Simple Clinical Risk Score Research Articles

A simple clinical risk score (ABCDMP) for predicting mortality in patients with AECOPD and cardiovascular diseases

BackgroundThe morbidity and mortality among hospital inpatients with AECOPD and CVDs remains unacceptably high. Currently, no risk score for predicting mortality has been specifically developed in patients with AECOPD and CVDs. We therefore aimed to derive and validate a simple clinical risk score to assess individuals’ risk of poor prognosis.Study design and methodsWe evaluated inpatients with AECOPD and CVDs in a prospective, noninterventional, multicenter cohort study. We used multivariable logistic regression analysis to identify the independent prognostic risk factors and created a risk score model according to patients’ data from a derivation cohort. Discrimination was evaluated by the area under the receiver-operating characteristic curve (AUC), and calibration was assessed by the Hosmer–Lemeshow goodness-of-fit test. The model was validated and compared with the BAP-65, CURB-65, DECAF and NIVO models in a validation cohort.ResultsWe derived a combined risk score, the ABCDMP score, that included the following variables: age > 75 years, BUN > 7 mmol/L, consolidation, diastolic blood pressure ≤ 60 mmHg, mental status altered, and pulse > 109 beats/min. Discrimination (AUC 0.847, 95% CI, 0.805–0.890) and calibration (Hosmer‒Lemeshow statistic, P = 0.142) were good in the derivation cohort and similar in the validation cohort (AUC 0.811, 95% CI, 0.755–0.868). The ABCDMP score had significantly better predictivity for in-hospital mortality than the BAP-65, CURB-65, DECAF, and NIVO scores (all P < 0.001). Additionally, the new score also had moderate predictive performance for 3-year mortality and can be used to stratify patients into different management groups.ConclusionsThe ABCDMP risk score could help predict mortality in AECOPD and CVDs patients and guide further clinical research on risk-based treatment.Clinical trial registrationChinese Clinical Trail Registry NO.:ChiCTR2100044625; URL: http://www.chictr.org.cn/showproj.aspx?proj=121626.

Establishing and validation of the VBV score for assessing Lung ground-glass nodules based on high-resolution computed tomography

BackgroundThe widespread utilization of chest High-resolution Computed Tomography (HRCT) has prompted detection of pulmonary ground-glass nodules (GGNs) in otherwise asymptomatic individuals. We aimed to establish a simple clinical risk score model for assessing GGNs based on HRCT.MethodsWe retrospectively analyzed 574 GGNs in 574 patients undergoing HOOK-WIRE puncture and pulmonary nodule surgery from January 2014 to November 2018. Clinical characteristics and imaging features of the GGNs were assessed. We analyzed the differences between malignant and benign nodules using binary logistic regression analysis and constructed a simple risk score model, the VBV Score, for predicting the malignancy status of GGNs. Then, we validated this model via other 1200 GGNs in 1041 patients collected from three independent clinical centers in 2022.ResultsFor the exploratory phase of this study, out of the 574 GGNs, 481 were malignant and 93 were benign. Vacuole sign, air bronchogram, and intra-nodular vessel sign were important indicators of malignancy in GGNs. Then, we derived a VBV Score = vacuole sign + air bronchogram + intra-nodular vessel sign, to predict the malignancy of GGNs, with a sensitivity, specificity, and accuracy of 95.6%, 80.6%, and 93.2%, respectively. We also validated it on other 1200 GGNs, with a sensitivity, specificity, and accuracy of 96.0%, 82.6%, and 95.0%, respectively.ConclusionsVacuole sign, air bronchogram, and intra-nodular vessel sign were important indicators of malignancy in GGNs. VBV Score showed good sensitivity, specificity, and accuracy for differentiating benign and malignant pulmonary GGNs.

Development, validation, and comparative analysis of a simple clinical and laboratory-based risk score system for predicting and stratifying moderate-to-severe AKI after cardiac surgery

Abstract Background Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is prevalent and detrimental following cardiac surgery, without effective prevention. Early prediction and stratification are critical in informing appropriate care. Recent studies highlighted the predictive value of some routine laboratory markers in addition to traditional clinical variables. However, existing models suffer from complexity and practical difficulties in implementation. Purpose We aim to develop a high-performance preoperative risk score system for predicting moderate-to-severe CSA-AKI, while preserving its simplicity and utility through the integration of the most predictive and routinely accessible clinical and laboratory variables. Methods A total of 14 303 patients undergoing coronary artery bypass grafting surgery at a single institution, with comprehensive perioperative data, were included. Cohort 1 (N=9 416, 2013-2017) and cohort 2 (N=4 887, 2018-2019) were used to develop and validate a risk score system for predicting moderate-to-severe CSA-AKI, respectively, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Bootstrapped stepwise regression was employed to select the robust candidate variables for a logistic regression model (i.e., the full model), which was then simplified to a more parsimonious model. Model performance was evaluated and compared to several established models. Results The overall incidence of moderate-to-severe CSA-AKI was 3.5% in the entire cohort. Two preoperative risk scores were developed: the simple 6-variable ABC2-Surgery2 score (age, a biomarker of NT-proBNP, two clinical status variables of hypertension and preoperative critical state, and two surgery-related variables of combined surgery and on-pump surgery), and the complete 10-variable AB2C3-Surgery4 score (ABC2-Surgery2 plus an additional biomarker of blood urea nitrogen, a clinical status variable of Canadian Cardiovascular Society angina class, and two surgery-related variables of urgent surgery and previous surgery). In the validation cohort, the simple score (area under the curve, AUC 0.765) outperformed the previously established UK-AKI model (AUC 0.720), Mehta score (AUC 0.700), and Ng score (AUC 0.697), while statistically similar to the most complex 19-variable Cleveland Clinic Score (AUC 0.725). The complete score (AUC 0.777) was superior to all four models. The current score system also effectively stratified CSA-AKI with respect to requirements for vasoactive support (measured by cumulative vasoactive-inotropic score), intravenous diuretics, and renal replacement therapy, as well as in-hospital and long-term mortality. Conclusion A simple risk score system incorporating routine clinical and laboratory variables was developed to predict and stratify moderate-to-severe CSA-AKI and outperformed previous complex models. Further external validation is currently underway for generalizability.

Clinical Risk Score for Prediction of Urgency in Carotid Cavernous Sinus Fistulas.

To develop a clinical risk score for the prediction of urgency in patients with carotid cavernous sinus fistulas (CCFs) and test for the discriminative ability of the diagnostic prediction. The medical charts of 60 patients with CCFs were retrospectively reviewed. The clinical characteristics of direct and dural CCFs were analyzed by logistic regression. The clinical risk score was developed from the coefficient in the multivariable regression model and used to predict direct CCFs which were more urgent than the dural type. The score prediction was reported as an area under the receiver operating characteristic (AuROC) curve and 95% confidence interval (95% CI). In a univariable analysis, the clinical characteristics which increased the risk of direct CCFs were age, gender, trauma, underlying diseases, visual acuity (VA) at presentation, bruit, chemosis, and dilated retinal vessels. However, in multivariable analysis, the significant predictors were limited to age, trauma, bruit, underlying diseases and logMAR VA. Regression coefficient of each predictor was converted to a risk score and summation of scores from these predictors for each patient was calculated. The total risk score predicted the urgent direct CCFs correctly with AuROC of 97.77% (95% CI; 93.57, 100). The clinical risk score for the prediction of urgent direct CCFs has been developed and used in the patients with CCFs in our setting. The discriminative ability of the score prediction is high. This simple clinical risk score may help clinicians suspect direct CCFs and urgently refer the patients to have prompt angiography and treatment.

Clinical Risk Score for Predicting Vascular Dementia after Ischemic Stroke in Thailand.

Background Poststroke dementia is an important consequence of stroke and warrants early prevention, detection, and management. The objective of the study was to develop a simple clinical risk score for predicting risk of vascular dementia in patients with ischemic stroke. Methods The design was a prospective cohort study with 177 ischemic stroke survivors. A standard stroke evaluation was performed at admission, and dementia evaluation was conducted at six months after stroke. The significant predictors were used to develop a risk score using a multivariable logistic regression model. Results Six months after stroke, 27.1% of the patients were diagnosed with vascular dementia. Five predictors were used in the risk score: age, education, history of stroke, white matter hyperintensities, and stroke subtype. The risk score had an area under receiver operating characteristic curve (AuROC) of 0.76, 72.9% sensitivity, and 79.1% specificity in predicting risk of vascular dementia. The predicted probability of vascular dementia for each risk score point was also reported. Conclusion The clinical risk score had an acceptable accuracy in predicting vascular dementia in ischemic stroke survivors. It can be used for identifying those who are at a high risk of developing vascular dementia.

A five-parameter score for predicting saphenous vein graft degenerative and/or occlusive disease in recurring ischemic symptoms after one year post coronary artery bypass grafting.

The recurrence rate of ischemic symptoms after coronary artery bypass grafting (CABG) is increasing in recent years. How to prevent and treat saphenous vein graft disease (SVGD [symptomatic ⩾50% stenosis in at least one Saphenous vein graft]) has been a clinical challenge to date. Different pathogenesis may exist in SVGD of different periods. There are currently few available scores for estimating the risk of SVGD after one year post CABG. We sought to develop and validate a simple predictive clinical risk score for SVGD with recurring ischemia after one year post CABG. This was a cross-sectional study and the results were validated using bootstrap resampling on a separate cohort. A nomogram and risk scoring system were developed based on retrospective data from a training cohort of 606 consecutive patients with recurring ischemia >1 year after CABG. Logistic regression model was used to find the predictive factors and to build a nomogram. To assess the generalization, models were validated using bootstrap resampling and an external cross-sectional study of 187 consecutive patients in four other hospitals. In multivariable analysis of the primary cohort, native lesion vessel number, SVG age, recurring ischemia type, very low-density lipoprotein level, and left ventricular end-diastolic diameter were independent predictors. A summary risk score was derived from nomogram, with a cut-off value of 15. In internal and external validation, the C-index was 0.86 and 0.82, indicating good discrimination. The calibration curve for probability of SVGD showed optimal agreement between actual observations and risk score prediction. A simple-to-use risk scoring system based on five easily variables was developed and validated to predict the risk of SVGD among patients who recurring ischemia after one year post CABG. This score may be useful for providing patients with individualized estimates of SVGD risk.

Clinical Predictors of Failed Medical Treatment in Patients with Tubo-ovarian Abscess: External Validation of a Recently Published Risk Score

To assess the external validity of a recently published clinical risk score estimating the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) based on 4 clinical variables on admission. The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. Results were assessed using rigorous methods for clinical prediction models. Safety-net teaching hospital system in Houston, Texas. One hundred and sixty nine consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with intravenous antibiotic agents; others required a drainage procedure. Electronic health records were reviewed and the 4 clinical predictors of failed conservative treatment were captured (age, white blood cell count on admission, abscess size, and presence of bilateral abscess). A clinical risk score was calculated for each patient. The prediction model was created using the risk score in a multivariate logistic regression. Then the calibration, discrimination, and accuracy of the model were evaluated to perform the external validation analysis. Among 169 eligible patients, 50.2% were successfully treated with intravenous antibiotic agents and 49.8% needed abscess drainage. Patients undergoing drainage were more likely to be older, be diabetic, to present with elevated white blood cell count and fever, and to have a larger abscess size on univariate analysis. Among the 4 known predictors of drainage, abscess size was found to be the strongest. Significant difference in clinical characteristics was noted between our cohort and the reference cohort, and the model needed recalibration to adjust for these differences. The area under the receiver operating characteristic curve was 0.77 (0.71-0.84) indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. Our results provide external validation of a simple clinical risk score predicting failed medical treatment in patients with TOA.

Clinical Predictors of Failed Medical Treatment in Patients with Tubo-Ovarian Abscess

<h3>Study Objective</h3> To estimate the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) and assess the external validity of a clinical risk score. <h3>Design</h3> External validation study. The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. <h3>Setting</h3> Safety-net teaching hospital system in Houston, Texas. <h3>Patients or Participants</h3> 169 consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with IV antibiotics; others required a drainage procedure. <h3>Interventions</h3> Predictors of failed conservative treatment were captured. The previously published predictors by Fouks et al, included age>36, WBC ≥ 16000), abscess diameter (≥ 7 cm) and bilateral abscesses. A clinical risk score was calculated for each patient and correlated with the risk of failed medical treatment. A multivariate logistic regression using the patient characteristics was created, in addition to the prediction model using the risk score. Then the calibration, discrimination and accuracy of the model were evaluated to perform the external validation analysis. <h3>Measurements and Main Results</h3> Among 169 eligible patients, 50.2% were successfully treated with IV antibiotics and 49.8% needed drainage via minimally invasive or traditional surgery. Patients undergoing the intervention were more likely to be older, diabetic, to present with elevated white blood cell count, have fever and a large abscess size on univariate analysis. Large abscess size was found to be the strongest independent predictor for intervention in our cohort. The AUC curve for the adjusted model was 0.77 (0.71-0.84), indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. <h3>Conclusion</h3> Our results provide external validation to a simple clinical risk score predicting failed medical treatment in patients with TOA. Large abscess size was found to be the strongest independent predictor for intervention.

Spotlight on the May 18 Issue

#### Notable in Neurology This Week This issue features an article that investigates whether MRI markers of cerebral small vessel disease differ according to self-reported race or ethnicity and whether any differences are associated with the risk of intracerebral hemorrhage; another examines the effect of adrenomedullin on patients with migraine. A featured Views & Reviews provides recommendations on outcome measures and statistical considerations for exploratory clinical trials in neurodegenerative dementias. ### Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage This article outlines a simple clinical risk score that identifies patients with intracerebral hemorrhage (ICH) at low risk for …

A simple clinical score to identify likely hepatitis B vaccination non-responders \u2013 data from a retrospective single center study

BackgroundAbout 10% of Hepatitis B vaccinated individuals mount no protective antibody levels against the hepatitis B surface antigen (HBs-Ag). Older age at primary immunization, obesity and smoking have previously been reported as risk factors associated with vaccine non-response. Here we tested whether these factors alone may allow selecting subjects that benefit from individualized immunization schedules.MethodsRetrospective database analysis screening > 15,000 individual anti-HBs-IgG measurements. Non-responders (NR; anti-HBs-IgG < 10 IU/L) and low-responders (LR; anti-HBs-IgG 10–100 IU/L) were identified. Vaccine type, demographics, lifestyle, and immunological factors (leucocyte subset counts) were compared between NR, LR, and responders (R).ResultsWe identified 113 LR/NR and compared them to 134 vaccine responders. We confirmed higher median age at primary vaccination (24.0 (R) vs. 30.5 (NR) vs. 31 (LR) years, p = 0.001), higher median BMI (23.2 kg/m2 (R) vs. 23.4 kg/m2 (NR) vs. 25.1 kg/m2 (LR), p = 0.001) and being a smoker (% smokers: 30.8% (R) vs. 57.1% (NR) vs. 52.5% (LR), p = 0.01) as factors negatively associated with anti-HBs-IgG levels. In a ROC analysis including these factors in a 6-point score, a high score predicted non-response with a specificity of 85% but at low sensitivity (47%).ConclusionA simple clinical risk score based on age, obesity, and smoking identifies individuals with a high likelihood of vaccine failure. Non-responders with a low score are candidates for in-depth analyses to better understand the immunological causes of HBV vaccine non-response.

A clinical score for identifying active tuberculosis while awaiting microbiological results: Development and validation of a multivariable prediction model in sub-Saharan Africa.

In highly resource-limited settings, many clinics lack same-day microbiological testing for active tuberculosis (TB). In these contexts, risk of pretreatment loss to follow-up is high, and a simple, easy-to-use clinical risk score could be useful. We analyzed data from adults tested for TB with Xpert MTB/RIF across 28 primary health clinics in rural South Africa (between July 2016 and January 2018). We used least absolute shrinkage and selection operator regression to identify characteristics associated with Xpert-confirmed TB and converted coefficients into a simple score. We assessed discrimination using receiver operating characteristic (ROC) curves, calibration using Cox linear logistic regression, and clinical utility using decision curves. We validated the score externally in a population of adults tested for TB across 4 primary health clinics in urban Uganda (between May 2018 and December 2019). Model development was repeated de novo with the Ugandan population to compare clinical scores. The South African and Ugandan cohorts included 701 and 106 individuals who tested positive for TB, respectively, and 686 and 281 randomly selected individuals who tested negative. Compared to the Ugandan cohort, the South African cohort was older (41% versus 19% aged 45 years or older), had similar breakdown of biological sex (48% versus 50% female), and had higher HIV prevalence (45% versus 34%). The final prediction model, scored from 0 to 10, included 6 characteristics: age, sex, HIV (2 points), diabetes, number of classical TB symptoms (cough, fever, weight loss, and night sweats; 1 point each), and >14-day symptom duration. Discrimination was moderate in the derivation (c-statistic = 0.82, 95% CI = 0.81 to 0.82) and validation (c-statistic = 0.75, 95% CI = 0.69 to 0.80) populations. A patient with 10% pretest probability of TB would have a posttest probability of 4% with a score of 3/10 versus 43% with a score of 7/10. The de novo Ugandan model contained similar characteristics and performed equally well. Our study may be subject to spectrum bias as we only included a random sample of people without TB from each cohort. This score is only meant to guide management while awaiting microbiological results, not intended as a community-based triage test (i.e., to identify individuals who should receive further testing). In this study, we observed that a simple clinical risk score reasonably distinguished individuals with and without TB among those submitting sputum for diagnosis. Subject to prospective validation, this score might be useful in settings with constrained diagnostic resources where concern for pretreatment loss to follow-up is high.

The F2RaD Score: A Novel Prediction Score and Calculator Tool to Identify Patients at Risk of Postoperative C5 Palsy.

Postoperative C5 palsy is a debilitating complication following posterior cervical decompression. To create a simple clinical risk score predicting the occurrence of C5 palsy. We retrospectively reviewed all patients who underwent posterior cervical decompressions between 2007 and 2017. Data was randomly split into training and validation datasets. Multivariable analysis was performed to construct the model from the training dataset. A scoring system was developed based on the model coefficients and a web-based calculator was deployed. The cohort consisted of 415 patients, of which 65 (16%) developed C5 palsy. The optimal model consisted of: mean C4/5 foraminal diameter (odds ratio [OR] = 9.1 for lowest quartile compared to highest quartile), preoperative C5 radiculopathy (OR=3.5), and dexterity loss (OR=2.9). The receiver operating characteristic yielded an area under the curve of 0.757 and 0.706 in the training and validation datasets, respectively. Every characteristic was worth 1 point except the lowest quartile of mean C4/5 foraminal diameter, which was worth 2 points, and the factors were summarized by the acronym F2RaD. The median predicted probability of C5 palsy increased from 2% in patients with a score of 0 to 70% in patients with a score of 4. The calculator can be accessed on https://jhuspine2.shinyapps.io/FRADscore/. This study yielded a simplified scoring system and clinical calculator that predicts the occurrence of C5 palsy. Individualized risk prediction for patients may facilitate better understanding of the risks and benefits for an operation, and better prepare them for this possible adverse outcome. Furthermore, modifying the surgical plan in high-risk patients may possibly improve outcomes.

P1628ASSESSING CORONARY HEART DISEASE IN SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION - IS THERE SPACE FOR A RISK SCORE MODEL?

Abstract Background and Aims Type 1 diabetes mellitus (DM1) is associated with an increased risk of coronary heart disease (CHD), which is generally more aggressive and frequently asymptomatic. This risk substantially increases for those with nephropathy. In selected patients, simultaneous pancreas-kidney transplantation (SPKT) is the renal and pancreatic replacement therapy of choice, as it increases longevity and stabilizes diabetic complications. Despite essential, universal screening protocols for silent CHD in this population are still debatable. As so, Gowdak recently developed a simple clinical risk score to determine the pre-test probability of significant CHD in single kidney transplant candidates. Our aim was to identify potential risk factors associated with the presence of significant lesions on pre-SPKT coronary angiography (CA) and test the utility of Gowdak score in SPKT candidates. Method 77 patients submitted to SPKT between 2011 and 2018 were retrospectively included in this study. All subjects underwent CA as screening method for CHD during the eligibility evaluation. Demographic, clinical, laboratory, therapeutic and imaging characteristics were studied. Continuous variables are presented as means or medians; categorical variables as frequencies. Univariate analysis (Qui2 or Fisher test) and multivariate analysis (logistic regression) were performed. Comparison between groups of patients with and without CA injury was performed using SPSS statistics version 23 and a p &amp;lt;0.05 was considered significant. Results In the past 8 years, 99 SPKT were performed; 78% of these patients (N=77) were submitted to preoperative CA; mean age was 36±5.9 years and 64% were male. The mean duration of DM1 was 25 years and 97% had retinopathy, 43% neuropathy, 31% dysautonomia, 19% peripheral arterial disease and 7% cerebrovascular disease. We excluded 1 due to missing data. A minority of SPKT (3%, N=2) was preemptive. The mean time on dialysis was 37 months. Only one patient had angor, wh0 was excluded of Gowdak risk score assessment. Most patients (87%, N=67) were hypertensive; 56% (N=43) were on statin; 48% (N=37) had smoking habits, and 5% (N=4) had a BMI&amp;gt;30 kg/m2. CA identified at least one lesion in 48% (N = 37) of the patients, of which 30% (N=11; 14% of all CA) underwent intervention; none had complaints of angor. Based on Gowdak risk score, mean probability for CHD was 30.8% and 19 patients had a risk &amp;gt;40% - the recommended cut off to pursuit CA as screening method - but only 2 required intervention. In a univariate analysis, we found that the only distinguishing feature between the group of patients with and without CA lesions was smoking (p=0.005). DM1 with 20 or more years of evolution was found to have a significant association with coronary artery disease development (identifiable by any diagnostic test) (p=0.048). In our population of SPKT recipients Gowdak risk score did not predicted those with significant CHD. Conclusion In our study, CA was positive for lesion in almost half of the patients, all of them asymptomatic. Despite the fact that Gowdak probability score failed to identify those with significant CHD before CA (probably because all of our patients were diabetic), in our population for every seven patients submitted to CA, one needed coronary intervention. We highlight that asymptomatic patients with long-term DM and smokers should be carefully evaluated. The task of correctly ascertaining the presence of CAD can be more overwhelming when we take into account that there is a high prevalence of asymptomatic patients with extensive CAD. Facing the importance of an unmissed diagnosis we encourage the use of CA as an initial screening method, even if it is invasive. Further studies should be encouraged to create screening algorithm for SPKT candidates. Finally, medium- and long-term follow-up studies are needed to evaluate the effects of preoperative selection on posttransplant cardiac events and survival rates.

Population-Based Screening or Targeted Screening Based on Initial Clinical Risk Assessment for Atrial Fibrillation: A Report from the Huawei Heart Study.

Background: A general-population approach has been advocated to improve the screening of patients with atrial fibrillation (AF). A more pragmatic alternative may be targeted screening of patients at high risk of developing AF. We assess the value of a simple clinical risk score, C2HEST (C2, coronary artery disease/chronic obstructive pulmonary disease; COPD (1 point each); H, hypertension; E, elderly (age ≥75, doubled); S, systolic heart failure; HF (doubled); T, hyperthyroidism)); to facilitate population screening and detection of incident AF in the general population, in a prespecified ancillary analysis of the Huawei Heart Study. Methods: The Huawei Heart Study investigated general population screening for AF, identified using photoplethysmography (PPG)-based HUAWEI smart devices. We compared the value of a general population approach to a target screening approach between 26 October 2018 and 20 November 2019. Results: There were 644,124 individuals (mean age ± standard deviation, SD 34 ± 11; female 15.9%) who monitored their pulse rhythm using smart devices, among which 209,274 individuals (mean age 34 years, SD11; 10.6% female) completed the questionnaire on cardiovascular risk factors, with 739 detecting AF. Of these, 31.4% (n = 65,810) subjects reported palpitations. The median (interquartile range, IQR) duration to first detected AF was 11 (1–46), 6 (1–49), and 4 (1–24) in the population with low, intermediate, and high C2HEST score category, respectively (p = 0.03). Detected AF events rates increased with increasing C2HEST score points, stratified by age (p for trend, p < 0.001). Hazard ratios of the components of the C2HEST score for detected AF were between 1.31 and 2.75. A combination of symptomatic palpitations and C2HEST score increased prediction of AF detection, compared to using C2HEST score alone (c-indexes 0.72 vs. 0.76, Delong test, p < 0.001). Conclusions: The C2HEST score, especially when combined with symptoms, could facilitate a targeted population-based screening and preventive strategy for AF.

Development of a risk score for prediction of poor treatment outcomes among patients with multidrug-resistant tuberculosis.

Treatment outcomes among patients treated for multidrug-resistant tuberculosis (MDR-TB) are often sub-optimal. Therefore, the early prediction of poor treatment outcomes may be useful in patient care, especially for clinicians when they have the ability to make treatment decisions or offer counselling or additional support to patients. The aim of this study was to develop a simple clinical risk score to predict poor treatment outcomes in patients with MDR-TB, using routinely collected data from two large countries in geographically distinct regions. We used MDR-TB data collected from Hunan Chest Hospital, China and Gondar University Hospital, Ethiopia. The data were divided into derivation (n = 343; 60%) and validation groups (n = 227; 40%). A poor treatment outcome was defined as treatment failure, lost to follow up or death. A risk score for poor treatment outcomes was derived using a Cox proportional hazard model in the derivation group. The model was then validated in the validation group. The overall rate of poor treatment outcome was 39.5% (n = 225); 37.9% (n = 86) in the derivation group and 40.5% (n = 139) in the validation group. Three variables were identified as predictors of poor treatment outcomes, and each was assigned a number of points proportional to its regression coefficient. These predictors and their points were: 1) history of taking second-line TB treatment (2 points), 2) resistance to any fluoroquinolones (3 points), and 3) smear did not convert from positive to negative at two months (4 points). We summed these points to calculate the risk score for each patient; three risk groups were defined: low risk (0 to 2 points), medium risk (3 to 5 points), and high risk (6 to 9 points). In the derivation group, poor treatment outcomes were reported for these three groups as 14%, 27%, and 71%, respectively. The area under the receiver operating characteristic curve for the point system in the derivation group was 0.69 (95% CI 0.60 to 0.77) and was similar to that in the validation group (0.67; 95% CI 0.56 to 0.78; p = 0.82). History of second-line TB treatment, resistance to any fluoroquinolones, and smear non-conversion at two months can be used to estimate the risk of poor treatment outcome in patients with MDR-TB with a moderate degree of accuracy (AUROC = 0.69).

A Five-Parameter Score for Predicting Saphenous Vein Graft Degenerative and/or Occlusive Disease in Recurring Ischemic Symptoms After Coronary Artery Bypass Grafting

Background: The recurrence rate of ischemic symptoms after coronary artery bypass grafting (CABG) is increasing in recent years. How to prevent and treat saphenous vein graft disease (SVGD) has been a clinical challenge to date. Although studies on risk factors for SVGD have been published, there is currently no available score for estimating the risk of SVGD. We sought to develop and validate a scoring system to predict SVGD among patients who recurring ischemia post CABG. Objective: To inform research on patient management including modifiable risk factors for SVGD [symptomatic ≥ 50% stenosis in at least 1 Saphenous vein grafts (SVG)], we sought to develop and validate a simple predictive clinical risk score index for SVGD with recurring ischemia after CABG. Methods and Results: This was a retrospective cohort study and the results were validated using bootstrap resampling on a separate cohort. A nomogram and risk scoring system were developed based on retrospectively collected data from a training cohort of 606 consecutive patients who were readmitted at Tianjin Chest Hospital between March 2015 and December 2017 with recurring ischemia >1 year after CABG. Logistic regression model was used to find the predictive factors and to build a nomogram. The predictive accuracy and discriminative ability of the model for SVGD were determined by concordance (C) index and calibration curve. To assess the generalization, models were validated using bootstrap resampling and an external cohort of 187 consecutive patients enrolled between March 2017 and December 2018 at 4 other local hospitals. In multivariable analysis of the primary cohort, native lesion vessel number, SVG age, recurring ischemia type, very low-density lipoprotein level, and left ventricular end-diastolic diameter were independent predictors of SVGD after CABG. A summary risk score was derived from nomogram, ranging from 0 to 30, with a cutoff value of 15. In internal and external validation, the C-index was 0.82[95%CI, 0.78-0.86] and 0.86 [0.79-0.92] for risk score-based predictions, indicating good overall discrimination. The calibration curve for probability of SVGD showed optimal agreement between actual observations and risk score prediction. Conclusions: A simple-to-use risk scoring system based on five easily obtainable demographic, clinical, biochemical variables was developed and validated to predict the risk of SVGD among patients who recurring ischemia post CABG. This score may be useful for providing patients with individualized estimates of SVGD risk. Funding Statement: This research project was funded by the Key Project of Scientific and Technological Support Plan of Tianjin in 2016 (No.16YFZCSY00800), the Key Project of Healthcare Industry of Tianjin in 2015 (No. 15KG128) and Major Science and Technology Projects of Tianjin Science and Technology Commission in 2016 (No. 16ZXMJSY00150). Declaration of Interests: All authors have no conflicts of interest to declare. Ethics Approval Statement: Ethical approval was obtained from participating institutions through their respective institutional review boards, and all participants provided written informed consent prior to treatment.

Risk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with HIV-associated tuberculosis in sub-Saharan Africa: Derivation and external validation cohort study.

BackgroundThe prevalence of and mortality from HIV-associated tuberculosis (HIV/TB) in hospital inpatients in Africa remains unacceptably high. Currently, there is a lack of tools to identify those at high risk of early mortality who may benefit from adjunctive interventions. We therefore aimed to develop and validate a simple clinical risk score to predict mortality in high-burden, low-resource settings.Methods and findingsA cohort of HIV-positive adults with laboratory-confirmed TB from the STAMP TB screening trial (Malawi and South Africa) was used to derive a clinical risk score using multivariable predictive modelling, considering factors at hospital admission (including urine lipoarabinomannan [LAM] detection) thought to be associated with 2-month mortality. Performance was evaluated internally and then externally validated using independent cohorts from 2 other studies (LAM-RCT and a Médecins Sans Frontières [MSF] cohort) from South Africa, Zambia, Zimbabwe, Tanzania, and Kenya. The derivation cohort included 315 patients enrolled from October 2015 and September 2017. Their median age was 36 years (IQR 30–43), 45.4% were female, median CD4 cell count at admission was 76 cells/μl (IQR 23–206), and 80.2% (210/262) of those who knew they were HIV-positive at hospital admission were taking antiretroviral therapy (ART). Two-month mortality was 30% (94/315), and mortality was associated with the following factors included in the score: age 55 years or older, male sex, being ART experienced, having severe anaemia (haemoglobin < 80 g/l), being unable to walk unaided, and having a positive urinary Determine TB LAM Ag test (Alere). The score identified patients with a 46.4% (95% CI 37.8%–55.2%) mortality risk in the high-risk group compared to 12.5% (95% CI 5.7%–25.4%) in the low-risk group (p < 0.001). The odds ratio (OR) for mortality was 6.1 (95% CI 2.4–15.2) in high-risk patients compared to low-risk patients (p < 0.001). Discrimination (c-statistic 0.70, 95% CI 0.63–0.76) and calibration (Hosmer-Lemeshow statistic, p = 0.78) were good in the derivation cohort, and similar in the external validation cohort (complete cases n = 372, c-statistic 0.68 [95% CI 0.61–0.74]). The validation cohort included 644 patients between January 2013 and August 2015. Median age was 36 years, 48.9% were female, and median CD4 count at admission was 61 (IQR 21–145). OR for mortality was 5.3 (95% CI 2.2–9.5) for high compared to low-risk patients (complete cases n = 372, p < 0.001). The score also predicted patients at higher risk of death both pre- and post-discharge. A simplified score (any 3 or more of the predictors) performed equally well. The main limitations of the scores were their imperfect accuracy, the need for access to urine LAM testing, modest study size, and not measuring all potential predictors of mortality (e.g., tuberculosis drug resistance).ConclusionsThis risk score is capable of identifying patients who could benefit from enhanced clinical care, follow-up, and/or adjunctive interventions, although further prospective validation studies are necessary. Given the scale of HIV/TB morbidity and mortality in African hospitals, better prognostic tools along with interventions could contribute towards global targets to reduce tuberculosis mortality.

A risk score for predicting respiratory complications after thoracic surgery.

Respiratory complications are some of the most common complications following thoracic surgery and can lead to higher perioperative morbidity and mortality. The purpose of this study was to develop a simple clinical score for prediction of respiratory complications after thoracic surgery, and determine the internal validity. In this retrospective cohort study, all consecutive patients were aged 18 years and over and undergoing non-cardiac thoracic surgery at a tertiary-care university hospital. Respiratory complications included bronchospasm, atelectasis, pneumonia, respiratory failure, and adult respiratory distress syndrome within 30 days of surgery or before discharge. A total of 1488 patients were included over a 7-year period, and 15.8% (235 of 1488 patients) developed respiratory complications. The significant predictors of respiratory complications were chronic obstructive pulmonary disease, American Society of Anesthesiologist physical status ≥ 3, right-sided surgery, duration of surgery longer than 180 min, preoperative arterial oxygen saturation on room air < 96%, and open thoracotomy. The area under receiving operating characteristic curve was 0.78 (95% confidence interval: 0.75-0.82) and 0.76 (95% confidence interval: 0.70-0.83) for the derivation and validation cohorts, respectively. The model was well calibrated with a Hosmer-Lemeshow goodness-of-fit of 7.32 ( p = 0.293). This study developed and internally validated a simple clinical risk score for prediction of respiratory complications following thoracic surgery. This score can be used to stratify high-risk patients, address modifiable risk factors for respiratory complications, and provide preventive strategies for improving postoperative outcomes.

A Simple Clinical Risk Score (C2HEST) for Predicting Incident Atrial Fibrillation in Asian Subjects: Derivation in 471,446 Chinese Subjects, With Internal Validation and External Application in 451,199 Korean Subjects

The incidence of atrial fibrillation (AF) is increasing, conferring a major health-care issue in Asia. No risk score for predicting incident AF has been specifically developed in Asian subjects. Our aim was to investigate risk factors for incident AF in Asian subjects and to combine them into a simple clinical risk score. Risk factors for incident AF were analyzed in 471,446 subjects from the Chinese Yunnan Insurance Database (internal derivation cohort) and then combined into a simple clinical risk score. External application of the new score was performed in 451,199 subjects from the Korean National Health Insurance Service (external cohort). In the internal cohort, structural heart disease (SHD), heart failure (HF), age≥ 75 years, coronary artery disease (CAD), hyperthyroidism, COPD, and hypertension were associated with incident AF. Given the low prevalence and the strong association of SHD with incident AF (hazard ratio, 26.07; 95%CI, 18.22-37.30; P< .001), these patients should be independently considered as high risk for AF and were excluded from the analysis. The remaining predictors were combined into the new simple C2HEST score: C2: CAD/COPD (1 point each); H: hypertension (1 point); E: elderly (age≥ 75 years, 2 points); S: systolic HF (2 points); and T: thyroid disease (hyperthyroidism, 1 point). The C2HEST score showed good discrimination with the area under the curve (AUC) of 0.75 (95%CI, 0.73-0.77) and had good calibration (P= .774). The score was internally validated by bootstrap sampling procedure, giving an AUC of 0.75 (95%CI, 0.73-0.77). External application gave an AUC of 0.65 (95%CI, 0.65-0.66). The C2HEST score was superior to CHADS2 and CHA2DS2-VASc scores in both cohorts in predicting incident AF. We have developed and validated the C2HEST score as a simple clinical tool to assess the individual risk of developing AF in the Asian population without SHD.

Predictors of long-term mortality with cardiac resynchronization therapy in mild heart failure patients with left bundle branch block.

Cardiac resynchronization therapy (CRT) is highly beneficial in patients with heart failure (HF) and left bundle branch block (LBBB); however, up to 30% of patients in this selected group are nonresponders. We hypothesized that clinical and echocardiographic variables can be used to develop a simple mortality risk stratification score in CRT. Best-subsets proportional-hazards regression analysis was used to develop a simple clinical risk score for all-cause mortality in 756 patients with LBBB allocated to the CRT with defibrillator (CRT-D) group enrolled in the multicenter automatic defibrillator implantation trial with cardiac resynchronization therapy. The score was used to assess the mortality risk within the CRT-D group and the associations with mortality reduction with CRT-D vs implantable cardioverter defibrillator (ICD) in each risk category. Four clinical variables comprised the risk score: age ≥ 65, creatinine ≥ 1.4 mg/dL, history of coronary artery bypass graft, and left ventricular ejection fraction (LVEF) < 26%. Every 1 point increase in the score was associated with 2-fold increased mortality within the CRT-D arm (P < 0.001). CRT-D was associated with mortality reduction as compared with ICD only in patients with moderate risk: score 0 (HR = 0.80, P = 0.615), score 1 (HR = 0.54, P = 0.019), score 2 (HR = 0.54, P = 0.016), score 3-4 risk factors (HR = 1.08, P = 0.811); however, the device by score interaction was not significant (P = 0.306). The score was also significantly predictive of left ventricular reverse remodeling (P < 0.001). Four clinical variables can be used for improved mortality risk stratification in mild HF patients with LBBB implanted with CRT-D.