High Risk For Poor Outcomes Research Articles

Clinical Frailty Scale in Predicting Postoperative Outcomes in Older Patients Undergoing Curative Surgery for Urologic Malignancies: A Prospective Observational Cohort Study

ObjectiveTo examine the utility of the Clinical Frailty Scale (CFS) in predicting outcomes in older adults with urologic malignancies undergoing curative surgeries. MethodsThis prospective observational cohort study was conducted in a university-based tertiary medical center. Patients aged 75 years or older who were scheduled to undergo curative surgery for a urologic malignancy from January 2017 to December 2017 were recruited. Patients were grouped according to the CFS scores. The primary postoperative outcome measures were a major complication within 30 days and a decline in the activities of daily living (ADL) within 30 days and 90 days. Multivariable analyses and the area under the receiver operating characteristic curve were performed to investigate the association between the CFS and postoperative outcomes. ResultsA total of 82 patients, 50% women, were enrolled with mean age 81.6 years. The CFS was significantly associated with postoperative outcomes in a dose-response relationship. When compared with those with a CFS <5, patients with CFS scores ≥5 had a 10.3-times higher risk for a major complication, 8.5-times and 21.4-times higher risk for a decline in ADL within 30 days and 90 days. The area under the receiver operating characteristic curves for the CFS to predict a major complication, the 30-day decline in ADL and the 90-day decline in ADL were 0.60, 0.73, and 0.79. ConclusionA higher CFS score predicted a higher risk of poor outcomes in this population. It is recommended that patients with higher CFS scores, especially above 5, are needed to receive further multidisciplinary perioperative care.

Elevated fasting blood glucose is predictive of the severity and poor outcome in nondiabetic patients with cerebral venous thrombosis

Background and purposeAlthough elevated fasting blood glucose (FBG) at admission is associated with poor outcome in patients with ischemic and hemorrhagic stroke, it has not been investigated in patients with cerebral venous thrombosis (CVT). We aimed to determine the correlation between elevated FBG and severity and outcome among CVT patients. MethodsConsecutive CVT patients between 2009 and 2019 were identified for this retrospective study. Patients with a history of diabetes mellitus or incomplete clinical data were excluded. Hyperglycemia was defined as FBG ≥ 6.1 mmol/L, further classified as mild (6.1–6.9 mmol/L) and severe hyperglycemia (≥7.0 mmol/L). The severity of CVT was assessed at admission using the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), CVT-related complications, and intracranial pressure. The outcome was assessed at discharge using mRS; mRS 3–6 indicated poor outcome. ResultsOf 160 patients, 36 (22.5%) had hyperglycemia, and 24 (15%) had severe hyperglycemia. Baseline FBG positively correlated with NIHSS at admission (r = 0.55, P < .001). Patients with hyperglycemia had higher baseline mRS scores (P < .001), higher incidence of cerebral venous infarction (P = .039), intracranial hemorrhage (P = .005), coma (P < .001), and seizure (P = .010). Multivariate regression analysis revealed that patients with hyperglycemia had a higher risk of poor outcome (adjusted OR: 4.47; 95% CI: 1.05–18.95), and subgroup analysis showed that severe hyperglycemia (adjusted OR: 6.66; 95% CI: 1.35–32.81) was a stronger independent predictor of poor outcome. ConclusionsAdmission FBG was associated with severity of CVT, and elevated FBG is a predictor of short-term poor outcome among CVT patients.

Low Plasma 25-Hydoxyvitamin D at Diagnosis Predicts Poor Outcomes in Patients with Bladder Cancer: A Prospective Cohort Study

This study aimed to investigate whether plasma 25-hydroxyvitamin D (25-OHD) at diagnosis predicts poor outcomes in patients with urothelial bladder cancer. A total of 177 patients with non-muscle-invasive bladder cancer (NMIBC) were prospectively followed up over a period extending beyond 6 years. Data on poor outcomes (ie., recurrence, progression, and mortality) were collected. Plasma 25-OHD was measured by immunoassay. Cutoff-Finder web application was used to determine the best 25-OHD cutoff point to predict a specific poor outcome. Cox-hazard models were applied to test how plasma 25-OHD affect patients outcome while adjusting for potential confounding factors. During the follow-up period, tumor recurrence and progression occurred in 40.7% and 14.1% of patients, respectively and 11.3% of patients died. Baseline 25-OHD was lower in patients who experienced poor outcome (12.2 ± 7.44 vs. 16.7 ± 10.6 ng/mL; p < 0.001). Multi-adjusted HR (95% CI) for vitamin D deficiency (25-OHD < 12 ng/mL) was 2.09 (1.27-3.44) for recurrence, 2.63 (1.06-6.49) for progression and 2.93 (1.04-8.25) for mortality in patients with NMIBC. Low plasma 25-OHD in NMIBC patients is associated with higher risk of poor outcome. Future work is required to test whether correction of vitamin D deficiency will improve quality of life and extend survival in these patients.

High-dose-rate brachytherapy and hypofractionated external beam radiotherapy combined with long-term androgen deprivation therapy for very high-risk prostate cancer.

To estimate the outcomes of high-dose-rate brachytherapy combined with hypofractionated external beam radiotherapy in prostate cancer patients classified as very high risk by the National Comprehensive Cancer Network. Between June 2009 and September 2015, 66 patients meeting the criteria for very high-risk disease received high-dose-rate brachytherapy (2 fractions of 9Gy) as a boost of external beam radiotherapy (13 fractions of 3Gy). Androgen deprivation therapy was administered for approximately 3years. Biochemical failure was assessed using the Phoenix definition. The median follow-up period was 53months from the completion of radiotherapy. The 5-year biochemical failure-free, distant metastasis-free, prostate cancer-specific and overall survival rates were 88.7, 89.2, 98.5 and 97.0%, respectively. The independent contribution of each component of the very high-risk criteria was assessed in multivariable models. Primary Gleason pattern5 was associated with increased risks of biochemical failure (P=0.017) and distant metastasis (P=0.049), whereas clinical stage ≥T3b or >4 biopsy cores with Gleason score8-10 had no significant impact on the two outcomes. Grade3 genitourinary toxicities were observed in two (3.0%) patients, whereas no grade ≥3 gastrointestinal toxicities occurred. The present study shows that this multimodal approach provides potentially excellent cancer control and acceptable associated morbidity for very high-risk disease. Patients with primary Gleason pattern5 are at a higher risk of poor outcomes, indicating the need for more aggressive approaches in these cases.

Complement levels in patients with bloodstream infection due to Staphylococcus aureus or Gram-negative bacteria.

The complement system is a vital component of the innate immune system, though its role in bacteremia is poorly understood. We present complement levels in Staphylococcus aureus bacteremia (SAB) and Gram-negative bacteremia (GNB) and describe observed associations of complement levels with clinical outcomes. Complement and cytokine levels were measured in serum samples from 20 hospitalized patients with SAB, 20 hospitalized patients with GNB, 10 non-infected hospitalized patients, and 10 community controls. C5a levels were significantly higher in patients with SAB as compared to patients with GNB. Low C4 and C3 levels were associated with septic shock and 30-day mortality in patients with GNB, and elevated C3 was associated with a desirable outcome defined as absence of (1) septic shock, (2) acute renal failure, and (3) death within 30 days of bacteremia. Low levels of C9 were associated with septic shock in patients with GNB but not SAB. Elevated IL-10 was associated with increased 30-day mortality in patients with SAB. Complement profiles differ in patients with SAB and those with GNB. Measurement of IL-10 in patients with SAB and of C4, C3, and C9 in patients with GNB may help to identify those at higher risk for poor outcomes.Electronic supplementary materialThe online version of this article (10.1007/s10096-020-03955-z) contains supplementary material, which is available to authorized users.

Patients with tuberculous meningitis and hepatitis B co-infection have increased risk for antituberculosis drug-induced liver injury and poor outcomes

Background Tuberculous meningitis (TBM) is one of the most severe forms of tuberculosis. Previous studies reported that hepatitis B virus (HBV) infection could increase the risk of antituberculosis drug-induced liver injury (ATB-DILI) in pulmonary tuberculosis patients. To date, only a few studies exist on the effect of HBV on TBM. Methods This inpatient study retrospectively analyzed the medical records of patients who were diagnosed with TBM between June 2002 and June 2018. Statistical analysis was used to reveal the difference between the HBV and non-HBV groups. Univariate analysis and multivariate regression analysis were performed on data to determine the prognostic factors of TBM. Results A total of 386 patients were enrolled in our study, 57 of whom were included in the HBV group and 329 in the non-HBV group. The HBV group showed a higher frequency of ATB-DILI (HBV group: 14.0% versus non-HBV group: 3.3%, p < .001) and a higher risk of poor outcomes (i.e. death during inpatient period or neurological deficit at discharge, HBV group: 31.6% versus non-HBV group: 19.8%, p = .045) than the non-HBV group. The multivariate regression analysis identified ATB-DILI, scores of 3–8 on the Glasgow Coma Scale and hydrocephalus as independent predictors of poor outcomes in TBM patients. Conclusions Our study demonstrated that HBV co-infection could increase the incidence of ATB-DILI and the risk of poor outcomes as identified by three predictors in TBM patients.

COVID-19 Telehealth for Indian Country: Tribal Response to an Emerging Pandemic

American Indian/Alaska Native communities are at higher risk of poor outcomes from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The Northwest Portland Area Indian Health Board’s program Indian Country Extensions for Community Healthcare Outcomes (ECHO) initiated telehealth sessions for health professionals. All resources were centralized at www.IndianCountryECHO.org. In its first six weeks, the program had 4,579 attendees. Participants submitted 563 questions to specialists. There were 22,683 webpage views, more than three times the pre-COVID-19 baseline. Evaluation found 94 percent of clinicians reported knowledge increase and 93 percent reported greater social support, demonstrating that a teleECHO network serving Indian country is an important part of emergency response.

COVID-19 and the pulmonary vasculature.

COVID-19 and the pulmonary vasculature.

Digoxin Initiation and Outcomes in Patients with Heart Failure (HFrEF and HFpEF) and Atrial Fibrillation

BackgroundDigoxin reduces the risk of heart failure hospitalization but has no effect on mortality in patients with heart failure without atrial fibrillation in the randomized controlled trial setting. Observational studies of digoxin use in patients with atrial fibrillation have suggested a higher risk for poor outcomes. Less is known about this association in patients with heart failure and atrial fibrillation, the examination of which was the objective of the current study. MethodsWe conducted an observational propensity score-matched study of predischarge digoxin initiation in 1768 hospitalized patients with heart failure and atrial fibrillation in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, balanced on 56 baseline characteristics (mean age, 79 years; 55% women; 7% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated for the 884 patients initiated on digoxin compared with 884 not initiated on digoxin. ResultsHRs (95% CIs) for 30-day, 2-year, and 4-year all-cause mortality were 0.80 (0.55-1.18; P = .261), 0.94 (0.87-1.16; P = .936), and 1.01 (0.90-1.14; P = .729), respectively. Respective HRs (95% CIs) for heart failure readmission were 0.67 (0.49-0.92; P = .014), 0.81 (0.69-0.94; P = .005), and 0.85 (0.74-0.97; P = .022), and those for all-cause readmission were 0.78 (0.64-0.96; P = .016), 0.90 (0.81-1.00; P = .057), and 0.91 (0.83-1.01; P = .603). These associations were homogeneous between patients with left ventricular ejection fraction ≤45% vs >45%. ConclusionsAmong hospitalized older patients with heart failure (HFrEF and HFpEF) and atrial fibrillation, initiation of digoxin was associated with a lower risk of heart failure readmission but had no association with mortality.

Recommendations for detection, prioritization, and treatment of thoracic oncology patients during the COVID-19 pandemic: the THOCOoP cooperative group.

The world currently faces a pandemic due to SARS-CoV-2. Relevant information has emerged regarding the higher risk of poor outcomes in lung cancer patients. As such, lung cancer patients must be prioritized in terms of prevention, detection and treatment. On May 7th, 45 experts in thoracic cancers from 11 different countries were invited to participate. A core panel of experts regarding thoracic oncology care amidst the pandemic gathered virtually, and a total of 60 initial recommendations were drafted based on available evidence, 2 questions were deleted due to conflicting evidence. By May 16th, 44 experts had agreed to participate, and voted on each of the 58 recommendation using a Delphi panel on a live voting event. Consensus was reached regarding the recommendations (>66 % strongly agree/agree) for 56 questions. Strong consensus (>80 % strongly agree/agree) was reached for 44 questions. Patients with lung cancer represent a particularly vulnerable population during this time. Special care must be taken to maintain treatment while avoiding exposure.

Latent Class Analysis to Determine Patients with Advanced Heart Failure at Highest Risk of Poor Outcomes (RP314)

•Examine the relationship between readily available clinical data and poor outcomes such as multiple hospitalization and death for patients with advanced heart failure.•Discuss the use of latent class analytic techniques for finding subgroups or phenotypes within a group of subjects. Predicting prognosis for patients with advanced heart failure (HF) is difficult. Most prediction models don't use regularly captured clinical data. To find a phenotype of patients with advanced HF that might be associated with poor outcomes. Latent class analysis was conducted using secondary data from a 6-site cluster RCT of an intervention to improve communication with advanced HF patients who had implantable cardioverter defibrillators (ICDs). Nine baseline measures were included: hospitalizations in the year before enrollment, HF severity (NYHA class), HF etiology, ICD indication (primary/secondary), functional status (ADLs), symptom burden (>2), comorbidities (>2), depression, and anxiety. Model fit criteria were compared for models testing 1 to 5 latent classes. Two groups of patients emerged: Class1 - “Healthier” - N=352 (62.5%) and Class2 - “More Sick” N=211 (37.5%). Class1 was more likely to be male (76% vs. 61%, p<0.001), married (58% vs. 50%, p<0.05), ischemic (48% vs. 39%, p<0.05) and less severe HF (NYHA class I or II) (12% vs. 2%, p<0.001), and to report no hospitalizations in the prior year (21% vs. 8%, p<0.001). Class2 was more likely to report ADL difficulty (93% vs. 26%, p<0.001), symptom burden (100% vs. 51%, p<0.001), comorbidities (86% vs. 74%, p<0.002), depression (28% vs. 1%, p<0.001), anxiety (30% vs. <1%, p<0.001), and have Medicaid (32% vs. 24%, p<0.05). Differences were not detected for age, race, ethnicity, or education. Patients in Class2 reported more hospitalizations (2.8 vs. 2.2, p<0.02) and were more likely to die (26% vs. 17%, p<0.01). We found a phenotype of advanced HF patients who were more likely to experience multiple hospitalizations and death based on readily available clinical data.

Cancer history is an independent risk factor for mortality in hospitalized COVID-19 patients: a propensity score-matched analysis

BackgroundAlthough research on the effects of comorbidities on coronavirus disease 2019 (COVID-19) patients is increasing, the risk of cancer history has not been evaluated for the mortality of patients with COVID-19.MethodsIn this retrospective study, we included 3232 patients with pathogen-confirmed COVID-19 who were hospitalized between January 18th and March 27th, 2020, at Tongji Hospital in Wuhan, China. Propensity score matching was used to minimize selection bias.ResultsIn total, 2665 patients with complete clinical outcomes were analyzed. The impacts of age, sex, and comorbidities were evaluated separately using binary logistic regression analysis. The results showed that age, sex, and cancer history are independent risk factors for mortality in hospitalized COVID-19 patients. COVID-19 patients with cancer exhibited a significant increase in mortality rate (29.4% vs. 10.2%, P < 0.0001). Furthermore, the clinical outcomes of patients with hematological malignancies were worse, with a mortality rate twice that of patients with solid tumors (50% vs. 26.1%). Importantly, cancer patients with complications had a significantly higher risk of poor outcomes. One hundred nine cancer patients were matched to noncancer controls in a 1:3 ratio by propensity score matching. After propensity score matching, the cancer patients still had a higher risk of mortality than the matched noncancer patients (odds ratio (OR) 2.98, 95% confidence interval (95% CI) 1.76–5.06). Additionally, elevations in ferritin, high-sensitivity C-reactive protein, erythrocyte sedimentation rate, procalcitonin, prothrombin time, interleukin-2 (IL-2) receptor, and interleukin-6 (IL-6) were observed in cancer patients.ConclusionsWe evaluated prognostic factors with epidemiological analysis and highlighted a higher risk of mortality for cancer patients with COVID-19. Importantly, cancer history was the only independent risk factor for COVID-19 among common comorbidities, while other comorbidities may act through other factors. Moreover, several laboratory parameters were significantly different between cancer patients and matched noncancer patients, which may indicate specific immune and inflammatory reactions in COVID-19 patients with cancer.

A Structured Tool for Communication and Care Planning in the Era of the COVID-19 Pandemic

Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident, and their family.

Decreased Serum Retinoic Acid May Predict Poor Outcome in Ischemic Stroke Patients.

Background and AimsDecreased serum retinoic acid (RA) levels have been shown to be linked with increased mortality in cardiovascular diseases. This study aimed to investigate the relationship between serum RA and 3-month functional outcome after ischemic stroke.MethodsBetween January 2019 and September 2019, we prospectively recruited ischemic stroke patients within 24 hrs of symptom onset. Serum RA levels were measured for all patients at admission. The primary outcome was defined as poor functional outcome (modified Rankin Scale 3–6) at 90 days. The secondary outcome was defined as early neurological deterioration (END), which is considered as an increase of ≥1 point in motor power or total National Institutes of Health Stroke Scale score of ≥2 points within 7 days.ResultsA total of 217 patients were included in the analysis. The median RA levels were 2.9 ng/mL. Ninety-four (43.3%) and 65 (30.0%) patients experienced 3-month poor outcome and END, respectively. After adjusted for potential confounders, decreased levels of serum RA were associated with a higher risk of poor outcome (P for trend = 0.001) and END (P for trend = 0.002). Adding RA quartile to the existing risk factors improved risk prediction for poor outcome [net reclassification improvement (NRI) = 42.6%, P = 0.001; integrated discrimination improvement (IDI) = 5.7%, P = 0.001] and END (NRI index = 45.4%, P = 0.001; IDI = 4.3%; P = 0.005).ConclusionLow serum RA levels at baseline were associated with poor prognosis at 90 days after ischemic stroke, suggesting that RA may be a potential prognostic biomarker for ischemic stroke.

Abstract C101: A prognostic risk model for African American women with breast cancer: Implications for meaningful accrual in clinical trials

Abstract Background: Racial disparities in breast cancer outcomes appear to be widening in the US despite multiple advancements in breast cancer (BC) management. Although BC incidence rates are similar between European-American (EA) and African American (AA) women in the US, striking differences exist in age-adjusted mortality rates. Moreover, AAs only represent 5-10% of BC clinical trials is the US, and there is a dearth of studies that stratify outcomes by race. Unfortunately, there is no reliable way to identify AA BC patients at high risk of poor outcomes, which would require more aggressive treatment. In this study, we aimed to develop a prognostic model for AA women that will allow for a deeper segmentation and an accurate patient stratification into high and low risk subgroups to aid clinical decision making. Methods: We obtained protein data from The Cancer Proteome Atlas (TCPA) dataset, which consists of reverse phase protein array (RPPA) expression levels of 224 proteins measured from BC TCGA cohort. Protein expression information were available for a total of 754 BC patients (134 AA and 620 EA). Sequential forward selection alongside cross-validation was used to select proteins, fit into a random forest model, based on their combined accuracy in predicting patient prognosis. Models were evaluated on the combined cross validated test sets either univariately through the Kaplan-Meier log-rank test or via multivariate analysis after adjusting for stage, age, and positive lymph nodes through Cox regression model. Results: The selection process resulted in combination of four proteins that optimized prognostic prediction: bcl2- like protein (BAX), Inositol polyphosphate-4-phosphatase, type II (INPP4B), X-ray repair cross-complementing protein 1 (XRCC1) and Cleaved Poly (ADP-ribose) polymerase (c-PARP)). Alone, these proteins did not have significant prognostic value in AA BC patients [BAX (HR=0.676, p=0.6276), INPP4B (HR=0.9935, p=0.9772), XRCC1(HR=0.2613, p=0.1455), c-PARP (HR=0.6375, p=0.6186)]; within random forest, these variables were able to stratify high-risk group patients with 86% accuracy and Hazard Ratio (HR) of 5 (p &amp;lt;0.001). The model retained its significant prognostic ability (HR=10.741, p=0.0006) when controlling for clinicopathologic variables like stage, age, and positive lymph nodes. Finally, we retrained our model to risk stratify BC patients in the EA cohort; the magnitude of risk stratification was very low (HR=1.33) compared to AA cohort, confirming its prognostic role specifically in AA BC patients. Conclusions: Based on statistical modeling and ML-based approaches, our data show that assessment of expression of a quartet of biomarkers—BAX, XRCC1, INPP4B and c-PARP—can be used to robustly stratify AA BC patients into high- and low-risk categories. We believe our model plays an important prognostic role in AA BC patients and could inform clinicians to prioritize AA patients for appropriate clinical trials and also help patients make decisions about enrolling in such trials. Citation Format: Shristi Bhattarai, Sergey Klimov, Ritu Aneja. A prognostic risk model for African American women with breast cancer: Implications for meaningful accrual in clinical trials [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C101.

Development and validation of a model predicting post-traumatic headache six months after a motor vehicle collision in adults

ImportanceThe prognosis of post-traumatic headache is poorly understood. ObjectiveTo develop and validate a prognostic model to predict the presence of post-traumatic headache six months after a traffic collision in adults with incident post-traumatic headache. DesignSecondary analyses of adults with incident post-traumatic headache injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada (development cohort); and between January 2004 and January 2005 in Sweden (validation cohort). SettingThe Saskatchewan cohort (development) was population-based (N = 4162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20 % of cars driven in Sweden in 2004. ParticipantsAll adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized >2 days, lost consciousness >30 min, or reported headache <3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80 %. PredictorsBaseline sociodemographic, pre-injury, and injury factors. OutcomeSelf-reported headache pain intensity ≥3 (numerical rating scale) six months after injury. ResultsBoth cohorts were predominantly female (69.7 % in Saskatchewan, 65.2 % in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, work status, headache pain intensity, symptoms in arms or hands, dizziness or unsteadiness, stiffness in neck, pre-existing headache, and lower recovery expectations. With a positive score (i.e., ≥0.75 probability), the model can rule in the presence of post-traumatic headache at six months (development: specificity = 99.8 %, 95 % CI 99.5 %–99.9 %; sensitivity = 1.6 %, 95 % CI 1.0 %–2.6 %; positive likelihood ratio (LR+) = 8.0, 95 % CI 2.7−24.1; negative likelihood ratio (LR-) = 1.0, 95 % CI 1.0−1.0; validation: specificity = 95.5 %, 95 % CI 91.1 %–97.8 %; sensitivity = 27.2 %, 95 % CI 20.4 %–35.2 %); LR+ = 6.0, 95 % CI 2.8−13.2; LR- = 0.8, 95 % CI 0.7−0.8). Conclusions and relevanceClinicians can collect patient information on the eight predictors of our model to identify patients that will report ongoing post-traumatic headache six months after a traffic collision. Future research should focus on selecting patients at high risk of poor outcomes (using our model) for inclusion in intervention studies, and determining effective interventions for these patients.

Vitamin D-Binding Protein (Gc-Globulin) in Acute Liver Failure in Children.

This study aimed to analyse vitamin D-binding protein (Gc-globulin) serum levels in acute liver failure (ALF) in children in relation to disease outcomes and correlations with other known markers used to evaluate the severity of ALF. Our study included 34 children (mean age 4.87 ± 5.30 years) with ALF of different causes (metabolic, 26.47%; autoimmune, 23.53%; toxic, 20.59%; infection, 17.65%; unknown, 11.76%) and 30 children without any liver injury (mean age 6.11 ± 4.26 years). The outcome was poor in 14 patients (41.18%), including one child with liver transplantation (2.94%). Serum Gc-globulin levels were significantly lower in ALF patients compared to the control group (151.57 ± 171.8 mg/L vs. 498.63 ± 252.50 mg/L; p < 0.000001), with an optimum cut-off of 163.5 mg/L (Area Under the Curve, AUC, 0.8921; sensitivity, 76.50%; specificity, 100%). Levels were also lower in patients with poor outcomes compared to survivors (59.34 ± 33.73 mg/L vs. 216.12 ± 199.69 mg/L; p < 0.0001), with an optimum cut-off 115 mg/L (AUC, 0.7642; sensitivity, 100%; specificity, 50%). Gc-globulin serum levels were variable according to ALF aetiology, i.e., lower in metabolic, infectious, or unknown causes compared to autoimmune and toxic causes. Gc-globulin serum levels were decreased in children with ALF and lower in those with poor outcomes compared with survivors. Gc-globulin serum levels were correlated with other known parameters used to evaluate the severity of ALF and could help to identify patients at high risk for poor outcomes.

Coronary Artery Disease in patients with End‐Stage Kidney Disease; Current perspective and gaps of knowledge

Coronary artery disease (CAD) is very common in dialysis patients. One third have preexisting CAD and another one third have significant occult disease at the time of starting dialysis. Symptoms are often absent or are atypical, emphasizing the need for vigorous screening, specifically in patients awaiting transplant. The lesions tend to be heavily calcified, diffuse, and involve multiple vessels, consequently, percutaneous coronary interventions are more complicated to perform, and are less successful in achieving and maintaining short- and long-term patency. Dialysis patients have been excluded from the randomized controlled trials on which the current standards for managing CAD have been established. Due to differences in pathobiology and risks and benefits, it is uncertain that the results of these clinical trials extrapolate to patients with advanced chronic kidney disease(CKD). Here we review the data from observational studies and identify special considerations concerning the diagnosis and management of CAD in dialysis patients, including the use of noninvasive functional testing vs anatomical testing, the management of acute coronary syndromes and of stable coronary artery disease, the role for percutaneousrevascularization vs coronary artery bypass grafting, and of platelet inhibitor therapy after coronary stenting. We review the preliminary results of the recently published ISCHEMIA-CKD trial, the only trial to date to involve large numbers of dialysis patients. This is the first of, hopefully, many trials in the pipeline that will examine therapies for CAD specifically in patients with advanced CKD, a growing population that is at particularly high risk for poor outcomes.

Age-Related Differences in the Association between Plasma High-Sensitivity C-Reactive Protein and Noncalcified or Mixed Coronary Atherosclerotic Plaques.

Background Previous studies have demonstrated that plasma high-sensitivity C-reactive protein (hsCRP) was the predictor for unstable coronary plaque. Patients with noncalcified plaque (NCP) or mixed plaque (MP) have a higher risk of poor outcomes. However, the association between hsCRP and the presence of NCP or MP (NCP/MP) in old adults remains unclear, and if present, whether there exist differences between young and old adults remain unknown. Thus, the aim of this study was to investigate the role of hsCRP in predicting the presence of NCP/MP and evaluate whether age has any impact on this association. Methods A total of 951 subjects were included in this study. Complete clinical and laboratory data were collected. According to the characteristics of the most stenotic plaque, we divided them into 2 groups: calcified plaque (CP) and NCP/MP. Subjects with no plaque were classified as the control group (CR). Subjects with age ≥ 60 years were defined as older adults, and those with age < 60 years were classified as nonelderly people. Results Patients with NCP/MP had significantly higher hsCRP level compared with subjects with CR or CP in older adults but not in nonelderly people. The proportion of NCP/MP was significantly increased from 27.0% in the hsCRP < 1.25 mg/L group to 42.7% in the hsCRP > 2.70 mg/L group in older adults. Multiple logistic regression analysis showed that hsCRP was an independent risk factor for the presence of NCP/MP (odds ratio (OR) = 1.093, 95% CI 1.032–1.157, P = 0.001) only in older adults. Conclusions hsCRP is independently associated with the presence of NCP/MP in older adults but not in nonelderly people. These results suggest the potential significance of hsCRP-lowering regimens in older adults with NCP/MP.

Geospatial Mapping of Orthopaedic Surgeons Age 60 and Over and Confirmed Cases of COVID-19.

Background:Although elective surgical procedures in the United States have been suspended because of the coronavirus disease 2019 (COVID-19) pandemic, orthopaedic surgeons are being recruited to serve patients with COVID-19 in addition to providing orthopaedic acute care. Older individuals are deemed to be at higher risk for poor outcomes with COVID-19. Although previous studies have shown a high proportion of older providers nationwide across medical specialties, we are not aware of any previous study that has analyzed the age distribution among the orthopaedic workforce. Therefore, the purposes of the present study were (1) to determine the geographic distribution of U.S. orthopaedic surgeons by age, (2) to compare the distribution with other surgical specialties, and (3) to compare this distribution with the spread of COVID-19.Methods:Demographic statistics from the most recent State Physician Workforce Data Reports published by the Association of American Medical Colleges were extracted to identify the 2018 statewide proportion of practicing orthopaedic surgeons ≥60 years of age as well as age-related demographic data for all surgical specialties. Geospatial data on the distribution of COVID-19 cases were obtained from the Environmental Systems Research Institute. State boundary files were taken from the U.S. Census Bureau. Orthopaedic workforce age data were utilized to group states into quintiles.Results:States with the highest quintile of orthopaedic surgeons ≥60 years of age included states most severely affected by COVID-19: New York, New Jersey, California, and Florida. For all states, the median number of providers ≥60 years of age was 105.5 (interquartile range [IQR], 45.5 to 182.5). The median proportion of orthopaedic surgeons ≥60 years of age was higher than that of all other surgical subspecialties, apart from thoracic surgery.Conclusions:To our knowledge, the present report provides the first age-focused view of the orthopaedic workforce during the COVID-19 pandemic. States in the highest quintile of orthopaedic surgeons ≥60 years old are also among the most overwhelmed by COVID-19. As important orthopaedic acute care continues in addition to COVID-19 frontline service, special considerations may be needed for at-risk staff. Appropriate health system measures and workforce-management strategies should protect the subset of those who are most potentially vulnerable.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.