Cleveland Clinic Score Research Articles

Effect of thumbtack needle on functional constipation: A pragmatic randomized controlled trial

ObjectiveThumbtack Needling (TN) has been employed in the treatment of functional constipation (FC), although the existing evidence supporting its effectiveness is limited. This study is to evaluate the efficacy of TN in ameliorating FC. MethodA total of 482 eligible patients were recruited and randomly assigned to the TN group or the Mosapride Citrate (MC) group. The TN was buried once for three days, rest for one day after two consecutive burials, followed by a 4-week follow-up. The primary outcome measure was the score for Complete and spontaneous bowel movement score (CSBMs). Secondary outcome measures included the Bristol Stool Form Scale (BSFS), Cleveland Clinic Score (CCS), and the Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QOL). ResultsOut of the 482 patients randomized, 241 were allocated to each group. Of these, 216 patients (89.6 %) in both groups completed the intervention and follow-up. Compared with the baseline, the differences of CSBMs in TN group [1.76(95 % CI, 1.61 to 1.91)] and MC group [1.35(95 % CI, 1.20 to 1.50)] at week 4 meet the threshold for minimal clinically important difference (MCID). However, there were no clinical difference from baseline at week 2 and week 8 in both groups. Mean CSBMs at week 4 was 3.35 ± 0.99 in the TN group and 3 ± 1.03 in the MC group (adjusted difference between groups, 0.37 points [95 % CI, 0.18 to 0.55]; P < 0.001), although differences between the two groups did not meet the MCID threshold. ConclusionCompared with mosapride citrate, thumbtack needling produced a greater improvement in CSBMs, although the difference from control was not clinically significant. ClinicalTrials.gov identifierChiCTR2100043684

Tissue Inhibitor Metalloproteinase-2·IGF-Binding Protein 7 for the Prediction of Acute Kidney Injury following Cardiac Surgery

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication associated with increased morbidity and mortality. Tissue inhibitor metalloproteinase-2·insulin-like growth factor-binding protein 7 (TIMP-2·IGFBP7) determines tubular stress markers, which may occur prior to tubular damage. Previous studies on the use of TIMP-2·IGFBP7 for the prediction of CSA-AKI showed divergent results. Therefore, this study aimed to explore the predictive value of TIMP-2·IGFBP7 measurements for the early detection of acute kidney injury (AKI) and short-term adverse outcomes after cardiac surgery. Methods: In the prospective cohort study, blood and urine samples were collected 6–12 h after cardiac surgery. Blood samples to monitor serum creatinine levels were additionally extracted from days 1 to 7. AKI was defined based on the KDIGO consensus guidelines. AKI within 7 days following surgery was the primary outcome. The initiation of renal replacement therapy, in intensive care unit mortality, and the combination of both were secondary outcomes. Results: A total of 557 patients were enrolled; 134 (24.06%) of them developed AKI and 33 (5.9%) had moderate or severe AKI. AKI developed more frequently in elderly patients with diabetes or with higher baseline serum creatinine levels. Patients with AKI had higher EuroSCORE II, Cleveland Clinic Score, and simplified renal index (SRI) than those without AKI. Urinary TIMP-2·IGFBP7 was significantly higher in patients with AKI. The area under the curve was 0.66 in predicting all AKI and 0.70 in predicting stages 2 and 3 AKI. The resulting sensitivity and specificity were 44.0% and 83.9%, respectively, for a calculated threshold TIMP-2·IGFBP7 value of 0.265 (ng/mL)2/1,000. The TIMP-2·IGFBP7 values, SRI score, and age were significantly associated with AKI within 7 days postoperatively. A total of 33 patients reached the composite endpoint; the percentage of patients who reached the composite endpoint in the TIMP-2·IGFBP7 of >0.265 (ng/ml)2/1,000 group was significantly higher than that of ≤0.265 (ng/mL)2/1,000 group. Conclusions: Postoperative implementation of TIMP-2·IGFBP7 improved the prediction of CSA-AKI and may aid in identifying patients at risk of short-term adverse outcomes. We identified an ideal calculated cutoff value of 0.265 (ng/mL)2/1,000 for the prediction of CSA-AKI among all AKI patients.

Anatomical sphincteroplasty as a surgical treatment for faecal incontinence: proposal for a global anatomical reconstructive surgical procedure and results from a case series.

The aim of this study is to describe the technical details and clinical and functional results of anatomical sphincteroplasty as a global reconstructive surgery for the treatment of faecal incontinence caused by anal sphincter lesions. This was a prospective, longitudinal study that included patients who underwent the anatomical sphincteroplasty procedure described here to treat complete sphincter damage. We have described the different technical steps in detail. We evaluated the intraoperative and postoperative complications rate, Cleveland Clinic Score (CCS), a modification of the CCS that included soiling (mCCS), the Faecal Incontinence Quality of Life Scale (FIQLS), and patient satisfaction. An endoanal ultrasound and anorectal manometric study were performed in all the patients. Forty-four patients were included with a mean of 40.5months follow-up. The CCS reduced from 15 to 3.3 points and the mCCS from 18.5 to 4.5 points over the study period; p < 0.001. Excellent or good results were achieved in 93% of cases. Endoanal ultrasounds showed a good sphincter repair in 66% of the cases. Anorectal manometry showed an increase in the mean maximal resting pressure from 27.6mmHg to 41.7mmHg and of the maximal squeeze pressure from 57.9 to 93mmHg (p < 0.001) with respect to the preoperative values. Anatomical sphincteroplasty is a surgical proposal for the global anatomical reconstruction of anal sphincter lesions, even in cases of very severe damage. The procedure is safe and produced excellent clinical and functional results after a medium-term follow-up.

Prediction of acute kidney injury incidence following acute type A aortic dissection surgery with novel biomarkers: a prospective observational study

BackgroundAcute kidney injury (AKI) is a prevalent complication following acute type A aortic dissection (ATAAD) surgery and is closely associated with unfavorable prognostic outcomes. Hence, the development of a robust and efficient diagnostic approach to identify high-risk patients is of paramount importance.MethodsWe conducted a prospective study involving 328 patients who underwent ATAAD surgery at our institution, comprising three distinct cohorts. In addition, 52 patients undergoing alternative cardiopulmonary surgeries and 37 healthy individuals were enrolled as control groups. Employing proteomic analysis, we initially identified plasma proteins potentially linked to AKI occurrence within the plasma proteomic cohort. Subsequent validation was performed in an independent cohort. Utilizing predictors derived from multivariate logistic regression analysis, a nomogram was meticulously formulated and its efficacy was validated in the model construction cohort.ResultsProteomics revealed significant elevation of plasma levels of S100A8/A9, pentraxin 3 (PTX3), and chitinase 3-like 1 (CHI3L1) immediately post-surgery in patients who developed ATAAD surgery-associated AKI (ASA-AKI). Receiver operating characteristic (ROC) curves demonstrated impressive predictive performance of S100A8/A9, PTX3, and CHI3L1 at 0 h post-surgery, yielding area under the curve (AUC) values of 0.823, 0.786, and 0.803, respectively, for ASA-AKI prediction. Furthermore, our findings exhibited positive correlations between plasma levels of S100A8/A9, PTX3, CHI3L1, and urinary neutrophil gelatinase-associated lipocalin (NGAL) at 0 h post-surgery, along with correlations between plasma S100A8/A9, CHI3L1 levels, and the Cleveland Clinic score. A logistic regression model incorporating plasma S100A8/A9, PTX3, CHI3L1 levels, urinary NGAL levels, and the Cleveland Clinic score facilitated the construction of a predictive nomogram for ASA-AKI. This nomogram demonstrated robust discriminative ability, achieving an AUC of 0.963 in the model construction cohort.ConclusionsOur study underscored the augmentation of plasma S100A8/A9, PTX3, and CHI3L1 levels immediately post-surgery in patients developing ASA-AKI. The incorporation of these three biomarkers, in conjunction with the Cleveland Clinic score and NGAL, into a nomogram demonstrated commendable predictive efficacy. This presents a practical tool for identifying patients at an elevated risk of AKI following ATAAD surgery.

Development, validation, and comparative analysis of a simple clinical and laboratory-based risk score system for predicting and stratifying moderate-to-severe AKI after cardiac surgery

Abstract Background Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is prevalent and detrimental following cardiac surgery, without effective prevention. Early prediction and stratification are critical in informing appropriate care. Recent studies highlighted the predictive value of some routine laboratory markers in addition to traditional clinical variables. However, existing models suffer from complexity and practical difficulties in implementation. Purpose We aim to develop a high-performance preoperative risk score system for predicting moderate-to-severe CSA-AKI, while preserving its simplicity and utility through the integration of the most predictive and routinely accessible clinical and laboratory variables. Methods A total of 14 303 patients undergoing coronary artery bypass grafting surgery at a single institution, with comprehensive perioperative data, were included. Cohort 1 (N=9 416, 2013-2017) and cohort 2 (N=4 887, 2018-2019) were used to develop and validate a risk score system for predicting moderate-to-severe CSA-AKI, respectively, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Bootstrapped stepwise regression was employed to select the robust candidate variables for a logistic regression model (i.e., the full model), which was then simplified to a more parsimonious model. Model performance was evaluated and compared to several established models. Results The overall incidence of moderate-to-severe CSA-AKI was 3.5% in the entire cohort. Two preoperative risk scores were developed: the simple 6-variable ABC2-Surgery2 score (age, a biomarker of NT-proBNP, two clinical status variables of hypertension and preoperative critical state, and two surgery-related variables of combined surgery and on-pump surgery), and the complete 10-variable AB2C3-Surgery4 score (ABC2-Surgery2 plus an additional biomarker of blood urea nitrogen, a clinical status variable of Canadian Cardiovascular Society angina class, and two surgery-related variables of urgent surgery and previous surgery). In the validation cohort, the simple score (area under the curve, AUC 0.765) outperformed the previously established UK-AKI model (AUC 0.720), Mehta score (AUC 0.700), and Ng score (AUC 0.697), while statistically similar to the most complex 19-variable Cleveland Clinic Score (AUC 0.725). The complete score (AUC 0.777) was superior to all four models. The current score system also effectively stratified CSA-AKI with respect to requirements for vasoactive support (measured by cumulative vasoactive-inotropic score), intravenous diuretics, and renal replacement therapy, as well as in-hospital and long-term mortality. Conclusion A simple risk score system incorporating routine clinical and laboratory variables was developed to predict and stratify moderate-to-severe CSA-AKI and outperformed previous complex models. Further external validation is currently underway for generalizability.

Improving the performance of the Cleveland Clinic Score for predicting acute kidney injury after cardiac surgery: a prospective multicenter cohort study.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is associated with high short- and long-term mortality rates. The prediction of CSA-AKI is crucial for early detection and treatment. Current predictive models may be improved by potentially useful preoperative and intraoperative information. This multicenter prospective cohort study recruited 261 consecutive patients at high risk for developing CSA-AKI, based on a Cleveland Clinical Score (CCS) of ≥4 points from July to December 2017 in 14 hospitals in Spain and the UK. Postoperative AKI occurred in 145 (55.5%) patients. The receiver operating characteristics curve (AUC) of a base model including only the CCS was compared with models including additional preoperative and intraoperative variables such as the estimated glomerular filtration rate (eGFR) instead of plasmatic creatinine, intraoperative urine output, baseline hemoglobin, nadir hemoglobin, and glycosylated hemoglobin (HbA<inf>1c</inf>) instead of diabetes mellitus. The performance of each model for AKI was compared. The CCS alone gave an AUC of 0.67 (95% CI, 0.56-0.78) for postoperative AKI. None of the single variables added to the base model CCS improve discrimination. The AUC for postoperative AKI was improved when baseline hemoglobin, eGFR instead of plasmatic creatinine, HbA<inf>1c</inf>, and nadir hemoglobin were added to the CCS (AUC=0.77; 95% CI, 0.67-0.87; P=0.02). The addition of baseline hemoglobin, eGFR, HbA<inf>1c</inf>, and nadir intraoperative hemoglobin may be useful for improving the discrimination of the clinical predictive risk scores for AKI.

Derivation and Validation a Risk Model for Acute Kidney Injury and Subsequent Adverse Events After Cardiac Surgery: A Multicenter Cohort Study.

PurposeTo establish a risk model for acute kidney injury and subsequent adverse events in Chinese cardiac patients.Patients and MethodsThis study included 11,740 patients who had cardiac surgery at 14 institutions in China. Patients were randomly assigned to a derivation cohort (n = 8197) or a validation cohort (n = 3543). Variables ascertained during hospitalization were screened using least absolute shrinkage and selection operator and logistic regression to construct a nomogram model. Model performance was evaluated using C-statistic, calibration curve, and Brier score. The nomogram was further compared with the five conventional models: Mehta score, Ng score, AKICS score, SRI score, and Cleveland Clinic score. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcomes criteria. Subsequent adverse events included mid-term outcomes: death from all causes and major adverse kidney events (defined as composite outcome of death from renal failure, dialysis, and advanced chronic kidney disease).ResultsAcute kidney injury occurred in 3237 (27.6%) patients. The model included 12 predictors. The total score generated from the nomogram ranged from 0 to 556. The nomogram achieved a C-statistic of 0.825 and 0.804 in the derivation and validation cohorts, respectively, and had well-fitted calibration curves. The model performance of the nomogram was better than other five conventional models. After risk stratification, moderate-risk or high-risk groups were associated with significantly higher rates of death from all causes and major adverse kidney events compared with low-risk group during 7-year follow-up.ConclusionThe nomogram could serve as an effective tool for predicting acute kidney injury and evaluating its subsequent adverse events after cardiac surgery.

A new model to predict acute kidney injury after cardiac surgery in patients with renal insufficiency

Objective To establish a simple model for predicting postoperative acute kidney injury (AKI) requiring renal replacement therapy (RRT) in patients with renal insufficiency (CKD stages 3–4) who underwent cardiac surgery. Methods A total of 330 patients were enrolled. Among them, 226 were randomly selected for the development group and the remaining 104 for the validation group. The primary outcome was AKI requiring RRT. A nomogram was constructed based on the multivariate analysis with variables selected by the application of the least absolute shrinkage and selection operator. Meanwhile, the discrimination, calibration, and clinical power of the new model were assessed and compared with those of the Cleveland Clinic score and Simplified Renal Index (SRI) score in the validation group. Results: The rate of RRT in the development group was 10.6% (n = 24), while the rate in the validation group was 14.4% (n = 15). The new model included four variables such as postoperative creatinine, aortic cross‐clamping time, emergency, and preoperative cystatin C, with a C-index of 0.851 (95% CI, 0.779–0.924). In the validation group, the areas under the receiver operating characteristic curves for the new model, SRI score, and Cleveland Clinic score were 0.813, 0.791, and 0.786, respectively. Furthermore, the new model demonstrated greater clinical net benefits compared with the Cleveland Clinic score or SRI score. Conclusions We developed and validated a powerful predictive model for predicting severe AKI after cardiac surgery in patients with renal insufficiency, which would be helpful to assess the risk for severe AKI requiring RRT.

Risk Factors for Acute Kidney Injury Following Cardiac Surgery and Performance of Leicester Score in a Spanish Cohort.

The incidence of acute kidney injury following cardiac surgery (CSA-AKI) is up to 30%, and it places patients at an increased risk of death. The Leicester score (LS) is a new score that predicts CSA-AKI of any stage with better discrimination compared to previous scores. The aim of this study was to identify risk factors for CSA-AKI and to assess the performance of LS. A unicentric retrospective study of patients that required cardiac surgery with cardio-pulmonary bypass (CPB) in 2015 was performed. The inclusion criteria were patients over 18 years old who were operated on for cardiac surgery (valve substitution (VS), Coronary Artery Bypass Graft (CABG), or a combination of both procedures and requiring CPB). CSA-AKI was defined with the Kidney Disease Improving Global Outcomes (KDIGO) criteria. In the multivariate analysis, hypertension (odds ratio 1.883), estimated glomerular filtration rate (EGFR) <60 mL/min (2.365), and peripheral vascular disease (4.66) were associated with the outcome. Both discrimination and calibration were better when the LS was used compared to the Cleveland Clinic Score and Euroscore II, with an area under the curve (AUC) of 0.721. In conclusion, preoperative hypertension in patients with CKD with or without peripheral vasculopathy can identify patients who are at risk of CSA-AKI. The LS was proven to be a valid score that could be used to identify patients who are at risk and who could benefit from intervention studies.

A Clinical Score to Predict Acute Renal Failure after Cardiac Surgery in Egypt

Background: Acute Kidney Injury (AKI) after cardiac surgery is a serious complication. AKI could occur in 30% of patients, and 1-5% develop severe kidney injury. The present study aimed to evaluate the use of the Cleveland Clinic Score (CCS) to identify patients at higher risk of AKI after cardiac surgery.&#x0D; Methods: This study included 100 patients, 83 were males, and the mean age was 52.47±11.3 years. All patients had elective operations; 30% had isolated valve surgery, 64% had isolated coronary artery bypass grafting (CABG), and 6% had combined CABG and valve operation.&#x0D; Results: Creatinine serum level ranged between 0.5-2 mg/dL with a mean of 0.98±0.32 mg/dL. Seventy-four patients had good renal function postoperatively, and their CCS was 1.45±0.36, while 26 patients had renal impairment, and their CCS was 12.5±0.44 (P= 0.001). Patients who had AKI were older (62.87±8.7 vs. 49.9±13.9; P&lt;0.001) and had higher preoperative creatinine (1.1±0.32 vs. 0.94±0.31; P= 0.03). AKI was more common in diabetics (23 (88.5%) vs. 28 (37.85, P&lt;0.001) and patients with COPD (6 (23.1%) vs. 3 (4.1%); P= 0.004). CCS score was significantly higher among the different degrees of severity of AKI.&#x0D; Conclusion: Cleveland Clinic Score could be good for predicting acute kidney injury after cardiac surgery.

D-pouch: a modified ileal J-pouch for patients with ulcerative colitis and familial adenomatous polyposis.

Ileal J-pouch anal anastomosis (J-IPAA) is the standard approach for patients requiring restorative proctocolectomy due to familial adenomatous polyposis (FAP) or ulcerative colitis (UC). To obviate the risk of a J-tip leak, we modified the J-pouch with a D-pouch anal anastomosis (D-IPAA) designed to eliminate the ileal stump. The aim of our study was to evaluate the feasibility, safety and medium-term functional outcomes of D-IPAA. A retrospective comparison was made between D-IPAA and J-IPAA constructions after a restorative proctocolectomy. Clinical data were collated between October 2014-March 2018 recording operation duration, pouch construction time, pouch volume, intraoperative estimated blood loss, complication rates, readmissions and cumulative length of hospitalization. Continence was assessed at the final visit with the Wexner Cleveland Clinic Score along with the Cleveland Global Quality of Life (CGQL) scale. A total of 97 patients with FAP (n = 28) and UC (n = 69) who had J-IPAA (n = 54) or D-IPAA (n = 43) after proctocolectomy were identified. Patients were well matched with no differences noted in the intraoperative variables between the J- and D-pouch groups. The D-pouch construction time was shorter than that for a standard J-pouch. There was no difference in major or minor complications between groups.Apouchleak developed in each group: a cutaneous fistula from J tip leak in the J-IPAA groupand a pouch-vaginal fistula from the IPAAthe D-IPAA group. Clinical outcomes (the number of bowel movements) were equivalent in the two groups with the Wexner score significantly improving within each group up to 2.5years and with improvement in the CGQL after surgery. The D-pouch construction is safe and feasible for patients with UC and FAP with good functional outcome over the medium term and the potential to reduce the risk of pouchleaks.

Acupoint catgut embedding therapy for functional constipation: A protocol for systematic review and meta-analysis.

Background:This review will assess current evidence related to the effectiveness and safety of acupoint catgut embedding therapy for functional constipation (FC) and provide efficacy assessments for clinical applications.Methods:We will search the following databases for relevant trials: PubMed, EMBASE OVID, Cumulative Index of Nursing and Allied Health Literature, OVID MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, Cochrane library, and Scopus. We will also search the following Chinese databases for trials published in the Chinese literature: China National Knowledge Infrastructure Database (CNKI), Chinese Scientific Journals Database, Wan Fang Database, Chinese Biomedicine and other resources from inception to December 2020. Only randomized controlled trials comparing acupoint catgut embedding versus acupuncture or sham acupuncture or placebo or other therapies will be included. The outcomes involved mean spontaneous bowel movements, complete spontaneous bowel movements, the Bristol Stool Form Scale, the Cleveland Clinic Score, Patient Assessment of Constipation symptom and so on. The risk of bias assessment and quality of evidence for outcomes will be appraised using the Cochrane Risk of Bias Tool and the Grading of Recommendations, Assessment, Development and Evaluation guidelines. RevMan 5.3 software will be employed for the meta-analysis.Results:This work will compare and arrange the comparative efficacy of acupoint catgut embedding with different treatments for FC by summarizing the current evidences.Conclusion:The results of this meta-analysis may help doctors determine the best treatments for patients to manage FC.Ethics and dissemination:This is a protocol with no patient recruitment and personal information collection, approval by the ethics committee is not required.OSF Registration number:DOI 10.17605/OSF.IO/XTKE2.

Relying on ST Segment Depression alone to Predict Ischemic Heart Disease- How Far We can Go ?

Introduction: Ischemic heart disease (IHD) or coronary artery disease (CAD) has become predominant cause of death across the world and frequently stable angina, which is the most common presentation of this disease, gives hard time to reach a proper diagnosis due to duality of non-invasive testing. While Exercise Treadmill Test (ETT) is an inexpensive non-invasive modality which may have many output depending on method of interpretation, ST segment depression is much utilized but traditionally less perfect than available treadmill scores. We have compared its accuracy to Duke Treadmill Score (DTS), Simple Treadmill Score (STS) and Cleveland Clinic Score (CCS) among Bangladesh people to generate a local insight.&#x0D; Objective: To estimate and compare accuracy of ST segment response, DTS, Simple Treadmill Score and Cleveland Clinic Score to predict CAD.&#x0D; Method: In a cross-sectional study total 130 patients who had visited at a medical university with stable chest pain were selected according to predefined inclusion and exclusion criteria over one year. After taking proper history and physical examination their ETT report and Coronary Angiogram (CAG) finding, which were done according to indication defined by their consultants. ETT interpretation as ST segment response and treadmill scores were compared with gold standard test for CAD that is CAG. Accuracy of STdepression and treadmill scores were calculated by the formula “Accuracy = TP+TN / Total Sample”.&#x0D; Result: Among the total sample (n=130) male and female were 93 &amp; 37, respectively. Nearly half of male sample fell into 5th decade and around same portion of female sample was in 4th decade. About 58%, 28% &amp; 14% patients came with typical, atypical &amp; non-cardiac chest pain. As calculated with above mentioned formula accuracy of ST segment response alone to diagnose IHD came about 68.4% (p value 0.004). Similarly DTS, STS and CCS had 83.3%, 83.9% and 77.2% accuracy, respectively (p value 0.000).&#x0D; Conclusion: During ETT relying on ST segment depression alone to diagnose CAD is significantly less accurate than treadmill scores namely, Duke Treadmill Score, Simple treadmill Score or Cleveland Clinic Score. Applying any of these treadmill scores during exercise test interpretation can identify ischemic heart disease patients with more accuracy.&#x0D; University Heart Journal Vol. 17, No. 1, Jan 2021; 10-15

Development and validation of a model for predicting acute kidney injury after cardiac surgery in patients of advanced age.

ObjectiveTo develop a clinical model for predicting postoperative acute kidney injury (AKI) in patients of advanced age undergoing cardiac surgery.MethodsA total of 848 patients (aged ≥ 60 years) undergoing cardiac surgery were consecutively enrolled. Among them, 597 were randomly selected for the development set and the remaining 251 for the validation set. AKI was the primary outcome. To develop a model for predicting AKI, visualized as a nomogram, we performed logistic regression with variables selected by Lasso regression analysis. The discrimination, calibration, and clinical usefulness of the new model were assessed and compared with those of Cleveland Clinic score and Simplified Renal Index (SRI) score in the validation set.ResultsThe incidence of AKI was 61.8% in the development set. The new model included seven variables including preoperative serum creatinine, hypertension, preoperative uric acid, New York Heart Association classification ≥ 3, cardiopulmonary bypass time > 120 min, intraoperative red blood cell transfusion, and postoperative prolonged mechanical ventilation. In the validation set, the areas under the receiver operating characteristic curves for assessing discrimination of the new model, Cleveland Clinic score, and SRI score were 0.801, 0.670, and 0.627, respectively. Compared with the other two scores, the new model presented excellent calibration according to the calibration curves. Decision curve analysis presented the new model was more clinically useful than the other two scores.ConclusionsWe developed and validated a new model for predicting AKI after cardiac surgery in patients of advanced age, which may help clinicians assess patients' risk for AKI.

Machine Learning Algorithms for Predicting and Risk Profiling of Cardiac Surgery-Associated Acute Kidney Injury

Using a large national database of cardiac surgical procedures, we applied machine learning (ML) to risk stratification and profiling for cardiac surgery-associated acute kidney injury. We compared performance of ML to established scoring tools. Four ML algorithms were used, including logistic regression (LR), gradient boosted machine (GBM), K-nearest neighbor, and neural networks (NN). These were compared to the Cleveland Clinic score, and a risk score developed on the same database. Five-fold cross-validation repeated 20 times was used to measure the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. Risk profiles from GBM and NN were generated using Shapley additive values. A total of 97,964 surgery events in 96,653 patients were included. For predicting postoperative renal replacement therapy using pre- and intraoperative data, LR, GBM, and NN achieved an AUC (standard deviation) of 0.84 (0.01), 0.85 (0.01), 0.84 (0.01) respectively outperforming the highest performing scoring tool with 0.81 (0.004). For predicting cardiac surgery-associated acute kidney injury, LR, GBM, and NN each achieved 0.77 (0.01), 0.78 (0.01), 0.77 (0.01) respectively outperforming the scoring tool with 0.75 (0.004). Compared to scores and LR, shapely additive values analysis of black box model predictions was able to generate patient-level explanations for each prediction. ML algorithms provide state-of-the-art approaches to risk stratification. Explanatory modeling can exploit complex decision boundaries to aid the clinician in understanding the risks specific to individual patients.

LONG-TERM EVOLUTION OF CONTINENCE AND QUALITY OF LIFE AFTER SPHINCTEROPLASTY FOR OBSTETRIC FECAL INCONTINENCE.

PurposeThis study was performed to evaluate the long-term evolution of continence and patient’s quality of life after surgical treatment for obstetric fecal incontinence.MethodsA prospective longitudinal study was conducted including consecutive patients who underwent sphincteroplasty for severe obstetric fecal incontinence. The first phase analyzed changes in continence and impact on quality of life. The second phase studied the long-term evolution reevaluating the same group of patients 6 years later. Degree of fecal incontinence was calculated using the Cleveland Clinic Score (CCS). Quality of life assessment was carried out with the Fecal Incontinence Quality of Life scale.ResultsThirty-five patients with median age of 55 years (range, 28 to 73 years) completed the study. Phase 1 results: after a postoperative follow-up of 30 months (4 to 132 months), CCS had improved significantly from a preoperative of 15.7 ± 3.1 to 6.1 ± 5.0 (P < 0.001). Phase 2 results: median follow-up in phase 2 was 110 months (76 to 204 months). The CCS lowered to 8.4 ± 4.9 (P = 0.04). There were no significant differences between phases 1 and 2 in terms of quality of life; lifestyle (3.47 ± 0.75 vs. 3.16 ± 1.04), coping/behavior (3.13 ± 0.83 vs. 2.80 ± 1.09), depression/self-perception (3.65 ± 0.80 vs. 3.32 ± 0.98), and embarrassment (3.32 ± 0.90 vs. 3.12 ± 1.00).ConclusionSphincteroplasty offers good short-medium term outcomes in continence and quality of life for obstetric fecal incontinence treatment. Functional clinical results deteriorate over time but did not impact on patients’ quality of life.

An Integrated Deep-Mutational-Scanning Approach Provides Clinical Insights on PTEN Genotype-Phenotype Relationships

Germline variation in PTEN results in variable clinical presentations, including benign and malignant neoplasia and neurodevelopmental disorders. Despite decades of research, it remains unclear how the PTEN genotype is related to clinical outcomes. In this study, we combined two recent deep mutational scanning (DMS) datasets probing the effects of single amino acid variation on enzyme activity and steady-state cellular abundance with a large, well-curated clinical cohort of PTEN-variant carriers. We sought to connect variant-specific molecular phenotypes to the clinical outcomes of individuals with PTEN variants. We found that DMS data partially explain quantitative clinical traits, including head circumference and Cleveland Clinic (CC) score, which is a semiquantitative surrogate of disease burden. We built logistic regression models that use DMS and CADD scores to separate clinical PTEN variation from gnomAD control-only variation with high accuracy. By using a survival-like analysis, we identified molecular phenotype groups with differential risk of early cancer onset as well as lifetime risk of cancer. Finally, we identified classes of DMS-defined variants with significantly different risk levels for classical hamartoma-related features (odds ratio [OR] range of 4.1-102.9). In stark contrast, the risk for developing autism or developmental delay does not significantly change across variant classes (OR range of 5.4-12.4). Together, these findings highlight the potential impact of combining DMS datasets with rich clinical data and provide new insights that might guide personalized clinical decisions for PTEN-variant carriers.

Prediction of acute kidney injury after left ventricular assist device implantation: Evaluation of clinical risk scores.

Acute kidney injury (AKI) is frequent in patients scheduled for implantation of a left ventricular assist device (LVAD) and associated with increased mortality. Although several risk models for the prediction of postoperative renal replacement therapy (RRT) have been developed for cardiothoracic patients, none of these scoring systems have been validated in LVADpatients. A retrospective, single center analysis of all patients undergoing LVAD implantation between September 2013 and July 2016 was performed. Primary outcome was AKI requiring RRT within 14 days after surgery. The predictive capacity of the ClevelandClinicScore (CCS), the SocietyofThoracicSurgeonsScore (STS), and the Simplified Renal Index Score(SRI) were evaluated. 76 patients underwent LVADimplantation, 19 patients were excluded due to preoperative RRT. RRT was associated with a prolonged ventilation time, length of stayon the ICU and 180 day mortality (14(60.9%) vs 6(17.6%), P<.01). Whereas the Thakar Score (7.43±1.75 vs 6.44±1.44, P=.02) and the Mehta Score (28.12±15.08 vs 21.53±5.43, P=.02) were significantly higher in patients with RRT than in those without RRT, the SRI did not differ between these groups (3.96±1.15 vs 3.44±1.05, P=.08). Using ROCanalyses, CCS, STS, and SRI showed moderate predictive capacity for RRT with an AUC of 0.661 ± 0.073 (P=.040), 0.637±0.079 (P=.792), and 0.618±0.075 (P=.764), respectively, with comparable accuracy in the Delong test. Using univariate logistic regression analysis, only the De RitisRatio (OR 2.67, P=.034) and MELD (OR 1.11, P=.028) were identified as predictors of postoperative RRT. Risk scores which arepredictive in general cardiac surgery cannot predict RRT in patients after LVAD implantation. Therefore, it seems to be necessary to develop a specific risk score for this patient population.

A Clinical Score to Predict Severe Acute Kidney Injury in Chinese Patients after Cardiac Surgery

Background/Aims: Cardiac surgery-associated severe acute kidney injury (SAKI) is associated with high mortality and poor quality of life. A prognostic score for SAKI may enable prevention of complications. Methods: This observational study of 2,552 patients undergoing cardiac surgery from January 2006 to December 2011 in our institution established associations between predictor variables and postoperative SAKI from a cohort of 1,692 patients and developed a clinical score that was assessed in a validation cohort of 860 patients. Results: Postoperative SAKI occurred in 262 ­patients (10.3%). We identified 7 independent and significant risk factors in the derivation model (adjusted OR 95% CI): age ≥81 years (vs. age < 40 years, 4.30, 1.52–12.21), age 61–80 years (vs. age < 40 years, 2.84, 1.24–6.52), age 41–60 years (vs. age < 40 years, 1.62, 0.68–3.87), hypertension (1.65, 1.13–2.39), previous cardiac surgery (3.62, 1.27–10.32), ­hyperuricemia (2.02, 1.40–2.92), prolonged operation time (1.32, 1.17–1.48), postoperative central venous pressure < 6 mm H₂O (3.53, 2.38–5.23), and low postoperative cardiac output (4.78, 2.97–7.69). The 7-variable risk prediction model had acceptable performance characteristics in the validation cohort (C statistic 0.80, 95% CI 0.74–0.85). The difference in the C statistic was 0.21 (95% CI 0.12–0.29, p < 0.001) compared with the Cleveland Clinic score. Conclusion: We developed and validated a practical risk prediction model for SAKI after cardiac surgery based on routinely available perioperative clinical and laboratory data. The prediction model can be easily applied at the bedside and provides a simple and interpretable estimation of risk.

Cleveland Clinic Socre – What is the Role of a Novel Prognostic Treadmil Score to Diagnose Coronary Artery Disease?

Background: Ischemic heart disease is increasing all over the world even in the developing countries like Bangladesh. The incidence rate of coronary artery disease is escalating very rapidly among both male and female population in our country. Though exercise treadmill test (ETT) is a well accepted non-invasive investigation to diagnose Coronary Artery Disease (CAD), it has a high false positive and false negative result if ST segment response alone is calculated for interpretation of the test. Accuracy of different treadmill scores in our population is largely unknown. Clevelan Clinic Score is a prognostic ETT score which is validated for prognostic indication but may have some diagnostic value as well.&#x0D; Objective: To know the diagnostic role of Cleveland Clinic Score, currently which has only prognostic implication. Method: A Cross-Sectional study was carried out on patients attending University Cardiac Center in Bangabandhu Sheikh Mujib Medical University (BSMMU) for stable chest pain to find out the accuracy of Cleveland Clinic Scores (CCS) in comparison to other diagnostic treadmill scores namely Duke Treadmill Score (DTS) and Simple Treadmill Score (STS).Total 130 persons including male and female who have undergone ETT were included according to inclusion and exclusion criteria. Coronary angiogram reports were collected after the procedure was performed as per clinical practice. The accuracy of ST segment response &amp; different treadmill scores were calculated and compared with each other.&#x0D; Result: ETT scores had better sensitivity and specificity than ST segment response which was affected by workup bias more. CCS, DTS and STS have 83.3% &amp; 60.9%; 71.4% &amp; 71.7%; 64.3% &amp; 78.3% sensitivity &amp; specificity, respectively. Receiver Operator Characteristics (ROC) curve analysis showed all of the three scores have similar area under curve (AUC) that means they have similar accuracy to diagnose CAD. But they have different sensitivity and specificity for different cut off value. Overall analysis showed accuracy of STS (83.9%) is comparable to that of DTS (83.3%), CCS (77%) .&#x0D; Conclusion: Among the three treadmill scores Cleveland Clinic Score has comparable predictive accuracy when compared with DTS, STS. Though a prognostic ETT score, CCS may have diagnostic role which need to be validated further.&#x0D; University Heart Journal Vol. 14, No. 2, Jul 2018; 62-66