Disease In Low-risk Patients Research Articles

Coronary atherosclerosis among symptomatic patients with zero coronary artery calcium score in computed tomography coronary angiography

BackgroundComputed tomographic coronary angiography has been recognized as a reliable imaging modality with excellent negative predictive value and a good negative likelihood ratio to exclude coronary artery disease in stable, symptomatic patients with intermediate or high risk. 1) Coronary calcium scoring has been extensively shown to be an invaluable tool to exclude the presence of coronary artery disease in low-risk patients. 2) Our aim was to identify the presence and extent of coronary atherosclerosis in computed tomographic coronary angiography in stable symptomatic patients with a zero Coronary Calcium score. ResultsThree hundred and eighty-three (383) consecutive patients aged ≥ 18 years fulfilling the criteria were enrolled as of January 1, 2021; 165 (43.1%) were male and 218 (56.9%) were female, with a mean age of 57.8 ± 4.9 years and a zero coronary artery calcium score. Two hundred and twenty-six (226) (59.0%) were hypertensive, followed by 125 (32.6%) who were smokers, and 117 (30.5%) who were diabetic. The frequency of atherosclerotic plaque in coronary arteries was 34 (8.9%), with 16 (47.1%) being male and 18 (52.9%) being female. The mean age of patients with atherosclerosis was 54.9 ± 3.3 years; among them, 13 (38.2%) were between the ages of 45 and 54, and 10 (29.4%) were between the ages of 55 and 64. Nineteen (19) (55.9%) were hypertensive, followed by 10 (29.4%) with dyslipidemia. Twenty-three (23) (67.6%) had non-obstructive plaque, and 11 (32.3%) had obstructive plaque. In the subgroup of patients with non-obstructive plaque, 13 (56.5%) were hypertensive, 8 (34.8%) were diabetic, and 16 (69.6%) had single vessel disease, while among patients with obstructive plaque, 6 (54.5%) were hypertensive, 5 (45.5%) were smokers, and all of them had single vessel disease. The most affected artery was the left anterior descending artery. ConclusionAs the frequency of atherosclerotic plaque in patients with a zero coronary calcium score is relatively high, computed tomographic coronary angiography is indicated in stable, symptomatic patients with a lower likelihood of coronary artery disease.

PSMA PET Validates Higher Rates of Metastatic Disease for European Association of Urology Biochemical Recurrence Risk Groups: An International Multicenter Study.

The European Association of Urology (EAU) prostate cancer guidelines panel recommends risk groups for biochemical recurrence (BCR) of prostate cancer to identify men at high risk of progression or metastatic disease. The rapidly growing availability of PSMA-directed PET imaging will impact prostate cancer staging. We determined the rates of local and metastatic disease in BCR and biochemical persistence (BCP) of prostate cancer stratified by EAU BCR risk groups and BCP. Methods: Patients with BCR or BCP were enrolled under the same prospective clinical trial protocol conducted at 3 sites (n = 1,777 [91%]: UCLA, n = 662 [NCT02940262]; University of California San Francisco, n = 508 [NCT03353740]; University of Michigan, n = 607 [NCT03396874]); 183 patients with BCP from the Universities of Essen, Bologna, and Munich were included retrospectively. Patients with BCR had to have sufficient data to determine the EAU risk score. Multivariate, binomial logistic regression models were applied to assess independent predictors of M1 disease. Results: In total, 1,960 patients were included. Post-radical prostatectomy EAU BCR low-risk, EAU BCR high-risk, and BCP groups yielded distant metastatic (M1) detection in 43 of 176 (24%), 342 of 931 (37%), and 154 of 386 (40%) patients. For postradiotherapy EAU BCR low-risk and EAU BCR high-risk groups, the M1 detection rate was 113 of 309 (37%) and 110 of 158 (70%), respectively. BCP, high-risk BCR, and higher levels of serum prostate-specific antigen were significantly associated with PSMA PET M1 disease in multivariate regression analysis. PSMA PET revealed no disease in 25% and locoregional-only disease in 33% of patients with post-radical prostatectomy or postradiotherapy EAU BCR high risk. Conclusion: Our findings support the new EAU classification; EAU BCR high-risk groups have higher rates of metastatic disease on PSMA PET than do the low-risk groups. Discordant subgroups, including metastatic disease in low-risk patients and no disease in high-risk patients, warrant inclusion of PSMA PET stage to refine risk assessment.

Pre-test Risk and Risk Factors as a Predictor of CTCA Severity and Calcium Score

Background: Coronary artery disease CTCA is a tool that is primarily used to rule out coronary artery disease in low-risk patients and reduces unnecessary invasive testing. Methods: This study included 169 patients, referred to a single large-volume centre from October 2015 to October 2016. Risk factors and CTCA severity results were collected and pre-test probability was calculated. Multinomial regression, and ANOVA were used to assess their prediction of CTCA results. Results: Pre-test probability was a significant predictor of moderate to severe disease on the CTCA (p = 0.016) but not a significant predictor of minimal/mild disease. Smoking was a significant predictor of minimal to mild disease on CTCA compared to normal CTCA findings (non-smokers 0.1 log-odds, B = - 2.289, p = 0.034). Current smoking was a significant predictor of moderate/severe disease compared with non-smokers (0.05, B = -2.84, p = 0.023). All other risk factors were not predictive. Low-risk pre-test scores had significantly lower calcium scores (309) than moderate or high pre-test risk (517, 521 respectively, F (2,162) = 15, p < 0.01). However, there was no significant difference in calcium scores between the moderate and high pre-test groups. Conclusion: Pre-test risk appears to have some utility in predicting significant coronary artery disease on CTCA and calcium score, however it was not a reliable discriminator of normal vs mild/minimal disease. Smoking correlated with the presence of at least mild disease and is strongly correlated with moderate disease and low pre-test risk was associated with significantly lower calcium scores.

Role of Endothelial Cell Function Assessment Using Flow-mediated Dilation for Diagnosing Coronary Artery Disease in Low-risk Patients

Role of Endothelial Cell Function Assessment Using Flow-mediated Dilation for Diagnosing Coronary Artery Disease in Low-risk Patients

What is the underlying rate of serious colonic disease in low-risk patients under age 50 with mild hematochezia?

Evidence-Based Answer Serious colonic disease—defined as colon cancer, adenomatous polyps, or inflammatory bowel disease—is found in 15% to 31% of hemodynamically stable patients aged less than 50 years with hematochezia (SOR: B, observational studies).

CT coronary angiography in low-risk, acute chest pain

The ROMICAT-II trial shows that CT coronary angiography is safe and fast for the exclusion of clinically significant obstructive coronary artery disease in low-risk patients with acute chest pain. Several issues and questions relating to the low prevalence of disease and the actual benefit to patients remain to be answered.

Spontaneous remission in thyroid cancer patients after biochemical incomplete response to initial therapy

To validate the American Thyroid Association (ATA) initial risk of recurrence scheme and the Memorial Sloan Kettering Cancer Center (MSKCC) response to therapy re-stratification approach in a large cohort of patients with differentiated thyroid cancer (DTC) treated outside of the United States. Retrospective chart review. Five hundred and six patients with DTC followed for a median of 10 years after total thyroidectomy and RAI remnant ablation at a major cancer centre in Brazil. Final clinical outcomes were assessed based on American Joint Cancer Committee (AJCC)/Union Internationale Contre le Cancer (UICC) staging, ATA risk stratification and response to therapy assessment (excellent, acceptable, biochemical incomplete and structural incomplete). The AJCC/UICC staging system did not adequately stratify patients with regard to the risk of recurrence/persistent disease. However, the ATA system demonstrated a 13% risk of recurrent/persistent disease in low-risk patients, 36% in intermediate risk patients, and 68% in high-risk patients. Furthermore, an excellent response to therapy decreased the risk of recurrent/persistent disease to 1·4%. At the time of final follow-up, 34% of the biochemical incomplete response patients had been re-classified as having no evidence of disease (NED) without having received any additional therapy beyond continue levothyroxine suppression. Conversely, even after additional therapies, only 9% of the patients with an incomplete structural response were eventually re-classified as NED. These data validate the ATA risk classification as an excellent initial predictor of recurrent/persistent disease and confirm the clinical utility of the MSKCC dynamic risk assessment system in a cohort of patients evaluated and treated outside the United States.

Which prediction models best identify additional axillary disease after a positive sentinel node biopsy for breast cancer?

To determine which web-based model best identifies women at low risk of further axillary disease after a positive sentinel lymph node (SLN+) biopsy. 673 women with T1-2cN0M0 SNB+ breast cancer who underwent completion axillary dissection (AxD) were identified. A subgroup not eligible to avoid AxD as part of the Z0011 study was defined (Z0011 exclusion group). Predicted risk of further axillary disease was generated using seven web-based models. "Low risk" was defined as a ≤10% risk of further axillary disease. False negative ("low risk" prediction but AxD+) rates (FNRs), area under the receiver operating characteristic curve (AUC), and Brier score were determined for each model. 6 of 7 models identified "low risk" patients but FNRs ranged from 14 to 30%. The Stanford and Memorial Sloan-Kettering (MSKCC) models had the best FNRs. FNRs were lower with SLN micrometastasis (7-15%) and higher in the Z0011 exclusion group (21-41%). All models under-predicted further nodal disease in low risk patients and over-predicted in higher-risk patients. The Stanford and MSKCC models were able to identify women with SLN micrometastasis with a ≤10% FNR. Models were not able to accurately identify low risk women from a cohort that would have been excluded from Z0011.

ABI May Predict Coronary Disease in Low-Risk Patients

ABI May Predict Coronary Disease in Low-Risk Patients

Contralateral papillary thyroid cancer at completion thyroidectomy has no impact on recurrence or survival after radioiodine treatment

This study investigated the rate of contralateral papillary thyroid cancer (PTC) in low-risk PTC patients who had completion thyroidectomy, and were referred for radioactive iodine (RAI) therapy. The study sought predictors of contralateral disease and examined the impact of contralateral disease in RAI-treated patients. We reviewed 20 years of data from a prospective registry for 150 patients with PTC. These patients had undergone thyroid lobectomy, followed by completion thyroidectomy, and had been referred for RAI. Of the 150 patients, 41% had PTC in the contralateral lobe. There was no difference in the rate of contralateral disease in low-risk patients (age <45 years, T1 tumors, lymph node-negative) compared with the remainder. There were no significant differences between patients with or without contralateral disease with respect to primary tumor size, mean age, time to completion thyroidectomy, or metastatic lymph node disease. Logistic regression analyses showed no histologic parameters that correlated with contralateral disease. There were no recurrence or survival differences in patients with or without contralateral disease after resection and RAI. The prevalence of tumor in the contralateral lobe of low-risk patients with PTC is significant and warrants consideration for completion thyroidectomy and radioiodine treatment. Our results, however, suggest that contralateral disease does not have an impact on recurrence or survival after treatment.

Cardiología intervencionista 2005

Drug-eluting stents have been shown to reduce the rate of restenosis significantly in all types of lesion, patient and clinical context without increasing thrombotic complications. Although their high cost limits the extent to which they can replace bare-metal stents, their use will increase inexorably in coming years. In addition to stents containing sirolimus and paclitaxel, which have already been approved, two additional drug-eluting stents have appeared on the market this year: one elutes tacrolimus and the other, ABT578 (a rapamycin analogue). Now that the restenosis rate has been dramatically reduced, the main limitations on percutaneous coronary intervention (PCI) stem from problematic lesions such as those at bifurcations and chronic total occlusions. Although these lesions can be tackled more often and more successfully than in the past, the results obtained are very different from those achieved with other types of lesion. With improvements in safety and long-term efficacy, the number of indications for PCI has expanded to include patients with multivessel disease, left main coronary artery disease, left ventricular dysfunction, and diabetes, conditions in which surgical revascularization was thought necessary only a few years ago. Acute coronary syndromes now make up an increasing proportion of indications for PCI, both in absolute and relative terms. One future challenge is the early identification and treatment of vulnerable plaques before they manifest clinically in the form of irreversible complications such as sudden death or acute myocardial infarction. The use of multislice computed tomography, such as 64-slice detector systems, has considerably increased the sensitivity, specificity, and positive and negative predictive values of diagnosis to around 90%, though diagnostic accuracy may be considerably less in patients with severe coronary calcification, stents, or cardiac arrhythmias. Although the technique is straightforward for patients, the image reconstruction process is time-consuming, few centers currently offer the technique, and radiation exposure is several times that with conventional invasive coronary angiography. It appears that the main application of the technique is in ruling out coronary disease in low-risk patients rather than being part of the diagnostic work-up in those with a high probability of coronary artery disease.

Serum Thyroglobulin Levels at the Time of131I Remnant Ablation Just after Thyroidectomy Are Useful for Early Prediction of Clinical Recurrence in Low-Risk Patients with Differentiated Thyroid Carcinoma

We investigated whether serum thyroglobulin (Tg) measured at the time of remnant ablation (ablation-Tg) could be a prognostic indicator complementary to serum Tg levels at the time of the first diagnostic whole-body scan (WBS) after thyroid hormone withdrawal (control-Tg; approximately 6-12 months after ablation-Tg) and whether ablation-Tg could predict the persistence or recurrence of disease in low-risk patients with differentiated thyroid carcinoma. Patients with differentiated thyroid carcinoma (n = 268) treated with total or near-total thyroidectomy followed by immediate (131)I remnant ablation were studied. Patients with anti-Tg autoantibodies and those showing evidence of extracervical metastases were excluded. Two patients showing remnant uptake on follow-up diagnostic WBS received a second ablation. We found significant correlation between ablation-Tg and control-Tg levels; 114 of 143 patients (80%) with ablation-Tg greater than 2 microg/liter showed detectable (>/=1 microg/liter) control-Tg, and 70 of 125 (56%) patients with ablation-Tg 2 microg/liter or less showed undetectable (<1 microg/liter) control-Tg [odds ratio 5.1, 95% confidence interval (CI) 3.0-8.9, P < 0.001]. When the 268 patients were followed up for a mean period of 5.7 +/- 1.4 yr (range 2.8-8.3 yr), 35 (13%) had recurrences; 73 (27%) were classified as "Tg positive, no evidence of disease"; and 160 (60%) showed complete remission. Of 143 patients with ablation-Tg greater than 2 microg/liter, recurrence was observed in 33 cases (23%); "Tg positive, no evidence of disease," was observed in 52 cases (36%); and complete remission was observed in 58 cases (41%). Of 125 patients with ablation-Tg 2 microg/liter or less, two patients (2%) showed recurrence during the follow-up; 21 patients (17%) were regarded as "Tg positive, no evidence of disease"; and 102 patients (81%) showed complete remission. The positive predictive value for recurrence in patients having ablation-Tg greater than 2 microg/liter was found to be 23.1% (33 of 143 patients, 95% CI 16.4-30.8%). The negative predictive value for recurrence in patients having ablation-Tg 2 microg/liter or less was found to be 98.4% (123 of 125 patients, 95% CI 94.4-99.8%). These data indicate that serum Tg levels measured at the time of immediate postoperative (131)I remnant ablation correlated well with serum Tg levels at the time of the initial diagnostic WBS and had a complementary role for predicting persistence or recurrence of disease in the earliest postoperative period.

Can the core length involved with prostate cancer identify clinically insignificant disease in low risk patients diagnosed on the basis of a single positive core?

Clinically insignificant prostate cancer, defined as at most microscopic foci of Gleason grade ≤3 disease in the radical prostatectomy specimen, has been recognized in some low risk (PSA <10, biopsy Gleason score ≤6, clinical T1c, 2a) patients with minimal biopsy cancer volume. The purpose of this study is to determine if the fraction of cancer in a single positive core biopsy could identify a subset of low risk prostate cancer patients with clinically insignificant disease. Of 1100 patients with T1c,2 prostate cancer that consecutively underwent radical prostatectomy at Brigham and Women’s Hospital between 1989 to 2000, 130 low risk patients whose diagnoses were made on the basis of a single positive core comprised the study cohort. The pathologic findings at radical prostatectomy were enumerated for men with ≤5% of a single core involved with prostate cancer in order to determine the rate of clinically insignificant prostate cancer in this population. Estimates of PSA survival were calculated using the actuarial method of Kaplan and Meier. Pairwise comparisons were made using the log rank test. For patients with ≤5% ( n = 14) and > 5% ( n = 116) involvement of a single positive core, the 4 year PSA failure free survivals were 100% vs. 89% ( P = 0.048), respectively. Within the subset of patients with ≤5% of a single core involved, 7% (1/14) met the criteria for clinically insignificant disease. However, of the remaining 93%, 3, 8, and 2 patients had pathologic stage T2a, T2b, and T3a, respectively. Eleven patients had prostatectomy Gleason scores ≤3 + 3, two patients had pathologic Gleason scores of 3 + 4, and one patient had a positive surgical margin. Given that only 7% of low risk patients in this cohort with ≤5% involvement of a single positive core had clinically insignificant disease, the involved core length alone cannot be used to identify patients with clinically insignificant disease. Further studies are needed in order to delineate which patients may not benefit from treatment.

A randomised controlled trial of prophylaxis of post‐abortal infection: ceftriaxone versus placebo

To investigate the incidence of post-operative infection after first trimester abortion in women treated with a long-acting cephalosporin (ceftriaxone) compared with low risk patients receiving no treatment and with high risk patients receiving our standard treatment of ampicillin/pivampicillin and metronidazole. A prospective, randomised controlled trial. Department of Obstetrics and Gynaecology, Rigshospitalet, University of Copenhagen, Denmark. Nine hundred and ninety-six women, admitted on an outpatient basis for legal termination of pregnancy at 12 weeks or less of gestation, were included in the study after giving informed consent. The women were divided into high risk and low risk categories and allocated either to treatment with ceftriaxone or to standard treatment. For high risk patients the standard treatment was initiated by a peroperative injection of ampicillin and metronidazole, followed by oral doses of metronidazole and pivampicillin three times daily for four days. No prophylactic antibiotics were given to the women randomised to standard treatment in the low risk group. All women were kept under observation, and, between six and 14 days postoperatively, underwent pelvic examination. Clinical endpoints were noted. Post-operative pelvic inflammatory disease in women applying for legal first trimester abortion. Seven hundred and eighty-six women fulfilled the criteria for evaluation. A tendency toward a prophylactic effect of ceftriaxone was observed in most clinical findings. A significant prophylactic effect of ceftriaxone was found in the low risk group. This study demonstrated a significant reduction in post-operative pelvic inflammatory disease in low risk patients, who were applying for legal first trimester abortion, treated peroperatively with ceftriaxone. No significant difference was demonstrated between high risk patients treated with ceftriaxone or ampicillin/pivampicillin and metronidazole.