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West MA, Loughney L, Ambler G, Dimitrov BD, Kelly JJ, Mythen MG, Sturgess R, Calverley PMA, Kendrick A, Grocott MPW, Jack S. The effect of neoadjuvant chemotherapy and chemoradiotherapy on exercise capacity and outcome following upper gastrointestinal cancer surgery: an observational cohort study. BMC Cancer 2016; 16:710. [PMID: 27589870 PMCID: PMC5010720 DOI: 10.1186/s12885-016-2682-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/05/2016] [Indexed: 11/13/2022] Open
Abstract
Background In 2014 approximately 21,200 patients were diagnosed with oesophageal and gastric cancer in England and Wales, of whom 37 % underwent planned curative treatments. Potentially curative surgical resection is associated with significant morbidity and mortality. For operable locally advanced disease, neoadjuvant chemotherapy (NAC) improves survival over surgery alone. However, NAC carries the risk of toxicity and is associated with a decrease in physical fitness, which may in turn influence subsequent clinical outcome. Lower levels of physical fitness are associated with worse outcome following major surgery in general and Upper Gastrointestinal Surgery (UGI) surgery in particular. Cardiopulmonary exercise testing (CPET) provides an objective assessment of physical fitness. The aim of this study is to test the hypothesis that NAC prior to upper gastrointestinal cancer surgery is associated with a decrease in physical fitness and that the magnitude of the change in physical fitness will predict mortality 1 year following surgery. Methods This study is a multi-centre, prospective, blinded, observational cohort study of participants with oesophageal and gastric cancer scheduled for neoadjuvant cancer treatment (chemo- and chemoradiotherapy) and surgery. The primary endpoints are physical fitness (oxygen uptake at lactate threshold measured using CPET) and 1-year mortality following surgery; secondary endpoints include post-operative morbidity (Post-Operative Morbidity Survey (POMS)) 5 days after surgery and patient related quality of life (EQ-5D-5 L). Discussion The principal benefits of this study, if the underlying hypothesis is correct, will be to facilitate better selection of treatments (e.g. NAC, Surgery) in patients with oesophageal or gastric cancer. It may also be possible to develop new treatments to reduce the effects of neoadjuvant cancer treatment on physical fitness. These results will contribute to the design of a large, multi-centre trial to determine whether an in-hospital exercise-training programme that increases physical fitness leads to improved overall survival. Trial registration ClinicalTrials.gov NCT01325883 - 29th March 2011.
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Affiliation(s)
- M A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - L Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - B D Dimitrov
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - J J Kelly
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - M G Mythen
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - R Sturgess
- Department of Gastroenterology, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - P M A Calverley
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - A Kendrick
- Department of Physiological Sciences, University of Bristol, Bristol, UK
| | - M P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK. .,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.
| | - S Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
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Pajouheshnia R, Pestman WR, Teerenstra S, Groenwold RHH. A computational approach to compare regression modelling strategies in prediction research. BMC Med Res Methodol 2016; 16:107. [PMID: 27557642 PMCID: PMC4997720 DOI: 10.1186/s12874-016-0209-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background It is often unclear which approach to fit, assess and adjust a model will yield the most accurate prediction model. We present an extension of an approach for comparing modelling strategies in linear regression to the setting of logistic regression and demonstrate its application in clinical prediction research. Methods A framework for comparing logistic regression modelling strategies by their likelihoods was formulated using a wrapper approach. Five different strategies for modelling, including simple shrinkage methods, were compared in four empirical data sets to illustrate the concept of a priori strategy comparison. Simulations were performed in both randomly generated data and empirical data to investigate the influence of data characteristics on strategy performance. We applied the comparison framework in a case study setting. Optimal strategies were selected based on the results of a priori comparisons in a clinical data set and the performance of models built according to each strategy was assessed using the Brier score and calibration plots. Results The performance of modelling strategies was highly dependent on the characteristics of the development data in both linear and logistic regression settings. A priori comparisons in four empirical data sets found that no strategy consistently outperformed the others. The percentage of times that a model adjustment strategy outperformed a logistic model ranged from 3.9 to 94.9 %, depending on the strategy and data set. However, in our case study setting the a priori selection of optimal methods did not result in detectable improvement in model performance when assessed in an external data set. Conclusion The performance of prediction modelling strategies is a data-dependent process and can be highly variable between data sets within the same clinical domain. A priori strategy comparison can be used to determine an optimal logistic regression modelling strategy for a given data set before selecting a final modelling approach. Electronic supplementary material The online version of this article (doi:10.1186/s12874-016-0209-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Romin Pajouheshnia
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Wiebe R Pestman
- Catholic University of Leuven, Research Unit for Quantitative Psychology and Individual Differences, Leuven, Belgium
| | - Steven Teerenstra
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department for Health Evidence, Section of Biostatistics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
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Ogundimu EO, Altman DG, Collins GS. Adequate sample size for developing prediction models is not simply related to events per variable. J Clin Epidemiol 2016; 76:175-82. [PMID: 26964707 PMCID: PMC5045274 DOI: 10.1016/j.jclinepi.2016.02.031] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 01/31/2016] [Accepted: 02/29/2016] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The choice of an adequate sample size for a Cox regression analysis is generally based on the rule of thumb derived from simulation studies of a minimum of 10 events per variable (EPV). One simulation study suggested scenarios in which the 10 EPV rule can be relaxed. The effect of a range of binary predictors with varying prevalence, reflecting clinical practice, has not yet been fully investigated. STUDY DESIGN AND SETTING We conducted an extended resampling study using a large general-practice data set, comprising over 2 million anonymized patient records, to examine the EPV requirements for prediction models with low-prevalence binary predictors developed using Cox regression. The performance of the models was then evaluated using an independent external validation data set. We investigated both fully specified models and models derived using variable selection. RESULTS Our results indicated that an EPV rule of thumb should be data driven and that EPV ≥ 20 generally eliminates bias in regression coefficients when many low-prevalence predictors are included in a Cox model. CONCLUSION Higher EPV is needed when low-prevalence predictors are present in a model to eliminate bias in regression coefficients and improve predictive accuracy.
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Affiliation(s)
- Emmanuel O Ogundimu
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Diseases, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK.
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Diseases, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Diseases, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
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54
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Pölsterl S, Conjeti S, Navab N, Katouzian A. Survival analysis for high-dimensional, heterogeneous medical data: Exploring feature extraction as an alternative to feature selection. Artif Intell Med 2016; 72:1-11. [PMID: 27664504 DOI: 10.1016/j.artmed.2016.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/15/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In clinical research, the primary interest is often the time until occurrence of an adverse event, i.e., survival analysis. Its application to electronic health records is challenging for two main reasons: (1) patient records are comprised of high-dimensional feature vectors, and (2) feature vectors are a mix of categorical and real-valued features, which implies varying statistical properties among features. To learn from high-dimensional data, researchers can choose from a wide range of methods in the fields of feature selection and feature extraction. Whereas feature selection is well studied, little work focused on utilizing feature extraction techniques for survival analysis. RESULTS We investigate how well feature extraction methods can deal with features having varying statistical properties. In particular, we consider multiview spectral embedding algorithms, which specifically have been developed for these situations. We propose to use random survival forests to accurately determine local neighborhood relations from right censored survival data. We evaluated 10 combinations of feature extraction methods and 6 survival models with and without intrinsic feature selection in the context of survival analysis on 3 clinical datasets. Our results demonstrate that for small sample sizes - less than 500 patients - models with built-in feature selection (Cox model with ℓ1 penalty, random survival forest, and gradient boosted models) outperform feature extraction methods by a median margin of 6.3% in concordance index (inter-quartile range: [-1.2%;14.6%]). CONCLUSIONS If the number of samples is insufficient, feature extraction methods are unable to reliably identify the underlying manifold, which makes them of limited use in these situations. For large sample sizes - in our experiments, 2500 samples or more - feature extraction methods perform as well as feature selection methods.
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Affiliation(s)
- Sebastian Pölsterl
- Computer Aided Medical Procedures, Technische Universität München, Boltzmannstraße 3, 85748 Garching bei München, Germany.
| | - Sailesh Conjeti
- Computer Aided Medical Procedures, Technische Universität München, Boltzmannstraße 3, 85748 Garching bei München, Germany.
| | - Nassir Navab
- Computer Aided Medical Procedures, Technische Universität München, Boltzmannstraße 3, 85748 Garching bei München, Germany; Johns Hopkins University, 3400 North Charles Street, Baltimore, MD 21218, USA.
| | - Amin Katouzian
- IBM Almaden Research Center, 650 Harry Road, San Jose, CA 95120, USA.
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Wynants L, Collins GS, Van Calster B. Key steps and common pitfalls in developing and validating risk models. BJOG 2016; 124:423-432. [DOI: 10.1111/1471-0528.14170] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2016] [Indexed: 01/09/2023]
Affiliation(s)
- L Wynants
- KU Leuven Department of Electrical Engineering‐ESAT STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics KU Leuven iMinds Medical IT Department Leuven Belgium
| | - GS Collins
- Centre for Statistics in Medicine Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - B Van Calster
- KU Leuven Department of Development and Regeneration Leuven Belgium
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56
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Ojeda FM, Müller C, Börnigen D, Trégouët DA, Schillert A, Heinig M, Zeller T, Schnabel RB. Comparison of Cox Model Methods in A Low-dimensional Setting with Few Events. GENOMICS PROTEOMICS & BIOINFORMATICS 2016; 14:235-43. [PMID: 27224515 PMCID: PMC4996851 DOI: 10.1016/j.gpb.2016.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 03/01/2016] [Accepted: 03/22/2016] [Indexed: 11/01/2022]
Abstract
Prognostic models based on survival data frequently make use of the Cox proportional hazards model. Developing reliable Cox models with few events relative to the number of predictors can be challenging, even in low-dimensional datasets, with a much larger number of observations than variables. In such a setting we examined the performance of methods used to estimate a Cox model, including (i) full model using all available predictors and estimated by standard techniques, (ii) backward elimination (BE), (iii) ridge regression, (iv) least absolute shrinkage and selection operator (lasso), and (v) elastic net. Based on a prospective cohort of patients with manifest coronary artery disease (CAD), we performed a simulation study to compare the predictive accuracy, calibration, and discrimination of these approaches. Candidate predictors for incident cardiovascular events we used included clinical variables, biomarkers, and a selection of genetic variants associated with CAD. The penalized methods, i.e., ridge, lasso, and elastic net, showed a comparable performance, in terms of predictive accuracy, calibration, and discrimination, and outperformed BE and the full model. Excessive shrinkage was observed in some cases for the penalized methods, mostly on the simulation scenarios having the lowest ratio of a number of events to the number of variables. We conclude that in similar settings, these three penalized methods can be used interchangeably. The full model and backward elimination are not recommended in rare event scenarios.
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Affiliation(s)
- Francisco M Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Christian Müller
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Luebeck, Germany
| | - Daniela Börnigen
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Luebeck, Germany
| | - David-Alexandre Trégouët
- Sorbonne Universités, Université Pierre et Marie Curie Paris 06, Institut National pour la Santé et la Recherche Médicale (INSERM), Unité Mixte de Recherche en Santé (UMR_S) 1166, F-75013 Paris, France; Institute for Cardiometabolism and Nutrition (ICAN), F-75013 Paris, France
| | - Arne Schillert
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany; German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Luebeck, Germany
| | - Matthias Heinig
- Institute of Computational Biology, German Research Center for Environmental Health, Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Luebeck, Germany
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, 20246 Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Luebeck, Germany
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Pavlou M, Ambler G, Seaman S, De Iorio M, Omar RZ. Review and evaluation of penalised regression methods for risk prediction in low-dimensional data with few events. Stat Med 2016; 35:1159-77. [PMID: 26514699 PMCID: PMC4982098 DOI: 10.1002/sim.6782] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 09/30/2015] [Accepted: 10/06/2015] [Indexed: 12/16/2022]
Abstract
Risk prediction models are used to predict a clinical outcome for patients using a set of predictors. We focus on predicting low-dimensional binary outcomes typically arising in epidemiology, health services and public health research where logistic regression is commonly used. When the number of events is small compared with the number of regression coefficients, model overfitting can be a serious problem. An overfitted model tends to demonstrate poor predictive accuracy when applied to new data. We review frequentist and Bayesian shrinkage methods that may alleviate overfitting by shrinking the regression coefficients towards zero (some methods can also provide more parsimonious models by omitting some predictors). We evaluated their predictive performance in comparison with maximum likelihood estimation using real and simulated data. The simulation study showed that maximum likelihood estimation tends to produce overfitted models with poor predictive performance in scenarios with few events, and penalised methods can offer improvement. Ridge regression performed well, except in scenarios with many noise predictors. Lasso performed better than ridge in scenarios with many noise predictors and worse in the presence of correlated predictors. Elastic net, a hybrid of the two, performed well in all scenarios. Adaptive lasso and smoothly clipped absolute deviation performed best in scenarios with many noise predictors; in other scenarios, their performance was inferior to that of ridge and lasso. Bayesian approaches performed well when the hyperparameters for the priors were chosen carefully. Their use may aid variable selection, and they can be easily extended to clustered-data settings and to incorporate external information.
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Affiliation(s)
- Menelaos Pavlou
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
| | | | - Maria De Iorio
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
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Burnell M, Iyer R, Gentry-Maharaj A, Nordin A, Liston R, Manchanda R, Das N, Gornall R, Beardmore-Gray A, Hillaby K, Leeson S, Linder A, Lopes A, Meechan D, Mould T, Nevin J, Olaitan A, Rufford B, Shanbhag S, Thackeray A, Wood N, Reynolds K, Ryan A, Menon U. Benchmarking of surgical complications in gynaecological oncology: prospective multicentre study. BJOG 2016; 123:2171-2180. [DOI: 10.1111/1471-0528.13994] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- M Burnell
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
| | - R Iyer
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
| | - A Gentry-Maharaj
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
| | - A Nordin
- East Kent Gynaecological Oncology Centre; Queen Elizabeth the Queen Mother Hospital; Margate UK
| | - R Liston
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
| | - R Manchanda
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
- Department of Gynaecological Cancer; Barts Cancer Centre; Barts and the London NHS Trust; London UK
| | - N Das
- Department of Gynaecological Cancer; Royal Cornwall Hospitals NHS Trust; Truro UK
| | - R Gornall
- Department of Gynaecological Oncology; Cheltenham General Hospital; Cheltenham UK
| | - A Beardmore-Gray
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
| | - K Hillaby
- Department of Gynaecological Oncology; Cheltenham General Hospital; Cheltenham UK
| | - S Leeson
- Department of Obstetrics and Gynaecology; BetsiCadwaladr University Health Board; Bangor UK
| | - A Linder
- Department of Gynaecological Oncology; The Ipswich Hospital NHS Trust; Ipswich Suffolk UK
| | - A Lopes
- Department of Gynaecological Cancer; Royal Cornwall Hospitals NHS Trust; Truro UK
| | | | - T Mould
- Department of Gynaecological Oncology; University College London Hospital NHS Foundation Trust; London UK
| | - J Nevin
- Pan Birmingham Gynaecological Cancer Centre; Birmingham City Hospital; Birmingham UK
| | - A Olaitan
- Department of Gynaecological Oncology; University College London Hospital NHS Foundation Trust; London UK
| | - B Rufford
- Department of Gynaecological Oncology; The Ipswich Hospital NHS Trust; Ipswich Suffolk UK
| | - S Shanbhag
- Department of Gynaecological Oncology; Glasgow Royal Infirmary; Glasgow UK
| | | | - N Wood
- Department of Gynaecological Oncology; Lancashire Teaching Hospitals NHS Foundation trust; Royal Preston Hospital; Preston UK
| | - K Reynolds
- Department of Gynaecological Cancer; Barts Cancer Centre; Barts and the London NHS Trust; London UK
| | - A Ryan
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
| | - U Menon
- Department of Women's Cancer; Gynaecological Cancer Research Centre; Institute for Women's Health; University College London; London UK
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Van Calster B, Nieboer D, Vergouwe Y, De Cock B, Pencina MJ, Steyerberg EW. A calibration hierarchy for risk models was defined: from utopia to empirical data. J Clin Epidemiol 2016; 74:167-76. [PMID: 26772608 DOI: 10.1016/j.jclinepi.2015.12.005] [Citation(s) in RCA: 459] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 12/06/2015] [Accepted: 12/23/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Calibrated risk models are vital for valid decision support. We define four levels of calibration and describe implications for model development and external validation of predictions. STUDY DESIGN AND SETTING We present results based on simulated data sets. RESULTS A common definition of calibration is "having an event rate of R% among patients with a predicted risk of R%," which we refer to as "moderate calibration." Weaker forms of calibration only require the average predicted risk (mean calibration) or the average prediction effects (weak calibration) to be correct. "Strong calibration" requires that the event rate equals the predicted risk for every covariate pattern. This implies that the model is fully correct for the validation setting. We argue that this is unrealistic: the model type may be incorrect, the linear predictor is only asymptotically unbiased, and all nonlinear and interaction effects should be correctly modeled. In addition, we prove that moderate calibration guarantees nonharmful decision making. Finally, results indicate that a flexible assessment of calibration in small validation data sets is problematic. CONCLUSION Strong calibration is desirable for individualized decision support but unrealistic and counter productive by stimulating the development of overly complex models. Model development and external validation should focus on moderate calibration.
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Affiliation(s)
- Ben Van Calster
- KU Leuven, Department of Development and Regeneration, Herestraat 49 Box 7003, 3000 Leuven, Belgium; Department of Public Health, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Yvonne Vergouwe
- Department of Public Health, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Bavo De Cock
- KU Leuven, Department of Development and Regeneration, Herestraat 49 Box 7003, 3000 Leuven, Belgium
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC 27705, USA; Department of Biostatistics and Bioinformatics, Duke University, 2424 Erwin Road, Durham, NC 27719, USA
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Wang J, Zhu P, Cui Z, Qu Z, Zhang YM, Wang F, Wang X, Wang JW, Zhu SN, Liu G, Zhou FD, Zhao MH. Clinical Features and Outcomes in Patients With Membranous Nephropathy and Crescent Formation. Medicine (Baltimore) 2015; 94:e2294. [PMID: 26683965 PMCID: PMC5058937 DOI: 10.1097/md.0000000000002294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cases of membranous nephropathy (MN) with crescent formation, in the absence of lupus, hepatitis B virus infection, anti-glomerular basement membrane (GBM) nephritis, or antineutrophil cytoplasmic antibody (ANCA), are on record. Clinical presentation and treatment outcomes in these patients are unclear. All patients with biopsy-proven MN diagnosed between years 2008 and 2014 and followed up were enrolled retrospectively. Patients with ANCA, anti-GBM antibodies, lupus, hepatitis B virus infection, or malignance were excluded. Clinical features and outcomes were compared between MN patients with and without crescent. Out of 401 consecutive patients with idiopathic MN, 28 (6.9%) showed crescent formation in 4.9% (2.2%-16.7%) of glomeruli. Mean age of these patients was 50.1 ± 11.1 years, and they presented with heavy proteinuria (6.5 ± 4.8 g/24 h) and hematuria; 21.4% of these patients had declined estimated glomerular filtration rate (<60 mL/min/1.73 m2) on biopsy. Anti-phospholipase A2 receptor antibody was detectable in 79.7% of these patients. These clinical features were comparable to the MN patients without crescent (P > 0.05). Twelve (42.9%) patients received steroids plus immunosuppressive therapy similar to that in patients without crescent (41.3%). Fewer patients with crescents achieved remission (67.9% vs 86.7%, P = 0.029). Crescent formation was a risk factor for no response to the treatments (odds ratio [OR] = 3.1, P = 0.033). Higher percentage of crescents predicted more risk for no remission (OR = 1.2, P = 0.038). Patients with crescents presented more frequencies of abnormal serum creatinine during follow-up (10.7% vs 1.3%, P = 0.031). Crescent formation was also a risk factor for worse renal outcome (relative risk = 10.2, P = 0.046). MN patients with crescents showed unfavorable therapeutic response and tended to have worse renal outcomes. More aggressive treatments and renal protection might be considered to improve the outcomes.
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Affiliation(s)
- Jia Wang
- From the Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing (JW, PZ, ZC, ZQ, Y-mZ, FW, XW, J-wW, GL, F-DZ, M-hZ); Renal Division (PZ), Department of Medicine, The First College of Clinical Medical Science, China Three Gorges University, Yichang; Department of Biostatistics (S-nZ), Peking University First Hospital; and Peking-Tsinghua Center for Life Sciences (M-hZ), Beijing, China
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Göbl CS, Bozkurt L, Tura A, Pacini G, Kautzky-Willer A, Mittlböck M. Application of Penalized Regression Techniques in Modelling Insulin Sensitivity by Correlated Metabolic Parameters. PLoS One 2015; 10:e0141524. [PMID: 26544569 PMCID: PMC4636325 DOI: 10.1371/journal.pone.0141524] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/09/2015] [Indexed: 12/20/2022] Open
Abstract
This paper aims to introduce penalized estimation techniques in clinical investigations of diabetes, as well as to assess their possible advantages and limitations. Data from a previous study was used to carry out the simulations to assess: a) which procedure results in the lowest prediction error of the final model in the setting of a large number of predictor variables with high multicollinearity (of importance if insulin sensitivity should be predicted) and b) which procedure achieves the most accurate estimate of regression coefficients in the setting of fewer predictors with small unidirectional effects and moderate correlation between explanatory variables (of importance if the specific relation between an independent variable and insulin sensitivity should be examined). Moreover a special focus is on the correct direction of estimated parameter effects, a non-negligible source of error and misinterpretation of study results. The simulations were performed for varying sample size to evaluate the performance of LASSO, Ridge as well as different algorithms for Elastic Net. These methods were also compared with automatic variable selection procedures (i.e. optimizing AIC or BIC).We were not able to identify one method achieving superior performance in all situations. However, the improved accuracy of estimated effects underlines the importance of using penalized regression techniques in our example (e.g. if a researcher aims to compare relations of several correlated parameters with insulin sensitivity). However, the decision which procedure should be used depends on the specific context of a study (accuracy versus complexity) and moreover should involve clinical prior knowledge.
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Affiliation(s)
- Christian S. Göbl
- Department of Gynecology and Obstetrics, Division of Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Latife Bozkurt
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Unit of Gender Medicine, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- Metabolic Unit, Institute of Neuroscience, National Research Council, Padova, Italy
| | - Giovanni Pacini
- Metabolic Unit, Institute of Neuroscience, National Research Council, Padova, Italy
| | - Alexandra Kautzky-Willer
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Unit of Gender Medicine, Medical University of Vienna, Vienna, Austria
| | - Martina Mittlböck
- Center of Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
- * E-mail:
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62
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Jinks RC, Royston P, Parmar MKB. Discrimination-based sample size calculations for multivariable prognostic models for time-to-event data. BMC Med Res Methodol 2015; 15:82. [PMID: 26459415 PMCID: PMC4603804 DOI: 10.1186/s12874-015-0078-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 10/02/2015] [Indexed: 12/12/2022] Open
Abstract
Background Prognostic studies of time-to-event data, where researchers aim to develop or validate multivariable prognostic models in order to predict survival, are commonly seen in the medical literature; however, most are performed retrospectively and few consider sample size prior to analysis. Events per variable rules are sometimes cited, but these are based on bias and coverage of confidence intervals for model terms, which are not of primary interest when developing a model to predict outcome. In this paper we aim to develop sample size recommendations for multivariable models of time-to-event data, based on their prognostic ability. Methods We derive formulae for determining the sample size required for multivariable prognostic models in time-to-event data, based on a measure of discrimination, D, developed by Royston and Sauerbrei. These formulae fall into two categories: either based on the significance of the value of D in a new study compared to a previous estimate, or based on the precision of the estimate of D in a new study in terms of confidence interval width. Using simulation we show that they give the desired power and type I error and are not affected by random censoring. Additionally, we conduct a literature review to collate published values of D in different disease areas. Results We illustrate our methods using parameters from a published prognostic study in liver cancer. The resulting sample sizes can be large, and we suggest controlling study size by expressing the desired accuracy in the new study as a relative value as well as an absolute value. To improve usability we use the values of D obtained from the literature review to develop an equation to approximately convert the commonly reported Harrell’s c-index to D. A flow chart is provided to aid decision making when using these methods. Conclusion We have developed a suite of sample size calculations based on the prognostic ability of a survival model, rather than the magnitude or significance of model coefficients. We have taken care to develop the practical utility of the calculations and give recommendations for their use in contemporary clinical research.
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Affiliation(s)
- Rachel C Jinks
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK.
| | - Patrick Royston
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK.
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK.
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Pavlou M, Ambler G, Seaman SR, Guttmann O, Elliott P, King M, Omar RZ. How to develop a more accurate risk prediction model when there are few events. BMJ 2015; 351:h3868. [PMID: 26264962 PMCID: PMC4531311 DOI: 10.1136/bmj.h3868] [Citation(s) in RCA: 358] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
When the number of events is low relative to the number of predictors, standard regression could produce overfitted risk models that make inaccurate predictions. Use of penalised regression may improve the accuracy of risk prediction
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Affiliation(s)
- Menelaos Pavlou
- Department of Statistical Science, University College London, WC1E 6BT London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, WC1E 6BT London, UK
| | | | - Oliver Guttmann
- School of Life and Medical Sciences, Institute of Cardiovascular Science, University College London
| | - Perry Elliott
- Inherited Cardiac Disease Unit, the Heart Hospital, London
| | - Michael King
- Division of Psychiatry, University College London
| | - Rumana Z Omar
- Department of Statistical Science, University College London, WC1E 6BT London, UK
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Charidimou A, Wilson D, Shakeshaft C, Ambler G, White M, Cohen H, Yousry T, Al-Shahi Salman R, Lip G, Houlden H, Jäger HR, Brown MM, Werring DJ. The Clinical Relevance of Microbleeds in Stroke study (CROMIS-2): rationale, design, and methods. Int J Stroke 2015; 10 Suppl A100:155-61. [PMID: 26235450 DOI: 10.1111/ijs.12569] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/02/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND RATIONALE The increasing use of oral anticoagulants, mostly to prevent ischemic stroke due to atrial fibrillation in an ageing population, has been associated with a fivefold increased incidence of oral anticoagulant-associated intracerebral hemorrhage: a rare, serious, and unpredictable complication. We hypothesize that cerebral microbleeds and other markers of cerebral small vessel disease on magnetic resonance imaging, and genetic polymorphisms (e.g. influencing cerebral small vessel integrity or anticoagulation stability), are associated with an increased risk of oral anticoagulant-associated intracerebral hemorrhage, with potential to improve risk prediction. AIMS (1) To determine the incidence, clinical, radiological, and genetic associations of oral anticoagulant-associated intracerebral hemorrhage in a prospective, multicentre cohort study of patients with atrial fibrillation-related ischemic stroke or transient ischemic attack started on oral anticoagulants; (2) To investigate characteristics of oral anticoagulant-associated intracerebral hemorrhage compared with non-oral anticoagulants related intracerebral hemorrhage in a prospective study. DESIGN AND METHODS Study 1: Prospective, multicentre, inception cohort study of 1425 adults started on oral anticoagulants (including vitamin K antagonists and the nonvitamin K oral anticoagulants) after recent ischemic stroke and concurrent atrial fibrillation. Participants will have standardized brain magnetic resonance imaging (including a T2*-weighted gradient-recalled echo sequence) and DNA sample collection at baseline, with two-year follow-up by postal questionnaire and medical records surveillance for symptomatic intracranial hemorrhage, other serious vascular events, and death. We will compare the rates of symptomatic intracranial hemorrhage (primary outcome; subclassified as intracerebral, subdural, extradural, intraventricular), other vascular events, and death (secondary outcomes) in participants with one or more cerebral microbleeds to the rates in those without cerebral microbleeds. STUDY Prospective case-control study of oral anticoagulant-associated intracerebral hemorrhage compared with non-oral anticoagulant-associated intracerebral hemorrhage to investigate genetic, clinical, and radiological associations with oral anticoagulant-associated intracerebral hemorrhage. In participants with intracerebral hemorrhage (including at least 300 with oral anticoagulant-associated intracerebral hemorrhage), we will collect a DNA sample, standardized clinical data and routine brain imaging (magnetic resonance imaging or computed tomography), and information on functional outcome. EXPECTED OUTCOMES We will identify the factors associated with increased intracranial hemorrhage risk after oral anticoagulants for secondary prevention after ischemic stroke due to atrial fibrillation. We will determine clinical, radiological and genetic factors, and clinical outcomes associated with oral anticoagulant-associated intracerebral hemorrhage.
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Affiliation(s)
- Andreas Charidimou
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Duncan Wilson
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Clare Shakeshaft
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Mark White
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Hannah Cohen
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Tarek Yousry
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Gregory Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Henry Houlden
- Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Hans R Jäger
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Martin M Brown
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - David J Werring
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Hypertrophic Cardiomyopathy Registry: The rationale and design of an international, observational study of hypertrophic cardiomyopathy. Am Heart J 2015; 170:223-30. [PMID: 26299218 DOI: 10.1016/j.ahj.2015.05.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/10/2015] [Indexed: 10/23/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common monogenic heart disease with a frequency as high as 1 in 200. In many cases, HCM is caused by mutations in genes encoding the different components of the sarcomere apparatus. Hypertrophic cardiomyopathy is characterized by unexplained left ventricular hypertrophy, myofibrillar disarray, and myocardial fibrosis. The phenotypic expression is quite variable. Although most patients with HCM are asymptomatic, serious consequences are experienced in a subset of affected individuals who present initially with sudden cardiac death or progress to refractory heart failure. The Hypertrophic Cardiomyopathy Registry study is a National Heart, Lung, and Blood Institute-sponsored 2,750-patient, 44-site, international registry and natural history study designed to address limitations in extant evidence to improve prognostication in HCM (NCT01915615). In addition to the collection of standard demographic, clinical, and echocardiographic variables, patients will undergo state-of-the-art cardiac magnetic resonance for assessment of left ventricular mass and volumes as well as replacement scarring and interstitial fibrosis. In addition, genetic and biomarker analyses will be performed. The Hypertrophic Cardiomyopathy Registry has the potential to change the paradigm of risk stratification in HCM, using novel markers to identify those at higher risk.
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66
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Guttmann OP, Pavlou M, O'Mahony C, Monserrat L, Anastasakis A, Rapezzi C, Biagini E, Gimeno JR, Limongelli G, Garcia-Pavia P, McKenna WJ, Omar RZ, Elliott PM. Prediction of thrombo-embolic risk in patients with hypertrophic cardiomyopathy (HCM Risk-CVA). Eur J Heart Fail 2015; 17:837-45. [PMID: 26183688 PMCID: PMC4737264 DOI: 10.1002/ejhf.316] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 05/14/2015] [Accepted: 06/04/2015] [Indexed: 11/13/2022] Open
Abstract
Aims Atrial fibrillation (AF) and thrombo‐embolism (TE) are associated with reduced survival in hypertrophic cardiomyopathy (HCM), but the absolute risk of TE in patients with and without AF is unclear. The primary aim of this study was to derive and validate a model for estimating the risk of TE in HCM. Exploratory analyses were performed to determine predictors of TE, the performance of the CHA2DS2‐VASc score, and outcome with vitamin K antagonists (VKAs). Methods and results A retrospective, longitudinal cohort of seven institutions was used to develop multivariable Cox regression models fitted with pre‐selected predictors. Bootstrapping was used for validation. Of 4821 HCM patients recruited between 1986 and 2008, 172 (3.6%) reached the primary endpoint of cerebrovascular accident (CVA), transient ischaemic attack (TIA), or systemic peripheral embolus within 10 years. A total of 27.5% of patients had a CHA2DS2‐VASc score of 0, of whom 9.8% developed TE during follow‐up. Cox regression revealed an association between TE and age, AF, the interaction between age and AF, TE prior to first evaluation, NYHA class, left atrial (LA) diameter, vascular disease, and maximal LV wall thickness. There was a curvilinear relationship between LA size and TE risk. The model predicted TE with a C‐index of 0.75 [95% confidence interval (CI) 0.70–0.80] and the D‐statistic was 1.30 (95% CI 1.05–1.56). VKA treatment was associated with a 54.8% (95% CI 31–97%, P = 0.037) relative risk reduction in HCM patients with AF. Conclusions The study shows that the risk of TE in HCM patients can be identified using a small number of simple clinical features. LA size, in particular, should be monitored closely, and the assessment and treatment of conventional vascular risk factors should be routine practice in older patients. Exploratory analyses show for the first time evidence for a reduction of TE with VKA treatment. The CHA2DS2‐VASc score does not appear to correlate well with the clinical outcome in patients with HCM and should not be used to assess TE risk in this population.
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Affiliation(s)
- Oliver P Guttmann
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Constantinos O'Mahony
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
| | - Lorenzo Monserrat
- Cardiology Department and Research Unit, A Coruña University Hospital, Galician Health Service, Spain
| | - Aristides Anastasakis
- Unit of Inherited Cardiovascular Diseases, 1st Department of Cardiology, University of Athens, Athens, Greece
| | - Claudio Rapezzi
- Institute of Cardiology, Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Elena Biagini
- Institute of Cardiology, Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Juan Ramon Gimeno
- Cardiac Department, University Hospital Virgen Arrixaca, Murcia-Cartagena s/n, El Palmar, Murcia, Spain
| | | | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
| | - William J McKenna
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK.,Biostatistics Group, University College London Hospitals/University College London Clinical Research Centre, University College London, London, UK
| | - Perry M Elliott
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
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Wolfe R, Carlin J. Statistical models for respiratory disease diagnosis and prognosis. Respirology 2015; 20:541-7. [DOI: 10.1111/resp.12519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 02/15/2015] [Accepted: 02/16/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Rory Wolfe
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Victorian Centre for Biostatistics (ViCBiostat); Melbourne Victoria Australia
| | - John Carlin
- Victorian Centre for Biostatistics (ViCBiostat); Melbourne Victoria Australia
- Clinical Epidemiology and Biostatistics Unit; Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
- Department of Paediatrics and School of Population and Global Health; University of Melbourne; Melbourne Victoria Australia
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Van Rompaye B, Eriksson M, Goetghebeur E. Evaluating hospital performance based on excess cause-specific incidence. Stat Med 2015; 34:1334-50. [PMID: 25640288 PMCID: PMC4657459 DOI: 10.1002/sim.6409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 12/16/2014] [Indexed: 12/03/2022]
Abstract
Formal evaluation of hospital performance in specific types of care is becoming an indispensable tool for quality assurance in the health care system. When the prime concern lies in reducing the risk of a cause-specific event, we propose to evaluate performance in terms of an average excess cumulative incidence, referring to the center's observed patient mix. Its intuitive interpretation helps give meaning to the evaluation results and facilitates the determination of important benchmarks for hospital performance. We apply it to the evaluation of cerebrovascular deaths after stroke in Swedish stroke centers, using data from Riksstroke, the Swedish stroke registry. © 2015 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Bart Van Rompaye
- Department of Statistics, School of Business and Economics, Umeå University, Umeå, SE-901 87, Sweden; Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Krijgslaan 281, S9, Ghent, 9000, Belgium
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Moons KGM, Altman DG, Reitsma JB, Ioannidis JPA, Macaskill P, Steyerberg EW, Vickers AJ, Ransohoff DF, Collins GS. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162:W1-73. [PMID: 25560730 DOI: 10.7326/m14-0698] [Citation(s) in RCA: 2907] [Impact Index Per Article: 323.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.
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Klein EA, Yousefi K, Haddad Z, Choeurng V, Buerki C, Stephenson AJ, Li J, Kattan MW, Magi-Galluzzi C, Davicioni E. A genomic classifier improves prediction of metastatic disease within 5 years after surgery in node-negative high-risk prostate cancer patients managed by radical prostatectomy without adjuvant therapy. Eur Urol 2014; 67:778-86. [PMID: 25466945 DOI: 10.1016/j.eururo.2014.10.036] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgery is a standard first-line therapy for men with intermediate- or high-risk prostate cancer. Clinical factors such as tumor grade, stage, and prostate-specific antigen (PSA) are currently used to identify those who are at risk of recurrence and who may benefit from adjuvant therapy, but novel biomarkers that improve risk stratification and that distinguish local from systemic recurrence are needed. OBJECTIVE To determine whether adding the Decipher genomic classifier, a validated metastasis risk-prediction model, to standard risk-stratification tools (CAPRA-S and Stephenson nomogram) improves accuracy in predicting metastatic disease within 5 yr after surgery (rapid metastasis [RM]) in an independent cohort of men with adverse pathologic features after radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS The study population consisted of 169 patients selected from 2641 men who underwent RP at the Cleveland Clinic between 1987 and 2008 who met the following criteria: (1) preoperative PSA>20 ng/ml, stage pT3 or margin positive, or Gleason score≥8; (2) pathologic node negative; (3) undetectable post-RP PSA; (4) no neoadjuvant or adjuvant therapy; and (5) minimum of 5-yr follow-up for controls. The final study cohort consisted of 15 RM patients and 154 patients as non-RM controls. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The performance of Decipher was evaluated individually and in combination with clinical risk factors using concordance index (c-index), decision curve analysis, and logistic regression for prediction of RM. RESULTS AND LIMITATIONS RM patients developed metastasis at a median of 2.3 yr (interquartile range: 1.7-3.3). In multivariable analysis, Decipher was a significant predictor of RM (odds ratio: 1.48; p=0.018) after adjusting for clinical risk factors. Decipher had the highest c-index, 0.77, compared with the Stephenson model (c-index: 0.75) and CAPRA-S (c-index: 0.72) as well as with a panel of previously reported prostate cancer biomarkers unrelated to Decipher. Integration of Decipher into the Stephenson nomogram increased the c-index from 0.75 (95% confidence interval [CI], 0.65-0.85) to 0.79 (95% CI, 0.68-0.89). CONCLUSIONS Decipher was independently validated as a genomic metastasis signature for predicting metastatic disease within 5 yr after surgery in a cohort of high-risk men treated with RP and managed conservatively without any adjuvant therapy. Integration of Decipher into clinical nomograms increased prediction of RM. Decipher may allow identification of men most at risk for metastatic progression who should be considered for multimodal therapy or inclusion in clinical trials. PATIENT SUMMARY Use of Decipher in addition to standard clinical information more accurately identified men who developed metastatic disease within 5 yr after surgery. The results suggest that Decipher allows improved identification of the men who should consider secondary therapy from among the majority that may be managed conservatively after surgery.
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Affiliation(s)
- Eric A Klein
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Kasra Yousefi
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Zaid Haddad
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | | | | | - Andrew J Stephenson
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jianbo Li
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael W Kattan
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Elai Davicioni
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
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Damaj G, Joris M, Chandesris O, Hanssens K, Soucie E, Canioni D, Kolb B, Durieu I, Gyan E, Livideanu C, Chèze S, Diouf M, Garidi R, Georgin-Lavialle S, Asnafi V, Lhermitte L, Lavigne C, Launay D, Arock M, Lortholary O, Dubreuil P, Hermine O. ASXL1 but not TET2 mutations adversely impact overall survival of patients suffering systemic mastocytosis with associated clonal hematologic non-mast-cell diseases. PLoS One 2014; 9:e85362. [PMID: 24465546 PMCID: PMC3897447 DOI: 10.1371/journal.pone.0085362] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 11/25/2013] [Indexed: 01/08/2023] Open
Abstract
Systemic mastocytosis with associated hematologic clonal non-mast cell disease (SM-AHNMD) is a rare and heterogeneous subtype of SM and few studies on this specific entity have been reported. Sixty two patients with Systemic mastocytosis with associated hematologic clonal non-mast cell disease (SM-AHNMD) were presented. Myeloid AHNMD was the most frequent (82%) cases. This subset of patients were older, had more cutaneous lesions, splenomegaly, liver enlargement, ascites; lower bone mineral density and hemoglobin levels and higher tryptase level than lymphoid AHNMD. Defects in KIT, TET2, ASXL1 and CBL were positive in 87%, 27%, 14%, and 11% of cases respectively. The overall survival of patients with SM-AHNMD was 85.2 months. Within the myeloid group, SM-MPN fared better than SM-MDS or SM-AML (p = 0.044,). In univariate analysis, the presence of C-findings, the AHNMD subtypes (SM-MDS/CMML/AML versus SM-MPN/hypereosinophilia) (p = 0.044), Neutropenia (p = 0.015), high monocyte level (p = 0.015) and the presence of ASXL1 mutation had detrimental effects on OS (p = 0.007). In multivariate analysis and penalized Cox model, only the presence of ASXL1 mutation remained an independent prognostic factor that negatively affected OS (p = 0.035). SM-AHNMD is heterogeneous with variable prognosis according to the type of the AHNMD. ASXL1 is mutated in a subset of myeloid AHNMD and adversely impact on OS.
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Affiliation(s)
- Gandhi Damaj
- Service d'Hématologie, Centre Hospitalier Universitaire, Hôpital Sud; Amiens, France
- Centre de Référence des Mastocytoses, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
- CNRS UMR 8147 and Institut Imagine, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
- * E-mail:
| | - Magalie Joris
- Service d'Hématologie, Centre Hospitalier Universitaire, Hôpital Sud; Amiens, France
| | - Olivia Chandesris
- Centre de Référence des Mastocytoses, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
- Service d'Hématologie Adulte, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
| | - Katia Hanssens
- Inserm, U1068, CRCM, (Signaling, Hematopoiesis and Mechanism of Oncogenesis); Institut Paoli-Calmettes,Marseille; Aix-Marseille Univ; CNRS, UMR7258, Marseille, France
| | - Erinn Soucie
- Inserm, U1068, CRCM, (Signaling, Hematopoiesis and Mechanism of Oncogenesis); Institut Paoli-Calmettes,Marseille; Aix-Marseille Univ; CNRS, UMR7258, Marseille, France
| | - Danielle Canioni
- Service d'Anatomo-pathologie, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
| | - Brigitte Kolb
- Service d'Hématologie, Centre Hospitalier Universitaire, Reims, France
| | - Isabelle Durieu
- Service de médecine interne, Groupe Hospitalier Sud. Hospices Civils, Lyon, France
| | - Emanuel Gyan
- Service d'Hématologie et thérapie cellulaire, CIC INSERMU202, Centre Hospitalier Universitaire, Tours, France
| | - Cristina Livideanu
- Département de Dermatologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Stephane Chèze
- Service d'Hématologie, Centre Hospitalier Universitaire, Caen, France
| | - Momar Diouf
- Département de bio-statistiques et de Recherche clinique, Centre Hospitalier Universitaire, Amiens, France
| | - Reda Garidi
- Service d'Hématologie, Centre Hospitalier, St Quentin, France
| | - Sophie Georgin-Lavialle
- Service de Médecine Interne, Hôpital Tenon, Assistance Publique-Hôpitaux, Université Pierre et Marie Curie, Paris, France
| | - Vahid Asnafi
- Laboratoire d'hématologie Biologique et UMR CNRS 8147, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et Assistance Publique-Hôpitaux de Paris (AP-HP) Necker-Enfants Malades, Paris, France
| | - Ludovic Lhermitte
- Laboratoire d'hématologie Biologique et UMR CNRS 8147, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et Assistance Publique-Hôpitaux de Paris (AP-HP) Necker-Enfants Malades, Paris, France
| | - Christian Lavigne
- Service d'Hématologie, Centre Hospitalier Universitaire, Angers, France
| | - David Launay
- Service de Médecine Interne, CHRU, Lille, France
| | - Michel Arock
- CNRS UMR 8113, Laboratoire de Biologie et Pharmacologie Appliquée, Ecole Normale Supérieure, Cachan, France
- Laboratoire Central d'Hématologie, Groupe Hospitalier Pitié-Salpetrière, Paris, France
| | - Olivier Lortholary
- Service de Médecine Interne et de Maladie Infectieuses, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
| | - Patrice Dubreuil
- Inserm, U1068, CRCM, (Signaling, Hematopoiesis and Mechanism of Oncogenesis); Institut Paoli-Calmettes,Marseille; Aix-Marseille Univ; CNRS, UMR7258, Marseille, France
| | - Olivier Hermine
- Centre de Référence des Mastocytoses, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
- CNRS UMR 8147 and Institut Imagine, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
- Service d'Hématologie Adulte, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France
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O'Mahony C, Jichi F, Pavlou M, Monserrat L, Anastasakis A, Rapezzi C, Biagini E, Gimeno JR, Limongelli G, McKenna WJ, Omar RZ, Elliott PM. A novel clinical risk prediction model for sudden cardiac death in hypertrophic cardiomyopathy (HCM risk-SCD). Eur Heart J 2013; 35:2010-20. [PMID: 24126876 DOI: 10.1093/eurheartj/eht439] [Citation(s) in RCA: 757] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS Hypertrophic cardiomyopathy (HCM) is a leading cause of sudden cardiac death (SCD) in young adults. Current risk algorithms provide only a crude estimate of risk and fail to account for the different effect size of individual risk factors. The aim of this study was to develop and validate a new SCD risk prediction model that provides individualized risk estimates. METHODS AND RESULTS The prognostic model was derived from a retrospective, multi-centre longitudinal cohort study. The model was developed from the entire data set using the Cox proportional hazards model and internally validated using bootstrapping. The cohort consisted of 3675 consecutive patients from six centres. During a follow-up period of 24 313 patient-years (median 5.7 years), 198 patients (5%) died suddenly or had an appropriate implantable cardioverter defibrillator (ICD) shock. Of eight pre-specified predictors, age, maximal left ventricular wall thickness, left atrial diameter, left ventricular outflow tract gradient, family history of SCD, non-sustained ventricular tachycardia, and unexplained syncope were associated with SCD/appropriate ICD shock at the 15% significance level. These predictors were included in the final model to estimate individual probabilities of SCD at 5 years. The calibration slope was 0.91 (95% CI: 0.74, 1.08), C-index was 0.70 (95% CI: 0.68, 0.72), and D-statistic was 1.07 (95% CI: 0.81, 1.32). For every 16 ICDs implanted in patients with ≥4% 5-year SCD risk, potentially 1 patient will be saved from SCD at 5 years. A second model with the data set split into independent development and validation cohorts had very similar estimates of coefficients and performance when externally validated. CONCLUSION This is the first validated SCD risk prediction model for patients with HCM and provides accurate individualized estimates for the probability of SCD using readily collected clinical parameters.
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Affiliation(s)
- Constantinos O'Mahony
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, 16-18 Westmoreland St., London W1H 8PH, UK
| | - Fatima Jichi
- Biostatistics Group, University College London Hospitals/University College London Research Support Centre, University College London, Gower St., London WC1E 6BT, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, Gower St, London WC1E 6BT, UK
| | - Lorenzo Monserrat
- Cardiology Department and Research Unit, A Coruña University Hospital, Galician Health Service, Spain
| | - Aristides Anastasakis
- Unit of Inherited Cardiovascular Diseases, 1st Department of Cardiology, University of Athens, 99 Michalakopoulou St, Athens 11527, Greece
| | - Claudio Rapezzi
- Institute of Cardiology, Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Elena Biagini
- Institute of Cardiology, Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Juan Ramon Gimeno
- Cardiac Department, University Hospital Virgen Arrixaca, Murcia-Cartagena s/n. El Palmar, Murcia 30120, Spain
| | - Giuseppe Limongelli
- Monaldi Hospital, Second University of Naples, Via Leonardo Bianchi 1, Naples 80131, Italy
| | - William J McKenna
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, 16-18 Westmoreland St., London W1H 8PH, UK
| | - Rumana Z Omar
- Biostatistics Group, University College London Hospitals/University College London Research Support Centre, University College London, Gower St., London WC1E 6BT, UK Department of Statistical Science, University College London, Gower St, London WC1E 6BT, UK
| | - Perry M Elliott
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, 16-18 Westmoreland St., London W1H 8PH, UK
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Park HW, Han S, Lee JS, Chang HS, Lee D, Choe JW, Myung SJ, Yang SK, Kim JH, Byeon JS. Risk stratification for advanced proximal colon neoplasm and individualized endoscopic screening for colorectal cancer by a risk-scoring model. Gastrointest Endosc 2012; 76:818-28. [PMID: 22884098 DOI: 10.1016/j.gie.2012.06.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 06/12/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Only 30% to 40% of patients with advanced proximal neoplasms (APN) have distal colon neoplasms. OBJECTIVE To develop a risk score model for APN and propose an individualized screening protocol for colorectal cancer. DESIGN Retrospective cohort study. SETTING Tertiary-care center. PATIENTS Derivation cohort (6200 adults) and validation cohort (1389 adults). INTERVENTION Screening colonoscopy. MAIN OUTCOME MEASUREMENTS An APN risk score model was developed from the derivation cohort (6200 adults) and was tested in the validation cohort (1389 adults), who underwent screening colonoscopy. RESULTS Age, male sex, and smoking were clinical risk factors for APN. The presence of a distal neoplasm was a sigmoidoscopic risk factor for APN. We calculated APN risk scores (0-8) based on these variables and classified patients as low risk (0-2) or high risk (3-8). In the validation cohort, the relative risk of APN was 3.5-fold higher in the high-risk group than in the low-risk group. Our model suggests that colonoscopy should be performed as an initial screening test in patients with a high clinical risk for APN. Sigmoidoscopy should be performed initially in patients with low clinical risk for APN followed by supplementary colonoscopy in those with high APN risk scores based on both clinical and sigmoidoscopic risk factors. This protocol detected APN in 22 of 34 APN+ patients (64.7%) with little increase in the endoscopy burden, whereas only 16 of 34 APN+ patients (47.1%) would be identified by initial sigmoidoscopy followed by colonoscopy only in cases with distal neoplasms. LIMITATIONS Retrospective design. CONCLUSION Our APN risk score model provides an algorithm for efficient screening of colorectal cancer by sigmoidoscopy and colonoscopy.
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Affiliation(s)
- Hye Won Park
- Health Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Polterauer S, Grimm C, Hofstetter G, Concin N, Natter C, Sturdza A, Pötter R, Marth C, Reinthaller A, Heinze G. Nomogram prediction for overall survival of patients diagnosed with cervical cancer. Br J Cancer 2012; 107:918-24. [PMID: 22871885 PMCID: PMC3464766 DOI: 10.1038/bjc.2012.340] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Nomograms are predictive tools that are widely used for estimating cancer prognosis. The aim of this study was to develop a nomogram for the prediction of overall survival (OS) in patients diagnosed with cervical cancer. Methods: Cervical cancer databases of two large institutions were analysed. Overall survival was defined as the clinical endpoint and OS probabilities were estimated using the Kaplan–Meier method. Based on the results of survival analyses and previous studies, relevant covariates were identified, a nomogram was constructed and validated using bootstrap cross-validation. Discrimination of the nomogram was quantified with the concordance probability. Results: In total, 528 consecutive patients with invasive cervical cancer, who had all nomogram variables available, were identified. Mean 5-year OS rates for patients with International Federation of Gynecologists and Obstetricians (FIGO) stage IA, IB, II, III, and IV were 99.0%, 88.6%, 65.8%, 58.7%, and 41.5%, respectively. Seventy-six cancer-related deaths were observed during the follow-up period. FIGO stage, tumour size, age, histologic subtype, lymph node ratio, and parametrial involvement were selected as nomogram covariates. The prognostic performance of the model exceeded that of FIGO stage alone and the model’s estimated optimism-corrected concordance probability was 0.723, indicating accurate prediction of OS. We present the prediction model as nomogram and provide a web-based risk calculator (http://www.ccc.ac.at/gcu). Conclusion: Based on six easily available parameters, a novel statistical model to predict OS of patients diagnosed with cervical cancer was constructed and validated. The model was implemented in a nomogram and provides accurate prediction of individual patients’ prognosis useful for patient counselling and deciding on follow-up strategies.
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Affiliation(s)
- S Polterauer
- Department of General Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria.
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