Prediction of malignancy in Main duct or Mixed-type Intraductal Papillary Mucinous Neoplasms of the Pancreas

BACKGROUND/PURPOSE

Surgical indications of main-duct involved intraductal papillary mucinous neoplasm (IPMN), especially for main pancreatic duct (MPD) of 5-9mm, remain controversial. We aimed to predict malignancy risk of main-duct involved IPMN.

METHODS

Total 258 patients with main-duct involved IPMN between 2000 and 2017 in our institute were retrospectively analyzed. Main-duct IPMN was classified into segmental and diffuse type by dilated MPD pattern. Clinicopathologic features and predictive factors for malignancy were analyzed.

RESULTS

Among 258, 47 and 211 had pure main-duct (segmental:27, diffuse-type:20) and mixed-type. Malignant IPMN presented higher in main-duct type (66.0%) compared to mixed-type (46.9%). The diffuse-type (72.2%) had more invasive carcinoma than the segmental type (40.7%). Invasive IPMN risk increased proportionally to the MPD diameter (5≤MPD <10mm vs. 10≤MPD<15mm vs. MPD≥15mm; 23.4% vs. 40.0% vs. 48.6%). Symptoms, elevated serum carbohydrate antigen, MPD ≥10mm, mural nodule, thickened wall, and distal atrophy were independent predictive factors for malignancy. Patients with MPD of 5-9mm with at least one predictive factor had 35.0% of malignancy risk.

CONCLUSIONS

The invasive IPMN risk was different according to the dilated main-duct pattern. Patients with main-duct type, diffuse-type, MPD ≥10mm, and MPD 5-9mm with at least one predictive factor should be candidates for immediate surgery.

Development and validation of nomogram to predict severe illness requiring intensive care follow up in hospitalized COVID-19 cases

BACKGROUND

Early identification of severe COVID-19 patients who will need intensive care unit (ICU) follow-up and providing rapid, aggressive supportive care may reduce mortality and provide optimal use of medical resources. We aimed to develop and validate a nomogram to predict severe COVID-19 cases that would need ICU follow-up based on available and accessible patient values.

METHODS

Patients hospitalized with laboratory-confirmed COVID-19 between March 15, 2020, and June 15, 2020, were enrolled in this retrospective study with 35 variables obtained upon admission considered. Univariate and multivariable logistic regression models were constructed to select potential predictive parameters using 1000 bootstrap samples. Afterward, a nomogram was developed with 5 variables selected from multivariable analysis. The nomogram model was evaluated by Area Under the Curve (AUC) and bias-corrected Harrell's C-index with 95% confidence interval, Hosmer-Lemeshow Goodness-of-fit test, and calibration curve analysis.

RESULTS

Out of a total of 1022 patients, 686 cases without missing data were used to construct the nomogram. Of the 686, 104 needed ICU follow-up. The final model includes oxygen saturation, CRP, PCT, LDH, troponin as independent factors for the prediction of need for ICU admission. The model has good predictive power with an AUC of 0.93 (0.902-0.950) and a bias-corrected Harrell's C-index of 0.91 (0.899-0.947). Hosmer-Lemeshow test p-value was 0.826 and the model is well-calibrated (p = 0.1703).

CONCLUSION

We developed a simple, accessible, easy-to-use nomogram with good distinctive power for severe illness requiring ICU follow-up. Clinicians can easily predict the course of COVID-19 and decide the procedure and facility of further follow-up by using clinical and laboratory values of patients available upon admission.

Short-Term Lung Function Changes and Predictors of Progressive Systemic Sclerosis-Related Interstitial Lung Disease

BACKGROUND

Systemic sclerosis (SSc) involves multiple organ systems and has the highest mortality among connective tissue diseases. Interstitial lung disease is the most common cause of death among SSc patients and requires closer studies and follow-ups. This study aimed to identify lung function changes and predictors of progressive disease in systemic sclerosis-related interstitial lung disease (SSc-ILD).

METHODS

A retrospective study extracted SSc patients from an electronic database January 2002-July 2019. Eligible cases were SSc patients >age 15 diagnosed with SSc-ILD. Factors associated with progressive disease were analyzed by univariate and multivariate logistic regression analyses.

RESULTS

Seventy-eight SSc-ILD cases were enrolled. Sixty-five patients (83.3%) were female, with mean age of 44.7±14.4, and 50 (64.1%) were diffuse type SSc-ILD. Most SSc-ILD patients had crackles (75.6%) and dyspnea on exertion (71.8%), and 19.2% of the SSc-ILD patients had no abnormal respiratory symptoms but had abnormal chest radiographic findings. The most common diagnosis of SSc-ILD patients was non-specific interstitial pneumonia (43.6%). The lung function values of diffusing capacity of the lung for carbon monoxide (DLCO) and DLCO per unit alveolar volume declined in progressive SSc-ILD during a 12-month follow-up. Male and no previous aspirin treatment were the two significant predictive factors of progressive SSc-ILD with adjusted odds ratios of 5.72 and 4.99, respectively.

CONCLUSION

This present study showed that short-term lung function had declined during the 12-month follow-up in progressive SSc-ILD. The predictive factors in progressive SSc-ILD were male sex and no previous aspirin treatment. Close follow-up of the pulmonary function tests is necessary for early detection of progressive disease.

Risk of schizophrenia in relatives of individuals affected by schizophrenia: A meta-analysis

A meta-analysis was conducted to estimate schizophrenia incidence in first-degree relatives (FDRs) of probands diagnosed with schizophrenia. The aim was to inform future schizophrenia research and improve accuracy of risk communication to patients. Schizophrenia risk in FDRs with 1 or 2 probands with schizophrenia was investigated by conducting a systematic review of cohort and case-control studies with the following criteria: published between 1977 and 2018; reported odds ratios (OR), relative risk (RR) or sufficient raw data to calculate OR or RR; used appropriate diagnostic criteria; and reported systematic proband recruitment and ascertainment of relatives. Studies were obtained via EMBASE and MEDLINE electronic database searches. From an initial 5755 articles, 19 met the inclusion criteria. Mean effect sizes across studies were estimated using random effects methods. Estimates for schizophrenia risk were OR = 7.69 (95% CI 5.11-11.56) for FDRs of one proband with schizophrenia compared to healthy control probands, increasing to OR = 11.11 (95% CI = 1.45-85.02) for FDRs with two probands with schizophrenia. These findings support the existing literature suggesting significant genetic liability for schizophrenia. The results can be used to educate individuals with a family history of schizophrenia about their risk.

Comparison of the International Association of Diabetes in Pregnancy Study Group Criteria with the Old American Diabetes Association Criteria for Diagnosis of Gestational Diabetes Mellitus

OBJECTIVES

This study aimed to assess the prevalence of gestational diabetes mellitus (GDM) based on two sets of criteria, namely the old criteria suggested in 2009 by the American Diabetes Association and new criteria of the International Association of Diabetes in Pregnancy Study Group. We also evaluated the predictive power of the risk factors of GDM.

METHODS

Pregnant women from three outpatient clinics in Tehran, Iran, participated in this cross-sectional observational study. During the first perinatal visit, demographic data, medical histories, weight, and height of mothers were recorded. The mother's fasting glucose and glycosylated hemoglobin were measured. An oral glucose tolerance test was also performed. The prevalence of GDM, based on the two criteria, was estimated and its predictive factors were investigated.

RESULTS

Of 1,117 pregnant women, 156 (15.6%) and 71 (7.1%) patients had GDM based on the new and old criteria, respectively. Multivariate analysis showed that older age at pregnancy (OR = 1.05; 95% CI: 1.006 - 1.107; P = 0.03), higher body mass index (OR = 1.2; 95% CI: 1.15 - 1.3; P < 0.001), family history of diabetes (OR = 1.97; 95% CI: 1.11 - 3.5; P = 0.02), and history of macrosomia (OR = 7.8; 95% CI: 1.96 - 30.9; P = 0.004) were independent predictive factors for GDM.

CONCLUSIONS

Using the new criteria, the prevalence of GDM increases by 2.2 folds compared to the old criteria. Several factors can independently predict the occurrence of GDM.

Maintenance Treatment Of Eosinophilic Esophagitis With Swallowed Topical Steroids Alters Disease Course Over A 5-Year Follow-up Period In Adult Patients

BACKGROUND & AIMS

Although swallowed topical corticosteroids (STCs) are effective in inducing remission of active eosinophilic esophagitis (EoE), there are few data on maintenance of long-term remission. We evaluated the long-term effectiveness of STC therapy for adults with EoE.

METHODS

We performed a retrospective study using the Swiss EoE database. We analyzed data on 229 patients with EoE treated with STCs (175 male; mean age at diagnosis, 39±15 years; median time until diagnosis, 6 years) from 2000 through 2014. Patients were followed for a median of 5 years (interquartile range [IQR], 3-7 years). We collected data from 819 follow-up visits on clinical, endoscopic and histological disease characteristics. The primary endpoint was proportions of clinical, endoscopic, and histological remission in all patients and groups, based on the status and duration of STC treatment.

RESULTS

Patients were taking STCs at 336 of the follow-up visits (41.0% of visits). The median duration of STC use before a follow-up visit was 347 days (IQR, 90-750 days) corresponding to 677 doses (IQR, 280-1413 doses) of 0.25 mg each. At the visits, higher proportions of patients who were still taking STCs were in clinical remission (31.0%) compared to patients not taking STCs (4.5%) (P <.001), as well as endoscopic remission (48.8% vs 17.8%; P < .001), histologic remission (44.8% vs 10.1%; P < .001), and complete remission (16.1% vs 1.3%; P < .001). Higher cumulative doses of STCs and longer durations of treatment were associated with higher proportions of clinical and complete remission. No dysplasia or mucosal atrophy was detected. Esophageal candidiasis was observed at 2.7% of visits in patients taking STCs.

CONCLUSION

In an analysis of data from the Swiss EoE database, we found maintenance therapy with STCs to achieve complete remission at 16.1% of follow-up visits, which was higher than in patients receiving no treatment (1.3%). Given the good safety profile of low-dose STC, we advocate for a prolonged treatment. Dose-finding trials are needed to achieve higher remission rates.

Multi-level obstruction in obstructive sleep apnoea: prevalence, severity and predictive factors

OBJECTIVES

To characterise multi-level obstruction in terms of prevalence, obstructive sleep apnoea severity and predictive factors, and to collect epidemiological data on upper airway morphology in obstructive sleep apnoea patients.

METHODS

Retrospective review of 250 obstructive sleep apnoea patients.

RESULTS

On clinical examination, 171 patients (68.4 per cent) had multi-level obstruction, 49 (19.6 per cent) had single-level obstruction and 30 (12 per cent) showed no obstruction. Within each category of obstructive sleep apnoea severity, multi-level obstruction was more prevalent. Multi-level obstruction was associated with severe obstructive sleep apnoea (more than 30 events per hour) (p = 0.001). Obstructive sleep apnoea severity increased with the number of obstruction sites (correlation coefficient = 0.303, p < 0.001). Multi-level obstruction was more likely in younger (p = 0.042), male (p = 0.045) patients, with high body mass index (more than 30 kg/m2) (p < 0.001). Palatal (p = 0.004), tongue (p = 0.026) and lateral pharyngeal wall obstructions (p = 0.006) were associated with severe obstructive sleep apnoea.

CONCLUSION

Multi-level obstruction is more prevalent in obstructive sleep apnoea and is associated with increased severity. Obstruction at certain anatomical levels contributes more towards obstructive sleep apnoea severity.

Early and Mid-term Outcomes in Female Patients Undergoing Isolated Conventional Coronary Surgery

Introduction: Several observational studies comparing outcomes between female and male patients after coronary artery bypass grafting (CABG) have shown that operative mortality rate is higher among female patients than in male patients. However, some conflicting studies report that early mortality among female patients is equivalent to that among male patients. We investigated predictive factors of morbidity, mortality and survival in female patients undergoing isolated conventional CABG.

Methods: Between January 2002 and December 2009, 1657 patients underwent isolated conventional CABG in our clinic. 21.8% (n=361) of patients were female and 78.2% (n=1296) males.

Results: Advanced age (P<0.0001), hypertension (P<0.0001), diabetes (P<0.0001), and hyperlipidemia (P<0.0001) were the independent predictive factors among female patients. Mean in-hospital mortality rates were 5.8% and 3.2%; for females and males, respectively (P=0.029). Prolonged ventilatory support (P=0.009) and postoperative atrial fibrillation (P=0.049) were the independent predictive factors of in-hospital mortality in female patients. Cardiopulmonary bypass time (P=0.041), prolonged ventilatory support (P<0.0001), and postoperative atrial fibrillation (P=0.031) were the independent predictive factors of in-hospital mortality in male patients. Mean follow-up was 47.51±25.06 months and 48.42±25.21 months among female and male patients (P=0.820). In follow-up, mortality rate was 6.1% (n=22) among female patients and 4.6% (n=60) among male patients (P=0.272). Left internal thoracic artery (LITA) usage (P=0.001) was the independent predictive factor of survival in female patients.

Conclusion: In-hospital mortality rate was higher in female patients. Length of ICU and hospital stay, and mid-term survival was similar between female and male patients.

Chronic kidney disease, hemodynamic instability, and endoscopic high-risk appearance are associated with 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding

The results of studies that evaluated predictive factors for rebleeding in non-variceal upper gastrointestinal bleeding are inconsistent. The aim of this study was to investigate predictive factors for 30-day rebleeding in these patients. A consecutive 312 patients presenting symptoms and signs of gastrointestinal bleeding were enrolled in this prospective, observational study. Clinical and demographic characteristics and endoscopic findings were evaluated for potential factors associated with 30-day rebleeding using logistic regression analysis. Overall, 176 patients were included (male, 80.1%; mean age, 59.7±16.0 yr). Rebleeding within 7 and 30 days occurred in 21 (11.9%) and 27 (15.3%) patients, respectively. We found that chronic kidney disease (CKD) (OR, 10.29; 95% CI, 2.84-37.33; P<0.001), tachycardia (pulse>100 beats/min) during the admission (OR, 3.79; 95% CI, 1.25-11.49; P=0.019), and Forrest classes I, IIa, and IIb (OR, 6.14; 95% CI, 1.36-27.66; P=0.018) were significant independent predictive factors for 30-day rebleeding. However, neither Rockall nor Blatchford scores showed statistically significant relationships with 30-day rebleeding in a multivariate analysis. CKD, hemodynamic instability during hospitalization, and an endoscopic high-risk appearance are significantly independent predictors of 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding. These factors may be useful for clinical management of such patients.

A scoring system for prediction of lateral neck node metastasis from papillary thyroid cancer

Lateral neck node metastasis is an important prognostic factor in thyroid carcinoma. We developed a scoring system for use in prediction of lateral neck node metastasis from papillary thyroid cancer. In this study, 161 consecutive patients were included in the training data set. This scoring system, named the Yonsei Estimated Value (YEV) for lymph node metastasis in papillary thyroid cancer, was developed on the basis of results from multivariate logistic regression analysis of preoperative clinical and radiologic data. Sixty eight consecutive patients were included for testing of the validity of the scoring system. The equation for prediction of lateral neck node metastasis was follows:YEV (Yonsei Estimated Value) = 1/(1+X)X = Exp (5.333-[0.902 × sex]+[0.036 × age]-[1.020 × tumor size]-[0.177 × lymph node size]-[0.032 × lymph node density])When the YEV was 0.3 or more, the probability of lateral neck node metastasis was 79.0%, with sensitivity of 76.3%, specificity of 69.8%, positive predictive value of 56.7%, and negative predictive value of 85.1% in the training set. When fine needle aspiration biopsy for suspicious lateral neck nodes is not possible, or the results are inadequate, our scoring system for prediction of lateral neck node metastasis can be helpful in optimization of the surgical extent for each patient.