Patient-specific Risk Factors Research Articles

Adverse drug reactions as cause of nonspecific symptoms in patients in the emergency department

In alarge proportion of patients admitted to the emergency department (ED), the initial main symptom is nonspecific. One possible reason for this, especially in older patients, may be adverse drug reactions (ADR) due to their frequent polypharmacy. To illustrate the incidence of ADRs, the affected patient population including risk factors, and drug classes with ADRs leading to nonspecific symptoms. To provide practice recommendations for the management of ADRs in the ED. Presentation of the pharmacological principles on ADRs, statistics of pharmacovigilance centers as well as original literature including experiences from clinical practice and own projects. In 10% of patients with nonspecific symptoms an ADR is responsible for presentation in the ED. In 60% of cases these ADRs are not correctly identified in the ED setting. Asmall number of drug classes are responsible for most of these referrals. Databases, risk stratification, clinical pharmacists, or clinical decision support systems are available to improve ADR identification and management. As these options are partly associated with considerable costs or the validation for German EDs is missing, awidespread application does not take place. Correct identification of ADRs in patients with nonspecific symptoms in the ED is necessary to initiate adequate treatment. These ADRs are often overlooked because processes and tools for identification and management are not applied in the ED, leading to a lack of awareness. For high-risk patients in the ED, the focus should be on drug history, ideally considering patient-specific risk factors and specific drug classes.

Incidence and risk factors of prostate cancer among the Northern and Eastern parts of the United Arab Emirates population.

Prostate cancer (PCa) is a prevalent disease worldwide. However, the incidence and patient-specific risk factors of PCa in the Middle East, specifically in the United Arab Emirates,have not been previously reported. We conducted a retrospective cohort study on 2377 men diagnosed with either benign prostatic hyperplasia (BPH) or PCa in the Northern and Eastern regions of the United Arab Emirates, excluding the Western part, which includes Abu Dhabi. The study spanned from January 2012 and December 2021. To calculate the PCa incidence rate, we utilized the world age-standardized incidence rates (W-ASIR) categorized by age groups. Patient-specific risk factors of PCa were identified through a multivariate logistic regression analysis of clinical data. A total of 247 cases of PCa and 2130 cases of BPH were included in the study. In our cohort, the W-ASIR for PCa was 21.3 per 100,000 men. The incidence of PCa showed an increasing trend with age, with the highest incidence observed among men aged 70 years and older. Accordingly, multivariate analysis revealed that age over 70 was associated with an increased risk of PCa (OR: 2.546, 95% confidence interval [CI]: 1.892-3.425, p < 0.01). On the other hand, preexisting conditions such as hypertensionand diabetes mellituswere found to lower the risk of PCa (OR: 0.222, 95% CI: 0.163-0.302, p < 0.001) and (OR: 0.364, 95% CI: 0.205-0.648, p < 0.001), respectively. Additionally, metformin intake was associated with a reduced risk of PCa (OR: 0.385, 95% CI: 0.190-0.782, p = 0.008); while insulin usage increased the risk of PCa (OR: 2.586, 95% CI: 1.539-4.344, p < 0.001). Anti-BPH medications such as phosphodiesteraseinhibitors (OR: 0.223, 95% CI: 0.069-0.723, p = 0.012) or 5-α reductase (OR: 0.206, 95% CI: 0.110-0.389, p < 0.000), were found to lower the risk of PCa. The findings underscore the high incidence of PCa in the United Arab Emirates, with age being a significant factor. Furthermore, the study highlights the influence of certain comorbidities and medications on the risk of developing PCa within the United Arab Emiratespopulation.

Risk and benefits of baseline antiplatelet therapy in 58,598 patients with atrial fibrillation randomized to NOACs vs warfarin

Abstract Background The efficacy and safety of NOAC versus warfarin (W) may differ in AF pts receiving antiplatelet therapy (APT) at baseline. Moreover, prior individual trial-specific analyses examining the treatment effect of NOAC vs. W as a function of APT are underpowered for interaction testing. Purpose We evaluated outcomes by randomized anticoagulant stratified by baseline APT in a pooled individual pt-level meta-analysis of 4 pivotal RCTs of NOAC vs. W in AF: RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE AF-TIMI 48. Methods Pts were stratified by use of APT vs. no APT at baseline. Pts randomized to low-dose NOAC not globally approved (edoxaban 30/15 mg or dabigatran 110 mg) were excluded. The primary efficacy and safety outcomes were stroke/systemic embolic events (S/SEE) and major bleeding, respectively; ischemic stroke (IS), intracranial hemorrhage (ICH), major GI bleeding and all-cause mortality (ACM) were secondary outcomes. Each outcome was assessed by randomized treatment using a Cox model stratified by trial with adjustment for age, sex, weight, CrCl, smoking status, HTN, DM, CAD, prior MI, PAD, and prior stroke. Interaction testing was performed by APT at baseline. Results Of 58,598 pts, 19,774 (34%) were on APT at baseline (92% aspirin only, 5% P2Y12 only, 3% DAPT). Pts treated with APT had greater prevalence of CAD (41% vs. 24%), prior MI (22% vs. 11%), and PAD (6% vs. 4%) (p&amp;lt;0.001 for each). Reflective of these baseline differences, the annualized event rate for each outcome was higher in the APT vs. no APT group (Figure). The treatment effect (HR) of NOAC vs. W for all 6 clinical outcomes was consistent irrespective of baseline APT (p-interaction [aHR] for each = NS; Figure). However, the absolute risk reduction (ARR) for NOAC vs. W differed for ICH and major GI bleeding as a function of baseline APT (Figure). Specifically, for ICH, a greater absolute benefit was seen with NOAC vs. W in those on APT at baseline (ARR 0.6% vs. 0.3%; p-int = 0.007). Conversely, for major GI bleeding, NOAC vs. W was associated with greater absolute risk in those on APT (ARR -0.6% vs. -0.2%; p-int = 0.04). Conclusions The treatment effect of NOAC vs. W is consistent irrespective of APT at baseline for S/SEE, major bleeding, and ACM. Given higher rates of bleeding in AF pts treated with both APT and anticoagulation, concomitant APT should be avoided when possible. In pts requiring concomitant APT, NOAC instead of W should be considered owing to greater absolute safety benefit for ICH, which should be weighed against individual patient-specific risk factors for GI bleeding.

Abstract 17323: Avoiding Procedural Closure of the Patent Ductus Arteriosus Following Late Acetaminophen Therapy in Preterm Infants

Introduction: Management of a hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants beyond 3 weeks of age continues to be a debate. Clinical equipoise exists between pharmacologic agents versus procedural closure techniques (surgical ligation or transcatheter occlusion). The efficacy of acetaminophen for early closure of hsPDA has been demonstrated, but there remains a paucity of data for late closure. Hypothesis: To test the hypothesis that late administration of acetaminophen for a hsPDA is associated with reduced rates of procedural closure in preterm infants. Methods: We performed a post-hoc analysis of preterm infants (&lt;37 weeks) referred to Boston Children’s Hospital for ongoing management of a hsPDA from January 2019 to January 2023. We compared neonates with a hsPDA exposed and not exposed to acetaminophen at &gt; 3 weeks of age. The primary outcome was avoidance of procedural closure. We assessed for predictors of closure following acetaminophen therapy. Results: We identified 110 preterm infants (median gestational age of 25 weeks at birth) referred for closure of a hsPDA beyond 3 weeks of age (Fig). Late acetaminophen was used in 26 patients (median postnatal age of 31 days). Late acetaminophen was associated with higher rates of non-procedural PDA closure 10/26 (38%), compared to 6/84 (7%) of infants who did not receive late acetaminophen (OR 0.12, CI 0.04 - 0.39, p &lt; 0.01). Presence of flow reversal in the descending aorta was associated with lower likelihood of PDA closure with late acetaminophen (OR 0.09, CI 0.01 - 0.85, p=0.017). Conclusions: This study found that preterm infants with a hsPDA treated with late acetaminophen had a decreased need for procedural closure. Infants who responded were less likely to have flow reversal in the descending aorta, suggesting that consideration of a course of late acetaminophen prior to procedural closure of a hsPDA in preterm neonates should be selective and based on patient-specific risk factors.

Development and External Validation of a Lymphoma-Specific Venous Thromboembolism Risk Assessment Model

Introduction: Venous thromboembolism (VTE) significantly affects cancer patients undergoing systemic therapy. Existing risk models developed in the pan-cancer population, such as the Khorana score, offer limited discrimination in cancer-specific setting. We aimed to develop and validate a risk assessment model (RAM) tailored for lymphoma patients, accounting for the clinical and sociodemographic heterogeneity across three distinct healthcare systems in the United States. Methods: Electronic health records (EHR) linked to cancer registry 2006-2021 from the Veterans Affairs national healthcare system (VA) with a total of 10,313 lymphoma patients were randomly divided into an 80% derivation cohort and a 20% internal validation cohort. Further external validation was carried out using data from two other healthcare systems - Harris Health System (HHS, N= 854, 2011-2020) and MD Anderson Cancer Center (MDACC, N=1,858, 2017-2020). Patients were included if they had newly diagnosed lymphoma requiring first-line systemic therapy within 1 year of diagnosis. Patients were excluded if they had recent diagnosis of acute VTE within the last 6 months or were prescribed anticoagulant within 1 month before index date. The index date was the time of systemic therapy, and all covariates were extracted on or before the index date. Incident VTE was defined using our published computable phenotype algorithm (PMID 36626707; 37067102). For RAM derivation (Figure 1), 32 candidate predictors were initially chosen based on clinical relevance and EHR data availability. Missing values were imputed via chain random forest. Parsimonious variable categories were selected by a combination of Least Absolute Shrinkage and Selection Operator (LASSO), Recursive Feature Elimination (RFE), and random forest to generate the final logistic regression model. For external validation, complete case analysis was performed using the derived beta coefficients without model refitting. Bootstrapped time-dependent c statistics and calibration curves for 6-month VTE were used to assess discrimination and fit. A pre-determined threshold of 8% VTE at 6-month from the predicted probability was used to stratify high vs. low-risk groups. Competing risk models were used to assess cumulative incidence. Results: At 6 months, the VTE incidence were 5.75% (n=469) in VA derivation and 6.12% (n=124), 8.24% (n=69), and 6.55% (n=112) in the VA, HHS, and MDACC validation cohorts, respectively. The three healthcare systems had different baseline characteristics in demographics, lymphoma types, systemic therapies, and comorbidities. Patients from VA were mostly older males with more comorbidities and remote history of VTE, patients from HHS were mostly uninsured minorities who were younger but with more aggressive histology, while those from MDACC were patients treated at a comprehensive cancer center. The variables in the final RAM included lymphoma type (4 groups ranging from very-low to very-high risk), body mass index, indwelling catheter, cytotoxic vs. targeted therapy, history of VTE, recent hospitalization, and paralysis/immobilization. Table 1 shows the variable prevalence in each cohort. As shown in Figure 1, the new RAM showed promising discrimination for VTE with a C-statistic of 0.69 in the derivation cohort and 0.67, 0.70, 0.72 in the internal and two external validation cohorts. By splitting patients using an 8% predicted risk threshold, the high- vs. low-risk group achieved a clear differentiation in risk stratification despite significant differences in baseline characteristics. This represented a noticeable improvement for lymphoma patients over the Khorana Score, which yielded C-statistics of 0.53-0.56. The overall calibration of the RAM appeared adequate. Conclusions: Using multiple cancer-EHR cohorts with heterogeneous patients and a wide range of lymphoma subtypes, we successfully derived and externally validated an improved RAM for VTE specifically in lymphoma patients requiring early initiation of systemic therapy. Along several well-known patient-specific risk factors, lymphoma type was an important predictor of VTE risk. The new RAM could improve VTE risk stratification and prevention efforts in lymphoma patients.

Risk Factors for Failure of Nonsurgical Management of Ulnar Shaft Fractures

Isolated ulnar shaft fractures are frequently managed nonsurgically. However, rates of nonsurgical treatment failure remain substantial, and risk factors for the failure of nonsurgical management are not well described. This study investigated radiographic and patient-specific risk factors for the failure of nonsurgical management of isolated ulnar shaft fractures. A retrospective review of patients with ulnar shaft fractures initially treated nonsurgically was performed at two tertiary referral centers over a 19-year period from 2001 to 2020. Patient- and injury-related variables, surgical interventions, and plain radiographic measurements were recorded. The outcome of interest was failure of nonsurgical management, defined as failure to achieve fracture union nonsurgically within 3 months of injury. One hundred fifty four patients initially treated nonsurgically for isolated ulnar shaft fractures were included. Twenty six patients (17%) experienced failure of nonsurgical management; these included five nonunions, 16 delayed unions, and 10 conversions to surgical management. Patients who experienced failure of nonsurgical management had a higher prevalence of diabetes mellitus, a higher employment rate, and fractures with higher initial median posteroanterior and lateral translations, fracture gap, and angulation; 83% of the patients with an initial fracture gap of ≥4 mm and 41% of the patients with an initial fracture angulation of >10° failed nonsurgical management. Although most ulnar shaft fractures heal successfully with nonsurgical management, a substantial percentage of these fractures do not. Patients who are currently working, have diabetes mellitus, or have fractures with an initial fracture gap of ≥4 mm or an initial fracture angulation of > 10° may be more likely to fail nonsurgical treatment, although additional studies with larger sample sizes are needed to confirm these associations. Prognostic IV.

Paraneoplastic dermatomyositis associated with urothelial cancer: report of a case and systematic review of the literature.

The idiopathic inflammatory myopathies (IIM) are a collection of autoimmune diseases that have a substantial impact on the entire body and include conditions such as dermatomyositis (DM), polymyositis (PM), sporadic inclusion body myositis, and immune-mediated necrotizing myopathy. These disorders are characterized by symptoms such as muscular weakness, pain, and dermal rash. This systematic review is intended to explore the potential link between bladder cancer and DM/PM. We performed a comprehensive systematic search on PubMed and Scopus until August 2022 to identify relevant research studies. The studies that met our inclusion criteria focused on patients with urinary bladder cancer and dermatomyositis, and/or polymyositis. The patients' median age was 65.5 years (47-79), with the majority being male (15, 39.47%). Bladder cancer manifested before PM/DM in 5 (13.15%) patients, while in the majority of cases occurred after the cancer diagnosis. The stage of cancer at the time of the initial PM/DM diagnosis were mostly locally (11/20, 50%).During the first presentation, the patients had a median creatine kinase level of 2227 U/L, ranging between 44 and 10471. In one case, anti-TIF-1γ antibodies were found to be present. Among the cases with reported medical history (20/38), treatment immediately improved DM symptoms in 16 patients(53.8%) and in 3 patients(15%), symptoms of DM resurfaced during the period after the operation. Death was reported in 14 (36.8%) patients. In conclusion, our study provides knowledge and understanding for identifying specific risk factors in patients with the coexistence of bladder cancer and DM/PM and their management. During the initial and follow-up screening, age, gender, and the clinicopathological subgroup of myositis should be considered to ensure proper management of the condition.

Application of Precision Medicine Concepts in Ambulatory Antibiotic Management of Acute Pyelonephritis.

Acute pyelonephritis (APN) is a relatively common community-acquired infection, particularly in women. The early appropriate antibiotic treatment of this potentially life-threatening infection is associated with improved outcomes. The international management guidelines for complicated urinary tract infections and APN recommend using oral antibiotics with <10% resistance among urinary pathogens. However, increasing antibiotic resistance rates among Escherichia coli and other Enterobacterales to fluoroquinolones, trimethoprim-sulfamethoxazole (TMP-SMX), and beta-lactams has left patients without reliable oral antibiotic treatment options for APN. This narrative review proposes using precision medicine concepts to improve empirical antibiotic therapy for APN in ambulatory settings. Whereas resistance rates to a particular antibiotic class may exceed 10% at the population-based level, the predicted antibiotic resistance rates based on patient-specific risk factors fall under 10% in many patients with APN on the individual level. The utilization of clinical tools for the prediction of fluoroquinolones, TMP-SMX, and third-generation cephalosporin resistance improves the ambulatory antibiotic management of APN. It may also reduce the need to switch antibiotic therapy later based on the in vitro antibiotic susceptibility testing results of bacterial isolates in urinary cultures. This approach may mitigate the burden of increasing antibiotic resistance in the community by ensuring that the initial antibiotic prescribed has the highest likelihood of treating APN appropriately.

Personalized, intuitive & visual QT-prolongation monitoring using patient-specific QTc threshold with pseudo-coloring and explainable AI

BackgroundDrug-induced QT-prolongation increases the risk of TdP arrhythmia attacks and sudden cardiac death. However, measuring the QT-interval and determining a precise cut-off QT/QTc value that could put a patient at risk of TdP is challenging and influenced by many factors including female sex, drug-free baseline, age, genetic predisposition, and bradycardia. ObjectivesThis paper presents a novel approach for intuitively and visually monitoring QT-prolongation showing a potential risk of TdP, which can be adjusted according to patient-specific risk factors, using a pseudo-coloring technique and explainable artificial intelligence (AI). MethodsWe extended the development and evaluation of an explainable AI-based technique− visualized using pseudo-color on the ECG signal, thus intuitively ‘explaining’ how its decision was made −to detect QT-prolongation showing a potential risk of TdP according to a cut-off personalized QTc value (using Bazett's ∆QTc > 60 ms relative to drug-free baseline and Bazett's QTc > 500 ms as examples), and validated its performance using a large number of ECGs (n = 5050), acquired from a clinical trial assessing the effects of four known QT-prolonging drugs versus placebo on healthy subjects. We compared this new personalized approach to our previous study that used a more general approach using the QT-nomogram. Results and conclusionsThe explainable AI-based algorithm can accurately detect QT-prolongation when adjusted to a personalized patient-specific cut-off QTc value showing a potential risk of TdP. Using ∆QTc > 60 ms relative to drug-free baseline and QTc > 500 ms as examples, the algorithm yielded a sensitivity of 0.95 and 0.79, and a specificity of 0.95 and 0.98, respectively. We found that adjusting pseudo-coloring according to Bazett's ∆QTc > 60 ms relative to a drug-free baseline personalized to each patient provides better sensitivity than using Bazett's QTc > 500 ms, which could underestimate a potentially clinically significant QT-prolongation with bradycardia.

Increased Union Rates in Subtalar Joint Arthrodesis with Hybrid Nitinol Dynamic Compression Device

Category: Hindfoot Introduction/Purpose: Subtalar joint arthrodesis (STJA) is a well-established and widely accepted surgical procedure utilized for the treatment of numerous hindfoot conditions. Several fixation constructs in STJA have been described in the literature. With the current advancements in orthopedic technology, new devices utilizing nitinol elements have been developed in an effort to maintain sustained compression in the event of bony resorption which may occur during arthrodesis healing. The primary aim of our study is to introduce a hybrid nitinol dynamic compression (HNDC) device for STJA which provides dynamic compression without proximal locking fixation and compare union rates with a previous nitinol dynamic compression nail (NDCN) as well as a standard two-compression screw fixation construct. The secondary aim was to compare hardware removal rates amongst the three cohorts. Methods: From May 2019 through February 2022, 26 consecutive patients treated with a novel HNDC for STJA were compared to 15 patients treated with NDCN for STJA and 41 patients undergoing STJA using a two-compression screw fixation method. Patients were included in our study if they were greater than 18 years of age, underwent STJA with the use of one of the internal fixation constructs under investigation, and had a minimum 1-year follow-up with radiographs; there were no other exclusion criteria. Arthrodesis sites were augmented with autologous bone graft with or without bone graft substitute in all patients. Standard postoperative protocols were used amongst all three cohorts. Primary outcomes included subtalar joint union rates determined by radiographic and clinical assessment. The incidence of hardware removal was recorded and compared between groups. Patient-specific risk factors were studied to assess any potential negative effects on STJA union rates. Results: Union rates between the HNDC device and the NDCN group did not demonstrate a statistically significant difference at final follow-up. There was a statistically significant difference in union rates between subjects who underwent STJA with the HNDC device versus those who underwent STJA with a two-compression screw construct. Furthermore, there was a statistically significant increase in union rates in subjects who received nitinol dynamic compression fixation devices, HNDC or NDCN, versus standard compression screws. There was not a statistically significant difference in hardware removal rates among the 3 cohorts. No significant relationship was seen between smoking, diabetes, or alcohol consumption and union rates. Conclusion: Our data supports the HNDC device to have superior union rates to the two-screw fixation group. In addition, the HNDC device provides improved union rates, though not statistically significant, when compared to the NDCN. Furthermore, the HNDC device was found to have lower rates of hardware removal when compared to the two-screw fixation and the NDCN groups though this was not statistically significant. The early results of this HNDC device for STJA are encouraging and appear to offer a further improved alternative fixation construct with excellent union rates and minimal complications.

Obstetric Anesthesia

Patient safety and reduction of possible complications are the top priorities for anesthesiologists in everyday clinical practice. Thus, interdisciplinary early assessment and optimization of patient specific medical conditions and risk factors are crucial. In obstetrics, regional anesthesia and general anesthesia are routinely being performed. To ensure maternal and fetal safety, knowledge regarding physiological changes during pregnancy is highly important. Regional anesthesia, particularly epidural analgesia, has its main field of application in the context of natural birth in the delivery room. Spinal anesthesia, as well as epidural and combined spinal-epidural anesthesia (CSE) are widely used for caesarean section. In this context, special attention should be paid to possible bleeding disorders. The combination of risk stratification and strategies to improve the patient's preoperative medical status is capable to reduce maternal and fetal complications.

Association Between Mirtazapine Use and Priapism in a Middle-Aged Man: A Case Report

A 43-year-old man presented with three episodes of priapism in 4 weeks following testosterone replacement therapy and mirtazapine use. He previously had a two-episode history of priapism 5 years ago after taking trazodone. The exact mechanism for mirtazapine-induced priapism is unclear. However, the timing of the patient's priapism onset suggests that mirtazapine was driving these episodes. Given the unusual circumstances of this case, there may be patient-specific risk factors for recurrent priapism, such as a history of priapism. Therefore, careful use of mirtazapine is advised in patients with previous episodes of priapism. Furthermore, men taking mirtazapine should be informed of the signs and symptoms of priapism and advised to seek medical attention if they experience prolonged erections. [ Psychiatr Ann . 2023;53(10):482–484.]

The Relationship Between Myocardial Infarction and Estrogen Use: A Literature Review.

This thorough literature evaluation was prompted by significant research into the complex interactions between estrogen use and myocardial infarction (MI). Estrogenhas fascinated researchers because of its possible cardioprotective benefits and its impact on cardiovascular health. In order to clarify the connection between estrogen use and the risk of MI, this review critically examines the body of prior evidence. This review focuses on estrogen and its pivotal role in cardiovascular health, concentrating on lipid metabolism, vasodilation, inflammation, and endothelial function. It examines contentious data about estrogen therapy's heart-protective effects, taking into account age, initiation timing, dosage, and dosage of administration. Genetic and epigenetic influences on MI risk among estrogen users highlight intricate, personalized estrogen effects. The conclusion summarizes the main findings and emphasizes the need for an all-encompassing strategy for initiating and managing estrogen medication. It is crucial to consider patient-specific traits and risk factors to successfully customize treatment regimens. This review sheds vital light on the potential directions for better cardiovascular treatment for postmenopausal women by shedding light on the complex link between estrogen use and myocardial infarction. The review also identifies research gaps and future objectives in this area, highlighting the demand for novel medicines and individualized strategies to improve cardiovascular outcomes.

Screw fixation after tripe pelvic osteotomy is reliable: changes of acetabular correction are rare and do not correlate with risk factors

PurposeThe aim of this examination was to assess whether there is a change of acetabular correction after triple pelvic osteotomy (TPO) and if so, whether there is a correlation with patient-specific risk factors or with certain periods in the postoperative course.MethodsA consecutive series of 241 TPO was reviewed retrospectively. The close-meshed radiographic follow-up of the first 12 weeks comprised pelvic radiographs performed immediately after the procedure, 5 days, 6 and 12 weeks after TPO. Three observers measured the lateral center edge angle, acetabular index and the craniocaudal offset of the pubic osteotomy. Patient-specific risk factors (e. g. age, gender, body mass index, nicotine abuse) and certain periods in the postoperative course were correlated with a change of acetabular correction.ResultsAfter application of the exclusion criteria, 225 hips were available for further examination. Intraclass correlation coefficient resulted in predominantly excellent agreement between the measurements of the three observers (0.74–0.91). In 27 cases (12%), the three observers agreed on a change of acetabular correction. In 18 cases (8%), there was a slight change, in 9 cases (4%), a relevant change. The latter entailed consequences in the postoperative aftercare. General equation estimation did not show any correlation between a change of acetabular correction and patient-specific risk factors or certain periods in the postoperative course (p = 0.79–0.99).ConclusionEvery once treated hip should be followed-up with the same attention, irrespective of the apparent risk profile. There is no rationale to skip a radiographic follow-up in the first 12 weeks after TPO.

Analysis of risk factors of infection in diabetic foot patients.

This cross-sectional study assessed the risk factors for infection in 150 diabetic foot patients admitted to the Xiamen University Hospital between October 2020 and October 2022. Patients were categorised as infected (n = 80) or uninfected (n = 70) cohorts. The diabetic foot was evaluated using the American Diabetic Foot Grading system, whereas ulcers were categorised using Wagner's method. Analysed were patient-specific information, clinical data and risk factors including neuropathy, arterial disease and foot deformities. Our findings revealed no statistically significant differences between infected and uninfected cohorts concerning age, body mass index, gender, duration of diabetes or ankle-brachial index values (p > 0.05). However, infected group had a higher proportion of smokers and reduced socio-economic status (p < 0.05). Wagner grades indicated a greater severity in the infected group, with grade 3, grade 4 and grade 5 differing significantly (p < 0.05). Comparative analysis of ulcer characteristics revealed no statistically significant differences in ulcer surface area and depth, but the infected group had a higher prevalence of osteomyelitis and a greater number of ulcers (p > 0.05). Blood vessel complications, retinopathy, the presence of three or more ulcers, osteomyelitis and diabetic nephropathy were substantially more prevalent in the infected group, as determined by univariate analysis (p < 0.05). Subsequent multivariate logistic analysis revealed that patients with blood vessel complications, retinopathy, osteomyelitis, diabetic nephropathy and three or more ulcers were at increased risk for infection (p < 0.05). In addition, lifestyle factors, such as smoking, sedentary behaviour, inadequate foot hygiene, obesity and poor glycaemic control, were also associated with higher infection rates. A multivariate analysis of foot wound factors revealed that deeper, longer and recurrent lesions increased the likelihood of infection. Escherichia coli was the most frequently isolated bacterium from the infected group's bacterial culture, followed by Pseudomonas aeruginosa and Staphylococcus aureus. The study enhanced our comprehension of the multifactorial risk factors associated with infections in diabetic foot patients, highlighting the need for thorough clinical evaluation, lifestyle modification and vigilant infection control.

Personalised decision making to predict absolute metastatic risk in cutaneous squamous cell carcinoma: development and validation of a clinico-pathological model

Cutaneous squamous cell carcinoma (cSCC) is a common skin cancer, affecting more than 2 million people worldwide yearly and metastasising in 2-5% of patients. However, current clinical staging systems do not provide estimates of absolute metastatic risk, hence missing the opportunity for more personalised treatment advice. We aimed to develop a clinico-pathological model that predicts the probability of metastasis in patients with cSCC. Nationwide cohorts from (1) all patients with a first primary cSCC in The Netherlands in 2007-2008 and (2) all patients with a cSCC in 2013-2015 in England were used to derive nested case-control cohorts. Pathology records of primary cSCCs that originated a loco-regional or distant metastasis were identified, and these cSCCs were matched to primary cSCCs of controls without metastasis (1:1 ratio). The model was developed on the Dutch cohort (n=390) using a weighted Cox regression model with backward selection and validated on the English cohort (n=696). Model performance was assessed using weighted versions of the C-index, calibration metrics, and decision curve analysis; and compared to the Brigham and Women's Hospital (BWH) and the American Joint Committee on Cancer (AJCC) staging systems. Members of the multidisciplinary Skin Cancer Outcomes (SCOUT) consortium were surveyed to interpret metastatic risk cutoffs in a clinical context. Eight out of eleven clinico-pathological variables were selected. The model showed good discriminative ability, with an optimism-corrected C-index of 0.80 (95% Confidence interval (CI) 0.75-0.85) in the development cohort and a C-index of 0.84 (95% CI 0.81-0.87) in the validation cohort. Model predictions were well-calibrated: the calibration slope was 0.96 (95% CI 0.76-1.16) in the validation cohort. Decision curve analysis showed improved net benefit compared to current staging systems, particularly for thresholds relevant for decisions on follow-up and adjuvant treatment. The model is available as an online web-based calculator (https://emc-dermatology.shinyapps.io/cscc-abs-met-risk/). This validated model assigns personalised metastatic risk predictions to patients with cSCC, using routinely reported histological and patient-specific risk factors. The model can empower clinicians and healthcare systems in identifying patients with high-risk cSCC and offering personalised care/treatment and follow-up. Use of the model for clinical decision-making in different patient populations must be further investigated. PPP Allowance made available by Health-Holland, Top Sector Life Sciences & Health, to stimulate public-private partnerships.

Informed consent for endoscopic procedures: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

All endoscopic procedures are invasive and carry risk. Accordingly, all endoscopists should involve the patient in the decision-making process about the most appropriate endoscopic procedure for that individual, in keeping with a patient's right to self-determination and autonomy. Recognition of this has led to detailed guidelines on informed consent for endoscopy in some countries, but in many no such guidance exists; this may lead to variations in care and exposure to risk of litigation. In this document, the European Society of Gastrointestinal Endoscopy (ESGE) sets out a series of statements that cover best practice in informed consent for endoscopy. These statements should be seen as a minimum standard of practice, but practitioners must be aware of and adhere to the law in their own country. 1: Patients should give informed consent for all gastrointestinal endoscopic procedures for which they have capacity to do so. 2: The healthcare professional seeking consent for an endoscopic procedure should ensure that the patient has the capacity to consent to that procedure. 3: For patients who lack capacity, healthcare personnel should at all times try to engage with people close to the patient, such as family, friends, or caregivers, to achieve consensus on the appropriateness of performing the procedure. 4: Where a patient lacks capacity to provide informed consent, the best interest decision should be clearly documented in the medical record. This should include information about the capacity assessment, reason(s) that the decision cannot be delayed for capacity recovery (or if recovery is not expected), who has been consulted, and where relevant the form of authority for the decision. 5: There should be a systematic and transparent disclosure of the expected benefits and harms that may reasonably affect patient choice on whether or not to undergo any diagnostic or interventional endoscopic procedure. Information about possible alternatives, as well as the consequences of doing nothing, should also be provided when relevant. 6: The information provided on the benefit and harms of an endoscopic procedure should be adapted to the procedure and patient-specific risk factors, and the preferences of the patient should be central to the consent process. 7: The consent discussion should be undertaken by an individual who is familiar with the procedure and its risks, and is able to discuss these in the context of the individual patient. 8: Patients should confirm consent to an endoscopic procedure in a private, unrushed, and non-coercive environment. 9: If a patient requests that an endoscopic procedure be discontinued, the procedure should be paused and the patient's capacity for decision making assessed. If a competent patient continues to object to the procedure, or if a conclusive determination of capacity is not feasible, the examination should be terminated as soon as it is safe to do so. 10: Informed consent should be sufficiently detailed to cover all findings that can be reasonably anticipated during an endoscopic examination. The scope of this consent should not be expanded, nor a patient's implicit consent for additional interventions assumed, unless failure to proceed with such interventions would result in immediate and predictable harm to the patient.

ULTRASOUND IN THE PREVENTION, DIAGNOSIS AND MANAGEMENT OF OVARIAN HYPERSTIMULATION SYNDROME IN BAMAKO

Ovarian hyperstimulation or ovarian hyperstimulation syndrome (OHSS) is a direct complication of in vitro fertilization with heavy morbidity and, in some cases, even mortality. The physiology remains poorly defined but seems to be moving towards a cascade activation of coagulation through the vascular endothelial growth factor (VEGF). There are patient-specific or pacing-specific risk factors, but this complication can occur in the absence of these factors. Two types can be described: early OHSS linked to the onset of ovulation and late linked to pregnancy. The management is poorly defined and must adapt to the severity of OHSS by taking care of the added complications.The major complication is thrombotic with the particularity of affecting both the venous and arterial territories, which can induce serious complications such as strokes or myocardial infarction. Prevention of this thrombotic risk therefore remains the priority of OHSS management. Since few studies have been carried out on this subject, we have shown here the place of ultrasound in the prevention, diagnosis and treatment of ovarian hyperstimulation syndrome. Aims: - Identify the risk factors of OHSS. - Describe the sonographic signs of OHSS. - Show the role of the radiologist/sonographer in the management of OHSS. Subjects And Methods: This was a cross-sectional, descriptive study concerning 350 women collected between March 2018 and March 2022 in different medically assisted procreation centers in Bamako. The study population consisted of consenting women presenting for assisted reproduction assessment in whom risk factors, signs of hyperstimulation and even complications were identified. The risk factors were: high anti-Müllerian hormone (AMH), the young age of the patient and the count of antral follicles (AFC) with more than 14 follicles. The patients had a biological assessment, the ultrasounds were made by endo-cavitary way and by high way with devices of General electric Voluson E8, Vivid 3 and Logic9. Results: 350 women were recruited into our. The average age was 26 years with extremes ranging from 18 to 37 years. 60.85% of the patients were between 18 and 25 years old. The risk factors were: high anti-Müllerian hormone (AMH) (7%), the young age of the patient (88%) and the count of antral follicles or AFC&gt;14 follicles (89.8%). The clinical signs of OHSS were abdominal distension (8.5%), abdominal pain (8.5%), nausea and vomiting (2.28%). Ultrasound signs, i.e. ascites, increased ovarian volume, presence of large ovarian follicles were present in 8.57% of patients. The number of punctured follicles varied between 10 and 30. In sum, hyperstimulation was recorded in 30 patients, i.e. 08.57% of the 30 patients who had the OHSS, 12 had a pregnancy. Conclusion: There are risk factors for OHSS that correspond to patients with good or even excessive ovarian reserves, as in the context of polycystic ovary syndrome. However, OHSS occurs in 33% of cases with no identified risk factor [1]. It is therefore advisable to carefully monitor ovarian stimulation in the context of In Vitro Fertilization with doses adapted to the patients and to remember that the best prevention remains the cancellation of the cycle without triggering or coasting, that is i.e. a cessation of gonadotropins. OHSS is a serious complication of PMA that can be life-threatening, so care and monitoring must be rigorous, adapted to each stage of the disease. The great variability of OHSS makes it difficult to draw up recommendations for clinical practice and it is therefore necessary to adapt the management according to each patient.

Development and external validation of a pretrained deep learning model for the prediction of non-accidental trauma

Non-accidental trauma (NAT) is deadly and difficult to predict. Transformer models pretrained on large datasets have recently produced state of the art performance on diverse prediction tasks, but the optimal pretraining strategies for diagnostic predictions are not known. Here we report the development and external validation of Pretrained and Adapted BERT for Longitudinal Outcomes (PABLO), a transformer-based deep learning model with multitask clinical pretraining, to identify patients who will receive a diagnosis of NAT in the next year. We develop a clinical interface to visualize patient trajectories, model predictions, and individual risk factors. In two comprehensive statewide databases, approximately 1% of patients experience NAT within one year of prediction. PABLO predicts NAT events with area under the receiver operating characteristic curve (AUROC) of 0.844 (95% CI 0.838–0.851) in the California test set, and 0.849 (95% CI 0.846–0.851) on external validation in Florida, outperforming comparator models. Multitask pretraining significantly improves model performance. Attribution analysis shows substance use, psychiatric, and injury diagnoses, in the context of age and racial demographics, as influential predictors of NAT. As a clinical decision support system, PABLO can identify high-risk patients and patient-specific risk factors, which can be used to target secondary screening and preventive interventions at the point-of-care.

Age and magnitude of acetabular correction impair bone healing after triple pelvic osteotomy.

The aim of this examination was to assess, which risk factors impair bone healing after triple pelvic osteotomy (TPO) in the treatment of symptomatic hip dysplasia. A consecutive series of 241 TPO was reviewed retrospectively. Of these, a set of five postoperative radiographs was available, performed in a standardized regimen in the first year after surgery. Two experienced observers had to agree on the existence of a non-union on the radiographs obtained 1year after TPO. Both observers measured the lateral center edge angle (LCEA) and acetabular index (AI) on all radiographs. Besides patient-specific risk factors, the magnitudes of acetabular correction and the amounts of a detectable slight change in acetabular correction were assessed. Binary logistic regression analysis and chi-squared test were used to detect the impact of the risk factor on bone healing. A total of 222 cases were left for further examination. In 19 of these, at least one osteotomy was not healed completely one year after surgery. Binary logistic regression showed a significant relationship between the risk factors "age" (p < 0.001; odds ratio (OR) 1.109 (95% CI 1.05-1.18)) as well as "magnitude of acetabular correction (LCEA)" (p = 0.01; OR 1.087 (95% CI 1.02-1.16)) and non-union. Pearson's chi-square test showed a relationship between the risk factor "wound healing disorder" and non-union (p < 0.001). LCEA and AI showed a slight increase from the first to the last follow-up (observer 1: 1.6° and 1.3°, resp.), but regression analysis for the risk factor "amount of postoperative change of acetabular correction (LCEA, AI)" did not show statistically significant values. The age at surgery and the magnitude of acetabular correction negatively influenced the healing progress of the osteotomy sites. The amount of a slight postoperative change of LCEA and AI did not correlate with a non-union.