Outcomes In Low-risk Patients Research Articles

Dosimetry of an Extracapsular Anulus Following Permanent Prostate Brachytherapy

Recent studies have suggested that extracapsular brachytherapy treatment margins correlate with biochemical control. It is likely that volumetric geographic dosimetric parameters will be more robust than selected radial measurements. Accordingly, we evaluated extracapsular volumetric dosimetric parameters in low-risk patients. A total of 263 low-risk prostate cancer patients randomized to Pd-103 versus I-125 were implanted with a brachytherapy target volume consisting of the prostate with a 5-mm periprostatic margin. The median follow-up was 4.2 years. All patients were implanted at least 3 years prior to analysis. Within 2 hours of implantation, an axial CT was obtained for postimplant dosimetry. A 5-mm three-dimensional periprostatic anulus was constructed around the prostate and evaluated in its entirety and in 90 degrees segments. Prostate and anular dosimetric parameters consisted of V100/V150/V200 and D90. Biochemical progression-free survival (bPFS) was defined as a PSA < or =0.50 ng/mL after nadir. The Pd-103 and I-125 arms were well-matched in terms of clinical, biochemical, and pathologic presentation. Six-year bPFS was 96.8% versus 99.2% for I-125 versus Pd-103 (P = 0.149). The most recent median posttreatment PSA was <0.04 ng/mL for both isotopes. No significant differences in postoperative anular doses were discerned between bPFS and failed patients. A postimplant 5-mm, three-dimensional periprostatic anulus provides substantial information regarding dosimetric coverage. However, with a median follow-up of 4.2 years, such volumetric and geographic parameters have not proven useful in predicting biochemical outcome in low-risk patients.

Clinical Outcomes of Low-Risk Patients Undergoing Beating-Heart Surgery With or Without Pulmonary Artery Catheterization

Clinical Outcomes of Low-Risk Patients Undergoing Beating-Heart Surgery With or Without Pulmonary Artery Catheterization

Characteristics of low-risk patients hospitalized with community-acquired pneumonia

Background Despite the wide distribution of different severity scoring systems for community-acquired pneumonia (CAP) patients, low-risk patients are frequently hospitalized, contrary to current recommendations. The aim of our study was to determine the rate, clinical characteristics, and outcome of low-risk patients with CAP admitted to our institution. Methods During an 18-month period, we prospectively screened all patients admitted to the Division of Internal Medicine with a presumptive diagnosis of CAP. Pneumonia Outcome Research Team (PORT) score and pneumonia severity index (PSI) were calculated for all patients during the first 24 h. Results A total of 591 patients had a diagnosis of CAP. Some 196 patients (33.1%) were low-risk (PSI class I, II), 98 (16.6%) intermediate (PSI III), and 297 (50.3%) high-risk patients (PSI IV, V). Patients in low-risk classes were younger (45.5 ± 15.8 vs. 65.0 ± 12.5 and 74.9 ± 11.8 years, respectively, p < 0.001) and had fewer background diseases. They had shorter hospitalizations than intermediate- and high-risk groups (4.4 ± 3.2, 5.3 ± 3.4, and 6.8 ± 6.4 days, respectively, p < 0.001). There was a significant difference in 30-day mortality between the different risk groups: 0% in the low-risk, 2.0% in the intermediate-risk, and 9.4% in the high-risk group ( p < 0.001). Conclusion The considerable proportion of low-risk patients hospitalized due to CAP was found to be comparable to the stable 30% rate reported in the literature. We conclude that physicians tend to opt for a wide safety range when considering a CAP patient hospitalization, rather than make a decision based only on severity score calculation.

Nonemergent coronary angioplasty without on-site surgical backup: A randomized study evaluating outcomes in low-risk patients

Background Percutaneous coronary intervention (PCI) in nonemergent patients with coronary artery disease in hospitals without on-site cardiac surgery backup is still controversial. To prospectively evaluate a set of low procedural risk criteria for PCI, patients with stable or unstable angina were randomized to treatment in either a community hospital, which had all supportive services except for on-site cardiac surgery, or a regional surgical hospital 213 km away. Methods and results During a 4-year period, 609 (57%) of 1064 consecutive patients with stable or unstable angina who underwent coronary angiography at a teaching community hospital in Norway fulfilled the predefined low-risk criteria for PCI. The patients were randomized to treatment at either the community hospital (n = 305) or at the regional hospital (n = 304). The angiographic success rate (96% at both hospitals) and number of major periprocedural complications (overall 0.3%) were equal at the 2 hospitals. In particular, there were no deaths or need for urgent transfer to cardiac surgery. At 6 months of clinical follow-up, there was a significant higher major adverse cardiac event rate rate at the community hospital, compared with the regional hospital (6.9% vs 2.3%, respectively, P = .03) because of more repeat target vessel revascularizations. Improvement in angina functional class and exercise capacity was similar in both groups. The excluded high-risk PCI patients had higher 6-month major adverse cardiac event compared with all low-risk patients (8.4% vs 4.3%, respectively, P = .01). Conclusion Selected nonemergent patients can, based on angiography, safely undergo PCI at hospitals without cardiac surgery backup. The angiographic selection criteria identified high-risk patients, which had worsened outcome at 6 months of follow-up.

SU-FF-T-239: Extracapsular Radiation Dose Annulus Correlates with Biochemical Control in Low-Risk Brachytherapy Patients: Results of a Prospective Randomized Trial

Purpose: Recent studies have suggested that extracapsular permanent prostate brachytherapy treatment margins correlate with biochemical control. It is likely that volumetric dosimetric parameters will be more robust than selected radial measurements. We evaluated the impact of extracapsular volumetric dosimetric parameters on biochemical control in low-risk patients. Materials and Methods: 263 consecutive low-risk prostate cancer patients randomized to Pd-103 versus I-125 were implanted with a brachytherapy target volume consisting of the prostate with a 5 mm periprostatic margin. The median follow-up was 4.2 years. All patients were implanted at least 3 years prior to analysis. Within 2 hours of implantation, an axial CT was obtained for post-implant dosimetry. A 5 mm 3-dimensional periprostatic annulus was constructed around the prostate gland and evaluated in its entirety and in 90° segments. Dosimetric parameters for the prostate gland and the annulus consisted of V100/150/200 and D90. Biochemical progression-free survival was defined by a PSA ⩽ 0.5 ng/mL. Results: Mean postoperative dosimetry was significantly different (p < 0.001) between I-125 versus Pd-103, respectively, for V100 of 97% versus 93% and D90 of 122% versus 112%. Annulus dosimetry was significant (p < 0.001) for a V100 of 80% versus 70% and a D90 of 91% versus 85% for I-125 versus Pd-103, respectively. Six-year biochemical progression-free survival was 99.6% versus 99.2% for I-125 versus Pd-103 (p = 0.125). The most recent median post-treatment PSA was 0.1 ng/mL and < 0.04 ng/mL for I-125 and Pd-103. Biochemically disease-free patients had statistically higher prostate and annular dosimetric values. In Cox regression analysis, variants of annulus dosimetry were the best predictors for biochemical control in the I-125, Pd-103, and overall cohorts. Conclusions: A postimplant 5 mm 3-dimensional periprostatic annulus provides substantial information regarding dosimetric coverage and appears to be an important predictor for biochemical outcome in low-risk patients.

Measurement of the clinical and cost-effectiveness of non-invasive diagnostic testing strategies for deep vein thrombosis

To estimate the diagnostic accuracy of non-invasive tests for proximal deep vein thrombosis (DVT) and isolated calf DVT, in patients with clinically suspected DVT or high-risk asymptomatic patients, and identify factors associated with variation in diagnostic performance. Also to identify practical diagnostic algorithms for DVT, and estimate the diagnostic accuracy, clinical effectiveness and cost-effectiveness of each. Electronic databases (to April 2004). A postal survey of hospitals in the UK. Selected studies were assessed against validated criteria. A postal survey of hospitals in the UK was undertaken to describe current practice and availability of tests, and identify additional diagnostic algorithms. Pooled estimates of sensitivity, specificity and likelihood ratios were obtained for each test using random effects meta-analysis. The effect of study-level covariates was explored using random effects metaregression. A decision-analytic model was used to combine estimates from the meta-analysis and estimate the diagnostic performance of each algorithm in a theoretical population of outpatients with suspected DVT. The net benefit of using each algorithm was estimated from a health service perspective, using cost--utility analysis, assuming thresholds of willingness to pay of pound 20,000 and pound 30,000 per quality-adjusted life-year (QALY). The model was analysed probabilistically and cost-effectiveness acceptability curves were generated to reflect uncertainty in estimated cost-effectiveness. Individual clinical features are of limited diagnostic value, with most likelihood ratios being close to 1. Wells clinical probability score stratifies proximal, but not distal, DVT into high-, intermediate- and low-risk categories. Unstructured clinical assessment by experienced clinicians may have similar performance to Wells score. In patients with clinically suspected DVT, D-dimer has 91% sensitivity and 55% specificity for DVT, although performance varies substantially between assays and populations. D-dimer specificity is dependent on pretest clinical probability, being higher in patients with a low clinical probability of DVT. Plethysmography and rheography techniques have modest sensitivity for proximal DVT, poor sensitivity for distal DVT, and modest specificity. Ultrasound has 94% sensitivity for proximal DVT, 64% sensitivity for distal DVT and 94% specificity. Computed tomography scanning has 95% sensitivity for all DVT (proximal and distal combined) and 97% specificity. Magnetic resonance imaging has 92% sensitivity for all DVT and 95% specificity. The diagnostic performance of all tests is worse in asymptomatic patients. The most cost-effective algorithm discharged patients with a low Wells score and negative D-dimer without further testing, and then used plethysmography alongside ultrasound, with venography in selected cases, to diagnose the remaining patients. However, the cost-effectiveness of this algorithm was dependent on assumptions of test independence being met and the ability to provide plethysmography at relatively low cost. Availability of plethysmography and venography is currently limited at most UK hospitals, so implementation would involve considerable reorganisation of services. Two algorithms were identified that offered high net benefit and would be feasible in most hospitals without substantial reorganisation of services. Both involved using a combination of Wells score, D-dimer and above-knee ultrasound. For thresholds of willingness to pay of pound 10,000 or pound 20,000 per QALY the optimal strategy involved discharging patients with a low or intermediate Wells score and negative D-dimer, ultrasound for those with a high score or positive D-dimer, and repeat scanning for those with positive D-dimer and a high Wells score, but negative initial scan. For thresholds of pound 30,000 or more a similar strategy, but involving repeat ultrasound for all those with a negative initial scan, was optimal. Diagnostic algorithms based on a combination of Wells score, D-dimer and ultrasound (with repeat if negative) are feasible at most UK hospitals and are among the most cost-effective. Use of repeat scanning depends on the threshold for willingness to pay for health gain. Further diagnostic testing for patients with a low Wells score and negative D-dimer is unlikely to represent a cost-effective use of resources. Recommendations for research include the evaluation of the costs and outcomes of using the optimal diagnostic algorithms in routine practice, the development and evaluation of algorithms appropriate for specific groups of patients with suspected DVT, such as intravenous drug abusers, pregnant patients and those with previous DVT, the evaluation of the role of plethysmography: interaction with other diagnostic tests, outcome of low-risk patients with negative plethysmography and measurement of the costs of providing plethysmography, and methodological research into the incorporation of meta-analytic data into decision-analytic modelling.

The impact of an hematocrit of 20% during normothermic cardiopulmonary bypass for elective low risk coronary artery bypass graft surgery on oxygen delivery and clinical outcome – a randomized controlled study [ISRCTN35655335

IntroductionCardiopulmonary bypass (CPB) induces hemodilutional anemia, which frequently requires the transfusion of blood products. The objective of this study was to evaluate oxygen delivery and consumption and clinical outcome in low risk patients who were allocated to an hematocrit (Hct) of 20% versus 25% during normothermic CPB for elective coronary artery bypass graft (CABG) surgery.MethodsThis study was a prospective, randomized and controlled trial. Patients were subjected to normothermic CPB (35 to 36°C) and were observed until discharge from the intensive care unit (ICU). Outcome measures were calculated whole body oxygen delivery, oxygen consumption and clinical outcome. A nonparametric multivariate analysis of variance for repeated measurements and small sample sizes was performed.ResultsIn a total of 54 patients (25% Hct, n = 28; 20% Hct, n = 26), calculated oxygen delivery (p = 0.11), oxygen consumption (p = 0.06) and blood lactate (p = 0.60) were not significantly different between groups. Clinical outcomes were not different between groups.ConclusionThese data indicate that an Hct of 20% during normothermic CPB maintained calculated whole body oxygen delivery above a critical level after elective CABG surgery in low risk patients. The question of whether a transfusion trigger in excess of 20% Hct during normothermic CPB is still supported requires a larger prospective and randomized trial.

The San Francisco Syncope Rule vs physician judgment and decision making

Objective To compare a clinical decision rule (San Francisco Syncope Rule [SFSR]) and physician decision making when predicting serious outcomes in patients with syncope. Methods In a prospective cohort study, physicians evaluated patients presenting with syncope and predicted the chance (0%-100%) of the patient developing a predefined serious outcome. They were then observed to determine their decision to admit the patient. All patients were followed up to determine whether they had a serious outcome within 7 days of their emergency department visit. Analyses included sensitivity and specificity to predict serious outcomes for low-risk patients and comparison of areas under the receiver operating characteristic curve for the decision rule, physician judgment, and admission decisions. Results During the study period, there were 684 visits for syncope with 79 visits resulting in serious outcomes. The area under the receiver operating characteristic curve was 0.92 (95% confidence interval [CI], 0.88-0.95) for the SFSR compared with physician judgment 0.89 (95% CI, 0.85-0.93) and physician decision making 0.83 (95% CI, 0.81-0.87). Physicians admitted 28% of patients in a low-risk group, with a median length of stay of 1 day (interquartile range, 1-2.5 days). The SFSR had the potential to absolutely decrease admissions by 10% in this low-risk group and still predict all serious outcomes. Conclusions Physician judgment is good when predicting which patients with syncope will develop serious outcomes, but contrary to their judgment, physicians still admit a large number of low-risk patients. The SFSR performs better than current physician performance and has great potential to aid physician decision making.

Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review.

While the effectiveness of upper endoscopy has been established for acute nonvariceal upper gastrointestinal tract hemorrhage, its optimal timing has not been clearly defined. Early endoscopy has been advocated for its ability to achieve prompt diagnosis, risk stratification, and therapeutic hemostasis. To determine whether early vs delayed endoscopy improves patient and economic outcomes for all risk groups with nonvariceal upper gastrointestinal tract hemorrhage. A systematic review of 3 computerized databases (MEDLINE, HEALTHSTAR, and Cochrane Database of Systematic Reviews) was performed along with hand searching of published abstracts to identify English-language citations from 1980 to 2000. Twenty-three studies met explicit inclusion criteria. The highest-quality study examining outcomes in low-risk patients found no significant complications at 1-month follow-up for any outpatients managed with early endoscopy. The largest randomized trial of high-risk patients showed no mortality benefit but a significant decrease in transfusion requirements with early endoscopy. Seven of the 8 studies examining the effect of early endoscopy on length of stay as a measure of resource utilization demonstrated a significant reduction compared with that of delayed endoscopy. However, most included studies were found to suffer from 1 or more potentially significant methodologic shortcomings. The overwhelming majority of existing data suggest that early endoscopy is safe and effective for all risk groups. The clinical and economic outcomes of early endoscopy should be confirmed in additional well-designed randomized controlled trials. Given the strength of the evidence, efforts to develop a more standardized and time-sensitive approach to acute nonvariceal upper gastrointestinal tract hemorrhage should be undertaken.

A Preoperative Program for Patients Awaiting Coronary Artery Bypass Graft (CABG) Surgery

Summaries for Patients15 August 2000A Preoperative Program for Patients Awaiting Coronary Artery Bypass Graft (CABG) SurgerySearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-133-4-200008150-00036 SectionsAboutFull Text ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail What is the problem and what is known about it so far?In some countries, patients often have to wait for medical procedures such as coronary artery bypass graft (CABG) surgery. In CABG surgery, blocked blood vessels that deliver blood to the heart are replaced with artificial vessels or ones taken from elsewhere in the body. For many patients, CABG is elective, meaning that it is judged to be relatively safe for them to wait for surgery. However, patients' emotional state and ability to perform their usual activities can deteriorate while they wait. Since waits for CABG can't always be ... Author, Article, and Disclosure InformationAffiliations: The summary below is from the full report titled “Effect of a Preoperative Intervention on Preoperative and Postoperative Outcomes in Low-Risk Patients Awaiting Elective Coronary Artery Bypass Graft Surgery. A Randomized, Controlled Trial.” It is in the 15 August 2000 issue of Annals of Internal Medicine (volume 133, pages 253-262). The authors are H.M. Arthur, C. Daniels, R. McKelvie, J. Hirsh, and B. Rush.Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians-American Society of Internal Medicine. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoEffect of a Preoperative Intervention on Preoperative and Postoperative Outcomes in Low-Risk Patients Awaiting Elective Coronary Artery Bypass Graft Surgery Heather M. Arthur , Charlotte Daniels , Robert McKelvie , Jack Hirsh , and Bonnie Rush Metrics 15 August 2000Volume 133, Issue 4Page: 253KeywordsAnxietyBlood vesselsCoronary arteriesExerciseIntensive care unitsMedical servicesPatientsQuality of lifeSurgeryThoracic surgery ePublished: 15 August 2000 Issue Published: 15 August 2000 Copyright & PermissionsCopyright © 2000 by American College of Physicians. All Rights Reserved.Loading ...

Prediction of short- and long-term outcomes by troponin t levels in low-risk patients evaluated for acute coronary syndromes

Study objective: Recent reports suggest a short series of cardiac troponin (cTnT) testing effectively identifies patients at risk for cardiac events. However, there are few studies validating this strategy. The purpose of this study was to determine the ability of cTnT levels to predict short- and long-term outcomes in low-risk patients with suspected acute coronary syndromes. Methods: This prospective longitudinal study was conducted in a 20-bed emergency department observation unit. Patients at low risk for acute coronary ischemia, with a normal creatine kinase–isoenzyme subunit MB (CKMB) index, were admitted to an observation unit for chest pain evaluation. Serum cTnT levels were measured at baseline and at 4, 8, and 16 hours after admission. The main outcome measures were adverse cardiac events (death, acute myocardial infarction, unstable angina, revascularization) during the index visit and within 6 months after discharge. Using manufacturer’s recommendations, the cTnT level was considered abnormal if it exceeded 0.2 μg/L. Results: Two hundred sixty-six patients were evaluated. Twenty-one (7.9%) had an adverse event during their index hospitalization. Troponin testing identified only 2 (9.5%) of these patients. Twenty (7.5%) had a cardiac event within 6 months; none were identified by cTnT testing. The sensitivity and specificity were 9.5% and 99.2%, respectively, at the index visit, and 0% and 98.4% at 6 months. The positive and negative predictive values were 50% and 93%, respectively, at the index visit; and 0% and 92% at 6 months. Conclusion: Determination of troponin T levels has a low sensitivity and high specificity for predicting outcomes in low-risk patients evaluated for suspected acute coronary syndromes. This study does not support a strategy of relying solely on troponin testing for disposition decisions. [Peacock WF IV, Emerman CL, McErlean ES, Deluca SA, van Lente F, Rao JS, Nissen SE: Prediction of short- and long-term outcomes by troponin T levels in low-risk patients evaluated for acute coronary syndromes. Ann Emerg Med. March 2000;35:213-220.]

Well‐differentiated thyroid carcinomas: p53 mutation status and microvessel density

Background. Risk-stratification schemes exist for well-differentiated thyroid carcinoma and include prognostic factors such as age, sex, extent of tumor, size of tumor, and presence of metastasis. Controversy continues, however, over the aggressiveness of initial surgical intervention because of anecdotal experiences of poor clinical outcomes in low-risk patients. Our objective is to determine the prognostic significance of two biologic tumor markers, the p53 gene mutation and CD34 microvessel density (MVD) count, in well-differentiated tumors of thyroid gland. Methods. We selected 38 patients with well-differentiated thyroid carcinomas from the University of Illinois Tumor Registry. Patients had an average clinical follow-up of 10 years. Paraffin-embedded tumor specimens were available for all patients. Immunohistochemistry was performed to identify mutations of the p53 gene (Ab 1801) and to determine the MVD count (CD34). Results. There were significant increases in MVD counts within thyroid tumor tissue, when compared with surrounding, normal thyroid tissue. There was no significant correlation noted, however, between increased MVD and histology or recurrence rates. There was a trend toward higher MVD counts in tumor specimens of patients initially seen with metastatic lymphadenopathy. The incidence of p53 mutation expression was 28%, and there was no correlation between p53 status and histology, sex, recurrence rate, or survival. Conclusions. This study supports the concept of tumor neovascularization but fails to correlate MVD with clinical behavior or pathologic features in well-differentiated thyroid carcinoma. Furthermore, we found that the p53 mutation status was not an independent prognosticator of tumor behavior in these lesions.

Percutaneous transluminal coronary angioplasty led to improved clinical outcomes in low-risk patients with acute MI

Source Citation Zijlstra F, Beukema WP, van't Hof AW, et al. Randomized comparison of primary coronary angioplasty with thrombolytic therapy in low risk patients with acute myocardial infarction. J Am Coll Cardiol. 1997 Apr;29:908-12.