Predictors Of Discordance Research Articles

Family dynamics in a multi-ethnic Asian society: comparison of elderly CKD patients and their family caregivers experience with medical decision making for managing end stage kidney disease

BackgroundElderly end stage kidney patients face a decision concerning whether or not to initiate dialysis. In Asia, this decision is highly influenced by family caregivers. The objective of this paper was to understand patients’ experience with and preferences for family involvement in treatment decisions, and via a series of hypothetical vignettes, to identify whether there was discordance in treatment preferences between patients and their caregivers, and how any potential conflicts were reconciled.MethodsWe conducted a survey with 151 elderly (aged ≥65) chronic kidney disease patients and their caregivers at outpatient renal clinics. The survey asked, when making treatment decisions, whom they wish makes the final decisions (i.e., preference) and who usually makes the final decisions (i.e., experience). The survey also presented a series of choice vignettes for managing patient’s condition and asked respondents to choose between two hypothetical treatment profiles in each vignette. Patients and caregivers were first interviewed separately in tandem, and then were brought together to choose a treatment jointly for vignettes where the initial treatment choice differed within the dyad. We used multivariate regressions to investigate the predictors of discordance and reconciliation.ResultsWe found that most (51%) patients preferred and experienced (64%) significant involvement from caregivers. However, 38% of patients preferred to make final decisions alone but only 27% of patients did. In the hypothetical vignettes, caregivers chose the more intensive option (i.e., dialysis) more than patients did (26% vs 19%; p < 0.01). Overall, 44% of the dyads had discordance in at least 3 vignettes, and the odds of discordance within patient-caregiver dyads was higher when caregivers chose dialysis or treatment with the higher cost (p < 0.01). In half the cases, discordance resolved in the patients’ favor, and this was more likely to be the case if the patient was employed and wanted to be in charge of final decisions (p < 0.01).ConclusionsOur results highlight the important role of caregivers in decision-making but also the potential for them to overstep. Clinicians should be aware of this challenge and identify strategies that minimize the chances that patients may receive treatments not consistent with their preferences.

Predictors of discordance between fractional flow reserve and instantaneous wave-free ratio in the real world

Introduction Invasive physiologic variables such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are used in clinical practice to assess the functional significance of epicardial coronary stenosis and guide the management. However, these two variables may show discrepancies when binary cut-offs are used to decide for revascularization strategy. We investigated the clinical characteristics of lesions with discordance between iFR and FFR. Methodology 256 vessels (220 patients mean age 61 ± 12, 77% males) with available pre-intervention FFR and iFR values were included in the study. The vessels were classified according to FFR and iFR into concordant normal (Group 1 [n = 112]; FFR > 0.8 and iFR > 0.89); discordant with abnormal FFR and normal iFR (Group 2 [n = 12); FFR 0.89); discordant with normal FFR and abnormal iFR (Group 3 [n = 43], FFR > 0.8 and iFR Results Haemodynamically significant lesions were found in 51.5% and 40% for FFR and iFR respectively. Overall, 22% of lesions were discordant with a significantly higher number of females showing disagreement than males (p Conclusion Our study shows that almost a quarter of lesions show discordance for FFR and iFR with a female preponderance. The four groups classified according to FFR and iFR are characterized by differences in clinical characteristics and predictors of discordance. The lesions with discordant FFR and iFR may have a different pathophysiology which warrants further investigation.

P4702Clinical and angiographic predictors of discordance between myocardial perfusion scintigraphy and fractional flow reserve

P4702Clinical and angiographic predictors of discordance between myocardial perfusion scintigraphy and fractional flow reserve

Discrepancy between fractional flow reserve and instantaneous wave-free ratio: Clinical and angiographic characteristics

BackgroundThe invasive physiologic index such as fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is used in clinical practice to identify ischemia-causing stenosis and to guide treatment strategy. We investigated clinical and angiographic characteristics of lesions with discrepancy between FFR and iFR. MethodsFrom the 3V FFR-FRIENDS study, 975 vessels (393 patients) with available pre-intervention FFR and iFR were included in this study. The vessels were classified according to FFR and iFR into: concordant normal (Group 1 [n=724]: FFR>0.80 and iFR≥0.90); high FFR and low iFR (Group 2 [n=33]: FFR>0.80 and iFR<0.90); low FFR and high iFR (Group 3 [n=82]: FFR≤0.80 and iFR≥0.90); and concordant abnormal (Group 4 [n=136]: FFR≤0.80 and iFR<0.90). ResultsAngiographic stenosis severity assessed by percent diameter stenosis, minimum lumen diameter and lesion length was increased from Group 1 to Group 4 (all p<0.001). SYNTAX score increased and FFR decreased proportionally from Group 1 to Group 4 (all p<0.001). In multivariable GEE model, female, diabetes mellitus, smaller reference vessel diameter, and higher %DS were significantly associated with low iFR among high FFR groups (Group 2 discordance). Conversely, males, absence of diabetes mellitus and lower %DS were significantly associated with high iFR among low FFR groups (Group 3 discordance). ConclusionsFour groups classified according to FFR and iFR were different in clinical and angiographic characteristics, SYNTAX score, and predictors of discordance. The lesions with discordant FFR and iFR may need to be interpreted as a different clinical entity.

Trockenes Auge: Welche Faktoren verantworten die Abweichung von Anzeichen und Symptomen?

Vehof J et al. Predictors of Discordance between Symptoms and Signs in Dry Eye Disease. Ophthalmology 2017; 124: 280 – 286

Discordance Between The Perceived And Actual Activity-supportive Built Environment Among College Students

An individual’s environment has a major impact on their activities, travel mode, and health. Thus, to improve physical activity (PA), active transportation, and health, it is important to understand a society’s awareness of their environment. PURPOSE: To evaluate discordance between perceived and actual presence of factors associated with the built environment. METHODS: A survey of 170 college students’ (19±.89 years) familiarity with their environment for PA and PA participation was conducted in Spring 2015. Objectively measured environmental audits of the environment were conducted simultaneously using an environment audit (WASABE). Variables included for the present study include: presence of trails, presence of parks, sidewalk maintenance, and perceived activity of those in the neighborhood. A continuous discordance score (-4 to 4) was created by summing the frequency by which an individual differed from the audit on each variable. A score of -4 represents always perceiving the presence of a variable when there was not one (negative discordance). A score of 4 represents always perceiving the absence of a variable when there was one (positive discordance). Paired-samples t-tests assessed discrepancies between the perceived and actual environment. Pearson correlations examined the relationship between fitness and discordance. A linear regression identified which factors within the individual (i.e., demographics, PA and environmental) most predicted discordance. P values were set at <.05. RESULTS: T-tests indicated significant differences between perceived and actual results for: the presence of bike trails (t=10.69), the presence of parks (t=5.81), and the presence of people being physically active (t=2.49). Positive discordance was correlated with a lack of moderate PA (r=-.27). There were no significant correlations with negative discordance. Predictors of discordance in either direction included: not owning a bike (β=-0.83), rarely using bike trails/routes (β=-.27), and not living near a park (β=-1.33). CONCLUSION: Students are unfamiliar with their environment, which may influence their activities and travel mode. Those who do not participate in activities that would place them in their neighborhood environment are even more unaware of their surroundings than others.

Predictors of Discordance between Symptoms and Signs in Dry Eye Disease

To investigate predictors of discordance between symptoms and signs in dry eye disease (DED). Cross-sectional association study. A total of 648 patients with dry eye from the Groningen LOngitudinal Sicca StudY (GLOSSY), a tertiary dry eye clinic patient cohort from the Netherlands. Patient symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire. Dry eye signs were assessed by tear osmolarity, Schirmer test, tear breakup time, corneal and conjunctival staining, and meibomian gland dysfunction, all in both eyes, and a composite dry eye signs severity score was calculated from these 6 tests for each patient. Linear regression analysis was used to test the association of discordance between symptoms and signs with a wide range of independent variables (demographic and environmental variables, systemic diseases, ocular traits, and medications). Predictors of discordance between symptoms and signs in DED, defined by the difference between the rank score of the OSDI and the rank score of the dry eye signs severity score. Of the 648 subjects in this cohort, 536 (82.7%) were female and the mean age was 55.8 years (standard deviation, 15.6 years). Significant predictors of greater symptoms than signs were the presence of a chronic pain syndrome, atopic diseases, a known allergy, the use of antihistamines (all P < 0.001), depression (P= 0.003), osteoarthritis (P= 0.008), and the use of antidepressants (P= 0.02). Predictors of lesser symptoms than signs were increased age (P < 0.001) and the presence of Sjögren's disease (P < 0.001) (primary Sjögren's disease, P<0.001) more than secondary Sjögren's disease (P= 0.08), and graft-versus-host disease (P= 0.04). Furthermore, greater symptoms compared with signs were highly associated with lower self-perceived health (P < 0.001). This large clinical study has shown that discordance between symptoms and signs in DED is an indicator of self-perceived health. The study found important predictors of greater symptoms to signs but also predictors of lesser symptoms to signs. Awareness of these predictors is helpful in assessing patients with dry eye in clinical practice.

Risk Factors and Predictors of Discordance Between Transient Elastography (FibroScan®) and Liver Biopsy

Introduction: Management of patients with liver diseases is frequently driven by the degree of liver fibrosis. Noninvasive methods for staging fibrosis via transient elastography (TE), such as Echosens FibroScan® device, have begun to replace the use of liver biopsy. However, discordance between FibroScan® and liver biopsy has been reported. The aim of this study is to evaluate the frequency and risk factors of discordance between liver biopsy and FibroScan® scores. Methods: This is a retrospective cohort study of all patients at Weill Cornell Medical Center who underwent TE evaluation via FibroScan® within one year of liver biopsy. Discordance was defined as ≥2-stage difference between fibrosis stage on biopsy compared to FibroScan®. Risk factors for patients with discordance versus concordance were compared. Univariate analysis was conducted using T-test testing and Fisher's Exact testing, while logistic regression was utilized to conduct multivariate model testing. All statistical analysis was performed using R. Results: 1036 patients underwent TE evaluation. 49 patients, with a mean age of 52.8 years (±12.6 years), had a liver biopsy within one year. 20.4% of patients were found to have discordant studies. 70% had a lower FibroScan® fibrosis staging compared to biopsy fibrosis staging. Patients had a mean 91.89% Fibroscan® success rate. On univariate analysis, younger age at the time of the FibroScan® was significantly associated with discordance (p=0.038). There was no statistical significance when comparing discordance with other pre-specified factors, including gender, BMI, ALT, percentage of steatosis or iron, FibroScan® operator, or FibroScan® probe. In a multivariate analysis, age, ALT, and biopsy diagnosis - particularly HBV, were statistically significant in being predictive of discordance (p=0.0495, p=0.0447 and p=0.023, respectively). Conclusion: We demonstrate that discordance between liver biopsy and FibroScan® fibrosis score occurs in a large proportion of patients. Younger age was associated with discordance. Multivariate analysis demonstrates the combination of age, ALT and the diagnosis of HBV are also predictive of discordance. Hepatologists should be wary of replacing liver biopsy with TE given a high rate of discordance. Future studies to validate these findings, and create prediction tools to direct clinicians to pursue biopsies over TE are needed, to improve clinical care and patient outcomes.

Liver stiffness measurement using acoustic radiation force impulse elastography in overweight and obese patients.

Obesity and overweight are global health problems. To evaluate the diagnostic accuracy of liver stiffness measurement (LSM) using acoustic radiation force impulse (ARFI) elastography in overweight and obese patients for staging liver fibrosis. Ninety-seven patients (mean age: 50 years, 50% male) with body mass index (BMI) ≥25 kg/m(2) (mean BMI: 31 kg/m(2) ) were prospectively enrolled. All patients underwent ARFI elastography and liver biopsy. In 87/97 patients, transient elastography (TE) was performed (M- and XL-probes). Patients were divided into two groups respectively: overweight: BMI <30 kg/m(2) (n = 61); and obese: BMI ≥30 kg/m(2) (n = 26). Acoustic radiation force impulse elastography correlated with liver fibrosis in overweight (r = 0.84, P < 0.0001) and obese patients (r = 0.85, P < 0.0001), while no correlation was observed with steatosis, steatohepatitis and BMI. Area under the curve detecting liver cirrhosis for ARFI and TE were 0.97 in overweight and 0.94 and 0.92 in obese patients. In both groups, the failure rate was lower for ARFI than TE. ARFI of liver segment 8 showed a lower discordance than TE in both groups (overweight: 3% vs. 12%, P = 0.002; obese: 8% vs. 27%, P = 0.034). Steatosis and steatohepatitis were neither predictors of discordance nor of performance in LSM by ARFI or TE in both groups. In overweight and obese patients, acoustic radiation force impulse can diagnose liver cirrhosis and significant fibrosis with high diagnostic accuracy. Liver stiffness measurement using the XL-probe reduces the influence of BMI, steatosis and steatohepatitis. The failure and discordance rates were lower for acoustic radiation force impulse than transient elastography in both patients groups.

Abstract P2-02-02: Predictors for discordance in HER2 phenotype between primary tumor and circulating tumor cells in women with metastatic breast cancer

Abstract Aim: The DETECT study program evaluates whether treatment efficacy in women with metastatic breast cancer (MBC) is increased by taking into account the molecular characteristics of circulating tumor cells (CTCs). Here, we present data on both prevalence and HER2 phenotype of CTCs in patients with HER2 negative MBC screened within the DETECT program. The aim of this study is to evaluate the rate of discordance in HER2 phenotype between primary tumor and CTCs and to analyze whether primary tumor and/or patient characteristics can predict discordance in HER2-status. Methods: The number of CTCs in 7.5 ml of peripheral blood (using the FDA-cleared CellSearch® System; Janssen Diagnostics, LLC) and their HER2 status were evaluated. Patients were defined as having a positive HER2-status on CTCs if at least 1 CTC with a strong (+++) immunocytochemical HER2 staining intensity was found. To assess which factors predict discordance of HER2 phenotype between primary tumor and CTCs, we used a multivariate binary logistic regression model with backward selection procedure. Patient and primary tumor characteristics included as independent factors were patient age, time since primary diagnosis, tumor stage, nodal stage, grading, histological type, and hormone receptor status (HRS). Results: 1123 women with HER2-negative MBC were screened for CTCs. Based on a cutoff of ≥ 1 CTC, 711 (63.3%) of 1123 screened patients were positive for CTCs, while 412 (36.7%) of the 1123 screened patients were categorized as CTC positive if a cutoff of ≥ 5 CTCs was used. At least one HER2-positive CTC was found in 134 of the 711 HER2-negative MBC patients with one or more CTCs (median 2 HER2-positive CTCs, range 1 – 80), indicating a discordance between primary tumor and CTCs with regard to HER2-status in 18.8% of patients. If the analysis was restricted to the 412 patients with 5 or more CTCs, at least one HER2-positive CTC was found in 121 patients, resulting in 29.4% discordance rate. A multivariate logistic regression with discordance in HER2 phenotype (yes/no) as binary response variable, including number of CTCs (1 – 4 CTCs vs. 5 or more CTCs) to account for the difference in discordance rate observed at different cutoff values for CTC positivity, showed that histological type (lobular vs. ductal, odds ratio OR 2.66, 95% confidence interval CI 1.62 – 4.37, p &amp;lt; 0.001), HRS (positive vs. negative, OR 2.89, 95% CI 1.16 – 7.19, p = 0.022) and CTC number (5 or more CTCs vs. 1 – 4 CTCs, OR 7.57, 95% CI 3.93 – 14.89, p &amp;lt; 0.001) significantly predicted discordance in HER2 phenotype between primary tumor and CTCs. Conclusion: Our data revealed discordance in HER2 status between primary tumor and CTCs in 19% to 29% of patients with HER2 negative MBC. Discordance in HER2 status was predicted by histological type and HRS of the primary tumor, as well as by the number of CTCs detected. Individualized breast cancer treatment based on CTC phenotype is currently investigated in Phase III trials and not part of clinical routine yet. However, the knowledge of factors associated with discordance in HER2 status may be incorporated in today's clinical practice by guiding the decision process for performing a biopsy to characterize a metastatic relapse. Citation Format: Janni W, Schramm A, Friedl TWP, Schochter F, Huober J, Rack B, Alunni-Fabbroni M, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Krawczyk N, Pantel K, Fehm T. Predictors for discordance in HER2 phenotype between primary tumor and circulating tumor cells in women with metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-02-02.

Differences in Performance Status Assessment Among Palliative Care Specialists, Nurses, and Medical Oncologists

ContextThe Eastern Cooperative Oncology Group performance status (ECOG PS) is one of the most commonly used assessments in oncology and palliative care (PC). However, the interobserver differences between medical oncologists and PC specialists have never been reported. ObjectivesTo determine the interobserver differences in ECOG PS assessment among PC specialists, PC nurses, and medical oncologists in patients with advanced cancer. MethodsWe retrospectively reviewed the medical records of all patients who had an outpatient PC consultation in 2013 and identified 278 eligible patients. We retrieved the ECOG PS scores and symptom burden assessed by the Edmonton Symptom Assessment System (ESAS). ResultsPC specialists (median +0.5, P < 0.0001) and nurses (median +1.0, P < 0.0001) rated the ECOG PS significantly higher than medical oncologists. The weighted kappa values were 0.26 between PC specialists and medical oncologists and 0.61 between PC specialists and nurses. PC specialists' assessments correlated with ESAS fatigue, dyspnea, anorexia, feeling of well-being, and symptom distress score. The ECOG PS assessments by all three groups were significantly associated with survival (P < 0.001). However, patients with ECOG PS 2 and 3–4 rated by their medical oncologists had similar survival (P = 0.67). Predictors of discordance in ECOG PS assessments between PC specialists and medical oncologists were the presence of a potentially effective treatment (odds ratio [OR] 2.39; 95% CI 1.09–5.23) and poor feeling of well-being (≥4) (OR 2.38, 95% CI 1.34–4.21). ConclusionECOG PS assessments by PC specialists and nurses were significantly higher than those of medical oncologists. Systematic efforts to increase regular interdisciplinary communications may help to bridge this gap.

Abstract 19105: Basis for Biochemical Discordance Between Activated Partial Thromboplastin Time and Anti-factor Xa in Patients with Continuous Flow Left Ventricular Assist Device on Unfractionated Heparin Infusion

Introduction: Unfractionated Heparin (UFH) has been the mainstay of therapy for bridging and treatment of suspected device thrombosis/hemolysis in Continuous Flow Left Ventricular Assist Device (CF-LVAD), however the optimal monitoring test has not been prospectively evaluated. We previously reported that that Activated Partial Thromboplastin Time (aPTT) and anti-Xa levels measured simultaneously are frequently discordant in these patients. Hypothesis: Warfarin administration and hemolysis might be the biochemical basis for discordance between aPTT and anti-Xa in patients with CF-LVAD requiring UFH. Methods: A prospective observational study consisting of 38 patients with HeartMateII, consecutively admitted for UFH therapy with simultaneous measurements of aPTT and anti-factor Xa levels. Patients were stratified based on requirement of UFH for either sub-therapeutic INR or suspected device thrombosis. Patients were grouped according to whether the paired values fell within or outside the concordant therapeutic range, when discordant thromboelastography and factor analysis were performed. Results: Anti-Xa and aPTT were concordant 41.9% of the time in those getting treated for sub-therapeutic INR and only 18.8% in the group that getting treated for hemolysis/ device thrombosis. Data pairs with a supratherapeutic aPTT values were most likely to be associated with an INR ≥1.5, (p&lt;0.001) (figure). On logistic regression analysis, high LDH was found to be a significant predictor of discordance (95% CI: 1.47-3.84). There was no consistent relationship between thromboelastography and factor analysis in the incidence of discordance. Conclusions: The relationship between aPTT and anti-factor Xa is not consistent in patients with CF-LVAD and the most common pattern was a supra-therapeutic aPTT relative to anti-factor Xa . Elevated LDH which is the sign for hemolysis and warfarin administration might contribute to an increased incidence of discordance.

The feasibility of the interferon gamma release assay and predictors of discordance with the tuberculin skin test for the diagnosis of latent tuberculosis infection in a remote Aboriginal community.

BackgroundThe tuberculin skin test (TST) is the standard test used to screen for latent TB infection (LTBI) in the northern Canadian territory of Nunavut. Interferon gamma release assays (IGRA) are T cell blood-based assays to diagnose LTBI. The Bacillus Calmette-Guerin (BCG) vaccine is part of the routine immunization schedule in Nunavut. The objective of this study was to test the feasibility, and predictors of discordance between the Tuberculin Skin Test (TST) and the IGRA assay in a medically under-serviced remote arctic Aboriginal population.MethodsBoth the TST and QuantiFERON-TB Gold (Qiagen group) IGRA tests were offered to people in their homes as part of a public health campaign aimed at high TB risk residential areas in Iqaluit, Nunavut, Canada. Feasibility was measured by the capacity of the staff to do the test successfully as measured by the proportion of results obtained.ResultsIn this population of predominantly young Inuit who were mostly BCG vaccinated, the use of IGRA for the diagnosis of LTBI was feasible. IGRA testing resulted in more available test results reaching patients (95.6% vs 90.9% p = 0.02) but took longer (median 8 days (IGRA) vs 2 days (TST), p value <0.0001). 44/256 participants (17.2%) had discordant results. Multivariable regression analysis suggested that discordant results were most likely to have received multiple BCG vaccinations (RR 20.03, 95% CI, 3.94–101.82)), followed by BCG given post infancy (RR 8.13, 95% CI, 2.54–26.03)) and then to a lesser degree when BCG was given in infancy (RR 6.43, 95% CI, 1.72–24.85).InterpretationIGRA is feasible in Iqaluit, Nunavut, a remote Arctic community. IGRA testing results in more test results available to patients compared to TST. This test could result in fewer patients requiring latent TB treatment among those previously vaccinated with BCG in a region with limited public health human resources.

Differences in performance status assessments between palliative care specialists, nurses, and oncologists.

19 Background: The Eastern Cooperative Oncology Group (ECOG) performance status (PS) is one of the most commonly used assessment tools among oncologists and palliative care specialists caring advanced cancer patients. However, the inter-observer difference between the oncologist and palliative care specialist has never been reported. Methods: We retrospectively reviewed the medical records of all patients who were first referred to an outpatient palliative care clinic in 2013 and identified 278 eligible patients. The ECOG PS assessments by palliative care specialists, nurses, and oncologists, and the symptom burden measured by Edmonton Symptom Assessment Scale (ESAS) were analyzed. Results: According to the pairwise comparisons using Sign tests, palliative care specialists rated the ECOG PS grade significantly higher than oncologists (median 0.5 grade, P&lt;0.0001) and nurses also rated significantly higher (median 1.0 grade, P&lt;0.0001). The assessments of palliative care specialists and nurses were not significantly different (P=0.10). Weighted kappa values for inter-observer agreement were 0.26 between palliative care specialists and oncologists, and 0.61 between palliative care specialists and nurses. Palliative care specialists’ assessments showed a moderate correlation with fatigue, dyspnea, anorexia, feeling of well-being, and symptom distress score measured by ESAS. The ECOG PS assessments by all three groups were significantly associated with survival (P&lt;0.001), but the assessments by oncologists could not distinguish survival of patients with PS 2 from 3. Independent predictors of discordance in PS assessments between palliative care specialists and oncologists were the presence of an effective treatment option (odds ratio [OR] 2.39, 95% confidence interval [CI] 1.09-5.23) and poor feeling of well-being (≥4) by ESAS (OR 2.38, 95% CI 1.34-4.21). Conclusions: ECOG PS assessments by the palliative care specialists and nurses were significantly different from the oncologists. Systematic efforts to increase regular interdisciplinary meetings and communications might be crucial to bridge the gap and establish a best care plan for each advanced cancer patients.

Transrectal biopsy scheme can predict incorrect histological grading in prostate cancer

ObjectiveTo identify factors that might explain why a prostate with a Gleason score (GS) <7 in the biopsy specimen can turn out to have a GS ≥7 in the surgical specimen. Material and methodsWe compared the GS of biopsy specimens with the GS of surgical specimens in 185 patients who underwent surgery for prostate cancer. We calculated the sensitivity, specificity, and predictive values for the GS of the biopsy specimens. We used Cohen's kappa to determine the degree of concordance between a GS of <7 and ≥7 for the biopsy specimen and the surgical specimen. Age, a family history of prostate cancer, total prostate-specific antigen (tPSA), digital rectal examination, prostate structure and volume, and the number of biopsy cores (biopsy scheme) were analyzed using multivariable logistic regression. ResultsHistological study of biopsy specimens yielded high sensitivity (98%) but low specificity (49%) for GS ≤6 and low sensitivity (35, 26%) and high specificity (93, 99%) for GS=7 and GS ≥7, respectively. Cohen's kappa for the GS from the biopsy and surgical specimens was 0.43 (95% CI=30–56%). The biopsy scheme was the only predictor of discordance in the GS between the two techniques. Among the other variables included in the model, only tPSA showed a slightly significant association. Taking a scheme with less than 7 cores as a reference, we found no difference with 8 to 9 cores but we did find a difference with 10 to 11 cores and with 12 or more cores, with a prevalence ratio of 0.138 (95% CI=0.030–0.513) and 0.277 (95% CI=0.091–0.806), respectively. ConclusionThe GS of the biopsy depends on the scheme. This factor must be taken into account when choosing a treatment option in patients with low tumor grade in biopsy specimens.

Predictors of discordance between physicians' and patients' appraisals of health-related quality of life in atrial fibrillation patients: Findings from the Angiotensin II Antagonist in Paroxysmal Atrial Fibrillation Trial

Assessing health status is fundamental when weighing treatment options for atrial fibrillation (AF) patients. Most health-related quality-of-life (HRQoL) data stem from self-ratings, whereas treatment decisions are based upon physicians' estimations. The degree of congruence between patients' and physicians' assessments of the patients' subjective health status was used as an indicator of good communication and shared understanding. A total of 334 patients with paroxysmal AF without significant concomitant heart diseases and their physicians were asked in a prospective blinded study to rate the patients' HRQoL. The Short Form-12 was used for self-ratings; the Short Form-8, for physician ratings. Using baseline data, intraclass correlations and Bland-Altman graphs were used to assess concordance; cross-sectional multivariate regression analyses assessed patient characteristics associated with discordance. On average, physicians rated their patients' HRQoL higher than patients did (∆mental component score [MCS] = -3.23, P < .0001, and ∆physical component score [PCS] = -2.21, P = .0001). Intraclass correlations and Bland-Altman graphs showed unsatisfactory concordance. Physical inactivity (∆ = 4.84) had the greatest bivariate effect on PCS discordance, and major depressive disorder (∆ = 7.01), on MCS discordance. In the regression analyses, depression was significantly associated with discord in the MCS (β = -0.94, P < .001) and the PCS (β = -0.37, P < .002). Sleeping disorder was associated with discord in the MCS (β = -4.13, P < .002), and physical inactivity, with discord in the PCS (β = -1.47, P = .006). In patients with AF, even in the absence of significant concomitant cardiac diseases, depression, followed by sleeping disorder and physical inactivity, was significantly associated with discordance. These findings should be considered by physicians when choosing treatment strategies.

Discordance Between Patient and Surgeon Satisfaction After Total Joint Arthroplasty

We surveyed 331 patients undergoing total hip or knee arthroplasty pre-operatively, and patients and surgeons were both surveyed 6 and 12 months post-operatively. We identified variables (demographic factors, operative factors and patient expectations) as possible predictors for discordance in patient–surgeon satisfaction. At 12 months, 94.5% of surgeons and 90.3% of patients recorded satisfaction with the outcome. The discordance between patient and surgeon satisfaction was mainly due to patient dissatisfaction–surgeon satisfaction. In an adjusted analysis, the strongest predictors of discordance in patient–surgeon satisfaction were unmet patient expectations and the presence of complications. Advice to potential joint arthroplasty candidates regarding the decision to proceed with surgery should be informed by patient reported outcomes, rather than the surgeon's opinion of the likelihood of success.

El esquema de biopsia transrectal puede predecir la gradación histológica incorrecta del cáncer de próstata

ObjectiveTo identify factors that might explain why a prostate with a Gleason score (GS) <7 in the biopsy specimen can turn out to have a GS ≥7 in the surgical specimen. Material and methodsWe compared the GS of biopsy specimens with the GS of surgical specimens in 185 patients who underwent surgery for prostate cancer. We calculated the sensitivity, specificity, and predictive values for the GS of the biopsy specimens. We used Cohen's kappa to determine the degree of concordance between a GS of <7 and ≥7 for the biopsy specimen and the surgical specimen. Age, a family history of prostate cancer, total prostate-specific antigen (tPSA), digital rectal examination, prostate structure and volume, and the number of biopsy cores (biopsy scheme) were analyzed using multivariable logistic regression. ResultsHistological study of biopsy specimens yielded high sensitivity (98%) but low specificity (49%) for GS ≤6 and low sensitivity (35, 26%) and high specificity (93, 99%) for GS=7 and GS ≥7, respectively. Cohen's kappa for the GS from the biopsy and surgical specimens was 0.43 (95% CI=30-56%). The biopsy scheme was the only predictor of discordance in the GS between the two techniques. Among the other variables included in the model, only tPSA showed a slightly significant association. Taking a scheme with less than 7 cores as a reference, we found no difference with 8 to 9 cores but we did find a difference with 10 to 11 cores and with 12 or more cores, with a prevalence ratio of 0.138 (95% CI=0.030-0.513) and 0.277 (95% CI=0.091-0.806), respectively. ConclusionThe GS of the biopsy depends on the scheme. This factor must be taken into account when choosing a treatment option in patients with low tumor grade in biopsy specimens.

Discordance on FMRI and Wada Tests of Language Dominance in a Large Epilepsy Cohort (IN5-1.007)

Objective: To quantify discordance between fMRI and Wada language tests, identify factors associated with discordance, and compare the predictive value of each test in discordant cases. Background FMRI assessment of language dominance has begun to replace the traditional Wada test, but the incidence of discordance and factors underlying discordance between these tests have not been well defined. Design/Methods: Participants were 229 epilepsy patients who underwent both fMRI and Wada language testing. The fMRI protocol used a semantic decision task contrasted with a tone decision task. Patients were classified as left dominant, right dominant, or symmetric based on cutoff values applied to the lateralization index (LI, range -100 to +100) from each test. Results were discordant if the two tests failed to classify the patient in the same dominance category AND the LIs from the two tests differed by more than 50 units. A variety of Wada and fMRI quality measures were assessed for association with discordance. Regression formulas for predicting postoperative naming outcome were computed for each test based on data from the 56 left anterior temporal lobectomy patients in whom the tests were concordant, and these formulas were used to compare predicted and observed outcomes in patients with discordant fMRI and Wada. Results: Discordant results occurred in 30/229 patients (13.1%). The main predictor of discordance was the fMRI LI (p Conclusions: FMRI and Wada language dominance tests are generally concordant, though fMRI appears to be more sensitive for detecting atypical dominance. Overall, fMRI may provide a more accurate prediction of postoperative language outcome. Supported by: NIH grant R01 NS035929. Disclosure: Dr. Binder has nothing to disclose. Dr. Janecek has nothing to disclose. Dr. Swanson has nothing to disclose. Dr. Sabsevitz has nothing to disclose. Dr. Hammeke has nothing to disclose.

How Many Valid Measurements Are Necessary to Assess Liver Fibrosis Using FibroScan® in Patients with Chronic Viral Hepatitis? An Analysis of Subjects with at Least 10 Valid Measurements

PurposeUsing FibroScan® to obtain a reliable liver stiffness measurement (LSM) may require more than 10 valid measurements (VMs), according to the manufacturer's recommendations. However, this requirement lacks scientific evidence in support thereof. We investigated the minimal number of VMs required to assess liver fibrosis without significant loss of accuracy in patients with chronic hepatitis B (CHB) and C (CHC) and predictors of discordance between LSM and liver biopsy (LB).Materials and MethodsBetween January 2005 and December 2009, we prospectively enrolled 182 patients with CHB and 68 patients with CHC who were to undergo LB and LSM before starting antiviral treatment. Only LSMs with at least 10 VMs were considered reliable. The Batts and Ludwig scoring system was used for histologic assessment.ResultsThe mean age and body mass index were 46.0 years and 23.4 kg/m2 in patients with CHB and 49.7 years and 23.1 kg/m2 in those with CHC, respectively. The median elasticity scores from the first 3, first 5, and all VMs taken significantly predicted fibrosis stages ≥F2 and F4 (all p<0.05) without significant differences (all p>0.05 by DeLong's method). Alanine aminotransferase (ALT) was the only predictor of discordance in fibrosis stage as estimated by the median elasticity score from the first 3 VMs and by LB in patients with CHB, whereas no significant predictor was identified in those with CHC.ConclusionAfter comparison of patients who had more than 10 valid measurements for LSM, three VMs may be enough to assess liver fibrosis using LSM without significant loss of accuracy in patients with CHC and patients with CHB. However, ALT should be considered when interpreting LSM for patients with CHB.