Echocardiography for the 10-year prediction of cardiomyopathy in long-term survivors of childhood cancer

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J.M Leerink ◽  
H.J.H Van Der Pal ◽  
E.A.M Feijen ◽  
P.G Meregalli ◽  
M.S Pourier ◽  
...  
Keyword(s):  
Childhood Cancer ◽  
Median Time ◽  
Cancer Diagnosis ◽  
Predictive Value ◽  
Validation Cohort ◽  
Funding Source ◽  
Derivation Cohort ◽  
After Cancer ◽  
Radiotherapy Dose

Abstract Background Childhood cancer survivors (CCS) treated with anthracyclines and/or chest-directed radiotherapy receive life-long echocardiographic surveillance to detect cardiomyopathy early. Current risk stratification and surveillance frequency recommendations are based on anthracycline- and chest-directed radiotherapy dose. We assessed the added prognostic value of an initial left ventricular ejection fraction (EF) measurement at >5 years after cancer diagnosis. Patients and methods Echocardiographic follow-up was performed in asymptomatic CCS from the Emma Children's Hospital (derivation; n=299; median time after diagnosis, 16.7 years [inter quartile range (IQR) 11.8–23.15]) and from the Radboud University Medical Center (validation; n=218, median time after diagnosis, 17.0 years [IQR 13.0–21.7]) in the Netherlands. CCS with cardiomyopathy at baseline were excluded (n=16). The endpoint was cardiomyopathy, defined as a clinically significant decreased EF (EF<40%). The predictive value of the initial EF at >5 years after cancer diagnosis was analyzed with multivariable Cox regression models in the derivation cohort and the model was validated in the validation cohort. Results The median follow-up after the initial EF was 10.9 years and 8.9 years in the derivation and validation cohort, respectively, with cardiomyopathy developing in 11/299 (3.7%) and 7/218 (3.2%), respectively. Addition of the initial EF on top of anthracycline and chest radiotherapy dose increased the C-index from 0.75 to 0.85 in the derivation cohort and from 0.71 to 0.92 in the validation cohort (p<0.01). The model was well calibrated at 10-year predicted probabilities up to 5%. An initial EF between 40–49% was associated with a hazard ratio of 6.8 (95% CI 1.8–25) for development of cardiomyopathy during follow-up. For those with a predicted 10-year cardiomyopathy probability <3% (76.9% of the derivation cohort and 74.3% of validation cohort) the negative predictive value was >99% in both cohorts. Conclusion The addition of the initial EF >5 years after cancer diagnosis to anthracycline- and chest-directed radiotherapy dose improves the 10-year cardiomyopathy prediction in CCS. Our validated prediction model identifies low-risk survivors in whom the surveillance frequency may be reduced to every 10 years. Calibration in both cohorts Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Dutch Heart Foundation

scholarly journals The Admit-AF risk score: a clinical risk score for predicting hospital admissions in patients with atrial fibrillation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P Meyre ◽  
S Aeschbacher ◽  
S Blum ◽  
M Coslovsky ◽  
J.H Beer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
High Risk ◽  
Risk Score ◽  
Hospital Admissions ◽  
Validation Cohort ◽  
Funding Source ◽  
Prediction Tool ◽  
Derivation Cohort

Abstract Background Patients with atrial fibrillation (AF) have a high risk of hospital admissions, but there is no validated prediction tool to identify those at highest risk. Purpose To develop and externally validate a risk score for all-cause hospital admissions in patients with AF. Methods We used a prospective cohort of 2387 patients with established AF as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator (LASSO) method fit to a Cox regression model. The developed risk score was externally validated in a separate prospective, multicenter cohort of 1300 AF patients. Results In the derivation cohort, 891 patients (37.3%) were admitted to the hospital over a median follow-up 2.0 years. In the validation cohort, hospital admissions occurred in 719 patients (55.3%) during a median follow-up 1.9 years. The most important predictors for admission were age (75–79 years: adjusted hazard ratio [aHR], 1.33; 95% confidence interval [95% CI], 1.00–1.77; 80–84 years: aHR, 1.51; 95% CI, 1.12–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.35–2.61), prior pulmonary vein isolation (aHR, 0.74; 95% CI, 0.60–0.90), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.18; 95% CI, 1.02–1.37), prior stroke/TIA (aHR, 1.28; 95% CI, 1.10–1.50), heart failure (aHR, 1.21; 95% CI, 1.04–1.41), peripheral artery disease (aHR, 1.31; 95% CI, 1.06–1.63), cancer (aHR, 1.33; 95% CI, 1.13–1.57), renal failure (aHR, 1.18, 95% CI, 1.01–1.38), and previous falls (aHR, 1.44; 95% CI, 1.16–1.78). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort. Conclusions Multiple risk factors were associated with hospital admissions in AF patients. This prediction tool selects high-risk patients who may benefit from preventive interventions. The Admit-AF risk score Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation (Grant numbers 33CS30_1148474 and 33CS30_177520), the Foundation for Cardiovascular Research Basel and the University of Basel

scholarly journals Development and validation of two SCORE-based cardiovascular risk prediction models for Eastern Europe: a multicohort study

2020 ◽  
Vol 41 (35) ◽  
pp. 3325-3333 ◽  
Author(s):  
Taavi Tillmann ◽  
Kristi Läll ◽  
Oliver Dukes ◽  
Giovanni Veronesi ◽  
Hynek Pikhart ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prediction Models ◽  
Validation Cohort ◽  
European Countries ◽  
Eastern European ◽  
Risk Prediction Models ◽  
Derivation Cohort ◽  
Score Model ◽  
Eastern European Countries

Abstract Aims Cardiovascular disease (CVD) risk prediction models are used in Western European countries, but less so in Eastern European countries where rates of CVD can be two to four times higher. We recalibrated the SCORE prediction model for three Eastern European countries and evaluated the impact of adding seven behavioural and psychosocial risk factors to the model. Methods and results We developed and validated models using data from the prospective HAPIEE cohort study with 14 598 participants from Russia, Poland, and the Czech Republic (derivation cohort, median follow-up 7.2 years, 338 fatal CVD cases) and Estonian Biobank data with 4632 participants (validation cohort, median follow-up 8.3 years, 91 fatal CVD cases). The first model (recalibrated SCORE) used the same risk factors as in the SCORE model. The second model (HAPIEE SCORE) added education, employment, marital status, depression, body mass index, physical inactivity, and antihypertensive use. Discrimination of the original SCORE model (C-statistic 0.78 in the derivation and 0.83 in the validation cohorts) was improved in recalibrated SCORE (0.82 and 0.85) and HAPIEE SCORE (0.84 and 0.87) models. After dichotomizing risk at the clinically meaningful threshold of 5%, and when comparing the final HAPIEE SCORE model against the original SCORE model, the net reclassification improvement was 0.07 [95% confidence interval (CI) 0.02–0.11] in the derivation cohort and 0.14 (95% CI 0.04–0.25) in the validation cohort. Conclusion Our recalibrated SCORE may be more appropriate than the conventional SCORE for some Eastern European populations. The addition of seven quick, non-invasive, and cheap predictors further improved prediction accuracy.

Abstract MP35: Physical Activity Before and After Cancer Diagnosis and Total and Cause-Specific Mortality

Circulation ◽  
2018 ◽  
Vol 137 (suppl_1) ◽  
Author(s):  
Paulette D Chandler ◽  
Deirdre Tobias ◽  
Jule E Buring ◽  
I-Min Lee ◽  
Daniel Chasman ◽  
...  
Keyword(s):  
Physical Activity ◽  
Cancer Diagnosis ◽  
Cancer Mortality ◽  
Total Mortality ◽  
Health Study ◽  
Specific Mortality ◽  
Before And After ◽  
After Cancer ◽  
Cvd Mortality

Background: Given the increased prevalence of cancer survivors in the United States, it is imperative to define risk factors for potential reductions in total and cause-specific mortality. Physical activity (PA) represents a promising target for intervention. Design: We prospectively evaluated PA from questionnaires before and after cancer diagnosis with total and cause-specific mortality among 13,297 subjects diagnosed with invasive cancer combined from the Physicians’ Health Study (PHS) (n=6328), Physicians’ Health Study II (PHS II) (n=912), and Women's Health Study (WHS) (n=6057). WHS and PHS participants were free of baseline cancer; PHS II participants reported no active cancer at baseline. We ascertained PA before and after an incident cancer diagnosis based on reports on repeated follow-up questionnaires. Death was ascertained by medical records and death certificates. Cox regression estimated combined hazard ratios (HRs) of mortality by PA adjusted for age, randomized treatments, BMI, and other lifestyle/demographic factors. We evaluated the interaction between PA before and after cancer diagnosis by comparing PA ≤1 versus ≥2 times/wk. Results: The mean follow-up after cancer diagnosis was 8.0, 7.5, and 5.2 y for WHS, PHS, and PHS II, respectively, during which there were 5623 deaths (WHS, 2164; PHS, 3269; PHS II; 190). Higher PA before cancer diagnosis was associated with significantly lower mortality. Compared with PA ≤ once/wk, the HRs (95% CIs) associated with PA 2-4 and >4 times/wk were 0.87 (0.82-0.93) and 0.88 (0.82-0.94) for total mortality; 0.77 (0.63-0.95) and 0.79 (0.62-0.997) for CVD mortality, and 0.90 (0.83-0.98) and 0.90 (0.83-0.98) for cancer mortality. Higher PA after cancer diagnosis was associated with significantly lower total and cancer mortality and non-significantly lower CVD mortality, with HRs (95% CIs) of 0.65 (0.58-0.72) and 0.66 (0.59-0.73) for total mortality; 0.78 (0.59-1.03) and 0.82 (0.61-1.10) for CVD mortality, and 0.66 (0.57-0.77) and 0.64 (0.55-0.74) for cancer mortality. There was a significant interaction of PA before and after cancer diagnosis for total (p int =0.02) and cancer (p int =0.007) mortality, but not CVD mortality (p int =0.38). Conclusions: Greater PA both before and after cancer diagnosis were significantly associated with lower total and cancer mortality. Higher PA before cancer diagnosis was also associated with lower CVD mortality. PA may be an important target for lower mortality after cancer diagnosis.

scholarly journals The validation of four published algorithms to predict the need for pacemaker implantation after TAVR

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M El Garhy ◽  
T Owais ◽  
H Lapp ◽  
T Kuntze ◽  
P Lauten
Keyword(s):  
Predictive Value ◽  
Validation Cohort ◽  
Pacemaker Implantation ◽  
Aortic Valve Calcification ◽  
Derivation Cohort ◽  
The Third ◽  
Funding Sources ◽  
Valve Implantation ◽  
Score Systems ◽  
Patients Acceptance

Abstract Background The identification of patients with high risk for PPMI after TAVR might change our decision as regard the type of the prosthesis and allow more patients' acceptance for this complication. Objective: we investigated the predictors of PPMI after TF-TAVR and validated the accuracy of four published algorithms in this group of patients. Methods and results We retrospectively examined all patients who were in need for pacemaker implantation during the index hospitalisation after TAVR between 2016 and 2019. We searched for the predictors of the new PPMI after TAVR in this group of patient and compared it with a matched group of patients. Moreover, we tested the accuracy of four published algorithms. The first tested algorithm from Kaneko et al had positive predictive value (PPV), negative predictive value (NPV) and accuracy from 50%, 65% and 60% consecutively. The second tested algorithm from Jilaihawi et al had PPV, NPV and accuracy from 13.6%, 100% and 26.9% consecutively. The third tested algorithm from Maeno et al had PPV, NPV and accuracy from 37%, 56% and 45% consecutively. The forth tested algorithm from Fujiti et al had PPV, NPV and accuracy from 42%, 65% and 50% consecutively. In this study, 3 ECG-predictors (RBBB, the presence of AF and LAHB) and 3 CT-predictors (Aortic valve calcification Volume >500mm3, eccentricity index >0.25, deep valve implantation in relation to the length of membranous septum) were independent predictors of PPMI. Moreover, the rate of preimplantation ballon valivuloplasty was higher in the group with new PPMI. Using these independent predictors, the new 7 points score was developed by assigning 1 point for each one. AUC of the new score in the derivation cohort was 0.809 (95% CI 0.758–0.86), with an optimal cut-off threshold of 4 points. All other scores had AUC from 0.6 or lower. In a validation cohort of 100 patients, the predictive value of the score was confirmed (AUC, 0.72; 95% CI, 0.70–0.87; P<0.001). Conclusion The four studied score systems had low accuracy to predict new PPMI after TAVR in our cohort of patients. The new score is more complex but might be more accurate. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Epigenome-wide association studies of three social determinants of health and implications for lung functions among survivors of childhood cancer

2020 ◽  
Author(s):  
Nan Song ◽  
Jin-ah Sim ◽  
Qian Dong ◽  
Yinan Zheng ◽  
Lifang Hou ◽  
...  
Keyword(s):  
Educational Attainment ◽  
Childhood Cancer ◽  
Social Determinants Of Health ◽  
Median Time ◽  
Social Determinants ◽  
Association Studies ◽  
Personal Income ◽  
Mediation Effect ◽  
Survivors Of Childhood Cancer

AbstractBackgroundEmerging evidence suggests that social determinants of health (SDOH) may influence health and wellness through an epigenetic mechanism in the general population. However, the social epigenomic approach has not yet been applied to survivors of childhood cancer, a vulnerable population with elevated risk for chronic health conditions (CHCs).MethodsStudy participants were drawn from the St Jude Lifetime Cohort, a hospital-based retrospective cohort with prospective follow up. DNA methylation (DNAm) profiling was generated based on blood derived DNA collected during follow-up visit. SDOH included educational attainment, personal income, and area deprivation index (ADI) based on baseline or follow-up questionnaires and geocoding. CHCs were clinically assessed with severity grade.ResultsWe included 258 childhood cancer survivors of African ancestry (AA) (median time from diagnosis=25.2 years, interquartile range [IQR]=19.9-32.1 years) and 1,618 survivors of European ancestry (EA) (median time from diagnosis=27.3, IQR=21.1-33.7 years). Through epigenome-wide association studies, we identified 130 SDOH-CpG associations including educational attainment (N=88), personal income (N=23), and ADI (N=19) at epigenome-wide significance level (P<9×10−8). There were 13 CpGs, commonly associated with all three SDOH factors, with attenuated remaining effect sizes (36.8-48.3%) after additionally adjusting body mass index and smoking, mapped to smoking-related genes including GPR55, CLDND1, CPOX, GPR15, AHRR, PRRC2B, and ELMSAN1. Among 130 SDOH-related CpGs, three independent CpGs (cg04180924, cg1120500, and cg27470486) had a significant combined mediation effect for educational attainment (%mediation=48.9%), and a single mediator cg08064403 was found with significant mediation effect for personal income (25.9%) and ADI (24.1%) on pulmonary diffusion deficit, which showed higher incidence in AA than in EA survivors implying racial disparity which is possibly due to more disadvantageous SDOH factors in AA than in EA.ConclusionsWe demonstrated striking DNAm signatures associated with multiple SDOH factors (educational attainment, personal income, and ADI) and many epigenome-wide significant CpG sites resembling the effect of smoking exposure. We also identified an exemplified racial health disparity in pulmonary diffusion deficit between AA and EA survivors and illuminated DNAm as potential mechanistic mediators for SDOH factors using a social epigenomic approach.

scholarly journals BNP/ NT-pro BNP thresholds for the assessment of the prognosis in patients without heart failure

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Hendricks ◽  
A A Mahabadi ◽  
L Vogel ◽  
F Al-Rashid ◽  
P Luedike ◽  
...  
Keyword(s):  
Heart Failure ◽  
Natriuretic Peptides ◽  
Validation Cohort ◽  
Skewed Distribution ◽  
Standard Deviation Increase ◽  
Term Survival ◽  
Derivation Cohort ◽  
Heart Failure Patients ◽  
Gender Specific

Abstract Background Natriuretic peptides (BNP/NT-proBNP) are predominantly used for risk stratification, diagnosis and therapeutic monitoring in heart failure patients. A potential value of BNP/NT-proBNP serum levels for the prediction of prognosis in the general population and for non-heart failure patient cohorts is suggested in the literature. However, for non-heart failure patients, no thresholds are established. We aimed to determine cut-off levels that allow prediction of long-term survival in patients without known heart failure. Methods The present analysis is based on a registry of patients undergoing coronary angiography between 2004 and 2019. Patients with existing diagnosis of heart failure or elevated natriuretic peptides (BNP &gt;100pg/nl, NT-proBNP &gt;400pg/nl), with missing follow-up information or without BNP/NT-proBNP levels at admission were excluded. As either BNP or NT-proBNP was available for singular patients and to adjust for the skewed distribution, BNP/NT-proBNP levels ranked based on gender specific percentile from 0 to 99. The cohort was then divided into a derivation and a validation cohort using random sampling. Incidence of death of any cause during follow-up was recorded. In the derivation cohort, cox regression analysis was used to determine the association of natriuretic peptides with incident mortality per 1 standard deviation increase in BNP/NT-proBNP rank. Multivariable models controlled for age, sex, LDL-cholesterol, systolic blood pressure, smoking status, and family history of premature cardiovascular disease. Receiver operating characteristics curve analysis was performed, with corresponding area under the curve, along with Youden's J index assessment, to establish a threshold for prediction of survival. The association of this threshold with incident mortality was tested in the validation cohort. Results Overall, 3,687 patients (age 62.9±12.5 years, 71% male) were included. During a mean follow-up of 2.6±3.4 years, 169 deaths occurred. In the derivation cohort, BNP/NT-proBNP was significantly associated with mortality (Hazard ratio [95% confidence interval]: 1.25 [1.01–1.54], p=0.04). Based on Youden's J index, BNP-thresholds of 9.6 and 29pg/ml and NT-proBNP thresholds of 65 and 77pg/ml for men and women, respectively, were determined. In the derivation cohort, BNP/NT-proBNP levels above these thresholds were significantly associated with increased mortality (2.44 [1.32–4.53], p=0.005). The predictive value of the determined thresholds was confirmed in the validation cohort (2.78 [1.26–6.14], p=0.01). Conclusion We here describe gender-specific BNP/NT-proBNP thresholds that allow prediction of impaired survival in patients without heart failure. Utilization of these thresholds in clinical routine may qualify for risk prediction in non-heart failure cohorts, independent of traditional cardiovascular risk factors. FUNDunding Acknowledgement Type of funding sources: None.

Hospitalization rates among survivors of childhood and adolescent cancer: A report from the Childhood Cancer Survivor Study (CCSS)

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 9556-9556
Author(s):  
B. A. Kurt ◽  
V. G. Nolan ◽  
K. K. Ness ◽  
J. P. Neglia ◽  
J. M. Tersak ◽  
...  
Keyword(s):  
Childhood Cancer ◽  
Cancer Diagnosis ◽  
Chronic Health Conditions ◽  
Health Conditions ◽  
Severe Toxicity ◽  
Chronic Health ◽  
Adolescent Cancer ◽  
Hospitalization Rates ◽  
Survivors Of Childhood Cancer

9556 Background: Survivors of childhood cancer have a high burden of chronic health conditions following cancer therapy, but the risk for subsequent hospitalization has not been reported. Methods: Hospitalizations during 1996–2000 among a cohort of 10,367 5-yr survivors of childhood cancer (diagnosed 1970–1986) and 2,540 siblings were ascertained. Age-and gender-stratified standardized incidence ratios (SIRs) for hospitalization were calculated using the sibling cohort and U.S. population from the National Hospital Discharge Survey (NHDS). Associations between demographic, cancer/treatment-related risk factors and non-obstetrical hospitalization among survivors were evaluated in multiple variable logistic regression models. Results: At follow-up, survivors were a mean of 20.9 yrs. from diagnosis (SD: 4.6, range: 13.3–32.2) and mean age of 28.6 yrs. (SD: 7.7, range: 13–51). Overall hospitalization rates among survivors were 1.5 times (95% CI 1.44–1.52) that of siblings and 1.2 times (95% CI 1.16–1.22) that of the U.S. general population. Increased risk of hospitalization was noted irrespective of gender, age at follow-up, or cancer diagnosis, with highest SIRs noted for male (SIR=12.7, 95% CI 9.5–15.8) and female (SIR=72.1, 95% CI 58.8–85.5) survivors aged 45–54. Females (OR=1.2, 95% CI 1.04–1.3) and survivors with a chronic health condition (OR=1.6, 95% CI 1.5–1.8) were more likely to have been hospitalized for non-obstetrical causes after adjusting for age at diagnosis, age at follow-up, cancer diagnosis, household income, insurance, and history of relapse/second malignancy. Among survivors, those with Hodgkin's lymphoma had the highest hospitalization rates for neoplastic, infectious, endocrine, pulmonary and cardiovascular causes. CNS malignancy survivors had the highest hospitalization rates for neurologic, psychological and external (e.g. traumatic) causes. Conclusions: Therapy for childhood and adolescent cancer is associated with a significant increase in subsequent hospitalization rates. Regular medical follow-up and early intervention for chronic health conditions may help to limit severe toxicity that would require hospitalization. No significant financial relationships to disclose.

Changes in physical activity from pre-diagnosis to first five years post-diagnosis: A prospective cohort study in Chinese breast cancer patient.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e24121-e24121
Author(s):  
Yuanyuan Lei ◽  
Winnie Yeo ◽  
Suzanne C. Ho ◽  
Ashley Chi Kin Cheng ◽  
Carol Kwok
Keyword(s):  
Breast Cancer ◽  
Physical Activity ◽  
Cohort Study ◽  
Cancer Patients ◽  
Cancer Diagnosis ◽  
Prospective Cohort ◽  
Chinese Women ◽  
Breast Cancer Patients ◽  
After Cancer

e24121 Background: The diagnosis of cancer can motivate patients to change their physical activity habits. No data has reported level of physical activity before and after breast cancer diagnosis in Chinese women. Methods: In an on-going prospective cohort study which involved 1462 Chinese women with early-stage breast cancer, a validated modified Chinese Baecke questionnaire was used to assess physical activity at baseline, 18-, 36- and 60-month after diagnosis. At baseline, patients recalled their habitual physical activity in the preceding 12 months before cancer diagnosis. At 18-, 36- and 60-month follow-up, patients reported their habitual physical activity over the previous 12 months. The level of physical activity at post-diagnosis was defined as the average value assessed at 18-, 36- and 60-month follow-up. Results: Breast cancer patients significantly increased level of physical activity, with median value of 0.6, 5.3, 4.4 and 3.9 MET-hours/week at baseline, 18-, 36- and 60-month follow-up. The average level of physical activity at post-diagnosis was also significantly higher than that at pre-diagnosis ( P < 0.001), with median value of 5.8 MET-hours/week. However, there was no significant difference between any two follow-ups at post-diagnosis. The proportions of participant who met the exercise recommendation (according to WCRF/AICR, 10 MET-hours/week) were low at pre- and post-diagnosis, being 20.7% and 35.1%, respectively. Compared to pre-diagnosis, most of the patients improved or had no change on level of recreational physical activity at post-diagnosis, with the respective proportion being 48.2% and 43.8%. Multivariate analysis showed that higher increase in physical activity after cancer diagnosis was observed among breast cancer patients who were married or cohabitation, unemployed (compared to full time) and had no comorbidity (compared to patients who had one comorbidity). Conclusions: Chinese breast cancer patients reported significant and long-term changes in physical activity after cancer diagnosis, which was in line with current recommendation. However, the proportion of patients who met the exercise recommendation for cancer survivors was still low. Empowering patients on the importance of durable high level of physical activity in breast cancer survivorship is warranted.

Predicting in-hospital mortality for patients admitted from the emergency department: An initial alarm score for inpatient care

2020 ◽  
Author(s):  
Ming-Ju Hsieh ◽  
Nin-Chieh Hsu ◽  
Yu-Feng Lin ◽  
Chin-Chung Shu ◽  
Wen-Chu Chiang ◽  
...  
Keyword(s):  
Emergency Department ◽  
Hospital Mortality ◽  
Predictive Value ◽  
Cancer Metastasis ◽  
Validation Cohort ◽  
Characteristic Curve ◽  
High Sensitivity ◽  
Cutoff Value ◽  
Derivation Cohort ◽  
Cox Proportional Hazard Regression

Abstract Background: The in-hospital mortality of patients admitted from the emergency department (ED) is high, but no appropriate initial alarm score is available. Methods: This prospective observational study enrolled ED-admitted patients in hospitalist-care wards and analyzed the predictors for seven-day in-hospital mortality from May 2010 to October 2016. Two-thirds were randomly assigned to a derivation cohort for development of the model and cross-validation was performed in the validation cohort. Results: During the study period, 8,649 patients were enrolled for analysis. The mean age was 71.05 years, and 51.91% were male. The most common admission diagnoses were pneumonia (36%) and urinary tract infection (20.05%). In the derivation cohort, multivariable Cox proportional hazard regression revealed that a low Barthel index score, triage level 1 at the ED, presence of cancer, metastasis, and admission diagnoses of pneumonia and sepsis were independently associated with seven-day in-hospital mortality. Based on the probability developed from the multivariable model, the area under the receiver operating characteristic curve in the derivation group was 0.81 [0.79–0.85]. The result in the validation cohort was comparable. The prediction score modified by the six independent factors had high sensitivity of 88.03% and a negative predictive value of 99.51% for a cutoff value of 4, whereas the specificity and positive predictive value were 89.61% and 10.55%, respectively, when the cutoff value was a score of 6. Conclusion: The seven-day in-hospital mortality in a hospitalist-care ward is 2.8%. The initial alarm score could help clinicians to prioritize or exclude patients who need urgent and intensive care.

Post-Thrombotic Syndrome Affecting the Upper Venous System in Children: Validation of Outcome Measurement and Application in a Single-Institutional Prospective Inception Cohort Study.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2979-2979 ◽  
Author(s):  
Neil A Goldenberg ◽  
Elizabeth Pounder ◽  
R. Knapp-Clevenger ◽  
Marilyn J. Manco-Johnson
Keyword(s):  
Cohort Study ◽  
Validation Cohort ◽  
Outcome Measurement ◽  
Venous Stasis ◽  
Healthy Children ◽  
Inception Cohort ◽  
Derivation Cohort ◽  
History Of

Abstract Abstract 2979 Poster Board II-952 BACKGROUND AND OBJECTIVES: Post-thrombotic syndrome (PTS) is an important long-term sequela of deep venous thrombosis (DVT) in children, which may involve the upper or lower venous systems (UVS, LVS). The understanding of pediatric PTS has been limited by variability in outcome measurement, and prospective data are particularly lacking for DVT involving the UVS. Validation data have been published for the performance of a pediatric PTS outcome measure (the Manco-Johnson instrument; Figure 1) in the LVS (Goldenberg et al., Blood 2007). The aims of the present work were to: (1) investigate validity of the Manco-Johnson instrument in the UVS in children, via a cross-sectional derivation cohort/validation cohort design; and (2) preliminarily determine the cumulative incidence of PTS in a prospective inception cohort study of children with DVT affecting the UVS. METHODS AND RESULTS: Validation study: All parameters of the Manco-Johnson instrument were assessed in a derivation cohort (n=78) consisting of healthy children aged 12 months to 21 years who were without personal or first-degree family history of thromboembolism before age 55 years, grouped by age as follows: preschool (12 mo – <6 y; n=30); school age (6 - <13 y, n=28); adolescent (13 – 21 y, n=20). Inter-rater reliability in each parameter of the instrument was evaluated in a mixed validation cohort (n=41) of healthy children and patients with history of DVT affecting the UVS. In the derivation cohort, the upper limit of normal values for contralateral difference in upper limb circumference was 1.0 cm for mid-forearm and mid-upper arm measurements, as calculated by the non-parametric method of Tukey. In addition, dilated superficial collateral veins, venous stasis dermatitis, venous stasis ulcers, and chronic pain of the upper limb, chest or neck that limits activities of daily living or aerobic exercise were all absent among these healthy children. Inter-rater reliability, measured as percent agreement, exceeded 95% for all parameters when applied in the validation cohort by mutually-blinded dual examiners trained in the use of the instrument. Prospective inception cohort study: Inclusion criteria consisted of radiologically confirmed DVT of the subclavian vein, brachiocephalic vein, and/or superior vena cava (SVC), and study enrollment between March 2006 and July 2009. All children underwent comprehensive thrombophilia testing and were managed with anticoagulation in accordance with ACCP pediatric guidelines, for a minimum duration of 3 months. In some cases, acute thrombolytic therapy was instituted based upon clinical decisions. Children were evaluated for PTS using the Manco-Johnson instrument at 3-6 months, 12 months, and annually thereafter in long-term follow-up. Repeat imaging was performed at minimum at 3-6 months post-diagnosis, and if persistent, again at 1 year. Prevalence of PTS was analyzed based upon findings at latest follow-up (minimum 1 year post-diagnosis). Individual patient data on diagnostic findings, treatment, thrombus resolution, and PTS outcome are given in Table 1. Among 13 subjects meeting eligibility criteria, median age at DVT diagnosis was 16 years (range: 2 - 21 years). The SVC was involved in one child. Clinical predisposition consisted of central venous catheterization in approximately 50% of cases and an underlying anatomic vascular abnormality (thoracic outlet syndrome, Paget-Schroetter syndrome) in an additional 23%. Thrombophilia at presentation consisted of elevated factor VIII in 70% and antiphospholipid antibodies in nearly 50%. Thrombolysis was employed in the 2 children with anatomic defects and one with catastrophic antiphospholipid antibody syndrome. DVT persisted following a 3-6 course of anticoagulant therapy in 50% of evaluable patients. The cumulative incidence of PTS at 1-2 years among 7 evaluable patients was 29%, and involved both physical findings and functional impairment (i.e., chronic pain limitation) in each case. CONCLUSIONS: The present findings demonstrate the validity of the Manco-Johnson instrument for pediatric PTS outcome measurement involving the UVS. Using this instrument, PTS appears to be common in children with DVT affecting the UVS, and functionally significant. Broader use of the Manco-Johnson instrument for PTS outcome assessment in prospective studies and clinical trials of pediatric DVT is warranted. Disclosures: Off Label Use: The presentation refers to the use of anticoagulants as a drug class in general in the treatment of venous thromboembolism (VTE) in children. Despite their use in the standard care for pediatric VTE, all anticoagulants remain off-label for this indication in children.

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