Risk Calculation Tool Research Articles

Cardiovascular risk assessment using SCORE2 in a population with hypertension – The reality at a primary health care unit

Introduction and objectivesCardiovascular disease (CVD) is the leading cause of morbidity and mortality in Portugal, thus it is important to identify individuals at risk. Patients with hypertension have an increased risk of adverse cardiovascular (CV) events. The role of LDL cholesterol (LDL-C) in atherosclerotic CVD is well-established. SCORE2, a new CV risk calculation tool, is used to predict the 10-year risk of fatal or non-fatal CVD. The aim of this study was to understand the impact of SCORE2 on CV risk assessment in a population with hypertension from a moderate risk country, compared to the previously used SCORE. MethodsThis observational cross-sectional study analyzed a population census of 3146 patients diagnosed with hypertension without complications (K86). After applying inclusion and exclusion criteria, 654 patients were included. Data from medical records were collected to calculate and compare SCORE and SCORE2 categories and LDL-C targets. ResultsPatients were classified into SCORE categories: 188 (28.75%) low, 448 (68.5%) moderate, 17 (2.6%) high and 1 (0.15%) very high risk. Using SCORE2, individuals in the SCORE low risk category were reclassified, requiring new targets: 149 individuals (80%) as low to moderate and 39 (20%) as high risk. These differences became more evident when considering SCORE moderate and high-risk categories, where 358 patients (77%) received a higher CV risk categorization, and therefore a lower LDL-C target. There was a significant increase in individuals failing to meet the target when using SCORE2, compared to SCORE (p<0.001). ConclusionThese findings support the importance of CV risk assessment using SCORE2 algorithm in patients with hypertension.

Short- and long-term performance of risk calculation tools for mortality in patients with acute coronary syndrome.

The mortality rate of acute coronary syndrome (ACS) remains high. Therefore, patients with ACS should undergo early risk stratification, for which various risk calculation tools are available. However, it remains uncertain whether the predictive performance varies over time between risk calculation tools for different target periods. This study aimed to compare the predictive performance of risk calculation tools in estimating short- and long-term mortality risks in patients with ACS, while considering different observation periods using time-dependent receiver operating characteristic (ROC) analysis. This study included 404 consecutive patients with ACS who underwent coronary angiography at our hospital from March 2017 to January 2021. The ACTION and GRACE scores for short-term risk stratification purposes and CRUSADE scores for long-term risk stratification purposes were calculated for all participants. The participants were followed up for 36 months to assess mortality. Using time-dependent ROC analysis, we evaluated the area under the curve (AUC) of the ACTION, CRUSADE, and GRACE scores at 1, 6, 12, 24, and 36 months. Sixty-six patients died during the observation periods. The AUCs at 1, 6, 12, 24, and 36 months of the ACTION score were 0.942, 0.925, 0.889, 0.856, and 0.832; those of the CRUSADE score were 0.881, 0.883, 0.862, 0.876, and 0.862; and those of the GRACE score 0.949, 0.928, 0.888, 0.875, and 0.860, respectively. The ACTION and GRACE scores were excellent risk stratification tools for mortality in the short term. The prognostic performance of each risk score was almost similar in the long term, but the CRUSADE score might be a superior risk stratification tool in the longer term than 3 years.

Feasibility of ADappt: towards personalized communication and prediction in early Alzheimer’s disease in memory clinics

AbstractBackgroundADappt is a Web‐based toolkit (www.ADappt.health) to support personalized communication and prediction in memory clinics. In the context of an iterative development process with professionals, patients, and care partners, we assessed feasibility, satisfaction, and usability of ADappt in the clinical workflow.MethodWe conducted a feasibility pilot in four Dutch memory clinics. Three neurologists, one geriatrician, two specialized nurses and two medical doctors (12±7y clinical experience) participated and recruited 21 patients (69±8yrs, 19%F) and 21 care partners (60±15yrs, 81%F). For professionals, ADappt‐modules comprised a 1) topic list, 2) shared decision‐making conversation guide, 3) overview of diagnostic tests, and 4) risk calculation tool. Prior to their visit, patients and care partners were informed about ADappt‐patient tools: 1) educational video‐animations, and 2) question prompt list. All participants completed questionnaires on feasibility, satisfaction, and usability after the first (n = 17) and/or the disclosure (n = 7) consultation. Professionals were interviewed afterward.ResultProfessionals reported good usability (68±14, range 50‐83, System Usability Scale, 0‐100) and high satisfaction (71±10, range 50‐85, scale 0‐100). They most often used the overview of diagnostic tests (67%) and reported this module as most helpful (3.8±0.4, range 3‐4, scale 1‐5). Patients and care partners were highly satisfied with the clinician‐patient consultations in general (81±14, range 50‐100, Patient Satisfaction Questionnaire, scale 0‐100). Of those who reported to know and have used the patient tools (54%), 97% would recommend them, whereby most used the question prompt list (84%) and a smaller proportion the video‐animations (64%). Recommendations from the interviews to improve feasibility include: 1) the development of more concrete instructions for professionals on how to use ADappt, and 2) a better alignment of patient tools with the patient journey and general information provided by that particular memory clinic.ConclusionStakeholders reported good usability and high satisfaction regarding ADappt. Points of attention to foster feasibility in the clinical workflow are: 1) improved training for professionals and 2) improving the accessibility of patient tools. We take these matters into account while preparing for the next step: a prospective validation study in the memory clinic setting to study the influence of ADappt on patient satisfaction.

10-Year Cardiovascular Risk, Serum Lipid Indices and High Sensitivity CRP in a Healthy Population

Objective: It is very important to identify individuals at high risk of atherosclerotic cardiovascular diseases (ASCVD) and for this purpose, many risk calculation tools and parameters are used. In this study, we aimed to investigate the correlation between the ACC/AHA cardiovascular risk and serum lipid indices and high sensitivity C-reactive protein (hs-CRP) in a healthy population.&#x0D; Methods: Our study was conducted retrospectively on individuals aged between 40 and 79 years and with sufficient data, using the hospital database. Patients with a history of any chronic disease and active infection were excluded. Individuals were analyzed by grouping them into low (5%) estimated 10-year risk of ASCVD.&#x0D; Results: 184 individuals with a median age of 46 and 37.5% women were included in the study. The median 10-year estimated risk of ASCVD in the study population was 3% (1.3/5.98). The low-risk group had a significantly lower atherogenic index of plasma (AIP), Castelli I risk index (CR-I), and Castelli II risk index (CR-II) compared to the borderline to high-risk group (p

194 ORIEL (Mortality Risk Prediction in Emergency Laparotomy): A Comparison of Mortality Risk Prediction Tools

Abstract Aim Emergency laparotomies carry significant risk of morbidity and mortality. Risk calculation tools are essential to identify high-risk patients and inform clinicians in decision making. As part of a multi-centre research initiative, a retrospective study of all emergency laparotomies in a major trauma centre was conducted to determine the most accurate predictor of thirty-day mortality by comparing four, internationally recognised, risk assessment tools. Method Patients who underwent emergency laparotomy were identified using hospital databases. National Emergency Laparotomy Audit (NELA) was used to record pre- and post-operative mortality scores. The Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM); American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Surgical Outcome Risk Tool (SORT) were used to calculate risk of mortality for each patient. The Receiver Operating Curve (ROC) statistical method was chosen to compare the results of each in order to establish the tool most pertinent to prediction of local mortality. Results 274 patients underwent emergency laparotomies at the Trust between December 2017 to December 2019. Of these, 96.7% (n=265) survived the 30-day post -operative period and 3.3% (n= 9) died. The ROC comparator demonstrated 100% sensitivity for the calculation of NELA, P-POSSUM and ACS-NSQIP and specificity of 77%, 76% and 63% for NELA, ACS-NSQIP and P-POSSUM respectively. SORT was found to be the poorest indicator of post-operative mortality. Conclusions NELA is the most accurate predictor of 30-day mortality in patients who undergo emergency laparotomy. Comparison with the outcomes of other centres will help confirm our results.

A practitioner's perspective of the latest lipid guidelines

The latest ESC recommendations propose several interesting new concepts for the practitioner. The recommendations distinguish between the «apparently healthy» patient and the patient at specific cardiovascular risk (diabetes, renal failure, and familial hypercholesterolemia). New risk calculation tools are proposed (SCORE2 and SCORE2-OP). The proposed LDL-C targets are specific to each group, as a general rule, < 1.8 mmol/l for individuals at high risk and < 1.4 mmol/l for individuals at very high risk. Presence of risk modifiers, comorbidities and patient preferences modulates therapeutic approach which is usually based on optimizing lifestyle and statin medication when necessary.

Risk factors for postoperative recurrence of anal fistula identified by an international, evidence-based Delphi consultation survey of surgical specialists

BackgroundDespite the emerging knowledge about postoperative anal fistula recurrence (AFR) and the increasing number of clinical studies, there is no better understanding or consensus regarding the risk factors for AFR. The aim of this study was to generate international consensus guidance statements focusing on AFR. MethodsA two-round modified Delphi process was conducted among international surgical specialists via an online survey delivered by email with a secure link created with Google Forms. Surgeons were asked to use a 9-point Likert scale to rate the importance of patient-, fistula-, and surgery-related statements developed based on our previous systematic review. Consensus was reached when at least 70% of panel members rated a statement as being of critical importance (ratings of 7–9). ResultsOf a total of 60 experts invited, 38 experts representing 13 countries from four continents agreed to participate in the first round of the Delphi process and 31 in the second round. In total, consensus was reached on 14 statements on the risk factors for AFR in three domains: patient-related risk factors included comorbid colitis, inflammatory bowel disease and use of immunosuppressants; fistula-related factors included transsphincteric fistula, number of fistula, horseshoe extension, undetected internal opening, location of anal fistula, recurrent fistula, suprasphincteric fistula, and height of the internal opening; and surgery-related factors included type of surgery, previous fistula surgery and surgeon. ConclusionThis Delphi study provides an evidence-based profile of risk factors for AFR in the patient-, surgery- and fistula-related domains from a global perspective. Clinically, these indicators can be incorporated to develop risk calculation tools for the early detection of AFR in high-risk patients, allowing early prevention and intervention.

Evolution and Outcomes of Premature Coronary Artery Disease.

The purpose of this review is to explore the evolution and outcomes of premature coronary artery disease (PCAD) while reviewing strategies for effective screening of those at high risk for developing this disease. Premature coronary artery disease (PCAD) affects a population of patients not typically identified as high risk by current risk stratification guidelines or traditional risk calculation tools. Not only does PCAD represent a large proportion of overall cardiovascular disease, it also afflicts a population in which the rate of mortality from cardiovascular disease has plateaued despite an overall declining population-wide cardiovascular mortality rate. There is ample opportunity for behavioral change strategies, screening tools, adapted imaging modalities, and precision pharmacotherapies to be more precisely targeted toward those at highest risk for premature coronary artery disease. Premature coronary artery disease (PCAD) is pervasive and not frequently represented within contemporary risk calculation models. Providers should pursue proactive screening and aggressive risk factor modification and deploy appropriate preventative therapies in caring for younger populations.

Safety assessment of local cooperative warnings and speed limit information

The study was designed to assess the impacts of cooperative intelligent transport systems (C-ITS) on traffic safety. The aim was also to review assumptions made in some previous studies and verify or update the earlier safety estimates. Seven informative C-ITS services warning about various situations and hazards were selected in the study. The expert estimates provided were grounded on new evidence about driver behaviour, the crash categories created in the European Risk Calculation tool (ERiC), and literature. The C-ITS services were assessed to reduce the number of fatalities and injury crashes. The clearly biggest drop in fatalities was assessed for ‘In-vehicle signage, speed limit’, ‘Weather warning’ being the second most effective. The next effective were assessed to be ‘Warning of emergency braking ahead’ and ‘Road works warning’. The smallest but still positive impacts were assessed for ‘Traffic jam ahead warning’, ‘Car breakdown warning’ and ‘In-vehicle signage, child and pedestrian crossing ahead’. Generally, the effectiveness was assessed to be somewhat smaller for injury crashes than fatalities. The authors conclude that the results are positive both for implementing C-ITS services as such and as supporting measure for the deployment of more intervening ITS and automated driving.

Insurance against Natural Hazards: Critical Elements on the Risk Premium Evaluation in the Italian Context

Abstract The aim of this paper is to highlight the insurance dynamics in relation to catastrophic events and how the insurance companies approach the insured parties (contractors) for the definition of a tailored insurance policy contract. Within this study the emphasis has been addressed more on the regulatory situation in the Italian context as a key example of the existing contractual problems regarding the drafting of insurance contracts against natural hazards. In particular, the study defines the drawbacks of having information asymmetry between the parties towards several substantial elements of the policy agreement, including the definition of the overall risk, exposure, vulnerability and the consequential insurance premium. This study provides an overview of the possible calculation as a specific one based on the risk / premium assessment tool of the Exceedance Probability curve (EP curve) method used by insurance companies. This method focuses on some of the most important insurance parameters for determining the insurance premium and the possible indemnity in relation to the risk related to natural hazards. In the results and discussion, the research reports on how an information discrepancy on contractual transparency appears evident in fact creating an obstacle to facilitate the access to the data referred to in the risk calculation inherent in the asset and obviating the information discrepancy, allowing the private individual to use the information consciously. With the presentation of a risk calculation tool based on the EP curve and relative loss or exceedance, the study shows a possible correlation between insurance dynamics and the new environmental, social, governance (ESG) parameters for implementation on the financial markets.

Editorial Volume 19 Issue 3 – We are all story-tellers

Story telling is a human universal1. It is as old as language. Creating and relating narratives form an integral part of how physicians understand and communicate about our patients and their diseases. We ask our patients to help us develop their story (‘tell me about when all of this first started’), and then we tell their story back to them to facilitate our understanding (‘let me just check I understood; this is how things have progressed’). We use individual patients to anchor our learning in medicine; conditions are better recalled when they are attached to a specific people. Thus, we write case vignettes to improve understand when we teach others. When we see an interesting case we advise our medical students to use the opportunity to revise the related conditions, as we know that an individual patient narrative establishes richer meaning and better recall. Case reports in medicine are therefore the perfect medium for learning. We unravel a patient’s story to communicate not only a timeline of events, but to harness the innate human predilection for story-telling as a tool of meaning-making, comprehension, and hopefully, recall. We share patient stories from past experience to improve the stories through better care in the future. We are delighted to present a heterogenous of collection of case reports in this issue that explore pacemakers, proteus, pneumorhachis, pain and POCUS. The clinical variety isaemblematic of the work of the acute physician. Continuing theme of patient stories; when does their healthcare story end? From the perspective of the acute medic, the story of a patient ends when they leave our department; the narrative is picked up by the receiving clinician. But all patients’ Acute Medicine Unit story has a postscript that we usually do not get to see. In this issue Ahmed et al2 outline their findings from following up patients after an admission for a medical or surgical emergency. Their findings are illuminating and disconcerting. Clinical stories are usually co-constructed by the patient and the clinician. Despite this collaborative effort there may still be a disparity between the patient’s and the doctor’s perception of the story, possibly due to inadequate information being supplied or elicited in the history-taking. Renggli et al3 describe a web-based software tool that allows patients (who are able to do so) tell their story: complete their own medical history. Their app provides a richer medical history, but the authors recognise that the art of the medical clerking by a trained physician remains a medical necessity. We have previously reported articles exploring the possibilities of predicting aspects of the patient’s story from the data available at the ‘first chapter’: at the point of admission.4,5 Conway et al6 have developed a risk calculation tool with the ambition of risk-stratifying patients based on their presenting vital signs. But complex systems require complex data analysis, and it seems that prognosticating from only a few small data is too limiting. Moving forward, we may be able to model patient outcomes with greater nuance (the ‘output’) if we get increase the complexity of the initial data (‘the input’).

Role of Multiparametric Magnetic Resonance Imaging in Predicting Pathologic Outcomes in Prostate Cancer.

Multiparametric magnetic resonance imaging (mpMRI) and the introduction of standardized protocols for its interpretation have had a significant impact on the field of prostate cancer (PC). Multiple randomized controlled trials have shown that the sensitivity for detection of clinically significant PC is increased when mpMRI results are the basis for indication of a prostate biopsy. The added value with regards to sensitivity has been strongest for patients with persistent suspicion for PC after a prior negative biopsy. Although enhanced sensitivity of mpMRI is convincing, studies that have compared mpMRI with prostatectomy specimens prepared by whole-mount section analysis have shown a significant number of lesions that were not detected by mpMRI. In this context, the importance of an additional systematic biopsy (SB) is still being debated. While SB in combination with targeted biopsies leads to an increased detection rate, most of the tumors detected by SB only are considered clinically insignificant. Currently, multiple risk calculation tools are being developed that include not only clinical parameters but mpMRI results in addition to clinical parameters in order to improve risk stratification for PC, such as the Partin tables. In summary, mpMRI of the prostate has become a standard procedure recommended by multiple important guidelines for the diagnostic work-up of patients with suspicion of PC.

Prospective revalidation of IOTA "two-step", "alternative two-step" and "three-step" strategies for characterization of adnexal masses - An Indian study focussing the radiology context.

Objectives:The purpose of this study was to revalidate the diagnostic performance of IOTA “two step” (Simple Descriptors and Simple Rules), “ alternative two step” (Simple Rules Risk Calculation tool / SRrisk score), and three step (two step with subjective assessment) strategies, for characterization of adnexal masses as benign or malignant, using histopathology as gold standard.Materials and Methods:This prospective, study comprised of 100 patients with newly diagnosed adnexal masses, who underwent ultrasound evaluation first by a level I and then by a level III investigator (EFSUMB criteria). Initially, the level I investigator evaluated each adnexal mass, applying IOTA “two-step” strategy and simultaneously assigned a risk category, by applying the simple rules risk score (SRrisk score) or performing the “alternative two step” strategy. Subsequently the inconclusive masses were evaluated by the level III investigator using “real time subjective assessment”, thereby performing the third step. Following histopathology diagnosis, the performance of each strategy was evaluated using diagnostic tests.Results:The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of “two-step” strategy were 87.5%, 79.2%, 89.4%, 76%, and 84.7%, respectively; those of “alternative two-step” strategy were 91.5%, 75.6%, 84.4%, 86.1% and 88%; and those of “three-step” strategy were 98.2%, 93.3%, 94.7%, 97.7% and 96%, respectively.Conclusion:All IOTA strategies showed good diagnostic performance for characterization of adnexal masses and the “three-step” strategy performed best. We believe this is the first ever prospective re-validation and comparative evaluation of all three IOTA strategies by Indian Radiologists. Since ultrasound is the primary modality for evaluation of adnexal masses, based on the good results of our study, a recommendation for henceforth standard application, of the three-step IOTA strategy in routine Radiology practice appears justified. Although, IOTA strategies been proposed and validated mainly by Gynaecologists and Oncology surgeons, based on the results of our study, this paradigm can now be made to shift back to the arena of Radiology and Radiologists, the imaging experts.

Development and Usability of ADappt: Web-Based Tool to Support Clinicians, Patients, and Caregivers in the Diagnosis of Mild Cognitive Impairment and Alzheimer Disease.

BackgroundAs a result of advances in diagnostic testing in the field of Alzheimer disease (AD), patients are diagnosed in earlier stages of the disease, for example, in the stage of mild cognitive impairment (MCI). This poses novel challenges for a clinician during the diagnostic workup with regard to diagnostic testing itself, namely, which tests are to be performed, but also on how to engage patients in this decision and how to communicate test results. As a result, tools to support decision making and improve risk communication could be valuable for clinicians and patients.ObjectiveThe aim of this study was to present the design, development, and testing of a Web-based tool for clinicians in a memory clinic setting and to ascertain whether this tool can (1) facilitate the interpretation of biomarker results in individual patients with MCI regarding their risk of progression to dementia, (2) support clinicians in communicating biomarker test results and risks to MCI patients and their caregivers, and (3) support clinicians in a process of shared decision making regarding the diagnostic workup of AD.MethodsA multiphase mixed-methods approach was used. Phase 1 consisted of a qualitative needs assessment among professionals, patients, and caregivers; phase 2, consisted of an iterative process of development and the design of the tool (ADappt); and phase 3 consisted of a quantitative and qualitative assessment of usability and acceptability of ADappt. Across these phases, co-creation was realized via a user-centered qualitative approach with clinicians, patients, and caregivers.ResultsIn phase 1, clinicians indicated the need for risk calculation tools and visual aids to communicate test results to patients. Patients and caregivers expressed their needs for more specific information on their risk for developing AD and related consequences. In phase 2, we developed the content and graphical design of ADappt encompassing 3 modules: a risk calculation tool, a risk communication tool including a summary sheet for patients and caregivers, and a conversation starter to support shared decision making regarding the diagnostic workup. In phase 3, ADappt was considered to be clear and user-friendly.ConclusionsClinicians in a memory clinic setting can use ADappt, a Web-based tool, developed using multiphase design and co-creation, for support that includes an individually tailored interpretation of biomarker test results, communication of test results and risks to patients and their caregivers, and shared decision making on diagnostic testing.

Abstract P184: 2017 ACC/AHA Blood Pressure Classification and Cardiovascular Risk by Sex and Age: a 10-year Follow-up of 17.7 Million Koreans

Introduction: The ACC/AHA has lowered the definition of high blood pressure (BP) in 2017 with emphasis on individual risk assessment. However, in clinical settings without feasible risk calculation tools, it is unclear whether such BP classification alone can accurately stratify cardiovascular disease (CVD) risk across various demographic groups. Hypothesis: We hypothesized that CVD risks according to ACC/AHA BP categories differ by sex and age subgroups. Methods: We followed 17 714 343 persons, who underwent national health screening and had no prior CVD, for 10 years using the Korean National Health Insurance database. BP was classified by ACC/AHA definitions. Stage 1 and 2 hypertensions were further subcategorized into narrower systolic and diastolic BP (SBP/DBP) intervals. Outcome was the first CVD event (myocardial infarction and/or stroke). We used multivariable Cox proportional hazards model, stratified by sex and age subgroups, to calculate hazard ratios (HR) according to BP categories. Results: Effect of high BP on CVD risk varied significantly by sex and age, with greater relative hazards in women and in younger ages (figure). Elevated BP was associated with higher CVD risk, compared with normal BP, in both sexes of age 20-69, but the association was no longer significant after age 70. Among stage 1 or 2 hypertension, CVD risks significantly diverged when the ACC/AHA category was divided into narrower SBP/DBP intervals. For instance, in men of age 50-59, HRs for SBP/DBP &lt;120/80-89, 120-129/80-89, 130-139/&lt;80, and 130-139/80-89 mmHg—all of which are stage 1 hypertensions—were 1.09, 1.20, 1.41, and 1.43, respectively. Similar trends were seen for both sexes, but there was a greater divergence of HRs toward higher pulse pressure in men and in older ages. Conclusion: Effect of high BP on CVD risk varies significantly by sex and age, and heterogeneous risk groups may coexist in the same ACC/AHA BP category. Therefore, an individual-level risk calculation tool is crucial for precise risk assessment in persons with high BP.

Utility of existing diabetes risk prediction tools for young black and white adults: Evidence from the Bogalusa Heart Study

AimsTo evaluate several adult diabetes risk calculation tools for predicting the development of incident diabetes and pre-diabetes in a bi-racial, young adult population. MethodsSurveys beginning in young adulthood (baseline age ≥18) and continuing across multiple decades for 2122 participants of the Bogalusa Heart Study were used to test the associations of five well-known adult diabetes risk scores with incident diabetes and pre-diabetes using separate Cox models for each risk score. Racial differences were tested within each model. Predictive utility and discrimination were determined for each risk score using the Net Reclassification Index (NRI) and Harrell's c-statistic. ResultsAll risk scores were strongly associated (p<.0001) with incident diabetes and pre-diabetes. The Wilson model indicated greater risk of diabetes for blacks versus whites with equivalent risk scores (HR=1.59; 95% CI 1.11–2.28; p=.01). C-statistics for the diabetes risk models ranged from 0.79 to 0.83. Non-event NRIs indicated high specificity (non-event NRIs: 76%–88%), but poor sensitivity (event NRIs: −23% to −3%). ConclusionsFive diabetes risk scores established in middle-aged, racially homogenous adult populations are generally applicable to younger adults with good specificity but poor sensitivity. The addition of race to these models did not result in greater predictive capabilities. A more sensitive risk score to predict diabetes in younger adults is needed.

Fracture risk calculation tool enhances dual-energy X-ray absorptiometry scan referral pathway in cirrhosis patients.

Liver cirrhosis is associated with osteoporosis leading to an increased risk of fractures. We aimed to establish whether a risk stratification strategy using a fracture risk calculation tool (FRAX) to determine which patients should receive a dual-energy X-ray absorptiometry (DXA) scan is effective in reducing scan rates without compromising sensitivity for detecting osteoporosis. A retrospective analysis of 252 patients with liver cirrhosis attending hepatoma surveillance clinics. Receiver operating characteristic analysis was performed to assess sensitivity and specificity at 10-year fracture risk thresholds of 5, 10 and 15%. DXA scans were performed among 252 patients. Mean age was 61.6±10.2 years, of which 53.2% were male. Cirrhosis aetiology was largely a result of alcohol excess (n=33.3%), chronic hepatitis C virus infection (n=20.2%) and nonalcoholic fatty liver disease (n=15.9%). The majority of patients were in good prognostic groups (87.4% Child-Pugh A, 11.3% Child-Pugh B, 1.3% Child-Pugh C). Osteoporosis was present in 19.0% of those who underwent DXA scanning. The optimum 10-year fracture risk threshold was found to be 10% using the FRAX tool. This retained a high sensitivity of 95.8%, specificity 64.7%, and negative predictive value 98.5%. Introduction of a 10% FRAX threshold would result in a reduction of the DXA scanning rate to 46.8% of the current rate. A risk stratification strategy for DXA scanning using a fracture risk assessment tool (FRAX) and a 10-year fracture risk threshold of 10% leads to a significant reduction in scan rates without compromising osteoporosis detection rates.

Eligibility Criteria and Genetic Testing Results from a High-Risk Cohort for Hereditary Breast and Ovarian Cancer Syndrome in Southeastern Ontario

Germline mutations in breast and ovarian cancer are rare, with approximately 5% to 10% and 13% being hereditary in origin, respectively. In 2001, the Ontario Ministry of Health and Long Term Care, in an effort to contain costs, defined criteria to determine an individual's eligibility for BRCA genetic screening. We studied a cohort of individuals that have undergone genetic testing at Kingston General Hospital between 2001 and late 2013. We focused on determining whether the 13 risk criteria, defined by an expert working group for the Ontario Ministry of Health and Long Term Care, have performed according to expectations in this cohort. Our findings show that all of the criteria perform well by identifying carriers at the expected 10% rate defined by the guidelines. We demonstrate that loose application of the risk criteria does not further enrich for BRCA variant carriers. Our assessment of the established risk criteria that have been in use in Ontario for more than a decade, provide evidence for their effectiveness, and offer insights into how they may be expanded or improved.

Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

IntroductionNational guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk.MethodsMortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification.ResultsThe actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%.Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening).Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01).DiscussionPre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively.ConclusionsIn the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient.

PWE-140 Fracture risk tool reduces need for dexa scanning in cirrhosis patients

Introduction Current British Society of Gastroenterology guidelines recommend DEXA scanning all patients with cirrhosis. All patients with a diagnosis of cirrhosis attending the cirrhosis clinic at Aberdeen Royal Infirmary are referred for DEXA scanning. We aimed to establish whether a risk stratification strategy using a fracture risk calculation tool (FRAX) to determine which patients should receive a DEXA scan is effective in reducing scan rates without compromising sensitivity for detecting osteoporosis. Method A retrospective analysis of 282 patients with liver cirrhosis undergoing hepatoma screening in Aberdeen Royal Infirmary. Receiver operating characteristic (ROC) analyses were performed to assess sensitivity and specificity of FRAX calculated 10-year fracture risk thresholds of 5%, 10% and 15%. Results DEXA scan results were available for 205 patients. Mean age was 61.2(±9.1) years, of which 58.0% were male. Cirrhosis aetiology was largely a result of alcohol excess (n = 68), hepatitis C infection (n = 47) and non-alcoholic fatty liver disease (n = 34). The majority of patients were in good prognostic groups (88.8% Child-Pugh A, 10.7% Child-Pugh B, 0.5% Child-Pugh C). The prevalence of osteoporosis was 18.0% consistent with existing literature. The optimum FRAX 10-year fracture threshold was found to be 10%. This retained a high sensitivity of 96.2%, specificity 63.1%, and negative predictive value 98.1%. DEXA scanning rates would have been reduced from 100% (current policy) to 47.3%. Conclusion A risk stratification strategy for diagnosing osteoporosis using a fracture risk assessment tool (FRAX) and 10-year fracture risk threshold of 10% has high sensitivity for detecting osteoporosis and leads to a clinically significant reduction in scan rates. Disclosure of interest None Declared. Reference Collier, JD, Ninkovic, M, Compston JE. Guidelines on the management of osteoporosis associated with chronic liver disease. Gut 2002; 50 (Suppl I):i1–i9