Characteristic Curve Model Research Articles

Noninvasive Evaluation of Liver Fibrosis and Portal Hypertension After Successful Portoenterostomy for Biliary Atresia

We investigated noninvasive follow‐up markers for histologic liver fibrosis and portal hypertension (PH) in patients with biliary atresia after successful portoenterostomy (PE). Among children with bilirubin <20 µmol/L after PE (n = 39), Metavir fibrosis stage was evaluated at PE and in follow‐up protocol liver biopsies (n = 83). PH was defined as endoscopically confirmed esophageal varices or thrombocytopenia associated with splenomegaly. The accuracy of liver biochemistry and stiffness in detecting liver fibrosis and PH was analyzed by the area under the receiving operating characteristic curve (AUROC) and multiple regression models. During a median native liver survival of 8.3 years (interquartile range 2.5‐10.8 years), cirrhosis (Metavir F4) had developed in 51% of patients and PH in 54% of patients. Cirrhosis was equally common in all age tertiles of 1.2‐2.1 years (n = 10/27), 3.9‐5.8 years (n = 12/28), and 9.0‐14 years (n = 12/28). In the two oldest age tertiles, histologic liver fibrosis had progressed further in patients with PH than without PH (P < 0.001). PH was accurately predicted by the aspartate aminotransferase‐to‐platelet ratio index (APRI) (cutoff, 0.70; AUROC, 0.92), bile acids (cutoff, 49 µmol/L; AUROC, 0.91), and liver stiffness (cutoff, 16.9 kPa; AUROC, 0.89; P < 0.001 each) across all age tertiles. Liver stiffness was the most accurate predictor of cirrhosis overall (AUROC, 0.82; P < 0.001), whereas bilirubin was >11 µmol/L in the youngest tertile (AUROC, 0.91; P < 0.001), bile acids was >80 µmol/L in the middle tertile (AUROC, 0.81; P = 0.009), and liver stiffness was >24 kPa in the oldest age tertile (AUROC, 0.96; P = 0.002). Conclusion: After successful PE, development of PH associates with progression of liver fibrosis and can be accurately detected by APRI and stiffness. Liver stiffness most accurately identified cirrhosis in older children, whereas biochemical markers of cholestasis closely reflected histologic cirrhosis in younger children.

Determination of Consistency Limits Based on Suction Stress Characteristic Curve

Consistency limits, especially the liquid and plastic limits, are prominent parameters to be determined in geotechnical investigations for classification and identification of finegrained soil. An investigation of the soil suction stress characteristic curve (SSCC) for determination of consistency limits is conducted in this work. The typical SSCC can be divided into five zones according to the state of pore water retention and the mechanisms of solid-liquid interactions. The correspondences between consistency limits of fine-grained soils and characteristic points of every zone in the SSCC are investigated. A detailed discussion of the intrinsic relationships between zones in the SSCC and soil consistency reveals the physical nature of each zone and the critical moisture content. Using experimental data from soil-water characteristic tests of undisturbed loess and disturbed loess, and van Genuchten's soil water characteristic curve (SWCC) model, consistency limits are determined for SSCCs with different void ratios. The feasibility of the presented approach for determining consistency limits of fine-grained soils based on SSCC is demonstrated.

Prognostic Value of Combined C-Reactive Protein, Body Mass Index, and Left Ventricular Ejection Fraction in Predicting Cardiovascular Events in Patients ≥80 Years of Age With Acute Myocardial Infarction

Elevated high-sensitivity C-reactive protein (hsCRP) and low body mass index (BMI) are linked to increased mortality in the elderly population. However, the combined value for predicting adverse cardiovascular events in the oldest-old (≥80 years old) with acute myocardial infarction (AMI) remains undetermined. A total of 463 AMI patients, who were ≥80 years old, were enrolled in this study between January 2012 and June 2017. A nested case-control study was implemented in 106 deaths and 212 controls, who were matched for age, gender, time of inclusion, and myocardial infarction type. Furthermore, the individual and additive values of hsCRP, BMI, and left ventricular ejection fraction (LVEF) were assessed using adjusted hazard ratio, unadjusted Kaplan-Meier analysis, and receiver-operating characteristic curve models. The median follow-up time was 19.15 months, and there were 106 deaths (33.3%). Furthermore, HsCRP, BMI, and LVEF were significantly associated with all-cause mortality (p <0.05, respectively). In addition, a negative correlation between BMI and LVEF, and the positive association of hsCRP with all-cause mortality in the fully adjusted Cox proportional hazards model were detected. The combination of hsCRP, BMI, and LVEF was found to exhibit an enhanced predictive value for all-cause mortality (0.733 in jointly vs 0.623 in cardiovascular risk factors, p = 0.0007) in these oldest-old AMI patients. HsCRP, BMI, and LVEF are the independent risk factors for all-cause mortality for the oldest-old patients with AMI, and this combination offers more appreciable and reliable predictive value for all-cause mortality.

Systematic review: diagnostic accuracy of non-invasive tests for staging liver fibrosis in autoimmune hepatitis.

Non-invasive fibrosis assessment has been highly recommended in many liver diseases. However, comparative diagnostic accuracy of laboratory markers, ultrasound and magnetic resonance elastography (MRE) for fibrosis in autoimmune hepatitis (AIH) patients has not been established. Medline, Embase and Cochrane Library were searched. Primary outcome was significant fibrosis (SF), advanced fibrosis (AF) and cirrhosis, defined as Metavir stage F ≥ 2, F ≥ 3 and F = 4 according to liver biopsy. Hierarchical summary receiver operating characteristic curve (ROC) model was used to evaluate diagnostic accuracy of non-invasive methods. Summary area under ROC (AUROC) and diagnostic odds ratio (DOR) with 95% confidence interval (CI) were calculated. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess quality of evidence. Overall, 16 studies with 861 patients were included, comparing aspartate aminotransferase to platelet ratio index (APRI), fibrosis-4 index (FIB-4), aspartate aminotransferase/alanine aminotransferase ratio, transient elastography (TE), acoustic radiation force impulse, shear wave elastography and MRE versus liver biopsy. Among all non-invasive markers, TE had good performance for fibrosis staging. Summary AUROCs and DORs of TE were 0.90 (95% CI 0.87, 0.92) and 23.7, 0.91 (95% CI 0.89, 0.93) and 31.6, 0.89 (95% CI 0.86, 0.92) and 80.5 for staging SF, AF and cirrhosis, whereas APRI and FIB-4 showed poor performance for detecting AF (DOR, 4.6 and 4.7) and cirrhosis (DOR, 5.5 and 12.9). TE performs well to stage liver fibrosis in patients with AIH, compared with other laboratory non-invasive indexes. Nevertheless, diagnostic accuracy of APRI and FIB-4 is poor.

Numerical calculation model performance analysis for aluminum alloy mortise-and-tenon structural joints used in electric vehicles

In this paper, several numerical calculation models for aluminum alloy MT joints are presented through experiments and simulation, which is applied to the joint deformation and failure process, compares with moment-rotation angle curve in the joint deformation process. Besides, the characteristic points are figured out, characteristic double broken line curve and numerical hybrid beam element model are established based on spring element. The results show that finite element model for solid elements is available. The model can simulate joint failure process better. The error is 3.8% during deformation process simulation. For numerical model based on mixed spring beam element, its calculation speed is 530 times faster than that of the solid element model, but its error is 5.1%. It guarantees calculation accuracy and greatly improves the calculation speed. The two models provide a theoretical basis for such metallic composite material structures used in intelligent electric vehicles based on characteristic analysis, framework and overall structure design. It is also give a useful reference to other metallic composite material design and calculation.

Arterial Spin-Labeling in Children with Brain Tumor: A Meta-Analysis.

The value of arterial spin-labeling in a pediatric population has not been assessed in a meta-analysis. Our aim was to assess the diagnostic accuracy of arterial spin-labeling-derived cerebral blood flow to discriminate low- and high-grade tumors. MEDLINE, EMBASE, the Web of Science Core Collection, and the Cochrane Library were used. Pediatric patients with arterial spin-labeling MR imaging with verified neuropathologic diagnoses were included. Relative CBF and absolute CBF and tumor grade were extracted, including sequence-specific information. Mean differences in CBF between low- and high-grade tumors were calculated. Study quality was assessed. Data were aggregated using the bivariate summary receiver operating characteristic curve model. Heterogeneity was explored with meta-regression and subgroup analyses. The study protocol was published at PROSPERO (CRD42017075055). Eight studies encompassing 286 pediatric patients were included. The mean differences in absolute CBF were 29.62 mL/min/100 g (95% CI, 10.43-48.82 mL/min/100 g), I2 = 74, P = .002, and 1.34 mL/min/100 g (95% CI, 0.95-1.74 mL/min/100 g), P < .001, I2 = 38 for relative CBF. Pooled sensitivity for relative CBF ranged from 0.75 to 0.90, and specificity, from 0.77 to 0.92 with an area under curve = 0.92. Meta-regression showed no moderating effect of sequence parameters TE, TR, acquisition time, or ROI method. Included tumor types, analysis method, and original data varied among included studies. Arterial spin-labeling-derived CBF measures showed high diagnostic accuracy for discriminating low- and high-grade tumors in pediatric patients with brain tumors. The relative CBF showed less variation among studies than the absolute CBF.

A numerical framework for infinite slope stability analysis under transient unsaturated seepage conditions

This paper presents a simple numerical framework for infinite slope stability analysis under transient unsaturated seepage conditions. The advantage of the proposed framework, from the practical point of view, is to predict the variability in stability of partially saturated slope along with rainfall data. Moreover, the presented framework is adaptable to different types of soil-water characteristic curve (SWCC) models, hydraulic boundary conditions, and heterogeneity in soil properties. A series of stability analyses for hypothetical hillslopes under various conditions was performed to scrutinize the potential failure mechanisms induced by rainfall. The examined factors include the soil texture, rainfall intensity, heterogeneity in soil properties and hydraulic boundary conditions. Also, four widely used SWCC models were applied to assess the influence of this component. The SWCC model was demonstrated to strongly dominate the results of the infinite slope stability analysis under transient unsaturated seepage conditions. For homogeneous hillslopes with a fixed water table, when the rainfall intensity (q) equals the saturated hydraulic conductivity (Ks), slope failure was expected to occur after a short time of rainfall with a relatively shallow slip depth. In contrast, for heterogeneous hillslopes or hillslopes with impermeable bedrock, the failure could take place when q is less than Ks, and the potential failure surface was close to the discontinuity interface or at the bottom of the hillslope. Finally, three case studies of landslides documented in literature were utilized to demonstrate the predictability of the proposed framework in practical applications.

Influence of hydraulic characteristics on stability of unsaturated slope under transient seepage conditions

This paper examines the current procedure for determining the soil-water characteristic curve (SWCC) model with a particular focus on its application to slope stability analysis under transient unsaturated seepage conditions. A series of laboratory experiments was performed to determine the SWCC of different soils, ranging from high plasticity clay to silty sand, found across the Korean Peninsula. The experimental results were utilized to identify the suitable SWCC model for each soil type based on the fitting criterion. Also, this paper developed a numerical framework for infinite slope stability analysis under transient unsaturated seepage conditions. The significant advantage of the proposed framework, from the practical viewpoint, is to directly predict the timing of failure and potential failure plane based on rainfall recording. The effect of choice of SWCC models on predictability in stability analysis was evaluated by adopting the present framework along with the identified SWCC models. Furthermore, a case study of landslides after a 3-month rainfall in Pohang, Korea, was revisited to assess the performance of the proposed framework. The obtained results demonstrate the significant role of SWCC model on the results of slope stability analysis. The analysis using the SWCC model satisfying the fitting criterion could still not capture the real behavior of unsaturated soil. The comprehensive transient analysis is strongly suggested as a complementary means to the current fitting criterion for determining the suitable SWCC model for stability analysis under transient seepage conditions.

Association of vitamin D level and vitamin D deficiency with risk of preeclampsia: A systematic review and updated meta-analysis

ObjectivesBecause of the immune modulatory effects of vitamin D3 in preeclampsia, we intend to have a systematic review and meta-analysis on association of both 25-hydroxy vitamin D (25-OHD) level (parametric approach) and 25-OHD deficiency (non-parametric approach) with preeclampsia. As well, for the parametric part, we used receiver operating characteristic (ROC) curve model. Materials and methodsWe used Web of Science, PubMed and Science Direct data bases through searching in titles. Google Scholar search engine was used in order to find missing papers. Finally 23 studies were imported. Both random and fixed models were reported. ResultsBased on the forest plot, lower levels of 25-OHD were significantly associated with risk of preeclampsia (fixed and random P < 0.001). Based on the forest plot, vitamin D deficiency (25-OHD < 20 ng/ml) was significantly associated with risk of preeclampsia (fixed P < 0.0001; random P = 0.0029; fixed OR = 1.33; random OR = 1.54). Based on ROC curve results, we found 2 cutoffs of 10.60 and 20.05 ng/ml. ConclusionWomen with vitamin D deficiency at cutoff 20 ng/ml are more at risk of preeclampsia. This association can be specific up to 90% at 10.60 ng/ml cutoff. Treatment of vitamin D deficiency is necessary before pregnancy.

Three-dimensional stability analysis of slope in unsaturated soils considering strength nonlinearity under water drawdown

In slope stability analyses, the soil has been frequently considered dry or saturated, whereas the soil is in fact unsaturated in many cases. Owing to the existence of matric suction, the strength properties of unsaturated soils are greatly different from dry or saturated soil, and thereby leading to diverse stability conditions of the slope. Based on the kinematical approach of limit analysis, in this study, a three-dimensional (3D) stability analysis was conducted for slopes in unsaturated soils. The effects of matric suction distribution patterns, the nonlinearity of the strength under soil-water characteristic curves and the water drawdown were investigated to explore the shear strength and stability of a slope in unsaturated soil. It was found that, when the matric suction is uniformly distributed, the stability factors of the slope increase linearly along with the matric suction. In addition, when the matric suction increases linearly with the depth, the enhancing effect of the matric suction on the slope stability intensifies as the variation magnitude of the matric suction increases, especially for a gentle slope with a narrower width. For nonlinear patterns, different soil-water characteristic curve (SWCC) models will lead to diverse shear strengths and stability conditions of the slope. The water drawdown has significant effects on the functions of the matric suction as well as slope stability.

Fecal immunochemical test for predicting mucosal healing in ulcerative colitis patients: A systematic review and meta-analysis.

Fecal immunochemical test (FIT) is a promising marker for assessment of inflammatory bowel disease activity. However, the utility of FIT for predicting mucosal healing (MH) of ulcerative colitis (UC) patients has yet to be clearly demonstrated. The objective of our study was to perform a diagnostic test accuracy test meta-analysis evaluating the diagnostic accuracy of FIT in predicting MH of UC patients. We systematically searched the databases from inception to November 2017 that evaluated MH in UC. The methodological quality of each study was assessed according to the Quality Assessment of Diagnostic Accuracy Studies checklist. The extracted data were pooled using a summary receiver operating characteristic curve model. Random-effects model was used to summarize the diagnostic odds ratio, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Six studies comprising 625 UC patients were included in the meta-analysis. The pooled sensitivity and specificity values for predicting MH in UC were 0.77 (95% confidence interval [CI], 0.72-0.81) and 0.81 (95% CI, 0.76-0.85), respectively. The FIT level had a high rule-in value (positive likelihood ratio, 3.79; 95% CI, 2.85-5.03) and a moderate rule-out value (negative likelihood ratio, 0.26; 95% CI, 0.16-0.43) for predicting MH in UC. The results of the receiver operating characteristic curve analysis (area under the curve, 0.88; standard error of the mean, 0.02) and diagnostic odds ratio (18.08; 95% CI, 9.57-34.13) also revealed improved discrimination for identifying MH in UC with FIT concentration. Our meta-analysis has found that FIT is a simple, reliable non-invasive marker for predicting MH in UC patients.

The psoas muscle transversal diameter predicts mortality in patients with cirrhosis on a waiting list for liver transplantation: A retrospective cohort study.

Malnutrition impairs prognosis in liver cirrhosis. Our aims were to determine (1) if transversal (TPTI) and axial (APTI) psoas thickness indices predict mortality in cirrhotic patients and (2) the feasibility and reproducibility of transversal (TDPM) and axial (ADPM) diameters of the psoas muscle measurements. This was a retrospective study. Inclusion criteria included cirrhosis diagnosis, on liver transplantation waiting list, and abdominal computed tomography (CT) scan within the 3 mo preceding list inscription. TDPM and ADPM were measured on a single umbilicus-targeted CT image by non-expert and expert operators. TPTI or APTI (mm/m) were calculated as TDPM or ADPM/height (m). Area under the receiver operating characteristic curve (AUC) and Cox proportional hazard models were assessed. TPTI and APTI interobserver agreement: κ correlation test. A total of 173 patients were included. Low TPTI was associated with increased mortality: AUC = 0.66 (95% confidence interval, 0.51-0.80). TPTI was the only factor associated with mortality (hazard ratio = 0.87, 95% confidence interval 0.76-0.99, P = 0.034). There was an almost perfect interobserver agreement between the two operators: TDPM, κ = 0.97; ADPM, κ = 0.94; P <0.0001. TPTI measured on umbilicus-targeted CT scan before inscription on the waiting list for liver transplantation predicts mortality of cirrhotic patients. TPTI measurement is easy and reliable, even by a non-trained operator, and this is highly feasible in daily clinical practice.

Abstract NS4: Predictors of Ischemic Stroke and Stroke Mimic During Pregnancy

Introduction: The risk of ischemic stroke is significantly higher in pregnancy. However, the neurologic symptoms that accompany stroke can be mimicked by other conditions. Because ischemic stroke has the potential for acute treatment, it is important to identify these patients quickly. Methods: A retrospective chart review was performed on pregnant patients from 2009-2014 using ICD-9 codes for stroke or other related vascular diseases. The diagnosis was based on the neurologist evaluation and neuroimaging. We identified candidate variables with p&lt;0.2 in univariable analysis and derived a predictive model using interactive variable selection, then fit logistic regression models to the outcome of ischemic stroke. Results: Thirty-eight patients met inclusion criteria, of which 13 had ischemic stroke (Table 1). Mimic diagnoses included: venous sinus thrombosis (8), intracerebral hemorrhage (2), complicated migraine (7), non-epileptic seizure (3), seizure (2), transient ischemic attack (1), and conversion disorder (2). The best model to predict ischemic stroke included age greater than 29 years and history of 1 st degree relative with stroke (Figure 1). Conclusion: Our scoring system is a promising hypothesis-generating concept that requires validation in a larger cohort of pregnant patients. Table 1: Baseline characteristics of patients with ischemic stroke versus mimics and p-value for difference (using Student’s t-test or the Chi-squared test). Figure 1: Comparison of the area under the Receiver Operating Characteristic curve for Model 1 (current smoking and age&gt;29), Model 2 (migraine with aura and age&gt;29), Model 3 (family history of stroke and age&gt;29).

Urinary N-acetyl-β-glucosaminidase and estimated Glomerular filtration rate may identify patients to be treated with immuno-suppression at diagnosis in idiopathic membranous nephropathy.

The clinical course of idiopathic membranous nephropathy (IMN) varies from spontaneous remission of nephrotic syndrome (NS) to end-stage renal disease (ESRD). The aim of the study was baseline identification of patients with high risk of progression for which immunosuppressive therapy is mandatory. Eighty-six IMN subjects were followed for a median of 69months (range 6-253). Receiver operating characteristic curve and Cox proportional hazards model were used to evaluate prognostic factors for progression, defined as ESRD or estimated glomerular filtration rate (eGFR) reduction ≥50% of baseline. Among all, 24 subjects had progression. Area under the ROC curve of N-acetyl-β-glucosaminidase/creatinine ratio (NAG/C) were significantly higher than proteinuria/24h (0.770 and 0.637 respectively, P = 0.018). In Cox proportional hazards regression analysis, NAG/C and eGFR were independent predictors of progression. Compared to lowest tertile of NAG/C (<9.4 UI/gC) or highest tertile of eGFR (≥88mL/min per 1.73m2 ), the multivariable-adjusted hazard ratio of highest tertile of NAG/C (≥19.2) was 18.97 (95%CI, 1.70-211.86) and lowest tertile of eGFR (<59) was 11.58 (95%CI, 2.02-66.29). Subjects with high NAG/C or low eGFR (high-risk, n=43) had greater progression rate compared to moderate to low NAG/C and high eGFR (low-risk, n=43) with or without NS at baseline (Log-rank test P = 0.001 and 0.006, respectively). In NS subjects (n=65), high-risk group progression rate was significantly higher (91% vs. 29%, P = 0.003) and remission rate significantly lower (0% vs. 42%, p<0.001) in non-immunosuppressed compared to steroids and cyclophosphamide treated patients; no significant differences were observed in low-risk group. Idiopathic membranous nephropathy subjects with high NAG/C and low eGFR have greater risk of progression, and immunosuppressive treatment is suggested at diagnosis.

Lingual flange protrusion: diagnostic marker for metastatic liver cancer

ObjectiveTo investigate the diagnostic significance of lingual flange protrusion for liver metastasis of patients with malignant neoplasia. MethodsThe data of 191 patients with malignant neoplasia were analyzed. All photos of patients' tongue image were recorded and lingual flange protrusion was the positive standard. χ2 test for paired data and Kappa test were used to determine the diagnostic value of lingual flange protrusion for metastatic liver cancer. Mann-Whitney U test was used to compare the levels of liver serological markers. The area under receiver operating characteristic curve (ROC) and logistic regression model were used to analyze the predictive values of lingual flange protrusion, alkaline phosphatase (ALP), and lactate dehydrogenase (LDH) levels. ResultsPatients with lingual flange protrusion had a higher risk of liver metastasis than those without it (P < 0.001). There was no significant difference in diagnosis of liver metastasis between lingual flange protrusion and traditional diagnostic criteria (P = 0.541). Kappa was 0.738 (P < 0.001). Lingual flange protrusion was significantly correlated with increased serum ALP and LDH levels (P < 0.01). Comparison of ROC curves showed that the diagnostic value of lingual flange protrusion is better than ALP, LDH and the combination of ALP and LDH (P < 0.01). Furthermore, the combined diagnostic values of lingual flange protrusion and ALP, lingual flange protrusion and LDH, and lingual flange protrusion, ALP and LDH are not better than lingual flange protrusion alone (P > 0.05). ConclusionLingual flange protrusion is a potential diagnostic marker for liver metastasis of patients with malignant neoplasia.

Accuracy of Presurgical Functional MR Imaging for Language Mapping of Brain Tumors: A Systematic Review and Meta-Analysis.

Purpose To compare functional magnetic resonance (MR) imaging for language mapping (hereafter, language functional MR imaging) with direct cortical stimulation (DCS) in patients with brain tumors and to assess factors associated with its accuracy. Materials and Methods PubMed/MEDLINE and related databases were searched for research articles published between January 2000 and September 2016. Findings were pooled by using bivariate random-effects and hierarchic summary receiver operating characteristic curve models. Meta-regression and subgroup analyses were performed to evaluate whether publication year, functional MR imaging paradigm, magnetic field strength, statistical threshold, and analysis software affected classification accuracy. Results Ten articles with a total of 214 patients were included in the analysis. On a per-patient basis, the pooled sensitivity and specificity of functional MR imaging was 44% (95% confidence interval [CI]: 14%, 78%) and 80% (95% CI: 54%, 93%), respectively. On a per-tag basis (ie, each DCS stimulation site or "tag" was considered a separate data point across all patients), the pooled sensitivity and specificity were 67% (95% CI: 51%, 80%) and 55% (95% CI: 25%, 82%), respectively. The per-tag analysis showed significantly higher sensitivity for studies with shorter functional MR imaging session times (P = .03) and relaxed statistical threshold (P = .05). Significantly higher specificity was found when expressive language task (P = .02), longer functional MR imaging session times (P < .01), visual presentation of stimuli (P = .04), and stringent statistical threshold (P = .01) were used. Conclusion Results of this study showed moderate accuracy of language functional MR imaging when compared with intraoperative DCS, and the included studies displayed significant methodologic heterogeneity. © RSNA, 2017 Online supplemental material is available for this article.

Early Warning Scores to Predict Noncritical Events Overnight in Hospitalized Medical Patients: A Prospective Case Cohort Study.

Physicians are often called to evaluate patients overnight with varying levels of clinical deterioration. Early warning scores predict critical clinical deterioration in patients; however, it is unknown whether they are able to reliably predict which patients will need to be seen overnight and whether these patients will require further resource use. A prospective case cohort study of 522 patient nights in a single tertiary care hospital in Vancouver, British Columbia, Canada, was conducted to assess the ability of Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) to predict patients who will need to be seen overnight by physicians and will require other healthcare resources. Prediction ability was assessed using area under the receiver operating characteristic curve and logistic regression models. The MEWS and NEWS both significantly predicted which patients needed to be seen overnight, and area under the receiver operating characteristic curves (95% confidence interval) for MEWS and NEWS were 0.72 (0.66-0.78) and 0.69 (0.63-0.76), respectively. Odds ratios (95% confidence interval) for MEWS and NEWS predicting need to be seen overnight were 1.52 (1.34-1.73) and 1.22 (1.14-1.31), respectively. Both MEWS and NEWS have fair ability to predict patients who will need to be seen overnight. This may be useful for improving handover and resource allocation for overnight care.

A predictive model for lack of partial clinical remission in new-onset pediatric type 1 diabetes

Importance>50% of patients with new-onset type 1 diabetes (T1D) do not enter partial clinical remission (PCR); early identification of these patients may improve initial glycemic control and reduce long-term complications.AimTo determine whether routinely obtainable clinical parameters predict non-remission in children and adolescents with new-onset T1D.Subjects and methodsData on remission were collected for the first 36 months of disease in 204 subjects of ages 2–14 years with new-onset type 1 diabetes. There were 86 remitters (age 9.1±3.0y; male 57%), and 118 non-remitters (age 7.0±3.1y; male 40.7%). PCR was defined as insulin-dose adjusted hemoglobin A1c of ≤9.ResultsNon-remission occurred in 57.8% of subjects. Univariable analysis showed that the risk for non-remission was increased 9-fold in patients with 4 diabetes-associated auto-antibodies (OR = 9.90, p = 0.010); 5-fold in patients <5 years old (odds ratio = 5.38, p = 0.032), 3-fold in those with bicarbonate of <15 mg/dL at diagnosis (OR = 3.71, p = 0.008). Combined estimates of risk potential for HC03 and the number of autoantibodies by multivariable analysis, adjusted for BMI standard deviation score, showed HC03 <15 mg/dL with a clinically significant 10-fold risk (OR = 10.1, p = 0.074); and the number of autoantibodies with a 2-fold risk for non-remission (OR = 1.9, p = 0.105). Male sex and older age were associated with decreased risk for non-remission. A receiver-operating characteristic curve model depicting sensitivity by 1-specificity for non-remission as predicted by bicarbonate <15 mg/dL, age <5y, female sex, and >3 diabetes-associated autoantibodies had an area under the curve of 0.73.ConclusionsMore than 50% of children and adolescents with new-onset T1D do not undergo partial clinical remission and are thus at an increased risk for long-term complications of diabetes mellitus. A predictive model comprising of bicarbonate <15 mg/dL, age <5y, female sex, and >3 diabetes-associated autoantibodies has 73% power for correctly predicting non-remission in children and adolescents with new-onset T1D. Early identification of these non-remitters may guide the institution of targeted therapy to limit dysglycemia and reduce the prevalence of long-term deleterious complications.

Dosimetric Predictors of Patient-Reported Xerostomia and Dysphagia With Deintensified Chemoradiation Therapy for HPV-Associated Oropharyngeal Squamous Cell Carcinoma

To estimate the association between different dose-volume metrics of the salivary glands and pharyngeal constrictors with patient reported severity of xerostomia/dysphagia in the setting of deintensified chemoradiation therapy (CRT). Forty-five patients were treated on a phase 2 study assessing the efficacy of deintensified CRT for favorable-risk, HPV-associated oropharyngeal squamous cell carcinoma. Patients received 60Gy intensity modulated radiation therapy with concurrent weekly cisplatin (30mg/m2), and reported the severity of their xerostomia/dysphagia (before and after treatment) using the patient-reported outcome version of the Common Terminology Criteria for Adverse Events (CTCAE) (PRO-CTCAE). Individual patient dosimetric data of the contralateral parotid and submandibular glands and pharyngeal constrictors were correlated with changes in PRO-CTCAE severity. A change in severity (from baseline) of ≥2 was considered clinically meaningful. Associations between dose-volume metrics and patient outcomes were assessed with receiver operating characteristic (ROC) curve and logistic regression model. Six months after CRT, patients reporting <2 change in xerostomia severity (n=14) had an average Dmean = 22 ± 9 Gy to the sum of the contralateral glands (parotid + submandibular) compared with the patients reporting ≥2 change (n=21), who had an average Dmean = 34 ± 8 Gy. V15 to V55 for the combined contralateral glands showed the strongest association with xerostomia (area under the curve [AUC] = 0.83-0.86). Based on the regression analysis, a 20% risk of toxicity was associated with V15=48%, V25=30%, and Dmean=21Gy. Six months after CRT, patients reporting <2 change in dysphagia severity (n=26) had an average V55=76±13 (%) to the superior pharyngeal constrictor compared with the patients reporting ≥2 change in severity (n=9), who had average V55=89±13 (%). V55to V60 had the strongest association with dysphagia (AUC=0.70-0.75). Based on the regression analysis, a 20% risk of toxicity was associated with V55=78%, V60=40%. The findings at 12months were similar. After deintensified CRT, the rate of patient-reported xerostomia/dysphagia appears to be associated with the V15 of the combined contralateral salivary glands and V55 to V60 of the superior pharyngeal constrictors.

Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic review.

OBJECTIVE The goal of this study was to evaluate the efficacy of intraoperative transcranial motor evoked potential (TcMEP) monitoring in predicting an impending neurological deficit during corrective spinal surgery for patients with idiopathic scoliosis (IS). METHODS The authors searched the PubMed and Web of Science database for relevant lists of retrieved reports and/or experiments published from January 1950 through October 2014 for studies on TcMEP monitoring use during IS surgery. The primary analysis of this review fit the operating characteristic into a hierarchical summary receiver operating characteristic curve model to determine the efficacy of intraoperative TcMEP-predicted change. RESULTS Twelve studies, with a total of 2102 patients with IS were included. Analysis found an observed incidence of neurological deficits of 1.38% (29/2102) in the sample population. Of the patients who sustained a neurological deficit, 82.8% (24/29) also had irreversible TcMEP change, whereas 17.2% (5/29) did not. The pooled analysis using the bivariate model showed TcMEP change with sensitivity (mean 91% [95% CI 34%-100%]) and specificity (mean 96% [95% CI 92-98%]). The diagnostic odds ratio indicated that it is 250 times more likely to observe significant TcMEP changes in patients who experience a new-onset motor deficit immediately after IS correction surgery (95% CI 11-5767). TcMEP monitoring showed high discriminant ability with an area under the curve of 0.98. CONCLUSIONS A patient with a new neurological deficit resulting from IS surgery was 250 times more likely to have changes in TcMEPs than a patient without new deficit. The authors' findings from 2102 operations in patients with IS show that TcMEP monitoring is a highly sensitive and specific test for detecting new spinal cord injuries in patients undergoing corrective spinal surgery for IS. They could not assess the value of TcMEP monitoring as a therapeutic adjunct owing to the limited data available and their study design.