Risk Stratification Algorithms Research Articles

Beyond Ejection Fraction: Novel Clinical Approaches Towards Sudden Cardiac Death Risk Stratification in Patients with Dilated Cardiomyopathy.

Implantable Cardioverter-Defibrillator (ICD) therapy is indicated for patients at risk for sudden cardiac death due to ventricular tachyarrhythmia. The most commonly used risk stratification algorithms use Left Ventricular Ejection Fraction (LVEF) to determine which patients qualify for ICD therapy, even though LVEF is a better marker of total mortality than ventricular tachyarrhythmias mortality. This review evaluates imaging tools and novel biomarkers proposed for better risk stratifying arrhythmic substrate, thereby identifying optimal ICD therapy candidates.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India.

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Nonstatin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals with statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Ventricular Arrhythmias and Sudden Death in Nonischemic Dilated Cardiomyopathy: Matter of Sex or Scar?

BackgroundTo evaluate the association between sex and ventricular arrhythmias (VA) or sudden death (SD) in nonischemic dilated cardiomyopathy, including analysis of potential confounders. Methods and ResultsRetrospective cohort study of consecutive patients with DCM referred for cardiac magnetic resonance at 2 tertiary hospitals. The primary combined end point encompassed sustained VA, appropriate implantable cardioverter defibrillator therapies, resuscitated cardiac arrest, and SD. We included 1165 patients with median follow-up of 36 months (interquartile range 20–58 months). The majority of patients (66%) were males. Males and females had similar left ventricular ejection fraction, but the prevalence of late gadolinium enhancement (LGE) at cardiac magnetic resonance was significantly higher among males (48% vs 30%, P < .001). Males had higher cumulative incidence of the primary end point (8% vs 4%, P = .02), and male sex was a significant predictor of the primary end point at univariate analysis (hazard ratio 1.93, P = .02). However, LGE had a major confounding effect in the association between sex and the primary outcome: the hazard ratio of male sex adjusted for LGE was 1.29 (P = .37). LGE+ females had significantly higher cumulative incidence of the primary end point than LGE– males (13% vs 1.8%, P < .001). ConclusionsIn patients with DCM, the prevalence of LGE is significantly higher among males, implying a major confounding effect in the association between male sex and VA or SD. LGE+ females have significantly higher risk than LGE– males. These data do not support the inclusion of sex into risk stratification algorithms for VA or SD in DCM.

Early Identification of Maternal Cardiovascular Risk Through Sourcing and Preparing Electronic Health Record Data: Machine Learning Study.

BackgroundHealth care data are fragmenting as patients seek care from diverse sources. Consequently, patient care is negatively impacted by disparate health records. Machine learning (ML) offers a disruptive force in its ability to inform and improve patient care and outcomes. However, the differences that exist in each individual’s health records, combined with the lack of health data standards, in addition to systemic issues that render the data unreliable and that fail to create a single view of each patient, create challenges for ML. Although these problems exist throughout health care, they are especially prevalent within maternal health and exacerbate the maternal morbidity and mortality crisis in the United States.ObjectiveThis study aims to demonstrate that patient records extracted from the electronic health records (EHRs) of a large tertiary health care system can be made actionable for the goal of effectively using ML to identify maternal cardiovascular risk before evidence of diagnosis or intervention within the patient’s record. Maternal patient records were extracted from the EHRs of a large tertiary health care system and made into patient-specific, complete data sets through a systematic method.MethodsWe outline the effort that was required to define the specifications of the computational systems, the data set, and access to relevant systems, while ensuring that data security, privacy laws, and policies were met. Data acquisition included the concatenation, anonymization, and normalization of health data across multiple EHRs in preparation for their use by a proprietary risk stratification algorithm designed to establish patient-specific baselines to identify and establish cardiovascular risk based on deviations from the patient’s baselines to inform early interventions.ResultsPatient records can be made actionable for the goal of effectively using ML, specifically to identify cardiovascular risk in pregnant patients.ConclusionsUpon acquiring data, including their concatenation, anonymization, and normalization across multiple EHRs, the use of an ML-based tool can provide early identification of cardiovascular risk in pregnant patients.

Predicting the subclinical carotid atherosclerosis in overweight and obese patients using a machine learning model

Aim. To develop a model for predicting the subclinical carotid atherosclerosis (SCA) in order to refine cardiovascular risk (CVR) using machine learning methods in overweight and obese patients without hypertension, diabetes and/or cardiovascular disease (CVD).Material and methods. Anonymized database (DB) Webiomed (2.9 million patients) was used. There were following inclusion criteria: age ≥18 years, body mass index ≥25 kg/m2, availability of data on ultrasound of extracranial arteries. Patients with hypertension, diabetes and/or CVD were excluded from the analysis. Data on 5750 patients were selected, of which atherosclerotic plaques were detected in 385 people. The final data set contained information on 447 patients, 197 (44,1%) of which had SCA. Quantitative and categorical traits for model training were taken with 40% occupancy in the database. The number of final traits for machine learning was 28. When creating the model, 3 Random Forest algorithms, AdaBoostClassifier, KNeighborsClassifier and the Scikit-learn library were used. To improve the model performance, the fill missing function was used. The target parameters of the model were given a predictive ability (accuracy) of at least 75%, while the area under the ROC curve was at least 0,75.Results. The resulting dataset was divided into training and test parts in a ratio of 80:20. Depending on the applied algorithms, the learned model was characterized by a predictive ability of 75-97%, sensitivity of 77-92%, specificity of 80-98%, and area under the ROC-curve of 0,88-0,97. Taking into account the accuracy metrics, the best results were obtained for the model learned by the Random Forest algorithm (95%, 92%, 98% and 0,95, respectively).Conclusion. The developed model can help a physician make a decision to refer an overweight and obese patient without cardiovascular diseases for ultrasound of extracranial arteries, which contributes to a more accurate CVR stratification. The introduction of such risk stratification algorithms into practice will increase the accuracy and quality of CVR prediction and optimize the system of preventive measures.

Predicting the subclinical carotid atherosclerosis in overweight and obese patients using a machine learning model

Aim. To develop a model for predicting the subclinical carotid atherosclerosis (SCA) in order to refine cardiovascular risk (CVR) using machine learning methods in overweight and obese patients without hypertension, diabetes and/or cardiovascular disease (CVD).Material and methods. Anonymized database (DB) Webiomed (2.9 million patients) was used. There were following inclusion criteria: age ≥18 years, body mass index ≥25 kg/m2, availability of data on ultrasound of extracranial arteries. Patients with hypertension, diabetes and/or CVD were excluded from the analysis. Data on 5750 patients were selected, of which atherosclerotic plaques were detected in 385 people. The final data set contained information on 447 patients, 197 (44,1%) of which had SCA. Quantitative and categorical traits for model training were taken with 40% occupancy in the database. The number of final traits for machine learning was 28. When creating the model, 3 Random Forest algorithms, AdaBoostClassifier, KNeighborsClassifier and the Scikit-learn library were used. To improve the model performance, the fill missing function was used. The target parameters of the model were given a predictive ability (accuracy) of at least 75%, while the area under the ROC curve was at least 0,75.Results. The resulting dataset was divided into training and test parts in a ratio of 80:20. Depending on the applied algorithms, the learned model was characterized by a predictive ability of 75-97%, sensitivity of 77-92%, specificity of 80-98%, and area under the ROC-curve of 0,88-0,97. Taking into account the accuracy metrics, the best results were obtained for the model learned by the Random Forest algorithm (95%, 92%, 98% and 0,95, respectively).Conclusion. The developed model can help a physician make a decision to refer an overweight and obese patient without cardiovascular diseases for ultrasound of extracranial arteries, which contributes to a more accurate CVR stratification. The introduction of such risk stratification algorithms into practice will increase the accuracy and quality of CVR prediction and optimize the system of preventive measures.

Abstract 150: Safety And Feasibility Of An ED-To-Outpatient Pathway For Transient Ischemic Attack Or Non-Disabling Stroke

Introduction: The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-to-Outpatient Pathway for TIA/NDS. Methods: In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a “safety checklist” were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020. Results: Mean age 68 years (range, 33-99); 53% men; median NIHSS score 0 (range 0-3). Symptom duration was classified as &lt;10 min (24%), 10-59 min (23%), &gt;60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%); 7% were lost to follow-up; 43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p&lt;0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p&lt;0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76). Conclusion: Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.

Metal Articulations as a Source of Total Hip Arthroplasty Pain

The consensus systematic risk stratification algorithm from the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and The Hip Society summarizes clinical challenges in evaluation and treatment of metal-on-polyethylene total hip arthroplasty (THA) patients with adverse local tissue reaction (ALTR) due to mechanically assisted crevice corrosion (MACC), reviews up-to-date evidence, and identifies the areas for future research in order to provide a useful resource for orthopedic surgeons providing care to these patients. A painful THA has various intrinsic and extrinsic causes. ALTR is one of the intrinsic causes in patients with painful THA. The occurrence of ALTR due to MACC at modular junctions is likely to be multifactorial, including implant, surgical, and patient factors. Therefore, a systematic evaluation needs to involve a focused clinical history, detailed physical examination, laboratory tests, and imaging in order to identify potential differential diagnoses. There should be a low threshold to perform a systematic evaluation of patients with painful non–metal-on-metal THA, including patients with metal-on-polyethylene THA, and modular dual-mobility THA with the CoCr metal acetabular insert, as early recognition and diagnosis of ALTR due to MACC will facilitate initiation of appropriate treatment prior to significant adverse biological reactions. Specialized tests such as blood metal analysis and metal artifact reduction sequence magnetic resonance imaging are important modalities in evaluation and management of ALTR in patients with painful THA.

NTCP polymorphisms were associated with fibrosis development in patients with chronic HBV infection.

Sodium taurocholate cotransporting polypeptide has been identified as the hepatitis B virus (HBV) entry receptor. However, information regarding the role of sodium taurocholate cotransporting polypeptide variants in the development of HBV-related advanced cirrhosis and hepatocellular carcinoma is limited. Overall, 581 patients with chronic HBV infection were divided into the liver fibrosis or cirrhosis group based on the Fibrosis-4 index. Further, 183 patients with hepatocellular carcinoma were distributed into early/intermediate and advanced/end stage groups based on Barcelona Clinic Liver Cancer Staging approach. Three single nucleotide polymorphisms were genotyped by high resolution melting curve method. Serum biomarkers of liver function were detected, and hepatocellular carcinoma properties were collected as well. Subjects with GA+AA genotypes at the rs4646287 polymorphism site were associated with a significantly higher rate of fibrosis development (rs4646287 GA+AA genotypes were 13.7% and 20.0% in the non-fibrosis and fibrosis group, respectively; p = 0.038). There were no significant differences between sodium taurocholate cotransporting polypeptide polymorphisms and hepatocellular carcinoma progression. The GA+AA genotype carriers of rs7154439 had relatively high albumin levels (p = 0.035). The rs2296651 GA genotype carriers tended to have solitary tumor nodule and without metastasis (p = 0.004 and 0.015, respectively). Rs4646287 was associated with HBV-related fibrosis development. Sodium taurocholate cotransporting polypeptide polymorphisms were correlated with serum albumin level as well as hepatocellular carcinoma multifocality and metastasis. Therefore, integrating sodium taurocholate cotransporting polypeptide polymorphisms to a risk stratification algorithm may help clinicians manage the chronic HBV infection patients better.

HFA-PEFF score: prognosis in patients with preserved ejection fraction after transcatheter aortic valve implantation.

AimsMany transcatheter aortic valve implantation (TAVI) candidates have underlying heart failure with preserved ejection fraction (HFpEF) in addition to symptomatic aortic stenosis. Diagnosis of HFpEF is challenging. The Heart Failure Association of the European Society of Cardiology proposed the HFA‐PEFF score as part of a novel diagnostic algorithm. This study assessed the prognostic value of the HFA‐PEFF score in patients with preserved ejection fraction after TAVI.Methods and resultsThis single‐centre study included 570 consecutive TAVI patients with a preserved left ventricular ejection fraction of ≥50%. Patients with an HFA‐PEFF score of ≥5 [n = 239 (41.9%)] were compared with those with <5 points [n = 331 (58.1%)]. The primary outcome was a composite of all‐cause mortality or first heart failure rehospitalization within 1 year after TAVI. Secondary endpoints were the individual components of the primary outcome. Patients with an HFA‐PEFF score ≥ 5 had higher rates of comorbidities commonly associated with HFpEF, a higher rate of new pacemaker implantation after TAVI, were at increased risk of the primary composite endpoint (25.5% vs. 10.0%, P < 0.001), and rehospitalization for heart failure (11.7% vs. 3.9%, P < 0.001). Multivariable analysis confirmed an HFA‐PEFF score ≥ 5 as an independent risk factor for the composite endpoint [hazard ratio 2.70, 95% confidence interval (CI) 1.70–4.28, P < 0.001] and for all‐cause mortality (hazard ratio 2.58, 95% CI 1.46–4.53, P = 0.001).ConclusionThe HFA‐PEFF score is associated with all‐cause mortality and heart failure rehospitalization in patients with preserved ejection fraction after TAVI. This practical tool can easily be incorporated into risk stratification algorithms for TAVI patients.

Hypertrophic Cardiomyopathy: New Concepts and Therapies.

Hypertrophic cardiomyopathy (HCM), a relatively common, globally distributed, and often inherited myocardial disorder, transformed over the last several years into a treatable condition with the emergence of effective management options that alter natural history at all ages. Now available are a matured risk stratification algorithm selecting patients for prophylactic implantable defibrillators that prevent arrhythmic sudden death; low-risk, high-benefit surgical myectomy to reverse progressive heart failure symptoms due to left ventricular outflow obstruction; anticoagulation prophylaxis to prevent atrial fibrillation-mediated embolic stroke; and heart transplant for refractory end-stage disease in the absence of obstruction. Those strategies have resulted in reduction of HCM-related morbidity and reduction of mortality to 0.5% per year.

P609 Significant variations in practice in managing mild-Crohn’s disease: results from the 2021 Y-ECCO-ClinCom survey

Abstract Background Epidemiological data suggests Crohn’s disease (CD) runs a mild course in a third of patients. Furthermore, the AZTEC study demonstrated that 30% of patients with uncomplicated CD responding to initial therapy remain in clinical remission at one year when maintained by placebo (Gastroenterology 2013;145:766). There are no proven maintenance strategies other than immunosuppression in CD. ECCO does not recommend maintenance therapy in those newly diagnosed with uncomplicated disease achieving remission with steroids, however in the absence of prognostic biomarkers treatment decisions can be difficult, risking over treatment for some. This questionnaire aimed to explore clinicians’ prescribing strategies and attitudes toward patients with mild CD. Methods A questionnaire was devised in conjunction with the Y-ECCO and ClinCom committees and distributed to attendees to the 2021 virtual ECCO conference. Results 124 complete responses were obtained from gastroenterologists 54%, gastroenterology trainees 29% with surgeons/nurses comprising most of the remainder. 61% respondents were from university hospitals, 33% general hospitals and 6% private clinics, 79% of whom practise in Europe. Approaches to induction and maintenance of remission were investigated in ileocolonic and isolated colonic CD (table and figure). Budesonide and or systemic steroids are often used for induction of remission in both CD subtypes, however a range of therapeutics are also used, with only one respondent taking a wait and see approach in colonic but not ileocolonic CD. In both CD subtypes &amp;gt;50% of patients who achieve steroid-induced remission would be maintained using immunosuppression with either an immunomodulator or biologic, whereas 28% and 6% (ileocolonic) and 20% and 19% (colonic) would watch and wait/treat with 5-ASA respectively, representing significant variation in practise. 80% respondents felt development of complicated disease was unlikely in these patients, despite this, 60% would treat with maintenance therapy. 55% respondents felt that mild CD was easy to manage, however 45% felt neutral or negative towards managing mild CD; the management approach undertaken by either group of respondents was equally varied. Conclusion Current practise does not reflect ECCO guidance, likely due to uncertainties over the natural history of disease and the difficulty in predicting complications. Perception of the difficulty of managing mild CD did not appear to influence treatment decisions. Patients with mild CD comprise a significant proportion of our patients, yet management may be less clear cut than for aggressive disease and further work on risk stratification and management algorithms may avoid over-treatment of patients who may never develop complications.

The new algorithm for stratification of the risk of venous thromboembolic events in elective neurosurgery and its prognostic significance

To assess predictive value of the developed algorithm for elective neurosurgical interventions. The study included 7914 patients who underwent surgery between January 2018 and December 2019. According to the algorithm, we identified the groups of low (1536 (19%) patients), moderate (4554 (58%) patients) and high risk (1824 (23%) patients). Moreover, patients were divided into subgroups depending on surgical procedure. We analyzed the incidence of VTE and mortality in all groups. Of VTE with a 95% confidence interval in the low-risk group was 0.65% [0.26; 1.04], in the moderate risk group - 1.82% [1.47; 2.24], in the high-risk group - 12.61% [11.02; 14.09]. When comparing various surgical interventions, we revealed more common VTE after vascular microsurgery (15.62%), in patients with brain tumors (12.63%) and spinal cord tumors (6.52%). The risk stratification algorithm has demonstrated its convenience and significant predictive value for determining the risk of VTE among elective neurosurgical patients. In addition, different incidence of VTE was demonstrated in patients with various neurosurgical diseases.

Current Frontline Treatment of Diffuse Large B-Cell Lymphoma.

Diffuse large B-cell lymphoma (DLBCL), the most common subtype of non-Hodgkin lymphoma, is an aggressive and biologically heterogeneous disease. Risk stratification and treatment algorithms vary based on stage of disease and bulk along with other clinical and biological factors, including the International Prognostic Index, cell of origin, and other molecular subsets. Rituximab (Rituxan), cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is the current standard of care and cures more than 60% of patients. The role of radiotherapy is largely restricted to patients with limited-stage disease. In elderly patients, geriatric assessments of baseline fitness and functional status help optimize therapy based on the balance of efficacy and toxicity. While numerous randomized trials have failed to improve upon R-CHOP, a recent press release from the POLARIX trial (NCT03274492) suggests that adding polatuzumab vedotin (Polivy) to rituximab, cyclophosphamide, doxorubicin, and prednisone (pola-R-CHP) improves progression-free survival and may replace R-CHOP in eligible patients. Ongoing trials are exploring frontline therapy that integrates other novel agents, including various small molecules, bispecific antibodies, and chimeric antigen receptor T-cell therapy, with promising preliminary results. Defining a population of patients with high-risk disease in whom R-CHOP is not effective is critical. Patient selection based on refining molecular subsets, quantitative PET metrics such as metabolic tumor volume, and dynamic risk assessments using interim PET and circulating tumor DNA analysis may allow for a personalized, response-adapted approach that will further improve outcomes in DLBCL.

Association of CHA2DS2-VASc score with successful recanalization in acute ischemic stroke patients undergoing endovascular thrombectomy.

The CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease and sex) score is a simple risk stratification algorithm to estimate stroke/thromboembolic risk in patients with non-valvular atrial fibrillation (AF). Higher pre-stroke CHA2DS2-VASc score is known to be associated with greater stroke severity and poorer outcomes. AF patients generally have higher CHA2DS2-VASc scores than non-AF patients. The Modified Thrombolysis in Cerebral Infarction (mTICI) score is the most widely used grading system to assess the result of recanalizing therapies in acute ischemic stroke (AIS). mTICI 2c and mTICI 3 are conventionally accepted as successful recanalization. We investigated whether pre-stroke CHA2DS2-VASc score is associated with mTICI recanalization score in AIS patients with and without AF undergoing percutaneous thrombectomy. One hundred fifty-nine patients with the diagnosis of AIS who were admitted within 6 h from symptom onset were included in the study (mean age: 65.7 ±12.9). All subjects underwent endovascular treatment. CHA2DS2-VASc scores of the participants were calculated. Subjects were grouped according to mTICI scores achieved after endovascular treatment. mTICI 2c and mTICI 3 were accepted as successful recanalization. Successful reperfusion was observed in 130 (81.8%) of all patients who underwent endovascular treatment (mTICI flow ≥ 2c) and first-pass reperfusion was observed in 107 (67.3%) patients. When the patients with successful (mTICI flow ≥ 2c) and unsuccessful (mTICI flow ≤ 2b) reperfusion were divided into groups, no significant difference was observed between the patients in terms of comorbidities such as AF, hypertension, hyperlipidemia, coronary artery disease and cerebrovascular accident history. Patients with unsuccessful reperfusion were older than patients with successful reperfusion (71.4 ±11.2 vs. 64.5 ±13.01, p = 0.006), with a higher CHA2DS2-VASc score (4.1 ±1.5 vs. 3.04 ±1.6, p = 0.002). In addition, the duration of the procedure was longer in the unsuccessful reperfusion group (92.4 ±27.2 min vs. 65.0 ±25.1 min, p < 0.001). CHA2DS2-VASc score significantly correlated with successful recanalization (correlation coefficient; 0.243, p = 0.002). Multivariate logistic regression analysis revealed that only CHA2DS2-VASc score (OR = 1.43, 95% CI: 1.09-1.87, p = 0.006) and procedure time (OR = 1.03, 95% CI: 1.01-1.05, p < 0.001) were independent predictors of successful reperfusion. The receiver-operating characteristic (ROC) curve was used to determine the cut-off value for the CHA2DS2-VASc score that best predicts successful reperfusion. The optimal threshold was 3.5, with a sensitivity of 58.6% and specificity of 59.2% (area under the curve (AUC): 0.669, p = 0.005). For the first time in the literature, we investigated and demonstrated that pre-stroke CHA2DS2-VASc score was associated with success of recanalization as assessed with mTICI 2c and mTICI 3 in a cohort of AIS patients regardless of AF presence who underwent endovascular treatment. Our findings deserve to be tested with large scale long term studies.

Spinal Morphometry As A Novel Predictor For Recurrent Lumbar Disc Herniation Requiring Revision Surgery: Results of A Case Control Study.

There is conflicting data on the risk factors for recurrent lumbar disc herniation (rLDH). Most of the predictors for rLDH identified so far are acquired risk factors or radiological factors at the level of the herniation. Whole lumbar spine (WLS) morphometry has not been evaluated as a possible predictor of rLDH. We aimed to evaluate if preoperative spinal morphometry can predict the occurrence of rLDH requiring revision surgery. This retrospective case-control study on 250 patients included 45 patients operated for rLDH, 180 controls without rLDH who had previously undergone microdiscectomy for a single level lumbar disc prolapse, and a holdout validation set of 25 patients. Morphometric variables related to the WLS were recorded in addition to previously identified predictors of rLDH. Logistic regression (LR) analysis was performed to identify independent predictors of rLDH. LR yielded four predictors of which two were WLS morphometric variables. While increasing age and smoking positively predicted rLDH, increasing WLS interfacet distance and WLS dural-sac circumference negatively predicted rLDH. The LR model was statistically significant, χ2 (4) =15.98, P = 0.003, and correctly classified 80.3% of cases. On validation, the model demonstrated a fair accuracy in predicting rLDH (accuracy: 0.80, AUC: 0.70). Larger mean lumbar bony canals and dural sacs protect from the occurrence of symptomatic rLDH. These WLS morphometric variables should be included in future risk stratification algorithms for lumbar disc disease. In addition to the previously recognized risk factors, our study points to an underlying developmental predisposition for rLDH.

Renal Morbidity Following Radical Cystectomy in Patients with Bladder Cancer

BackgroundPatients with chronic kidney disease (CKD) are poor candidates for standard treatments for muscle-invasive bladder cancer (MIBC) and may be more likely to experience adverse outcomes when diagnosed with MIBC. ObjectiveTo investigate factors associated with the development of advanced CKD following radical cystectomy. Design, setting, and participantsUsing national Veterans Health Administration utilization files, we identified 3360 patients who underwent radical cystectomy for MIBC between 2004 and 2018. Outcome measurements and statistical analysisWe examined factors associated with the development of advanced CKD (estimated glomerular filtration rate [eGFR] of <30 ml/min/1.73 m2) after radical cystectomy using multivariable logistic and proportional hazard regression, with and without consideration of competing risks. We examined survival using Kaplan-Meier product limit estimates and proportional hazard regression. Results and limitationsThe median age at surgery was 67 yr and the mean preoperative eGFR was 69.1 ± 20.3 ml/min/1.73 m2. Approximately three out of ten patients (n = 962, 29%) progressed to advanced CKD within 12 mo. Older age (hazard ratio [HR] per 5-yr increase 1.15, 95% confidence interval [CI] 1.10–1.20), preoperative hydronephrosis (HR 1.50, 95% CI 1.29–1.76), adjuvant chemotherapy (HR 1.19, 95% CI 1.00–1.41), higher comorbidity index (HR 1.13, 95% CI 1.11–1.16 per point), and lower baseline kidney function (HR 0.75, 95% CI 0.73–0.78) were associated with the development of advanced CKD. Baseline kidney function at the time of surgery was associated with survival. Generalizability is limited due to the predominantly male cohort. ConclusionsImpaired kidney function at baseline is associated with progression to advanced CKD and mortality after radical cystectomy. Preoperative kidney function should be incorporated into risk stratification algorithms for patients undergoing radical cystectomy. Patient summaryImpaired kidney function at baseline is associated with progression to advanced chronic kidney disease and mortality after radical cystectomy.

HCC risk stratification after cure of hepatitis C in patients with compensated advanced chronic liver disease

Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality in patients with advanced chronic liver disease (ACLD) caused by chronic hepatitis C who have achieved sustained virologic response (SVR). We developed risk stratification algorithms for de novo HCC development after SVR and validated them in an independent cohort. We evaluated the occurrence of de novo HCC in a derivation cohort of 527 patients with pre-treatment ACLD and SVR to interferon-free therapy, in whom alpha-fetoprotein (AFP) and non-invasive surrogates of portal hypertension including liver stiffness measurement (LSM) were assessed pre-/post-treatment. We validated our results in 1,500 patients with compensated ACLD (cACLD) from other European centers. During a median follow-up (FU) of 41 months, 22/475 patients with cACLD (4.6%, 1.45/100 patient-years) vs. 12/52 decompensated patients (23.1%, 7.00/100 patient-years, p <0.001) developed de novo HCC. Since decompensated patients were at substantial HCC risk, we focused on cACLD for all further analyses. In cACLD, post-treatment-values showed a higher discriminative ability for patients with/without de novo HCC development during FU than pre-treatment values or absolute/relative changes. Models based on post-treatment AFP, alcohol consumption (optional), age, LSM, and albumin, accurately predicted de novo HCC development (bootstrapped Harrel's C with/without considering alcohol: 0.893/0.836). Importantly, these parameters also provided independent prognostic information in competing risk analysis and accurately stratified patients into low- (~2/3 of patients) and high-risk (~1/3 of patients) groups in the derivation (algorithm with alcohol consumption; 4-year HCC-risk: 0% vs. 16.5%) and validation (3.3% vs. 17.5%) cohorts. An alternative approach based on alcohol consumption (optional), age, LSM, and albumin (i.e., without AFP) also showed a robust performance. Simple algorithms based on post-treatment age/albumin/LSM, and optionally, AFP and alcohol consumption, accurately stratified patients with cACLD based on their risk of de novo HCC after SVR. Approximately two-thirds were identified as having an HCC risk <1%/year in both the derivation and validation cohort, thereby clearly falling below the cost-effectiveness threshold for HCC surveillance. Simple algorithms based on age, alcohol consumption, results of blood tests (albumin and α-fetoprotein), as well as liver stiffness measurement after the end of hepatitis C treatment identify a large proportion (approximately two-thirds) of patients with advanced but still asymptomatic liver disease who are at very low risk (<1%/year) of liver cancer development, and thus, might not need to undergo 6-monthly liver ultrasound.

Thyroid nodule location and the risk of thyroid cancer: What do we know?

Thyroid nodules are common in clinical practice and are routinely evaluated with neck ultrasound. Multiple guidelines rely on sonographic features to assist physicians when deciding if nodules require observation or fine-needle aspiration (FNA). Existing classification systems for risk stratification of thyroid nodules are different but equally accurate. The purpose of this article is to review the significance of thyroid nodule location as an important factor in assessing the risk of malignancy. Several topical issues are addressed. (1) Thyroid nodule location and risk of differentiated thyroid cancer, (2) Thyroid nodule location and risk of nodal metastasis, (3) Thyroid nodule location and surgical approach, (4) Thyroid nodule location and stratifications systems (5) Conclusions and future direction. In conclusion, it is advisable not to reply solely on ultrasound-derived risk levels when evaluating thyroid nodules to determine optimal management including nodule FNA, follow-up or no additional intervention. This is likely because other clinically important features might not be accounted for when using those risk stratification algorithms. There are now reasonable data to suggest thyroid nodule location may be an additional prognostic predictor. In the lack of clear radiologic guidance, clinical judgment remains the main driving factor.

Validation of a Novel Predictive Algorithm for Kidney Failure in Patients Suffering from Chronic Kidney Disease: The Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD).

Current equation-based risk stratification algorithms for kidney failure (KF) may have limited applicability in real world settings, where missing information may impede their computation for a large share of patients, hampering one from taking full advantage of the wealth of information collected in electronic health records. To overcome such limitations, we trained and validated the Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD), a novel algorithm predicting end-stage kidney disease (ESKD). PROGRES-CKD is a naïve Bayes classifier predicting ESKD onset within 6 and 24 months in adult, stage 3-to-5 CKD patients. PROGRES-CKD trained on 17,775 CKD patients treated in the Fresenius Medical Care (FMC) NephroCare network. The algorithm was validated in a second independent FMC cohort (n = 6760) and in the German Chronic Kidney Disease (GCKD) study cohort (n = 4058). We contrasted PROGRES-CKD accuracy against the performance of the Kidney Failure Risk Equation (KFRE). Discrimination accuracy in the validation cohorts was excellent for both short-term (stage 4–5 CKD, FMC: AUC = 0.90, 95%CI 0.88–0.91; GCKD: AUC = 0.91, 95% CI 0.86–0.97) and long-term (stage 3–5 CKD, FMC: AUC = 0.85, 95%CI 0.83–0.88; GCKD: AUC = 0.85, 95%CI 0.83–0.88) forecasting horizons. The performance of PROGRES-CKD was non-inferior to KFRE for the 24-month horizon and proved more accurate for the 6-month horizon forecast in both validation cohorts. In the real world setting captured in the FMC validation cohort, PROGRES-CKD was computable for all patients, whereas KFRE could be computed for complete cases only (i.e., 30% and 16% of the cohort in 6- and 24-month horizons). PROGRES-CKD accurately predicts KF onset among CKD patients. Contrary to equation-based scores, PROGRES-CKD extends to patients with incomplete data and allows explicit assessment of prediction robustness in case of missing values. PROGRES-CKD may efficiently assist physicians’ prognostic reasoning in real-life applications.