Stratification System Research Articles

A Risk Stratification System in Myeloma Patients with Autologous Stem Cell Transplantation.

Autologous stem cell transplantation (ASCT) has been a mainstay in myeloma treatment for over three decades, but patient prognosis post-ASCT varies significantly. In a retrospective study of 5259 patients with multiple myeloma (MM) at the University of Arkansas for Medical Sciences undergoing ASCT with a median 57-month follow-up, we divided the dataset into training (70%) and validation (30%) subsets. Employing univariable and multivariable Cox analyses, we systematically assessed 29 clinical variables, identifying crucial adverse prognostic factors, such as extended duration between MM diagnosis and ASCT, elevated serum ferritin, and reduced transferrin levels. These factors could enhance existing prognostic models. Additionally, we pinpointed significant poor prognosis markers like high serum calcium and low platelet counts, though they are applicable to a smaller patient population. Utilizing seven easily accessible high-risk variables, we devised a four-stage system (ATM4S) with primary stage borders determined through K-adaptive partitioning. This staging system underwent validation in both the training dataset and an independent cohort of 514 ASCT-treated MM patients from the University of Iowa. We also explored cytogenetic risk factors within this staging system, emphasizing its potential clinical utility for refining prognostic assessments and guiding personalized treatment approaches.

The immune cell infiltration-associated molecular subtypes and gene signature predict prognosis for osteosarcoma patients

Host immune dysregulation involves in the initiation and development of osteosarcoma (OS). However, the exact role of immune cells in OS remains unknown. We aimed to distinguish the molecular subtypes and establish a prognostic model in OS patients based on immunocyte infiltration. The gene expression profile and corresponding clinical feature of OS patients were obtained from TARGET and GSE21257 datasets. MCP-counter and univariate Cox regression analyses were applied to identify immune cell infiltration-related molecular subgroups. Functional enrichment analysis and immunocyte infiltration analysis were performed between two subgroups. Furthermore, Cox regression and LASSO analyses were performed to establish the prognostic model for the prediction of prognosis and metastasis in OS patients. The subgroup with low infiltration of monocytic lineage (ML) was related to bad prognosis in OS patients. 435 DEGs were screened between the two subgroups. Functional enrichment analysis revealed these DEGs were involved in immune- and inflammation-related pathways. Three important genes (including TERT, CCDC26, and IL2RA) were identified to establish the prognostic model. The risk model had good prognostic performance for the prediction of metastasis and overall survival in OS patients. A novel stratification system was established based on ML-related signature. The risk model could predict the metastasis and prognosis in OS patients. Our findings offered a novel sight for the prognosis and development of OS.

Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores.

Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity. Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots. A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated. A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries. · EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..

Impact of Flagging/Risk Stratification System on Complications in Hospitalist Hip Fracture Co-management: Retrospective Cohort Study.

Hip fractures are associated with high morbidity and mortality, the rates of which can be improved by comprehensive care. To improve hospitalist co-management of hip fractures, we designed and implemented hip fracture template (HFT), a flagging and risk stratification algorithm system. It includes consideration of perioperative management and preventative measures against hip fractures. We examined its effect on morbidity in patients with hip fractures and the factors associated with complications. We conducted a retrospective cohort study of patients who underwent surgery for hip fracture. The primary outcome was the perioperative complication rate, comparing patients managed with and without HFT. Multivariate analysis was adjusted for age, gender, and any significant variables shown in univariate analysis. HFT was used in 121 patients and not used in 147 patients. In univariate analysis, patients were less likely to have complications if HFT was used (19.0% vs. 29.9%, P = 0.047), but there was no difference in length of stay (17days vs. 17days, P = 0.27) or in-hospital-mortality (0.8% vs. 0.7%, P = 1.00) between the groups. In adjusted analysis, patients managed by HFT had lower likelihood of complications (OR 0.55, 95% CI 0.31-0.98). Among patients managed by HFT, those with revised cardiac risk index (RCRI) ≥ 1 were more likely to have complications in both univariate (42.1% vs. 14.7%, P = 0.01) and adjusted analysis (OR 3.37, 95% CI 1.03-10.84). Patients with hip fractures managed with HFT were less likely to have complications, especially those with RCRI ≥ 1, suggesting benefits of using HFT.

Benteng Wuna: Tantangan Golongan Bangsawan Muna di Era Modern

Fort Wuna as evidence of the residential separation of the Muna noble class shows that the social stratification system still applies in Muna even though many people still have middle to lower economic conditions. This research aims to find out what challenges are faced by the Muna noble class in the modern era with middle to lower economic conditions. The theory used in this research is Everyday Form of Resistance by James C. Scott. By using ethnographic methods, it was found that the Muna aristocrats who are in the middle to lower economic conditions must always maintain traditions by performing life cycle rituals that require a lot of money. The tactics used in overcoming these problems are by way of donations from relatives and superimposing their children in the procession of life cycle rituals carried out by other noble families.

Development and evaluation of nomograms and risk stratification systems to predict the overall survival and cancer-specific survival of patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, and patients with HCC have a poor prognosis and low survival rates. Establishing a prognostic nomogram is important for predicting the survival of patients with HCC, as it helps to improve the patient’s prognosis. This study aimed to develop and evaluate nomograms and risk stratification to predict overall survival (OS) and cancer-specific survival (CSS) in HCC patients. Data from 10,302 patients with initially diagnosed HCC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. Patients were randomly divided into the training and validation set. Kaplan–Meier survival, LASSO regression, and Cox regression analysis were conducted to select the predictors of OS. Competing risk analysis, LASSO regression, and Cox regression analysis were conducted to select the predictors of CSS. The validation of the nomograms was performed using the concordance index (C-index), the Akaike information criterion (AIC), the Bayesian information criterion (BIC), Net Reclassification Index (NRI), Discrimination Improvement (IDI), the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analyses (DCAs). The results indicated that factors including age, grade, T stage, N stage, M stage, surgery, surgery to lymph node (LN), Alpha-Fetal Protein (AFP), and tumor size were independent predictors of OS, whereas grade, T stage, surgery, AFP, tumor size, and distant lymph node metastasis were independent predictors of CSS. Based on these factors, predictive models were built and virtualized by nomograms. The C-index for predicting 1-, 3-, and 5-year OS were 0.788, 0.792, and 0.790. The C-index for predicting 1-, 3-, and 5-year CSS were 0.803, 0.808, and 0.806. AIC, BIC, NRI, and IDI suggested that nomograms had an excellent predictive performance with no significant overfitting. The calibration curves showed good consistency of OS and CSS between the actual observation and nomograms prediction, and the DCA showed great clinical usefulness of the nomograms. The risk stratification of OS and CSS was built that could perfectly classify HCC patients into three risk groups. Our study developed nomograms and a corresponding risk stratification system predicting the OS and CSS of HCC patients. These tools can assist in patient counseling and guiding treatment decision making.

Conditional survival analysis and dynamic survival prediction for intracranial solitary-fibrous tumor/hemangiopericytoma

BackgroundAs the form of World Health Organization Central Nervous System (WHO CNS) tumor classifications is updated, there is a lack of research on outcomes for intracranial combined solitary-fibrous tumor and hemangiopericytoma (SFT/HPC). This study aimed to explore conditional survival (CS) pattern and develop a survival prediction tool for intracranial SFT/HPC patients.MethodsData of intracranial SFT/HPC patients was gathered from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. The patients were split into training and validation groups at a 7:3 ratio for our analysis. CS is defined as the likelihood of surviving for a specified period of time (y years), given that the patient has survived x years after initial diagnosis. Then, we used this definition of CS to analyze the intracranial SFT/HPC patients. The least absolute shrinkage and selection operator (LASSO) regression and best subset regression (BSR) were employed to identify predictive factors. The Multivariate Cox regression analysis was applied to establish a novel CS-based nomogram, and a risk stratification system was developed using this model.ResultsFrom the SEER database, 401 patients who were diagnosed with intracranial SFT/HPC between 2000 and 2019 were identified. Among them, 280 were included in the training group and 121 were included in the internal validation group for analysis. Our study revealed that in intracranial SFT/HPC, 5-year survival rates saw significant improvement ranging from 78% at initial diagnosis to rates of 83%, 87%, 90%, and 95% with each successive year after surviving for 1–4 years. The LASSO regression and BSR identified patient age, tumor behavior, surgery and radiotherapy as predictors of CS-based nomogram development. A risk stratification system was also successfully constructed to facilitate the identification of high-risk patients.ConclusionThe CS pattern of intracranial SFT/HPC patients was outlined, revealing a notable improvement in 5-year survival rates after an added period of survival. Our newly-established CS-based nomogram and risk stratification system can provide a real-time dynamic survival estimation and facilitate the identification of high-risk patients, allowing clinicians to better guide treatment decision for these patients.

Head-to-head comparison of American, European, and Asian TIRADSs in thyroid nodule assessment: systematic review and meta-analysis.

Ultrasound-based risk stratification systems (Thyroid Imaging Reporting and Data Systems (TIRADSs)) of thyroid nodules (TNs) have been implemented in clinical practice worldwide based on their high performance. However, it remains unexplored whether different TIRADSs perform uniformly across a range of TNs in routine practice. This issue is highly relevant today, given the ongoing international effort to establish a unified TIRADS (i.e. I-TIRADS), supported by the leading societies specializing in TNs. The study aimed to conduct a direct comparison among ACR-, EU-, and K-TIRADS in the distribution of TNs: (1) across the TIRADS categories, and (2) based on their estimated cancer risk. A search was conducted on PubMed and Embase until June 2023. Original studies that sequentially assessed TNs using TIRADSs, regardless of FNAC indication, were selected. General study characteristics and data on the distribution of TNs across TIRADSs were extracted. Seven studies, reporting a total of 41,332 TNs, were included in the analysis. The prevalence of ACR-TIRADS 1-2 was significantly higher than that of EU-TIRADS 2 and K-TIRADS 2, with no significant difference observed among intermediate- and high-risk categories of TIRADSs. According to malignancy risk estimation, K-TIRADS often classified TNs as having more severe risk, ACR-TIRADS as having moderate risk, and EU-TIRADS classified TNs as having lower risk. ACR-, EU-, and K-TIRADS assess TNs similarly across their categories, with slight differences in low-risk classifications. Despite this, focusing on cancer risk estimation, the three TIRADSs assess TNs differently. These findings should be considered as a prerequisite for developing the I-TIRADS.

Validation of a new risk stratification system-based management for methicillin-resistant Staphylococcus aureus bacteraemia: analysis of a multicentre prospective study.

Distinguishing between complicated and uncomplicated Staphylococcus aureus bacteraemia (SAB) is therapeutically essential. However, this distinction has limitations in reflecting the heterogeneity of SAB and encouraging targeted diagnostics. Recently, a new risk stratification system for SAB metastatic infection, involving stepwise approaches to diagnosis and treatment, has been suggested. We assessed its applicability in methicillin-resistant SAB (MRSAB) patients. We retrospectively analysed data of a 3-year multicentre, prospective cohort of hospitalised patients with MRSAB. We classified the patients into three risk groups: low, indeterminate, and high, based on the new system and compared between-group management and outcomes. Of 380 patients with MRSAB, 6.3% were classified as low-, 7.6% as indeterminate-, and 86.1% as high-risk for metastatic infection. No metastatic infection occurred in the low-, 6.9% in the indeterminate-, and 19.6% in the high-risk groups (P < 0.001). After an in-depth diagnostic work-up, patients were finally diagnosed as 'without metastatic infection (6.3%)', 'with metastatic infection (17.4%)', and 'uncertain for metastatic infection (76.3%)'. 30-day mortality increased as the severity of diagnosis shifted from 'without metastatic infection' to 'uncertain for metastatic infection' and 'with metastatic infection' (P = 0.09). In multivariable analysis, independent factors associated with metastatic complications were suspicion of endocarditis in transthoracic echocardiography, clinical signs of metastatic infection, Pitt bacteraemia score ≥ 4, and persistent bacteraemia. The new risk stratification system shows promise in predicting metastatic complications and guiding work-up and management of MRSAB. However, reducing the number of cases labelled as 'high-risk' and 'uncertain for metastatic infection' remains an area for improvement.

Quality of life after emergency laparotomy: a systematic review

BackgroundEmergency laparotomy is a commonly performed surgical procedure that has higher post-operative morbidity and mortality than elective surgery. Previous research has identified that patients valued postoperative quality of life (QoL) more than the risk of mortality when deciding to undergo emergency surgery. Current pre-operative scoring and risk stratification systems for emergency laparotomy do not account for or provide prediction tools for post-operative QoL. This study aims to systematically review previous literature to determine post-operative QoL in patients who undergo emergency laparotomy.MethodsA literature search was undertaken in Medline, EMBASE and the Cochrane Library to identify studies measuring post-operative QoL in patients who have had emergency laparotomy up to 29th April 2023. Mean QoL scores from the studies included were combined to calculate the average effect of emergency laparotomy on QoL. The primary outcome of the review was postoperative QoL after emergency laparotomy when compared with a comparator group. Secondary outcomes included the quality of included studies.ResultsTen studies in the literature assessing the QoL of patients after emergency laparotomy were identified. Three studies showed that patients had improved QoL and seven showed worse QoL following emergency laparotomy. Length of time for QoL to return to baseline varied ranged from 3 to 12 months post-operatively. Length of hospital stay was identified as an independent risk factor for poorer QoL post-surgery.ConclusionsOutcome reporting for patients who undergo emergency laparotomy should be expanded further to include QoL. Further work is required to investigate this and elicit factors that can improve QoL post-operatively.

Fukuchi-Manabe Score for Infection Control Measures During the Very Early COVID-19 Pandemic Period When Access to Reverse Transcription-Polymerase Chain Reaction Testing Was Poor in Japan: A Single-Center Observational Prospective Cohort Study.

During the early stages of the COVID-19 pandemic in Japan, access to reverse transcription-polymerase chain reaction (RT-PCR) testing was limited. All patients with COVID-19 required hospitalization, and isolation of suspected COVID-19 patients had not yet been implemented. With the recently acquired evidence on COVID-19, it is important to develop a risk stratification system for isolation rooms in the context of limited resources for better resource management. This study aimed to develop and validate a COVID-19 risk-scoring strategy, the Fukuchi-Manabe score, to safely stratify and manage isolation rooms, personal protective equipment (PPE), and RT-PCR testing in the context of limited RT-PCR testing and a short supply of PPE. This single-center prospective study consecutively enrolled suspected COVID-19 adult inpatients between March 1 and August 31, 2020. The primary and secondary outcomes were a positive RT-PCR test and the occurrence of nosocomial infections during the study period, respectively. Factors related to patient history, symptoms, chest computed tomography findings, and laboratory data suggestive of COVID-19 were scored, totaled, and divided into four categories ("probable," "possible," "less likely," and "non-suspicious") based on the likelihood of COVID-19. Sensitivity, specificity, and positive and negative predictive values were evaluated for each probability category. Twenty of 224 inpatients were positive on the RT-PCR test, including 18 "probable" patients (90.0%), one "possible" patient, and one "less likely" patient. The area under the curve (AUC) (95% confidence interval: 0.841-0.977), sensitivity, and specificity were 0.909, 90.0%, and 80.4%, respectively. The positive and negative predictive values and accuracy for the "probable" category were 0.90, 0.80, and 0.82, respectively. The mean and standard deviation of AUCs, validated by bootstrap analysis, were 0.910±0.034. No nosocomial infections were observed. The Fukuchi-Manabe score will be helpful when other novel pathogens emerge in the future before the availability of genetic testing methods.

A Novel Risk Stratification-Based Immunomodulatory Treatment Strategy for Vogt-Koyanagi-Harada Disease

PurposeTo develop a more tailored immunomodulatory treatment (IMT) strategy based on a novel two-arm risk stratification system in Vogt-Koyanagi-Harada (VKH) patients. DesignA retrospective clinical cohort study. Methods79 VKH patients in the acute stage were stratified into low (n = 58) and high-risk (n = 21) groups based on their exposure to risk factors. They were treated with oral glucocorticoids (GCs) plus pro re nata (PRN) or first-line IMT. Best corrected visual acuity (BCVA), sunset glow fundus (SGF) occurrence, relapse rate, and systemic adverse events were evaluated during follow-up. ResultsCompared with the low-risk group, the high-risk showed poorer BCVA at baseline (estimated difference, 0.51; 95% CI, 0.30-0.78; p < 0.001) and 6-month follow-up (estimated difference, 0.08; 95% CI, 0.00-0.08; p = 0.006), higher incidence of SGF at 12 months (52% vs 28%; RR, 1.9; 95% CI, 1.1-3.4; p = 0.040), and higher relapse rate at 6 months (24% vs 5%; RR, 4.6; 95% CI, 1.2-17.5; p = 0.028) and 12 months (52% vs 12%; RR, 4.4; 95% CI, 1.9-9.7; p < 0.001). In the low-risk cohort, no significant difference between the two IMT strategies was observed in primary outcomes. In the high-risk cohort, patients with the immediate IMT showed better BCVA (estimated difference, -0.20; 95% CI, -0.3 to -0.08; p = 0.007), lower incidence of SGF (27% vs 80%; RR, 0.3; 95% CI, 0.1-0.9; p = 0.030), and lower relapse rate (27% vs 80%; RR, 0.3; 95% CI, 0.1-0.9; p = 0.030) compared with the PRN regimen. Moreover, the immediate IMT regimen had a higher frequency of systemic adverse events than the PRN regimen (47% vs 7%; RR, 7.1; 95% CI, 2.5-20.4; p < 0.001). ConclusionsHigh-risk stratification at baseline was associated with poor prognosis. The immediate IMT regimen was only beneficial for high-risk VKH patients regarding visual outcome, SGF, and relapse rate. This study suggests a potential need for a customized IMT strategy for VKH patients.

An interpretable knee replacement risk assessment system for osteoarthritis patients

ObjectiveKnee osteoarthritis (OA) is a complex disease with heterogeneous representations. Although it is modifiable to prevention and early treatment, there still lacks a reliable and accurate prognostic tool. Hence, we aim to develop a quantitative and self-administrable knee replacement (KR) risk stratification system for knee osteoarthritis (KOA) patients with clinical features. MethodA total of 14 baseline features were extracted from 9592 cases in the Osteoarthritis Initiative (OAI) cohort. A survival model was constructed using the Random Survival Forests algorithm. The prediction performance was evaluated with the concordance index (C-index) and average receiver operating characteristic curve (AUC). A three-class KR risk stratification system was built to differentiate three distinct KR-free survival groups. Thereafter, Shapley Additive Explanations (SHAP) was introduced for model explanation. ResultsKR incidence was accurately predicted by the model with a C-index of 0.770 (±0.0215) and an average AUC of 0.807 (±0.0181) with 14 clinical features. Three distinct survival groups were observed from the ten-point KR risk stratification system with a four-year KR rate of 0.79%, 5.78%, and 16.2% from the low, medium, and high-risk groups respectively. KR is mainly caused by pain medication use, age, surgery history, diabetes, and a high body mass index, as revealed by SHAP. ConclusionA self-administrable and interpretable KR survival model was developed, underscoring a KR risk scoring system to stratify KOA patients. It will encourage regular self-assessments within the community and facilitate personalised healthcare for both primary and secondary prevention of KOA.

Book Review: “Chasing Dignity”

Rachhpal Sahota’s novel Chasing Dignity is a compelling narrative, set in the 1980s and ‘90s in Punjab, India, tracing the many twists and turns in the life of a low caste boy, Jaggi. The Indian caste system is a social stratification system characterized by hereditary status and endogamy, enforcing crippling social barriers for those on the lower end of that spectrum. Bound by this rigid system of social hierarchy, Jaggi, a Keera, faces many hurdles as he sets out on his pursuit of a successful life. In the story, his mother Bindo, and his friends, Navi and Rani, serve as catalysts on this journey.

Intensity and Variation of Health Navigator Support: Addressing Medical and Social Needs of Diabetes Patients in East Oakland.

Healthcare systems are increasingly screening and referring patients for unmet social needs (e.g., food insecurity). Little is known about the intensity of support necessary to address unmet needs, how this support may vary by circumstance or time (duration), or the factors that may contribute to this variation. Describe health navigator services and the effort required to support patients with complex needs at a community health center in East Oakland, CA. Retrospective analysis of de-identified patient contact notes (e.g., progress notes). Convenience sample of patients (n = 27) enrolled in diabetes education and referred to health navigators. Navigators provide education on managing conditions (e.g., diabetes), initiate and track medical and social needs referrals, and navigate patients to medical and social care organizations. Descriptive statistics for prevalence, mean, median, and range values of patient contacts and navigation services. We described patterns and variation in navigation utilization (both contacts and navigation services) based on types of need. We identified 811 unmet social and medical needs that occurred over 710 contacts with health navigators; 722 navigation services were used to address these needs. Patients were supported by navigators for a median of 9months; approximately 25% of patients received support for > 1year. We categorized patients into 3 different levels of social risk, accounting for patient complexity and resource needs. The top tertile (n = 9; 33%) accounted for the majority of resource utilization, based on health navigator contacts (68%) and navigation services (75%). The required intensity and support given to meet patients' medical and social needs is substantial and has significant variation. Meeting the needs of complex patients will require considerable investments in human capital, and a risk stratification system to help identify those most in need of services.

Prediction of futile recanalisation after endovascular treatment in acute ischaemic stroke: development and validation of a hybrid machine learning model

BackgroundIdentification of futile recanalisation following endovascular therapy (EVT) in patients with acute ischaemic stroke is both crucial and challenging. Here, we present a novel risk stratification system based on hybrid...

Decitabine-containing conditioning improved outcomes for children with higher-risk myelodysplastic syndrome undergoing allogeneic hematopoietic stem cell transplantation.

Myelodysplastic syndrome (MDS) is a rare clonal hematopoietic disorder in children. The risk stratification system and treatment strategy for adults are unfit for children. The role of hypomethylating agents (HMAs) in higher-risk childhood MDS has not been identified. This study aimed to investigate the outcomes of hematopoietic stem cell transplantation (HSCT) in children with higher-risk MDS at one single center. A retrospective study was conducted in children with higher-risk MDS undergoing HSCT between September 2019 and March 2023 at Blood Diseases Hospital CAMS. The clinical characteristics and transplantation information were reviewed and analyzed. A total of 27 patients were analyzed, including 11 with MDS with excess blasts (MDS-EB), 14 with MDS-EB in transformation (MDS-EBt) or acute myeloid leukemia with myelodysplasia-related changes (AML-MRC), and 2 with therapy-related MDS/AML (t-MDS/AML). Eight patients harbored monosomy 7. Before transplantation, induction therapy was administered to 25 patients, and 19 of them achieved bone marrow blasts <5% before HSCT. The stem cell source was unmanipulated-related bone marrow or peripheral blood stem cells for nineteen patients and unrelated cord blood for eight. All patients received decitabine-containing and Bu/Cy-based myeloablative conditioning; 26 patients achieved initial engraftment. The cumulative incidences of grade II-IV and grade III-IV acute graft-versus-host disease (GvHD) at 100 days were 65.4% and 42.3%, respectively. The incidence of cGvHD was 38.5%. The median follow-up was 26 (range 4-49) months after transplantation. By the end of follow-up, two patients died of complications and two died of disease progression. The probability of 3-year overall survival (OS) was 84.8% (95%CI, 71.1 to 98.5%). In summary, decitabine-containing myeloablative conditioning resulted in excellent outcomes for children with higher-risk MDS undergoing allogeneic HSCT.

Tailored Concept for Accurate Neuroendoscopy: A Comparative Retrospective Single-Center Study on Image-Guided Neuroendoscopic Procedures

OBJECTIVEPrecise planning and execution is key for neuroendoscopic interventions which may be based on different available aiding technologies. The aim of this retrospective study is to report a case-based utilization of guided neuroendoscopy and to develop a stratification algorithm for the available technologies. METHODSWe reviewed consecutive neuroendoscopic cases performed at our center from 2016 to 2018. We distinguished between patients receiving a new burr hole (group A) from cases with preexisting burr hole (group B). Case specific technical requirements for procedure planning and execution, complication rate, surgical outcome, and possible subsequent surgeries were evaluated. From this experience a stratification system was developed to tailor available guiding technologies. RESULTS309 neuroendoscopic interventions in 243 patients were included in the study. Cases included hydrocephalic (81.6%) and non-hydrocephalic (18.4%) conditions. The interventions were supported either by coordinate-based (CB: group A n=49; group B n=67), guide-based (GB: group A n=42; group B n=0), ultrasound-assisted (UG: group A n=50; group B n=7) or augmented reality-navigated (NAR: group A n=85; group B n=9) techniques, respectively. Overall complication rate was at 4.5%. Depending on surgical indication, fontanel status, entry point localization, preexisting burr hole, ventricular size, and number of targets a stratified approach towards image-guided neuroendoscopy is suggested. CONCLUSIONSPlanning and technical guidance is of essential in neuroendoscopic procedures. The stratified decision making algorithm for different available technologies aimed to achieve lower cost and time consumption, which was experienced to be safe and efficient. Further investigation are warranted to deliver solid data on procedure efficiency.

The dynamics of housing cost burden among renters in the United States

ABSTRACT Housing cost burden—defined as paying more than 30% of household income for housing—has become a central feature of the American stratification system with dire consequences for the health and well-being of adults and children living in burdened households. To date, existing research has largely focused on the overall prevalence and distribution of housing cost burden—that is, the percentage of households that are cost burdened at a given time and differences in exposure to housing cost burden based on race and income using cross-sectional sources of data. To more fully understand the dynamics of housing cost burden among renter households in the United States including the frequency and duration of spells, we use 50 years of longitudinal data from the Panel Study of Income Dynamics (PSID). The analysis reveals that, in contrast to the episodic nature of poverty, housing cost burden is deep, frequent, and persistent for a growing share of American households.

Improved cancer risk stratification of isoechoic thyroid nodules to reduce unnecessary biopsies using quantitative ultrasound.

Gray-scale ultrasound (US) is the standard-of-care for evaluating thyroid nodules (TNs). However, the performance is better for the identification of hypoechoic malignant TNs (such as classic papillary thyroid cancer) than isoechoic malignant TNs. Quantitative ultrasound (QUS) utilizes information from raw ultrasonic radiofrequency (RF) echo signal to assess properties of tissue microarchitecture. The purpose of this study is to determine if QUS can improve the cancer risk stratification of isoechoic TNs. Patients scheduled for TN fine needle biopsy (FNB) were recruited from the Thyroid Health Clinic at Boston Medical Center. B-mode US and RF data (to generate QUS parameters) were collected in 274 TNs (163 isoechoic, 111 hypoechoic). A linear combination of QUS parameters (CQP) was trained and tested for isoechoic [CQP(i)] and hypoechoic [CQP(h)] TNs separately and compared with the performance of conventional B-mode US risk stratification systems. CQP(i) produced an ROC AUC value of 0.937+/- 0.043 compared to a value of 0.717 +/- 0.145 (p >0.05) for the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS) and 0.589 +/- 0.173 (p >0.05) for the American Thyroid Association (ATA) risk stratification system. In this study, CQP(i) avoids unnecessary FNBs in 73% of TNs compared to 55.8% and 11.8% when using ACR TI-RADS and ATA classification system. This data supports that a unique QUS-based classifier may be superior to conventional US stratification systems to evaluate isoechoic TNs for cancer and should be explored further in larger studies.