Clinical Classification System Research Articles

Clinical examination and classification systems of congenital clubfoot: a narrative review.

Clinical examination of the newborn’s foot is a complex exercise that requires a lot of sensitivity, practice and deep understanding of normal and pathological anatomy, and the clinical assessment of a child with congenital talipes equinovarus, or congenital clubfoot, must be complete and it should not be limited to a simple orthopedic evaluation of the foot; the search for a cause is a pressing concern. This narrative review article aims to provide the key information about clinical examination of children with congenital clubfoot; classification systems are also described. Clinical examination of children with congenital clubfoot is essential. In particular, it is important to evaluate the mental age of the child (developmental milestones), to rule out the presence of a spinal dysraphism, to eliminate a mild form of neurological disease (congenital myopathy or arthrogryposis), as well as to carefully examine the face and hands of the patient. The examination of the foot and the classification of the clubfoot deformity complete the clinical evaluation. In the end, the pediatric orthopedic surgeon must not underestimate any clinical signs, and must act as a pediatrician. This narrative review summarizes the key points in taking a history and performing a comprehensive clinical examination for patients with congenital clubfoot; the review also briefly describes the normal foot anatomy and growth as to give the reader the opportunity to better understand the morphological and functional modifications secondary to congenital clubfoot.

Sports psychiatry and medical views on mild traumatic brain injury in competitive sport: a current review and recommendations

Head injuries are common in competitive and recreational sport. Nomenclature, though inconsistent, identifies mild traumatic brain injury (mTBI) based on acute diagnostic criteria, whereas a sport-related concussion (SRC) is event-related and specific to mTBI experienced while participating in athletic activity. The effects of SRC are often neurological, neuropsychological and/or psychiatric with a variety of symptoms. Different organizations categorize these symptoms differently and this variance demonstrates that no uniform clinical classification system has been agreed upon. Diagnosis of SRC is based on clinical examination. Numerous symptom checklists and assessments are available for clinical diagnosis, but their validity is somewhat limited. There is increasing awareness regarding the psychiatric deficits associated with SRC and the potential for developing post-concussion syndrome (PCS). In addition to complex, causal SRC-associated symptoms, reactive psychological complaints may also occur, as well as social mistreatment on recovery from SRC. Pre-existing mental health conditions are associated with an increased risk for developing PCS. This often necessitates the implementation of psychiatric or psychotherapeutic care after SRC. As with mTBI and SRC, no standardized classification has been established for PCS. Multi-stage rehabilitation strategies can help injured athletes navigate a successful recovery and prevent premature return to play. Further research on the utility of psychotherapy, psychopharmacotherapy, and exercise therapy of PCS is needed. Key Words: Concussion, Mental Health, Post-Concussion Syndrome, Interdisciplinarity

State of the art and challenges for the classification of studies on electromechanical and robotic devices in neurorehabilitation: a scoping review.

The rapid development of electromechanical and robotic devices has profoundly influenced neurorehabilitation. Growth in the scientific and technological aspects thereof is crucial for increasing the number of newly developed devices, and clinicians have welcomed such growth with enthusiasm. Nevertheless, improving the standard for the reporting clinical, technical, and normative aspects of such electromechanical and robotic devices remains an unmet need in neurorehabilitation. Accordingly, this study aimed to analyze the existing literature on electromechanical and robotic devices used in neurorehabilitation, considering the current clinical, technical, and regulatory classification systems. Within the CICERONE Consensus Conference framework, studies on electromechanical and robotic devices used for upper- and lower-limb rehabilitation in persons with neurological disabilities in adulthood and childhood were reviewed. We have conducted a literature search using the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, Science Direct, and Google Scholar. Clinical, technical, and regulatory classification systems were applied to collect information on the electromechanical and robotic devices. The study designs and populations were investigated. Overall, 316 studies were included in the analysis. More than half (52%) of the studies were randomised controlled trials (RCTs). The population investigated the most suffered from strokes, followed by spinal cord injuries, multiple sclerosis, cerebral palsy, and traumatic brain injuries. In total, 100 devices were described; of these, 19% were certified with the CE mark. Overall, the main type of device was an exoskeleton. However, end-effector devices were primarily used for the upper limbs, whereas exoskeletons were used for the lower limbs (for both children and adults). The current literature on robotic neurorehabilitation lacks detailed information regarding the technical characteristics of the devices used. This affects the understanding of the possible mechanisms underlying recovery. Unfortunately, many electromechanical and robotic devices are not provided with CE marks, strongly hindering the research on the clinical outcomes of rehabilitation treatments based on these devices. A more significant effort is needed to improve the description of the robotic devices used in neurorehabilitation in terms of the technical and functional details, along with high-quality RCT studies.

Onyiuke Grading Scale: A clinical classification system for the diagnosis and management of Bertolotti syndrome

BackgroundLumbosacral transitional vertebrae (LSTV) is a common anatomic variant of the spine, characterized by the formation of a pseudoarticulation between the transverse process of the lumbar vertebrae and sacrum or ilium. LSTVs have been implicated as a potential source of low back pain – dubbed Bertolotti syndrome. Traditionally, LSTVs have only been subdivided into types I–IV based on the Castellvi radiographic classification system. ObjectiveSolely identifying the type of LSTV radiographically provides no clinical relevance to the treatment of Bertolotti syndrome. Here, we seek to analyze such patients and identify a clinical grading scale and diagnostic-therapeutic algorithm to optimize care for patients with this congenital anomaly. MethodsPatients presenting with back pain between 2011 and 2018 attributable to a lumbosacral transitional vertebra were identified retrospectively. Data was collected from these patients’ charts regarding demographic information, clinical presentation, diagnostic imaging, treatment and outcomes. Based on evaluation of these cases and review of the literature, a diagnostic-therapeutic algorithm is proposed. ResultsBased on our experiences evaluating and treating these patients and review of the existing literature, we propose a clinical classification system for Bertolotti syndrome: we proposed a 4-grade scale for patients with Bertolotti syndrome based upon location, severity, and characteristics of pain experienced due to LSTVs. ConclusionBased on our experience with the cases illustrated here, we recommend managing patients with LSTV based on our diagnostic-therapeutic algorithm. Moving forward, a larger prospective study with a larger patient cohort is needed to further validate the treatment paradigm.

Placenta Accreta Spectrum: Correlation between FIGO Clinical Classification and Histopathologic Findings.

Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes. We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team. Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification (p < 0.001). However, we found no association between FIGO classifications and maternal complications. The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research. · PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..

Clinical Classification and Scales for Myasthenia Gravis

The variable predominance of the affected muscle groups and the fluctuating severity and extent of myasthenia gravis (MG) makes it difficult to assess and classify these patients. With new treatments being developed and applied, it has become more important to properly classify MG patients and objectively evaluate the results of treatment. So far, a number of clinical classification and assessment systems have been proposed and used individually. However, for the comparative analysis, a uniform set of classifications and reliable measurement methods of muscle impairment are necessary. In this article, MG-clinical classification and several MG-specific assessment tools that are widely used are mentioned.

Influence of Comorbidities on Healthcare Expenditures and Perceived Physical and Mental Health Status Among Adults with Multiple Sclerosis: A Propensity Score-Matched US National-Level Study.

ObjectiveTo evaluate the effect of comorbidities on healthcare expenditures and perceived physical and mental health status among adults with multiple sclerosis (MS) compared to propensity score-matched non-MS controls.MethodsA retrospective, cross-sectional, matched cohort study was conducted using Medical Expenditure Panel Survey (2005–2015) data. The base study sample consisted of adults (age ≥18 years) who were alive and had positive total healthcare expenditures during the survey calendar year. Adults with MS were propensity-matched (1:1) to non-MS controls based on age, gender, and race/ethnicity using greedy matching algorithm. Healthcare expenditures consisted of total and subtypes of expenditures. Health status consisted of perceived physical and mental health status. Comorbidities were identified using ICD-9-CM and Clinical Classification System codes. Ordinary least squares regression and multinomial logistic regression were used to analyze the healthcare expenditures and health status variables, respectively.ResultsFinal study sample consisted of 541 adults in each MS and non-MS control groups after propensity score matching. After adjusting for potential confounders, individuals with MS had greater total and subtypes of expenditures compared to non-MS controls, and several comorbidities (eg, depression, hypertension) were significantly associated with increased healthcare expenditures. Yearly average total expenditures (expressed in 2018 US$) were significantly (p<0.001) higher for adults with MS ($29,396) than propensity score-matched non-MS adults ($7875). Moreover, after adjusting for all individual-level factors, adults with MS experienced 363% (p<0.001) higher total expenditures compared to propensity score-matched non-MS controls. Individuals with MS were more likely to report poorer physical and good mental health status compared to propensity score-matched non-MS controls, and several comorbidities (eg, anxiety, depression) were significant independent predictors of poorer health status. For example, adults with MS were four times more likely (OR: 4.10, 95% CI: 2.42–6.96) to report fair/poor physical health status compared to excellent/very good physical health status compared with non-MS controls. Adults with MS were 42% (OR: 1.42, 95% CI: 1.01–1.99) more likely than propensity score-matched non-MS controls to report good rather than very good or excellent mental health status. However, there was no difference between adults with MS and propensity score-matched non-MS controls in terms of reporting fair or poor than very good or excellent mental health status.ConclusionFindings from this study indicate substantial economic and health status burdens among adults with MS at the US national-level that are significantly influenced by comorbidities.

Clinical Staging, Angioarchitecture Type, and Surgical Treatment of Arteriovenous Malformations in the Head and Neck: A Single-Center Retrospective Analysis.

Head and neck are the predilection sites of arteriovenous malformations (AVMs). Although embolization is the first-line treatment for AVMs, complete surgical removal of the lesion still has its value due to the best outcome with low recurrence rate. Here, the authors made a retrospective analysis on the surgical treatment of AVMs in the head and neck. From January 2006 to December 2019, a total of 18 patients with AVMs in the head and neck were enrolled in this study, including 10 males. The Schobinger clinical staging, Yakes' angioarchitecture type, and surgical treatment were analyzed. The follow-up data were collected. Then, individual treatment strategies were summarized. According to Schobinger clinical classification system, 6 patients were at stage I, 7 patients at stage II, and 5 patients at stage III. According to Yakes' AVM classification system, 3 Type I, 4 Type II, 5 Type III, and 3 Type IV were confirmed. 3 patients cannot be confirmed due to lacking of arteriographic data. Surgical treatments included simple surgical excision (8 patients), dilator therapy (6 patients), and skin grafting after surgical excision (4 patients). In the follow-up period, 2 patients had recurrence and accepted operation again. All patients were satisfied with the appearance. Individual surgical treatment based on the clinical stage and angioarchitecture type can achieve satisfactory results in AVMs in the head and neck.

51130 Risk of Prolonged Opioid Use After Intensive Care Unit Admission

ABSTRACT IMPACT: This is the first examination of risk factors for prolonged opioid use after an ICU stay and will inform efforts to strengthen prescribing guidelines and care transition models for patients after critical illness. OBJECTIVES/GOALS: The majority of patients in intensive care units (ICU) receive opioids during admission, and up to 25% receive a prescription at discharge. However, transitions of care and prolonged use after discharge remain unknown. We aim to characterize risk factors for prolonged opioid use after an ICU stay. METHODS/STUDY POPULATION: A retrospective study using insurance claims from Optum Clinformatics ®Data Mart was conducted for opioid-naive adult patients (18-64 years) with an ICU admission from 2010 to 2019. The primary outcome was new persistent opioid use, defined as a continued prescription fill 91-180 days after discharge, in addition to a fill in the first 90 days. The primary exposure was an opioid fill at discharge. The ICU admission was characterized using the Clinical Classification System from the Agency of Healthcare Research and Quality, based on patients’primary diagnosis code. Diagnoses were combined into 11 groups highlighting the affected organ system/mechanism of injury. Logistic regression evaluated the associations of patient demographic and clinical characteristics with the probability of persistent opioid use. RESULTS/ANTICIPATED RESULTS: In this cohort of 90,721 patients discharged from the ICU, 3.3% continued to fill opioids at 6 months. An opioid prescription fill (OR 3.1; 95% CI 28 - 3.3) and benzodiazepine prescription fill (OR 1.6; 95% CI 1.4 - 1.8) within 3 days of ICU discharge were each significantly associated with the development of new persistent opioid use. Patient diagnosis groups of Musculoskeletal/Trauma (OR 2.3; 95% CI 2.0 - 2.6), Neoplasms (OR 1.6; 95% CI 1.5 - 1.9), and GI/Hepatobiliary (OR 1.5; 95% CI 1.3 - 1.8) were significantly more likely to develop new persistent use when compared to the Cardiovascular diagnosis group. DISCUSSION/SIGNIFICANCE OF FINDINGS: Opioid prescriptions at discharge after an ICU stay increase the odds of prolonged opioid use. These results will inform efforts to strengthen prescribing guidelines and care models after a critical illness. Further work will characterize the trajectory of prescribing and patient exposure to high-risk prescribing after ICU discharge.

Pediatric Clinical Classification System for Use in Inpatient Settings

This cross-sectional study assesses the specificity of the Pediatric Clinical Classification System and Healthcare Cost and Utilization Project diagnosis categories for clinical classification in pediatric inpatient settings.

A Clinical Classification System for the Treatment of Postextraction Sites.

A postextraction socket is always open to different treatment possibilities. A straightforward clinical classification may help evaluate which surgical approach is best suited for the case being treated. Four different classes are defined on the basis of the local anatomy of the site, available bone volume, and soft tissue level. For every clinical situation, either immediate placement, early placement, alveolar ridge preservation, or staged approach can be selected as a treatment modality according to the classifications listed.

Association of High Serum Homocysteine Levels and Severe Chronic Venous Disease

Homocysteine (Hcy) is considered as a modifiable risk factor for vascular disease. This study was aimed to explore the association between serum concentration and the severity of primary chronic venous disease (CVD). Clinical data of 582 patients diagnosed with primary CVD were collected and analyzed retrospectively. The Clinical Etiology Anatomy Pathophysiology classification system was used to grade the severity of chronic venous disease. Patients were divided into 2 groups (group A: C1-C3; group B: C4-C6). The association between serum homocysteine levels and the severity of primary chronic venous disease was investigated using rank sum test and logistic regression. The difference between the level of homocysteine in each grade has statistical significance. Group A has higher median Hcy concentrations than Group B (15.40 μmol/L vs. 14.05 μmol/L, P< 0.01). Further binary logistic regression showed no statistical significance among the level of Hcy (11.00-14.75 μmol/L [OR 0.66, 95% CI 0.40-1.11, P= 0.12], 14.75-20.38μmol/L [OR 0.97, 95% CI 0.59-1.69, P = 0.89], ≥20.38 μmol/L [OR 0.67, 95% CI 0.41-1.10, P = 0.11]), but age (OR 1.03, 95% CI 1.01-1.04, P< 0.01) and female (OR 0.41, 95% CI 0.28-0.59, P< 0.01) are associated with more severe stages of CVD. Higher level of Hcy is associated with more severe stages of CVD, but it not an independent risk factor. However, Advanced age and female are risk factors for CVD development based on logistic regression analysis.

The Impact of Parental Injury on Children's Mental Health Diagnoses and Classes of Psychotropic Medication by Child Age.

Civilian and military research has linked parental illness and injury with increased overall mental health care and psychiatric medication use in children. Care for specific mental health conditions and medications by child age have not been reported. We sought to quantify the effect of parental illness and injury on child mental health care and psychiatric medication use in children overall and stratified by age. A self-controlled case series analyzed the impact of parental illness/injury on mental health and psychiatric medication use of military dependent children. Children were aged 2-16 years (51% male) when their parents were injured and received care in the Military Health System for 2 years before and 2 years after their parent's illness/injury. We used International Classification of Diseases 9th edition codes to identify outpatient mental healthcare visits. Outpatient care for 14 specific mental health diagnoses was classified using the Agency for Healthcare Research and Quality clinical classification system. Outpatient pharmacy records identified psychiatric medication prescriptions by therapeutic class. Parental illness/injury was identified by inclusion in the Military Health System Ill, Injured, and Wounded Warrior database. Adjusted negative binomial regression analysis compared rates of outpatient visits and medication days in the 2 years following parental illness/injury to the 2 years before the parent's illness/injury overall. Secondary analyses were stratified by age groups of 2-5 years (n = 158,620), 6-12 years (n = 239,614), and 13-16 years n = 86,768) and adjusted for parental pre-injury/illness deployment and child sex. Additional secondary analysis compared post-parental injury/illness care of children whose parents had post-traumatic stress disorder or traumatic brain injury to children of parents with physical/mental health injury/illness. There were 485,002 children of 272,211 parents injured during the study period. After adjustment for child sex, years of pre-injury/illness parental deployment, and child age, parental illness/injury was associated with increased mental visits across all categories of care except developmental diagnoses. Post-parental injury visits for suicidal ideation, alcohol abuse, mood, and anxiety disorders were all doubled. For children aged 2-5 years at parental illness/injury, the largest increases in care were in psychotic, anxiety, attention deficit, and mood disorders. In children aged 6-12 years, the largest increases were in psychotic conditions, suicidal ideation, and personality disorders. In adolescents aged 13-16 years, the largest increases were for alcohol and substance abuse disorders, with visits increasing by 4-5 times. For children of all ages, parental injury was associated with increased use of all therapeutic classes of psychiatric medications; use of stimulant medications was increased in younger children and decreased in older children following parental injury (P < .001). Parental illness/injury is associated with increased mental health care and days of psychiatric medication use in dependent children. Practitioners who care for families impacted by parental illness/injury should be cognizant of children's mental health risk. Early identification and treatment of child-related mental health issues can improve family functioning and increase military family readiness.

The application and enlightenment of Clinical Care Classification System in nursing practice

The application and enlightenment of Clinical Care Classification System in nursing practice

Childhood myasthenia gravis − clinical characteristics, diagnostic modalities, treatment strategies, and outcome

Background Childhood myasthenia gravis (CMG) is MG occurring in childhood or adolescence (i.e. &lt;18 years of age). Aim The aim of the work was to identify different clinical presentations and classifications of CMG, current diagnostic modalities, treatment strategies, and outcome to provide a profile of CMG among a cohort of Egyptian children attending Alexandria University Children’s Hospital as a tertiary pediatric center. Patients and methods All children diagnosed as having CMG who attended Pediatric Neurology Clinic at Alexandria University Children’s Hospital from January 1, 2010 to December 31, 2019 were included. A questionnaire for parents or caregivers including demographic data was administered. Clinical examination, clinical scoring system for MG, MG Foundation of America (MGFA) clinical classification system, electrophysiological studies, laboratory investigations, and clinic records review were done. Results Male : female ratio was 1 : 2.75. Mean age at start of symptoms was 4.97±3.78 years. Ptosis was presented in all (100%) patients, swallowing difficulty and choking in 40% of the patients, generalized weakness in 40% of the patients, and slurred speech and nasal tone in 33.3% of the patients. Overall, 46.7% of the patients were classified as pure ocular myasthenia gravis (MGFA class I), 20.0% as MGFA class II (mild generalized), 26.7% as MGFA class III (moderate generalized), and 6.7% as MGFA class IV (severe generalized). Pyridostigmine was used by 100% of the patients, prednisolone by 60% of the patients, and azathioprine by four (26.7%) patients. Pyridostigmine was the commonest single drug used by 40% of the patients. The common combinations were pyridostigmine with prednisolone alone or with added azathioprine. The comparison between the MG-Activities of Daily Living scale profile scores in first and last visits for patients was statistically significant. There was a significant improvement in the class of diseases, with remission in 70% of the patients. Failure rate of management was found in 20% of the patients. Conclusion Ocular myasthenia gravis was the most common subclass of CMG; ptosis was the most common presenting symptom. All patients received pyridostigmine as the first-line treatment. Remission occurred in 70% of the patients.

Pterygium: an update on pathophysiology, clinical features, and management.

Pterygium is a relatively common ocular surface disease. The clinical aspects and the treatment options have been studied since many years ago, but many uncertainties still exist. The core pathologic pathway and the role of heredity in the development of pterygium are still attractive fields for the researchers. The role of pterygium in corneal irregularities, in addition to the refractive properties of pterygium removal, has been increasingly recognized through numerous studies. The association between pterygium and ocular surface neoplasia is challenging the traditional beliefs regarding the safe profile of the disease. The need for a comprehensive clinical classification system has encouraged homogenization of trials and prediction of the recurrence rate of the pterygium following surgical removal. Evolving surgical methods have been associated with some complications, whose diagnosis and management are necessary for ophthalmic surgeons. According to the review, the main risk factor of pterygium progression remains to be the ultraviolet exposure. A major part of the clinical evaluation should consist of differentiating between typical and atypical pterygia, where the latter may be associated with the risk of ocular surface neoplasia. The effect of pterygium on astigmatism and the aberrations of the cornea may evoke the need for an early removal with a purpose of reducing secondary refractive error. Among the surgical methods, conjunctival or conjunctival-limbal autografting seems to be the first choice for ophthalmic surgeons because the recurrence rate following the procedure has been reported to be lower, compared with other procedures. The use of adjuvant options is supported in the literature, where intraoperative and postoperative mitomycin C has been the adjuvant treatment of choice. The efficacy and safety of anti–vascular endothelial growth factor agents and cyclosporine have been postulated; however, their exact role in the treatment of the pterygium requires further studies.

Venous leg symptoms, ecchymosis, and coldness in patients with peripheral varicose vein: A multicenter assessment and validation study (VEIN-VIOLET study).

We aimed to evaluate peripheral varicose vein symptoms including ecchymosis and coldness by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire. A total of 1120 patients were enrolled to the analysis after the exclusion of 199 patients who did not match the inclusion criteria. Patients were asked to answer the VEINES-Sym questionnaire and questions about ecchymosis and coldness. Scores of ecchymosis and coldness were calculated similar to VEINES-Sym questionnaire. Classifications of peripheral varicose vein were made according to the clinical part of clinical, etiological, anatomical, and pathophysiological classification system and patients with grade 2 or higher were considered as positive for peripheral varicose vein. Frequency of symptoms present in the VEINES-Sym instrument, ecchymosis and coldness were significantly higher in patients with peripheral varicose vein. Mean score of each symptom was significantly lower in peripheral varicose vein patients including scores of ecchymosis and coldness. Logistic regression analysis revealed that presence of hemorrhoids and all symptoms in VEINES-Sym questionnaire except restless leg were significantly and independently associated with peripheral varicose vein. Besides, ecchymosis (odds ratio: 2.04, 95% confidence interval: 1.34-3.08, p = 0.008) but not coldness was significantly and independently associated with peripheral varicose vein. There was also significant correlation of VEINES-Sym score with ecchymosis (r = 0.43, p < 0.001) and coldness (r = 0.47, p < 0.001). Venous leg symptoms present in VEINES-Sym questionnaire except restless legs, presence of hemorrhoids and ecchymosis are significantly and independently associated with peripheral varicose vein. Not only ecchymosis but also coldness has shown an independent association with total VEINES-Sym score.

Hormone replacement therapy and asthma onset in menopausal women: National cohort study

There is uncertainty about the role of hormonal replacement therapy (HRT) in the development of asthma. We investigated whether use of HRT and duration of use was associated with risk of development of asthma in perimenopausal and postmenopausal women. We constructed a 17-year (from January 1, 2000, to December 31, 2016) open cohort of 353,173 women (aged 46-70 years) from the Optimum Patient Care Database, a longitudinal primary care database from across the United Kingdom. HRT use, subtypes, and duration of use; confounding variables; and asthma onset were defined by using the Read Clinical Classification System. We fitted multilevel Cox regression models to estimate hazard ratios (HRs) with 95% CIs. During the 17-year follow-up (1,340,423 person years), 7,614 new asthma cases occurred, giving an incidence rate of 5.7 (95% CI= 5.5-5.8) per 1,000 person years. Compared with nonuse of HRT, previous use of any (HR= 0.83; 95% CI= 0.76-0.88), estrogen-only (HR= 0.89; 95% CI= 0.84-0.95), or combined estrogen and progestogen (HR= 0.82; 95% CI= 0.76-0.88) HRT was associated with a reduced risk of asthma onset. This was also the case with current use of any (HR= 0.79; 95% CI= 0.74-0.85), estrogen-only (HR= 0.80; 95% CI= 0.73-0.87), and combined estrogen and progestogen (HR=0.78; 95% CI= 0.70-0.87) HRT. Longer duration of HRT use (1-2 years [HR= 0.93; 95% CI= 0.87-0.99]; 3-4 years [HR= 0.77; 95% CI= 0.70-0.84]; and ≥5 years [HR= 0.71; 95% CI= 0.64-0.78]) was associated with a dose-response reduced risk of asthma onset. We found that HRT was associated with a reduced risk of development of late onset asthma in menopausal women. Further cohort studies are needed to confirm these findings.

Linking progression patterns in ischaemic heart disease to comorbidities and genetics by integrated analysis of electronic health records and population-wide registries

Abstract Background Ischaemic heart disease (IHD) is a diverse phenotype conventionally characterized by presence of the cardinal symptom, angina pectoris (fig. 1). Evidence of scientific value in electronic health records (EHRs) is accumulating although point of care applications are still limited. In this context, we have curated an EHR database (BTH) containing population-wide medical history of 2,658,323 patients from years 2006–2016 for discovery of new risk stratifying principles, by linkage of phenotypic data from EHRs, genotypes from 107,690 cardiovascular patients and 40 years of population-wide registry data. Purpose To establish a model that defines IHD onset, categorizes IHD patients by degree of disease progression and then discover phenotypic and genetic features that demarcate these patient strata. Features may be combinations of e.g. symptoms, vital signs, diagnosis and genetic variants that reduce or increase risk of disease progression, factor each other out or enhance the effect of one another, interacting non-linearly. Methods In this retrospective cohort study, cases were defined by integrated assessment of The Danish National Patient Registry (NPR) and BTH. Inclusion criteria were patients with an entry in BTH who were: (i) subject to a coronary arteriography (CAG), cardiac CT or MRI where IHD was the action diagnosis or (ii) subject to CAG, cardiac CT or MRI and diagnosed with IHD within one month. EHRs covering the two criteria were available for all cases and facilitated longitudinal alignment of patients with respect to disease onset and progression. IHD was assessed by lookup in NPR of ICD-10 codes I20-I25 and Danish Health Care Classification codes UXAC85, UXCC00A and UXMC80. Vital signs and symptoms were extracted from the free text in EHRs by application of regular expressions (regex) and named entity recognition using controlled vocabularies, respectively. Results In the dataset, 78,896 patients (50,761 males) met the inclusion criteria. The inclusion criteria aligned patients longitudinally facilitating clustering into subgroups displaying different progression patterns. By application of regex to the free text in the EHR, systolic and diastolic blood pressure were identified in 87% of cases. The controlled vocabulary identified about 60,000 patients, who had chest pain recorded in the EHR at time of diagnosis. Ongoing work is centered on optimizing clustering strategies and subsequently performing comorbidity and biochemical enrichment analysis. Genetic enrichment will be performed on 21,994 cases. Conclusion Integrated assessment of various population-wide registries is a promising strategy to curate EHR for obtainment of point of care applications, here exemplified by IHD. We argue that genetically enriched EHRs have potential to be a key element in efforts to obtain a clinical classification system that concertedly reflects etiology and clinically actionable differences in disease progression patterns. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Novo Nordisk Foundation and Innovationsfonden

Multimodality Imaging of Pulmonary Hypertension

Pulmonary hypertension (PH) is a complex, progressive abnormal physiologic and hemodynamic state seen in many conditions. The purpose of this review is to discuss the updated clinical and hemodynamic classification systems and diagnostic criteria of PH, discuss the role of noninvasive imaging for diagnosing PH, and outline a diagnostic pathway to facilitate targeted therapies. PH is defined as a mean pulmonary arterial pressure (mPAP) > 20 mmHg since the sixth World Symposium on Pulmonary Hypertension (WSPH) in 2018, a lower threshold than the longstanding definition of mPAP > 25 mmHg. Additionally, in 2018, Truong et al. established a four-tier classification for the diagnosis of PH based upon the degree of main pulmonary artery enlargement on computed tomography, whereby the likelihood of PH increases with increasing tier severity. Other noninvasive modalities, particularly echocardiography and cardiac magnetic resonance imaging (CMR), aid in prognostication of PH and drive clinical decision-making and treatment strategies. Multimodality imaging is paramount in the screening, diagnosis, and management of PH by providing anatomical, physiologic, functional, and prognostic information. Cumulative findings on echocardiography, ventilation/perfusion scintigraphy, computed tomography, and CMR imaging can often identify the etiology of PH and provide insight into pathophysiology and disease stage.