Stratification Index Research Articles

Marriage and mortality after noncardiac surgery

BackgroundMarriage is linked to substantial societal and economic benefits, and it has been associated with improved outcomes following acute illness. However, it is not known if being married confers benefit to patients undergoing noncardiac surgical procedures. Materials and methodsPatients undergoing any noncardiac surgical procedure were included over a period of 19 months. All-cause mortality at 2 years was determined by linking patient records to the National Death Index. Risk adjustment was performed using Cox modeling and the Cleveland Clinic risk stratification index. ResultsOf the 11,588 patients included, 7830 (68.0%) were married at the time of surgery. There was a significant interaction between sex and marital status (P = 0.03), so the remainder of the analysis was performed separately by sex. Among men, not being married was associated with significantly worse survival (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.06, 1.63), whereas among women, there was no significant association between marital status and survival (HR: 0.94, 95% CI: 0.77, 1.15). Furthermore, divorced men (HR: 1.76, 95% CI: 1.25, 2.51) and never married men (HR: 1.53, 95% CI: 1.14, 2.05) had significantly worse survival than married men, whereas there was no significant difference between widowed men and married men, nor when comparing widowed, divorced, or never married women to married women. ConclusionsAmong a diverse group of surgical patients, being married at the time of surgery is associated with significantly improved survival only among men. Focused efforts to improve social support for unmarried male patients may improve outcomes.

Depth distribution of soil organic carbon in an Oxisol under different land uses: Stratification indices and multifractal analysis

Understanding the depth distributions of soil organic carbon (SOC) content in a soil profile has become increasingly important to examine land use effects on soil carbon sequestration and soil quality. We addressed the variability of SOC in deep soil profiles under different land uses using the multifractal approach. In addition, classical indices such as proportion of SOC stored at the upper soil horizon and stratification ratios (SR) were used to evaluate organic matter accumulation near to the soil surface. Six soil profiles belonging to a Rhodic Hapludox were sampled at two sites with different textures under three land uses: native forest (NF) and sugar cane managed as continuous cropping, during either 5 (SuCa 5) or 10 (SuCa 10) years. Sixty-five soil samples per profile were analyzed for SOC. Soil carbon storage at the surface horizons and stratification ratios were significantly higher (P<0.05) under SuCa 10 than under SuCa 5 and NF. Vertical distributions of SOC exhibited various degrees of scaling heterogeneity, so that those under SuCa 10 clearly showed multifractal behavior, while those under SuCa 5 and NF behave as quasi monofractal. In all the SOC depth distributions, the amplitude of the Rényi and singularity spectra was higher for positive than for negative q moments. Multifractal parameters estimated for the most positive moments were negatively correlated to SR, while those for the most negative q moments were best correlated to the proportion of SOC stored at the soil surface. Our results suggest that single scale analysis may not be sufficient to fully characterize vertical variability of SOC content.

Novel conduction-repolarization indices for the stratification of arrhythmic risk.

Sudden cardiac death (SCD) affects approximately 800,000 individuals per annum globally.[1] It is most frequently due to cardiac tachy-arrhythmias, which include mono-morphic or polymorphic ventricular tachycardia (VT), torsade de pointes and ventricular fibrillation (VF). Risk stratification for SCD remains a challenging problem in clinical practice. Patients with structural heart disease or cardiac ion channelopathies have an increased risk of SCD, their risks are not the same. Consequently, several indices have been devised for this purpose, mainly focusing on ventricular repolarization, which is reflected by the QT interval on the electrocardiogram.[2] These include QT interval corrected for heart rate (QTc), QT dispersion (QTd), interval from the peak to the end of the T wave (Tpeak – Tend, reflecting increased transmural dispersion of repolarization, TDR), and (Tpeak – Tend)/QT ratio.[3]

Abstract PR622

Background & Objectives: A patient’s health status often determines whether surgery is recommended for cancer therapy. The risk of complications may outweigh the perceived benefit. Consequently, measures that predict surgical outcomes may be helpful in determining whether or not to operate. Materials & Methods: We retrospectively apply four mortality predictors to 62,763 adult surgical cancer patients from the University of Texas MD Anderson Cancer Center during January 2007 - March 2014. We use the first surgery for each patient that is over 60 minutes in duration and compare the following indexes: Charlson Comorbidity Index1 as implemented by Deyo et al.2; Dalton’s Risk Quantification Index (RQI)3; Sessler’s Risk Stratification Index (RSI)4 and the Surgical Apgar Score5. We implement each metric as described by the authors and evaluate each score’s ability to predict 30-day mortality using logistic regression, randomly selecting two-thirds of the cases for learning the model and using the remaining cases for evaluation. We report the C-Statistic for each metric in isolation and in combination with the other measures. Results: We obtain individual C-Statistics from 0.639 to 0.784 and a combined C-Statistic of 0.817. The least predictive index is the RQI and the most predictive is the RSI.Conclusion: Despite not being designed specifically for cancer patients, or even necessarily for 30-day mortality, these metrics provide accurate predictions for our patient body. Furthermore, by combining the scores together, we are able to improve predictions, as each index is based on a different set of patient characteristics. RQI was the least useful metric, contributing only 0.01 to the combined C-Statistic. These indexes can be used to calculate and communicate the likelihood of 30-day mortality and may aid in clinical decision-making.

PS 05-38 BRACHIAL-ANKLE PULSE WAVE VELOCITY AS A RISK STRATIFICATION INDEX FOR THE SHORT-TERM PROGNOSIS OF PATIENTS WITH ESTABLISHED CORONARY ARTERY DISEASE

Objective: We evaluated that brachial-ankle pulse wave velocity (baPWV) can be a risk stratification index to predict prognosis in patients with established CAD. Design and Method: We recruited the patients undergoing emergent or elective PCI for stable angina or acute coronary syndrome from Chungbuk national university hospital cathlab database. The clinical outcomes were surveilled via chart reviews and telephone call. Results: In total, 925 patients were enrolled (Male 670, 72.4%) with median follow-up of 524 days. The higher baPWV was defined as a median baPWV of 1730 cm s–1 or more. The patients were diagnosed as ST elevation MI (221, 23.0%), non ST elevation MI (221, 23.9%), unstable angina (294, 31.8%), stable angina (189, 20.4%). The composite end points of the study at follow-up of 12 months were cardiovascular death, nonfatal MI, and coronary revascularization. At a 12-month follow-up, we found 61 total ischemic events (higher PWV 7.9% vs normal PWV 5.8% (p = 0.211)), 18 cardiovascular deaths (2.0% vs 1.9% (p = 0.964)), 5 nonfatal MIs (0.8% vs 0.4% (p = 0.319)), 3 stent thrombosis (0.6% vs 0.3% (p = 0.313)) and 45 target-vessel revascularizations (5.9% vs 4.2% (p = 0.241)). In survival analysis, there was no significant difference between patients with higher baPWV and normal velocity. Multivariate analysis revealed that a higher baPWV was not significantly associated with poorer short-term prognosis (hazard ratio, 0.793; 95% confidence interval, 0.529–1.188) in established CAD patients. Conclusions: baPWV, a marker for arterial stiffness, is not a risk stratification index for short-term prognosis in patients with established CAD patients. Routine use of PWV to predicting future cardiovascular events in patients with established CAD seems to be unnecessary.

Frailty predicts major bleeding within 30 days in elderly patients with Acute Coronary Syndrome

ObjectiveBleeding in ACS patients is an independent marker of adverse outcomes. Its prognostic impact is even worse in elderly population. Current bleeding risk scores include chronological age but do not consider biologic vulnerability. No studies have assessed the effect of frailty on major bleeding. The aim of this study is to determine whether frailty status increases bleeding risk in patients with ACS. MethodsThis prospective and observational study included patients aged ≥75years admitted due to type 1 myocardial infarction. Exclusion criteria were severe cognitive impairment, impossibility to measure handgrip strength, cardiogenic shock and limited life expectancy due to oncologic diseases. The primary endpoint was 30-day major bleeding defined as a decrease of ≥3g/dl of haemoglobin or need of transfusion. ResultsA total of 190 patients were included. Frail patients (72, 37.9%) were older, with higher comorbidity features and with a higher CRUSADE score at admission. On univariate analysis, frailty predicted major bleeding during 30-day follow-up despite less frequent use of a P2Y12 inhibitor (66.2% vs 83.6%, p=0.007) and decreased catheterisation rate (69.4% vs 94.1%, p<0.001). Major bleeding was associated with increased all-cause mortality at day 30 (18.2% vs 2.5%, p<0.001). On multivariate analysis, frailty was an independent predictor for major bleeding. ConclusionFrailty phenotype, as a marker of biological vulnerability, is an independent predictor of major bleeding in elderly patients with ACS. Frailty can play an important role in bleeding risk stratification and objective indices should be integrated into routine initial evaluation of these patients.

Evaluation of complications of PTBD using Hull’s Risk Stratification Index

Introduction: Obstructive jaundice is a common surgical problem. Percutaneous transhepatic biliary drainage (PTBD) is one of the effective treatments in the management of biliary obstruction. Hull Risk stratification index has been proposed to identify which patients are more likely to suffer from immediate and early complications and procedural mortality.Materials and Methods: This is a descriptive observational study conducted at the department of surgery TUTH over a period of 1 year between october 2014 and october 2015. Hull risk stratification index was used to predict the complications of the procedure.Results: 79 patients who underwent PTBD were included during the study period of one year. Among them 39(49%) were male and 40(51%) were female. The median age of patients undergoing the procedure was 59yrs (range 35-90yrs). Twenty nine patients (36%) were in the medium Hull risk group, 50 (64%) of patients were in the low risk group and there were no patients in the high risk group. Six patients (7.5%) died after the procedure. Seven patients (8%) developed sepsis following the procedure. One patient (1.2%) developed hemobilia. Two patients (2.4%) developed pneumonia following the procedure. The sensitivity, specificity, positive predictive value, negative predictive value of the index for complications of PTBD were 81%, 74%, 44% and 94% respectively. Patients with medium Hull’s risk were 3 times more likely to develop complications of PTBD than those with low risk.Conclusion: Hull’s Risk Stratification Index can be utilized as a marker for predicting the early, immediate complications as well as procedure related mortality.

Stratification Studies with Sub Grade Iron Ore from Deposit No. 10 and 11A, Bacheli Complex, Bailadila, Chhattisgarh, India

Experiments were carried out with two different sizes of (−30 + 6 and −6 + 1 mm) sub grade iron ore sample from Deposit No. 10 and 11A, Bacheli Complex, Bailadila, India to study the stratification behaviour at optimised parameters in a under bed air pulsed jig at 1, 2, 5, 10, 15 and 20 minutes residence time. This paper deals with the rate at which stratification takes place and determines the optimum stratification time (residence time) for above two size fractions. Average apparent density along with Jig Stratification Index (JSI) of both the size fractions was calculated. It was observed that the stratification rate is high for fines (−6 + 1 mm) and stratification index was higher for lump (−30 + 6 mm) when compared with the other size fraction. The maximum JSI observed was 0.35 for lump (−30 + 6 mm) and 0.30 for fines (−6 + 1 mm).

Shock index for outcome and risk stratification in acute pulmonary embolism

IntroductionRisk stratification of patients with acute pulmonary embolism (PE) is crucial in deciding appropriate therapy management. Shock index (SI) is rapidly available and a reliable parameter. We aimed to investigate SI for short term outcome in acute PE. Materials and methodsData of 182 patients with acute PE were analysed retrospectively. SI was defined as heart rate divided by systolic blood pressure. Logistic regression models were calculated to investigate associations between SI and in-hospital-death, myocardial necrosis and presence of right ventricular dysfunction (RVD) respectively. Moreover ROC curves and cut-off values for SI predicting in-hospital death, myocardial necrosis and RVD were computed. Results182 patients (61.5% female, mean age 68.5 ± 15.3 years) with acute PE event were included in the study. 5 patients (2.7%) died an in-hospital death.Logistic regression models revealed an association between SI and respectively in-hospital death (OR 5.854, 95% CI 1.876–18.274, P = 0.00234), myocardial necrosis (OR 5.043, 95% CI 1.362–18.674, P = 0.0154) and RVD (OR 53.539, 95% CI 6.810–420.914, P = 0.000155).ROC analysis for SI predicting in-hospital death, myocardial necrosis and RVD revealed an AUC of 0.806, 0.636 and 0.713 respectively with respectively SI cut-off values of 0.89, 0.75 and 0.54. ConclusionsSI is a significant predictor of in-hospital death, myocardial necrosis and RVD. The effectiveness of SI to predict in-hospital death is high with an optimal cut-off value of 0.89 for differentiation between PE patients with lower and higher risk to die in hospital after acute PE event.

The Ventricular Ectopic QRS Interval: A Potential Marker for Ventricular Arrhythmia inIschemicHeartDisease.

The purpose of this study was to determine the potential value of a novel marker for the severity of structural heart disease and the risk of arrhythmia. The ventricular ectopic QRS interval (VEQSI) has been shown to identify structural heart disease and predict mortality in an unselected population. In ischemic heart disease (IHD), risk stratification for sudden death is imperfect. We hypothesized that VEQSI would identify patients with prior myocardial infarction (MI) compared with healthy subjects and distinguish IHD patients who have suffered life-threatening events from those without prior significant ventricular arrhythmia. The 12-lead Holter recordings from 189 patients with previous MI were analyzed: 38 with prior ventricular tachycardia/ventricular fibrillation (MI-VT/VF) (66 ± 9 years; 92% male); 151 without prior significant ventricular arrhythmia (MI-no VT/VF) (64 ± 11 years; 74% male). These were compared with 60 healthy controls (62 ± 7 years; 70%male). All ventricular ectopic beats were reviewed and maximal VEQSI duration (VESQI max) was recorded as the duration of the longest ventricular ectopic beat. VEQSI max was longer in post-MI patients compared with normal controls (185 ± 26 ms vs. 164 ± 16 ms; p<0.001) and in MI-VT/VF patients with prior life-threatening events compared with MI-no VT/VF patients without prior life-threatening events (214 ± 20 ms vs. 177 ± 22 ms; p< 0.001). Multivariate analysis established VEQSI max as the strongest independent marker for prior serious ventricular arrhythmia. VEQSI max >198 ms had 86% sensitivity, 85% specificity, 62% positive predictive value, and 96% negative predictive value for identifying patients with prior life-threatening events (odds ratio: 37.4; 95% confidence interval: 13.0 to 107.5). VEQSI max >198 ms distinguishes post-MI patients with prior life-threatening events from those without prior significant ventricular arrhythmia. This may be a useful additional index for risk stratification in IHD.

Effect of Baseline Red Blood Cell Distribution Width on Short- and Intermediate-term Mortality of Patients Under Primary Percutaneous Coronary Intervention: A Survival Analysis.

Considering the limited studies specifically evaluating the role of Red blood cell distribution width (RDW) in primary percutaneous coronary intervention (PCI), we aimed to investigate the role of baseline RDW in short- and intermediate-term cardiovascular events in ST-elevation myocardial infarction patients under primary PCI. This is a historical cohort registry analysis of 1161 patients with ST-elevation myocardial infarction under primary PCI. According to inclusion criteria, 838 patients were allocated for analysis. Patients with RDW levels of 13.6% or higher were considered as high RDW group (third tertile). All the individuals were followed up for in-hospital and 6-month mortality along with readmission and composite major adverse cardiac events. In-hospital deaths occurred in 53 (6.3%) patients and at 6-month follow-up 79 (9.4%) cases of mortality were documented. In-hospital and 6-month mortalities showed a significant trend in favor of high RDW group (13.3% vs. 5.9%, P = 0.003; 19.7% vs. 7.9%, P < 0.001, respectively). Multivariate analysis showed that high RDW was significantly and independently associated with higher rates of 6-month mortality (hazard ratio: 2.909; 95% confidence interval: 1.166-7.257; P = 0.022). RDW was also a significant predictor for 6-month mortality independent of anemia (hazard ratio: 2.811; 95% confidence interval: 1.047-7.551; P = 0.040). We found a significant association between high RDW and in-hospital and 6-month mortality as well as the occurrence of major adverse cardiac event. Meanwhile RDW was found to be a significant predictor for 6-month mortality independent of anemia. Thus, it would be beneficial to use RDW as a risk stratification index to identify high risk intent-to-treat patients.

House of Delegates Moves Forward on Key Issues

ORLANDO, FL — The Society House of Delegates (HoD) passed several significant resolutions and white papers at its recent meeting. “It was an incredibly productive and interesting meeting. We made tremendous progress on several key issues within a limited time frame,” said 2015–2016 HoD Chair Milta Little, DO, CMD. “The issues addressed — and the items passed — highlight the amount of public policy work that is being done and what additional work the Society is being asked to do. There is a big push on public policy efforts, and that will be a key part of HoD efforts in the year ahead,” said Dr. Little. Among the policy-related resolutions: •%Ensuring Appropriate Risk Adjustment Prior to Implementation of Value-Based Purchasing (B16): This directs the Society to work with stakeholder organizations and federal agencies to require the Centers for Medicare & Medicaid Services to clearly define risk stratification indices and develop a cost-to-risk algorithm. This algorithm is to be based on previous utilization data and will incorporate unique patient characteristics including age and frailty.•%Reimbursing Physician Practices for Administrative Costs of VBP Programs (C16): This directs the Society to work with the American Medical Association and other interested parties to seek legislative action modifying the CMS value-based purchasing regulations to ensure that all eligible professionals who participate in the VBP programs receive appropriate compensation on their Medicare charges for the attributed population and for added administrative costs.•%Support for the End of the Meaningful Use Program by CMS (I16): This calls for the Society to seek legislative and regulatory action to remove PA/LTC patient encounters from the Meaningful Use program. This would include any future iterations of Meaningful Use under the Merit-Based Incentive Payment System, until such time that interoperable certified technology is widely available in these settings. It also directs the Society to work with appropriate stakeholders to incentivize health information technology systems that support the interoperability, continuity of care, and care coordination specific to PA/LTC residents. The HoD also passed two resolutions about establishing specialty of post-acute and long-term care medicine that call for the Society to work with CMS to seek full recognition of PA/LTC medicine as a medical specialty and engage American Board of Medical Specialties to prepare for this recognition. The HoD also passed three white papers on the following topics: •%Capacity for Sexual Consent in Dementia in Long-Term Care (A16)•%Dementia Care in Transitions (M16)•%Post-Acute and Long-Term Care Population Served (N16) Suzanne Gillespie, MD, RD, CMD, 2016–2017 HoD chair, noted that the topics addressed “reflect the diversity of our membership and the issues that affect and interest us all.” She was impressed by the level of knowledge demonstrated by House delegates and the “robust dialogue that took place on the various topics.” For details about the white papers and resolutions passed by the HoD, go to http://www.paltc.org/papers?type=All&topic=All. Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations.

Territorio estratégico y segregación: la región noreste del Área Metropolitana de Montevideo

Las áreas metropolitanas de América Latina transitan por diversos cambios territoriales que se han profundizado durante las últimas décadas. En este estudio se analizan las dinámicas territoriales que han ocurrido en la región noreste del Área Metropolitana de Montevideo, se considera a la segregación territorial y a los territorios estratégicos como conceptos claves para entender dichas transformaciones. En este sentido se emplean técnicas de Geoprocesamiento y se elabora un índice de estratificación socioeconómica. Los resultados indican un crecimiento sostenido de los procesos de urbanización sobre el uso rural y se evidencia un desarrollo acelerado de cambios en las distintas clases sociales donde el Estado es un actor clave para favorecer los procesos de segregación territorial.

Drug Prescribing in the Elderly Receiving Home Care

BackgroundTo compare the prevalence of potentially inappropriate medications (PIMs) using the 2012 and 2003 Beers Criteria in frail older patients receiving home health care services (HHS), and to explore the correlates of PIMs based on the 2012 Beers criteria. Materials and MethodsA total of 145 older patients (mean age, 80.9 ± 7.6 years) with Barthel scale ≤ 60 receiving regular HHS from a university hospital between January 2013 and June 2013 were retrospectively enrolled. The 2003 and 2012 Beers criteria were used separately to detect PIMs. Logistic regressions, receiver-operating-characteristic curve analyses and number needed to harm were used, where appropriate. ResultsThe 2012 Beers Criteria identified more PIM cases than did the 2003 Beers Criteria (66.9% versus 55.9%, P < 0.05). Multivariate analysis revealed that PIM identified by the 2012 Beers Criteria was associated with an increased number of medications prescribed (P = 0.019) and the presence of psychiatric diseases (P = 0.001). Moreover, the area under the receiver-operating-characteristic curve for the number of drugs to predict the risk of PIM was 0.674 (P < 0.001) with the optimal cutoff value of 6 medications. After adjusting for age, sex, Charlson comorbidity index and psychiatric disorders, patients taking ≥6 drugs (adjusted odds ratio, 2.33; adjusted number needed to harm, 3.93; P < 0.05) had a significantly higher risk for PIM than those taking <6 drugs. ConclusionsOur data showed that the 2012 Beers Criteria was more sensitive in detecting PIMs than the 2003 Beers Criteria. Furthermore, frail older patients receiving HHS with polymedication and with psychiatric illnesses had higher risk of PIM when using the 2012 criteria. The number of medications prescribed could be a useful index for risk stratification, and at the same time help physicians to be aware of the high risk for PIM when prescribing 6 or more drugs to frail older adults during in-home visits.

Inclusion of Respiratory Frequency Information in Heart Rate Variability Analysis for Stress Assessment.

Respiratory rate and heart rate variability (HRV) are studied as stress markers in a database of young healthy volunteers subjected to acute emotional stress, induced by a modification of the Trier Social Stress Test. First, instantaneous frequency domain HRV parameters are computed using time-frequency analysis in the classical bands. Then, the respiratory rate is estimated and this information is included in HRV analysis in two ways: 1) redefining the high-frequency (HF) band to be centered at respiratory frequency; 2) excluding from the analysis those instants where respiratory frequency falls within the low-frequency (LF) band. Classical frequency domain HRV indices scarcely show statistical differences during stress. However, when including respiratory frequency information in HRV analysis, the normalized LF power as well as the LF/HF ratio significantly increase during stress ( p-value 0.05 according to the Wilcoxon test), revealing higher sympathetic dominance. The LF power increases during stress, only being significantly different in a stress anticipation stage, while the HF power decreases during stress, only being significantly different during the stress task demanding attention. Our results support that joint analysis of respiration and HRV obtains a more reliable characterization of autonomic nervous response to stress. In addition, the respiratory rate is observed to be higher and less stable during stress than during relax ( p-value 0.05 according to the Wilcoxon test) being the most discriminative index for stress stratification (AUC = 88.2 % ).

Evaluating planktonic diatom response to climate change across three lakes with differing morphometry

We applied a diatom-based thermal stratification index to sediment cores from three lakes in the northeast USA to evaluate the influence of lake morphometry and within-lake processes on diatom responses to climate change. The three lakes all had surface area >5 km2 and experienced the same regional declines in wind speed and progressively earlier ice-out dates, but differed in morphometry, particularly surface area and mean depth. We coupled this paleolimnological approach with contemporary ecological measurements to validate the use of two indicator species (Aulacoseira subarctica (O. Muller) Haworth and Discostella stelligera (Cleve & Grunow) Houk & Klee) in the stratification index. D. stelligera was abundant during stratified conditions in Tunk Lake and Sebago Lake, but not in Lobster Lake. Diatom-inferred stratification shifted to shallower and/or longer duration in Tunk Lake starting in the late nineteenth century, and continued to become shallower over much of the twentieth century. A shift to shallower and/or longer duration was also apparent in Sebago Lake starting around 1850, after which the index suggested little change, even though ice-out occurred 30 days earlier in 2000 than in 1807 and wind speed began to decline in the 1960s. This lake has very slow sedimentation rates, experiences regular seiches, and has D. stelligera present during circulation and stratified periods. These factors may smooth stratification-driven diatom responses. Contemporary ecological measurements did not support the application of the stratification index in Lobster Lake because D. stelligera bloomed only during spring turnover. In Lobster Lake, the relative abundances of D. stelligera in the sediment record showed some variation over time, were generally lower in periods with earlier ice-out in the region, and have been lower since the 1980s. Our results highlight the different responses recorded in the sediments of three large lakes in the same region to climate-driven changes and support the use of indicator species in reconstructing lake thermal stratification patterns when paired with site-specific morphometric and ecological data.

A new comorbidities index for risk stratification for treatment of unruptured cerebral aneurysms.

OBJECTIVE Comorbidities have an impact on risk stratification for outcomes in analyses of large patient databases. Although the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) are the most commonly used comorbidity indexes, these have not been validated for patients with unruptured cerebral aneurysms; therefore, the authors created a comorbidity index specific to these patients. METHODS The authors extracted all records involving unruptured cerebral aneurysms treated with clipping, coiling, or both from the Nationwide Inpatient Sample (2002-2010). They assessed the effect of 37 variables on poor outcome and used the results to create a risk score for these patients. The authors used a validation data set and bootstrapping to evaluate the new index and compared it to CCI and ECI in prediction of poor outcome, mortality, length of stay, and hospital charges. RESULTS The index assigns integer values (-2 to 7) to 20 comorbidities: neurological disorder, renal insufficiency, gastrointestinal bleeding, paralysis, acute myocardial infarction, electrolyte disorder, weight loss, metastatic cancer, drug abuse, arrhythmia, coagulopathy, cerebrovascular accident, psychosis, alcoholism, perivascular disease, valvular disease, tobacco use, hypothyroidism, depression, and hypercholesterolemia. Values are summed to determine a patient's risk score. The new index was better at predicting poor outcome than CCI or ECI (area under the receiver operating characteristic curve [AUC] 0.814 [95% CI 0.798-0.830], vs 0.694 and 0.712, respectively, for the other indices), and it was also better at predicting mortality (AUC 0.775 [95% CI 0.754-0.792], vs 0.635 and 0.657, respectively, for CCI and ECI). CONCLUSIONS This new comorbidity index outperforms the CCI and ECI in predicting poor outcome, mortality, length of stay, and total charges for patients with unruptured cerebral aneurysm. Reevaluation of other patient cohorts is warranted to determine the impact of more accurate patient stratification.

Elevated Biomarkers of Inflammation and Coagulation in Patients with HIV Are Associated with Higher Framingham and VACS Risk Index Scores.

BackgroundBiomarkers of inflammation and altered coagulation are of increasing interest as predictors of chronic disease and mortality in HIV patients, as well as the use of risk stratification scores such as the Framingham index and the Veterans Aging Cohort Study (VACS) score.MethodsDemographic and laboratory data for 252 HIV patients were assessed for their relationship with 5 biomarkers: hsCRP, D-dimer, Cystatin C, IL-6 and TNF-alpha. Analysis of variance was used to model the association between the number of elevated biomarkers patients had and their Framingham 10 year cardiovascular risk and VACS scores.Results87% of patients were male and 75.7% were virally suppressed (HIV RNA <48 copies/ml). The median and interquartile ranges for each biomarker were: hsCRP 1.65 ug/mL (0.73, 3.89), D-dimer 0.17 ug/mL (0.09, 0.31), Cystatin C 0.87 mg/L (0.78, 1.01), IL-6 2.13 pg/mL (1.3, 3.59), TNF-alpha 4.65 pg/mL (3.5, 5.97). 62.6% of patients had more than one biomarker >75th percentile, while 18.6% had three or more elevated biomarkers. Increased age, cigarette smoking, CD4 counts of <200 cells/mm3, Framingham scores and VACS scores were most strongly associated with elevations in biomarkers. When biomarkers were used to predict the Framingham and VACS scores, those with a higher number of elevated biomarkers had higher mean VACS scores, with a similar but less robust finding for Framingham scores.ConclusionsDespite viral suppression and immunological stability, biomarkers of inflammation and coagulation remain elevated in a significant number of patients with HIV and are associated with higher scores on risk stratification indices.

Abstract 19826: Utility of Stroke Volume Index for Stratification of Patients With Low Gradient Severe Aortic Stenosis and Normal Left Ventricular Ejection Fraction

Background: Decision of intervention for low gradient severe aortic stenosis (AS) with normal left ventricular ejection fraction (LVEF) is clinically challenging. The study was to determine the impact of stroke volume index (SVi) on prognosis in patients (pts) with AS. Methods: We examined 410 pts with moderate or severe AS and normal EF (≥50%). Pts were divided into four groups based on aortic valve area (AVA), mean pressure gradient (MPG) and SVi: Group I: low flow low gradient severe AS (AVA≤1.0cm 2 , MPG&lt;40mmHg and SVi&lt;35mL/m 2 , n=75); Group II: normal flow low gradient severe AS (AVA≤1.0cm 2 , MPG&lt;40mmHg and SVi≥35mL/m 2 , n=97); Group III: severe AS with matched gradient-AVA (AVA≤1.0cm 2 and MPG≥40mmHg, n=88); Group IV: moderate AS (AVA&gt;1.0cm 2 and MPG&gt;20mmHg, &lt;40 mmHg, n=150). Aortic valve gradients, AVA and SVi were assessed by echocardiography. Clinical charts were reviewed. Mean follow-up duration was 3.2±1.6 years. Results: Group I had higher prevalence of atrial fibrillation, more pronounced LV hypertrophy, lower SVi, smaller AVA, higher valvuloarterial impedance (Zva) (Table) and lower 3-year cumulative survival compared to Group II and Group IV (61% vs. 75% and 80%, p=0.004). Group II had a 3-year cumulative survival similar to moderate AS (75% vs. 80%, p&gt;0.05). In pts with medical management, Group I and Group III had lower 3-year cumulative survival in comparison with Group II and Group IV (48% and 56% vs. 73% and 76%, p=0.001). Multivariate analysis showed SVi was a strong predictor of mortality in low gradient severe AS (HR 0.95, CI: 0.91-0.99, P=0.02). However, in gradient-AVA matched severe AS and moderate AS, SVi was not associated with mortality (p&gt;0.05). Conclusions: Without AS intervention, low flow low gradient severe AS with normal EF carries poor prognosis similar to high gradient AS, but normal flow low gradient AS does not, suggesting that SVi may be used to identify the pts benefiting most from AS intervention in pts with low gradient AS.

Soil quality assessment based on carbon stratification index in different olive grove management practices in Mediterranean areas

In Mediterranean areas, conventional tillage increases soil organic matter losses, reduces soil quality, and contributes to climate change due to increased CO2 emissions. CO2 sequestration rates in soil may be enhanced by appropriate agricultural soil management and increasing soil organic matter content. This study analyzes the stratification ratio (SR) index of soil organic carbon (SOC), nitrogen (N) and C:N ratio under different management practices in an olive grove (OG) in Mediterranean areas (Andalusia, southern Spain). Management practices considered in this study are conventional tillage (CT) and no tillage (NT). In the first case, CT treatments included addition of alperujo (A) and olive leaves (L). A control plot with no addition of olive mill waste was considered (CP). In the second case, NT treatments included addition of chipped pruned branches (NT1) and chipped pruned branches and weeds (NT2). The SRs of SOC increased with depth for all treatments. The SR of SOC was always higher in NT compared to CT treatments, with the highest SR of SOC observed under NT2. The SR of N increased with depth in all cases, ranging between 0.89 (L-SR1) and 39.11 (L-SR3 and L-SR4).The SR of C:N ratio was characterized by low values, ranging from 0.08 (L-SR3) to 1.58 (NT1-SR2) and generally showing higher values in SR1 and SR2 compared to those obtained in SR3 and SR4. This study has evaluated several limitations to the SR index such as the fact that it is descriptive but does not analyze the behavior of the variable over time. In addition, basing the assessment of soil quality on a single variable could lead to an oversimplification of the assessment. Some of these limitations were experienced in the assessment of L, where SR1 of SOC was the lowest of the studied soils. In this case, the higher content in the second depth interval compared to the first was caused by the intrinsic characteristics of this soil's formation process rather than by degradation. Despite the limitations obtained SRs demonstrate that NT with the addition of organic material improves soil quality.