Risk Score Categories Research Articles

Abstract 5620: Relationship Between Stroke Risk (CHADS 2 Score) and C-reactive Protein in Patients With Non- Rheumatic Atrial Fibrillation

Background- CHADS 2 score is used for the stroke risk stratification in patients with atrial fibrillation (AF). Although C-reactive protein (CRP) has been shown as a possible correlate of left atrial (LA) thrombus formation in patients with non-rheumatic AF (NRAF), the relationship between CHADS 2 score and CRP is unclear. Methods- A total of 165 patients with NRAF (105 male, age 71±10 years) who underwent transesophageal echocardiography (TEE) were enrolled and analyzed. Patients with prosthetic valve, aortic dissection and infectious disease were excluded from this study. The CHADS 2 score was calculated based on a presence or absence of risk factors ( C ongestive heart failure, H ypertension, A ge≥75years, D iabetes mellitus, S troke or transient ischemic attack) as reported previously. Based on the CHADS 2 score, study patients were grouped into low (0 to 1 score), moderate (2 to 3 score) and high (4 to 6 score) risk categories. Results- Patients at low risk had significantly lower CRP levels than those at moderate or high risk (Low: 0.27±0.46 vs. Moderate: 0.40±0.56 vs. High: 0.93±0.85mg/dl, p<0.01). As expected, incidence of LA spontaneous echo contrast and LA thrombus by TEE increased with increasing CHADS 2 score. Conclusion- In patients with NRAF, CHADS 2 score is related to CRP and LA thrombus formation.

Intravascular ultrasound measures of coronary atherosclerosis are associated with the Framingham risk score: an analysis from a global IVUS registry

In addition to an adjunctive imaging platform during coronary angiography, intravascular ultrasound (IVUS) with Virtual Histology (VH) is increasingly being used to quantify coronary atherosclerosis. The relationship between VH-IVUS measures of coronary atherosclerosis and traditional cardiovascular risk factors has not been completely described. The objective of this study was to determine if an association exists between VH-IVUS measures of coronary atherosclerosis and the Framingham risk score in a prospective, multinational registry. Patients enrolled from 2004-2006 at 37 multinational centres in the prospective VHIVUS Global Registry were analysed. All subjects underwent diagnostic coronary angiography followed by IVUS. A Framingham risk score (FRS) was calculated for each subject, then stratified into three exclusive estimates (<10%, 10-19%, or >or= 20%) for future coronary heart disease (CHD) event risk over 10 years. Among 531 patients, plaque volume of the most diseased 10 mm segment increased with increasing FRS (P=0.006, adjusted for multiple comparisons). Patients with higher FRS estimates of CHD risk had a higher proportion of plaque classified as thin cap fibroatheroma compared with patients in the middle and lower risk score categories (21.4% vs 15.2% and 11.3%, respectively, P=0.008, adjusted for multiple comparisons). Using data from a large, multinational VH-IVUS registry we describe an association between the Framingham risk score and VH-IVUS measures of atherosclerosis within the most diseased 10 mm segment, namely plaque volume and the proportion of thin cap fibroatheroma.

Social support as a factor inhibiting teenage risk-taking: views of students, parents and professionals

A large-scale study conducted in Tasmania, Australia, of teenage risk-taking across 26 potentially harmful risk activities has examined a range of factors that encourage or inhibit risk-taking. Among these factors, the degree of social and professional support the teenage students say they would access for personal, study or health problems has been examined and correlated with the respondents’ risk-taking profiles. Findings reveal that the wider the range of social support, including parents, family and friends, the less likely are teenagers to participate in risk-taking activities, as measured by the Personal Risk Score Category Index developed for the research. Respondents who relied only on friends’ support or had no-one to access for support had higher risk-taking profiles. Comparative analysis of parents’ and pre-service professionals’ expectations differed from those of the students in overestimating the extent to which students would access professionals for advice and help with personal, study and health problems, and their degree of trust in professional help. Parents also overestimated the extent to which the students would rely on their parents for support and advice compared with the students' views. The implications of this intergenerational mismatch for risk prevention and intervention programmes are discussed.

Preoperative Use of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers Is Associated with Increased Risk for Acute Kidney Injury after Cardiovascular Surgery

Acute kidney injury (AKI) occurs commonly after cardiac surgery. Most patients who undergo cardiac surgery receive long-term treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB). The aim of this study was to determine whether long-term use of ACEI/ARB is associated with an increased incidence of AKI after cardiac surgery. This was a retrospective cohort study of 1358 adult patients who underwent cardiac surgery between January 1, 2001, and December 31, 2005, in two tertiary care hospitals in Buffalo, NY. The incidence of AKI was determined after cardiac surgery. Clinical data were collected using a standardized form that included comorbid condition, use of ACEI/ARB, and intraoperative and postoperative complications. Overall, 40.2% of patients developed AKI. Preoperative variables that were significantly associated with development of AKI included increasing age; nonwhite race; combined valve surgery and coronary artery bypass grafting compared with coronary artery bypass grafting alone; American Society of Anesthesiologists (ASA) Risk Score category 4/5 compared with 2 to 3; presence of diabetes, congestive heart failure, or neurologic disease at baseline; use of ACEI/ARB; and emergency surgery. Intra- and postoperative factors that were associated with postoperative AKI were hypotension during surgery, use of vasopressors, and postoperative hypotension. Multiple regression logistic model confirmed an independent and significant association of AKI and preoperative use of ACEI/ARB. This was confirmed using a bivariate-probit and propensity score model that adjusts for confounding by indication of use and selection bias. Preoperative use of ACEI/ARB is associated with a 27.6% higher risk for AKI postoperatively. Stopping ACEI or ARB before cardiac surgery may reduce the incidence of AKI.

Defibrillators and cardiac resynchronization therapy in congenital heart disease: evolving indications

(A) In patients with primary prevention indications, Kaplan-Meier survival curves for freedom from first appropriate ICD shock are plotted and compared according to risk score classification. (B) R...

Determinants for the Effectiveness of Lifestyle Intervention in the Finnish Diabetes Prevention Study

Intensive lifestyle intervention significantly reduced diabetes incidence among the participants in the Finnish Diabetes Prevention Study. We investigated whether and to what extent risk factors for type 2 diabetes and other baseline characteristics of the study participants modified the effectiveness of the lifestyle intervention. Overweight, middle-aged volunteers with impaired glucose tolerance were randomly assigned to intensive lifestyle intervention (n = 265) or to a control group (n = 257) for a median of 4 years. Diabetes status was ascertained annually with repeated oral glucose tolerance testing. Incidence rates of diabetes and hazard ratios (HRs) comparing the intervention group with the control group were calculated by sex and baseline tertiles of age, BMI, waist circumference, plasma glucose concentration at fasting and 2 h after a glucose load, fasting serum insulin and insulin resistance index, and categories of composite baseline Finnish Diabetes Risk Score (FINDRISC). Interactions between the intervention assignment and baseline risk factors on diabetes risk were analyzed. The intervention was most effective among the oldest individuals (HRs 0.77, 0.49, and 0.36 by increasing age tertiles, respectively; P(interaction) = 0.0130) and those with a high baseline FINDRISC (HRs 1.09, 0.84, 0.34, and 0.22 by increasing risk score category, respectively; P(interaction) = 0.0400). The effect of the intervention on diabetes risk was not modified by other baseline characteristics or risk factors. The FINDRISC may be useful in identifying high-risk groups most likely to benefit from intensive lifestyle intervention to prevent type 2 diabetes.

Combining Measures of Risk Perceptions and Risk Activities: The Development of the RAPRA and PRISC Indices

The influence of risk perceptions on risk activities of teenagers is well known, but the development of indices, which combine measures of perception as well as behavioral outcomes, has proved problematical. This article discusses the ways in which this methodological problem was tackled within a five-year, multiphase, multimethod study of factors affecting adolescent risk-taking in Tasmania, Australia, which included an intergenerational comparison of adolescents and parents. The development of the Risk Activity by Personal Risk Assessment (RAPRA) Index combines measures of perceived riskiness of 26 activities identified by young people as involving varying degrees of risk, with the degree of participation by each respondent, through a rectangular model of weights. The Personal Risk Score Category (PRISC) Index summarizes and categorizes an individual's risk-taking profile relative to the group's risk values and risk hierarchy established by the RAPRA Index. The article discusses ways in which technical problems involved in combining measures of risk perceptions and risk activities were addressed during index construction, compared with examples in the literature. Some key findings from analysis of two student and parent samples are presented as exemplars of the methods used and the results produced. Findings demonstrate the widespread nature of risk-taking among teenagers, and the similarity of levels of risk-taking between teenager and parental generations. The indices allow for detailed comparison of particular risk-taking activities and reveal differences among teenagers now compared with parents when they were teenagers, and illustrate the dynamic cultural context of risk-taking perceptions and values.

Risk Stratification for Primary Implantation of a Cardioverter-Defibrillator in Patients With Ischemic Left Ventricular Dysfunction

The study was designed to develop a simple risk stratification score for primary therapy with an implantable cardioverter-defibrillator (ICD). Current guidelines recommend primary ICD therapy in patients with a low ejection fraction (EF). However, the benefit of the ICD in the low EF population may not be uniform. Best-subset proportional-hazards regression analysis was used to develop a simple clinical risk score for the end point of all-cause mortality in patients allocated to the conventional therapy arm of MADIT (Multicenter Automatic Defibrillator Implantation Trial)-II after excluding a pre-specified subgroup of very high-risk (VHR) patients (defined by blood urea nitrogen [BUN] >or=50 mg/dl and/or serum creatinine >or=2.5 mg/dl). The benefit of the ICD was then assessed within risk score categories and separately in VHR patients. The selected risk score model comprised 5 clinical factors (New York Heart Association functional class >II, age >70 years, BUN >26 mg/dl, QRS duration >0.12 s, and atrial fibrillation). Crude mortality rates in the conventional group were 8% and 28% in patients with 0 and >or=1 risk factors, respectively, and 43% in VHR patients. Defibrillator therapy was associated with a 49% reduction in the risk of death (p < 0.001) among patients with >or=1 risk factors (n = 786), whereas no ICD benefit was identified in patients with 0 risk factors (n = 345; hazard ratio 0.96; p = 0.91) and in VHR patients (n = 60; hazard ratio 1.00; p > 0.99). Our data suggest a U-shaped pattern for ICD efficacy in the low-EF population, with pronounced benefit in intermediate-risk patients and attenuated efficacy in lower- and higher-risk subsets.

Risk Assessment for Bridge Maintenance Projects: Neural Networks versus Regression Techniques

Bridge risk assessment often serves as the basis for bridge maintenance priority ranking and optimization and conducted periodically for the purpose of safety. This paper presents an application of artificial neural networks in bridge risk assessment, in which back-propagation neural networks are developed to model bridge risk score and risk categories. The study investigated and utilized 506 bridge maintenance projects to develop the models. It is shown that neural networks have a very strong capability of modeling and classifying bridge risks. The average accuracies for risk score and risk categories are both over 96%. A comparative study is conducted with an alternative methodology using multiple regression techniques. The results revealed that neural networks achieved much better performances than regression analysis models. In addition an integrated forecasting approach was utilized to combine neural networks and regression analysis to generate hybrid models, which produced better accuracies than any of the individually developed models.

Cardiovascular and mortality risk prediction and stratification using urinary albumin excretion in older adults ages 68–102: The cardiovascular Health Study

BackgroundElevated urinary albumin excretion (UAE) is associated with the risk of cardiovascular disease (CVD) and all-cause mortality. We tested the hypothesis that elevated UAE improves cardiovascular risk stratification in an elderly cohort aged 68–102 years. MethodsWe evaluated UAE in 3112 participants of the Cardiovascular Health Study who attended the 1996–1997 examination and had median follow up of 5.4 years. Elevated UAE was defined as urinary albumin to creatinine ratio ≥30μg/mg. Microalbuminuria and macroalbuminuria were defined as urinary albumin to creatinine ratio 30–300μg/mg and >300μg/mg, respectively. Outcomes included CVD (myocardial infarction, stroke, cardiovascular death) and all-cause mortality. Cox proportional hazards models were used to assess the risk of outcomes associated with elevated UAE. ResultsThe prevalence of elevated UAE was 14.3%, 17.1% and 26.9% in those aged 68–74, 75–84 and 85–102 years, respectively. CVD incidence and all-cause mortality were doubled (7.2% and 8.1% per year) in those with microalbuminuria and tripled (11.1% and 12.3% per year) in those with macroalbuminuria compared to those with normal UAE (3.3% and 3.8% per year). The increased CVD and mortality risks were observed in all age groups after adjustment for conventional risk factors. The adjusted population attributable risk percent of CVD and all-cause mortality for elevated UAE was 11% and 12%, respectively. When participants were cross-classified by UAE and Framingham Risk Score categories, the 5-year cumulative incidence of coronary heart disease among participants with elevated UAE and a 5-year predicted risk of 5–10% was 20%, substantially higher than 6.3% in those with UAE <30μg/mg. ConclusionElevated UAE was associated with an increased risk of CVD and all-cause mortality in all age groups from 68 to 102 years. Combining elevated UAE with the Framingham risk scores may improve risk stratification for CVD in the elderly.

Adjuvant Chemotherapy Improves Survival after Resection of Hepatic Colorectal Metastases: Analysis of Data from Two Continents

In the US, systemic chemotherapy is often administered after liver resection for hepatic colorectal metastases, even though no clinical trials data directly support this practice. The bias in America for chemotherapeutic treatment has made studies difficult. Until recently, no well accepted staging systems existed to categorize these patients with liver metastases, who have greatly varied prognoses. All liver resections from an American and from a European tertiary care center performed between 1991 and 1998 were assembled from two prospective databases. Of 792 liver resections, the 518 patients treated with no chemotherapy (379 American, 139 European) were compared with 274 patients treated (240 American, 34 European) with 5-FU-based adjuvant chemotherapy. Patients treated by all other treatment regimens, including regional chemotherapy, were excluded, as were patients who died perioperatively. Patient survival analysis was performed by log-rank, with stratification by the clinical risk score (CRS, a staging system grading risk of recurrence by five clinical parameters: node-positive primary, short disease-free interval, large (> 5 cm) liver tumor, multiple liver tumors, and high carcinoembryonic antigen). Patients subjected to adjuvant chemotherapy had improved survival (p=0.007, log-rank test) even after stratification by clinical risk score (p=0.001, stratified log-rank test). In every clinical risk score category, patients subjected to adjuvant chemotherapy had a higher chance of survival (range 1.3 to 2.0 times). Adjuvant chemotherapy was an independent predictor of outcomes. This large study, with patients stratified by risk of recurrence, demonstrates that systemic adjuvant chemotherapy, such as a 5-FU-based regimen, prolongs survival after hepatic resection for colorectal metastases.

Assessment by Cardiovascular Magnetic Resonance, Electron Beam Computed Tomography, and Carotid Ultrasonography of the Distribution of Subclinical Atherosclerosis Across Framingham Risk Strata

Screening for subclinical atherosclerosis has been advocated for individuals at intermediate global risk for coronary heart disease (CHD). However, the distribution of subclinical atherosclerosis test values across CHD risk strata is unknown. We studied a stratified random sample of 292 participants (mean age 59.5 years, 50% women) from the offspring cohort of the Framingham Heart Study who were free of clinically apparent cardiovascular disease. We assessed abdominal and thoracic aortic plaque burden by cardiovascular magnetic resonance (CMR), coronary artery calcification (CAC) and thoracic aortic calcification (TAC) by electron beam computed tomography, and common carotid intima-media thickness (C-IMT) by ultrasonography. We categorized the upper 20% of each measurement as a high level of atherosclerosis and evaluated these variables across clinically relevant Framingham CHD risk score strata (low, intermediate, and high risk). In age-adjusted analyses in men and women, correlations across CMR aortic plaque, CAC, TAC, and C-IMT were low (maximum r = 0.30 for CAC:TAC in women, p <0.005). In men and women, the proportion of subjects with high atherosclerosis test results for any of these measurements increased significantly across Framingham CHD risk score strata (Kruskal-Wallis test, p <0.0001). In the intermediate Framingham CHD risk score category, 14% of men and 25% of women had a high atherosclerosis result on >or=2 measurements. However, different participants were identified as having high atherosclerosis by each modality. For example, in a comparison of the overlap across CMR aortic plaque, CAC, and C-IMT, only 4% of men and 16% of women were classified as having high atherosclerosis on all 3 measurements. In conclusion, in a community-based sample, correlations among subclinical atherosclerosis test results are low, and a substantial proportion has high levels of subclinical atherosclerosis detected on >or=2 imaging tests.

Does the Aristotle Score predict outcome in congenital heart surgery?☆

The Aristotle Score has been proposed as a measure of 'complexity' in congenital heart surgery, and a tool for comparing performance amongst different centres. To date, however, it remains unvalidated. We examined whether the Basic Aristotle Score was a useful predictor of mortality following open-heart surgery, and compared it to the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system. We also examined the ability of the Aristotle Score to measure performance. The Basic Aristotle Score and RACHS-1 risk categories were assigned retrospectively to 1085 operations involving cardiopulmonary bypass in children less than 18 years of age. Multiple logistic regression analysis was used to determine the significance of the Aristotle Score and RACHS-1 category as independent predictors of in-hospital mortality. Operative performance was calculated using the Aristotle equation: performance = complexity x survival. Multiple logistic regression identified RACHS-1 category to be a powerful predictor of mortality (Wald 17.7, p < 0.0001), whereas Aristotle Score was only weakly associated with mortality (Wald 4.8, p = 0.03). Age at operation and bypass time were also highly significant predictors of postoperative death (Wald 13.7 and 33.8, respectively, p < 0.0001 for both). Operative performance was measured at 7.52 units. The Basic Aristotle Score was only weakly associated with postoperative mortality in this series. Operative performance appeared to be inflated by the fact that the overall complexity of cases was relatively high in this series. An alternative equation (performance = complexity/mortality) is proposed as a fairer and more logical method of risk-adjustment.

Fuzzy-Reasoning-Based Approach to Qualitative Railway Risk Assessment

This article presents the development of a fuzzy-reasoning-based railway risk assessment system. The proposed method can evaluate qualitative and quantitative risk data in a uniform manner for railway risk assessment. It permits risk analysts to assess the risks associated with the failure modes directly using linguistic terms. The proposed railway risk assessment system is capable of assessing the risks at component level, subsystem level, and system level. The outcomes of the risk assessment are represented in two formats, risk score and risk category with a belief of percentage, which provide very useful risk information to railway designers, operators, engineers, and maintainers. A case study on rolling stock asset risk assessment is used to demonstrate the proposed railway risk assessment system. The results indicate that by using this system, risks associated with a railway system can be assessed effectively and efficiently.

The metabolic syndrome and risk of major coronary events in the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS)

The metabolic syndrome, which is a set of lipid and nonlipid risk factors of metabolic origin linked with insulin resistance, is believed to be associated with an elevated risk for cardiovascular disease, but few have studied this association in prospective long-term cardiovascular outcomes trials. Placebo data from the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) were used post hoc to estimate the long-term relative risk of major coronary events (MCEs) associated with the metabolic syndrome, after excluding diabetes mellitus. In 4S and AFCAPS/TexCAPS, respectively, placebo-treated patients with the metabolic syndrome were 1.5 (95% confidence interval 1.2 to 1.8) and 1.4 (95% confidence interval 1.04 to 1.9) times more likely to have MCEs than those without it. Of the components of the metabolic syndrome, low high-density lipoprotein levels were associated with elevated risk of MCEs in both studies, whereas high triglycerides in 4S and elevated blood pressure and obesity in AFCAPS/TexCAPS were associated with significantly increased relative risk. Patients with the metabolic syndrome showed increased risk of MCEs irrespective of their Framingham-calculated 10-year risk score category (>20% vs ≤20%). These data demonstrate that the metabolic syndrome is associated with increased risk of MCEs in both hypercholesterolemic patients with coronary heart disease in 4S and in those with low high-density lipoprotein cholesterol but without coronary heart disease in AFCAPS/TexCAPS. It appears that the metabolic syndrome is associated with risk that is not entirely accounted for by traditional risk scoring paradigms.

What “Shrinkage” of the MnSOST-R? A Response to Wollert (2002b)

Abstract In a previous issue of the Journal of Threat Assessment, an article by Wollert (2002b) documented an analysis of the actuarial risk assessment instrument known as the Minnesota Sex Offender Screening Tool-Revised (MnSOST-R). Based on that analysis, he drew the conclusion that a cross-validation study of the MnSOST-R showed a very significant degree of “shrinkage” in the percentages of recidivists associated with scale score risk categories. Additional conclusions indicated that the MnSOST-R was not a proper instrument for use within the sex offender civil commitment context. This article takes issue with the underlying analysis conducted in Wollert. The analysis documented herein serves to dispute the conclusion drawn concerning cross-validation shrinkage in the MnSOST-R's recidivism risk percentages. Essentially, the same type of comparison used by Wollert (2002b) was employed, but using more proper numbers. The new results indicate that, in fact, there was no shrinkage in risk percentages acros...

Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease.

In the past decade, significant advances have been made in the ability to image the heart with radionuclide tracers under stress and resting conditions in patients with suspected or known coronary artery disease (CAD) for the detection of ischemia, determination of prognosis, assessment of myocardial viability, preoperative risk assessment for patients undergoing noncardiac surgery, and evaluation of the efficacy of revascularization in patients undergoing coronary artery bypass surgery or an interventional procedure.1 For many years, planar imaging and SPECT with 201Tl constituted the only scintigraphic techniques available for detecting CAD and assessing prognosis in patients undergoing stress perfusion imaging. The major limitation of 201Tl scintigraphy is the high false-positive rate observed in many laboratories, which is attributed predominantly to image attenuation artifacts and variants of normal that are interpreted as defects consequent to a significant coronary artery stenosis. Although quantification of 201Tl images improves specificity, the false-positive rate remains problematic, particularly in women and in obese patients. Breast attenuation artifacts in women are sometimes difficult to distinguish from perfusion abnormalities secondary to inducible ischemia or myocardial scar. In recent years, new 99mTc-labeled perfusion agents have been introduced into clinical practice to enhance the specificity of SPECT and to provide additional information regarding regional and global left ventricular systolic function via ECG gating of images. It was immediately apparent that the quality of images obtained with these new 99mTc-labeled radionuclides was superior to that of images obtained with 201Tl because of the more favorable physical characteristics of 99mTc imaging with a gamma camera. With 99mTc, doses of ≈10 to 20 times higher than those that are feasible with 201Tl can be administered, yielding images with higher count density. 99mTc demonstrates less scatter and attenuation than 201Tl, which is associated …

Long-Term Follow-Up of a High Risk Cohort After Stent Implantation in Saphenous Vein Grafts

Objectives. We sought to provide short- and long-term clinical outcomes of a high risk cohort treated with stents in saphenous vein grafts (SVGs).Background. Data on the long-term outcome of SVG stenting in high risk patients are limited.Methods. Johnson & Johnson stents were implanted in the SVGs of 186 patients (302 stents, 244 lesions). Ninety percent of patients presented with myocardial infarction (MI) or unstable angina (mean ±SD ejection fraction [EF] 44 ± 11%, patient age 71 ± 9 years, graft age 9.4 ± 5 years). Using a risk score classification, 155 patients (83%) were defined as high risk for repeat surgical repair or angioplasty.Results. The procedural success rate was 97.3%, with 2.7% major complications (death, Q wave MI, coronary artery bypass graft surgery [CABG]). Clinical follow-up was obtained in 177 patients (mean 19.1 ± 13.5 months, range 7 to 59). Event rates were 10% for death; 9% for MI; 11% for repeat CABG; and 15% for repeat angioplasty (total events 45%). Kaplan-Meier estimated survival and event-free survival at 4 years were 0.79 ± 0.06 and 0.29 ± 0.07, respectively. Predictors of death were congestive heart failure (p < 0.01) and EF <44% (p < 0.05). Predictors of combined events of death, MI and CABG were low EF (p < 0.01) and high SVG age (>10 years, p < 0.01). There were 66 revascularization procedures (35% of patients), 24% of which were in nontarget lesions. Fifty-three percent of the cardiac events occurred during the first year of follow-up. Of the 160 survivors, 36% were free of angina, 49% were in Canadian Cardiovascular Society functional class I or II, and 15% were in class III or IV. Sixty-nine percent of patients were in class I or II according to the Specific Activity Scale, and 31% of patients were in class III or IV.Conclusions. Balloon-expandable stent implantation in the SVGs of high risk patients is associated with a low early complication rate. Expected survival rates are good, as are the anginal and functional classifications, but there is a high rate of recurrent events and need for repeat revascularization. Vein graft stenting is an acceptable palliative option in many high risk patients.

Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage

SummaryBackground Acute upper gastrointestinal haemorrhage is a common medical emergency and hospital admission has usually been regarded as obligatory until the risk of further haemorrhage has receded. This policy means that some patients at low risk stay in hospital for longer than is necessary especially when diagnostic endoscopy is delayed. We attempted to identify patients who had negligible risk of further bleeding or death and for whom early discharge or even outpatient management would be possible with no adverse effect on standards of care.Methods We used a validated risk scoring system based on age (score 0-2), presence of shock (0-2), comorbidity (0-3), diagnosis (0-2), and endoscopic stigmata of recent haemorrhage (0-2); the maximum possible score was 11. We studied patients identified through the UK National Audit of acute upper gastrointestinal haemorrhage; they had been admitted with upper gastrointestinal haemorrhage to hospitals in the UK during 4 months of 1993. This analysis was based on the 2531 patients from the national audit who underwent endoscopy after an acute admission.Findings 744(29·4%) of the 2531 patients scored 2 or less on the risk score. Of these patients only 32 (4·3% [95% Cl 3·0-6·0] rebled and only one (0·1% [0·006-0·75] died). Thus, the risk score identifies patients at low risk of rebleeding or death. The median hospital stay for these patients was 4 days; duration of hospital stay increased with risk score. Within risk score categories of 5 or less, there was a trend of increasing hospital stay as the time between admission and endoscopy increased.Interpretation Our risk score identifies a large proportion of patients with acute upper gastrointestinal haemorrhage who are at low risk of further bleeding or death. Early endoscopy and discharge of such patients could allow substantial resource savings.

RESISTANCE TO PUERPERAL INFECTION

<h3>Introduction</h3> In our previous pilot study on the internet I Want The Kit (IWTK) home self-collection program for sexually transmitted infections (STIs), a voluntary risk score tool predicted STIs well for the female volunteers but not for the males. We investigated the association of IWTK risk score and the presence of STIs in male users when the risk score quiz became mandatory for the program. <h3>Methods</h3> A six-question quiz which includes demographic and sexual risk behaviour became a mandatory part of IWTK in August 2103. This analysis was restricted to male participants living in Maryland and Washington DC using IWTK August 2013–April 2015. Cochran-Armitage trend test was performed to determine if the prevalence of STIs (chlamydia, gonorrhoea, or trichomonas infection) increased with the higher score of risk score category. <h3>Results</h3> Overall, 592 male participants submitted specimens for STI testing and completed risk score quizzes. The majority (57%) were &lt; 30 years (mean: 30.1 ± 9.3 years); 42% white, 42% black, and 16% other races. 203 (34.3%) resided in zip codes of Baltimore City. The majority (53%) of the participants had risk score of 4–6, followed by scores of 0–3 (25%), and &nbsp;7–10 (22%). The overall prevalence of STIs was 10.5% (62/592). The prevalence of STIs was 6.2% for users with risk score of 0–3, 10.9% for those with 4–6, and 14.3% for those with &nbsp;7–10 (trend test: p = 0.026). 52% (13/25) of STI positive participants resided in three zip codes located in central and northeast Baltimore City and participants in these three zip codes had a marginally higher risk score than others (p = 0.082). <h3>Conclusions</h3> After excluding potential selection bias, IWTK risk score tool predicted the presence of STIs for male users and could potentially be used for identifying hotspots for STI intervention. <h3>Disclosure of interest statement</h3> The research group has received research funding from U54EB007958, NIBIB, NIH; AI068613–01, NIH, NIAID.