 0.82-1.41) when taking into account BMI using a Monte Carlo sensitivity analysis. No significant associations were found for sulfonylureas (OR=1.16, 95% CI 0.91-1.47), thiazolidinediones (OR=0.77, 95% CI 0.48-1.24), repaglinide (OR=1.32, 95% CI 0.94-1.87), incretins (OR=1.21, 95% CI 0.63-2.32), and insulin (OR=1.19, 95% CI 0.82-1.71). Our data indicate that metformin, insulin, and other antidiabetic drugs did not meaningfully affect the risk of endometrial cancer.

Features of Borderline Personality Disorder and Risk Factors of Suicide : A phenomenological approach

Features of Borderline Personality Disorder and Risk Factors of Suicide : A phenomenological approach

Frequency and Outcomes of Postrandomization Atrial Tachyarrhythmias in the Resynchronization/Defibrillation in Ambulatory Heart Failure Trial.

Whether adding cardiac resynchronization therapy (CRT-D) to an implanted cardioverter-defibrillator alters the risk of atrial fibrillation or other atrial tachyarrhythmias (AF/AT), or if postimplantation AF/AT modulate the benefits of CRT-D, remain unknown. We studied 972 Resynchronization/Defibrillation in Ambulatory Heart Failure Trial (RAFT) participants without permanent AF, who were randomized to CRT-D (n=495) versus nonresynchronization defibrillator (implanted cardioverter-defibrillator; n=477) within the predefined stratum eligible for an atrial lead. Occurrence of postrandomization AF/AT was prospectively assessed, and Cox models were used to test the independent association between the postrandomization AF/AT and the RAFT primary composite outcome of all-cause mortality or hospitalization for heart failure. Over 41 (±19) months, postrandomization AF/AT occurred in 216 (45.3%) patients randomized to implanted cardioverter-defibrillator and 249 (50.3%) randomized to CRT-D. After adjusting for competing risk of death, randomization to CRT-D increased risk of postrandomization AF/AT (hazard ratio, 1.20; 95% confidence interval, 1.00-1.42; P=0.045). Postrandomization AF/AT, which remained paroxysmal in 69.5%, did not reduce biventricular pacing percentage. In adjusted models, postrandomization AF/AT was not associated with the primary outcome (hazard ratio, 1.04; 95% confidence interval, 0.84-1.30). However, AF/AT was associated with a borderline decreased risk of mortality (hazard ratio, 0.75; 95% confidence interval, 0.58-1.00) but increased risk of heart failure hospitalization (hazard ratio, 1.43; 95% confidence interval, 1.08-1.90). In RAFT, nearly half of the patients developed postrandomization AF/AT, and those randomized to CRT-D had borderline significant higher risk. Postrandomization AF/AT was associated with risk of heart failure hospitalization, but not with the primary composite outcome. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00251251.

Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis.

The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.

Borderline personality disorder in adolescence. Prevention and early intervention from a cognitive analytic approach

IntroductionBorderline personality disorder begins in adolescence, however, its diagnosis is subject to some controversy and tends to be underdiagnosed. Stigma associated with its diagnosis, comorbidity with other axis I disorders or the changeable sense of identity during adolescence are some of the elements that obscure the diagnosis. Increasingly, recent studies have shown the utility of prevention programs as well as instituting early intervention in adolescents, with very hopeful outcomes.ObjectivesThe aim of this study is to review the benefits derived from early prevention and intervention programs in adolescents with borderline symptoms from a cognitive analytic approach.MethodsA systematic review for scientific articles extracted from research databases including Dialnet, EBSCO, Pubmed, Unika and Scholar Google was conducted. Other high-impact studies in the field were also included.ResultsEvidence reported by reviewed articles supports Cognitive analytical therapy as one of the most successful approaches, the same as Mentalization based therapy, in the treatment of Borderline personality disorder. From this approach, prevention and early intervention have shown their effectiveness in reducing borderline symptoms and risk factors besides they contribute to interpersonal functioning improvement.ConclusionsPrevention and early intervention constitute the main pillars to prevent the potential development of Borderline personality disorder or its evolution in more complex and irreversible forms. But this intervention must be carried not only in young already diagnosed, but also in those who are on the diagnostic threshold, presenting risk factors for further development.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Preliminary safety and efficacy of perioperative COI-B (capecitabine, oxaliplatin, irinotecan, and bevacizumab) in patients with borderline resectable or high–recurrence risk colorectal cancer liver metastases (CLM).

719 Background: FOLFOXIRI and bevacizumab achieves high objective response rate (ORR)/R0 resections in pts with unresectable CLM. Bevacizumab increases pathological response, a surrogate endpoint of survival after CLM resection. COI-B regimen is feasible in pts with advanced colorectal cancer. In this phase II study, we aimed at assessing safety and efficacy of perioperative COI-B for pts with borderline resectable or high recurrence risk CLM. Methods: Inclusion criteria: borderline resectability with portal embolization/2-stage hepatectomy, involvement of &gt; 1 hepatic vein or &gt; 4 segments; and/or at least one poor prognostic factor: &gt; 4 metastases; CEA &gt; 200; synchronicity. Limited resectable extraepatic disease and in situ primary allowed. Primary endpoint: TRG1-3 (Rubbia-Brandt et al) according to Simon 2-stage design (first step 22; target 46 pts); secondary endpoints: ORR; R0 resection; safety; progression-free and overall survival. Pts received bi-weekly irinotecan (180 mg/m2) and bevacizumab (5 mg/Kg) day 1, oxaliplatin (85 mg/m2) day 2 and capecitabine (1000 mg/m2/day b.i.d.) days 2–6; 5 cycles pre-operatively (the last without bevacizumab) and 4 post-operatively. Results: We present preliminary data on the first 25 pts. M/F: 13/12, median age 61 years, synchronous disease 19 (76%), multiple nodules 15 (60%), N+ primary tumour 14 (56%), CEA &gt; 200 4 (16%), extrahepatic disease 1, RAS mutation 15 (60%)/BRAF mutation 0. Involvement ≥ 4 hepatic segments 9 (36%) and involvement of &gt; 1 hepatic veins 4 (16%). ORR was 91% (21 out of 23 evaluable, 2 too early), while 1 SD and 1 PD. Surgery performed in 21 pts (4 awaiting) and R0 resection in 18 (86%). TRG1-2 was observed in 6 (29%), TRG3 in 9 (43%), i.e. pathological response 72% (first step reached). Grade ≥ 3 toxicities: neutropenia 2, diarrhea 2, thrombosis 2. Median follow up 13 months, with only 4 relapses and 1 death. Conclusions: COI-B regimen is a feasible neoadjuvant strategy for borderline resectable or high recurrence risk CLM. This is the first trial to select pathological response as primary surrogate endpoint with encouraging results. Clinical trial information: NCT02086656.

Sports Eligibility After Risk Assessment and Treatment in Children with Asymptomatic Ventricular Pre-excitation.

Many studies concern the management of young patients with symptomatic Wolff-Parkinson-White (WPW) syndrome, but little information exists on the significance and prognosis of ventricular pre-excitation (VPE) in asymptomatic children. The aim of the study was to evaluate the risk of sudden death in young athletes with asymptomatic VPE by transesophageal electrophysiological study (TEEPS) and their sports eligibility after the risk assessment and/or ablative treatment. Ninety-one asymptomatic children and adolescents underwent TEEPS both at rest and during adrenergic stress (exercise testing or isoproterenol infusion). After electrophysiological testing, patients were assessed in the 36months of follow-up. Thirty-three patients (36.3%) had a benign form of VPE and were allowed to participate in competitions. Ten patients (11%) were at borderline risk; thus, sport eligibility was evaluated individually. Forty-eight patients (52.7%) showed inducible sustained atrioventricular reentrant tachycardia and/or atrial fibrillation (AF), 11 of whom (12.1% of total population) had a potential risk of sudden cardiac death due to AF inducibility during physical stress. Forty-five young athletes underwent transcatheter ablation (TCA). TCA was interrupted in 12 patients (26.7%) because of the high procedural risk linked to septal accessory pathway (AP) location. There were no TCA-related complications, and all patients remained asymptomatic during follow-up. Most of the young athletes with asymptomatic VPE may be allowed to participate in competitive sports after an adequate risk assessment and/or ablative treatment. However, in our opinion, special care should be taken to avoid procedural complications, which are unacceptable in asymptomatic patients.

Novel Clinical Scale for Evaluating Pre-Operative Risk of Cerebral Herniation from Traumatic Epidural Hematoma.

Secondary massive cerebral infarction (MCI) is the predominant prognostic factor for cerebral herniation from epidural hematoma (EDH) and determines the need for decompressive craniectomy. In this study, we tested the clinical feasibility and reliability of a novel pre-operative risk scoring system, the EDH-MCI scale, to guide surgical decision making. It is comprised of six risk factors, including hematoma location and volume, duration and extent of cerebral herniation, Glasgow Coma Scale score, and presence of preoperative shock, with a total score ranging from 0 to 18 points. Application of the EDH-MCI scale to guide surgical modalities for initial hematoma evacuation surgery for 65 patients (prospective cohort, 2012.02-2014.01) showed a significant improvement in the accuracy of the selected modality (95.38% vs. 77.95%; p = 0.002) relative to the results for an independent set of 126 patients (retrospective cohort, 2007.01-2012.01) for whom surgical modalities were decided empirically. Results suggested that simple hematoma evacuation craniotomy was sufficient for patients with low risk scores (≤9 points), whereas decompressive craniectomy in combination with duraplasty were necessary only for those with high risk scores (≥13 points). In patients with borderline risk scores (10-12 points), those having unstable vital signs, coexistence of severe secondary brainstem injury, and unresponsive dilated pupils after emergent burr hole hematoma drainage had a significantly increased incidence of post-traumatic MCI and necessity of radical surgical treatments. In conclusion, the novel pre-operative risk EDH-MCI evaluation scale has a satisfactory predictive and discriminative performance for patients who are at risk for the development of secondary MCI and therefore require decompressive craniectomy.

Profile of coronary artery disease cases in diabetics and non-diabetics: a comparative prospective study

Background: Diabetes mellitus is one of the commonest disease worldwide ranking next to cardiovascular disorder. The estimated prevalence of diabetes among adults is expected to rise about 100% in future. Cardiac involvement in diabetes commonly manifests as CAD and less commonly as dilated (diabetic) cardiomyopathy and autonomic cardiovascular neuropathy. The risk of CAD among diabetic patients is directly related to the levels of blood pressure, cigarette smoking and total cholesterol. Methods: The present study was undertaken at Chandulal Chandrakar memorial hospital, Bhilai, Chhattisgarh (India) between the periods of September 2010-2012 (2 years). 120 cases of CAD were studied, out of which 60 cases are diabetic CAD and 60 cases are non-diabetic CAD. Sample is drawn by simple random technique. Ethical approval was obtained from institutional ethical committee. Total Cases-120, Diabetic CAD [group – 1]-60 and Non-diabetic CAD [group – 2] – 60. On recruiting the subjects into Group 1 and Group 2 following protocol is followed-history, clinical examination, pt. stabilization, anthropometric measurement, routine investigations, specific investigations including echocardiography. Procedures, definitions and criteria were used in the study as per standard protocol. In the present study values are expressed as mean ±1 SD. Demographic characteristics of patient with or without diabetes and other unpaired variables were compared. Results: Mean age in diabetic group was (55.7 ± 9.5) years while in non-diabetic group (55.6 ± 9.32) years. Diabetic group consists of 42 males and 18 females. Non Diabetic Group consists of 38 males and 22 females. Most of the patients in diabetic group presented with chest pain with sweating and with symptoms of sympathetic stimulation (vomiting/ apprehension 83.33%). A small fraction of diabetic patients presented with breathlessness – 20%, syncope (3.33%) and palpitation (8.3%). In diabetic group 55% of patients were hypertensive, pre-HTN was seen in 18.33% and 26.66% had optimal blood pressure. Non-diabetics have higher ideal body weight 58.33% than diabetic (36.66%). Among the diabetic group and non-diabetic group maximum number of cases belonged to low risk category with total cholesterol, triglycerides and LDL cholesterol, but with borderline risk with HDL cholesterol. Diabetics are more vulnerable to mortality than non-diabetics (p<0.05). Conclusions: Diabetics had considerably higher percent of typical and atypical presentation. Hence, CAD should be considered as one of the differential diagnoses in diabetics who have presented with chest pain, however less severe it may be.

Concordant Versus Discordant Ultrasound Guided Breast Biopsy Results: How They Effect Patient Management?

Background: To determine concordant or discordant breast biopsy results and see their effect on patient management and outcome. Material and methods: This descriptive analytical study was conducted at the department of Diagnostic Radiology Aga Khan University Hospital Karachi Pakistan from January to December 2013. All patients fulfilling our selection criteria were included. A concordant result was defined when the imaging and pathology results concluded same diagnosis and a discordant result when they did not match. All histopathology results were reviewed and a decision was made regarding concordant/discordant biopsy results and recommendations given for further management of all patients. Results: A total of 282 patients underwent core biopsy of lesions in the breast. The mean age was 47.87 ± 13.99 years. Out of 282 lesions biopsied, 172 were concordant malignant and 105 were concordant benign. Two lesion out of 282 were borderline or high risk, one case was discordant benign and 2 cases discordant malignant. The appropriate management for all cases was recommended after radiology-pathology correlation. Conclusion: Cautious Radiology-Pathology co relation is indispensable in addition to appropriate post biopsy management for managing a successful core breast biopsy program. This practice identifies a substantial number of false negative results of core biopsy by identifying discordant results avoiding delays in diagnosis of breast cancer.

Scleral Buckling for Rhegmatogenous Retinal Detachment Associated with Pars Planitis.

Purpose. To evaluate the surgical outcome of scleral buckling (SB) in rhegmatogenous retinal detachment (RRD) patients associated with pars planitis. Methods. Retrospective review of RRD patients (32 eyes of pars planitis RRD and 180 eyes of primary RRD) who underwent SB. We compared primary and final anatomical success rates and visual outcomes between two groups. Results. Primary and final anatomical success were achieved in 25 (78.1%) and 31 (96.8%) eyes in the pars planitis RRD group and in 167 eyes (92.7%) and 176 eyes (97.7%) in primary RRD group, respectively. Both groups showed significant visual improvement (p < 0.001) and there were no significant differences in final visual acuity. Pars planitis RRD group was associated with higher rate of postoperative proliferative vitreoretinopathy (PVR) development (12.5% versus 2.8%, p = 0.031). Pars planitis and high myopia were significant preoperative risk factors and pseudophakia was borderline risk for primary anatomical failure after adjusting for various clinical factors. Conclusions. Pars planitis associated RRD showed inferior primary anatomical outcome after SB due to postoperative PVR development. However, final anatomical and visual outcomes were favorable. RRD cases associated with pars planitis, high myopia, and pseudophakia might benefit from different surgical approaches, such as combined vitrectomy and SB.

Reasons for discrepancies in hip fracture risk estimates using FRAX and Garvan calculators

ObjectivesBoth the FRAX and Garvan calculators are used to estimate absolute risk of fracture, but they sometimes produce different estimates. We sought to determine which patient characteristics contribute to these discrepancies. Study designTen-year hip fracture risk was estimated for 122 women, using both FRAX and Garvan with bone mineral density (BMD). Main outcome measuresDifferences in estimates of hip fracture were assessed, both in absolute terms and with respect to a treatment threshold of 3%. ResultsGarvan estimates were higher than FRAX estimates across the range of ages and BMDs studied. A history of falls or of multiple fractures increased risk calculated by Garvan 3–6-fold, but did not account for all differences between calculators. Discrepancies around a 3% treatment threshold occurred in 31/122 (25%). Women aged 70–74 years, and women with osteopenia were most likely to have discordant estimates. Most discordant estimates (29/31) had a Garvan estimate ≥3% and FRAX <3%. Falls, multiple fractures, ethnicity and a history of parental hip fracture contributed to some discordant estimates. ConclusionsHip fracture risk estimates are usually higher with Garvan than FRAX, and these differences could impact on treatment decisions in about a quarter of patients. Falls and multiple fractures have a strong influence on Garvan risk estimates, when present. Clinically important discrepancies tend to occur in patients who are at borderline fracture risk. In patients with hip fracture risks near the treatment threshold with one calculator, use of the other calculator should be considered to help guide treatment decisions.

Optimal serum cholesterol concentrations are associated with accelerated bone loss in African ancestry men.

We tested if serum lipid and lipoprotein cholesterol levels are associated with longitudinal measures of bone mineral density (BMD) in 1289 African ancestry men. After 6years of mean follow-up, men with clinically optimal levels of low-density lipoprotein (LDL), high-density lipoprotein (HDL), or triglycerides at baseline experienced the greatest BMD loss, independent of potential confounding factors (all p < 0.05). Studies of lipid and lipoprotein cholesterol associations with bone mineral density (BMD) and bone loss have been inconclusive, and longitudinal data are sparse. Therefore, the aim of this study was to test if fasting serum lipid and lipoprotein cholesterol levels are associated with areal and volumetric BMD and BMD change. We determined the association of serum triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) cholesterol concentrations with cross-sectional and longitudinal (mean follow-up, 6.1years) measures of BMD in a cohort of 1289 in African ancestry men (mean age, 56.4years). Fasting serum triglycerides, HDL, and LDL were measured at baseline concurrent with BMD assessments. Dual-energy X-ray absorptiometry was used to quantify integral hip BMD, and peripheral quantitative computed tomography at the radius and tibia was used to quantify volumetric BMD. Men were categorized as optimal, borderline, or high risk for triglyceride, HDL, and LDL concentrations based on Adult Treatment Panel III guidelines. Lower serum triglyceride or LDL and higher HDL concentrations were associated with lower trabecular BMD at baseline (all p < 0.05). Similarly, men classified as having optimal levels of LDL, HDL, or triglycerides at baseline experienced the greatest integral BMD loss at the hip and trabecular BMD loss at the tibia (all p < 0.05), independent of potential confounding factors. We found that clinically optimal serum lipid and lipoprotein cholesterol concentrations were associated with accelerated bone loss among Afro-Caribbean men. Further studies are needed to better understand the mechanisms involved and potential clinical significance of these findings.

Abstract 12117: Screening for Metabolic Risk in Adolescent Blood Donors

Introduction: Cardiometabolic risk factors such as elevated blood pressure, total cholesterol and glycated hemoglobin (HbA1C) in adolescents persist into adulthood and are associated with increased risk for cardiovascular disease and diabetes. These risks are increased when multiple risk factors are present. High school blood drives are a unique opportunity to provide screening for cardiometabolic risk factors at low cost and minimum inconvenience to participants. Methods: Blood pressure (SBP and DPB), total nonfasting cholesterol and HbA1C were measured in volunteer blood donors aged 16-19 years, donating blood between January 2011 and December 2012, through Carter BloodCare in Dallas/Fort Worth, Texas. Cardiometabolic risk factors were classified as elevated (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg, cholesterol ≥ 200 mg/dL, HbA1C ≥ 6.5%) and borderline or elevated (SBP ≥ 120 mmHg and/or DBP ≥ 80 mmHg, cholesterol ≥ 170 mg/dL, HbA1C ≥ 5.7%). Results: The study included 24,925 donors (11,590 boys and 13,335 girls), including 8.4% African American, 2.2% Asian, 52.7% Caucasian, 24.9% Hispanic and 11.8% other/unknown. Only 33.6% of the entire cohort had no borderline or elevated risk factors (Table). However, 41.6% of females and 51.8% of males had at least 1 borderline or elevated risk factor. When viewed by ethnicity, 48.2% of Caucasians and 45.1% of African Americans had 1 borderline or elevated risk factor, with almost 25 % of African Americans having 2 or more borderline or elevated risk factors. Conclusions: Blood donor screening is confirmed as an opportunity to monitor the prevalence of multiple metabolic risk factors in an ostensibly healthy subset of the population. This scrutiny does identify individuals with multiple risk factors and also reveals ethnic and gender differences.