High-risk Ones Research Articles

Modes of death and prognostic outliers in chronic heart failure

The impact of incident sudden cardiac death (SCD) on the predictive accuracy of prognostic risk scores for patients with chronic heart failure (HF) has rarely been examined. We assessed the relationship between estimated probability of death and modes of death in this population, as well as the predictors of death and survival in prognostic outliers. The MAGGIC 3-year probability of death was estimated in 6,859 participants of the GISSI-HF trial (mean age 67±11 years, 78% men, 91% with ejection fraction <40%, mean follow-up 3.5±1.3 years, observed mortality 28.4%). The incidence of SCD progressively decreased with increased probability of death, and occurred in 52.5% of patients estimated at low-risk (N = 61 with probability <14%) vs. in 23.5% of the high-risk ones (N = 375 with probability >56%, P < .0001). On the contrary, death from worsening HF was significantly more frequent in the latter group (19.7% vs. 46.1%, P < .0001). The overall predictive accuracy of the MAGGIC model improved after excluding deaths from SCD (AUC from 0.731 to 0.760, P = .0034). Among patients estimated at low-risk (N = 61 dead, 743 alive), independent predictors of death were older age, longer history of HF, higher serum uric acid and chronic obstructive pulmonary disease. The only predictor of survival in patients estimated at high-risk (N = 210 alive, 375 dead) was higher systolic blood pressure. The MAGGIC risk score demonstrated its scarce ability to capture SCD, particularly in chronic HF patients estimated at low risk of death. Newer and better prognostic tools in the evolving horizon of HF are needed.

Mortality attributable to different Klebsiella susceptibility patterns and to the coverage of empirical antibiotic therapy: a cohort study on patients admitted to the ICU with infection.

To evaluate the prognostic importance of different Klebsiella spp. sensitivity patterns: multi-susceptible Klebsiella (MS-K), extended-spectrum cephalosporin-resistant, but carbapenem-susceptible Klebsiella (ESCR-CS-K), and carbapenem-resistant Klebsiella (CR-K). We developed a prognostic model to predict hospital mortality in patients with infection on admission to the intensive care units (ICUs), and assessed its calibration in the subgroups of interest: patients with infections due to MS-K, ESCR-CS-K, CR-K. We assessed the calibration of the model also in ESCR-CS-K treated empirically with carbapenems and with piperacillin-tazobactam. A total of 13,292 adults with an ongoing infection were admitted to 137 Italian ICUs in 2012-2013. Of 801 Klebsiella spp. infected patients, 451 had MS-K, 116 ESCR-CS-K, and 234 CR-K. The prognostic model calibrated well for the MS-K and ESCR-CS-K subgroups. In the CR-K subgroup there were more deaths than predicted (standardized mortality ratio 1.20; 95% CI 1.08-1.31), indicating a negative prognostic role of the infection, mainly in the medium and high risk-of-death patients. When infection was caused by ESCR-CS-K, treatment with piperacillin-tazobactam increased adjusted mortality among the most severe patients (similarly to CR-K), while treatment with carbapenems did not (similarly to MS-K). In low risk-of-death patients admitted to the ICU with a Klebsiella spp. infection, the appropriateness of empirical antibiotic therapy seemed uninfluential to eventual mortality, while it appeared to be crucial in high-risk ones. The use of piperacillin-tazobactam may be inappropriate in severe patients with ESCR-CS-K infection. CR-K is associated to a significant 20% increase of adjusted mortality, only for patients at higher risk of death.

Application of chest CT scan in gestational trophoblastic neoplasia with lung metastasis

Objective: To explore the role of CT scan for the diagnosis of lung metastasis in stage Ⅲ gestational trophoblastic neoplasia (GTN) . Methods: To figure out the role of CT scan for lung metastasis in GTN initial diagnosis, treatment and follow-up, 93 GTN patients with lung metastasis from January, 2015 to December, 2016 were retrospectively analyzed in Obstetrics and Gynecology Hospital of Fudan University. Results: (1) Among 93 GTN patients with lung metastasis, 70 patients with the International Federation of Gynecology and Obstetrics (FIGO) score ≤6 were defined as low risk GTN and 23 patients score score ≥7 were defined as high risk GTN. Forty nine patients had negative chest X-ray findings and 39 cases with pulmonary lesions were identified both by chest X-ray compared to CT scan. Five cases were excluded due to no consensus could make for the results of chest X-ray. The true positive rate of chest X-ray for lung metastasis were 41% (29/70) in low risk GTN and 43% (10/23) in high risk GTN patients without statistical difference (χ(2)=0.090, P=0.925) . For those patients with positive chest CT scan and negative chest X-ray finding, pulmonary lesions in 32 (65%, 32/49) cases were blocked by heart, chest wall or diaphragm in chest X-ray. Seventeen (35%,17/49) patients with lung lesions less than 5 mm had negative chest X-ray results due to the lower sensitivity compared to CT scan. (2) In 88 patients with stage Ⅲ, 78 patients had successful initial treatment, but 4 of them were recurrence in twelve months follow-up. Ten patients were chemotherapy resistance for the initial treatment. The initial chemotherapy remission rate in low risk GTN patients was higher than that in high risk ones (χ(2)=4.911, P=0.027) . In 49 cases with negative chest X-ray, there was no correlation with the rate of remission,chemotherapy resistance and recurrence in stage Ⅲ patients (P>0.05) . (3) For those patients who had poorly response to initial chemotherapy, the diameters of lesions in lung were unchanged or increased during the treatment, form (5.1±4.1) mm to (7.4±2.8) mm. The pulmonary lesions were continuously shrunk from (7.8±5.3) mm to (4.7±4.4) mm for those patients with complete and partial remission including the recurrent GTN patients (Z=-2.713, P=0.007) . Conclusions: Patients with GTN in stage Ⅲ have down staging if only use chest X-ray for imaging at the initial diagnosis. Chest CT scan is recommended for primary imaging evaluation of FIGO staging in qualified medical organization. For those patients with persistent abnormal serum hCG level and negative chest X-ray, chest CT scan is strongly recommended to identify the persist or resistant lung lesions and follow up.

Could Whole Body MRI Change Staging for Patients Affected by High Risk Prostate Cancer Candidate to Local Radiation Therapy?

The purpose of our experience is to understand if Whole Body MRI (WBMRI) could be useful in identifying bone metastasis in patients affected by high risk prostatic adenocarcinoma with negative bone scan (BS) so as to avoid a local radiotherapy anticipating the proper systemic treatment. Routinely we use multiparametric pelvic MRI in patients undergoing to local radiotherapy to better identify volumes to be treated. In high risk patients we extended the MRI study to whole body to obtain a more accurate staging. Between 1/1/2016 and 21/3/2016, we evaluated 34 patients, with diagnosis of high risk (PSA ≥ 20 ng/ml or G-S ≥ 8 or cT3-4) prostatic adenocarcinoma (median age 69, range 48-63), of which 17 underwent to surgery, 1 to trans urethral resection of the prostate (TURP) and 16 to prostatic biopsy, sent to our ambulatory to evaluate an adjuvant or definitive radiotherapy. All patients had a negative BS for the standard staging of disease and then they underwent to WBRMI to compare the data on the M parameter. We used an 1.5 T MRI scan performing T1, T2, DWI and STIR (sagittal coronal or axial depending on the district) images with and without m.d.c. Bone metastases were detected at WBMRI in 6 (18%) patients. All of them were positive on assile skeleton (vertebrae or pelvis). Considering the six patients positive for bone metastasis, 3 of them could be considered oligometastatic (not more than 2 bone metastasis) and 3 had more than 2 bone sites involved. Local radiotherapy was not performed for all the six metastatic patients and was administered a systemic treatment (hormonal therapy or chemotherapy). Despite the exiguous number of patients, WBRMI seems to be a valid method to identify patients, among high risk ones, who are affected by bone metastasis and are not suitable for local, definitive treatment. The value of 18% of patients with negative bone scan and positive WBMRI for bone metastasis, seems to be confirmed in patients just seen after our observation but indeed we need a larger number of patients to confirm this result.

Enumerating bone marrow blasts from nonerythroid cellularity improves outcome prediction in myelodysplastic syndromes and permits a better definition of the intermediate risk category of the Revised International Prognostic Scoring System (IPSS-R).

The Revised International Prognostic Scoring System (IPSS-R) has been recognized as the score with the best outcome prediction capability in MDS, but this brought new concerns about the accurate prognostication of patients classified into the intermediate risk category. The correct enumeration of blasts is essential in prognostication of MDS. Recent data evidenced that considering blasts from nonerythroid cellularity (NECs) improves outcome prediction in the context of IPSS and WHO classification. We assessed the percentage of blasts from total nucleated cells (TNCs) and NECs in 3924 MDS patients from the GESMD, 498 of whom were MDS with erythroid predominance (MDS-E). We assessed if calculating IPSS-R by enumerating blasts from NECs improves prognostication of MDS. Twenty-four percent of patients classified into the intermediate category were reclassified into higher-risk categories and showed shorter overall survival (OS) and time to AML evolution than those who remained into the intermediate one. Likewise, a better distribution of patients was observed, since lower-risk patients showed longer survivals than previously whereas higher-risk ones maintained the outcome expected in this poor prognostic group (median OS < 20 months). Furthermore, our approach was particularly useful for detecting patients at risk of dying with AML. Regarding MDS-E, 51% patients classified into the intermediate category were reclassified into higher-risk ones and showed shorter OS and time to AML. In this subgroup of MDS, IPSS-R was capable of splitting our series in five groups with significant differences in OS only when blasts were assessed from NECs. In conclusion, our easy-applicable approach improves prognostic assessment of MDS patients.

Abstract 8: Breast Reconstruction Pre-operative Risk Assessment: Applying the Risk Calculator to Define High Risk Patients

PURPOSE: In the last decade an increasing number of patients with breast cancer have undergone breast reconstruction, including high risk ones. Patients with multiple comorbidity factors have been associated with increased complications. However, how should we define a high risk patient and should their reconstruction plan follow the same of a lower risk patient? The BRA Score has been proposed to calculate the pre-operative risk. Our aim was to correlate the validity of BRA Score as a pre-operative risk calculator for its practical use. METHODS: Patients that underwent different types of breast reconstruction had their pre-operative risk retrospectively calculated per breast using the BRA Score, and the actual complications they developed were collected. From the BRA Score we calculated risk of overall complication based on MROC (Risk-MROC) and TOPS (Risk-TOPS), surgical site infection risk (SSI-Risk), and 30 day reoperation risk (Reop-Risk). Data gathered from patient charts included post-operative overall complications (PO-Comp), surgical site infection (SSI), and reoperations due to complications. The following groups were considered: group 1, reconstructed breasts that had the analyzed complication; group 2, breasts without the complication. The ROC curve was used to evaluate the calculated risk as a complication predictor test. RESULTS: Charts of 389 breast reconstructions from 255 patients were evaluated. Compared to Group 2, Group 1 had a significantly higher Risk-MROC (20.8 ± 11.12 vs 15.24 ± 9.16, p≤0.01), Risk-TOPS (19.7 ± 7.28 vs 15.5 ± 6.56, p≤0.01), and Reop-Risk (7.48 ± 3.27 vs 6.22 ± 5.22, p≤0.01); and similar SSI-Risk (3.75 ± 2.3 vs 3.94 ± 2.38, p=0.96). As tests for predicting the PO-Comp, Risk-MROC and Risk-TOPS were adequate, with areas under the ROC curve of 0.662 and 0.669, respectively. For predicting the reoperations, Risk-MROC, Risk-TOPS, and Reop-Risk presented areas of 0.666, 0.691, and 0.652, respectively. A predicted risk of 25.5% using Risk-MROC and Risk-TOPS would provide a specificity of 79% and 89%, respectively. CONCLUSIONS: In this patient population, the BRA Score was a helpful tool to predict overall complications and reoperations. The calculator was not found to be useful in predicting surgical site infection. An overall risk of 25.5% derived from either the MROC or TOPS database would provide high specificity in determining a very high risk breast reconstruction patient. Patients with such high pre-operative risk may benefit from modifications in the breast reconstruction treatment plan to lower the complication rate. By using BRA Score, we can reliably predict the possible outcome of the reconstructions which can be used to better counsel the patient.

Cardiovascular risk assessment and screening in diabetes.

Diabetes used to be considered as a coronary heart disease equivalence and universally classified high cardiovascular risk population. However increasing epidemiological evidence now indicates the heterogeneity of risk among the diabetic patients and imposes animportance of stratifying those with relative low-risk from high-risk ones. Despite the existing risk assessment tools, current cardivoascualr disease prevention guidelines fail to provide more detailed stratification strategies for patient with diabetes and expose them to either overtreatment or undertreatment. On the other hand, various screening modality, including novel biomarkers and subclinical asthrosclerosis scanning, including coronary calcium scanning, carotid intima-media thickness, myocardial perfusion imaging and coronary computed tomography angiography, have provided very promising usage is risk stratification. With better developed test techniques and more extensive evidence, these modalities may serve in standardized screening algorithm to improve the cardiovascular risk assessment of patients with diabetes and better instruct their individualized preventive therapy.

Prevalence of High-Risk Human Papillomavirus (HPV) among Negative Visual Inspection of Acetic Acid (VIA)

Objective: Persistence of high-risk HPV infection is known to be the&#x0D; major cause of cervical cancer. It is important to differentiate the&#x0D; genotype of HPV infection, whether it is high, intermediate or low&#x0D; risk. The aim of this study was to assess the prevalence of high-risk&#x0D; HPV types among Indonesian women with negative VIA.&#x0D; Method: We analyzed cervical swabs from 1,214 patients with negative&#x0D; VIA. By using INNO-Lipa HPV DNA test, we detected the HPV&#x0D; DNA and its genotype.&#x0D; Result: From the 1,214 women with negative VIA, 48 (3.95%) samples&#x0D; were confirmed to have positive HPV DNA by using PCR and&#x0D; electrophoresis. However, hybridization test were not able to detect&#x0D; HPV genotypes in 9 samples. These 9 samples were tested again&#x0D; with PCR and electrophoresis and resulted in negative HPV DNA.&#x0D; Among the remaining 39 samples (3.21%), we detected 19 types of&#x0D; HPV, consisting of 13 types of high-risk HPV, 5 types of low-risk HPV,&#x0D; and 1 type of unknown HPV (type X).&#x0D; Conclusion: Among patients with negative VIA, 3.21% was found to&#x0D; be positive for HPV DNA. From this percentage, the prevalence of&#x0D; high-risk HPV is higher than the low-risk and unknown HPV. Therefore&#x0D; we cannot ignore results of negative VIA, particularly in highrisk&#x0D; group, because there is a slight possibility that presence of HPV&#x0D; can be identified, especially the high risk ones which have a tendency&#x0D; to be persistent. We support the importance of HPV DNA test&#x0D; as cervical cancer screening method.&#x0D; [Indones J Obstet Gynecol 2014; 3: 153-156]&#x0D; Keywords: cervical cancer, high-risk HPV, negative VIA

OP.6C.05] THE POSSIBILITY OF IMPROVING THE COMPLIANCE TO THE TREATMENT BY USING OF ELECTRONIC VERSION OF SCORE IN HYPERTENSIVE PATIENTS

Objective: It is well-known that pts without signs of atherosclerotic disease are weakly motivated to drug treatment. We suggested that vivid demonstration to the pts their real risk and its favorable changes if achieving goals of therapy using electronic version of SCORE (EV SCORE) would lead to better motivation and compliance to drug treatment in hypertensive pts. Design and method: 140 hypertensive males aged 40–55 with high risk according to SCORE evaluation (all of them were smokers and had high level of total cholesterol - more than 5 mmol/l) and without signs of atherosclerotic disease were included in the trial. They were randomly divided in two groups by 70 pts in each. In one group total risk was calculated by using EV SCORE (main group). In the second group total risk was evaluated by chart version of SCORE (reference group). In both groups pts were shown not only initial risk but its change if achieving goals of therapy. All pts as high risk ones were prescribed antihypertensive and lipid-lowering drugs as well as healthy life-style recommendations during 9 months. Results: Compliance to both antihypertensive and lipid lowering therapy was significantly higher in the group where EV SCORE was used. In this group 46 pts out of 70 (65,7%) remained on antihypertensive drugs by the end of the study, while only 35 pts (50,0%) - in reference group, p < 0,05. The difference especially was pronounced concerning lipid- lowering treatment. The percentage of pts who remained on lipid- lowering drugs by the end of the study was significantly higher in the main group comparing with the reference group – respectively 42 pts (60,0%) and 12 pts (17,1%), p < 0,001. As a result more pts in the main group achieved blood pressure and lipid variables goals, then in the reference group. Conclusions: Results show, that using EV SCORE in clinical practice allows not only quick evaluation of total risk but also motivates hypertensive pts without signs of atherosclerotic disease to better compliance to antihypertensive and lipid-lowering therapy.

Management of transient loss of consciousness of suspected syncopal cause, after the initial evaluation in the Emergency Department

The recommendations enclosed in the present document have been developed by a group of experts appointed by the &lt;em&gt;Gruppo Multidisciplinare per lo Studio della Sincope&lt;/em&gt; (Multidisciplinary Group for the Study of Syncope; GIMSI) and Academy of Emergency Medicine and Care (AcEMC). The aim is to define the diagnostic pathway and the management of patients referred to the Emergency Department (ED) for transient loss of consciousness of suspected syncopal cause, which is still unexplained after the initial evaluation. The risk stratification enables the physician to admit, discharge or monitor shortly the patient in the intensive short-stay Syncope Observation Unit (SOU). There are three risk levels of life-threatening events or serious complications (low, moderate, high). Low risk patients can be discharged, while high risk ones should be monitored and treated properly in case of worsening. Moderate risk patients should undergo clinical and instrumental monitoring in SOU, inside the ED. In all these three cases, patients can be subsequently referred to the Syncope Unit for further diagnostic investigations.

Combined treatment of the highly differentiated cancer of thyroid gland: recombinant human thyrotropin-alpha is in the focus

Aim . An assessment of the effectiveness of treatment and also the detection of advantages of prescription of the recombinant human thyrotropin-alpha (rhTTH) in postoperative period in patients with the highly differentiated cancer of thyroid gland (HDCTG) comparing with traditional method of preparation (cancellation of the thyroid hormones) to the treatment using radioactive iodine. Methods . There was carried out an analysis of the treatment of 100 patients with HDCTG: the control group – 56 patients (standard tactics), the main group – 44 patients (the use of rhTTH). There was carried out the scanning of all the body in 48 hours after administration of 150 MBc 131 I, was detected the concentration of thyroglobulin and antibodies to it, the level of thyrotropic hormone, was carried out the ultrasound of neck and also questioning about the life quality. Results . The comparative analysis of the data of studied groups demonstrated the reliably less number of isotope accumulation nidi in persons whose preparation was carried out with the help of rhTTH, that is the absence of visible catch in 25 % of cases in patients from the category of low risk (in 5,7 times higher than in analogous cohort of the control group– 4,4 %) and in 7,1 % – in patients from the high risk group. The number of cases of the minimal visible catch 2,0 ng/ml was detected in 3,1 % of cases in the main group whereas in the control one – 13,1 %; within 1,0–2,0 ng/ml was detected reliably less often in the main group: 8,3 % in the low risk patients and 12,5 % – in the high risk ones comparing with the control group (28,6 % and 31,7 % respectively). The effective decrease of thyroglobulin level in 6–8 months after radioiodine therapy was detected in 22 (91,7 %) patients of the main low risk group and in 27 (84,4 %) – ones of the high risk that is reliably higher than in the control group (60,0 % and 53,7 % respectively, Р<0,01). In the main group was not observed any clinical relapse of disease or persistence of pathological tumor process, in the control group on the contrary – 2 clinical relapses (4,9 %) and 4 cases (9,7 %) of persistence of disease. In the main group nobody needed the repeated operation during 6 months after radioiodine therapy because of absence of the regional metastases of papillary carcinoma. The negative assessment of health was observed in 10,7 % of cases in the control group and was not fixed in the main one. The positive assessment of health was observed in 63,6 % of patient who took recombinant TTH comparing with the control group – 21,4 %. Conclusions . The research demonstrated that combined treatment of the group of patients with HDCTG with the use of rhTTH is reliably more effective comparing with the group of patients who were prepared to treatment with the radioactive iodine using traditional method. The received results ground by the new proofs the advantages of the use of recombinant human thyrotropin-alpha

Effectiveness of early warning assessment for risks and management during pregnancy on perinatal outcomes

Objective To explore the effectiveness of early warning assessment and management for maternity on perinatal outcomes. Methods From January 1, 2013, a cohort prospective study was conducted on 49 261 pregnant women who registered initially at 6-13 gestational weeks and were followed up at 246 community health centers from 17 districts or counties of Shanghai. The first screening was conducted in community health centers for gestational age verification, medical history collection and physical examination. The pregnant women would be marked as green alert if all of the above three indices were normal. A woman would be transferred to level two or above hospitals if the first screening results were abnormal and the early warning signs were divided into five categories, including green alert (normal), red alert (complicated with sever mobility and complications during pregnancy), orange alert (complicated with sever mobility and complications during pregnancy, but not as severe as that of red alert), purple alert (concomitant communicable diseases during pregnancy), yellow alert (complicated with milder mobility and complications during pregnancy compared with that of red alert). The low risk pregnancy referred to yellow alert, and the high risk ones referred to orange, red or purple alert. We offered corresponding management and follow-up program for women with different warning signs, and analyzed the in-process indices such as screening-transport time, transport-diagnosis time, diagnosis-feedback time, feedback-initial-follow-up time, times of follow-up and regular or irregular follow-up. The association between in-process indices and perinatal outcomes (women with severe diseases during pregnancy and delivery, maternal mortality, preterm and low birth weight children and neonatal mortality) in both low and high risk pregnant women were analyzed using logistic regression model. Results Out of the 49 261 pregnant women, 10 485(21.28%) were positive in the first screening and 38 776 (78.72%) were negative. For early warning classification, 36 250(73.59%) were classified as green alert, 12 277(24.92%) as yellow alert, 625(1.27%) as orange alert, 8(0.02%) as red alert, and 101(0.21%) as purple alert. The regular follow-up rate for low risk pregnant women was 82.7%(10 153/12 277), and that of high risk women was 74.1%(544/734). Prolonged feedback-initial-follow-up time increased the risk of maternal mortality (OR=1.051, 95%CI: 1.015-1.088, P=0.008) among low and high risk pregnant women. The increased times of follow-up for risk pregnancies decreased the occurrence of critical illed complications (OR=0.851, 95%CI:0.725-0.999, P=0.049) and maternal mortality (OR=0.534, 95%CI: 0.307-0.930, P=0.014). Prolonged diagnosis-feedback time increased the risk of preterm birth (OR=1.009, 95%CI: 1.004~1.015, P=0.000). Prolonged feedback-initial-follow-up time increased the risk of neonatal mortality (OR=1.019, 95%CI: 1.001-1.038, P=0.045). However, the increase of follow-up times decreased the risk of preterm birth (OR=0.803, 95%CI: 0.762-0.847, P<0.001), low-birth weight (OR=0.882, 95%CI: 0.775-0.873, P<0.001) and neonatal mortality (OR=0.653, 95%CI: 0.543-0.785, P<0.001), so did regular follow-up (OR=0.432, 95%CI: 0.353-0.528; OR=0.494, 95%CI: 0.392-0.621; OR=0.226, 95%CI: 0.117-0.435; all P<0.001). Conclusions The system of early warning assessment and management for pregnancy is effective on perinatal outcomes to some in both low and high risk gravidas extend and is worthwhile to be generalized and to form long-term mechanism. Key words: Pregnancy complications; Risk management; Pregnancy outcome

INTERNATIONAL STANDARDS OF BANKING CAPITAL: ADAPTATION IN UKRAINE

The peculiarities of the state supervision of the Ukrainian banks and the regulation of their activities are re-searched. The state of the Ukrainian banking system at the present stage is analyzed, and the factors of influence on it are given. It is shown that common problem is lack of capitalization of Ukrainian banks, which led to the insolvency of a large number of them, the outflow of deposits, the growth of distrust to the banking system from the side of depositors and investors. In order to increase the efficiency of banking supervision and regulation some recommendations on adaptation the formation of bank capital to international standards of Basel III are offered, the advantages and disadvantages of the transition to international standards are shown. The study was conducted on the basis of data from a representative sample of the annual financial statements of the Ukrainian banks by the method of cluster analysis, k-means, on the basis of indicators of adequacy of regulatory capital H2 averaged by annual data. As a result of the analysis three groups of banks are selected in accordance with the level of riskiness approaches to capital formation: low-risk approach, moderate and high-risk ones. The division of banks into groups was carried out on the basis of analysis of variance, the calculations were made in the Statistica application. It is proposed to use additional analytical factors characterizing the formation of capital by banks, – a margin of safety of the capital base (the difference between the available sources of stable funding and needs for stable funding) and capital risk of systemically important banks (probability of failure by the bank regulatory capital adequacy). The establishment of minimum requirements for the formation of banks of systemic importance of the buffer was grounded on the basis of probability of failure of economic capital requirements and approaches to the formation of bank capital, which will lead, in practice, to effective management of the system and the individual capital of banking institutions risk. These proposals take into account the specifics of the national system of accounting and financial reporting of banks and formalized appropriate calculation algorithms.

The influence of disease and comorbidity risk assessments on the survival of MDS and oligoblastic AML patients treated with 5-azacitidine: A retrospective analysis in ten centers of the “Rete Ematologica Lombarda”

5-Azacytidine is an effective therapy in high risk MDS and oligoblastic AML. This “real life” analysis was made on 185 patients treated with 5-azacytidine in 10 centers afferent to REL (“Rete Ematologica Lombarda”), a network in Lombardia region. The aim was to assess the influence of disease and comorbidity risk assessments on the survival. The results confirm the utility of 5-azacitidine in prolonging OS regardless of advanced age and the presence of comorbidities. They also encourage an early treatment since patients with IPSS-R High risk MDS have better outcome with respect to Very High risk ones. According to the IPSS cytogenetic risk, there was no difference in the outcome between Intermediate and High risk patients. Nevertheless, a poorer cytogenetic risk, according to the IPSS-R cytogenetic stratification, negatively influenced the outcome.

Best treatment option for clinical stage I seminoma patients.

In the present cross sectional study comprising 106 patients, the authors compared a risk adapted therapeutic strategy in patients with CSI seminoma [1]. The patients were distributed to active surveillance (AS) (n = 84) and adjuvant chemotherapy (ACT) (n = 22) with single dose carboplatin groups. The relapse rates between the 2 groups were similar. The authors advocated AS for patients with low risk of relapse and, on the other hand, ACT for those with high risk of relapse. The current management options for CSI seminomas include adjuvant radiotherapy (ART), AS, and ACT. ART has been the preferred treatment modality for a long time, but concerns regarding its side effects, such as risks of cardiovascular disease and secondary malignancies, resulted in a significant change in the concept of ART. Thus, the option of ART has been removed from the current guidelines [2, 3]. Surveillance avoids overtreatment in approximately 85% of patients when appropriate follow-up protocols are used [4]. However, identifying the 15% who may harbor micrometastatic disease should be of utmost importance in patients under AS. Surveillance requires highly compliant patients willing to have multiple abdominal CT scans. The radiation from abdominal CT is not benign, with a lifetime attributable risk of secondary malignancy from 4 scans for an 18 year old patient calculated at 0.64% [5]. ACT has been shown to be non-inferior to ART [6]. In the largest series of ACT, a 4.1% relapse rate was demonstrated with a median time to relapse of 22.7 months among 517 patients [7]. A recent study which investigated the practice patterns for adjuvant therapies for CSI seminoma in the US population has demonstrated that ART has been largely replaced by ACT, rather than AS [8]. However, the authors concluded that the lack of an increase in AS in their cohort might represent overtreatment of the population. Proponents of AS consider ACT a potentially harmful and unnecessary intervention. However, in recent studies, especially low risk patients were selected for AS, whereas high risk patients were given ACT [9]. Due to this reason, such series may possibly be flawed by selection bias in favor of AS, whereas predominantly low risk patients were included rather than high risk ones [10]. The long term side effects of single dose ACT remain unclear; moreover, the use of ACT does not obviate the need for abdominal CT scans, which has been proposed as a concern against AS. A risk adapted treatment strategy seems to be logical for CSI seminoma patients. Although rete testis invasion and primary tumor >4 cm were reported to be independent prognostic factors for relapse, these data have not been validated in prospective studies [11]. Currently, AS has been recognized as the treatment of choice of CSI seminomas in the EAU and American Society of Clinical Oncology guidelines [2, 3].

Diffusion volume (DV) measurement in endometrial and cervical cancer: A new MRI parameter in the evaluation of the tumor grading and the risk classification

PurposeA new MRI parameter representative of active tumor burden is proposed: diffusion volume (DV), defined as the sum of all the voxels within a tumor with apparent diffusion coefficient (ADC) values within a specific range. The aims of the study were: (a) to calculate DV on ADC maps in patients with cervical/endometrial cancer; (b) to correlate DV with histological grade (G) and risk classification; (c) to evaluate intra/inter-observer agreement of DV calculation. Materials and methodsFifty-three patients with endometrial (n=28) and cervical (n=25) cancers underwent pelvic MRI with DWI sequences. Both endometrial and cervical tumors were classified on the basis of G (G1/G2/G3) and FIGO staging (low/medium/high-risk).A semi-automated segmentation procedure was used to calculate the DV. A freehand closed ROI outlined the whole visible tumor on the most representative slice of ADC maps defined as the slice with the maximum diameter of the solid neoplastic component. Successively, two thresholds were generated on the basis of the mean and standard deviation (SD) of the ADC values: lower threshold (LT=“mean minus three SD”) and higher threshold (HT=“mean plus one SD”). The closed ROI was expanded in 3D, including all the contiguous voxels with ADC values in the range LT-HT×10–3mm2/s.A Kruskal–Wallis test was used to assess the differences in DV among G and risk groups.Intra-/inter-observer variability for DV measurement was analyzed according to the method of Bland and Altman and the intraclass-correlation–coefficient (ICC). ResultsDV values were significantly different among G and risk groups in both endometrial (p<0.05) and cervical cancers (p≤0.01). For endometrial cancer, DV of G1 (mean±sd: 2.81±3.21 cc) neoplasms were significantly lower than G2 (9.44±9.58 cc) and G3 (11.96±8.0 cc) ones; moreover, DV of low risk cancers (5.23±8.0 cc) were significantly lower than medium (7.28±4.3 cc) and high risk (14.7±9.9 cc) ones. For cervical cancer, DV of G1 (0.31±0.13 cc) neoplasms was significantly lower than G3 (40.68±45.65 cc) ones; moreover, DV of low risk neoplasms (6.98±8.08 cc) was significantly lower than medium (21.7±17.13 cc) and high risk (62.9±51.12 cc) ones and DV of medium risk neoplasms was significantly lower than high risk ones.The intra-/inter-observer variability for DV measurement showed an excellent correlation for both cancers (ICC≥0.86). ConclusionsDV is an accurate index for the assessment of G and risk classification of cervical/endometrial cancers with low intra-/inter-observer variability.

Early Detection of Lung Cancer with Meso Tetra (4-Carboxyphenyl) Porphyrin-Labeled Sputum

Early detection of lung cancer in high-risk individuals reduces mortality. Low-dose spiral computed tomography (LDCT) is the current standard but suffers from an exceedingly high false-positive rate (>96%) leading to unnecessary and potentially dangerous procedures. We, therefore, set out to develop a simple, noninvasive, and quantitative assay to detect lung cancer. This proof-of-concept study evaluated the sensitivity/specificity of the CyPath Early Lung Cancer Detection Assay to correctly classify LDCT-confirmed cohorts of high-risk control (n = 102) and cancer (n = 26) subjects. Fluorescence intensity parameters of red fluorescent cells (RFCs) from tetra (4-carboxyphenyl) porphyrin (TCPP)-labeled lung sputum samples and subjects' baseline characteristics were assessed for their predictive power by multivariable logistic regression. A receiver operating characteristic curve was constructed to evaluate the sensitivity/specificity of the CyPath assay. RFCs were detectable in cancer subjects more often than in high-risk ones (p = 0.015), and their characteristics differed between cohorts. Two independent predictors of cancer were the mean of RFC average fluorescence intensity/area per subject (p < 0.001) and years smoked (p = 0.003). The CyPath-based classifier had an overall accuracy of 81% in the test population; false-positive rate of 40% and negative predictive value of 83%. The tetra (4-carboxyphenyl) porphyrin -based CyPath assay correctly classified study participants into cancer or high-risk cohorts with considerable accuracy. Optimizing sputum collection, sample reading, and refining the classifier should improve sensitivity and specificity. The CyPath assay thus has the potential to complement LDCT screening or serve as a stand-alone approach for early lung cancer detection.

Human papillomavirus prevalence and genotypes distribution among female outpatients in Qingdao, East China

Persistent infection with human papillomavirus, especially high risk ones, is a necessary cause of cervical cancer. This study aimed to investigate the distribution of HPV genotypes in female outpatients from Qingdao, East China. A total of 4,534 cervical swabs from women visiting this medical institution for gynecologic care were included. HPV genotypes were examined by a PCR-based hybridization gene chip assay and liquid-based cytology analysis was used to evaluate cervical cytology. The overall HPV prevalence in this study was 32.2% (1,459/4,534). A total of 23 HPV genotypes were identified and the five most prevalent ones were HPV16 (16.1%), HPV52 (8.9%), HPV58 (7.9%), HPV6 (7.0%), and HPV53 (6.5%). Age-specific prevalence of HPV exhibited one peak at the youngest age group and the HPV positive rate decreased gradually with age growth. But high risk HPV infections were more prevalent among aged women. Besides, association between cervical cytology and HPV infection was also determined, 27.2% (1124/4,126) of women with normal cytology were HPV positive while 82.1% (335/408) of women with abnormal cytology were HPV positive. These findings give new epidemiological data and may provide guidance for the vaccination program in this area.

Long-term prognosis of patients with acute non-ST-segment elevation myocardial infarction undergoing different treatment strategies.

Background:In cardiology, it is controversial whether different therapy strategies influence prognosis after acute coronary syndrome. We examined and compared the long-term outcomes of invasive and conservative strategies in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and characterized the patients selected for an invasive approach.Methods:A total of 976 patients with acute NSTEMI were collected from December 2006 to October 2012 in the First Affiliated Hospital of Dalian Medical University Hospital. They are divided into conservative strategy (586 patients) and invasive strategy (390 patients) group. Unified follow-up questionnaire was performed by telephone contact (cut-off date was November, 2013). The long-term clinical events were analyzed and related to the different treatment strategies.Results:The median follow-up time was 29 months. Mortality was 28.7% (n = 168) in the conservative group and 2.1% (n = 8) in the invasive management at long-term clinical follow-up. The secondary endpoint (the composite endpoint) was 59.0% (n = 346) in the conservative group and 30.3% (n = 118) in the invasive management. Multivariate analysis showed that patients in the conservative group had higher all-cause mortality rates than those who had the invasive management (adjusted risk ratio [RR] = 7.795; 95% confidence interval [CI]: 3.796–16.006, P < 0.001), and the similar result was also seen in the secondary endpoint (adjusted RR = 2.102; 95% CI: 1.694–2.610, P < 0.001). In the subgroup analysis according to each Thrombolysis in Myocardial Infarction risk score (TRS), log-rank analysis showed lower mortality and secondary endpoint rates in the invasive group with the intermediate and high-risk patients (TRS 3–7).Conclusions:An invasive strategy could improve long-term outcomes for NSTEMI patients, especially for intermediate and high-risk ones (TRS 3–7).

Infection status of cervical human papilloma virus in patients with cervical intraepithelial neoplasia

To explore the human papilloma virus (HPV) infection and genotypes distribution in female patients with cervical intraepithelial neoplasia so as to provide rationales for preventing and treating HPV and developing HPV vaccine. Polymerase chain reaction (PCR) amplification, flow-through hybridization and gene chip were used to identify 23 HPV genotypes in cervical cells collected from 823 female patients with cervical intraepithelial neoplasia at Third Municipal People's Hospital and Central Municipal Hospital during January 2011 and December 2013. Among them, HPV infections were detected in 47.51% (391/823). From 2011 to 2013, there was a trend of increase year by year and the difference was statistically significant (P < 0.05). With the greater degree of cervical intraepithelial neoplasia, LR-HPV and HR-HPV infection rate increased. And there were statistically significant differences (P < 0.05). And single or double genotype infection dominated (86.19%). Multiple genotype infection accounted for 0.51%. And 76.21% of HPV infections were high-risk genotypes and most of them belonged to HPV16. Otherwise, most low-risk genotypes were HPV6. Besides, HPV39 and HPV82 were not detected. HPV infections, particularly high-risk ones, are widespread among female patients with condyloma acuminatum or cervical erosion in Qingdao. Thus active clinical therapy should be provided.