677 Quick, Simple and just as Effective – Comparing PM:L3 Ratio to NELA, P-POSSUM and NSQIP Scores for Emergency Laparotomy

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
J Y Ming ◽  
M Holmes ◽  
P Pockney ◽  
J Gani
Keyword(s):  
Risk Assessment ◽  
Assessment Tool ◽  
Emergency Laparotomy ◽  
Routine Practice ◽  
Mortality Risks ◽  
Risk Assessment Models ◽  
Psoas Muscles ◽  
Discrete Area ◽  
Risk Patients ◽  
Axial Ct

Abstract Aim Multiple tools (NELA, P-POSSUM, ACS-NSQIP) are available to assess mortality risks in patients requiring emergency laparotomy(1–3), but they are time-consuming to perform and have had limited uptake in routine clinical practice in many countries(4). Simpler measures, including psoas muscle:L3 vertebrae (PM:L3) ratio(5,6), may be useful alternates. This measure is quick to perform, requiring no special skills or equipment apart from basic CT viewing software. Method We performed an analysis on all patients in the Hunter Emergency Laparotomy Audit (HELA) database, from January 2016 to December 2017. HELA is a retrospective review of all emergency laparotomy undertaken in a discrete area in NSW, Australia. Patients with an available CT abdomen were included (N = 500/562). A single slice axial CT image at the L3 endplate level was analysed using ImageJ® software to measure the area of L3 and bilateral psoas muscles. This can be done using normal PACS software in routine practice. Results PM:L3 ratios in this cohort have a mean of 1.082 (95%CI 1.042-1.122; range 0.141-3.934). PM:L3 ratio is significantly lower (p < 0.00001) in those patients who did not survive beyond 30 days (mean 0.865 [95% CI 0.746-0.984 ]) and 90 days (mean 0.888 [95%CI 0.768-1.008]) compared to patients that survived these periods (30 day mean 1.106 [95% vs. 1.033-1.179], 90 day mean 1.112 [95% CI 1.070-1.154]) . These associations are similar to those calculated by established risk assessment models. Conclusions PM:L3 ratio is a reliable, quick and easy risk assessment tool to identify high risk patients undergoing emergency laparotomy.

O20 Quick, simple and just as effective—comparing pm: L3 ratio to NELA, P-POSSUM and NSQIP scores in assessing mortality risk for emergency laparotomy

2021 ◽  
Vol 108 (Supplement_5) ◽  
Author(s):  
J Y Ming ◽  
M Holmes ◽  
P Pockney ◽  
J Gani
Keyword(s):  
Risk Assessment ◽  
High Risk ◽  
Assessment Tool ◽  
Risk Assessment Tool ◽  
Emergency Laparotomy ◽  
Routine Practice ◽  
High Risk Patients ◽  
Acs Nsqip ◽  
Psoas Muscles ◽  
Risk Patients

Abstract Introduction Multiple tools (NELA, P-POSSUM, ACS-NSQIP) are available to assess mortality risks in patients requiring emergency laparotomy(1–3), but they are time-consuming to perform and have had limited uptake in routine clinical practice in many countries(4). Simpler measures, including psoas muscle: L3 vertebrae (PM: L3) ratio(5,6), may be useful alternates. This measure is quick to perform, requiring no special skills or equipment apart from basic CT viewing software. Method We performed an analysis on all patients in the Hunter Emergency Laparotomy Audit (HELA) database, from January 2016 to December 2017. HELA is a retrospective review of all emergency laparotomy undertaken in a discrete area in NSW, Australia. Patients with an available CT abdomen were included (N = 500/562). A single slice axial CT image at the L3 endplate level was analysed using ImageJ® software to measure the area of L3 and bilateral psoas muscles. This can be done using normal PACS software in routine practice. Result PM: L3 ratios in this cohort have a mean of 1.082 (95%CI 1.042–1.122; range 0.141–3.934). PM: L3 ratio is significantly lower (P < 0.00001) in those patients who did not survive beyond 30 days (mean 0.865 [95% CI 0.746–0.984]) and 90 days (mean 0.888 [95%CI 0.768–1.008]) compared to patients that survived these periods (30 day mean 1.106 [95% vs. 1.033–1.179], 90 day mean 1.112 [95% CI 1.070–1.154]). These associations are similar to those calculated by established risk assessment models. Conclusion PM: L3 ratio is a reliable, quick and easy risk assessment tool to identify high risk patients undergoing emergency laparotomy. Take-home Message PM: L3 ratio is a reliable, quick and easy risk assessment tool to identify high risk patients undergoing emergency laparotomy. It is comparable to NELA, P-POSSUM and ACS-NSQIP.

678 Can patients have their old life back? Using PM:L3 ratio to predict discharge destination of emergency laparotomy survivors

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
J Y Ming ◽  
M Holmes ◽  
J Gani ◽  
P Pockney
Keyword(s):  
Assessment Tool ◽  
Care Facility ◽  
Psoas Muscle ◽  
Emergency Laparotomy ◽  
Ct Image ◽  
Discharge Destination ◽  
Skeletal Muscle Index ◽  
Psoas Muscles ◽  
Discrete Area ◽  
Axial Ct

Abstract Aim Psoas muscle:L3 vertebra (PM:L3) ratio is a relatively new risk assessment tool for emergency laparotomy(1,2) based upon the proven concept that sarcopenia – as diagnosed by low skeletal muscle index(3–6), psoas muscle density(7–9) or total psoas area(10–13) in a single axial slice CT image – correlates with increasing risks of bad outcomes in surgery. This study looks into the association between PM:L3 ratio of emergency laparotomy patients from home and their discharge destination. Method We performed an analysis on patients in the Hunter Emergency Laparotomy Audit (HELA) database, from January 2016 to December 2017. HELA is a retrospective review of all emergency laparotomy undertaken in a discrete area in NSW, Australia. All patients admitted from home, survived to be discharged from hospital and had an available CT abdomen were included (N = 433/562). A single slice axial CT image at the L3 endplate level was analysed using ImageJ® software to measure the area of L3 and bilateral psoas muscles. Results PM:L3 ratio is significantly lower in the group of patient discharged to a care facility than the group discharging back to their previous home residence (mean 0.951 vs. mean 1.128, p < 0.001). Upon further analysis, the PM:L3s are divided into quartiles and stratified by sex. There is an association between lower PM:L3 and risk of discharging into a care facility (Q1 22.45%, Q2 19.59%, Q3 19.10%, Q4 5.71%). Conclusions PM:L3 ratio can predict the discharge destination of patients undergoing emergency laparotomy.

scholarly journals Initial Experience in Predicting the Risk of Hospitalization of 496 Outpatients with COVID-19 Using a Telemedicine Risk Assessment Tool

2020 ◽  
Author(s):  
James B O'Keefe ◽  
Elizabeth J Tong ◽  
Thomas H Taylor ◽  
Ghazala D Datoo O'Keefe ◽  
David C Tong
Keyword(s):  
Risk Assessment ◽  
Assessment Tool ◽  
Cox Regression ◽  
Risk Assessment Tool ◽  
Individual Risk ◽  
Tier 2 ◽  
Tier 1 ◽  
Risk Patients ◽  
Tier 3

Objective: To determine whether a risk prediction tool developed and implemented in March 2020 accurately predicts subsequent hospitalizations. Design: Retrospective cohort study, enrollment from March 24 to May 26, 2020 with follow-up calls until hospitalization or clinical improvement (final calls until June 19, 2020) Setting: Single center telemedicine program managing outpatients from a large medical system in Atlanta, Georgia Participants: 496 patients with laboratory-confirmed COVID-19 in isolation at home. Exclusion criteria included: (1) hospitalization prior to telemedicine program enrollment, (2) immediate discharge with no follow-up calls due to resolution. Exposure: Acute COVID-19 illness Main Outcome and Measures: Hospitalization was the outcome. Days to hospitalization was the metric. Survival analysis using Cox regression was used to determine factors associated with hospitalization. Results: The risk-assessment rubric assigned 496 outpatients to risk tiers as follows: Tier 1, 237 (47.8%); Tier 2, 185 (37.3%); Tier 3, 74 (14.9%). Subsequent hospitalizations numbered 3 (1%), 15 (7%), and 17 (23%) and for Tiers 1-3, respectively. From a Cox regression model with age ≥ 60, gender, and self-reported obesity as covariates, the adjusted hazard ratios using Tier 1 as reference were: Tier 2 HR=3.74 (95% CI, 1.06-13.27; P=0.041); Tier 3 HR=10.87 (95% CI, 3.09-38.27; P<0.001). Tier was the strongest predictor of time to hospitalization. Conclusions and Relevance: A telemedicine risk assessment tool prospectively applied to an outpatient population with COVID-19 identified both low-risk and high-risk patients with better performance than individual risk factors alone. This approach may be appropriate for optimum allocation of resources.

scholarly journals Successful Model for Guideline Implementation to Prevent Cancer-Associated Thrombosis: Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic

2020 ◽  
Vol 16 (9) ◽  
pp. e868-e874 ◽  
Author(s):  
Chris E. Holmes ◽  
Steven Ades ◽  
Susan Gilchrist ◽  
Daniel Douce ◽  
Karen Libby ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Assessment Tool ◽  
Guideline Implementation ◽  
Vte Prophylaxis ◽  
Successful Model ◽  
Venous Thromboembolism Prevention ◽  
Risk Patients ◽  
Cancer Associated Thrombosis

PURPOSE: Guidelines recommend venous thromboembolism (VTE) risk assessment in outpatients with cancer and pharmacologic thromboprophylaxis in selected patients at high risk for VTE. Although validated risk stratification tools are available, < 10% of oncologists use a risk assessment tool, and rates of VTE prophylaxis in high-risk patients are low in practice. We hypothesized that implementation of a systems-based program that uses the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations would increase VTE risk assessment rates in patients initiating outpatient chemotherapy. PATIENTS AND METHODS: Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTEPACC) was a multidisciplinary program implemented by nurses, oncologists, pharmacists, hematologists, advanced practice providers, and quality partners. We prospectively identified high-risk patients using the Khorana and Protecht scores (≥ 3 points) via an EHR-based risk assessment tool. Patients with a predicted high risk of VTE during treatment were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation were communicated to the treating oncologist, and clinical outcomes were tracked. RESULTS: A total of 918 outpatients with cancer initiating cancer-directed therapy were evaluated. VTE monthly education rates increased from < 5% before VTEPACC to 81.6% (standard deviation [SD], 11.9; range, 63.6%-97.7%) during the implementation phase and 94.7% (SD, 4.9; range, 82.1%-100%) for the full 2-year postimplementation phase. In the postimplementation phase, 213 patients (23.2%) were identified as being at high risk for developing a VTE. Referrals to hematology were offered to 151 patients (71%), with 141 patients (93%) being assessed and 93.8% receiving VTE prophylaxis. CONCLUSION: VTEPACC is a successful model for guideline implementation to provide VTE risk assessment and prophylaxis to prevent cancer-associated thrombosis in outpatients. Methods applied can readily translate into practice and overcome the current implementation gaps between guidelines and clinical practice.

Immunoscore clinical utility to identify good prognostic colon cancer stage II patients with high-risk clinico-pathological features for whom adjuvant treatment may be avoided.

2019 ◽  
Vol 37 (4_suppl) ◽  
pp. 487-487 ◽  
Author(s):  
Jerome Galon ◽  
Fabienne Hermitte ◽  
Bernhard Mlecnik ◽  
Florence Marliot ◽  
Carlo Bruno Bifulco ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Colon Cancer ◽  
High Risk ◽  
Assessment Tool ◽  
Tnm Classification ◽  
Low Risk ◽  
Stage Ii ◽  
Pathological Feature ◽  
Prognostic Features ◽  
Risk Patients

487 Background: Immunoscore Colon is an IVD test predicting the risk of relapse in early-stage colon cancer (CC) patients, by measuring the host immune response at the tumor site. It is a risk-assessment tool providing independent and superior prognostic value than the usual tumor risk parameters and is intended to be used as an adjunct to the TNM classification. Risk assessment is particularly important to decide when to propose an adjuvant (adj.) treatment for stage (St) II CC patients. High-risk stage II patients defined as those with poor prognostic features including T4, lymph nodes < 12, poor differentiation, VELIPI, bowel obstruction/perforation can be considered for adj. chemotherapy (CT). However, additional risk factors are needed to guide treatment decisions. Methods: A subgroup analysis was performed on the St II untreated patients (n = 1130) from the Immunoscore international validation study (Pagès The Lancet 2018). The high-risk patients (with at least 1 clinico-pathological high-risk feature) were classified in 2 categories using pre-defined cutoffs: Low Immunoscore versus High Immunoscore and their five-year time to recurrence (5Y TTR) was compared to the TTR of the low-risk patients (without any clinico-pathological high-risk feature). Results: Among the patients with high-risk features (n = 630), 438 (69.5%) had a High Immunoscore with a corresponding 5Y TTR of 87.4 (95% CI 83.9-91.0), statistically similar (logrank pv not stratified p > 0.42, wald pv stratified by center p > 0.20) to the TTR 89.1 (95% CI 86.1-92.1) observed for the 500 low-risk patients (with no clinico-pathological feature). Furthermore, 5Y TTR for these patients were statistically similar to those of St II patients with high-risk features and a High Immunoscore (n = 438), who received adj. CT (n = 162) (5Y TTR of 83.4 (95% CI 77.6-89.9). Conclusions: These data show that despite the presence of high-risk features that usually trigger adj. treatment, when not treated with CT, a significant part of these patients (69.5%) have a recurrence risk similar to the low risk patients. Therefore, the Immunoscore test could be a good tool for adj. treatment decision in St II patients.

scholarly journals 812 Mortality Risk prediction in Emergency Laparotomy (ORIEL) Study Outcomes at Wythenshawe Hospital

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
C Carey ◽  
B Pittam ◽  
S Mobarak ◽  
R Varley ◽  
J Kingston ◽  
...  
Keyword(s):  
High Risk ◽  
Operative Mortality ◽  
Scoring Systems ◽  
Mortality Rates ◽  
National Study ◽  
Emergency Laparotomy ◽  
Mortality And Morbidity ◽  
Mortality Risks ◽  
Acs Nsqip ◽  
Risk Patients

Abstract Aim Emergency laparotomy is a high-risk procedure with significant morbidity and mortality. ORIEL is a multi-centre national study aiming to compare the 30-day mortality predictions generated by NELA, P-POSSUM, ACS-NSQIP and SORT risk calculators with observed 30-day mortality rates in patients undergoing emergency laparotomies. We present the data collected from Wythenshawe hospital. Method Data were collected retrospectively on adult patients undergoing an emergency laparotomy between 01/12/2017 to 30/11/2019 at Wythenshawe hospital from the online NELA database. The median pre-operative mortality risks were calculated using the four risk calculators for all patients. Mortality and morbidity were compared with data reported in the Sixth NELA report. Results The median predicted pre-operative mortality (IQR) for all patients studied using NELA, P-POSSUM, ACS-NSQIP and SORT were: 4.3 (13.0), 5.2 (14.2), 3.4 (8.2) and 2.9 (9.3) respectively. Among patients who were alive 30 days post-operatively, the median predicted mortalities (IQR) were: 3.8 (8.5), 4.8 (11.0), 2.6 (6.9) and 2.8 (7.1) respectively, and among those who died were: 30.8 (18.9), 30.3 (63.4), 16.9 (13.9) and 20.3 (16.2). Compared to the national average, mortality rates at Wythenshawe were lower (9% v 9.3%), the median length of stay in hospital was lower (12 days v 15.4 days) and the percentage of high-risk patients admitted to critical care was higher (93% v 85%). Conclusions Similar values were generated with all the scoring systems among all patients. Wythenshawe hospital reports lower mortality rates and shorter stays in hospital despite operating on higher risk patients (ASA grades 3-5).

scholarly journals Feasibility of a structured risk assessment tool in general adult psychiatry admissions

2007 ◽  
Vol 31 (11) ◽  
pp. 418-420 ◽  
Author(s):  
Helen Smith ◽  
Tom White
Keyword(s):  
Risk Assessment ◽  
High Risk ◽  
Personality Disorder ◽  
Assessment Tool ◽  
Risk Assessment Tool ◽  
Clinical Implications ◽  
Royal Hospital ◽  
Comorbid Diagnosis ◽  
Adult Psychiatry ◽  
Risk Patients

AIMS AND METHODTo assess the feasibility of using a structured risk assessment tool (Historical Clinical Risk 20-Item (HCR–20) Scale) in general adult psychiatry admissions and the characteristics of ‘high-risk’ patients. A notes review and interviews were used to conduct an HCR–20 assessment of 135 patients admitted to Murray Royal Hospital, Scotland.RESULTSPatients scoring higher on the HCR–20 were discharged earlier and more likely to have a diagnosis of personality disorder and a comorbid diagnosis.CLINICAL IMPLICATIONSIt was possible to complete an HCR–20 assessment of over 80% of patients within 48 h of admission.

Predicting Adverse Perioperative Events in Patients Undergoing Primary Cleft Palate Repair

2018 ◽  
Vol 55 (4) ◽  
pp. 574-581 ◽  
Author(s):  
Marten N. Basta ◽  
John E. Fiadjoe ◽  
Albert S. Woo ◽  
Kenneth N. Peeples ◽  
Oksana A. Jackson
Keyword(s):  
Risk Assessment ◽  
Cleft Palate ◽  
Clinical Decision Making ◽  
Assessment Tool ◽  
Clinical Decision ◽  
Assessment Tools ◽  
C Statistic ◽  
Extreme Risk ◽  
Risk Patients ◽  
Cleft Palate Repair

Objective: This study aimed to identify risk factors for adverse perioperative events (APEs) after cleft palatoplasty to develop an individualized risk assessment tool. Design: Retrospective cohort. Setting: Tertiary institutional. Patients: Patients younger than 2 years with cleft palate. Interventions: Primary Furlow palatoplasty between 2008 and 2011. Main Outcome Measure(s): Adverse perioperative event, defined as laryngo- or bronchospasm, accidental extubation, reintubation, obstruction, hypoxia, or unplanned intensive care unit admission. Results: Three hundred patients averaging 12.3 months old were included. Cleft distribution included submucous, 1%; Veau 1, 17.3%; Veau 2, 38.3%; Veau 3, 30.3%; and Veau 4, 13.0%. Pierre Robin (n = 43) was the most prevalent syndrome/anomaly. Eighty-three percent of patients received reversal of neuromuscular blockade, and total morphine equivalent narcotic dose averaged 0.19 mg/kg. Sixty-nine patients (23.0%) had an APE, most commonly hypoventilation (10%) and airway obstruction (8%). Other APEs included reintubation (4.7%) and laryngobronchospasm (3.3%). APE was associated with multiple intubation attempts (odds ratio [OR] = 6.6, P = .001), structural or functional airway anomaly (OR = 4.5, P < .001), operation >160 minutes (OR = 2.2, P = .04), narcotic dose >0.3 mg/kg (OR = 2.3, P = .03), inexperienced provider (OR = 2.1, P = .02), and no paralytic reversal administration (OR = 2.0, P = .049); weight between 9 and 13 kg was protective (OR = 0.5, P = .04). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (APE 2.5%-91.7%) with excellent risk discrimination (C-statistic = 0.79). Conclusions: APE incidence was 23.0% after palatoplasty, with a 37-fold higher incidence in extreme-risk patients. Individualized risk assessment tools may enhance perioperative clinical decision making to mitigate complications.

scholarly journals 1332. Single Dose Oral Amoxicillin Challenge is a Safe and Effective Strategy to Delabel Penicillin Allergies among Low Risk Hospitalized Children

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S677-S678
Author(s):  
Justin B Searns ◽  
Amy Stein ◽  
Christine MacBrayne ◽  
Tara Sarin ◽  
Taylor Lin ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Assessment Tool ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Risk Assessment Tool ◽  
Effective Strategy ◽  
Oral Amoxicillin ◽  
Treatment Dose ◽  
Risk Patients ◽  
Drug Challenge

Abstract Background Over 90% of children with reported penicillin allergy can tolerate penicillin without incident. Developing effective and safe strategies to remove inappropriate penicillin allergies has the potential to improve care; however, guidance on how to identify, test, and delabel patients is limited. Methods In April 2019, Children’s Hospital Colorado (CHCO) implemented a penicillin allergy clinical pathway (CP) alongside a risk assessment tool to stratify patients based on allergic history (Figure 1). Patients at “no increased risk” were educated and delabeled without testing. Low risk patients were offered an oral amoxicillin drug challenge with close observation. A single, non-graded, treatment dose of amoxicillin (45 mg/kg, max dose 1000mg) was used for low risk patients, and no preceding allergic skin testing was performed. Patients with no signs or symptoms of allergic response 60 minutes after amoxicillin administration were delabeled. Children delabeled of penicillin allergies on the CHCO hospital medicine service were compared between the pre-CP (1/1/17-3/31/19) and post-CP (4/1/19-3/31/20) cohorts. Figure 1. Penicillin Allergy Risk Assessment Results Pre-CP, 683/10624 (6.4%) patients reported a penicillin allergy and 18/683 (2.6%) were delabeled by discharge. Post-CP, 345/6559 (5.3%) patients reported a penicillin allergy and 47/345 (13.6%) were delabeled by discharge (P-value &lt; 0.0001, Figure 2). Among the 47 post-CP patients, 11 were delabeled by history alone, 19 underwent oral amoxicillin drug challenge per CP, and 17 received a different treatment dose penicillin per treatment team. Only one penicillin-exposed patients had a reaction. This patient developed a delayed, non-progressive rash and had penicillin allergy restored to their chart. No patient required emergency medical intervention, and none were “relabeled” penicillin allergic in the 6 months following discharge. Figure 2. Monthly Rate of Penicillin Allergic Patients Delabeled by Discharge Conclusion A drug challenge using a single non-graded dose of oral amoxicillin is a safe and effective strategy to delabel low risk children of inappropriate penicillin allergies when implemented alongside a risk assessment tool. Further studies are needed to evaluate the long-term benefits of delabeling inappropriate penicillin allergies and to continue monitoring for adverse events. Disclosures All Authors: No reported disclosures

Sign in / Sign up

Export Citation Format

Share Document