Total Risk Score Research Articles

Nutritional risk in early childhood and parent-reported school concerns.

To determine if nutritional risk in early childhood is associated with parent-reported school concerns. A prospective cohort study conducted through the TARGet Kids! primary care research network (2011-2018). Nutritional risk was measured between 18 months and 5 years of age using validated parent-completed NutriSTEP® questionnaires with eating behaviour and dietary intake subscores (0 = lowest and 68 = highest total nutritional risk score). Parent-reported school concerns were measured at school age (4-10 years of age) and included: speech and language; learning; attention; behaviour; social relationships; physical coordination; fine motor coordination and self-help skills and independence. The primary outcome was any parent-reported school concerns, and individual school concerns were used as secondary outcomes. Multiple logistic regression models were conducted adjusting for clinically relevant confounders to assess the relationship between nutritional risk and school concerns. Toronto, Canada. Children aged 18 months to 10 years. The study included 3655 children, 52 % were male, mean NutriSTEP® score was 14·4 (sd 6·4). Each 1 sd increase in NutriSTEP® total score was associated with a 1·18 times increased odds of school concerns (adj OR: 1·18, 95 % CI 1·07, 1·28, P = 0·0004), and high nutritional risk was associated with a 1·42 times increased odds of school concerns (adj OR: 1·42, 95 % CI 1·13, 1·78, P = 0·002). Nutritional risk in early childhood was associated with school concerns. Nutritional interventions in early childhood may reveal opportunities to enhance school outcomes.

GALLBLADDER ADENOCARCINOMA. CURRENT STATUS OF THE NEW FORECAST FACTORS AND THEIR IMPACT ON SURVIVAL. CASES AND CONTROLS STUDY

Abstract INTRODUCTION We present the results after surgery for gallbladder adenocarcinoma in our centre. The Total Risk Score (TRS) is a useful index to predict the amount of residual disease that is observed in reinterventions with curative intent that are carried out in these tumors. MATERIAL AND METHODS Retrospective study of cases and controls. Review of 2019 patients who underwent cholecystectomy from 2012 to 2019 in a Hepatobiliopancreatic Surgery Unit. Exposure of a total of 75 patients for the study (15 cases versus 60 controls, 1: 4 ratio). RESULTS 15 patients were diagnosed with gallbladder adenocarcinoma, 10 of which were incidental (66.7%). Oncological resection was R0 in 93.33% of the cases and R1 in the remaining 6.67%. TRS was low in 9% of cases, moderate in 45.45%, and high in another 45.45%. The rate of reoperation with oncological intention is 60% in our series (9 patients), and residual disease was observed in 4 of them (44.4%). In 3 of the patients, an exploratory laparotomy was performed without associated resection due to the extent of the disease (33.3%). The percentage of R0 after reoperation was 77.7%. The median survival after surgery is 38.67 months (95% confidence interval (29.73 - 67.34). CONCLUSIONS The study of the pathological tissue results for the performance of revision surgery could guide the oncological attitude in the future if its validity is confirmed with more multicentre studies.

Risk Prediction Model of Gestational Diabetes Mellitus in a Chinese Population Based on a Risk Scoring System.

IntroductionGestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. Accurate models for early prediction of GDM are lacking. This study aimed to explore an early risk prediction model to identify women at high risk of GDM through a risk scoring system.MethodsThis was a retrospective cohort study of 785 control pregnancies and 855 women with GDM. Maternal clinical characteristics and biochemical measures were extracted from the medical records. Logistic regression analysis was used to obtain coefficients of selected predictors for GDM in the training cohort. The discrimination and calibration of the risk scores were evaluated by the receiver-operating characteristic (ROC) curve and a Hosmer-Lemeshow test in the internal and external validation cohort, respectively.ResultsIn the training cohort (total = 1640), two risk scores were developed, one including predictors collected at the first antenatal care visit for early prediction of GDM, such as age, height, pre-pregnancy body mass index, educational background, family history of diabetes, menstrual history, history of cesarean delivery, GDM, polycystic ovary syndrome, hypertension, and fasting blood glucose (FBG), and the total risk score also including FBG and triglyceride values during 14–20 gestational weeks. Our total risk score yielded an area under the curve (AUC) of 0.845 (95% CI = 0.805–0.884). This performed better in an external validation cohort, with an AUC of 0.886 (95% CI = 0.856–0.916).ConclusionThe GDM risk score, which incorporates several potential clinical features with routine biochemical measures of GDM, appears to be a sensitive and reliable screening tool for earlier detection of GDM risk.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-021-01066-2.

Patient"s awareness of recommended LDL-C goals in primary prevention and observed achievement

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The novel 2019 ESC/EAS Guidelines on lipids recommend more intensive reduction on LDL-C across CV risk categories in comparison with the 2016 edition. Purpose This cross-sectional observation study aims to assess whether patients on lipid lowering therapy, as a primary prevention measure, are aware of the new set goals and if they achieved them. Methods Patients, taking currently any statin as a primary prevention measure, visiting the Emergency Department of a tertiary hospital in northern Greece were invited to participate by answering a short questionnaire followed by a phone call to provide the exact lab results or other details. Results In total 412 eligible patients (54.1% female) were enrolled from January to October 2020 (mean age 61 ± 13 years old). Mean duration of statin prescription was about 8 years (7.8 ± 5 years). The majority (381, 92.5%) of patients reported lab tests yearly while most of them (394, 95.6%) were being followed up in outpatient clinics or private offices. Patients were allocated into CV categories: low (48, 11.7%), medium (239, 58.0%), high (108, 26.2%) and very high (17, 4.1%). The estimated 10-year risk of CV death was calculated using SCORE. Almost two thirds of the patients (282, 68.4%) were taking moderate intensity statins (as monotherapy) while one out of ten (45, 10.9%) was taking a statin plus ezetimibe combination. No patient was prescribed a PCSK9 inhibitor. Only two out of five (171, 41.5%) patients reached the LDL-C goal, though differences were noted between risk categories with almost half of the low and medium CV risk patients achieving the desired LDL-L level: low (23, 47.9%), medium (124, 51.9%), high (21, 19.4%) and very high (3, 17.6%). No significant difference was observed in terms of potency of statin. As expected, patients taking a statin and ezetimibe combination achieved lower LDL-C levels, with almost two thirds (31 out of 45 patients, 68.9%) reaching the goal. No information could be collected regarding why patients not reaching the goal were not offered a statin of higher potency and/or dosing, a combination with ezetimibe or a PCSK9 inhibitor. Disturbingly enough, none of the patient was aware that the LDL-C goals recommended by scientific societies had been lowered in 2019, while only 29 patients (7.0%) could recall discussing LDL-C goals with their physician. Moreover, merely three patients could remember the calculation of any CV risk score. The majority of the patients (379, 92.0%) reported that they would like to know their personal CV risk score and their LDL-C goal. Conclusions Greek primary prevention patients taking statins are overall unaware of the novel set LDL-C goals and it seems that they have not been offered a total CV risk score assessment. Hardly acceptable attainment of LDL-C goals was observed. Further research is warranted to assess the barriers that obstruct a satisfactory goal achievement. Abstract Figure.

＜Editors' Choice＞ Differential effects of combination therapy on the components of the risk stratification table in patients with idiopathic or heritable pulmonary arterial hypertension in a Japanese population.

ABSTRACTRisk stratification by ESC/ERS guideline is recommended to estimate the vital prognosis and select the treatment strategy in patients with idiopathic or heritable pulmonary arterial hypertension (IPAH/HPAH). However, we are not confident whether we can achieve low-risk status in the risk table at the follow-up shortly after combination therapy. Therefore, we aimed to verify the effects of combination therapy in IPAH/HPAH on each category of the risk table at diagnosis and at the first follow-up. We retrospectively analyzed 10 consecutive patients with IPAH/HPAH with no previous treatment history diagnosed at Nagoya University Hospital between October 2014 and January 2019. Four categories including symptoms, exercise tolerance, BNP levels and hemodynamics were validated both at baseline and at the first follow-up of right heart catheterization. Score of 1, 2 and 3 were assigned to the low risk, intermediate risk and high risk, respectively. In each category the highest score was adopted. The scores at diagnosis were compared with those at the first follow-up. The result shows that all patients were female, median age was 32 years old, and were treated with initial combination therapy. The median total risk score also was improved from 2.6 to 1.4 (p<0.01). However, the score in exercise tolerance was not improved (3 to 2.5 p=0.16). In conclusion, at the first follow up shortly after the initial combination therapy of IPAH/HPAH, the mean total risk score was significantly improved, however, even patients in the low-risk status may not achieve improvement in exercise tolerance.

Predicting atrial fibrillation after cardiac surgery using a simplified risk index

BackgroundPostoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and can lead to increased risk of postoperative adverse events. However, atrial fibrillation and postoperative adverse events are preventable. In this study, a risk index was developed to predict atrial fibrillation after cardiac surgery. MethodsA prospective cohort study of 405 patients who had undergone adult cardiac surgery from 2015 September to 2016 August at Heart Institute of HCMC and Cho Ray Hospital were obtained. In order to predict POAF, a logistic regression model was developed, and a risk score was derived and validated by bootstrap. ResultsIn our study, 98 patients developed POAF (24.2%). The risk score included three significant risk factors (age ≥ 60, left atrial diameter > 41 mm, Coronary Artery Bypass Graft with concomitant mitral valve replacement or repair) that were consistent with other reports. Each of these risk factors was assigned one point. The total risk score ranges from 0 to 3 (AUC = 0.69, 95% CI: 0.63–0.75) with the best cutoff point at 1. According to this scoring system, the incidences of POAF in patients associated with each score of 0, 1, 2, and 3 were 8.6%, 30.1%, 40.8%, and 58.3% respectively. Bootstrapping with 5000 samples confirmed the final model provided was consistent with predictions. ConclusionsWe developed and validated a simple risk score based on clinical variables that can be obtained before surgery in order to accurately predict the risk of POAF in patients undergoing cardiac surgery.

A dynamic prognostic nomogram to predict the benefit from surgical treatment modality for patients with laryngeal squamous cell carcinoma.

Although nonsurgical treatment strategy is increasingly adopted in patients with locoregionally advanced laryngeal squamous cell carcinoma (LSCC), survival disparities were reported between surgical treatment modality and organ preservation protocols, highlighting the great importance for accurate patients' selection. This secondary analysis used data from the Surveillance, Epidemiology, and End Results database between 2010 and 2015 with follow-up data up to 2018. We developed and validated a dynamic prognostic nomogram for overall survival (OS) in 4237 patients with LSCC and subgroup of 2087 patients with locoregionally advanced laryngeal squamous cell carcinoma (LALSCC). Based on the total risk score derived from the dynamic nomogram, two well-matched risk groups (i.e., low- and high-risk) were created via X-tile software and 1-to-1 propensity score matching (PSM); surgical treatment modality was compared with nonsurgical one in each risk group. A more accurate and convenient dynamic prognostic nomogram based on age, marital status, T category, N category, M category, tumor size, and tumor differentiation was developed and validated, of which the predictive performance was superior to that of TNM staging system. For high-risk LALSCC selected by the dynamic nomogram, after 1-to-1 PSM, significantly improved OS was observed in patients with receiving surgical treatment compared to those receipt of nonsurgical management (restricted mean survival time at 36-month: 26.6 vs 22.7, p < 0.001; restricted mean survival time at 60-month: 36.7 vs 31.0, p=0.003). We establish and validate a more accurate and convenient dynamic prognostic nomogram for patients with LSCC, which may predict the benefit from surgical treatment modality for patients with high-risk LALSCC.

The Relationship Between Patterns of Change in Dynamic Risk and Strength Scores and Reoffending for Men on Community Supervision

Research is needed focusing on the predictive nature of dynamic risk and strength score changes. The current study includes 11,953 Canadian men under community supervision with Service Planning Instrument re-assessment data. Using a retrospective, multi-wave longitudinal design, hierarchical linear modeling (HLM) was conducted to assess patterns of change in total dynamic risk and strength scores across three to five timepoints over 30 months. Change parameters from the HLM were incorporated into regression models, linking change to three reoffending outcomes: technical violations, new charges, and new violent charges. Results indicated that total dynamic risk scores decreased over time and total dynamic strength scores increased over time, although the rate of change for both was gradual. Change in total dynamic risk scores was predictive of all outcomes, whereas change in total dynamic strength scores only predicted technical violations. Results demonstrated the utility of re-assessing dynamic risk and strength scores over time.

Gabapentinoid misuse, abuse and non-prescribed obtainment in a United States general population sample.

Background Reports of gabapentinoid (gabapentin and pregabalin) misuse are on the rise, but few studies have assessed this within the general US population. Objective Describe lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids and descriptive characteristics associated with such actions in a US general population sample. Setting This cross-sectional questionnaire was administered online by Qualtrics® research panel aggregator via quota-based sampling. Methods Data were collected from a sample of respondents that mirrored the general US population aged 18-59years with regards to age, geographic region, ethnicity, income, and education level, based on most recent census data. Misuse/abuse/non-prescribed obtainment was collectively defined as use of a gabapentinoid for reasons other than a diagnosed medical condition, using with the intention of altering one's state of consciousness, or obtaining without a prescription. A multivariable logistic regression model was created to predict misuse/abuse/non-prescribed obtainment of gabapentinoids, incorporating relevant covariates. Main outcome measure Proportion of sample indicating lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids. Results Among 1,843 respondents, 121 (6.6%) reported gabapentinoid misuse/abuse/non-prescribed obtainment. Specifically, 2.1% (n = 39) and 1.5% (n = 27) of respondents for gabapentin and pregabalin, respectively, met study criteria for abuse. Opioids were the most common medication co-administered with gabapentinoids (among 50-70% of respondents) for misuse/abuse. Previous treatment for addiction (OR: 2.61, 95% CI: 1.32-5.14, p = 0.005) and the total attitudinal risk score (OR: 1.14, 95% CI: 1.09-1.19, p < 0.001) were associated with gabapentinoid misuse/abuse/non-prescribed obtainment. Conclusion Among those surveyed, 6.6% reported previous gabapentinoid misuse/abuse/non-prescribed obtainment, providing one of the first estimates within a nationally distributed, US general population sample.

Dysphonia Risk Screening Protocol for Musical Theatre Actors: a preliminary study.

To propose the Dysphonia Risk Screening Protocol for Musical Theatre Actors (DRSP-MTA), to verify its applicability in association with the General Dysphonia Risk Screening Protocol (G-DRSP), to correlate the final scores of both, and these with the total risk score, and to compare the risk of dysphonia measured in musical theater actors with and without vocal complaint. An observational cross-sectional study with 34 musical theater actors, adults, of both genders, with and without vocal complaints and regardless of whether they are professionals or students. The questionnaires were applied individually. Statistical analysis made it possible to verify the correlation between the dysphonia risk scores and to compare the groups with and without vocal complaint. Most of the participants were male, young adults, professional actors and without vocal complaint. There was a high risk of dysphonia, evidenced by the application of G-DRSP, with means scores compatible with values found in individuals with dysphonia, and reinforced by the indices found with DRSP-MTA application. There was a moderate and directly proportional correlation between the two questionnaire scores; and a correlation of both with the total risk score. Higher G-DRSP scores were observed in the vocal complaint group. DRSP-MTA was feasible and easy to apply and was positively correlated with the total score and G-DRSP score. A high risk of dysphonia was evidenced in individuals with vocal complaints. Although the specific DRSP-MTA score did not differentiate musical theatre actors with and without vocal complaints, the G-DRSP score and the total risk score performed such differentiation.

A novel risk-scoring system conducing to chemotherapy decision for patients with pancreatic ductal adenocarcinoma after pancreatectomy

Background: Chemotherapy is suggested to use in all stages of pancreatic cancer. Is it reasonable to recommend chemotherapy for all PDAC patients? It is necessary to distinguish low-risk PDAC patients underwent pancreatectomy, who may not lose survival time due to missed chemotherapy and not need to endure pain, nausea, tiredness, drowsiness, and breath shortness caused by chemotherapy.Methods: Nomograms were constructed with basis from the multivariate Cox regression analysis. X-tile software was utilized to perform risk stratification. Survival curves were used to display the effect of chemotherapy in different risk-stratification.Results: All of the significant variables were used to create the nomograms for overall survival (OS). The total risk score of each patient was calculated by summing the scores related to each variable. X-tile software was utilized to classify patients into high-risk (score >283), median-risk (197<score ≤283), and low-risk (score ≤197) according to the total risk score. The low-risk PDAC patients after pancreatectomy cannot gain survival benefit from chemotherapy after surgery (p=0.443). Moreover, chemotherapy improved survival for patients with resected PDAC in the median-risk (p<0.001) and high-risk (p<0.001) groups.Conclusions: our research constructed a new risk-scoring system based on survival nomogram to screen low-risk PDAC patients after pancreatectomy and confirmed that those can avoid enduring side effects caused by chemotherapy without affecting the survival time.

Periprocedural risk factors for incomplete radiofrequency ablation of liver metastases from colorectal cancer: a single-center retrospective analysis

Objective To explore independent risk factors for incomplete radiofrequency ablation (iRFA) of colorectal cancer liver metastases (CRLM) and evaluate adverse outcomes following iRFA. Materials and Methods Magnetic resonance imaging data of CRLM patients who received percutaneous RFA were randomized into training (70%) and validation set 1 (30%) data sets. An independent validation set 2 was derived from computed tomography scans. Uni- and multivariate analyses identified independent risk factors for iRFA. Area under the curve (AUC) values were used to evaluate the predictive model performance. Risk points were assigned to independent predictors, and iRFA was predicted according to the total risk score. Kaplan–Meier curves were used to assess new intrahepatic metastases (NIHM), unablated tumor progression, and overall survival (OS). Results Multivariate regression determined as independent iRFA risk factors perivascular tumor location, subcapsular tumor location, tumor size ≥20 mm, and minimal ablative margin ≤5 mm. The AUC values of the model in the training set, validation set 1, and validation set 2 were 0.867, 0.772, and 0.820, respectively. The respective AUC values of the total risk score were 0.864, 0.768, and 0.817. During the 6-year follow-up, the cumulative OS was significantly shorter in the iRFA than in the complete RFA group, and NIHM (hazard ratio [HR] = 2.79; 95% confidence interval [CI]: 1.725, 4.513) and unablated tumor progression (HR = 3.473; 95% CI: 1.506, 8.007) were more severe. Conclusions Perivascular tumor location, subcapsular tumor location, tumor size ≥20 mm, and minimal ablative margin ≤5 mm were independent risk factors for iRFA. iRFA may be a potential predictor of NIHM, unablated tumor progression, and OS.

Risk-Scoring System for Prediction of Non-Curative Endoscopic Submucosal Dissection Requiring Additional Gastrectomy in Patients with Early Gastric Cancer

PurposeWhen patients with early gastric cancer (EGC) undergo non-curative endoscopic submucosal dissection requiring gastrectomy (NC-ESD-RG), additional medical resources and expenses are required for surgery. To reduce this burden, predictive model for NC-ESD-RG is required.Materials and MethodsData from 2,997 patients undergoing ESD for 3,127 forceps biopsy-proven differentiated-type EGCs (2,345 and 782 in training and validation sets, respectively) were reviewed. Using the training set, the logistic stepwise regression analysis determined the independent predictors of NC-ESD-RG (NC-ESD other than cases with lateral resection margin involvement or piecemeal resection as the only non-curative factor). Using these predictors, a risk-scoring system for predicting NC-ESD-RG was developed. Performance of the predictive model was examined internally with the validation set.ResultsRate of NC-ESD-RG was 17.3%. Independent pre-ESD predictors for NC-ESD-RG included moderately differentiated or papillary EGC, large tumor size, proximal tumor location, lesion at greater curvature, elevated or depressed morphology, and presence of ulcers. A risk-score was assigned to each predictor of NC-ESD-RG. The area under the receiver operating characteristic curve for predicting NC-ESD-RG was 0.672 in both training and validation sets. A risk-score of 5 points was the optimal cut-off value for predicting NC-ESD-RG, and the overall accuracy was 72.7%. As the total risk score increased, the predicted risk for NC-ESD-RG increased from 3.8% to 72.6%.ConclusionsWe developed and validated a risk-scoring system for predicting NC-ESD-RG based on pre-ESD variables. Our risk-scoring system can facilitate informed consent and decision-making for preoperative treatment selection between ESD and surgery in patients with EGC.

Combining Sanitary Inspection and Water Quality Data in Western Uganda: Lessons Learned from a Field Trial of Original and Revised Sanitary Inspection Forms

Risk assessment for drinking water systems combines sanitary inspections (SI) and water quality testing and is critical for effectively managing the safety of these systems. SI forms consist of question sets relating to the presence of potential sources and pathways of contamination specific to different types of water points, piped distribution systems, and household collection and storage practices. As part of the revision to the Guidelines for Drinking-water Quality (GDWQ), the World Health Organization (WHO) is updating the suite of SI forms to reflect and include the most recent technical and scientific information available. This paper reports the results from a field pilot of a selection of published and revised SI forms and water quality testing in the municipality of Bushenyi-Ishaka, Uganda. We collected data from 45 springs, 61 taps from piped distribution systems, and 129 household storage containers filled with water from those springs and taps. The median total risk scores, according to the revised forms, for spring, tap, and household practices were 36, 53, and 33%, respectively, with higher percentages indicating greater risk. The median Escherichia coli concentrations of spring, tap, and household storage systems were 17, &lt;1, and 7 CFU/100 mL, respectively. We found that increased questioning in the revised SI forms do not necessarily translate to a higher total risk. There is potential for misinterpretation of terminology in the revised SI forms and occasional redundancy of concepts. For the revised SI form for springs, we suggest specific text changes to reduce potential bias. We recommend that users of SI forms receive training in their use and be familiar with their locale. Furthermore, the revised SI forms may need to be adapted in accordance with the local context.

Validation of a Clinical Prediction Rule to Predict Asymptomatic Chlamydia and Gonorrhea Infections Among Internet-Based Testers.

Clinical prediction rules (CPRs) can be used in sexually transmitted infection (STI) testing environments to prioritize individuals at the highest risk of infection and optimize resource allocation. We previously derived a CPR to predict asymptomatic chlamydia and/or gonorrhea (CT/NG) infection among women and heterosexual men at in-person STI clinics based on 5 predictors. Population differences between clinic-based and Internet-based testers may limit the tool's application across settings. The primary objective of this study was to assess the validity, sensitivity, and overall performance of this CPR within an Internet-based testing environment (GetCheckedOnline.com). We analyzed GetCheckedOnline online risk assessment and laboratory data from October 2015 to June 2019. We compared the STI clinic population used for CPR derivation (data previously published) and the GetCheckedOnline validation population using χ2 tests. Calibration and discrimination were assessed using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating curve, respectively. Sensitivity and the fraction of total screening tests offered were quantified for CPR-predicted risk scores. Asymptomatic CT/NG infection prevalence in the GetCheckedOnline population (n = 5478) was higher than in the STI clinic population (n = 10,437; 2.4% vs. 1.8%, P = 0.007). When applied to GetCheckedOnline, the CPR had reasonable calibration (Hosmer-Lemeshow, P = 0.90) and discrimination (area under the receiver operating characteristic, 0.64). By screening only individuals with total risk scores ≥4, we would detect 97% of infections and reduce screening by 14%. The application of an existing CPR to detect asymptomatic CT/NG infection is valid within an Internet-based STI testing environment. Clinical prediction rules applied online can reduce unnecessary STI testing and optimize resource allocation within publicly funded health systems.

Sudden Unexpected Death in Epilepsy (SUDEP) and seizure safety: Modifiable and non-modifiable risk factors differences between primary and secondary care

IntroductionThe SUDEP and Seizure Safety Checklist (“Checklist”) is a risk factors Checklist based around a person with epilepsy (PWE) demographics, seizure, physical, psychological, and lifestyle issues. The Checklist provides a cumulative picture of current risk when applied to a PWE. This study compares and contrasts risk factors of PWE in primary versus secondary care. MethodsThe Checklist was applied to all PWE registered in four primary care practices in central Cornwall UK (pop: 120,000). Individual, modifiable, non-modifiable, and total risk factors and scores were compared between PWE open to secondary care and those not. Statistical tests were used to calculate significance of individual risk factors in primary or secondary care, to compare the total risk scores between care settings and to find the frequency differences of each risk factor between primary practices. ResultsPeople with total and non-modifiable risk scores were higher in secondary care (both p < 0.001). However, modifiable risk scores were higher in primary care (p < 0.001). Psychiatric concerns were the most prevalent modifiable risk factor in primary care. There were significant differences in the risk profiles between all four primary care practices. ConclusionThis study highlights that there is a lack of clarity on who is referred to secondary care and when. There needs to be an evidence-based system to allow for a bidirectional flow of PWE considering their fluctuating risk. The Checklist can be a decision support tool to enable this.

Risk-Adapted Postmastectomy Radiotherapy Decision Based on Prognostic Nomogram for pT1-2N1M0 Breast Cancer: A Multicenter Study.

PurposeThe aim of this study was to develop a widely accepted prognostic nomogram and establish a risk-adapted PMRT strategy based on locoregional recurrence for pT1-2N1M0 breast cancer.Methods and MaterialsA total of 3,033 patients with pT1-2N1M0 breast cancer treated at 6 participating institutions between 2000 and 2016 were retrospectively reviewed. A nomogram was developed to predicted locoregional recurrence-free survival (LRFS). A propensity score-matched (PSM) analyses was performed in risk-adapted model.ResultsWith the median follow-up of 65.0 months, the 5-year overall survival (OS), disease free survival (DFS) and LRFS were 93.0, 84.8, and 93.6%, respectively. There was no significant difference between patients who received PMRT or not for the entire group. A nomogram was developed and validated to estimate the probability of 5-year LRFS based on five independent factors including age, primary tumor site, positive lymph nodes number, pathological T stage, and molecular subtype that were selected by a multivariate analysis of patients who did not receive PMRT in the primary cohort. According to the total nomogram risk scores, the entire patients were classified into low- (40.0%), moderate- (42.4%), and high-risk group (17.6%). The 5-year outcomes were significantly different among these three groups (P<0.001). In low-risk group, patients who received PMRT or not both achieved a favorable OS, DFS, and LRFS. In moderate-risk group, no differences in OS, DFS, and LRFS were observed between PMRT and no PMRT patients. In high-risk group, compared with no PMRT, PMRT resulted in significantly different OS (86.8 vs 83.9%, P = 0.050), DFS (77.2 vs 70.9%, P = 0.049), and LRFS (90.8 vs. 81.6%, P = 0.003). After PSM adjustment, there were no significant differences in OS, DFS, and LRFS in low-risk and moderate-risk groups. However, in the high-risk group, PMRT still resulted in significantly better OS, DFS and improved LRFS.ConclusionsThe proposed nomogram provides an individualized risk estimate of LRFS in patients with pT1-2N1M0 breast cancer. Risk-adapted PMRT for high-risk patients is a viable effective strategy.

Genetic Risk, Lifestyle, and Age-Related Macular Degeneration in Europe: The EYE-RISK Consortium

Age-related macular degeneration (AMD) is a common multifactorial disease in the elderly with a prominent genetic basis. Many risk variants have been identified, but the interpretation remains challenging. We investigated the genetic distribution of AMD-associated risk variants in a large European consortium, calculated attributable and pathway-specific genetic risks, and assessed the influence of lifestyle on genetic outcomes. Pooled analysis of cross-sectional data from the European Eye Epidemiology Consortium. Seventeen thousand one hundred seventy-four individuals 45 years of age or older participating in 6 population-based cohort studies, 2 clinic-based studies, and 1 case-control study. Age-related macular degeneration was diagnosed and graded based on fundus photographs. Data on genetics, lifestyle, and diet were harmonized. Minor allele frequencies and population-attributable fraction (PAF) were calculated. A total genetic risk score (GRS) and pathway-specific risk scores (complement, lipid, extra-cellular matrix, other) were constructed based on the dosage of SNPs and conditional β values; a lifestyle score was constructed based on smoking and diet. Intermediate and late AMD. The risk variants with the largest difference between late AMD patients and control participants and the highest PAFs were located in ARMS2 (rs3750846) and CHF (rs570618 and rs10922109). Combining all genetic variants, the total genetic risk score ranged from -3.50 to 4.63 and increased with AMD severity. Of the late AMD patients, 1581 of 1777 (89%) showed a positive total GRS. The complement pathway and ARMS2 were by far the most prominent genetic pathways contributing to late AMD (positive GRS, 90% of patients with late disease), but risk in 3 pathways was most frequent (35% of patients with late disease). Lifestyle was a strong determinant of the outcome in each genetic risk category; unfavorable lifestyle increased the risk of late AMD at least 2-fold. Genetic risk variants contribute to late AMD in most patients. However, lifestyle factors have a strong influence on the outcome of genetic risk and should be a strong focus in patient management. Genetic risks in ARMS2 and the complement pathway are present in most late AMD patients but are mostly combined with risks in other pathways.

Abstract 16337: A Risk Score That Predicts Recurrence of Neurally Mediated Syncope Using Electrocardiographic and Vectorcardiographic Parameters

Introduction: We have previously demonstrated that isolated very low QRS voltage (VLV defined as ≤0.3mV) in the frontal leads on the electrocardiogram (ECG; Figure A), as well as flat QRS loops in the frontal plane on ECG-derived vectorcardiograms (VCG; Figure B) predict recurrence of neurally mediated syncope (NMS). This phenomenon is possibly related to a specific ventricular geometry and activation pattern. Hypothesis: The aim of this study was to attempt to incorporate these novel ECG and VCG risk factors for recurrence of syncope into a prognostic risk score. Methods: We included 215 patients (age 48±20years), with NMS and a median of 3 syncopal episodes. The patients were followed for a median of 10 months (IQR 4-20). To weigh the relative importance of the prognostic risk factors identified in multivariate Cox regression analysis we attributed a score of 1 point for HR 1.5-1.99, 2 points for HR 2.0-2.49, and 3 points for HR ≥ 2.5. The total risk score, was divided into three categories: low risk (0-2), intermediate risk (3-5) and high risk (≥6). Results: The multivariate analysis identified history of ≥ 2 syncopal events (HR 3.85, 95%CI 1.62-9.14), left ventricular end-diastolic diameter of &lt; 39mm by echocardiography (HR 1.94, 95%CI 1.00-3.82), isolated VLV QRS in frontal leads (HR 2.60, 95%CI 1.37-4.86) and flat QRS VCG loops in frontal plane (HR 2.23, 95%CI 1.24-3.99) as independent predictors for NMS recurrence (all P &lt; 0.05). The actuarial total syncope recurrence rate at 1 year was 54.6% (95%CI 38.2-72.6) in the high-risk score category, 25.3% (95%CI 16.8-37.1) in the intermediate risk category, and 6.2% (95%CI 2.2-16.2) in the low-risk category (log rank test P&lt;0.0001; Figure C). The ROC curve showed an AUC of 0.77 for the predictive value of the total risk score. Conclusions: The risk of recurrence of NMS could be stratified using a risk score that incorporates novel ECG and VCG parameters in addition to more established clinical and echocardiographic variables.

The Differential Influence of Immune, Endocytotic, and Lipid Metabolism Genes on Amyloid Deposition and Neurodegeneration in Subjects at Risk of Alzheimer's Disease.

Over 20 single-nucleotide polymorphisms (SNPs) are associated with increased risk of Alzheimer's disease (AD). We categorized these loci into immunity, lipid metabolism, and endocytosis pathways, and associated the polygenic risk scores (PRS) calculated, with AD biomarkers in mild cognitive impairment (MCI) subjects. The aim of this study was to identify associations between pathway-specific PRS and AD biomarkers in patients with MCI and healthy controls. AD biomarkers ([18F]Florbetapir-PET SUVR, FDG-PET SUVR, hippocampal volume, CSF tau and amyloid-β levels) and neurocognitive tests scores were obtained in 258 healthy controls and 451 MCI subjects from the ADNI dataset at baseline and at 24-month follow up. Pathway-related (immunity, lipid metabolism, and endocytosis) and total polygenic risk scores were calculated from 20 SNPs. Multiple linear regression analysis was used to test predictive value of the polygenic risk scores over longitudinal biomarker and cognitive changes. Higher immune risk score was associated with worse cognitive measures and reduced glucose metabolism. Higher lipid risk score was associated with increased amyloid deposition and cortical hypometabolism. Total, immune, and lipid scores were associated with significant changes in cognitive measures, amyloid deposition, and brain metabolism. Polygenic risk scores highlights the influence of specific genes on amyloid-dependent and independent pathways; and these pathways could be differentially influenced by lipid and immune scores respectively.