Risk Counseling Research Articles

Improving Uptake of Cancer Genetic Risk Assessment in a Remote Tailored Risk Communication and Navigation Intervention: Large Effect Size but Room to Grow.

Cancer genetic risk assessment (CGRA) is recommended for women with ovarian cancer or high-risk breast cancer, yet fewer than 30% receive recommended genetic services, with the lowest rates among underserved populations. We hypothesized that compared with usual care (UC) and mailed targeted print (TP) education, CGRA uptake would be highest among women receiving a phone-based tailored risk counseling and navigation intervention (TCN). In this three-arm randomized trial, women with ovarian or high-risk breast cancer were recruited from statewide cancer registries in Colorado, New Jersey, and New Mexico. Participants assigned to TP received a mailed educational brochure. Participants assigned to TCN received the mailed educational brochure, an initial phone-based psychoeducational session with a health coach, a follow-up letter, and a follow-up navigation phone call. Participants' average age was 61 years, 25.4% identified as Hispanic, 5.9% identified as non-Hispanic Black, and 17.5% lived in rural areas. At 6 months, more women in TCN received CGRA (18.7%) than those in TP (3%; odds ratio, 7.4; 95% CI, 3.0 to 18.3; P < .0001) or UC (2.5%; odds ratio, 8.9; 95% CI, 3.4 to 23.5; P < .0001). There were no significant differences in CGRA uptake between TP and UC. Commonly cited barriers to genetic counseling were lack of provider referral (33.7%) and cost (26.5%), whereas anticipated difficulty coping with test results (14.0%) and cost (41.2%) were barriers for genetic testing. TCN increased CGRA uptake in a group of geographically and ethnically diverse high-risk breast and ovarian cancer survivors. Remote personalized interventions that incorporate evidence-based health communication and behavior change strategies may increase CGRA among women recruited from statewide cancer registries.

Ocular manifestations: A novel association of Monkeypox virus outbreak in 2022

Monkeypox virus (MPXV) is a double-stranded DNA zoonotic virus of the Poxviridae family. Infected persons, animals, or inanimate items can all spread the virus to humans when they come into close contact. The first human-to-human transmission was reported in 1970 in the Democratic Republic of Congo. The outbreak emerged in May 2022 involved mostly men who had sex with men (MSM). Patients usually present with symptoms of rash along with fever, flu-like symptoms, and lesions in the genital and perineal region. A rising concern is ocular manifestations seen with MPVX like conjunctivitis, blepharitis, keratitis, and corneal lesions, especially in unvaccinated patients which might lead to blindness. Although it is self-limiting with supportive care, many patients benefited from tecovirimat. Combination therapy of brincidofovir and tecovirimat was also used for severe disease. Smallpox vaccinations will also play a vital role as unvaccinated patients had serious complications. Risk counseling should be carried out to prevent further spread amongst high-risk populations. Ophthalmologists should also remain aware of these ocular manifestations during the current outbreak and keep it as a differential diagnosis whenever they come across with aforementioned complaints that can be seen in MPVX illness.

Transforming the perioperative medicine care model: The Singapore experience.

More than 300 million surgeries are performed worldwide annually. Established perioperative centres in the UK, USA and Australia have demonstrated the impact of improving perioperative care in reducing costs, increasing patient satisfaction and improving population health. Likewise, the surgical burden of care in Asia is increasing, but with sociocultural, economic and epigenetic differences compared to the west. As Singapore's largest hospital, the Singapore General Hospital pre-admission perioperative clinic sees about 20,000 patients annually. We aim to illustrate Singapore General Hospital's perioperative model of care to contribute to the paucity of literature describing perioperative programme implementation within Asia, and to encourage the cross-sharing of perioperative practices internationally. Our perioperative framework navigates risk assessment, risk counselling, and mitigation of health, medical and functional risks to better patients' perioperative outcomes and population health. We have implemented evidence-based pathways for common conditions such as anaemia and malnutrition, including a multidisciplinary programme for the elderly to tackle frailty and reduce length of stay. We describe how we have enhanced local risk profiling with the Combined Assessment of Risk Encountered in Surgery surgical risk calculator derived locally using a gradient boosting machine learning model. Finally, we report clinical outcomes of these interventions and discuss further challenges and new initiatives at each tier of our perioperative model. Our perioperative care model provides a framework that other centres can adopt to promote value-driven care, while catering for differences in the Asian population, thereby promoting evidence-based improvements in the area of perioperative medicine.

Patients' experience with a community pharmacy fall prevention service

BackgroundPharmacists can contribute to fall prevention, by offering services such as fall risk screenings, counselling, and medication reviews. Patient acceptance of the role of pharmacists in fall prevention is crucial. Objective(s)The aim of this study was to explore patients' experience with a community pharmacy fall prevention service. MethodsInterviews were conducted with patients one month after they participated in a pharmacy fall prevention service, in the Netherlands. Patient inclusion criteria for the service were: age ≥ 70 years, use of ≥5 drugs including ≥1 fall risk-increasing drug. The service included a fall risk screening followed by counselling and a medication review. The semi-structured interview guide was based on the consolidated framework for implementation research and included the following topics: outcomes, patient's motivation, and contact with the pharmacy technician. ResultsOf the 91 participants of the fall prevention service, 87 patients were interviewed with a median age of 78.0 years (first quartile [Q1] – third quartile [Q3]: 74.0–84.75) and 46.3% were female. Many patients expressed positive feedback about receiving a medication review. Most patients whose medication was deprescribed expressed to be positive about this. Others were reassured about the appropriateness of their medication use. Patients reported that the service enhanced their awareness about fall prevention. Only a few patients were motivated to adapt their lifestyle. Patients appreciated the attention and contact. ConclusionsPatients see a potential benefit for a community pharmacy falls prevention service, including a medication review. Patient education appeared to enhance their fall risk awareness.

Promoting oral and dental health in early childhood - knowledge, views and current practices among paediatricians in Israel.

The aim of this study was to evaluate the knowledge and practice of paediatricians in promoting oral and dental health among young patients (under age 36 months) and their parents. 145 anonymous questionnaires were distributed among paediatricians, 130 of them were 90% or above answered and were suitable for analysis for this study.75% of the questionnaires were distributed during the national convention of the Israeli Association of Clinical Paediatrics, 10% in paediatric ambulatory clinics and 15% in paediatric departments in hospitals. Questionnaires were distributed between 2018 and 2020. The inclusion criteria were physicians specialists in paediatrics or residents in paediatrics, all have Israeli licences to practice in Israel. exclusion criteria were partially filled questionnaires. The questionnaire was validated in a pilot study during the years 2010-2012. In addition to demographic variables that included medical training, post-graduate education and clinical practice the questionnaire included 42 questions. Eleven questions on demographics and amount of dental training during academic and clinical training 31 questions belonged to several sections that referred to the participants' awareness of the AAP guidelines regarding oral and dental health and knowledge of oral health. In each section paediatricians were asked to answer or give an opinion on a specific issue, their answers were coded to scores on a scale of 0-5 and summed per section. Correlations between different variables were analysed. The t-test and Mann-Whitney U test were performed for comparing two variables. For comparing more than two variables, we used the Kruskal-Wallis one-way analysis of variance test or ANOVA. The response rate was 89% (130 questionnaires out of 145). The survey showed that most paediatricians (80%) recognized their role in maintaining the oral and dental health of their young patients. Nevertheless, most admitted that they do not perform simple procedures on a regular basis, like dental examinations (64.6%), or asking parents about feeding habits (59.2%) or teeth brushing (75.4%). Only 21% of the participants expressed adequate knowledge of dental care for children younger than age 3 years. Fifty-eight percent of the participants never had any dental training during their entire paediatric medicine training, including medical school. Paediatricians in private or baby clinics received higher scores in practicing caries prevention, 24.15 ± 5.17 (SD), than paediatricians in hospitals, 2.79 ± 0.54 (SD) (p = 0.006). Caries prevention practice was not found to correlate with paediatricians' knowledge or attitudes regarding oral and dental caries prevention. Oral and dental knowledge should be incorporated into the paediatric medicine curriculum. With their heavy workload, paediatricians generally do not implement dental caries risk assessment and counselling.

Perception and Counseling for Cardiac Health in Breast Cancer Survivors.

Context: Breast cancer survivors have increased cardiovascular disease (CVD) risk compared to those without cancer history. CVD is the leading cause of death for breast cancer survivors. Objective: To assess current CVD risk counseling practices and risk perception in breast cancer survivors. Study design and analysis: Interviews conducted with breast cancer survivors. Analysis of categorical data by frequency and quantitative variables by mean and standard deviation. Inductive qualitative analysis performed using NVIVO. Setting: Academic Family Medicine Outpatient Practices Population studied: Breast cancer survivors with an identified primary care provider. Intervention/instrument: Interviews on CVD risk behaviors, risk perception, challenges with risk reduction, and previous history of risk counseling. Outcome measures: Self-reported history of CVD, risk perception, and risk behaviors. Results: The average age of participants (n=19) was 57 with 57% being white and 32% African American. Of interviewed women, 89.5% reported a personal history and 89.5% reported a family history of CVD. Only 52.6% had previously reported receipt of CVD counseling. Primary care providers most commonly provided the counseling (72.7%), however it was additionally provided by oncology (27.3%). Among breast cancer survivors, 31.6% perceived they were at increased CVD risk and 47.5% were unsure of their relative CVD risk compared to women their age. Factors affecting perceived CVD risk included family history, cancer treatments, cardiovascular diagnoses, and lifestyle factors. Video (78.9%) and text messaging (68.4%) were the most highly reported mechanisms through which breast cancer survivors requested to receive additional information and counseling on CVD risk and risk reduction. Commonly reported barriers to adopting risk reduction strategies (such as increasing physical activity) included time, resources, physical limitations, and competing responsibilities. Barriers specific to survivorship status include concerns for immune status during COVID, physical limitations associated with cancer treatment, and psychosocial aspects of cancer survivorship. Conclusions: These data suggest improving the frequency and content of CVD risk reduction counseling is needed. Strategies should identify the best methods for providing CVD counseling, and should address general barriers as well as unique challenges faced by cancer survivors.

JS-CME-2: REDUCTION IN CARDIOVASCULAR MORBIDITY AND MORTALITY BY CARDIAC REHABILITATION: WHAT'S THE EVIDENCE?

The Japanese Society of Cardiac Rehabilitation defines cardiac rehabilitation (CR) as follows. Cardiac rehabilitation refers to a long-term, multifaceted, comprehensive program designed to optimize a cardiac patients physical, psychological, social, and vocational status, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic or heart failure processes, thereby reducing recurrence, rehospitalization and mortality and enabling patients to live comfortably and actively. CR programs include medical assessment, prescribed exercise training, coronary risk factor modification, patient education, counseling and optimal medical therapy for individual patients, which are provided by a multi-disciplinary team in a coordinated manner. Comprehensive CR consists of continuous multidisciplinary team medical care centered on exercise therapy and disease management. Comprehensive CR improves exercise tolerance and physical function in most heart diseases. Improvements in subjective symptoms and QOL are also observed in many heart diseases. Concerning long-term prognostic improvement effect, it is observed in coronary artery disease and heart failure. Reduced readmissions are also observed in heart failure patients. Mechanisms for improving the long-term prognosis of patients with coronary artery disease and heart failure include: 1) improvement of coronary risk factors, 2) improvement of vascular endothelial function and systemic anti-arteriosclerosis/anti-inflammatory effects via suppression of oxidative stress, 3) improvement of autonomic nerve function, 4) increase in skeletal muscle mass and associated various myokine actions. Based on the above-mentioned evidence, all clinical guidelines of the Japanese Circulation Society, AHA, and ESC strongly recommend participation in CR as class I (evidence and/or general agreement that a given procedure or treatment is effective and useful) for patients after acute myocardial infarction. In post-CABG patients, American and European guidelines recommend CR as Class I. As for chronic heart failure, exercise therapy is strongly recommended as class I in all heart failure clinical guidelines in Japan, Europe, and the United States. However, a clinical problem is the low rate of CR participation in patients with heart disease. This tendency is particularly conspicuous in Japan. Furthermore, an increase in the number of elderly heart failure patients with frailty is also a major issue. There is a need to create a system that supports patients through a community network throughout the acute, recovery, and maintenance phases.

Feasibility of conducting HIV prevention trials among key populations in Nairobi, Kenya

ObjectiveTo assess the feasibility of conducting HIV prevention trials among key populations in Nairobi, Kenya.BackgroundHIV prevention trials require the inclusion of those at high risk of HIV infection and their informed decision to take part and remain in the clinical trial to the end is crucial. In Kenya key populations including men who have sex with men (MSM) and female sex workers (FSW) are, disproportionately, at high risk of HIV infection when compared to the general population. Few trials testing biomedical prevention products against HIV have enrolled Kenyan FSW and MSM.MethodsWe performed simulated vaccine efficacy trial (SiVET) using licensed hepatitis B vaccines as substitutes for a HIV vaccine candidate and included randomization for those immune to hep B. The SiVET was an observational study designed to mimic the rigors of a clinical trial; we assessed HIV risk, provided risk counselling and prevention tools and performed HIV testing at baseline and periodically until the end of the trial. MSM and FSW were enrolled at a ratio of 4:1. Volunteers were assigned to either hepatitis B vaccine or placebo.ResultsRecruitment took approximately 24 months between Sep 2015 and Sep 2017. Of the 368 volunteers screened, 250 (200 MSM and 50 FSW) were enrolled. Reasons for exclusion at screening included: being positive for HIV (n = 7), hepatitis (n = 14), other pre-existing medical conditions (n = 41), eligible but chose not to enrol (n = 47). Most of the volunteers adhered to study procedures and attended their study visits within the study window. These include volunteers who received the second vaccination 244 (98%), the third vaccination 228 (91%) and, the final study visit 217 (87%). The reasons volunteers discontinued from the study early included: relocation and loss to follow up (n = 14). A total of 8 cases of HIV infection were observed in 174.5 Person Years at Risk (PYAR), all among MSM, including 5 seroconversions identified at the last study visit, for a HIV incidence of 4.58 cases/ 100 PYAR, among MSM enrolled in the study.ConclusionOur findings suggest that it is possible to conduct HIV prevention trials among key populations in Nairobi with a good adherence to a vaccine efficacy trial schedule. Despite HIV prevention efforts, we also noted a high incidence of HIV infection. This demonstrates the need for effective HIV prevention products in these populations.

Alpha-1-Antitrypsin Pi*MZ variant increases risk of developing hepatic events in nonalcoholic fatty liver disease patients,

AimsHeterozygous alpha-1-antitrypsin (A1AT) Pi*MZ variant has been shown to increase the risk of developing liver cirrhosis in patients with non-alcoholic fatty liver disease (NAFLD). We aimed to determine the association between heterozygous Pi*MZ and Pi*MS variants and development of hepatic decompensation events in NAFLD patients. MethodsWe included patients with NAFLD who also had A1AT genotyping performed from 2005 to 2020. We recorded demographic and clinical variables, and data on hepatic events (ascites, hepatic encephalopathy, esophageal variceal bleed, or hepatocellular carcinoma), if any. We performed binary logistic regression analysis to assess the association between A1AT variants and hepatic events, and calculated Odds ratio (OR) with their 95% confidence intervals (Cl). ResultsWe included 1532 patients with NAFLD, of which 1249 patients had Pi*MM, 121 had Pi*MS, and 162 had Pi*MZ. Of the 1532 patients, hepatic events developed in 521 (34%) patients. The percentage of patients with Pi*MZ variant was significantly higher in patients with hepatic events as compared to patients without hepatic events (18.7 % vs 8.1%, p<0.0001). Pi*MZ variant was noted to significantly increase the odds of developing hepatic events in NAFLD patients, unadjusted OR: 1.82 (1.3–2.5, p<0.001), adjusted OR (for age, sex, body mass index, and diabetes mellitus) 1.76 (1.2–2.5, p = 0.002). Pi*MS variant did not increase the odds of hepatic events in NAFLD patients, OR: 0.92 (0.6–1.4, p = 0.70). ConclusionPatients with NAFLD and A1AT Pi*MZ variant are at increased risk for developing hepatic decompensation. NAFLD patients should be offered A1AT genotyping for risk stratification, counseling, and multidisciplinary intervention for NAFLD.

Primary and Revision Total Hip Arthroplasty in Patients With Pulmonary Hypertension: High Perioperative Mortality and Medical Complications

BackgroundPerioperative medical management during total hip arthroplasty (THA) is continuously improving, allowing an increasing number of medically complex patients to undergo total joint arthroplasty. This study examined mortalities, medical complications, implant survivorships, and clinical outcomes of THA in patients who have pulmonary hypertension (HTN). MethodsWe identified 638 patients who had pulmonary HTN and underwent 508 primary THAs and 191 revision THAs from 2000 to 2016 at a tertiary care center. Patients were followed up at regular intervals until death, revision surgery, or last clinical follow-up. Perioperative medical complications were individually reviewed. The risk of death was examined by calculating standardized mortality ratios and Cox proportional hazards regression models. Cumulative incidence analyses were used for reporting mortality, reoperation, and revision with death as a competing risk. ResultsThe 90-day mortality was 1.8% and 3.1% for primary and revision THAs, respectively. The risk of death was approximately two-fold higher compared to primary (hazard ratio 2.69) and revision (hazard ratio 2.04) THA patients who did not have pulmonary HTN. Rate of medical complications within 90 days from surgery were 6.2% and 13.1% in primary and revision THAs, respectively. The 10-year cumulative incidence of any revision was 9% and 14% following primaries and revisions, respectively. ConclusionPatients who had pulmonary HTN undergoing primary and revision THAs had an increased risk of death and experienced a high rate of medical complications within 90 days of surgery. Counseling of risks, medical optimization, and referral to medical centers expert at managing complex medical problems should be considered. Level of EvidenceLevel IV.

Risk Factors for Complications following Volar Locking Plate (VLP) Fixation of Unstable Distal Radius Fracture (DRF).

To evaluate the incidence and risk factors for complications following volar locking plate (VLP) fixation of unstable distal radius fracture (DRF). This retrospective study identified patients who underwent VLP fixation of unstable DRF between 2017 and 2020 with a minimum 12-month follow-up assessments. By reviewing electronic medical records and follow-up notes, patients were categorized complication or noncomplication group. Differences in variables were detected by using univariate analyses, and independent factors were identified using multivariate logistic regression analysis. During this study period, 423 patients were included, and 63 (rate, 14.9%) complications in 58 patients were documented. Wound infection (17, 4.0%) was most common, followed in decreasing frequency by carpal tunnel syndrome (13, 3.1%), tendon rupture/irritation (10, 2.4%), complex regional pain syndrome (8, 1.9%), and plate/screw-related complications (5, 1.7%). In the univariate analyses, 18 variables were found to be significantly different (p < 0.05). Logistic regression analysis identified 5 independent factors, including being male (OR, 3.5; p = 0.014), type C fracture (vs. type A, OR: 2.7, and p = 0.035), general anesthesia (vs. regional, OR: 2.4, and p = 0.045), bone grafting (OR, 6.3; p < 0.001), and surgery performed by less experienced surgeons (OR, 3.1; p = 0.003). The goodness-of-fit of the final model was acceptable. These factors will help surgeons individualize and stratify the risk of complications and help patients for risk counselling; especially, an informed clinical decision targeting those modifiable factors (anesthesia mode, bone grafting, and surgeon experience) can be considered, when indicated.

SUDEP Risk Counseling: What We Don't Do in the Shadows.

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Juvenile idiopathic arthritis polygenic risk scores are associated with cardiovascular phenotypes in early adulthood: a phenome-wide association study

BackgroundThere is growing concern about the long-term cardiovascular health of patients with juvenile idiopathic arthritis (JIA). In this study we assessed the association between JIA polygenic risk and cardiovascular phenotypes (cardiovascular risk factors, early atherosclerosis/arteriosclerosis markers, and cardiac structure and function measures) early in life.MethodsJIA polygenic risk scores (PRSs) were constructed for 2,815 participants from the Avon Longitudinal Study of Parents and Children, using the single nucleotide polymorphism (SNP) weights from the most recent JIA genome wide association study. The association between JIA PRSs and cardiovascular phenotypes at age 24 years was assessed using linear and logistic regression. For outcomes with strong evidence of association, further analysis was undertaken to examine how early in life (from age seven onwards) these associations manifest.ResultsThe JIA PRS was associated with diastolic blood pressure (β 0.062, 95% CI 0.026 to 0.099, P = 0.001), insulin (β 0.050, 95% CI 0.011 to 0.090, P = 0.013), insulin resistance index (HOMA2_IR, β 0.054, 95% CI 0.014 to 0.095, P = 0.009), log hsCRP (β 0.053, 95% CI 0.011 to 0.095, P = 0.014), waist circumference (β 0.041, 95% CI 0.007 to 0.075, P = 0.017), fat mass index (β 0.049, 95% CI 0.016 to 0.083, P = 0.004) and body mass index (β 0.046, 95% CI 0.011 to 0.081, P = 0.010). For anthropometric measures and diastolic blood pressure, there was suggestive evidence of association with JIA PRS from age seven years. The findings were consistent across multiple sensitivity analyses.ConclusionsGenetic liability to JIA is associated with multiple cardiovascular risk factors, supporting the hypothesis of increased cardiovascular risk in JIA. Our findings suggest that cardiovascular risk is a core feature of JIA, rather than secondary to the disease activity/treatment, and that cardiovascular risk counselling should form part of patient care.

Impact of Objective Colonic and Whole Gut Motility Data as Measured by Wireless Motility Capsule on Outcomes of Antireflux Surgery.

Studies show higher rates of dissatisfaction with antireflux surgery (ARS) outcomes in patients with chronic constipation. This suggests a relationship between colonic dysmotility and suboptimal surgical outcome. However, due to limitations in technology, there is no objective data available examining this relationship. The wireless motility capsule (WMC) is a novel technology consisting of an ingestible capsule equipped with pH, temperature, and pressure sensors, which provide information regarding regional and whole gut transit times, pH and motility. The aim of this study was to assess the impact of objective regional and whole gut motility data on the outcomes of ARS. This was a retrospective review of patients who underwent WMC testing before ARS. Transit times, motility, and pH data obtained from different gastrointestinal tract regions were used in analysis to determine factors that impact surgical outcome. A favorable outcome was defined as complete resolution of the predominant reflux symptom and freedom from antisecretory medications. The final study population consisted of 48 patients (fundoplication [n = 29] and magnetic sphincter augmentation [n = 19]). Of those patients, 87.5% were females and the mean age ± SD was 51.8 ± 14.5 years. At follow-up (mean ± SD, 16.8 ± 13.2 months), 87.5% of all patients achieved favorable outcomes. Patients with unfavorable outcomes had longer mean whole gut transit times (92.0 hours vs 55.7 hours; p = 0.024) and colonic transit times (78.6 hours vs 47.3 hours; p = 0.028), higher mean peak colonic pH (8.8 vs 8.15; p = 0.009), and higher mean antral motility indexes (310 vs 90.1; p = 0.050). This is the first study to demonstrate that objective colonic dysmotility leads to suboptimal outcomes after ARS. WMC testing can assist with preoperative risk assessment and counseling for patients seeking ARS.

Provision of a personalized survivorship care plan and its impact on cancer-related health literacy among childhood cancer survivors in Hong Kong.

To evaluate the short-term effectiveness of a personalized survivorship care plan (SCP) in improving cancer-related literacy among childhood cancer survivors, and to identify characteristics of survivors who demonstrated minimal gain from the intervention. We recruited survivors diagnosed with cancer at ≤18years old and were >2years post treatment. The intervention included a personalized SCP and 30-minute health risk counseling. The participants' knowledge of their cancer diagnosis and potential treatment-related late effects (LEs) was assessed at baseline, immediately post intervention, and 1-3months post intervention. Generalized estimating equation was used to test for changes in the awareness scores, with interacting terms (time*factor) added to identify differences in the score trajectory across clinically relevant subgroups. In total, 248 survivors completed the intervention (mean age: 19.4 [SD=6.7] years; 54.1% male; 66.1% hematological malignancies), of whom 162 completed all assessments. There was significant increase in survivors' awareness of their cancer diagnoses (mean adjusted score: baseline 66.9, post intervention 86.3; p<.001) and potential LEs (baseline 30.9, post intervention 66.3; p<.001). The proportion of survivors who demonstrated awareness of their potential LEs increased from 9.7% to 54.3%. The interaction analysis showed that there was significantly less improvement in awareness among survivors of non-central nervous system (non-CNS) solid tumors (p=.032), lower socioeconomic status (p=.014), and parents of pediatric survivors (vs. adult survivors; p=.013). The provision of a personalized SCP showed preliminary effectiveness in improving survivors' understanding of their treatment-related LEs. Health counseling with SCP should be reinforced in vulnerable subgroups. Future work includes evaluating its long-term impact on lifestyle and health outcomes.

A machine learning-based prediction model for in-hospital mortality among critically ill patients with hip fracture: An internal and external validated study

IntroductionFew studies have investigated the in-hospital mortality among critically ill patients with hip fracture. This study aimed to develop and validate a model to estimate the risk of in-hospital mortality among critically ill patients with hip fracture. MethodsFor this study, data from the Medical Information Mart for Intensive Care III (MIMIC-III) Database and electronic Intensive Care Unit (eICU) Collaborative Research Database were evaluated. Enrolled patients (n=391) in the MIMIC-III database were divided into a training (2/3, n=260) and a validation (1/3, n=131) group at random. Using machine learning algorithms such as random forest, gradient boosting machine, decision tree, and eXGBoosting machine approach, the training group was utilized to train and optimize models. The validation group was used to internally validate models and the optimal model could be obtained in terms of discrimination (area under the receiver operating characteristic curve, AUROC) and calibration (calibration curve). External validation was done in the eICU Collaborative Research Database (n=165). To encourage practical use of the model, a web-based calculator was developed according to the eXGBoosting machine approach. ResultsThe in-hospital death rate was 13.81% (54/391) in the MIMIC-III database and 10.91% (18/165) in the eICU Collaborative Research Database. Age, gender, anemia, mechanical ventilation, cardiac arrest, and chronic airway obstruction were the six model parameters which were identified using the Least Absolute Shrinkage and Selection Operator (LASSO) method combined with 10-fold cross-validation. The model established using the eXGBoosting machine approach showed the highest area under curve (AUC) value (0.797, 95% CI: 0.696-0.898) and the best calibrating ability, with a calibration slope of 0.999 and intercept of -0.019. External validation also revealed favorable discrimination (AUC: 0.715, 95% CI: 0.566-0.864; accuracy: 0.788) and calibration (calibration slope: 0.805) in the eICU Collaborative Research Database. The web-based calculator could be available at https://doctorwangsj-webcalculator-main-yw69yd.streamlitapp.com/. ConclusionThe model has the potential to be a pragmatic risk prediction tool that is able to identify hip fracture patients who are at a high risk of in-hospital mortality in ICU settings, guide patient risk counseling, and simplify prognosis bench-marking by controlling for baseline risk.

Utility of PSA density in patients with PI-RADS 3 lesions across a large multi-institutional collaborative.

Prostate MRI detecting PI-RADs = 3 lesions has low diagnostic utility for prostate malignancy. Use of PSA density has been suggested to further risk-stratify these men, to potentially avoid biopsies in favor of monitoring. We evaluate the ability of PSA density (PSAd) to risk-stratify PIRADs 3 lesions across patients who underwent a prostate biopsy in a large multi-institutional collaborative. Pennsylvania Urology Regional Collaborative (PURC) is a voluntary quality improvement collaborative of 11 academic and community urology practices in Pennsylvania and New Jersey. A retrospective analysis was performed on all patients in the PURC database that had a prostate MRI with PI-RADs 3 lesions only. PSA just before the MRI and prostate size reported on MRI were used to calculate the PSA. Clinicopathologic data were evaluated. Univariable analysis using Chi-Square and Kruskal Wallis tests and multivariable logistic regression were used to identify predictors of any PCa, and clinically significant prostate cancer (csPCa) was defined as ≥ Grade Group 2 (GG2.) RESULTS: Between May 2015 and March 2021, 349 patients with PIRADs 3 lesions only were identified and comprised the cohort of interest. Median PSA was 5.0 with a prostate volume of 58cc and a median PSA density of 0.11, 10.6% of the cohort was African American with 81.4% being Caucasian. Significant prostate cancer was detected in 70/349 (20.0%) men. Smaller prostate volume, abnormal DRE, and higher PSAd were significantly associated with clinically significant prostate cancer on univariable analysis. In men with PSAd <0.15, 31/228 (13.6%) harbored csPCa. Multivariable analysis confirmed that men with PSAd >0.15 were more likely to harbor clinically significant prostate cancer (P < 0.001). Across a large regional collaborative, patients with PIRADs 3 lesions on mpMRI were noted to have clinically significant cancer in 20% of biopsies. Using a PSA density cut-off of 0.15 may result in missing clinically significant prostate cancer in 13.6%. This information is useful for prebiopsy risk stratification and counseling.

Interdisciplinary risk counseling for hereditary breast and ovarian cancer: real-world data from a specialized center

PurposeHereditary breast and ovarian cancer has long been established to affect a considerable number of patients and their families. By identifying those at risk ideally before they have been diagnosed with breast and/or ovarian cancer, access to preventive measures, intensified screening and special therapeutic options can be obtained, and thus, prognosis can be altered beneficially. Therefore, a standardized screening and counseling process has been established in Germany under the aegis of the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC). As one of these specialized clinics, the HBOC-Center at Charité offers genetic counseling as well as genetic analysis based on the GC-HBOC standards. This analysis aims first at depicting this process from screening through counseling to genetic analysis as well as the patient collective and second at correlating the results of genetic analysis performed. Thus, real-world data from an HBOC-Center with a substantial patient collective and a high frequency of pathogenic variants in various genes shall be presented.MethodsThe data of 2531 people having been counseled at the HBOC-Center at Charité in 2016 and 2017 were analyzed in terms of patient and family history as well as pathogenic variants detected during genetic analysis with the TruRisk® gene panel when genetic analysis was conducted. This standardized analysis is compiled and regularly adjusted by the GC-HBOC. The following genes were included at time of research: BRCA1, BRCA2, ATM, CDH1, CHEK2, PALB2, RAD51C, RAD51D, NBN, and TP53.ResultsGenetic analysis was conducted in 59.8% of all cases meeting the criteria for genetic analysis and 286 pathogenic variants were detected among 278 (30.3%) counselees tested using the TruRisk® gene panel. These were primarily found in the genes BRCA1 (44.8%) and BRCA2 (28.3%) but also in CHEK2 (12.2%), ATM (5.6%) and PALB2 (3.5%). The highest prevalence of pathogenic variants was seen among the families with both ovarian and breast cancer (50.5%), followed by families with ovarian cancer only (43.2%) and families with breast cancer only (35.6%)—these differences are statistically significant (p < 0.001). Considering breast cancer subtypes, the highest rate of pathogenic variants was detected among patients with triple-negative breast cancer (40.7%) and among patients who had had been diagnosed with triple-negative breast cancer before the age of 40 (53.4%)—both observations proved to be statistically significant (p = 0.003 and p = 0.001).ConclusionGenetic counseling and analysis provide the foundation in the prevention and therapy of hereditary breast and ovarian cancer. The rate of pathogenic variants detected is associated with family history as well as breast cancer subtype and age at diagnosis, and can reach considerable dimensions. Therefore, a standardized process of identification, genetic counseling and genetic analysis deems mandatory.

Preventing HIV infection in pregnancy: a comprehensive ANC-based intervention in Western Uganda

Abstract Introduction Pregnant women in sub-Saharan Africa represent a high-risk group for HIV infection, but most endemic countries including Uganda do not engage specific HIV prevention measures in pregnancy. This longitudinal study aimed to assess outcomes of a comprehensive, ANC-embedded strategy to prevent seroconversions during pregnancy in Western Uganda. Methods HIV-negative ANC clients were administered an HIV risk assessment tool, followed by individual risk counselling. They received a fixed appointment for repeat HIV testing after three months. Those attending ANC without partners obtained formal partner invitation letters. At follow-up after three months, women not attending repeat testing were reminded via text message. Post-intervention risk behavior engagement was captured. We analyzed uptake of the intervention, HIV incidence rate, and associations with risk behavior. Results Of 1081 participants, 116 (10.7%) reported risk behavior engagement at first ANC visit, 148/1081 (13.7%) were accompanied by partners. The repeat test visit was attended by 848/1081 (78.5%) women, 42 (5.0%, p &amp;lt; 0.001) reported post-intervention risk behavior engagement, and 248 (29.4%, p &amp;lt; 0.001) were accompanied by partners. Seroconversion occurred in two women. In multivariable logistic regression, rural facility clients compared to urban ones (aOR 3.96; 95%CI 1.53-10.26), and women with positive or unknown partner HIV-status (aOR 2.86; 1.18-6.91) and partner alcohol abuse (aOR 2.68; 1.15-6.26) had increased odds for engagement in risk behavior despite the intervention. Conclusions After our intervention, risk behavior in pregnancy was reduced by half, and partner attendance had doubled compared to baseline. Our cohort showed a 0.76/100 women-years HIV incidence rate compared to 2.85 in pre-intervention data from the same setting. Clients from rural settings and women experiencing precarious partner situations require special attention to reduce risk behavior engagement during pregnancy. Key messages • HIV incidence in pregnancy in Western Uganda can be significantly reduced through a comprehensive, ANC-based counselling intervention. • Pregnant women from rural settings and those experiencing precarious partner situations require special attention regarding sexual risk behavior.

Initial implementation of HIV pre-exposure prophylaxis for people who are incarcerated in Zambia: a cross-sectional observational study

There are over 23 000 incarcerated people in Zambia, a population which has higher HIV prevalence than the general population yet has no access to HIV prevention. To evaluate the feasibility of HIV pre-exposure prophylaxis (PrEP) implementation in Zambian criminal justice facilities, we offered PrEP services to incarcerated people and aimed to describe early implementation outcomes. In this cross-sectional observational study, we implemented a PrEP programme between Oct 1, 2020, and March 31, 2021, supporting 16 criminal justice facilities in four Zambian provinces. Before implementation, we held stakeholder engagement meetings with Zambia Correctional Service officials to discuss PrEP benefits, and trained Zambia Correctional Service health-care workers in PrEP management using the national PrEP training package. People who were incarcerated and screened positive for substantial HIV risk by use of a standardised HIV risk assessment tool were offered voluntary HIV testing and counselling. Those who tested positive were linked to antiretroviral therapy, and those who tested negative and met national HIV prevention eligibility criteria were offered PrEP. We assessed PrEP uptake and used descriptive statistics to characterise programme beneficiaries and the cascade of PrEP services. During the study period, we reached 12 367 people older than 15 years with HIV risk assessment and counselling, including 11 794 (95·4%) men and 573 (4·6%) women. Of these, 2610 people received HIV testing, with 357 (13·7%) testing HIV positive; positivity was significantly higher in women (20·6%) than men (13·2%, p=0·011). 1276 people were identified as HIV negative and PrEP eligible. Of these, 1190 (93·3%) initiated PrEP. The age group with the highest proportion reached and initiated on PrEP was those aged 25-29 years, representing 19·2% (2377 of 12 367) of all people reached and 24·1% (287 of 1190) of those who initiated PrEP. Delivery of PrEP to people who are incarcerated is feasible with adequate resourcing and support to the criminal justice health system, and can result in high uptake among eligible individuals. Further assessment is needed of PrEP persistence and adherence, and the perceptions of people who are incarcerated regarding their HIV risk and preferences for combination HIV prevention services. US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.