1
|
Sathe NA, Zelnick LR, Morrell ED, Bhatraju PK, Kerchberger VE, Hough CL, Ware LB, Fohner AE, Wurfel MM. Development and External Validation of Models to Predict Persistent Hypoxemic Respiratory Failure for Clinical Trial Enrichment. Crit Care Med 2024; 52:764-774. [PMID: 38197736 PMCID: PMC11018468 DOI: 10.1097/ccm.0000000000006181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Improving the efficiency of clinical trials in acute hypoxemic respiratory failure (HRF) depends on enrichment strategies that minimize enrollment of patients who quickly resolve with existing care and focus on patients at high risk for persistent HRF. We aimed to develop parsimonious models predicting risk of persistent HRF using routine data from ICU admission and select research immune biomarkers. DESIGN Prospective cohorts for derivation ( n = 630) and external validation ( n = 511). SETTING Medical and surgical ICUs at two U.S. medical centers. PATIENTS Adults with acute HRF defined as new invasive mechanical ventilation (IMV) and hypoxemia on the first calendar day after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated discrimination, calibration, and practical utility of models predicting persistent HRF risk (defined as ongoing IMV and hypoxemia on the third calendar day after admission): 1) a clinical model with least absolute shrinkage and selection operator (LASSO) selecting Pa o2 /F io2 , vasopressors, mean arterial pressure, bicarbonate, and acute respiratory distress syndrome as predictors; 2) a model adding interleukin-6 (IL-6) to clinical predictors; and 3) a comparator model with Pa o2 /F io2 alone, representing an existing strategy for enrichment. Forty-nine percent and 69% of patients had persistent HRF in derivation and validation sets, respectively. In validation, both LASSO (area under the receiver operating characteristic curve, 0.68; 95% CI, 0.64-0.73) and LASSO + IL-6 (0.71; 95% CI, 0.66-0.76) models had better discrimination than Pa o2 /F io2 (0.64; 95% CI, 0.59-0.69). Both models underestimated risk in lower risk deciles, but exhibited better calibration at relevant risk thresholds. Evaluating practical utility, both LASSO and LASSO + IL-6 models exhibited greater net benefit in decision curve analysis, and greater sample size savings in enrichment analysis, compared with Pa o2 /F io2 . The added utility of LASSO + IL-6 model over LASSO was modest. CONCLUSIONS Parsimonious, interpretable models that predict persistent HRF may improve enrichment of trials testing HRF-targeted therapies and warrant future validation.
Collapse
Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lorraine B, Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison E Fohner
- Department of Epidemiology, School of Public Health, University of Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| |
Collapse
|
2
|
Ebell MH, Dale A, Merenstein DJ, Barrett B, Hulme C, Walters S, Sabry A, Bentivegna M. Prospective external validation of the FluScore risk score for influenza in outpatients. Fam Pract 2024; 41:207-211. [PMID: 38466150 DOI: 10.1093/fampra/cmae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Testing for influenza in patients with acute lower respiratory tract infection (LRTI) is common and in some cases is performed for all patients with LRTI. A more selective approach to testing could be more efficient. METHODS We used data from two prospective studies in the US primary and urgent care settings that enrolled patients with acute LRTI or influenza-like illness. Data were collected in the 2016, 2019, 2021, and 2022 flu seasons. All patients underwent polymerase chain reaction (PCR) testing for influenza and the FluScore was calculated based on patient-reported symptoms at their initial visit. The probability of influenza in each risk group was reported, as well as stratum-specific likelihood ratios (SSLRs) for each risk level. RESULTS The prevalence of influenza within risk groups varied based on overall differences in flu seasons and populations. However, the FluScore exhibited consistent performance across various seasons and populations based on the SSLRs. The FluScore had a consistent SSLR range of 0.20 to 0.23 for the low-risk group, 0.63 to 0.99 for the moderate-risk group, and 1.46 to 1.67 for the high-risk group. The diagnostic odds ratio based on the midpoints of these ranges was 7.25. CONCLUSIONS The FluScore could streamline patient categorization, identifying patients who could be exempted from testing, while identifying candidates for rapid influenza tests. This has the potential to be more efficient than a "one size fits all" test strategy, as it strategically targets the use of tests on patients most likely to benefit. It is potentially usable in a telehealth setting.
Collapse
Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| | - Ariella Dale
- Maricopa County Department of Public Health, Phoenix, AZ, United States
| | - Dan J Merenstein
- Department of Family Medicine, Georgetown University, Washington, DC, United States
| | - Bruce Barrett
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, United States
| | - Cassie Hulme
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| | - Sarah Walters
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, United States
| | - Alea Sabry
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, United States
| | - Michelle Bentivegna
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| |
Collapse
|
3
|
Papadimitriou‐Olivgeris M, Monney P, Carron P, Tzimas G, Beysard N, Tozzi P, Kirsch M, Guery B. Evaluation of the Clinical Rule for Endocarditis in the Emergency Department Among Patients With Suspected Infective Endocarditis. J Am Heart Assoc 2024; 13:e032745. [PMID: 38353256 PMCID: PMC11010110 DOI: 10.1161/jaha.123.032745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024]
Affiliation(s)
| | - Pierre Monney
- Department of CardiologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Pierre‐Nicolas Carron
- Emergency DepartmentLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Georgios Tzimas
- Department of CardiologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Nicolas Beysard
- Emergency DepartmentLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Piergiorgio Tozzi
- Department of Cardiac SurgeryLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Matthias Kirsch
- Department of Cardiac SurgeryLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Benoit Guery
- Infectious Diseases ServiceLausanne University Hospital and University of LausanneLausanneSwitzerland
| |
Collapse
|
4
|
Chean LN, Tan C, Hiskens MI, Rattenbury M, Sundaram P, Perara J, Smith K, Kumar P. Overuse of Computed Tomography Pulmonary Angiography and Low Utilization of Clinical Prediction Rules in Suspected Pulmonary Embolism Patients at a Regional Australian Hospital. Healthcare (Basel) 2024; 12:278. [PMID: 38275557 PMCID: PMC10815163 DOI: 10.3390/healthcare12020278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
A pulmonary embolism (PE) is an obstruction in the pulmonary arterial system and may include non-specific signs and symptoms. Clinical prediction rules (CPRs) assess the pretest probability (PTP) of a PE to prevent the overuse of computed tomography pulmonary angiography (CTPA). CTPA overuse results in patient harm and health system waste. This study aimed to evaluate CTPA usage in an Australian regional hospital through analyzing CTPA encounters. A retrospective chart analysis was undertaken of 100 CTPAs conducted at an Australian regional hospital from April to May 2023. Analysis was undertaken for parameters including risk factors, signs and symptoms, investigations, and the use of CPRs. Overall, 86% of patients had signs and/or symptoms of a PE within a week of examination, and 6% of the population had signs of deep vein thrombosis. More than half of the population had no risk factors, while the most prevalent risk factors were a recent history of immobilization/trauma and/or having surgery that required general anesthesia in the last 4 weeks. The most common co-morbidity was chronic lung disease (11%). For the pre-test diagnostic workup, the ECG was the most ordered investigation. The Wells' score was used at 10%, while most patients did not have any CPRs applied. The prevalence of PEs discovered on CTPAs was 9%. CPRs were under-utilized in this Australian regional hospital. The D-dimers for ruling out subjects with low PTP derived from CPRs were also underused. This led to the inappropriate overordering of CTPAs, resulting in negative implications for patients and unnecessary costs to the health system.
Collapse
Affiliation(s)
| | - Clement Tan
- Mackay Base Hospital, Mackay 4740, Australia (C.T.)
- College of Medicine and Dentistry, James Cook University, Mackay 4740, Australia
| | | | | | - Prahalath Sundaram
- College of Medicine and Dentistry, James Cook University, Mackay 4740, Australia
| | - Jithmy Perara
- College of Medicine and Dentistry, James Cook University, Mackay 4740, Australia
| | - Karen Smith
- Mackay Base Hospital, Mackay 4740, Australia (C.T.)
| | - Pranav Kumar
- Mackay Base Hospital, Mackay 4740, Australia (C.T.)
| |
Collapse
|
5
|
Pagano T, Fabbri IS, Benedetto M, D'Angelo L, Galizia G, Portoraro A, Guarino M, Perna B, Passaro A, Cariani D, Spampinato MD, De Giorgio R. Predicting in-hospital mortality in patients admitted from the emergency department for pulmonary embolism: Incidence and prognostic value of deep vein thrombosis. A retrospective study. Clin Respir J 2024; 18:e13697. [PMID: 37726801 PMCID: PMC10775884 DOI: 10.1111/crj.13697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is one of the most common causes of death from cardiovascular disease. Although deep vein thrombosis (DVT) is the leading cause of PE, its prognostic role is unclear. This study investigated the incidence and prognostic value of DVT in predicting in-hospital mortality (IHM) in patients admitted from the emergency department (ED) for PE. METHODS This retrospective cohort study was conducted in the ED of a third-level university hospital. Patients over 18 years admitted for PE between 1 January 2018 and 31 December 2022 were included. RESULTS Five hundred and thirty patients (mean age 73.13 years, 6% IHM) were included. 69.1% of cases had DVT (36.4% unilateral femoral vein, 3.6% bilateral, 39.1% unilateral popliteal vein, 2.8% bilateral, 45.7% distal vein thrombosis and 7.4% iliocaval involvement). Patients who died in hospital had a higher Pulmonary Embolism Severity Index (PESI) (138.6 vs. 99.65, p < 0.001), European Society of Cardiology risk class (15.6% vs. 1%, intermediate-high in 50% vs. 6.4%, p < 0.001) and more DVT involving the iliac-caval vein axis (18.8% vs. 6.6%, p = 0.011). PESI class >II, right ventricular dysfunction, increased blood markers of myocardial damage and involvement of the iliocaval venous axis were independent predictors of IHM on multivariate analysis. CONCLUSIONS Although further studies are needed to confirm the prognostic role of DVT at PE, involvement of the iliocaval venous axis should considered to be a sign of a higher risk of IHM and may be a key factor in prognostic stratification.
Collapse
Affiliation(s)
- Teresa Pagano
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Irma Sofia Fabbri
- Department of Translational MedicineUniversity of FerraraFerraraItaly
| | - Marcello Benedetto
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Luca D'Angelo
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Giorgio Galizia
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Andrea Portoraro
- Department of Translational MedicineUniversity of FerraraFerraraItaly
| | - Matteo Guarino
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Benedetta Perna
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Angelina Passaro
- Department of Translational MedicineUniversity of FerraraFerraraItaly
| | - Daniele Cariani
- Emergency Medicine Unit, Department of EmergencySt. Anna University HospitalFerraraItaly
| | - Michele Domenico Spampinato
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| | - Roberto De Giorgio
- Department of Translational MedicineUniversity of FerraraFerraraItaly
- School of Emergency MedicineUniversity of FerraraFerraraItaly
| |
Collapse
|
6
|
Hakimjavadi R, Hong HA, Fallah N, Humphreys S, Kingwell S, Stratton A, Tsai E, Wai EK, Walden K, Noonan VK, Phan P. Enabling knowledge translation: implementation of a web-based tool for independent walking prediction after traumatic spinal cord injury. Front Neurol 2023; 14:1219307. [PMID: 38116110 PMCID: PMC10728823 DOI: 10.3389/fneur.2023.1219307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction Several clinical prediction rules (CPRs) have been published, but few are easily accessible or convenient for clinicians to use in practice. We aimed to develop, implement, and describe the process of building a web-based CPR for predicting independent walking 1-year after a traumatic spinal cord injury (TSCI). Methods Using the published and validated CPR, a front-end web application called "Ambulation" was built using HyperText Markup Language (HTML), Cascading Style Sheets (CSS), and JavaScript. A survey was created using QualtricsXM Software to gather insights on the application's usability and user experience. Website activity was monitored using Google Analytics. Ambulation was developed with a core team of seven clinicians and researchers. To refine the app's content, website design, and utility, 20 professionals from different disciplines, including persons with lived experience, were consulted. Results After 11 revisions, Ambulation was uploaded onto a unique web domain and launched (www.ambulation.ca) as a pilot with 30 clinicians (surgeons, physiatrists, and physiotherapists). The website consists of five web pages: Home, Calculation, Team, Contact, and Privacy Policy. Responses from the user survey (n = 6) were positive and provided insight into the usability of the tool and its clinical utility (e.g., helpful in discharge planning and rehabilitation), and the overall face validity of the CPR. Since its public release on February 7, 2022, to February 28, 2023, Ambulation had 594 total users, 565 (95.1%) new users, 26 (4.4%) returning users, 363 (61.1%) engaged sessions (i.e., the number of sessions that lasted 10 seconds/longer, had one/more conversion events e.g., performing the calculation, or two/more page or screen views), and the majority of the users originating from the United States (39.9%) and Canada (38.2%). Discussion Ambulation is a CPR for predicting independent walking 1-year after TSCI and it can assist frontline clinicians with clinical decision-making (e.g., time to surgery or rehabilitation plan), patient education and goal setting soon after injury. This tool is an example of adapting a validated CPR for independent walking into an easily accessible and usable web-based tool for use in clinical practice. This study may help inform how other CPRs can be adopted into clinical practice.
Collapse
Affiliation(s)
| | - Heather A. Hong
- Praxis Spinal Cord Institute, Blusson Spinal Cord Centre, Vancouver, BC, Canada
| | - Nader Fallah
- Praxis Spinal Cord Institute, Blusson Spinal Cord Centre, Vancouver, BC, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine, The University of British Columbia, UBC Hospital, Vancouver, BC, Canada
| | - Suzanne Humphreys
- Praxis Spinal Cord Institute, Blusson Spinal Cord Centre, Vancouver, BC, Canada
| | - Stephen Kingwell
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexandra Stratton
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Eve Tsai
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Eugene K. Wai
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kristen Walden
- Praxis Spinal Cord Institute, Blusson Spinal Cord Centre, Vancouver, BC, Canada
| | - Vanessa K. Noonan
- Praxis Spinal Cord Institute, Blusson Spinal Cord Centre, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Philippe Phan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
7
|
Blok G, Burger H, van der Lei J, Berger M, Holtman G. Development and validation of a clinical prediction rule for acute appendicitis in children in primary care. Eur J Gen Pract 2023; 29:2233053. [PMID: 37578416 PMCID: PMC10431724 DOI: 10.1080/13814788.2023.2233053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Recognising acute appendicitis in children presenting with acute abdominal pain in primary care is challenging. General practitioners (GPs) may benefit from a clinical prediction rule. OBJECTIVES To develop and validate a clinical prediction rule for acute appendicitis in children presenting with acute abdominal pain in primary care. METHODS In a historical cohort study data was retrieved from GP electronic health records included in the Integrated Primary Care Information database. We assigned children aged 4-18 years presenting with acute abdominal pain (≤ 7 days) to development (2010-2012) and validation (2013-2016) cohorts, using acute appendicitis within six weeks as the outcome. Multiple logistic regression was used to develop a prediction model based on predictors with > 50% data availability derived from existing rules for secondary care. We performed internal and external temporal validation and derived a point score to stratify risk of appendicitis into three groups, i.e. low-risk, medium-risk and high-risk. RESULTS The development and validation cohorts included 2,041 and 3,650 children, of whom 95 (4.6%) and 195 (5.3%) had acute appendicitis. The model included male sex, pain duration (<24, 24-48, > 48 h), nausea/vomiting, elevated temperature (≥ 37.3 °C), abnormal bowel sounds, right lower quadrant tenderness, and peritoneal irritation. Internal and temporal validation showed good discrimination (C-statistics: 0.93 and 0.90, respectively) and excellent calibration. In the three groups, the risks of acute appendicitis were 0.5%, 7.5%, and 41%. CONCLUSION Combined with further testing in the medium-risk group, the prediction rule could improve clinical decision making and outcomes.
Collapse
Affiliation(s)
- Guus Blok
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Huib Burger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjolein Berger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gea Holtman
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
8
|
Ling LLL, Zhang VJW, Lim HY, Lim MJ, Ho P. Clinical predictors of pulmonary embolism for inpatients: are computed tomography pulmonary angiograms being requested appropriately? Intern Med J 2023; 53:1224-1230. [PMID: 35049098 DOI: 10.1111/imj.15696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/14/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The heterogeneity of inpatient pulmonary embolism (PE) presentations may lead to computed tomography pulmonary angiograms (CTPA) being over-requested. Current clinical predictors for PE, including Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC), have predominantly focussed on outpatient and emergency department populations. AIM To determine the clinical indicators for ordering inpatient CTPA and the predictors of positive scans for PE. METHODS Consecutive inpatient CTPA (performed >24 h after admission) from January 2017 to December 2017 were retrospectively reviewed. Variables including baseline characteristics, vital signs and risk factors for PE were extracted. RESULTS A total of 312 CTPA was reviewed (average patient age 67 years; 46% male) and 36 CTPA were positive for PE (11.5%). The average time to inpatient CTPA request was 7 days. Clinical indicators associated with positive scans were hypoxia (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.1-5.6), tachypnoea (OR 2.5; 95% CI 1.2-6.0), recent surgery or immobilisation (OR 2.7; 95% CI 1.2-6.4), S1Q3T3 pattern on electrocardiogram (ECG; OR 7.2; 95% CI 1.4-35.7) and right bundle branch block pattern on ECG (OR 4.7; 95% CI 1.6-13.1). Hypotension, fever and malignancy were not significant. Both PERC and Wells criteria had poor positive predictive value (12% and 27% respectively), but the negative predictive value for PERC and Wells was 100% and 95.8% respectively. CONCLUSION Inpatient CTPA appear to be over-requested and can potentially be rationalised based on a combination of clinical predictors and Wells criteria and/or PERC rule. Further prospective studies are needed to develop accurate clinical decision tools targeted towards inpatients.
Collapse
Affiliation(s)
- Lisa Luo-Lan Ling
- Department of Haematology, Northern Health, Melbourne, Victoria, Australia
| | | | - Hui Yin Lim
- Department of Haematology, Northern Health, Melbourne, Victoria, Australia
| | - Ming Joe Lim
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Health, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Ohyama Y, Iwamura T, Hoshino T, Miyata K. Prognostic models of quality of life after total knee replacement: A systematic review. Physiother Theory Pract 2023:1-12. [PMID: 37162481 DOI: 10.1080/09593985.2023.2211716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To systematically review and critically appraise prognostic models for quality of life (QOL) in patients with total knee replacement (TKA). METHODS Subjects were TKA recipients recruited from inpatient postoperative settings. Searches were made on June 2022 and updated on April 2023. Databases included PubMed.gov, CINAHL, The Cochrane Library, Web of Science. Two authors performed all review stages independently. Risk of bias assessments on participants, predictors, outcomes and analysis methods followed the Prediction study Risk Of Bias ASsessment Tool (PROBAST). RESULTS After screening 2204 studies, 9 were eligible for inclusion. Twelve prognostic models were reported, of which 10 models were developed from data without validation and 2 were both developed and validated. The most frequently applied predictor was the pre-TKA QOL score. Discriminatory measures were reported for 9 (75.0%) models with areas under the curve values of 0.66-0.95. All models showed a high risk of bias, mostly due to limitations in statistical methods and outcome assessments. CONCLUSION Several prognostic models have been developed for QOL in patients with TKA, but all models show a high risk of bias and are unreliable in clinical practice. Future, prognostic models overcoming the risk of bias identified in this study are needed.
Collapse
Affiliation(s)
- Yuki Ohyama
- Department of Rehabilitation, Hidaka Rehabilitation Hospital, Takasaki, Japan
| | - Taiki Iwamura
- Department of Rehabilitation, Azumabashi Orthopedics, Tokyo, Japan
| | - Taichi Hoshino
- Department of Rehabilitation, Gunma Chuo Hospital, Maebashi, Gunma, Japan
| | - Kazuhiro Miyata
- Department of Physical Therapy, Ibaraki Prefectural University of Health Science, Ibaraki, Japan
| |
Collapse
|
10
|
Covino M, De Vita A, d'Aiello A, Ravenna SE, Ruggio A, Genuardi L, Simeoni B, Piccioni A, De Matteis G, Murri R, Leone AM, Flex A, Gasbarrini A, Liuzzo G, Massetti M, Franceschi F. A New Clinical Prediction Rule for Infective Endocarditis in Emergency Department Patients With Fever: Definition and First Validation of the CREED Score. J Am Heart Assoc 2023; 12:e027650. [PMID: 37119081 PMCID: PMC10227214 DOI: 10.1161/jaha.122.027650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/23/2023] [Indexed: 04/30/2023]
Abstract
Background Infective endocarditis (IE) could be suspected in any febrile patients admitted to the emergency department (ED). This study was aimed at assessing clinical criteria predictive of IE and identifying and prospectively validating a sensible and easy-to-use clinical prediction score for the diagnosis of IE in the ED. Methods and Results We conducted a retrospective observational study, enrolling consecutive patients with fever admitted to the ED between January 2015 and December 2019 and subsequently hospitalized. Several clinical and anamnestic standardized variables were collected and evaluated for the association with IE diagnosis. We derived a multivariate prediction model by logistic regression analysis. The identified predictors were assigned a score point value to obtain the Clinical Rule for Infective Endocarditis in the Emergency Department (CREED) score. To validate the CREED score we conducted a prospective observational study between January 2020 and December 2021, enrolling consecutive febrile patients hospitalized after the ED visit, and evaluating the association between the CREED score values and the IE diagnosis. A total of 15 689 patients (median age, 71 [56-81] years; 54.1% men) were enrolled in the retrospective cohort, and IE was diagnosed in 267 (1.7%). The CREED score included 12 variables: male sex, anemia, dialysis, pacemaker, recent hospitalization, recent stroke, chest pain, specific infective diagnosis, valvular heart disease, valvular prosthesis, previous endocarditis, and clinical signs of suspect endocarditis. The CREED score identified 4 risk groups for IE diagnosis, with an area under the receiver operating characteristic curve of 0.874 (0.849-0.899). The prospective cohort included 13 163 patients, with 130 (1.0%) IE diagnoses. The CREED score had an area under the receiver operating characteristic curve of 0.881 (0.848-0.913) in the validation cohort, not significantly different from the one calculated in the retrospective cohort (P=0.578). Conclusions In this study, we propose and prospectively validate the CREED score, a clinical prediction rule for the diagnosis of IE in patients with fever admitted to the ED. Our data reflect the difficulty of creating a meaningful tool able to identify patients with IE among this general and heterogeneous population because of the complexity of the disease and its low prevalence in the ED setting.
Collapse
Affiliation(s)
- Marcello Covino
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
| | - Antonio De Vita
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Alessia d'Aiello
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | | | - Aureliano Ruggio
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Lorenzo Genuardi
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Benedetta Simeoni
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Andrea Piccioni
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Giuseppe De Matteis
- Department of Internal MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Rita Murri
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Infectious DiseaseFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Antonio Maria Leone
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Andrea Flex
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Antonio Gasbarrini
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Internal MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Giovanna Liuzzo
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Massimo Massetti
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
| | - Francesco Franceschi
- Emergency MedicineFondazione Policlinico Universitario A, Gemelli, IRCCSRomeItaly
- Università Cattolica del Cattolica del Sacro CuoreRomeItaly
| |
Collapse
|
11
|
Candel BG, de Groot B, Nissen SK, Thijssen WA, Lameijer H, Kellett J. The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study. Eur J Emerg Med 2023; 30:110-116. [PMID: 36729955 PMCID: PMC9946171 DOI: 10.1097/mej.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/10/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h. AIM The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital. METHODS This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment. RESULTS The risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%. CONCLUSION The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED.
Collapse
Affiliation(s)
- Bart G.J. Candel
- Emergency Department, Maxima Medical Centre, Veldhoven, Noord-Brabant
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | | | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| |
Collapse
|
12
|
Lin CH, Kuo YW, Huang YC, Lee M, Huang YW, Kuo CF, Lee JD. Development and Validation of a Novel Score for Predicting Long-Term Mortality after an Acute Ischemic Stroke. Int J Environ Res Public Health 2023; 20:3043. [PMID: 36833741 PMCID: PMC9961287 DOI: 10.3390/ijerph20043043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Long-term mortality prediction can guide feasible discharge care plans and coordinate appropriate rehabilitation services. We aimed to develop and validate a prediction model to identify patients at risk of mortality after acute ischemic stroke (AIS). METHODS The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular death. This study included 21,463 patients with AIS. Three risk prediction models were developed and evaluated: a penalized Cox model, a random survival forest model, and a DeepSurv model. A simplified risk scoring system, called the C-HAND (history of Cancer before admission, Heart rate, Age, eNIHSS, and Dyslipidemia) score, was created based on regression coefficients in the multivariate Cox model for both study outcomes. RESULTS All experimental models achieved a concordance index of 0.8, with no significant difference in predicting poststroke long-term mortality. The C-HAND score exhibited reasonable discriminative ability for both study outcomes, with concordance indices of 0.775 and 0.798. CONCLUSIONS Reliable prediction models for long-term poststroke mortality were developed using information routinely available to clinicians during hospitalization.
Collapse
Affiliation(s)
- Ching-Heng Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Bachelor Program in Artificial Intelligence, Chang Gung University, Taoyuan 333, Taiwan
| | - Ya-Wen Kuo
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi 613, Taiwan
- Associate Research Fellow, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Yen-Chu Huang
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Meng Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yi-Wei Huang
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chang-Fu Kuo
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| |
Collapse
|
13
|
Ramírez Cervantes KL, Mora E, Campillo Morales S, Huerta Álvarez C, Marcos Neira P, Nanwani Nanwani KL, Serrano Lázaro A, Silva Obregón JA, Quintana Díaz M. A Clinical Prediction Rule for Thrombosis in Critically Ill COVID-19 Patients: Step 1 Results of the Thromcco Study. J Clin Med 2023; 12:jcm12041253. [PMID: 36835788 PMCID: PMC9966844 DOI: 10.3390/jcm12041253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
The incidence of thrombosis in COVID-19 patients is exceptionally high among intensive care unit (ICU)-admitted individuals. We aimed to develop a clinical prediction rule for thrombosis in hospitalized COVID-19 patients. Data were taken from the Thromcco study (TS) database, which contains information on consecutive adults (aged ≥ 18) admitted to eight Spanish ICUs between March 2020 and October 2021. Diverse logistic regression model analysis, including demographic data, pre-existing conditions, and blood tests collected during the first 24 h of hospitalization, was performed to build a model that predicted thrombosis. Once obtained, the numeric and categorical variables considered were converted to factor variables giving them a score. Out of 2055 patients included in the TS database, 299 subjects with a median age of 62.4 years (IQR 51.5-70) (79% men) were considered in the final model (SE = 83%, SP = 62%, accuracy = 77%). Seven variables with assigned scores were delineated as age 25-40 and ≥70 = 12, age 41-70 = 13, male = 1, D-dimer ≥ 500 ng/mL = 13, leukocytes ≥ 10 × 103/µL = 1, interleukin-6 ≥ 10 pg/mL = 1, and C-reactive protein (CRP) ≥ 50 mg/L = 1. Score values ≥28 had a sensitivity of 88% and specificity of 29% for thrombosis. This score could be helpful in recognizing patients at higher risk for thrombosis, but further research is needed.
Collapse
Affiliation(s)
- Karen L. Ramírez Cervantes
- Patient Blood Management Research Group, Hospital La Paz Institute for Health Research, 28040 Madrid, Spain
- Correspondence:
| | - Elianne Mora
- Department of Statistics, Charles III University of Madrid, 28903 Getafe, Spain
| | - Salvador Campillo Morales
- Patient Blood Management Research Group, Hospital La Paz Institute for Health Research, 28040 Madrid, Spain
| | - Consuelo Huerta Álvarez
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - Pilar Marcos Neira
- Intensive Care Unit, Hospital Germans Trias i Pujol, 08916 Badalona, Spain
| | | | | | | | - Manuel Quintana Díaz
- Patient Blood Management Research Group, Hospital La Paz Institute for Health Research, 28040 Madrid, Spain
- Intensive Care Unit, La Paz University Hospital, 28040 Madrid, Spain
| |
Collapse
|
14
|
Chayangsu C, Khorana J, Charoentum C, Sriuranpong V, Patumanond J, Tantraworasin A. Development of Clinical Prediction Score for Chemotherapy Response in Advanced Non-Small Cell Lung Cancer Patients. Healthcare (Basel) 2023; 11:healthcare11030293. [PMID: 36766868 PMCID: PMC9914574 DOI: 10.3390/healthcare11030293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/09/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
The outcomes of advanced non-small cell lung cancer (NSCLC) patients have been significantly improved with novel therapies, such as tyrosine kinase inhibitors and immune checkpoint inhibitors. However, in resource-limited countries, platinum-doublet chemotherapy is mainly used as a first-line treatment. We investigate clinical parameters to predict the response after chemotherapy, which may be useful for patient selection. A clinical prediction score (CPS) was developed, based on data from a retrospective cohort study of unresectable stage IIIB or IV NSCLC patients who were treated with platinum-doublet chemotherapy in the first-line setting with at least two cycles and an evaluated response by RECIST 1.1 at Surin Hospital Cancer Center, Thailand, between July 2014 and December 2018. The clinical parameters in the prediction model were derived by risk regression analysis. There were 117 responders (CR or PR) and 90 non-responders (SD or PD). The clinical prediction score was developed by six clinical parameters including gender, age, smoking status, ECOG, pre-treatment albumin, and histologic subtype. The AuROC of the model was 0.71 (95% CI 0.63-0.78). The internal validation was performed using a bootstrap technique and showed a consistent AuROC of 0.66 (95% CI 0.59-0.72). The prediction score ranged from 0-13, with a score of 0-8 meaning a low probability (PPV = 50%) and a score of 8.5-13 meaning a high probability (PPV = 83.7%) for chemotherapy response. Advanced NSCLC patients who cannot access novel therapies and have a CPS of 8.5-13 have a high probability for chemotherapy response in the first-line setting. This CPS could be used for risk communication and making decisions with patients, especially in regard to chemotherapy.
Collapse
Affiliation(s)
- Chawalit Chayangsu
- Department of Internal Medicine, Surin Hospital, Institute of Medicine, Suranaree University of Technology, Surin 32000, Thailand
| | - Jiraporn Khorana
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chaiyut Charoentum
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Virote Sriuranpong
- Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University & The King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Jayanton Patumanond
- Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Apichat Tantraworasin
- Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Clinical Surgical Research Center, Chiang Mai University, Chiang Mai 50200, Thailand
- Correspondence: ; Tel.: +66-8-9633-6342
| |
Collapse
|
15
|
Teixeira PEP, Tavares DRB, Pacheco-Barrios K, Branco LC, Slawka E, Keysor J, Trevisani VFM, Gross DK, Fregni F. Development of a Clinical Prediction Rule for Treatment Success with Transcranial Direct Current Stimulation for Knee Osteoarthritis Pain: A Secondary Analysis of a Double-Blind Randomized Controlled Trial. Biomedicines 2022; 11. [PMID: 36672512 DOI: 10.3390/biomedicines11010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
The study’s objective was to develop a clinical prediction rule that predicts a clinically significant analgesic effect on chronic knee osteoarthritis pain after transcranial direct current stimulation treatment. This is a secondary analysis from a double-blind randomized controlled trial. Data from 51 individuals with chronic knee osteoarthritis pain and an impaired descending pain inhibitory system were used. The intervention comprised a 15-session protocol of anodal primary motor cortex transcranial direct current stimulation. Treatment success was defined by the Western Ontario and McMaster Universities’ Osteoarthritis Index pain subscale. Accuracy statistics were calculated for each potential predictor and for the final model. The final logistic regression model was statistically significant (p < 0.01) and comprised five physical and psychosocial predictor variables that together yielded a positive likelihood ratio of 14.40 (95% CI: 3.66−56.69) and an 85% (95%CI: 60−96%) post-test probability of success. This is the first clinical prediction rule proposed for transcranial direct current stimulation in patients with chronic pain. The model underscores the importance of both physical and psychosocial factors as predictors of the analgesic response to transcranial direct current stimulation treatment. Validation of the proposed clinical prediction rule should be performed in other datasets.
Collapse
|
16
|
Li N, Mahamad S, Parpia S, Iorio A, Foroutan F, Heddle NM, Hsia CC, Sholzberg M, Rimmer E, Shivakumar S, Sun HL, Refaei M, Hamm C, Arnold DM. Development and internal validation of a clinical prediction model for the diagnosis of immune thrombocytopenia. J Thromb Haemost 2022; 20:2988-2997. [PMID: 36121734 DOI: 10.1111/jth.15885] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a diagnosis of exclusion that can resemble other thrombocytopenic disorders. OBJECTIVES To develop a clinical prediction model (CPM) for the diagnosis of ITP to aid hematogists in investigating patients presenting with undifferentiated thrombocytopenia. METHODS We designed a CPM for ITP diagnosis at the time of the initial hematology consultation using penalized logistic regression based on data from patients with thrombocytopenia enrolled in the McMaster ITP registry (n = 523) called the Predict-ITP Tool. The case definition for ITP was a platelet count less than 100 × 109 /L and a platelet count response after high-dose corticosteroids or intravenous immune globulin, defined as the achievement of a platelet count above 50 × 109 /L and at least a doubling of baseline. Internal validation was done using bootstrap resampling. Model discrimination was assessed by the c-statistic, and calibration was assessed by the calibration slope, calibration-in-the-large, and calibration plot. RESULTS The final model included the following variables: (1) platelet count variability (based on three or more platelet count values), (2) lowest platelet count value, (3) maximum mean platelet volume, and (4) history of major bleeding (defined by the ITP bleeding scale). The optimism-corrected c-statistic was 0.83, the calibration slope was 0.88, and calibration-in-the-large for all performance measures was <0.001 with standard error <0.001, indicating good discrimination and excellent calibration. CONCLUSIONS The Predict-ITP Tool can estimate the likelihood of ITP for a given patient with thrombocytopenia at the time of the initial hematology consultation. The tool had high predictive accuracy for the diagnosis of ITP.
Collapse
Affiliation(s)
- Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Syed Mahamad
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Hamilton, Ontario, Canada
| | - Cyrus C Hsia
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Emily Rimmer
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Sudeep Shivakumar
- Department of Medicine, Division of Hematology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Haowei Linda Sun
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammad Refaei
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Caroline Hamm
- Department of Biomedical Sciences, University of Windsor, Windsor, Ontario, Canada
- Division of Oncology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University - Windsor Campus, Windsor, Ontario, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
17
|
Ebell MH, Lennon RP, Tarn DM, Barrett B, Krist AH, Dong H, Cai X, Mainous AG, Zgierska AE, Tuan WJ, Goyal M. External Validation of the COVID-NoLab and COVID-SimpleLab Prognostic Tools. Ann Fam Med 2022; 20:548-550. [PMID: 36443081 PMCID: PMC9705033 DOI: 10.1370/afm.2872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022] Open
Abstract
Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates for COVID-SimpleLab were 0.0%, 9.8%, and 20.0%, respectively. These values were similar to those in the original derivation cohort. The 2 simple risk scores, now successfully externally validated, offer clinicians a reliable way to quickly identify low-risk inpatients who could potentially be managed as outpatients in the event of a bed shortage. Both are available online (https://ebell-projects.shinyapps.io/covid_nolab/ and https://ebell-projects.shinyapps.io/COVID-SimpleLab/).
Collapse
Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia
| | - Robert P Lennon
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Derjung M Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California
| | - Bruce Barrett
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin
| | - Alex H Krist
- Department of Family Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Huamei Dong
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Xinyan Cai
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia
| | - Arch G Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida
| | - Aleksandra E Zgierska
- Departments of Public Health Sciences, and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Wen-Jan Tuan
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Munish Goyal
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC
| |
Collapse
|
18
|
Leslie WD, Bryanton M, Goertzen A, Slomka P. Prediction of 2-year major adverse cardiac events from myocardial perfusion scintigraphy and clinical risk factors. J Nucl Cardiol 2022; 29:1956-1963. [PMID: 33913097 PMCID: PMC8551291 DOI: 10.1007/s12350-021-02617-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We developed CRAX2MACE, a new tool derived from clinical and SPECT myocardial perfusion imaging (MPI) variables, to predict 2-year probability of major adverse cardiac event (MACE) comprising death, hospitalized acute myocardial infarction or coronary revascularization. METHODS Consecutive individuals with SPECT MPI 2001-2008 had two-year MACE determined from population-based health services data. CRAX2MACE included age, sex, diabetes, recent cardiac hospitalization, pharmacologic stress, stress total perfusion deficit (TPD), ischemic (stress-rest) TPD, left ventricular ejection fraction and transient ischemic dilation ratio. Two-year event rates were classified as low (< 5%), moderate (5.0-9.9%), high (10-19.9%) and very high (20% or greater). RESULTS The study population comprised 3896 individuals for the development and 1946 for the validation subgroups with subsequent MACE in 589 (15.1%) and 272 (14.0%), respectively. CRAX2MACE, derived from the development subgroups, accurately stratified MACE risk in the validation subgroup (area under the receiver operating characteristics curve 0.79) with stepwise increase in the observed event rate with increasing predicted risk category (low, 2.3%; moderate, 5.5%; high, 18.8%; very high 33.2%; P-trend < 0.001). CONCLUSIONS A simple tool based upon clinical risk factors and MPI variables predicts 2-year cardiac events. Risk stratification between the low and very high groups was greater than tenfold.
Collapse
Affiliation(s)
- William D Leslie
- Department of Radiology, University of Manitoba, C5121-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada.
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Mark Bryanton
- Department of Radiology, University of Manitoba, C5121-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada
| | - Andrew Goertzen
- Department of Radiology, University of Manitoba, C5121-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada
| | - Piotr Slomka
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
19
|
D'Amico G, Maruzzelli L, Airoldi A, Petridis I, Tosetti G, Rampoldi A, D'Amico M, Miraglia R, De Nicola S, La Mura V, Solcia M, Volpes R, Perricone G, Sgrazzutti C, Vanzulli A, Primignani M, Luca A, Malizia G, Federico A, Dallio M, Andriulli A, Iacobellis A, Addario L, Garcovich M, Gasbarrini A, Chessa L, Salerno F, Gobbo G, Merli M, Ridola L, Baroni GS, Tarantino G, Caporaso N, Morisco F, Pozzoni P, Colli A, Belli LS. Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology. J Hepatol 2021; 75:1355-1366. [PMID: 34333100 DOI: 10.1016/j.jhep.2021.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/02/2021] [Accepted: 07/16/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model. METHODS In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. RESULTS In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD. CONCLUSIONS In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed. LAY SUMMARY While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.
Collapse
Affiliation(s)
- Gennaro D'Amico
- Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Gastroenterology Unit, Clinica La Maddalena, Palermo, Italy.
| | - Luigi Maruzzelli
- Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Aldo Airoldi
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Ioannis Petridis
- Hepatology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Giulia Tosetti
- Gastroenterology and Hepatology Unit Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | | | - Mario D'Amico
- Radiology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Radiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Miraglia
- Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Stella De Nicola
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Luigi Villa, Milan, Italy
| | - Marco Solcia
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | - Riccardo Volpes
- Hepatology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | | | - Cristiano Sgrazzutti
- University of Milan, Department of Oncology and Hemato-oncology and Radiology, Department ASST Niguarda, Milan, Italy
| | - Angelo Vanzulli
- University of Milan, Department of Oncology and Hemato-oncology and Radiology, Department ASST Niguarda, Milan, Italy
| | - Massimo Primignani
- Gastroenterology and Hepatology Unit Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Angelo Luca
- Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Giuseppe Malizia
- Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Federico
- Hepato-Gastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marcello Dallio
- Hepato-Gastroenterology Unit, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Angelo Andriulli
- Department of Gastroenterology and Endoscopy, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Angelo Iacobellis
- Department of Gastroenterology and Endoscopy, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | - Matteo Garcovich
- Department of Internal Medicine and Gastroenterology, Policlinico Gemelli, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Policlinico Gemelli, Rome, Italy
| | - Luchino Chessa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Giulia Gobbo
- Internal Medicine Unit, IRCCS Policlinico San Donato, Milano, Italy
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Translational and Precision Medicine, Università Sapienza, Roma, Italy
| | - Lorenzo Ridola
- Gastroenterology Unit, ASL Latina, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | | | - Giuseppe Tarantino
- Liver Injury and Transplant Unit, Polytechnic University of Marche, Ancona, Italy
| | - Nicola Caporaso
- Gastroenterology Unit, Federico II University, Naples, Italy
| | | | - Pietro Pozzoni
- General Medicine Unit,Presidio Ospedaliero, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy
| | - Agostino Colli
- General Medicine Unit,Presidio Ospedaliero, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy
| | | |
Collapse
|
20
|
Zapała P, Kozikowski M, Dybowski B, Zapała Ł, Dobruch J, Radziszewski P. External validation of a magnetic resonance imaging-based algorithm for prediction of side-specific extracapsular extension in prostate cancer. Cent European J Urol 2021; 74:327-333. [PMID: 34729221 PMCID: PMC8552930 DOI: 10.5173/ceju.2021.0128.r2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Recently developed algorithm for prediction of side-specific extracapsular extension (ECE) of prostate cancer required validation before being recommended to use. The algorithm assumed that ECE on a particular side was not likely with same side maximum tumor diameter (MTD) <15 mm AND cancerous tissue in ipsilateral biopsy <15% AND PSA <20 ng/mL (both sides condition). The aim of the study was to validate this predictive tool in patients from another department. Material and methods Data of 154 consecutive patients (308 prostatic lateral lobes) were used for validation. Predictive factors chosen in the development set of patients were assessed together with other preoperative parameters using logistic regression to check for their significance. Sensitivity, specificity, negative and positive predictive values were calculated for bootstrapped risk-stratified validation dataset. Results Validation cohort did not differ significantly from development cohort regarding PSA, PSA density, Gleason score (GS), MTD, age, ECE and seminal vesicle invasion rate. In bootstrapped data set (n = 200 random sampling) algorithm revealed 70.2% sensitivity (95% confidence interval (CI) 58.8–83.0%), 49.9% specificity (95%CI: 42.0–57.7%), 83.9% negative predictive value (NPV; 95%CI: 76.1–91.4%) and 31.1% positive predictive value (PPV; 95%CI: 19.6–39.7%). When limiting analysis to high-risk patients (Gleason score >7) the algorithm improved its performance: sensitivity 91%, specificity 47%, PPV 53%, NPV 89%. Conclusions Analyzed algorithm is useful for identifying prostate lobes without ECE and deciding on ipsilateral nerve-sparing technique during radical prostatectomy, especially in patients with GS >7. Due to significant number of false positives in case of: MTD ≥15 mm OR cancer in biopsy ≥15% OR PSA ≥20 ng/mL additional evaluation is necessary to aid decision-making.
Collapse
Affiliation(s)
- Piotr Zapała
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Poland
| | - Mieszko Kozikowski
- Department of Urology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Bartosz Dybowski
- Department of Urology, Roefler Memorial Hospital, Pruszków, Poland.,Faculty of Medicine, Lazarski University, Warsaw, Poland
| | - Łukasz Zapała
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Poland
| | - Jakub Dobruch
- Department of Urology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Piotr Radziszewski
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Poland
| |
Collapse
|
21
|
Maraveyas A, Kraaijpoel N, Bozas G, Huang C, Mahé I, Bertoletti L, Bartels-Rutten A, Beyer-Westendorf J, Constans J, Iosub D, Couturaud F, Muñoz AJ, Biosca M, Lerede T, van Es N, Di Nisio M. The prognostic value of respiratory symptoms and performance status in ambulatory cancer patients and unsuspected pulmonary embolism; analysis of an international, prospective, observational cohort study. J Thromb Haemost 2021; 19:2791-2800. [PMID: 34532927 DOI: 10.1111/jth.15489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/16/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimal risk stratification of unsuspected pulmonary embolism (UPE) in ambulatory cancer patients (ACPs) remains unclear. Existing clinical predictive rules (CPRs) are derived from retrospective databases and have limitations. The UPE registry is a prospective international registry with pre-specified characteristics of ACPs with a recent UPE. The aim of this study was to assess the utility of risk factors captured in the UPE registry in predicting proximate (30-, 90- and 180-day) mortality and how they performed when applied to an existing CPR. OBJECTIVES To evaluate risk factors for proximate mortality, overall survival, recurrent venous thromboembolism and major bleeding, in the patients enrolled in the UPE registry cohort. METHODS Data from the 695 ACPs in this registry were subjected to multivariate logistic regression analyses to identify predictors independently associated with proximate mortality and overall survival. The most consistent predictors were applied to the Hull CPR, an existing 5-point prediction rule. RESULTS The most consistent predictors of mortality were patient-reported respiratory symptoms within 14 days before, and ECOG performance status at the time of UPE. These predictors applied to the Hull-CPR produced a consistent correlation with proximate mortality and overall survival (area under the curve [AUC] = 0.70 [95% CI 0.63, 077], AUC = 0.65 [95% CI 0.60, 070], AUC = 0.64 [95% CI 0.59, 068], and AUC = 0.61, 95% CI 0.57, 0.65, respectively). CONCLUSION In ACPs with UPE, ECOG performance status logged contemporaneously to the UPE diagnosis and respiratory symptoms prior to UPE diagnosis can stratify mortality risk. When applied to the HULL-CPR these risk predictors confirmed the risk stratification clusters of low-intermediate and high-risk for proximate mortality as seen in the original derivation cohort.
Collapse
Affiliation(s)
- Anthony Maraveyas
- Faculty of Health Sciences, Joint Centre for Cancer Studies, The Hull York Medical School, Castle Hill Hospital, Hull, UK
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - George Bozas
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis Mourier, AP-HP, Colombes, France
- Université de Paris, Paris, France
- Innovative Therapies in Haemostasis, INSERM UMR-_S1140, Paris, France
- INNOVTE-FCRIN, Saint-Etienne, France
| | - Laurent Bertoletti
- CHU de St-Etienne, Service de Médecine Vasculaire et Thérapeutique, INSERM, UMR1059, Université Jean-Monnet, INSERM, CIC-1408, CHU de Saint-Etienne, INNOVTE, CHU de Saint-Etienne, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Annemarieke Bartels-Rutten
- Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jan Beyer-Westendorf
- Department of Medicine, Division Hematology, University Hospital "Carl Gustav Carus", Dresden, Germany
| | - Joel Constans
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Diana Iosub
- Thromboembolic Disease Unit, Fondazione Policlinico IRCCS San Matteo, Pavia, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital Centre "La Cavale Blanche", EA 3878, Brest, France
| | - Andres J Muñoz
- Medical Oncology, Hospital General Universitario Gregorio Maranon, Madrid, Spain
| | | | - Teresa Lerede
- Immunohematology and Transfusion Medicine, Azienda Socio Sanitaria Territoriale Bergamo, Seriate, Italy
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti, Italy
| |
Collapse
|
22
|
Martín-Rodríguez F, Sanz-García A, Castro-Portillo E, Delgado-Benito JF, Del Pozo Vegas C, Ortega Rabbione G, Martín-Herrero F, Martín-Conty JL, López-Izquierdo R. Prehospital troponin as a predictor of early clinical deterioration. Eur J Clin Invest 2021; 51:e13591. [PMID: 34002363 DOI: 10.1111/eci.13591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Elevated troponin T (cTnT) values are associated with comorbidities and early mortality, in both cardiovascular and noncardiovascular diseases. The objective of this study is to evaluate the prognostic accuracy of the sole utilization of prehospital point-of-care cardiac troponin T to identify the risk of early in-hospital deterioration, including mortality within 28 days. METHODS We conducted a prospective, multicentric, controlled, ambulance-based, observational study in adults with acute diseases transferred with high priority by ambulance to emergency departments, between 1 January and 30 September 2020. Patients with hospital diagnosis of acute coronary syndrome were excluded. The discriminative power of the predictive cTnT was assessed through a discrimination model trained using a derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on a validation cohort. RESULTS A total of 848 patients were included in our study. The median age was 68 years (25th-75th percentiles: 50-81 years), and 385 (45.4%) were women. The mortality rate within 28 days was 12.4% (156 cases). The predictive ability of cTnT to predict mortality presented an area under the curve of 0.903 (95% CI: 0.85-0.954; P < .001). Risk stratification was performed, resulting in three categories with the following optimal cTnT cut-off points: high risk greater than or equal to 100, intermediate risk 40-100 and low risk less than 40 ng/L. In the high-risk group, the mortality rate was 61.7%, and on the contrary, the low-risk group presented a mortality of 2.3%. CONCLUSIONS The implementation of a routine determination of cTnT on the ambulance in patients transferred with high priority to the emergency department can help to stratify the risk of these patients and to detect unknown early clinical deterioration.
Collapse
Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Life Support Unit, Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain.,Advanced Clinical Simulation Center, Medicine Faculty, Valladolid University, Valladolid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain
| | - Enrique Castro-Portillo
- Emergency Department, Hospital Universitario Rio Hortega de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - Juan F Delgado-Benito
- Advanced Life Support Unit, Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Emergency Department, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - Guillermo Ortega Rabbione
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Francisco Martín-Herrero
- Department of Cardiology, Complejo Asistencial de Salamanca, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - José Luis Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain
| | - Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| |
Collapse
|
23
|
Pérez-García F, Bailén R, Torres-Macho J, Fernández-Rodríguez A, Jiménez-Sousa MÁ, Jiménez E, Pérez-Butragueño M, Cuadros-González J, Cadiñanos J, García-García I, Jiménez-González M, Ryan P, Resino S. Age-Adjusted Endothelial Activation and Stress Index for Coronavirus Disease 2019 at Admission Is a Reliable Predictor for 28-Day Mortality in Hospitalized Patients With Coronavirus Disease 2019. Front Med (Lausanne) 2021; 8:736028. [PMID: 34568391 PMCID: PMC8455820 DOI: 10.3389/fmed.2021.736028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/05/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Endothelial Activation and Stress Index (EASIX) predict death in patients undergoing allogeneic hematopoietic stem cell transplantation who develop endothelial complications. Because coronavirus disease 2019 (COVID-19) patients also have coagulopathy and endotheliitis, we aimed to assess whether EASIX predicts death within 28 days in hospitalized COVID-19 patients. Methods: We performed a retrospective study on COVID-19 patients from two different cohorts [derivation (n = 1,200 patients) and validation (n = 1,830 patients)]. The endpoint was death within 28 days. The main factors were EASIX [(lactate dehydrogenase * creatinine)/thrombocytes] and aEASIX-COVID (EASIX * age), which were log2-transformed for analysis. Results: Log2-EASIX and log2-aEASIX-COVID were independently associated with an increased risk of death in both cohorts (p < 0.001). Log2-aEASIX-COVID showed a good predictive performance for 28-day mortality both in the derivation cohort (area under the receiver-operating characteristic = 0.827) and in the validation cohort (area under the receiver-operating characteristic = 0.820), with better predictive performance than log2-EASIX (p < 0.001). For log2 aEASIX-COVID, patients with low/moderate risk (<6) had a 28-day mortality probability of 5.3% [95% confidence interval (95% CI) = 4-6.5%], high (6-7) of 17.2% (95% CI = 14.7-19.6%), and very high (>7) of 47.6% (95% CI = 44.2-50.9%). The cutoff of log2 aEASIX-COVID = 6 showed a positive predictive value of 31.7% and negative predictive value of 94.7%, and log2 aEASIX-COVID = 7 showed a positive predictive value of 47.6% and negative predictive value of 89.8%. Conclusion: Both EASIX and aEASIX-COVID were associated with death within 28 days in hospitalized COVID-19 patients. However, aEASIX-COVID had significantly better predictive performance than EASIX, particularly for discarding death. Thus, aEASIX-COVID could be a reliable predictor of death that could help to manage COVID-19 patients.
Collapse
Affiliation(s)
- Felipe Pérez-García
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología Clínica, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - Rebeca Bailén
- Servicio de Hematología y Hemoterapia, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Juan Torres-Macho
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Amanda Fernández-Rodríguez
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Ángeles Jiménez-Sousa
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Eva Jiménez
- Servicio de Medicina Preventiva, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Juan Cuadros-González
- Servicio de Microbiología Clínica, Hospital Universitario Príncipe de Asturias, Madrid, Spain
- Departamento de Biomedicina y Biotecnología, Facultad de Medicina, Universidad de Alcalá de Henares, Madrid, Spain
| | - Julen Cadiñanos
- Servicio de Medicina Interna, Hospital General de Villalba, Collado Villalba, Spain
| | - Irene García-García
- Servicio de Farmacología Clínica, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | | | - Pablo Ryan
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Salvador Resino
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
24
|
Jose T, Rajesh PS. Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis. Surg J (N Y) 2021; 7:e127-e131. [PMID: 34295969 PMCID: PMC8289675 DOI: 10.1055/s-0041-1731446] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/17/2021] [Indexed: 12/29/2022] Open
Abstract
Appendicitis is a common differential diagnosis of right lower quadrant pain. Clinical evaluation alone results in high negative appendicectomy rates. Alvarado scoring is the most commonly used clinical prediction rule. The study aimed to compare the recently developed appendicitis inflammatory response (AIR) score with the Alvarado score. This cross-sectional observational study included patients who underwent appendicectomy for clinical suspicion of appendicitis. The clinical and laboratory parameters required for obtaining Alvarado score and AIRS were gathered. Area under ROC curve was calculated for both Alvarado score and AIRS. The study included 130 patients (77 males and 53 females). The negative appendicectomy rate was 10.7%. The perforation rate was 10.3%. The area under ROC for Alvarado score was 0.821 and for AIR score was 0.901. The Alvarado score had a sensitivity of 72% and a specificity of 79% at score ≥6. The appendicitis inflammatory response score had a sensitivity of 98% for scores ≥5 and a specificity of 97% for score ≥6. The C-reactive protein (CRP) value was the best performing individual parameter with an area under ROC of 0.789, followed by WBC count with an area under ROC of 0.762. Appendicitis inflammatory response score is a recently developed score that outperforms the Alvarado score. AIR score has a higher specificity. The sound construction, gradation of parameters, the inclusion of CRP, and avoidance of subjective parameters make the AIR score an attractive clinical prediction rule which can decrease the rate of negative appendicectomy.
Collapse
Affiliation(s)
- Toney Jose
- Department of Surgical Gastroenterology, Bangalore Medical College and Research Institute, Bangalore, India
| | - P S Rajesh
- Department of General Surgery, Government Medical College, Kottayam, Kerala, India
| |
Collapse
|
25
|
Bruyndonckx R, Stuart B, Little P, Hens N, Ieven M, Butler CC, Verheij TJM, Goossens H, Coenen S. The Effect of Amoxicillin in Adult Patients Presenting to Primary Care with Acute Cough Predicted to Have Pneumonia or a Combined Viral-Bacterial Infection. Antibiotics (Basel) 2021; 10:antibiotics10070817. [PMID: 34356738 PMCID: PMC8300796 DOI: 10.3390/antibiotics10070817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
While most cases of acute cough are self-limiting, antibiotics are prescribed to over 50%. This proportion is inappropriately high given that benefit from treatment with amoxicillin could only be demonstrated in adults with pneumonia (based on chest radiograph) or combined viral-bacterial infection (based on modern microbiological methodology). As routine use of chest radiographs and microbiological testing is costly, clinical prediction rules could be used to identify these patient subsets. In this secondary analysis of data from a multicentre randomised controlled trial in adults presenting to primary care with acute cough, we used prediction rules for pneumonia or combined infection and assessed the effect of amoxicillin in patients predicted to have pneumonia or combined infection on symptom duration, symptom severity and illness deterioration. In total, 2056 patients that fulfilled all inclusion criteria were randomised, 1035 to amoxicillin, 1021 to placebo. Neither patients with a predicted pneumonia nor patients with a predicted combined infection were significantly more likely to benefit from amoxicillin. While the studied clinical prediction rules may help primary care clinicians to reduce antibiotic prescribing for low-risk patients, they did not identify adult acute cough patients that would benefit from amoxicillin treatment.
Collapse
Affiliation(s)
- Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, 3500 Hasselt, Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
- Correspondence: ; Tel.: +32-11-268-631
| | - Beth Stuart
- Aldermoor Health Centre, University of Southampton, Southampton SO16 5ST, UK; (B.S.); (P.L.)
| | - Paul Little
- Aldermoor Health Centre, University of Southampton, Southampton SO16 5ST, UK; (B.S.); (P.L.)
| | - Niel Hens
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, 3500 Hasselt, Belgium;
- Centre for Health Economic Research and Modelling Infectious Diseases (CHERMID), Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK;
| | - Theo J. M. Verheij
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands;
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, 2610 Antwerp, Belgium
| | | |
Collapse
|
26
|
Saengdao O, Surasak B, Jayanton P. A Diagnostic Assistant Tool for Work-Related Low Back Pain in Hospital Workers. Indian J Occup Environ Med 2021; 25:11-16. [PMID: 34295056 PMCID: PMC8259585 DOI: 10.4103/ijoem.ijoem_153_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 05/02/2020] [Accepted: 05/25/2020] [Indexed: 11/05/2022] Open
Abstract
Aims: The study objective was to develop a clinical risk score to assist occupational medicine physicians in diagnosing hospital workers’ occupational lower back pain (LBP). Settings and Design: A cross-sectional data collection design was conducted at Saraburi Hospital, Thailand. Methods and Materials: The sample consisted of 220 hospital workers who cared for patients and had LBP. They were assessed for the frequency of targeted activities (CPR, lifting, transferring patients) and other activities from work as well as ergonomic assessments, and diagnosed with LBP by three occupational medicine physicians. Statistical Analysis Used: Predicted factors of multivariable logistic regression were analysed to find clinical risk scores to help the diagnosis. Results: The physicians agreed on the diagnosis, based on ergonomic risk factors and their experiences that 86 persons have occupational LBP. A diagnostic assistant tool consists of six predictors: the duration of LBP, having LBP within the last 7 days, bending, twisting, lateral bending, and reaching. The scores predicted occupational LBP correctly with an AuROC of 90.0% (95% CI; 84.8–93.5%). The positive likelihood ratio for occupational LBP was 0 in the low risk category (<6 points) and 16.8 (95% CI; 8.0–35.6) in the high risk (>8 points). Conclusions: A diagnostic assistant tool is used to assist occupational medicine physicians in diagnosing hospital workers' occupational LBP.
Collapse
Affiliation(s)
- Oopara Saengdao
- Department of Occupational Health, Saraburi Regional Hospital, Thailand
| | - Buranatrevedh Surasak
- Departments of Community Medicine, Faculty of Medicine, Thammasart University, Thailand
| | - Patumanond Jayanton
- Departments of Clinical Epidemiology, Faculty of Medicine, Thammasart University, Thailand
| |
Collapse
|
27
|
Qiu P, Liu J, Wan F, Chen Y, Ye K, Qin J, Huang Q, Lu X. A predictive model for postthrombotic syndrome in proximal deep vein thrombosis patients. Ann Transl Med 2021; 9:558. [PMID: 33987256 DOI: 10.21037/atm-20-3239] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Postthrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT). Predictive models for PTS after hospitalized DVT patients, especially those with proximal DVT for whom preventative intervention decisions need to be made, are rare. We aimed to develop and externally validate a clinical predictive model for PTS in patients with proximal DVT. Methods This study was a retrospective, single-center, case-control study. The data used in our model were retrospectively collected from a prospective registry database in which 210 (derivation) and 90 (validation) consecutive patients were first diagnosed with proximal DVT. We developed a nomogram using the multivariate logistic regression model. External validation of our predictive model and previous predictive models in our validation set was assessed by discrimination, calibration, and clinical utility. Results Of the 30 candidate predictors, 5 were significantly associated with PTS in our final multivariable model, including the number of signs and symptoms (OR 1.33, 95% CI: 1.17 to 1.53, P<0.001), male sex (OR 1.79, 95% CI: 1.07 to 3.06, P=0.028), varicose vein history (OR 3.02, 95% CI: 1.04 to 7.60, P<0.001), BMI (OR 1.06, 95% CI: 1.00 to 1.12, P=0.052), and chronic DVT (OR 2.66, 95% CI: 1.49 to 4.79, P<0.001). The area under the curve was 0.724 in our predictive model, indicating suitable external performance. Conclusions A simple-to-use nomogram effectively predicts the risk of PTS in patients with proximal DVT. This predictive model may be considered for use in clinical care.
Collapse
Affiliation(s)
- Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junchao Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fuzhen Wan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Yuqian Chen
- School of Public Economics and Administration, Shanghai University of Finance and Economics, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qun Huang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
28
|
Matsuda KM, Yoshizaki A, Kotani H, Kuzumi A, Fukayama M, Ebata S, Fukasawa T, Yoshizaki-Ogawa A, Sato S. Development of a prediction model of treatment response in patients with cutaneous arteritis: Insights from a cohort of 33 patients. J Dermatol 2021; 48:1021-1026. [PMID: 33768589 DOI: 10.1111/1346-8138.15868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 03/10/2021] [Indexed: 11/28/2022]
Abstract
Cutaneous arteritis (CA) is necrotizing vasculitis invading the small- to medium-sized arteries of the skin. The majority of patients can be favorably managed by low- to medium-dose systemic corticosteroids (prednisolone, <0.5 mg/kg/day) or other oral medications such as non-steroidal anti-inflammatory drugs, dapsone, and azathioprine. Meanwhile, some patients require more intensive therapy including high-dose systemic corticosteroids (prednisolone, ≥0.5 mg/kg/day), i.v. immunoglobulin, and i.v. cyclophosphamide therapy. Although predicting such treatment response among CA patients is critical in clinical decision-making, prediction rules have not yet been established. Herein, we retrospectively reviewed 33 patients regularly visiting our clinic to reveal predictive factors of their treatment response. Clinical data were collected from electronic medical records. Association between each factor and treatment response was examined by logistic regression analysis. Progression-free time was calculated by Kaplan-Meier's method and analyzed by log-rank test and Cox progression hazard model. Potential predictive factors were selected, given 1 point for each, and integrated into a classification model. Discrimination of the model was examined by the receiver operating characteristic (ROC) curve analysis. In total, 33 CA patients were enrolled in our study. Of these, 11 patients required intensive therapy, classified as treatment non-responders. Logistic analyses revealed that treatment response was significantly associated with male sex, presence of skin ulcers, and elevated serum levels of C-reactive protein at the initial work-up. Kaplan-Meier analyses also demonstrated that those factors are predictive of progression-free time. The area under the ROC curve of our classification model was 0.92 (95% confidence interval, 0.83-1.00), which classified non-responders from the others with a sensitivity of 90.9% and specificity of 81.8% at the cut-off point of 2 or more. Collectively, treatment response of CA could be predictable by a combination of sex, presence of skin ulcers, and serum levels of C-reactive protein.
Collapse
Affiliation(s)
- Kazuki Mitsuru Matsuda
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hirohito Kotani
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ai Kuzumi
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Maiko Fukayama
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Ebata
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takemichi Fukasawa
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Asako Yoshizaki-Ogawa
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
29
|
Czihal M, Lottspeich C, Bernau C, Henke T, Prearo I, Mackert M, Priglinger S, Dechant C, Schulze-Koops H, Hoffmann U. A Diagnostic Algorithm Based on a Simple Clinical Prediction Rule for the Diagnosis of Cranial Giant Cell Arteritis. J Clin Med 2021; 10:jcm10061163. [PMID: 33802092 PMCID: PMC8001831 DOI: 10.3390/jcm10061163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/19/2021] [Accepted: 02/26/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Risk stratification based on pre-test probability may improve the diagnostic accuracy of temporal artery high-resolution compression sonography (hrTCS) in the diagnostic workup of cranial giant cell arteritis (cGCA). Methods: A logistic regression model with candidate items was derived from a cohort of patients with suspected cGCA (n = 87). The diagnostic accuracy of the model was tested in the derivation cohort and in an independent validation cohort (n = 114) by receiver operator characteristics (ROC) analysis. The clinical items were composed of a clinical prediction rule, integrated into a stepwise diagnostic algorithm together with C-reactive protein (CRP) values and hrTCS values. Results: The model consisted of four clinical variables (age > 70, headache, jaw claudication, and anterior ischemic optic neuropathy). The diagnostic accuracy of the model for discrimination of patients with and without a final clinical diagnosis of cGCA was excellent in both cohorts (area under the curve (AUC) 0.96 and AUC 0.92, respectively). The diagnostic algorithm improved the positive predictive value of hrCTS substantially. Within the algorithm, 32.8% of patients (derivation cohort) and 49.1% (validation cohort) would not have been tested by hrTCS. None of these patients had a final diagnosis of cGCA. Conclusion: A diagnostic algorithm based on a clinical prediction rule improves the diagnostic accuracy of hrTCS.
Collapse
Affiliation(s)
- Michael Czihal
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.L.); (C.B.); (T.H.); (I.P.); (U.H.)
- Correspondence:
| | - Christian Lottspeich
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.L.); (C.B.); (T.H.); (I.P.); (U.H.)
- Interdisciplinary Sonography Center, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Christoph Bernau
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.L.); (C.B.); (T.H.); (I.P.); (U.H.)
| | - Teresa Henke
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.L.); (C.B.); (T.H.); (I.P.); (U.H.)
| | - Ilaria Prearo
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.L.); (C.B.); (T.H.); (I.P.); (U.H.)
| | - Marc Mackert
- Department of Ophthalmology, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (M.M.); (S.P.)
| | - Siegfried Priglinger
- Department of Ophthalmology, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (M.M.); (S.P.)
| | - Claudia Dechant
- Division of Rheumatology and Clinical Immunology, Medical Clinical and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.D.); (H.S.-K.)
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Medical Clinical and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.D.); (H.S.-K.)
| | - Ulrich Hoffmann
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany; (C.L.); (C.B.); (T.H.); (I.P.); (U.H.)
| |
Collapse
|
30
|
Reimer JR, Ahmed SM, Brintz B, Shah RU, Keegan LT, Ferrari MJ, Leung DT. Using a clinical prediction rule to prioritize diagnostic testing leads to reduced transmission and hospital burden: A modeling example of early SARS-CoV-2. Clin Infect Dis 2021; 73:1822-1830. [PMID: 33621329 PMCID: PMC7929067 DOI: 10.1093/cid/ciab177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/19/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prompt identification of infections is critical for slowing the spread of infectious diseases. However, diagnostic testing shortages are common in emerging diseases, low resource settings, and during outbreaks. This forces difficult decisions regarding who receives a test, often without knowing the implications of those decisions on population-level transmission dynamics. Clinical prediction rules (CPRs) are commonly used tools to guide clinical decisions. METHODS Using early SARS-CoV-2 as an example, we used data from electronic health records to develop a parsimonious 5-variable CPR to identify those who are most likely to test positive. To consider the implications of gains in daily case detection at the population level, we incorporated testing using the CPR into a compartmentalized model of SARS-CoV-2. RESULTS We found that applying this CPR (AUC: 0.69 (95% CI: 0.68 - 0.70)) to prioritize testing increased the proportion of those testing positive in settings of limited testing capacity. We found that prioritized testing led to a delayed and lowered infection peak (i.e., "flattens the curve"), with the greatest impact at lower values of the effective reproductive number (such as with concurrent community mitigation efforts), and when higher proportions of infectious persons seek testing. Additionally, prioritized testing resulted in reductions in overall infections as well as hospital and intensive care unit (ICU) burden. CONCLUSION We highlight the population-level benefits of evidence-based allocation of limited diagnostic capacity.
Collapse
Affiliation(s)
- Jody R Reimer
- University of Utah, Department of Mathematics, Salt Lake City, UT, United States of America
| | - Sharia M Ahmed
- University of Utah School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, Salt Lake City UT, United States of America
| | - Benjamin Brintz
- University of Utah School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, Salt Lake City UT, United States of America.,University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, Salt Lake City UT, United States of America
| | - Rashmee U Shah
- University of Utah School of Medicine, Department of Internal Medicine, Division of Cardiovascular Medicine, Salt Lake City UT, United States of America
| | - Lindsay T Keegan
- University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, Salt Lake City UT, United States of America
| | - Matthew J Ferrari
- The Pennsylvania State University, Department of Biology, State College, PA, United States of America
| | - Daniel T Leung
- University of Utah School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, Salt Lake City UT, United States of America
| |
Collapse
|
31
|
Brintz BJ, Haaland B, Howard J, Chao DL, Proctor JL, Khan AI, Ahmed SM, Keegan LT, Greene T, Keita AM, Kotloff KL, Platts-Mills JA, Nelson EJ, Levine AC, Pavia AT, Leung DT. A modular approach to integrating multiple data sources into real-time clinical prediction for pediatric diarrhea. eLife 2021; 10:63009. [PMID: 33527894 PMCID: PMC7853717 DOI: 10.7554/elife.63009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/17/2021] [Indexed: 11/13/2022] Open
Abstract
Traditional clinical prediction models focus on parameters of the individual patient. For infectious diseases, sources external to the patient, including characteristics of prior patients and seasonal factors, may improve predictive performance. We describe the development of a predictive model that integrates multiple sources of data in a principled statistical framework using a post-test odds formulation. Our method enables electronic real-time updating and flexibility, such that components can be included or excluded according to data availability. We apply this method to the prediction of etiology of pediatric diarrhea, where 'pre-test’ epidemiologic data may be highly informative. Diarrhea has a high burden in low-resource settings, and antibiotics are often over-prescribed. We demonstrate that our integrative method outperforms traditional prediction in accurately identifying cases with a viral etiology, and show that its clinical application, especially when used with an additional diagnostic test, could result in a 61% reduction in inappropriately prescribed antibiotics.
Collapse
Affiliation(s)
- Ben J Brintz
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, United States.,Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, United States
| | - Benjamin Haaland
- Population Health Sciences, University of Utah, Salt Lake City, United States
| | - Joel Howard
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, United States
| | - Dennis L Chao
- Institute of Disease Modeling, Bill and Melinda Gates Foundation, Seattle, United States
| | - Joshua L Proctor
- Institute of Disease Modeling, Bill and Melinda Gates Foundation, Seattle, United States
| | - Ashraful I Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sharia M Ahmed
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, United States
| | - Lindsay T Keegan
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, United States
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, United States
| | | | - Karen L Kotloff
- Division of Infectious Disease and Tropical Pediatrics, University of Maryland, Baltimore, United States
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States
| | - Eric J Nelson
- Departments of Pediatrics, University of Florida, Gainesville, United States.,Departments of Environmental and Global Health, University of Florida, Gainesville, United States
| | - Adam C Levine
- Department of Emergency Medicine, Brown University, Providence, United States
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, United States
| | - Daniel T Leung
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, United States.,Division of Microbiology and Immunology, Department of Internal Medicine, University of Utah, Salt Lake City, United States
| |
Collapse
|
32
|
Fletcher S, Chondros P, Densley K, Murray E, Dowrick C, Coe A, Hegarty K, Davidson S, Wachtler C, Mihalopoulos C, Lee YY, Chatterton ML, Palmer VJ, Gunn J. Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial. Br J Gen Pract 2021; 71:e85-94. [PMID: 33431380 DOI: 10.3399/BJGP.2020.0783] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/11/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Mental health treatment rates are increasing, but the burden of disease has not reduced. Tools to support efficient resource distribution are required. AIM To investigate whether a person-centred e-health (Target-D) platform matching depression care to symptom severity prognosis can improve depressive symptoms relative to usual care. DESIGN AND SETTING Stratified individually randomised controlled trial in 14 general practices in Melbourne, Australia, from April 2016 to February 2019. In total, 1868 participants aged 18-65 years who had current depressive symptoms; internet access; no recent change to antidepressant; no current antipsychotic medication; and no current psychological therapy were randomised (1:1) via computer-generated allocation to intervention or usual care. METHOD The intervention was an e-health platform accessed in the GP waiting room, comprising symptom feedback, priority-setting, and prognosis-matched management options (online self-help, online guided psychological therapy, or nurse-led collaborative care). Management options were flexible, neither participants nor staff were blinded, and there were no substantive protocol deviations. The primary outcome was depressive symptom severity (9-item Patient Health Questionnaire [PHQ-9]) at 3 months. RESULTS In intention to treat analysis, estimated between- arm difference in mean PHQ-9 scores at 3 months was -0.88 (95% confidence interval [CI] = -1.45 to -0.31) favouring the intervention, and -0.59 at 12 months (95% CI = -1.18 to 0.01); standardised effect sizes of -0.16 (95% CI = -0.26 to -0.05) and -0.10 (95% CI = -0.21 to 0.002), respectively. No serious adverse events were reported. CONCLUSION Matching management to prognosis using a person-centred e-health platform improves depressive symptoms at 3 months compared to usual care and could feasibly be implemented at scale. Scope exists to enhance the uptake of management options.
Collapse
|
33
|
Balzer LB, Havlir DV, Kamya MR, Chamie G, Charlebois ED, Clark TD, Koss CA, Kwarisiima D, Ayieko J, Sang N, Kabami J, Atukunda M, Jain V, Camlin CS, Cohen CR, Bukusi EA, Van Der Laan M, Petersen ML. Machine Learning to Identify Persons at High-Risk of Human Immunodeficiency Virus Acquisition in Rural Kenya and Uganda. Clin Infect Dis 2020; 71:2326-2333. [PMID: 31697383 PMCID: PMC7904068 DOI: 10.1093/cid/ciz1096] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In generalized epidemic settings, strategies are needed to prioritize individuals at higher risk of human immunodeficiency virus (HIV) acquisition for prevention services. We used population-level HIV testing data from rural Kenya and Uganda to construct HIV risk scores and assessed their ability to identify seroconversions. METHODS During 2013-2017, >75% of residents in 16 communities in the SEARCH study were tested annually for HIV. In this population, we evaluated 3 strategies for using demographic factors to predict the 1-year risk of HIV seroconversion: membership in ≥1 known "risk group" (eg, having a spouse living with HIV), a "model-based" risk score constructed with logistic regression, and a "machine learning" risk score constructed with the Super Learner algorithm. We hypothesized machine learning would identify high-risk individuals more efficiently (fewer persons targeted for a fixed sensitivity) and with higher sensitivity (for a fixed number targeted) than either other approach. RESULTS A total of 75 558 persons contributed 166 723 person-years of follow-up; 519 seroconverted. Machine learning improved efficiency. To achieve a fixed sensitivity of 50%, the risk-group strategy targeted 42% of the population, the model-based strategy targeted 27%, and machine learning targeted 18%. Machine learning also improved sensitivity. With an upper limit of 45% targeted, the risk-group strategy correctly classified 58% of seroconversions, the model-based strategy 68%, and machine learning 78%. CONCLUSIONS Machine learning improved classification of individuals at risk of HIV acquisition compared with a model-based approach or reliance on known risk groups and could inform targeting of prevention strategies in generalized epidemic settings. CLINICAL TRIALS REGISTRATION NCT01864603.
Collapse
Affiliation(s)
- Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Catherine A Koss
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Mark Van Der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
| | - Maya L Petersen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
| |
Collapse
|
34
|
Sufriyana H, Husnayain A, Chen YL, Kuo CY, Singh O, Yeh TY, Wu YW, Su ECY. Comparison of Multivariable Logistic Regression and Other Machine Learning Algorithms for Prognostic Prediction Studies in Pregnancy Care: Systematic Review and Meta-Analysis. JMIR Med Inform 2020; 8:e16503. [PMID: 33200995 PMCID: PMC7708089 DOI: 10.2196/16503] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 06/22/2020] [Accepted: 10/24/2020] [Indexed: 02/06/2023] Open
Abstract
Background Predictions in pregnancy care are complex because of interactions among multiple factors. Hence, pregnancy outcomes are not easily predicted by a single predictor using only one algorithm or modeling method. Objective This study aims to review and compare the predictive performances between logistic regression (LR) and other machine learning algorithms for developing or validating a multivariable prognostic prediction model for pregnancy care to inform clinicians’ decision making. Methods Research articles from MEDLINE, Scopus, Web of Science, and Google Scholar were reviewed following several guidelines for a prognostic prediction study, including a risk of bias (ROB) assessment. We report the results based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were primarily framed as PICOTS (population, index, comparator, outcomes, timing, and setting): Population: men or women in procreative management, pregnant women, and fetuses or newborns; Index: multivariable prognostic prediction models using non-LR algorithms for risk classification to inform clinicians’ decision making; Comparator: the models applying an LR; Outcomes: pregnancy-related outcomes of procreation or pregnancy outcomes for pregnant women and fetuses or newborns; Timing: pre-, inter-, and peripregnancy periods (predictors), at the pregnancy, delivery, and either puerperal or neonatal period (outcome), and either short- or long-term prognoses (time interval); and Setting: primary care or hospital. The results were synthesized by reporting study characteristics and ROBs and by random effects modeling of the difference of the logit area under the receiver operating characteristic curve of each non-LR model compared with the LR model for the same pregnancy outcomes. We also reported between-study heterogeneity by using τ2 and I2. Results Of the 2093 records, we included 142 studies for the systematic review and 62 studies for a meta-analysis. Most prediction models used LR (92/142, 64.8%) and artificial neural networks (20/142, 14.1%) among non-LR algorithms. Only 16.9% (24/142) of studies had a low ROB. A total of 2 non-LR algorithms from low ROB studies significantly outperformed LR. The first algorithm was a random forest for preterm delivery (logit AUROC 2.51, 95% CI 1.49-3.53; I2=86%; τ2=0.77) and pre-eclampsia (logit AUROC 1.2, 95% CI 0.72-1.67; I2=75%; τ2=0.09). The second algorithm was gradient boosting for cesarean section (logit AUROC 2.26, 95% CI 1.39-3.13; I2=75%; τ2=0.43) and gestational diabetes (logit AUROC 1.03, 95% CI 0.69-1.37; I2=83%; τ2=0.07). Conclusions Prediction models with the best performances across studies were not necessarily those that used LR but also used random forest and gradient boosting that also performed well. We recommend a reanalysis of existing LR models for several pregnancy outcomes by comparing them with those algorithms that apply standard guidelines. Trial Registration PROSPERO (International Prospective Register of Systematic Reviews) CRD42019136106; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=136106
Collapse
Affiliation(s)
- Herdiantri Sufriyana
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Department of Medical Physiology, College of Medicine, University of Nahdlatul Ulama Surabaya, Surabaya, Indonesia
| | - Atina Husnayain
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Department of Biostatistics, Epidemiology, and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ya-Lin Chen
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chao-Yang Kuo
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Onkar Singh
- Bioinformatics Program, Taiwan International Graduate Program, Institute of Information Science, Academia Sinica, Taipei, Taiwan.,Institute of Biomedical Informatics, National Yang-Ming University, Taipei, Taiwan
| | - Tso-Yang Yeh
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Wei Wu
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Emily Chia-Yu Su
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| |
Collapse
|
35
|
Li R, Nordio F, Huang CC, Contreras C, Calderon R, Yataco R, Galea JT, Zhang Z, Becerra MC, Lecca L, Murray MB. Two Clinical Prediction Tools to Improve Tuberculosis Contact Investigation. Clin Infect Dis 2020; 71:e338-e350. [PMID: 31905406 PMCID: PMC7643741 DOI: 10.1093/cid/ciz1221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/02/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Efficient contact investigation strategies are needed for the early diagnosis of tuberculosis (TB) disease and treatment of latent TB infections. METHODS Between September 2009 and August 2012, we conducted a prospective cohort study in Lima, Peru, in which we enrolled and followed 14 044 household contacts of adults with pulmonary TB. We used information from a subset of this cohort to derive 2 clinical prediction tools that identify contacts of TB patients at elevated risk of progressing to active disease by training multivariable models that predict (1) coprevalent TB among all household contacts and (2) 1-year incident TB among adult contacts. We validated the models in a geographically distinct subcohort and compared the relative utilities of clinical decisions based on these tools to existing strategies. RESULTS In our cohort, 296 (2.1%) household contacts had coprevalent TB and 145 (1.9%) adult contacts developed incident TB within 1 year of index patient diagnosis. We predicted coprevalent disease using information that could be readily obtained at the time an index patient was diagnosed and predicted 1-year incident TB by including additional contact-specific characteristics. The area under the receiver operating characteristic curves for coprevalent TB and incident TB were 0.86 (95% confidence interval [CI], .83-.89]) and 0.72 (95% CI, .67-.77), respectively. These clinical tools give 5%-10% higher relative utilities than existing methods. CONCLUSIONS We present 2 tools that identify household contacts at high risk for TB disease based on reportable information from patient and contacts alone. The performance of these tools is comparable to biomarkers that are both more costly and less feasible than this approach.
Collapse
Affiliation(s)
- Ruoran Li
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Francesco Nordio
- TIMI Study Group, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Chuan-Chin Huang
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | | | | | - Jerome T Galea
- School of Social Work, College of Behavioral and Community Sciences, University of South Florida, Tampa, Florida, USA
| | - Zibiao Zhang
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonid Lecca
- Socios En Salud, Lima, Peru
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
36
|
Garg T, McMullen CK, Leo MC, O'Keeffe-Rosetti MC, Weinmann S, Nielsen ME. Predicting risk of multiple levels of recurrence and progression after initial diagnosis of nonmuscle-invasive bladder cancer in a multisite, community-based cohort. Cancer 2020; 127:520-527. [PMID: 33146913 DOI: 10.1002/cncr.33300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/08/2020] [Accepted: 10/05/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Nonmuscle-invasive bladder cancer (NMIBC) has heterogeneous recurrence and progression outcomes. Available risk calculators estimate recurrence and progression but do not predict the recurrence stage or grade, which may influence downstream treatment. The objective of this study was to predict risk-stratified NMIBC recurrence and progression based on recurrence tumor classification and grade. METHODS In total, 2956 patients with NMIBC (<T2) who were diagnosed at Kaiser Permanente Northwest and Geisinger from 1994 to 2015 were identified. Recurrences were annotated for tumor classification and grade. Four risk-stratified outcomes were created based on the tumor classification and grade of the recurrence: 1) any recurrence, 2) intermediate-risk recurrence (Ta high grade, carcinoma in situ, T1 low grade) or higher, 3) high-risk recurrence (T1 high grade) or progression (clinical T2), and 4) progression. Multivariable Cox proportional hazards regression was used to compute 1-year and 5-year risk estimates for each outcome based on initial tumor classification and grade. RESULTS Over a median follow-up of 29.4 months, there were 1062 recurrences (35.9%), including 111 progressions (3.8%). The adjusted hazard of high-risk recurrence or progression increased, depending on initial tumor classification and grade: The adjusted hazard ratio was 2.60 (95% CI, 1.62-4.15) for Ta high-grade tumors, 4.74 (95% CI, 3.01-7.47) for tumor in situ or Ta with carcinoma in situ, and 7.14 (95% CI, 4.97-10.26) T1 high-grade tumors. Using Ta high-grade tumors as an example, the 1-year and 5-year predicted rates of adjusted risk of a high-risk recurrence or progression were 4.4% and 7.9%, respectively. CONCLUSIONS The 1-year and 5-year predicted risk of high-risk recurrences and progression increased with higher tumor classification and grade at diagnosis. These granular risk estimates may further inform risk-stratified treatment and surveillance for patients with NMIBC.
Collapse
Affiliation(s)
- Tullika Garg
- Department of Urology, Geisinger, Danville, Pennsylvania.,Department of Population Health Sciences, Geisinger, Danville, Pennsylvania
| | - Carmit K McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Matthew E Nielsen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.,Department of Urology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.,Departments of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina
| |
Collapse
|
37
|
Xie F, Chakraborty B, Ong MEH, Goldstein BA, Liu N. AutoScore: A Machine Learning-Based Automatic Clinical Score Generator and Its Application to Mortality Prediction Using Electronic Health Records. JMIR Med Inform 2020; 8:e21798. [PMID: 33084589 PMCID: PMC7641783 DOI: 10.2196/21798] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Risk scores can be useful in clinical risk stratification and accurate allocations of medical resources, helping health providers improve patient care. Point-based scores are more understandable and explainable than other complex models and are now widely used in clinical decision making. However, the development of the risk scoring model is nontrivial and has not yet been systematically presented, with few studies investigating methods of clinical score generation using electronic health records. OBJECTIVE This study aims to propose AutoScore, a machine learning-based automatic clinical score generator consisting of 6 modules for developing interpretable point-based scores. Future users can employ the AutoScore framework to create clinical scores effortlessly in various clinical applications. METHODS We proposed the AutoScore framework comprising 6 modules that included variable ranking, variable transformation, score derivation, model selection, score fine-tuning, and model evaluation. To demonstrate the performance of AutoScore, we used data from the Beth Israel Deaconess Medical Center to build a scoring model for mortality prediction and then compared the data with other baseline models using the receiver operating characteristic analysis. A software package in R 3.5.3 (R Foundation) was also developed to demonstrate the implementation of AutoScore. RESULTS Implemented on the data set with 44,918 individual admission episodes of intensive care, the AutoScore-created scoring models performed comparably well as other standard methods (ie, logistic regression, stepwise regression, least absolute shrinkage and selection operator, and random forest) in terms of predictive accuracy and model calibration but required fewer predictors and presented high interpretability and accessibility. The nine-variable, AutoScore-created, point-based scoring model achieved an area under the curve (AUC) of 0.780 (95% CI 0.764-0.798), whereas the model of logistic regression with 24 variables had an AUC of 0.778 (95% CI 0.760-0.795). Moreover, the AutoScore framework also drives the clinical research continuum and automation with its integration of all necessary modules. CONCLUSIONS We developed an easy-to-use, machine learning-based automatic clinical score generator, AutoScore; systematically presented its structure; and demonstrated its superiority (predictive performance and interpretability) over other conventional methods using a benchmark database. AutoScore will emerge as a potential scoring tool in various medical applications.
Collapse
Affiliation(s)
- Feng Xie
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Bibhas Chakraborty
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Statistics and Applied Probability, National University of Singapore, Singapore, Singapore
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Benjamin Alan Goldstein
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
| | - Nan Liu
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- Institute of Data Science, National University of Singapore, Singapore, Singapore
| |
Collapse
|
38
|
Matsuo T, Hayashi K, Uehara Y, Mori N. The STAPH Score: A Predictor of Staphylococcus aureus as the Causative Microorganism of Native Vertebral Osteomyelitis. Open Forum Infect Dis 2020; 8:ofaa504. [PMID: 33447627 PMCID: PMC7790121 DOI: 10.1093/ofid/ofaa504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022] Open
Abstract
Background Staphylococcus aureus (SA) is the most common causative microorganism in native vertebral osteomyelitis (NVO). Few studies have compared the clinical features of NVO due to SA (SA-NVO) and NVO due to other organisms (NSA-NVO). This study was conducted to validate a predictive score for SA-NVO to facilitate NVO treatment without broad-spectrum antimicrobial agents. Methods This retrospective study compared the clinical features of patients with SA-NVO and NSA-NVO who were diagnosed from 2004 to 2019. Univariate associations were assessed using χ 2, Fisher's exact, or Mann-Whitney U test. Multivariable analysis was conducted using logistic regression. The optimal age cutoff point was determined by classification and regression tree analysis. Results Among 155 NVO patients, 98 (63.2%) had a microbiologically confirmed diagnosis: 40 (25.8%) with SA-NVO and 58 (37.4%) with NSA-NVO. Six predictors, either independently associated with SA-NVO or clinically relevant, were used to develop the STAPH prediction score: atopic dermatitis (Skin) (3 points); recent Trauma (2 points); Age < 67 years (1 point); Abscess (1 point); central venous Port catheter (2 points); and History of puncture (2 points). In a receiver operating characteristic analysis, the area under the curve was 0.84 (95% confidence interval, 0.76-0.91). The best cutoff point was 3. A score ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value of 58%, 84%, 84%, and 73%, respectively. Conclusions The STAPH score has relatively high specificity for use by clinicians to predict SA as the causative microorganism in patients with NVO until results of a confirmatory culture are available.
Collapse
Affiliation(s)
- Takahiro Matsuo
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
| | - Kuniyoshi Hayashi
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yuki Uehara
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan.,Department of Clinical Laboratory, St. Luke's International Hospital, Tokyo, Japan.,Department of Microbiology, Juntendo University Faculty of Medicine, Tokyo, Japan.,Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobuyoshi Mori
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
| |
Collapse
|
39
|
Abstract
Focusing on the current state of the art, this article (a) describes recent advances in the understanding of the pathogenesis of venous thromboembolism (VTE), (b) discusses current approaches for the prevention, diagnosis and treatment of VTE, (c) outlines the role of aspirin for VTE prevention and treatment, and (d) highlights the unmet needs in VTE management and describes novel approaches to address them.
Collapse
Affiliation(s)
- Noel C Chan
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
40
|
Kingston M, Griffiths R, Hutchings H, Porter A, Russell I, Snooks H. Emergency admission risk stratification tools in UK primary care: a cross-sectional survey of availability and use. Br J Gen Pract 2020; 70:e740-8. [PMID: 32958534 DOI: 10.3399/bjgp20X712793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022] Open
Abstract
Background Stratifying patient populations by risk of adverse events was believed to support preventive care for those identified, but recent evidence does not support this. Emergency admission risk stratification (EARS) tools have been widely promoted in UK policy and GP contracts. Aim To describe availability and use of EARS tools across the UK, and identify factors perceived to influence implementation. Design and setting Cross-sectional survey in UK. Method Online survey of 235 organisations responsible for UK primary care: 209 clinical commissioning groups (CCGs) in England; 14 health boards in Scotland; seven health boards in Wales; and five local commissioning groups (LCGs) in Northern Ireland. Analysis results are presented using descriptive statistics for closed questions and by theme for open questions. Results Responses were analysed from 171 (72.8%) organisations, of which 148 (86.5%) reported that risk tools were available in their areas. Organisations identified 39 different EARS tools in use. Promotion by NHS commissioners, involvement of clinical leaders, and engagement of practice managers were identified as the most important factors in encouraging use of tools by general practices. High staff workloads and information governance were identified as important barriers. Tools were most frequently used to identify individual patients, but also for service planning. Nearly 40% of areas using EARS tools reported introducing or realigning services as a result, but relatively few reported use for service evaluation. Conclusion EARS tools are widely available across the UK, although there is variation by region. There remains a need to align policy and practice with research evidence.
Collapse
|
41
|
van Hoorn F, Koster M, Naaktgeboren CA, Groenendaal F, Kwee A, Lamain-de Ruiter M, Franx A, Bekker MN. Prognostic models versus single risk factor approach in first-trimester selective screening for gestational diabetes mellitus: a prospective population-based multicentre cohort study. BJOG 2020; 128:645-654. [PMID: 32757408 PMCID: PMC7891327 DOI: 10.1111/1471-0528.16446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
Abstract
Objectives To evaluate whether (1) first‐trimester prognostic models for gestational diabetes mellitus (GDM) outperform the currently used single risk factor approach, and (2) a first‐trimester random venous glucose measurement improves model performance. Design Prospective population‐based multicentre cohort. Setting Thirty‐one independent midwifery practices and six hospitals in the Netherlands. Population Women recruited before 14 weeks of gestation without pre‐existing diabetes. Methods The single risk factor approach (presence of at least one risk factor: BMI ≥30 kg/m2, previous macrosomia, history of GDM, positive first‐degree family history of diabetes, non‐western ethnicity) was compared with the four best performing models in our previously published external validation study (Gabbay‐Benziv 2014, Nanda 2011, Teede 2011, van Leeuwen 2010) with and without the addition of glucose. Main outcome measures Discrimination was assessed by c‐statistics, calibration by calibration plots, added value of glucose by the likelihood ratio chi‐square test, net benefit by decision curve analysis and reclassification by reclassification plots. Results Of the 3723 women included, a total of 181 (4.9%) developed GDM. The c‐statistics of the prognostic models were higher, ranging from 0.74 to 0.78 without glucose and from 0.78 to 0.80 with glucose, compared with the single risk factor approach (0.72). Models showed adequate calibration, and yielded a higher net benefit than the single risk factor approach for most threshold probabilities. Teede 2011 performed best in the reclassification analysis. Conclusions First‐trimester prognostic models seem to outperform the currently used single risk factor approach in screening for GDM, particularly when glucose was added as a predictor. Tweetable abstract Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes. Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes.
Collapse
Affiliation(s)
- F van Hoorn
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mph Koster
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - C A Naaktgeboren
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F Groenendaal
- Department of Neonatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A Kwee
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - M Lamain-de Ruiter
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A Franx
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M N Bekker
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
42
|
Nye NS, Covey CJ, Pawlak M, Olsen C, Boden BP, Beutler AI. Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries. Sports Health 2020; 12:449-455. [PMID: 32762527 DOI: 10.1177/1941738120943540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. HYPOTHESIS A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. STUDY DESIGN Prospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated. RESULTS Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance. CONCLUSION The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. CLINICAL RELEVANCE For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.
Collapse
Affiliation(s)
| | - Carlton J Covey
- Travis Family Medicine Residency, Travis Air Force Base, California
| | - Mary Pawlak
- 559th Trainee Health Squadron, JBSA-Lackland, Texas
| | - Cara Olsen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barry P Boden
- The Orthopaedic Center, a Division of CAO, Rockville, Maryland
| | - Anthony I Beutler
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| |
Collapse
|
43
|
Uchida K, Yoshimura S, Sakakibara F, Kinjo N, Araki H, Saito S, Morimoto T. Simplified Prehospital Prediction Rule to Estimate the Likelihood of 4 Types of Stroke: The 7-Item Japan Urgent Stroke Triage (JUST-7) Score. PREHOSP EMERG CARE 2020; 25:465-474. [PMID: 32701385 DOI: 10.1080/10903127.2020.1800877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Prehospital prediction models to estimate the likelihood of several types of stroke (large vessel occlusion [LVO], intracranial hemorrhage [ICH], and subarachnoid hemorrhage [SAH], and other types of stroke) should be useful to transfer those with suspected stroke to appropriate facilities. We recently reported Japan Urgent Stroke Triage (JUST) score with 21 items had excellent predictive abilities, and we further tried to simplify the score with parsimonious items and comparable predictive abilities. METHODS We conducted historical and prospective multicenter cohort studies at 8 centers from June 2015 to March 2018. We developed the prediction rules with select variables from JUST score for LVO, ICH, SAH and other types of stroke in 2236 patients with suspected stroke in historical derivation cohort. We validated the developed prediction rules in 964 patients in prospective validation cohort. RESULTS There were 1150 stroke, including 235 LVO, 352 ICH, 107 SAH and 456 other types of stroke in the derivation cohort. We developed the scores with 7 items (high blood pressure, arrhythmia, conjugate deviation, headache, dysarthria, disturbance of consciousness, paralysis of upper limbs) and the developed scores had area under the receiver-operating curve (AUC) of 0.84 for any type of stroke, 0.89 for LVO, 0.79 for ICH, and 0.90 for SAH in the derivation cohort. There were 490 stroke, including 102 LVO, 138 ICH, 28 SAH and 222 other types of stroke in the validation cohort. The scores well discriminated these strokes in the validation cohort (AUC of 0.76 for any type of stroke; 0.81 for LVO, 0.73 for ICH, and 0.85 for SAH). CONCLUSIONS The simplified 7-item JUST (JUST-7) score had good predictive ability and can help healthcare providers to estimate the likelihood of different types of stroke and decide the referral hospital.
Collapse
|
44
|
Khalifa M, Magrabi F, Gallego Luxan B. Evaluating the Impact of the Grading and Assessment of Predictive Tools Framework on Clinicians and Health Care Professionals' Decisions in Selecting Clinical Predictive Tools: Randomized Controlled Trial. J Med Internet Res 2020; 22:e15770. [PMID: 32673228 PMCID: PMC7381257 DOI: 10.2196/15770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 03/05/2020] [Accepted: 05/14/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND While selecting predictive tools for implementation in clinical practice or for recommendation in clinical guidelines, clinicians and health care professionals are challenged with an overwhelming number of tools. Many of these tools have never been implemented or evaluated for comparative effectiveness. To overcome this challenge, the authors developed and validated an evidence-based framework for grading and assessment of predictive tools (the GRASP framework). This framework was based on the critical appraisal of the published evidence on such tools. OBJECTIVE The aim of the study was to examine the impact of using the GRASP framework on clinicians' and health care professionals' decisions in selecting clinical predictive tools. METHODS A controlled experiment was conducted through a web-based survey. Participants were randomized to either review the derivation publications, such as studies describing the development of the predictive tools, on common traumatic brain injury predictive tools (control group) or to review an evidence-based summary, where each tool had been graded and assessed using the GRASP framework (intervention group). Participants in both groups were asked to select the best tool based on the greatest validation or implementation. A wide group of international clinicians and health care professionals were invited to participate in the survey. Task completion time, rate of correct decisions, rate of objective versus subjective decisions, and level of decisional conflict were measured. RESULTS We received a total of 194 valid responses. In comparison with not using GRASP, using the framework significantly increased correct decisions by 64%, from 53.7% to 88.1% (88.1/53.7=1.64; t193=8.53; P<.001); increased objective decision making by 32%, from 62% (3.11/5) to 82% (4.10/5; t189=9.24; P<.001); decreased subjective decision making based on guessing by 20%, from 49% (2.48/5) to 39% (1.98/5; t188=-5.47; P<.001); and decreased prior knowledge or experience by 8%, from 71% (3.55/5) to 65% (3.27/5; t187=-2.99; P=.003). Using GRASP significantly decreased decisional conflict and increased the confidence and satisfaction of participants with their decisions by 11%, from 71% (3.55/5) to 79% (3.96/5; t188=4.27; P<.001), and by 13%, from 70% (3.54/5) to 79% (3.99/5; t188=4.89; P<.001), respectively. Using GRASP decreased the task completion time, on the 90th percentile, by 52%, from 12.4 to 6.4 min (t193=-0.87; P=.38). The average System Usability Scale of the GRASP framework was very good: 72.5% and 88% (108/122) of the participants found the GRASP useful. CONCLUSIONS Using GRASP has positively supported and significantly improved evidence-based decision making. It has increased the accuracy and efficiency of selecting predictive tools. GRASP is not meant to be prescriptive; it represents a high-level approach and an effective, evidence-based, and comprehensive yet simple and feasible method to evaluate, compare, and select clinical predictive tools.
Collapse
Affiliation(s)
- Mohamed Khalifa
- Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Farah Magrabi
- Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Blanca Gallego Luxan
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| |
Collapse
|
45
|
Kotsopoulos AMM, Vos P, Jansen NE, Bronkhorst EM, van der Hoeven JG, Abdo WF. Prediction Model for Timing of Death in Potential Donors After Circulatory Death (DCD III): Protocol for a Multicenter Prospective Observational Cohort Study. JMIR Res Protoc 2020; 9:e16733. [PMID: 32459638 PMCID: PMC7380979 DOI: 10.2196/16733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background Controlled donation after circulatory death (cDCD) is a major source of organs for transplantation. A potential cDCD donor poses considerable challenges in terms of identification of those dying within the predefined time frame of warm ischemia after withdrawal of life-sustaining treatment (WLST) to circulatory arrest. Several attempts have been made to develop models predicting the time between treatment withdrawal and circulatory arrest. This time window determines whether organ donation can occur and influences the quality of the donated organs. However, the selected patients used for these models were not always restricted to potential cDCD donors (eg, patients with cancer or severe infections were also included). This severely limits the generalizability of those data. Objective The objectives of this study are the following: (1) to develop a model predicting time to death within 60 minutes in potential cDCD patients; (2) to validate and update previous prediction models on time to death after WLST; (3) to determine timing and patient characteristics that are associated with prognostication and the decision-making process that leads to initiating end-of-life care; (4) to evaluate the impact of timing of family approach on organ donation approval; and (5) to assess the influence of variation in WLST processes on postmortem organ donor potential and actual postmortem organ donors. Methods In this multicenter observational prospective cohort study, all patients admitted to the intensive care unit of 3 university hospitals and 3 teaching hospitals who met the criteria of the cDCD protocol as defined by the Dutch Transplant Foundation were included. The target of enrolment was set to 400 patients. Previously developed models will be refitted in our data set. To further update previous prediction models, we will apply least absolute shrinkage and selection operator (LASSO) as a tool for efficient variable selection to develop the multivariable logistic regression model. Results This protocol was funded in August 2014 by the Dutch Transplant Foundation. We expect to have the results of this study in July 2020. Patient enrolment was completed in July 2018 and data collection was completed in April 2020. Conclusions This study will provide a robust multimodal prediction model, based on clinical and physiological parameters, that can predict time to circulatory arrest in cDCD donors. In addition, it will add valuable insight in the process of WLST in cDCD donors and will fill an important knowledge gap in this essential field of health care. Trial Registration ClinicalTrials.gov NCT04123275; https://clinicaltrials.gov/ct2/show/NCT04123275 International Registered Report Identifier (IRRID) DERR1-10.2196/16733
Collapse
Affiliation(s)
| | - Piet Vos
- Department of Intensive Care, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | | | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, Netherlands
| | | | - Wilson F Abdo
- Department of Intensive Care, Radboudumc, Nijmegen, Netherlands
| |
Collapse
|
46
|
Rabinovich A, Gu CS, Vedantham S, Kearon C, Goldhaber SZ, Gornik HL, Kahn SR. External validation of the SOX-PTS score in a prospective multicenter trial of patients with proximal deep vein thrombosis. J Thromb Haemost 2020; 18:1381-1389. [PMID: 32145144 PMCID: PMC7545582 DOI: 10.1111/jth.14791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/23/2020] [Accepted: 02/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Using data from the SOX Trial, we recently developed a clinical prediction model for occurrence of the postthrombotic syndrome (PTS) after proximal deep vein thrombosis (DVT), termed the SOX-PTS score. The score includes anatomical extent of DVT; body mass index; and baseline Villalta score. OBJECTIVE To externally validate the SOX-PTS score. METHODS Logistic regression analysis of data from the ATTRACT Trial that evaluated pharmacomechanical catheter directed thrombolysis in patients with proximal DVT. The primary outcome was the occurrence of PTS (defined as Villalta score ≥ 5) from 6 to 24 months after DVT. Secondary outcomes included moderate-severe PTS (Villalta scale ≥ 10) and severe PTS (Villalta scale ≥ 14). Predictive performance was assessed by discrimination and calibration. An updated score was evaluated in an exploratory analysis. RESULTS Six hundred and ninety-one ATTRACT patients were included, of whom 328 (47%) developed PTS. The c-statistic was 0.63; 95% confidence interval (CI) 0.59-0.67 for PTS. The model's performance appeared to be better for the outcomes moderate to severe PTS and severe PTS (c-statistic 0.67; 95% CI 0.62-0.72 for moderate-severe PTS and 0.70; 0.64-0.77 for severe PTS). An updated model with age as an additional variable performed similarly to the original model. CONCLUSION We externally validated the SOX-PTS score for estimating the risk of developing PTS, moderate to severe PTS, and severe PTS, in patients with proximal DVT. The score may be useful to predict PTS at the time of DVT diagnosis. Further external validation in different patient cohorts is required.
Collapse
Affiliation(s)
- Anat Rabinovich
- Thrombosis and Hemostasis unit, Hematology institute, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Chu-Shu Gu
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, MO, USA
| | - Clive Kearon
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Heather L. Gornik
- University Hospitals, Case Western Reserve University, Cleveland Ohio, USA
| | - Susan R. Kahn
- Jewish General Hospital, Lady Davis Institute, Center for Clinical Epidemiology, Montreal, QC, Canada
| |
Collapse
|
47
|
Quan AML, Stiell I, Perry JJ, Paradis M, Brown E, Gignac J, Wilson L, Wilson K. Mobile Clinical Decision Tools Among Emergency Department Clinicians: Web-Based Survey and Analytic Data for Evaluation of The Ottawa Rules App. JMIR Mhealth Uhealth 2020; 8:e15503. [PMID: 32012095 PMCID: PMC7016628 DOI: 10.2196/15503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The Canadian CT Head Rule (CCHR), the Canadian Transient Ischemic Attack (TIA) Score, and the Subarachnoid Hemorrhage (SAH) Rule have all previously demonstrated the potential to significantly standardize care and improve the management of patients in emergency departments (EDs). On the basis of user feedback, we believe that the addition of these rules to the Ottawa Rules App has the potential to increase the app's usability and user acceptability. OBJECTIVE This study aimed to evaluate the perceived usefulness, acceptability, and uptake of the enhanced Ottawa Rules App (which now includes CCHR, TIA, and SAH Rules) among ED clinicians (medical students, residents, nurses, and physicians). METHODS The enhanced Ottawa Rules App was publicly released for free on iOS and Android operating systems in November 2018. This study was conducted across 2 tertiary EDs in Ottawa, Canada. Posters, direct enrollment, snowball sampling, and emails were used for study recruitment. A 24-question Web-based survey was administered to participants via email, and this was used to determine user acceptability of the app and Technology Readiness Index (TRI) scores. In-app user analytics were collected to track user behavior, such as the number of app sessions, length of app sessions, frequency of rule use, and the date app was first opened. RESULTS A total of 77 ED clinicians completed the study, including 34 nurses, 12 residents, 14 physicians, and 17 medical students completing ED rotations. The median TRI score for this group was 3.38, indicating a higher than average propensity to embrace and adopt new technologies to accomplish goals in their work or daily lives. The majority of respondents agreed or strongly agreed that the app helped participants accurately carry out the clinical rules (56/77, 73%) and that they would recommend this app to their colleagues (64/77, 83%). Feedback from study participants suggested further expansion of the app-more clinical decision rules (CDRs) and different versions of the app tailored to the clinician role. Analysis and comparison of Google Analytics data and in-app data revealed similar usage behavior among study-enrolled users and all app users globally. CONCLUSIONS This study provides evidence that using the Ottawa Rules App (version 3.0.2) to improve and guide patient care would be feasible and widely accepted. The ability to verify self-reported user data (via a Web-based survey) against server analytics data is a notable strength of this study. Participants' continued app use and request for the addition of more CDRs warrant the further development of this app and call for additional studies to evaluate its feasibility and usability in different settings as well as assessment of clinical impact.
Collapse
Affiliation(s)
- Amanda My Linh Quan
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Ian Stiell
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
- University of Ottawa, Department of Emergency Medicine, Ottawa, ON, Canada
| | - Jeffrey J Perry
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
- University of Ottawa, Department of Emergency Medicine, Ottawa, ON, Canada
| | - Michelle Paradis
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Erica Brown
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Jordan Gignac
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Lindsay Wilson
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Kumanan Wilson
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| |
Collapse
|
48
|
Fujii T, Tanaka A, Katami H, Shimono R. Usefulness of the pediatric appendicitis score for assessing the severity of acute appendicitis in children. Pediatr Int 2020; 62:70-73. [PMID: 31654464 DOI: 10.1111/ped.14032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/25/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND We investigated relationships between the Pediatric Appendicitis Score (PAS) and pathological progression and disease severity in pediatric acute appendicitis. METHODS We retrospectively evaluated 72 children who underwent surgery for acute appendicitis. We divided them into groups: simple appendicitis (n = 28) or complicated appendicitis (n = 44). We compared the influence of age, body temperature, blood test findings, hospitalization period, number of complications, and PAS between the groups. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the PAS for diagnosing complicated appendicitis. A receiver operating characteristic curve was constructed to evaluate the cut-off value for diagnosing complicated appendicitis. To assess the severity of acute appendicitis, we divided the patients into groups according to that cut-off value. RESULTS There were statistically significant differences in the PAS between simple appendicitis and complicated appendicitis (5.8 versus 7.9). The receiver operating characteristic curve indicated a PAS cut-off value of 8. A PAS ≥ 8 had a sensitivity of 73%, a specificity of 89%, a positive predictive value of 91%, and a negative predictive value of 68%. A PAS ≥ 8 was associated with significantly longer hospitalization and more complications than a PAS < 8. CONCLUSIONS The PAS may be associated with pathological progression and disease severity in appendicitis.
Collapse
Affiliation(s)
- Takayuki Fujii
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| | - Aya Tanaka
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| | - Hiroto Katami
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| | - Ryuichi Shimono
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| |
Collapse
|
49
|
Alali AS, Temkin N, Barber J, Pridgeon J, Chaddock K, Dikmen S, Hendrickson P, Videtta W, Lujan S, Petroni G, Guadagnoli N, Urbina Z, Chesnut RM. A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury. J Neurosurg 2019; 131:612-619. [PMID: 30265194 DOI: 10.3171/2018.4.jns173166] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension. METHODS Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT). RESULTS The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%-98.3%), a specificity of 42.3% (95% CI 31.7%-53.6%), a positive predictive value of 55.5% (95% CI 50.7%-60.2%), and a negative predictive value of 90% (95% CI 77.1%-96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort. CONCLUSIONS A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).
Collapse
Affiliation(s)
- Aziz S Alali
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Nancy Temkin
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,Departments of2Biostatistics
| | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Jim Pridgeon
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Kelley Chaddock
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Sureyya Dikmen
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,3Rehabilitation Medicine, and
| | - Peter Hendrickson
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Walter Videtta
- 4Hospital Nacional Profesor Alejandro Posadas, Buenos Aire
| | - Silvia Lujan
- 5Hospital de Emergencias Dr. Clemente Alvarez, Rosario
| | | | - Nahuel Guadagnoli
- 6Hospital Emergencia, Hospital Privado de Rosario, Rosario, Argentina; and
| | | | - Randall M Chesnut
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,8Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
50
|
Sanfilippo KM, Luo S, Wang TF, Fiala M, Schoen M, Wildes TM, Mikhael J, Kuderer NM, Calverley DC, Keller J, Thomas T, Carson KR, Gage BF. Predicting venous thromboembolism in multiple myeloma: development and validation of the IMPEDE VTE score. Am J Hematol 2019; 94:1176-1184. [PMID: 31379000 PMCID: PMC7058359 DOI: 10.1002/ajh.25603] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 07/29/2019] [Indexed: 01/06/2023]
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality among patients with multiple myeloma (MM). The International Myeloma Working Group (IMWG) developed guidelines recommending primary thromboprophylaxis, in those identified at high-risk of VTE by the presence of risk factors. The National Comprehensive Cancer Network (NCCN) has adopted these guidelines; however, they lack validation. We sought to develop and validate a risk prediction score for VTE in MM and to evaluate the performance of the current IMWG/NCCN guidelines. Using 4446 patients within the Veterans Administration Central Cancer Registry, we used time-to-event analyses to develop a risk score for VTE in patients with newly diagnosed MM starting chemotherapy. We externally validated the score using the Surveillance, Epidemiology, End Results (SEER)-Medicare database (N = 4256). After identifying independent predictors of VTE, we combined the variables to develop the IMPEDE VTE score (Immunomodulatory agent; Body Mass Index ≥25 kg/m2 ; Pelvic, hip or femur fracture; Erythropoietin stimulating agent; Dexamethasone/Doxorubicin; Asian Ethnicity/Race; VTE history; Tunneled line/central venous catheter; Existing thromboprophylaxis). The score showed satisfactory discrimination in the derivation cohort, c-statistic = 0.66. Risk of VTE significantly increased as score increased (hazard ratio 1.20, P = <.0001). Within the external validation cohort, IMPEDE VTE had a c-statistic of 0.64. For comparison, when evaluating the performance of the IMWG/NCCN guidelines, the c-statistic was 0.55. In summary, the IMPEDE VTE score outperformed the current IMWG/NCCN guidelines and could be considered as the new standard risk stratification for VTE in MM.
Collapse
Affiliation(s)
- Kristen M Sanfilippo
- Division of Hematology/Oncology, Veterans Administration St. Louis Health Care System, St. Louis, Missouri
- Division of Hematology, Washington University School of Medicine Saint Louis, St. Louis, Missouri
| | - Suhong Luo
- Division of Hematology/Oncology, Veterans Administration St. Louis Health Care System, St. Louis, Missouri
| | - Tzu-Fei Wang
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Mark Fiala
- Division of Oncology, Washington University School of Medicine Saint Louis, St. Louis, Missouri
| | - Martin Schoen
- Division of Hematology/Oncology, Saint Louis University, St. Louis, Missouri
| | - Tanya M Wildes
- Division of Oncology, Washington University School of Medicine Saint Louis, St. Louis, Missouri
| | - Joseph Mikhael
- Applied Cancer Research and Drug Discovery,Translational Genomics Research Institute (TGen), City of Hope Cancer Center, Duarte, California
| | - Nicole M Kuderer
- Advanced Cancer Research Group, University of Washington, Seattle, Washington
| | - David C Calverley
- Division of Hematology/Oncology, Veterans Administration Portland Health Care System, Portland, Oregon
| | - Jesse Keller
- Division of Hematology/Oncology, Veterans Administration St. Louis Health Care System, St. Louis, Missouri
- Division of Hematology/Oncology, Saint Louis University, St. Louis, Missouri
| | - Theodore Thomas
- Division of Hematology/Oncology, Veterans Administration St. Louis Health Care System, St. Louis, Missouri
| | - Kenneth R Carson
- Division of Hematology/Oncology, Veterans Administration St. Louis Health Care System, St. Louis, Missouri
- Flatiron Health, New York, New York
| | - Brian F Gage
- Division of General Medical Sciences, Washington University School of Medicine Saint Louis, St. Louis, Missouri
| |
Collapse
|