Development Of Risk Stratification Models Research Articles

A Deep Learning Framework with Explainability for the Prediction of Lateral Locoregional Recurrences in Rectal Cancer Patients with Suspicious Lateral Lymph Nodes.

Malignant lateral lymph nodes (LLNs) in low, locally advanced rectal cancer can cause (ipsi-lateral) local recurrences ((L)LR). Accurate identification is, therefore, essential. This study explored LLN features to create an artificial intelligence prediction model, estimating the risk of (L)LR. This retrospective multicentre cohort study examined 196 patients diagnosed with rectal cancer between 2008 and 2020 from three tertiary centres in the Netherlands. Primary and restaging T2W magnetic resonance imaging and clinical features were used. Visible LLNs were segmented and used for a multi-channel convolutional neural network. A deep learning model was developed and trained for the prediction of (L)LR according to malignant LLNs. Combined imaging and clinical features resulted in AUCs of 0.78 and 0.80 for LR and LLR, respectively. The sensitivity and specificity were 85.7% and 67.6%, respectively. Class activation map explainability methods were applied and consistently identified the same high-risk regions with structural similarity indices ranging from 0.772-0.930. This model resulted in good predictive value for (L)LR rates and can form the basis of future auto-segmentation programs to assist in the identification of high-risk patients and the development of risk stratification models.

Risk stratification for clinical severity of pulmonary embolism in patients with cancer: a narrative review and MASCC clinical guidance for daily care.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality in patients with cancer. The clinical presentation and outcomes of PE range from an acute life-threatening condition requiring intensive care to a mild symptomatic condition associated with favorable outcomes and potentially candidate for early hospital discharge. The wide clinical spectrum of PE has led to the development of risk stratification models aimed at the triage of patients in emergency care departments and optimizing the utilization of health care resources. Incidental or unsuspected PE (UPE), detected during routine staging computed tomography scans, make up a significant proportion of this cohort among the oncology population. The present narrative review is aimed at examining the currently available PE risk assessment models developed for the general population and for patients with cancer including UPE. We include general recommendations for the daily care of patients with cancer-related PE and hypothesize on the factors that would potentially favor hospitalization with early discharge or ambulatory management in this setting.

Burden and Impact of Arrhythmias in Repaired Tetralogy of Fallot.

Arrhythmias are a leading cause of morbidity and mortality following repair of tetralogy of Fallot (TOF). This review will highlight current understanding of arrhythmia pathogenesis in this patient population and review novel therapeutic options. Risk factors for developing ventricular arrhythmias in repaired TOF have thus far been better defined than for atrial arrhythmias. Growing understanding of the pathophysiology of arrhythmias, development of risk stratification models, and novel techniques such as electrophysiologic ultrahigh-density mapping should help to better identify patients that benefit from advanced therapies such as ablation and implantable cardioverter defibrillators. Atrial and ventricular arrhythmias are common in TOF patients. Methods of risk stratification and therapeutic approaches are rapidly evolving, leading to ever improving clinical outcomes in this patient population.

A Review of Approaches in the Development of Risk Stratification Models for Diabetic Patients at Risk of Vascular Complications

This paper presents an overview of risk stratification tools development framework for the population of diabetics at risk of vascular complications to provide a guide to future risk stratification studies in developing risk stratification tools that can be applied to other clinical endpoints.

Gaps in Evidence for Risk Stratification for Sudden Cardiac Death in Hypertrophic Cardiomyopathy.

Gaps in Evidence for Risk Stratification for Sudden Cardiac Death in Hypertrophic Cardiomyopathy.

Abstract C059: A case-control study of risk factors for advanced gastric intestinal metaplasia in a multiethnic United States population (The Stanford GAPS Study)

Abstract Introduction Gastric intestinal metaplasia (GIM) is a precursor to gastric cancer (GC). It is not cost effective to survey the general American population for progression from GIM onto GC; however, development of risk-stratification models may allow for targeted surveillance. There exist very limited data regarding GIM epidemiology or risk derived from North American populations. The Stanford Gastric Precancerous Conditions Study (GAPS) is an ongoing, prospective study incorporating both 1) a cross-sectional, case-control study of subjects with GIM compared to controls, and 2) a longitudinal evaluation of subjects with GIM to evaluate risk factors for progression. The purpose of GAPS is to both improve the detection of GIM, and to predict risk for progression of GIM onto dysplasia or GC. Methods At time of enrollment in GAPS, all patients complete a standardized questionnaire inquiring about medical, family, dietary, and exposure history. Biopsies are performed from both antrum and body, and bio-specimens from the gastric mucosa, blood, and saliva are collected. Subjects are assigned an operative link for GIM (OLGIM) score based on adjudication by an expert pathologist. Demographic, clinical, and environmental covariates are compared between cases of GIM and controls. Subgroup analysis is performed to compare cases of advanced GIM (defined as OLGIM >=2) and controls. Continuous variables are analyzed using Student’s T-test, and categorical variables are analyzed using the Chi-squared test. Results As of July 2019, 44 cases and 49 controls have undergone questionnaire administration, endoscopy, and bio-specimen collection. Of cases, 23 demonstrate advanced GIM. Subjects with GIM were older (65 vs 56 years, p<0.001), more likely to have a history of H. pylori treatment (48% vs 20%, p=0.005), and more likely to be first-generation immigrants (p=0.03) compared to controls. Subjects with advanced GIM were older (65 vs 58 years, p=0.03), and more likely to be first-generation immigrants (p=0.04) compared to subjects without advanced GIM. Differences in family history, smoking status, presence of symptoms, presence of medical comorbidity, and dietary patterns did not reach statistical significance. Discussion Age and immigration status, known risk factors for GC, may also be risk factors for advanced GIM. As advanced GIM significantly increases risk for GC, detection of advanced GIM may improve GC morbidity and mortality. With ongoing enrollment in GAPS, it is hoped that additional environmental risk factors may be isolated from this cohort. Additional research should be focused on non-invasive testing to detect advanced GIM in North American populations. Citation Format: Robert J Huang, Sungho Park, Tanvi Chitre, Jeanne Shen, Teri Longacre, Joo Ha Hwang. A case-control study of risk factors for advanced gastric intestinal metaplasia in a multiethnic United States population (The Stanford GAPS Study) [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C059.

From Genome-Wide Association Studies to Cardiac Electrophysiology: Through the Maze of Biological Complexity.

Genome Wide Association Studies (GWAS) have provided an enormous amount of data on genomic loci associated with cardiac electrophysiology and arrhythmias. Clinical relevance, however, remains unclear since GWAS do not provide a mechanistic explanation for this association. Determining the electrophysiological relevance of variants for arrhythmias would aid development of risk stratification models for patients with arrhythmias. In this review, we give an overview of genetic variants related to ECG intervals and arrhythmogenic pathologies and discuss how these variants may influence cardiac electrophysiology and the occurrence of arrhythmias.

78Predictors of perioperative mortality in adults with congenital heart disease (ACHD): utility of the EuroSCORE and creation of an ACHD-specific score

Abstract Introduction Adult patients with congenital heart disease (ACHD) are a heterogeneous population and a variety of procedures are performed in ACHD centers, which differ significantly from those performed in the general adult population. Therefore, ACHD patients have not been included in the development of risk stratification models, such as the EuroSCORE. We assessed the utility of the components of the EuroSCORE in predicting in-hospital mortality around surgery in a large cohort of ACHD patients and tested a modified risk score for the ACHD population. Methods Data were collected retrospectively on all consecutive patients >16 years who underwent congenital heart disease surgery in a large tertiary center in 2015–18. Preoperative characteristics and perioperative outcomes were collected from clinical records and databases. Wilcoxon rank sum test, Fisher's test and Logistic regression analysis were used to identify predictors of in-hospital death. Variables significant on univariate linear regression were used to create a risk score for each patient, either attributing 1 point for each risk factor (unweighted model), or weighing this by its log(Odds ratio) in the logistic regression model (weighted score). Receive operator characteristic (ROC) analysis with calculation of the areas under the curve (AUC) was used to assess the performance of each scoring system in predicting in-hospital mortality. Results A total of 476 operations occurred in 459 patients who underwent cardiac surgery during the study period. Age at surgery was 35.9±14.7 years, 258 (56.2%) were male, 231 (51.3%) patients had a previous sternotomy. There were 19 (4.1%) in-hospital deaths. Certain components of EuroSCORE were very rarely observed in our ACHD patients and were not included in the analysis. Of components of the EuroSCORE, female sex (OR 3.79, 95% CI: 1.42–11.89, p=0.01), functional NYHA class>2 (OR 7.65, 95% CI: 2.35–29.26, p=0.001), left ventricle dysfunction (OR 3.14, 95% CI: 1.22–8.01, p=0.02), previous surgery (OR 5.33, 95% CI: 1.41–34.68, p=0.03), emergency or urgent surgery (OR 7.96, 95% CI: 3.1–21.99, p<0.0001), renal dysfunction (MDRD GFR<60 OR 6.56, 95% CI: 1.73–20.52, p=0.002), endocarditis (OR 7.71, 95% CI: 1.6–28.85, p=0.004), and a critical preoperative state (OR 28.65, 95% CI: 5.11–147.93, p<0.0001) were predictive of an adverse perioperative outcome. Moreover, the number of previous sternotomies was predictive of mortality (OR 2.45, 95% CI: 1.58–3.85, p<0.0001). Both the unweighted (AUC 0.78, 95% CI: 70.6–85.3), but especially the weighted risk score (AUC 0.82, 95% CI: 74.8–89) had an optimal discriminative power (Figure). Conclusions While several components of the EuroSCORE are relevant to ACHD patients, an ACHD-specific scoring system for predicting perioperative mortality is needed. In this analysis, we propose a simplified risk score for ACHD patients undergoing surgery, which performs well in this population.

Plasma Biomarkers for Prediction of Sudden Cardiac Death

Sudden cardiac death (SCD) accounts for most cardiovascular deaths in the United States, claiming an estimated 300 000 lives per year.1 Despite intense efforts to develop resuscitation techniques, survival rates are still low, at ≈5%.2 This has led to a renewed focus in this field directed toward optimizing risk prediction to identify the candidate that would qualify for prophylactic or preventive interventions.3 At present, the clinical risk stratification is largely limited to the use of left ventricular ejection fraction (LVEF) for identifying primary prophylaxis candidates, but specificity of this predictor is modest.4 Moreover, the absolute numbers of these high-risk patients in the general population are low. Instead, the highest prevalence of SCD is likely observed among previously asymptomatic individuals, even though it is well-known that coronary artery disease (CAD) is present in most SCD cases.5 This underscores the need for the development of risk stratification models that can be applied to the general population where the largest health benefit is likely to be realized. The underpinnings of SCD are complex, and it is reasonable to believe that the risk stratification instrument of the future is likely to involve other components beyond clinical risk markers. Novel genomic variants show promise but are still in early phases of development as risk stratification targets. However, the “unbiased” approaches made possible through genomewide association studies have led to the recent identification of specific genetic variants that could predict SCD.6,7 This has reignited the interest in plasma biomarkers as a means for risk stratification. This article will review the emerging evidence and role of plasma biomarkers in predicting SCD in the general population and suggest a blueprint for future studies of potential utility. ### Uniform Definition of SCD Given the complexity and dynamic nature of the condition, there has been some variability …

Neutropenia febril en pacientes pediátricos: un enfoque diagnóstico y terapéutico

Durante las últimas décadas ha habido un progreso muy notorio en el tratamiento de los pacientes con cáncer: se ha reducido significativamente la tasa de mortalidad gracias a los nuevos agentes quimioterapéuticos y a la puesta en práctica de modalidades modernas de tratamiento; sin embargo, la mayoría de los agentes usados producen una profunda depresión del sistema inmune aumentando la susceptibilidad a las infecciones. La neutropenia febril es la complicación más común en pacientes que reciben terapia contra el cáncer; hace cuarenta años se estableció por primera vez la asociación entre el recuento bajo de neutrófilos circulantes, la fiebre y el riesgo de infección y desde entonces la terapia antibiótica empírica se ha convertido en la piedra angular en el tratamiento de esta complicación; infortunadamente, las hospitalizaciones prolongadas que son necesarias para estos tratamientos, además de ser muy costosas, tienen un gran impacto psicológico en los niños y sus familias. El desarrollo de modelos de estratificación del riesgo ha permitido identificar a qué pacientes se les pueden ofrecer otras opciones, como la terapia oral o la ambulatoria. En esta revisión se presentan conceptos actualizados sobre la neutropenia febril en pediatría.

Perspectives for the management of febrile neutropenic patients with cancer in the 21st century

Over the past several decades, there has been substantial progress in the management of patients with febrile neutropenia. However, the ever-changing patterns of infection, ecology, and antibiotic-resistance trends do not allow the development of treatment guidelines that could be applied universally. Hence, the institution's predominant pathogens and resistance patterns should guide the empirical choice of antimicrobials. Prompt initiation of antimicrobial therapy remains the gold standard. Monotherapy with the newer broad-spectrum antimicrobials has tended to replace the classic combination therapy. Empirical administration of glycopeptides, such as vancomycin, without documentation of a gram-positive infection is not favored. The development of risk-stratification models has allowed for identification of low-risk patients with additional treatment options, such as early discharge and exclusively outpatient treatment with oral antimicrobials. The initiation of empirical antifungal therapy in persistently febrile neutropenic patients has become common practice, especially recently, since the introduction of new, effective, less toxic antifungal drugs. It is hoped that the development of new nonculture-based diagnostic methods will allow for the early detection of invasive fungal infections and, thus, the replacement of empirical antifungal therapy with pathogen-specific, preemptive therapy.