Simple Risk Research Articles

A tertiary care center-based study of a novel ‘ICU Mortality and Prolonged Stay Risk Scoring System’

Background & objective: Intensive care has been associated with high cost and resource-intensive medical care. Therefore, a risk prediction model is required to plan time allocation, human resources, and the required equipment. Various risk predictions for ICU mortality and ‘Prolonged Length of Stay’ (PLOS) scores are already available. Still, the established model, such as the APACHE IV score or SAPS II, sometimes became impractical since they required many laboratory parameters. A model based on co-morbidities and demographic factors may be more useful in limited resources setting. Hence, we developed a simple ICU mortality and PLOS risk prediction model based on co-morbidities and demographic data. Methodology: This retrospective cohort study was performed to develop a risk scoring for mortality and PLOS, using data from Dr. Sardjito Hospital Yogyakarta database between January 01-December 31, 2019. Logistic regression and bootstrap methods were used to create a risk score for estimating the risk. The discrimination performance of the model was evaluated using the area under the curve (AUC) of the receiver operating characteristic (ROC). The Hosmer-Lemeshow test was employed to assess the model’s calibration. Results: A total of 415 patients were included in this study. The risk factors for mortality were perioperative support medication, kidney failure, neurologic disorder, respiratory failure, and intraoperative blood transfusion. The mortality score of 6 was associated with a 100% probability of mortality. Medical cases, GCS < 8, vasoactive/inotropic medication, sepsis, respiratory failure, and kidney failure were the risk factors for PLOS. PLOS score of 3 was associated with a 100% probability of PLOS. The discrimination for either mortality or PLOS was considered excellent with the AUC (± 95% CI) for mortality 0.896 (0.853-0.94), while for PLOS 0.878 (0.80-0.90). The calibration test found that both models had good calibration with P values of 0.53 and 0.55 for mortality and PLOS, respectively. Conclusion: The ‘Mortality and Prolonged Length of Stay Prediction Score’ based on co-morbidities and demographic data upon admission to ICU had good accuracy and can be applied as a potential new scoring system in healthcare institutions. Abbreviations: APACHE- Acute Physiologic Assessment and Chronic Health Evaluation; AUC; Area Under the Curve GCS- Glasgow Coma Scale; ICU- Intensive Care Unit; PLOS- ‘Prolonged Length of Stay’; PRC- Packed Red Cells; SAPS- Simplified Acute Physiology Score Keywords: Risk Scoring; Mortality; Prolonged Length of Stay; ICU Citation: Widyastuti Y, Jufan AY, Widodo U, Wisudarti CFR, Sudadi, Fauzi RA, Ardiansyah F. A tertiary care center-based study of a novel ‘ICU Mortality and Prolonged Stay Risk Scoring System’. Anaesth. pain intensive care 2024;28(1):100−107; DOI: 10.35975/apic.v28i1.2382 Received: October 02, 2023; Reviewed: November 27, 2023; Accepted: December 17, 2023

Transcranial Direct Current Stimulation for Improving Spasticity, Gross Motor Functions, Balance and Gait in Spastic Cerebral Palsy: Systematic Review of Clinical Trials.

Context: Cerebral palsy is known as a non-progressive neuromotor disorder that is characterized by abnormalities of muscular tonicity, gross and fine motor skills, balance, posture and gait. Transcranial direct current stimulation (tDCS) has emerged as a rather promising therapeutic tool for the management of the above-mentioned symptoms and to possibly to optimize the rehabilitation strategies. Purpose: This review study evaluates the effectiveness of tDCS on spasticity, gross motor function, balance, and gait; it also tends to summarize the beneficial protocols of tDCS for spastic cerebral palsy patients. Methods: Comprehensive searches were performed on three electronic databases including PubMed, PEDro, and Cochrane. The inclusion criteria for considered articles were (1) English-language publications available in full text between 2000 and 2023.(2), The PEDro scale, where a score of at least 5 out of 10 was acceptable, (3) Human studies using the tDCS intervention with control group , and (4) Study design (PICOS) method, where P = spastic CP; I = transcranial direct current stimulation; C = conventional physical Therapy; O = muscle strength, spasticity, , and gait kinematics; and S = RCT. Results: Nine RCTs were included based on the inclusion criteria. This systematic review showed transcranial direct current stimulation is a non-invasive safe modality, and well-tolerated brain stimulation technique with positive effects on gross motor function, spasticity, balance, muscle strength, and gait. Besides, it can be used in conjunction with different modalities as well as conventional physical therapy. Conclusion: It can be concluded that transcranial direct current stimulation is a novel, fairly simple, low cost and low risk therapeutic modality that can be easily administered in a clinic as well as at home to produce a significant change in spasticity, balance, gross motor function, and gait.

A Simple Risk Formula for the Prediction of COVID-19 Hospital Mortality.

SARS-CoV-2 respiratory infection is associated with significant morbidity and mortality in hospitalized patients. We aimed to assess the risk factors for hospital mortality in non-vaccinated patients during the 2021 spring wave in the Czech Republic. A total of 991 patients hospitalized between January 2021 and March 2021 with a PCR-confirmed SARS-CoV-2 acute respiratory infection in two university hospitals and five rural hospitals were included in this analysis. After excluding patients with unknown outcomes, 790 patients entered the final analyses. Out of 790 patients included in the analysis, 282/790 (35.7%) patients died in the hospital; 162/790 (20.5) were male and 120/790 (15.2%) were female. There were 141/790 (18%) patients with mild, 461/790 (58.3%) with moderate, and 187/790 (23.7%) with severe courses of the disease based mainly on the oxygenation status. The best-performing multivariate regression model contains only two predictors-age and the patient's state; both predictors were rendered significant (p < 0.0001). Both age and disease state are very significant predictors of hospital mortality. An increase in age by 10 years raises the risk of hospital mortality by a factor of 2.5, and a unit increase in the oxygenation status raises the risk of hospital mortality by a factor of 20.

Human Trypanosoma cruzi infection in the Argentinean Chaco: risk factors and identification of households with infected children for treatment

BackgroundChagas disease is a neglected tropical disease (NTD). Cost-effective strategies for large-scale implementation of diagnosis and etiological treatment are urgently needed to comply with NTD control goals. We determined the seroprevalence of Trypanosoma cruzi infection and associated risk factors in a well-defined rural population of Pampa del Indio municipality including creole and indigenous (Qom) households and developed two indices to identify houses harboring infected children.MethodsWe serodiagnosed and administered a questionnaire to 1337 residents (48.2% of the listed population) in two sections of the municipality (named Areas II and IV) 6–9 years after deploying sustained vector control interventions. Multiple logistic regression models were used to evaluate the relationship between human infection and a priori selected predictors. Two risk indices were constructed based on environmental and serostatus variables, and we used spatial analysis to test whether households harboring T. cruzi-seropositive children were randomly distributed.ResultsThe global seroprevalence of T. cruzi infection was 24.8%. Human infection was positively and significantly associated with exposure time to triatomines, the household number of seropositive co-inhabitants, maternal seropositivity for T. cruzi, recent residence at the current house and the presence of suitable walls for triatomine colonization in the domicile. The pre-intervention mean annual force of infection (FOI) was 1.23 per 100 person-years. Creoles from Area IV exhibited the highest seroprevalence and FOI; Qom people from both areas displayed intermediate ones and creoles from Area II the lowest. Three hotspots of infected children were spatially associated with hotspots of triatomine abundance at baseline and persistent house infestation. No child born after vector control interventions was T. cruzi seropositive except for one putative transplacental case. Two simple risk indices (based on self-reported inhabiting an infested house and suitable walls for triatomines or maternal serostatus) identified 97.3–98.6% of the households with at least one T. cruzi-seropositive child.ConclusionsWe showed strong heterogeneity in the seroprevalence of T. cruzi infection within and between ethnic groups inhabiting neighboring rural areas. Developed indices can be used for household risk stratification and to improve access of rural residents to serodiagnosis and treatment and may be easily transferred to primary healthcare personnel.Graphical

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.

Prognostic impact of MitraScore in elderly Asian patients with heart failure: sub-analysis of FRAGILE-HF.

MitraScore is a novel, simple, and manually calculatable risk score developed as a prognostic model for patients undergoing transcatheter edge-to-edge repair (TEER) for mitral regurgitation. As its components are considered prognostic in heart failure (HF), we aimed to investigate the usefulness of the MitraScore in HF patients. We calculated MitraScore for 1100 elderly patients (>65years old) hospitalized for HF in the prospective multicentre FRAGILE-HF study and compared its prognostic ability with other simple risk scores. The primary endpoint was all-cause deaths, and the secondary endpoints were the composite of all-cause deaths and HF rehospitalization and cardiovascular deaths. Overall, the mean age of 1100 patients was 80±8years, and 58% were men. The mean MitraScore was 3.2±1.4, with a median of 3 (interquartile range: 2-4). A total of 326 (29.6%), 571 (51.9%), and 203 (18.5%) patients were classified into low-, moderate-, and high-risk groups based on the MitraScore, respectively. During a follow-up of 2years, 226 all-cause deaths, 478 composite endpoints, and 183 cardiovascular deaths were observed. MitraScore successfully stratified patients for all endpoints in the Kaplan-Meier analysis (P<0.001 for all). In multivariate analyses, MitraScore was significantly associated with all endpoints after covariate adjustments [adjusted hazard ratio (HR) (95% confidence interval): 1.22 (1.10-1.36), P<0.001 for all-cause deaths; adjusted HR 1.17 (1.09-1.26), P<0.001 for combined endpoints; and adjusted HR 1.24 (1.10-1.39), P<0.001 for cardiovascular deaths]. The Hosmer-Lemeshow plot showed good calibration for all endpoints. The net reclassification improvement (NRI) analyses revealed that the MitraScore performed significantly better than other manually calculatable risk scores of HF: the GWTG-HF risk score, the BIOSTAT compact model, the AHEAD score, the AHEAD-U score, and the HANBAH score for all-cause and cardiovascular deaths, with respective continuous NRIs of 0.20, 0.22, 0.39, 0.39, and 0.29 for all-cause mortality (all P-values<0.01) and 0.20, 0.22, 0.42, 0.40, and 0.29 for cardiovascular mortality (all P-values<0.02). MitraScore developed for patients undergoing TEER also showed strong discriminative power in HF patients. MitraScore was superior to other manually calculable simple risk scores and might be a good choice for risk assessment in clinical practice for patients receiving TEER and those with HF.

Prediction of severe infections in chronic lymphocytic leukemia: a simple risk score to stratify patients at diagnosis

Chronic Lymphocytic Leukemia (CLL) is well-known for increasing susceptibility to infections. Factors such as immune dysregulation, IGHV status, hypogammaglobulinemia, and patient comorbidity and treatment, contribute to higher infection rates and mortality. However, the impact of hypogammaglobulinemia on infection rates is controversial. We aimed to identify clinical and biological parameters linked to the risk of severe infectious events. Additionally, we set up a straightforward risk infection score to stratify CLL patients at diagnosis, thereby enabling the development of suitable infection prevention strategies. We retrospectively evaluated 210 unselected CLL patients diagnosed between 1988 and 2018. This evaluation encompassed demographics, Binet stage, immunoglobulin (Ig) levels, treatment history, comorbidities, and IGHV mutational status at diagnosis. The frequency and severity of infectious events were recorded. Analysis revealed that age, IGHV mutational status, Binet stage, and hypogammaglobulinemia were statistically associated with the Time to First Infection (TTFI) in univariate and multivariate analyses. Using hazard ratios from the multivariate analysis, we finally devised a risk scoring system that integrated age, IGHV mutational status, immunoglobulin levels, and Binet stage to stratify patients at diagnosis based on their specific infection risk. In our cohort, disease progression and infections were the leading cause of death. These findings pointed out the clinical need for a screening process strategic for defining infectious risk at the time of CLL diagnosis, with a significant enhancement in the clinical management of these patients.

Development of a gastric cancer risk calculator for questionnaire-based surveillance of Iranian dyspeptic patients

BackgroundGastric cancer (GC) is considered a silent killer, taking more than three quarters of a million lives annually. Therefore, prior to further costly and invasive diagnostic approaches, an initial GC risk screening is desperately in demand.MethodsIn order to develop a simple risk scoring system, the demographic and lifestyle indices from 858 GC and 1132 non-ulcer dyspeptic (NUD) patients were analysed. We applied a multivariate logistic regression approach to identify the association between our target predictors and GC versus NUD. The model performance in classification was assessed by receiver operating characteristic (ROC) analysis. Our questionnaire covering 64 predictors, included known risk factors, such as demographic features, dietary habits, self-reported medical status, narcotics use, and SES indicators.ResultsOur model segregated GC from NUD patients with the sensitivity, specificity, and accuracy rates of 85.89, 63.9, and 73.03%, respectively, which was confirmed in the development dataset (AUC equal to 86.37%, P < 0.0001). Predictors which contributed most to our GC risk calculator, based on risk scores (RS) and shared percentages (SP), included: 1) older age group [> 70 (RS:+ 241, SP:7.23), 60–70 (RS:+ 221, SP:6.60), 50–60 (RS:+ 134, SP:4.02), 2) history of gastrointestinal cancers (RS:+ 173, SP:5.19), 3) male gender (RS:+ 119, SP:3.55), 4) non-Fars ethnicity (RS:+ 89, SP:2.66), 5) illiteracy of both parents (RS:+ 78, SP:2.38), 6) rural residence (RS:+ 77, SP:2.3), and modifiable dietary behaviors (RS:+ 32 to + 53, SP:0.96 to 1.58).ConclusionOur developed risk calculator provides a primary screening step, prior to the subsequent costly and invasive measures. Furthermore, public awareness regarding modifiable risk predictors may encourage and promote lifestyle adjustments and healthy behaviours.

Clinical predictors of left ventricular thrombus after myocardial infarction as detected by magnetic resonance imaging.

The diagnosis of a left ventricular (LV) thrombus in patients with ST-segment elevation myocardial infarction (STEMI) remains challenging. The aim of the current study is to characterize clinical predictors for LV thrombus formation, as detected by cardiac magnetic resonance imaging (CMRI). We retrospectively evaluated 337 consecutive STEMI patients. All patients underwent transthoracic echocardiography (TTE) and CMRI during their index hospitalization. We developed a novel risk stratification model (ThrombScore) to identify patients at risk of developing an LV thrombus. CMRI revealed the presence of LV thrombus in 34 patients (10%), of whom 33 (97%) had experienced an anterior wall myocardial infarction (MI), and the majority (77%) had at least mildly reduced left ventricular ejection fraction (LVEF < 45%). The sensitivity for thrombus formation of the first and second TTE was 5.9% and 59%, respectively. Multivariate logistic regression model revealed that elevated C-reactive protein levels, lack of ST-segment elevation (STe) resolution, elevated creatine phosphokinase levels, and STe in anterior ECG leads are robust independent predictors for developing an LV thrombus. These variables were incorporated to construct the ThrombScore: a simple six-point risk model. The odds ratio for developing thrombus per one-point increase in the score was 3.2 (95% CI 2.1-5.01; p < 0.001). The discrimination analysis of the model revealed a c-statistic of 0.86 for thrombus development. The model identified three distinct categories (I, II, and III) with corresponding thrombus incidences of 0%, 1.6%, and 27.6%, respectively. ThrombScore is a simple and practical clinical model for risk stratification of thrombus formation in patients with STEMI.

Genetic risk score for gestational weight gain

Gestational weight gain (GWG) involves health consequences for both mother and offspring. Genetic factors seem to play a role in the GWG trait. For small effect sizes of a single genetic polymorphism (SNP), a genetic risk score (GRS) summarizing risk-associated variation from multiple SNPs can serve as an effective approach to genetic association analysis.The aim of the study was to analyze the association between genetic risk score (GRS) and gestational weight gain (GWG).GWG was calculated for a total of 342 healthy Polish women of Caucasian origin, aged 19 to 45 years. The SNPs rs9939609 (FTO), rs6548238 (TMEM18), rs17782313 (MC4R), rs10938397 (GNPDA2), rs10913469 (SEC16B), rs1137101 (LEPR), rs7799039 (LEP), and rs5443 (GNB3) were genotyped using commercial TaqMan SNP assays. A simple genetic risk score was calculated into two ways: GRS1 based on the sum of risk alleles from each of the SNPs, while GRS2 based on the sum of risk alleles of FTO, LEPR, LEP, and GNB3.Positive association between GRS2 and GWG (β = 0.12, p = 0.029) was observed. Genetic risk variants of TMEM18 (p = 0.006, OR = 2.6) and GNB3 (p < 0.001, OR = 3.3) are more frequent in women with increased GWG, but a risk variant of GNPDA2 (p < 0.001, OR = 2.7) is more frequent in women with adequate GWG, and a risk variant of LEPR (p = 0.011, OR = 3.1) in women with decreased GWG.GRS2 and genetic variants of TMEM18, GNB3, GNPDA2, and LEPR are associated with weight gain during pregnancy.

The 365 km tunnels assessment along ASPI Motorways Network – Key findings addressing risk analysis procedures and structural conditions evaluation and strategy of interventions

An extraordinary assessment plan, performed on 365 km of motorway tunnels, has been carried out in Italy since 2020 starting with detailed inspections and testing. Hundreds of laser scanning kilometres and ground-penetrating radargrams, thousands of concrete compressive strength tests, endoscope inspections and flat-jack tests have been performed so far. Tens of thousands structural defects were detected and several square meters of temporary safety measures installed as well. This allowed to acquire a significant amount of knowledges about the current condition of the asset. According to the process defined by the new Italian Regulations, the dataset analysis provides an insight into the condition of the asset, guiding the entire maintenance process. The visual and detailed inspections frequency is driven by the simplified risk analysis outcome and further safety evaluation are designed based on multidisciplinary criticality. A comprehensive approach, based on in-depth knowledge of the characteristics of the existing tunnel, has been engineered for structural risk, with a focus on tunnel “history” (excavation stages and techniques, construction materials, etc.), design and dimensioning approaches (e.g. Kommerel’s graphical method), identified as standard methods for the tunnel construction period from literature review. Additional analyses are carried out for likely local structural failure modes of tunnel lining (punching and flexural strength of residual concrete layers, spalling hazard of concrete thickness anomalies due to temperature variations). When re-lining is needed, the design of a new shell aimed to ensure at least the same structural performance of the original one is addressed, including seismic loads that were neglected in the original design. The tunnel assessment, from inspections to re-lining works passing through risk analysis, is an on-going process open to be improved in the upcoming years within a wider asset management strategy.

Simplified risk stratification based on cardiopulmonary exercise test: A Spanish two-center experience.

A simplified 4-strata risk stratification approach based on three variables is widespread in pulmonary arterial hypertension (PAH)at follow-up. This study aimed to assess the impact of replacing the 6-min walk test (6MWT)with the peak 02 uptake evaluated by the cardiopulmonary exercise test (CPET)on risk stratification by this scale. We included 180 prevalent patients with PAH from two reference hospitals in Spain, followed up between 2006 and 2022. Patients were included if all the variables of interest were available within a 3-month period on the Spanish Registry of Pulmonary Arterial Hypertension (REHAP):functional class (FC);NT-proBNP;6MWT; and CPET. The original 4-strata model (NT-proBNP,6MWT, FC) identified most patients at low or intermediate-low risk (36.7% and 51.1%, respectively). Notably, the modified scale (NT-proBNP,CPET, FC) improved the identification of patients at intermediate-high risk up to 18.9%, and at high risk up to 1.1% in comparison with the previous 12.2% and 0.0% in the original scale. This new model increased the number of patients correctly classified into higher-risk strata (positive NRI of 0.06), as well as classified more patients without events in lower-risk strata (negative NRI of 0.04). The proposed score showed a slightly superior prognostic capacity compared with the original model (Harrel's C-index 0.717 vs. 0.709). Using O2 uptake instead of distance walked in the 6MWT improves the identification of high-risk patients using the 4-strata scale. This change could have relevant prognostic implications and lead to changes in the specific treatment of PAH.

Risk of repeat self-harm among individuals presenting to healthcare services: development and validation of a clinical risk assessment model (OxSET)

BackgroundA self-harm episode is a major risk factor for repeat self-harm. Existing tools to assess and predict repeat self-harm have major methodological limitations, and few are externally validated.ObjectiveTo develop and...

Developing a calculable risk prediction model for sternal wound infection after median sternotomy: a retrospective study.

Diagnosing sternal wound infection (SWI) following median sternotomy remains laborious and troublesome, resulting in high mortality rates and great harm to patients. Early intervention and prevention are critical and challenging. This study aimed to develop a simple risk prediction model to identify high-risk populations of SWI and to guide examination programs and intervention strategies. A retrospective analysis was conducted on the clinical data obtained from 6715 patients who underwent median sternotomy between January 2016 and December 2020. The least absolute shrink and selection operator (LASSO) regression method selected the optimal subset of predictors, and multivariate logistic regression helped screen the significant factors. The nomogram model was built based on all significant factors. Area under the curve (AUC), calibration curve and decision curve analysis (DCA) were used to assess the model's performance. LASSO regression analysis selected an optimal subset containing nine predictors that were all statistically significant in multivariate logistic regression analysis. Independent risk factors of SWI included female [odds ratio (OR) = 3.405, 95% confidence interval (CI) = 2.535-4.573], chronic obstructive pulmonary disease (OR = 4.679, 95% CI = 2.916-7.508), drinking (OR = 2.025, 95% CI = 1.437-2.855), smoking (OR = 7.059, 95% CI = 5.034-9.898), re-operation (OR = 3.235, 95% CI = 1.087-9.623), heart failure (OR = 1.555, 95% CI = 1.200-2.016) and repeated endotracheal intubation (OR = 1.975, 95% CI = 1.405-2.774). Protective factors included bone wax (OR = 0.674, 95% CI = 0.538-0.843) and chest physiotherapy (OR = 0.446, 95% CI = 0.248-0.802). The AUC of the nomogram was 0.770 (95% CI = 0.745-0.795) with relatively good sensitivity (0.798) and accuracy (0.620), exhibiting moderately good discernment. The model also showed an excellent fitting degree on the calibration curve. Finally, the DCA presented a remarkable net benefit. A visual and convenient nomogram-based risk calculator built on disease-associated predictors might help clinicians with the early identification of high-risk patients of SWI and timely intervention.

Development and validation of a simple risk scoring system for a COVID-19 diagnostic prediction mode.

In a resource-constrained situation, a clinical risk stratification system can assist in identifying individuals who are at higher risk and should be tested for COVID-19. This study aims to find a predictive scoring model to estimate the COVID-19 diagnosis." Patients who applied to the emergency pandemic clinic between April 2020 and March 2021 were enrolled in this retrospective study. At admission, demographic characteristics, symptoms, comorbid diseases, chest computed tomography (CT), and laboratory findings were all recorded. Development and validation datasets were created. The scoring system was performed using the coefficients of the odds ratios obtained from the multivariable logistic regression analysis." Among 1187 patients admitted to the hospital, the median age was 58 years old (22-96), and 52.7% were male. In a multivariable analysis, typical radiological findings (OR= 8.47, CI= 5.48-13.10, p< 0.001) and dyspnea (OR= 2.85, CI= 1.71-4.74, p< 0.001) were found to be the two important risk actors for COVID-19 diagnosis, followed by myalgia (OR= 1.80, CI= 1.08- 2.99, p= 0.023), cough (OR= 1.65, CI= 1.16-2.26, p= 0.006) and fatigue symptoms (OR= 1.57, CI= 1.06-2.30, p= 0.023). In our scoring system, dyspnea was scored as 2 points, cough as 1 point, fatigue as 1 point, myalgia as 1 point, and typical radiological findings were scored as 5 points. This scoring system had a sensitivity of 71% and a specificity of 76.3% for a cut-off value of >2, with a total score of 10 (p< 0.001). The predictive scoring system could accurately predict the diagnosis of COVID-19 infection, which gave clinicians a theoretical basis for devising immediate treatment options. An evaluation of the predictive efficacy of the scoring system necessitates a multi-center investigation.

BANKRUPTCY RISK ASSESSMENT FOR INSURANCE COMPANIES UNDER UNCERTAINTY

The insurance market is an integral part of the country's financial system and is therefore extremely important for economic development. Any shocks in the insurance market may cause a slowdown in economic growth and development and have a negative impact on the country's financial system. The stability of the insurance market is ensured by the companies operating in it. That is why our analysis focuses on assessing the risk of insurance companies' bankruptcy and analyzing the main factors that affect the situation in the insurance market.This article analyzes the main approaches to assessing the risk of insurance companies depending on the size of the risk premium. A simple dynamic risk assessment model was applied.Our analysis of the literature has shown that general approaches to assessing the risk of insurance company failure depend on the overall situation in the country and the market itself. In countries with more frequent force majeure events, more complex and sophisticated models have been introduced to assess the required amount of risk premium to avoid bankruptcy.The market situation in Ukraine had been stable for a long time, but with the onset of the pandemic, certain problems began to arise. An analysis of one of the leading insurance companies in the market showed that before the war started, it had a bankruptcy risk close to zero. Unfortunately, it should be noted that military actions, which are force majeure circumstances, complicate the quantitative analysis, as Ukrainian companies do not have effective mechanisms to cover this type of risk.It is established that a company cannot arbitrarily determine the amount of risk premium based on its own needs. This value will also be influenced by external macroeconomic factors that will affect not only the overall economic situation but also all participants in the insurance market, including consumers of insurance services.

Outcomes of latent rheumatic heart disease: External validation of a simplified score in patients with and without secondary prophylaxis

BackgroundSecondary antibiotic prophylaxis reduces progression of latent rheumatic heart disease (RHD) but not all children benefit. Improved risk stratification could refine recommendations following positive screening. We aimed to evaluate the performance of a previously developed echocardiographic risk score to predict mid-term outcomes among children with latent RHD. MethodsWe included children who completed the GOAL, a randomized trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. Outcomes were determined by a 4-member adjudication panel. We applied the point-based score, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3 points), MV regurgitation jet length ≥ 2 cm (6 points), aortic valve focal thickening (4 points) and any aortic regurgitation (5 points)), to panel results. Unfavorable outcome was defined as progression of diagnostic category (borderline to definite, mild definite to moderate/severe definite), worsening valve involvement or remaining with mild definite RHD. Results799 patients (625 borderline and 174 definite RHD) were included, with median follow-up of 24 months. At total 116 patients (14.5%) had unfavorable outcome per study criteria, 57.8% not under prophylaxis. The score was strongly associated with unfavorable outcome (HR = 1.26, 95% CI 1.16–1.37, p < 0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7–9 points) and high-risk (≥10 points) children at follow-up were 11.8%, 30.4%, and 42.2%, (p < 0.001) respectively (C-statistic = 0.64 (95% CI 0.59–0.69)). ConclusionsThe simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes.

A PORTABLE TECHNOLOGY-BASED BALANCE ASSESSMENT PREDICTS FALL RISKS IN LOW-INCOME COMMUNITY-DWELLING OLDER ADULTS

Abstract Despite strong evidence on the association between balance performance and fall risks, there is a need for further studies among racially diverse low-income communities. Sixty-two healthy, low-income community-dwelling older adults (mean 74.11, SD: 6.34, 61-88 years old) in Central Florida were recruited and administered the BTrackS Balance Tracking System (BBS) for measuring balance performance. BBS is a postural sway-based balance performance assessment, where participants were guided to stand still on the BBS plate with hands on hips and eyes closed for about 1-2 minutes. Fall risk was assessed by the Centers for Disease Control and Prevention (CDC)’s twelve-item self-assessment checklist, Stopping Elderly Accidents, Deaths &amp; Injuries (STEADI). About 58% of participants were African Americans, completed high school (54.8%), lived alone (67.7%), and earned just enough financially (54.8%). The simple regression results indicated that the model explained 14.9% of the variance (R2=.149, F (1,60) = 10.47, p =.002). Higher BBS scores (β = .100, p =.002) were significantly associated with higher fall risk scores. As older adults had reduced balance, their fall risks increased. The findings of this study confirmed the benefits of using a combination of a simple fall risk checklist and a portable assessment technology in enhancing the accessibility of balance and fall risk screening. Furthermore, a technology-based balance performance assessment is key in tailoring fall interventions for older adults with poor balance.

Alternative Approach in Colorectal Anastomotic Stricture: Bougie Dilatation

Dear Editor, Anostomotic stricture (AS) is seen in 2-30% of patients after colorectal surgery. Various factors such as tissue ischaemia, anastomotic leakage and radiotherapy have been suggested in its pathogenesis [1,2]. Endoscopic methods (balloon dilatation, bougie dilatation, stents, endoscopic electroincision), digital dilatation, surgical methods (stapler stricturoplasty, transanal circular stapler resection, transabdominal redo-anastomosis) and corticosteroids are used in AS [3,4]. Surgery is generally preferred in complete/near complete AS [1]. Stents; the benefit of stents in AS after oncological surgery has not been shown [3]. However, Philip BC Pangg et al. treated near-total AS non-operatively with the colonic/rectal endoscopic ultrasound (EUS) anastomosis technique and a hot lumen metallic stent [5]. We applied 3-stage bougie dilation to the patient with near complete anastomotic stricture. A 59-year-old female patient who underwent laparoscopic anterior resection due to sigmoid colon tumor was followed up with complaints of abdominal swelling, intermittent abdominal pain and difficulty in defecation. One month later, when colonoscopy was performed, near complete anastomotic stricture was observed. Bougie dilatation was performed with maloney flexible bougie dilators under wire guidance. Bougie dilatation was performed 3 times with fifteen days intervals. After the first (33, 36 and 42 F) and the second bougie dilatation (36, 42 F), the upper segment of the anastomotic stricture was reached by gastroscopy. After dilatation with a bougie (42, 45 F) for the third time, the colonoscope was easily passed through the anastomosis line to the upper segment. Six months later, colonoscopy was performed and the proximal part of the anastomosis was easily passed without the use of bougie dilators. Balloon dilatation is the first method used in AS. However, several repetitions are necessary for the success of the procedure. In addition, the risk of perforation increases when the stricture diameter is &lt;5 mm and length &gt;1 cm. The chances of success in AS are lower compared to bougie dilatation. Endoscopic electroincision is recommended in failure of balloon dilatation. Digital dilatation: used in distal anorectal anostamotic strictures. Corticosteroid application: very large studies are not available. Bougie dilatation in AS provides tactile feedback, allowing the amount of resistance to the passage of the dilator to be estimated and perforation to be avoided. Bougie dilatation method is simple, inexpensive and low risk of complications. Especially Maloney flexible silicone bougie minimise the risk of complications. Bougie dilatators can remain intact for many years and can be reused. But balloon dilatators are not reused. Surgical methods are used in 3-4% (complete/near complete AS) in the failure of endoscopic methods. But mortality risk is high [1,4-6]. Therefore, the alternative method of Philip BC Pang et al. can be applied [5]. However, due to limited endoscopic ultrasonography (EUS) centers, gradual dilatation can be performed with flexible bougie dilators in case of anastomosis stricture. Yours Sincerely

Analysis of the Larissa Heart Failure Risk Score: Predictive Value in 9207 Patients Hospitalized for Heart Failure from a Single Center.

Early risk stratification is of outmost clinical importance in hospitalized patients with heart failure (HHF). We examined the predictive value of the Larissa Heart Failure Risk Score (LHFRS) in a large population of HHF patients from the Cleveland Clinic. A total of 13,309 admissions for heart failure (HF) from 9207 unique patients were extracted from the Cleveland Clinic's electronic health record system. For each admission, components of the 3-variable simple LHFRS were obtained, including hypertension history, myocardial infarction history, and red blood cell distribution width (RDW) ≥ 15%. The primary outcome was a HF readmission and/or all-cause mortality at one year, and the secondary outcome was all-cause mortality at one year of discharge. For both outcomes, all variables were statistically significant, and the Kaplan-Meier curves were well-separated and in a consistent order (Log-rank test p-value < 0.001). Higher LHFRS values were found to be strongly related to patients experiencing an event, showing a clear association of LHFRS with this study outcomes. The bootstrapped-validated area under the curve (AUC) for the logistic regression model for each outcome revealed a C-index of 0.64 both for the primary and secondary outcomes, respectively. LHFRS is a simple risk model and can be utilized as a basis for risk stratification in patients hospitalized for HF.