P5619Comparison of different resting physiological indices: are diastolic pressure ratio and resting full-cycle ratio equal?

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Hoshino ◽  
Y Kanaji ◽  
T Sugiyama ◽  
M Yamaguchi ◽  
H Ohya ◽  
...  
Keyword(s):  
Predictive Value ◽  
Diagnostic Performance ◽  
Diastolic Pressure ◽  
Characteristic Curve ◽  
Pressure Ratio ◽  
Pairwise Comparison ◽  
Roc Curve Analysis ◽  
Coronary Pressure ◽  
Significant Difference ◽  
Highly Correlated

Abstract Background Previous reports showed all diastolic resting indexes tested were virtually identical to the instantaneous wave-free ratio (iFR). Although RFR has been also reported to be diagnostically equivalent to iFR, no comparisons have been reported about the prevalence and characteristics of discordance in diagnosis between diastolic pressure ratio (dPR) and resting full-cycle ratio (RFR). Purpose This study sought to determine the coronary pressure characteristics of lesions classified as discordant between dPR and RFR in angiographically intermediate stenoses. Methods We recruited 532 patients with 668 intermediate (angiographically stenosis between 30% to 70% severity) coronary lesions undergoing FFR assessment and analyzed DICOM pressure tracings of resting state (dPR and RFR) using a fully automated off-line software algorithm in a blind fashion. Diagnostic performance of dPR and RFR was evaluated using FFR as a reference. Furthermore, we investigated similarity and difference between dPR and RFR. Results Median FFR was 0.81 with an interquartile range of 0.74 to 0.87. RFR was highly correlated to dPR (R2=0.94, p<0.001), with a mean bias of 0.012 (95% limits of agreement −0.008 to 0.031). The diagnostic performance of RFR versus dPR was diagnostic accuracy 95.4%, sensitivity 100.0%, specificity 91.6%, positive predictive value 90.6%, negative predictive value 100.0%). Using the binary cut-off of dPR ≤0.89 as a cut-off value, RFR showed near identical agreement according to ROC curve analysis (AUC: 0.996, 95% CI: 0.994–0.999, p<0.001). Although dPR and RFR demonstrated equivalent performance against FFR ≤0.8 (79.5% vs. 79.3% accuracy; p=0.960; area under the receiver-operating characteristic curve: 0.869 vs. 0.870; p=0.528), RFR disagreed with dPR in 4.6% (31 of 668). When all lesions (668 vessels) were divided into groups according to the concordance and discordance between dPR and RFR: RFR+/dPR+ (298 vessels, n=240), RFR+/dPR– (31 vessels, n=31 patients), RFR-/dPR- (339 vessels, n=259). There was no lesion showing RFR-/dPR+. The prevalence of ischemia was tended to be higher in lesions evaluated by RFR (49.3% vs 44.6%, P=0.100) when using FFR ≤0.80 as a reference standard. An overall significant difference in the prevalence of FFR ≤0.80 and the FFR values were detected among these 3 groups. Furthermore, pairwise comparison also revealed the prevalence of FFR >0.80 and the FFR values were significantly lower in RFR+/dPR– than in RFR-/dPR-, and significantly higher in RFR+/dPR– than in RFR+/dPR+. (P<0.001 and P<0.001, respectively) Conclusion Significant difference in FFR values was observed according to dPR/RFR agreement and disagreement. Revascularization decision making might defer according to the resting index used. Compared with RFR, lesions might be more frequently deferred when dPR was used to assess physiological significance. Acknowledgement/Funding None

scholarly journals Diastolic pressure ratio: new approach and validation vs. the instantaneous wave-free ratio

2019 ◽  
Vol 40 (31) ◽  
pp. 2585-2594 ◽  
Author(s):  
Nils P Johnson ◽  
Wenguang Li ◽  
Xi Chen ◽  
Barry Hennigan ◽  
Stuart Watkins ◽  
...  
Keyword(s):  
Diagnostic Performance ◽  
Operating Characteristic ◽  
Diastolic Pressure ◽  
Pressure Ratio ◽  
New Approach ◽  
Coronary Pressure ◽  
Linear Transform ◽  
The Difference ◽  
Definition Of ◽  
Post Hoc

Abstract Aims The instantaneous wave-free ratio (iFR) and whole-cycle Pd/Pa investigate coronary physiology during non-hyperaemic conditions. To test for unique physiologic properties of the wave-free period when making resting coronary pressure measurements, we compared post hoc a diastolic pressure ratio (dPR) and Pd/Pa against iFR for numerical similarity and test/retest repeatability. Methods and results Eight hundred and ninety-three lesions from 833 subjects were included from the VERIFY 2 and CONTRAST studies. Diastolic pressure ratio and a linear transform of Pd/Pa were compared against iFR for diagnostic performance. Mean difference between dPR and iFR [Δ = −0.006 ± 0.011, r2 = 0.993, area under receiver operating characteristic (ROC) curve (AUC) = 0.997] mirrored the difference of two iFR measurements repeated immediately (Δ = <0.001 ± 0.004, r2 = 0.998, AUC = 1.00). Minor variations in the definition of dPR changed its value by <1–2% over a broad range of the cardiac cycle. A linear transform of Pd/Pa showed very good diagnostic performance (Δ = −0.012 ± 0.031, r2 = 0.927, AUC = 0.979). Post hoc iFR values were validated against real-time iFR values and matched almost exactly (average Δ = <0.001 ± 0.004, 99.6% within ±0.01). Conclusions Our dPR offers numerical equivalency to iFR. Despite different technical approaches for identifying the relevant period of diastole, the agreement between dPR and iFR and the insensitivity of dPR to minor variations in its definition further confirm numerical equivalency among resting metrics.

scholarly journals Exploring the Value of Radiomics Features Based on B-Mode and Contrast-Enhanced Ultrasound in Discriminating the Nature of Thyroid Nodules

2021 ◽  
Vol 11 ◽  
Author(s):  
Shi Yan Guo ◽  
Ping Zhou ◽  
Yan Zhang ◽  
Li Qing Jiang ◽  
Yong Feng Zhao
Keyword(s):  
Diagnostic Performance ◽  
Thyroid Nodules ◽  
New Technologies ◽  
Statistical Significance ◽  
Characteristic Curve ◽  
Logistic Models ◽  
Contrast Enhanced Ultrasound ◽  
Clinical Value ◽  
Contrast Enhanced ◽  
Significant Difference

BackgroundWith the improvement of ultrasound imaging resolution and the application of various new technologies, the detection rate of thyroid nodules has increased greatly in recent years. However, there are still challenges in accurately diagnosing the nature of thyroid nodules. This study aimed to evaluate the clinical application value of the radiomics features extracted from B-mode ultrasound (B-US) images combined with contrast-enhanced ultrasound (CEUS) images in the differentiation of benign and malignant thyroid nodules by comparing the diagnostic performance of four logistic models.MethodsWe retrospectively collected and ultimately included B-US images and CEUS images of 123 nodules from 123 patients, and then extracted the corresponding radiomics features from these images respectively. Meanwhile, a senior radiologist combined the thyroid imaging reporting and data system (TI-RADS) and the enhancement pattern of the ultrasonography to make a graded diagnosis of the malignancy of these nodules. Next, based on these radiomics features and grades, logistic regression was used to help build the models (B-US radiomics model, CEUS radiomics model, B-US+CEUS radiomics model, and TI-RADS+CEUS model). Finally, the study assessed the diagnostic performance of these radiomics features with a comparison of the area under the curve (AUC) of the receiver operating characteristic curve of four logistic models for predicting the benignity or malignancy of thyroid nodules.ResultsThe AUC in the differential diagnosis of the nature of thyroid nodules was 0.791 for the B-US radiomics model, 0.766 for the CEUS radiomics model, 0.861 for the B-US+CEUS radiomics model, and 0.785 for the TI-RADS+CEUS model. Compared to the TI-RADS+CEUS model, there was no statistical significance observed in AUC between the B-US radiomics model, CEUS radiomics model, B-US+CEUS radiomics model, and TI-RADS+CEUS model (P&gt;0.05). However, a significant difference was observed between the single B-US radiomics model or CEUS radiomics model and B-US+CEUS radiomics model (P&lt;0.05).ConclusionIn our study, the B-US radiomics model, CEUS radiomics model, and B-US+CEUS radiomics model demonstrated similar performance with the TI-RADS+CEUS model of senior radiologists in diagnosing the benignity or malignancy of thyroid nodules, while the B-US+CEUS radiomics model showed better diagnostic performance than single B-US radiomics model or CEUS radiomics model. It was proved that B-US radiomics features and CEUS radiomics features are of high clinical value as the combination of the two had better diagnostic performance.

scholarly journals Accuracy of computational pressure-fluid dynamics applied to coronary angiography to derive fractional flow reserve: FLASH FFR

2019 ◽  
Vol 116 (7) ◽  
pp. 1349-1356 ◽  
Author(s):  
Jianping Li ◽  
Yanjun Gong ◽  
Weimin Wang ◽  
Qing Yang ◽  
Bin Liu ◽  
...  
Keyword(s):  
Fluid Dynamics ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Fractional Flow Reserve ◽  
Predictive Value ◽  
Diagnostic Performance ◽  
Characteristic Curve ◽  
Fractional Flow ◽  
Performance Goal ◽  
Flow Reserve

Abstract Aims Conventional fractional flow reserve (FFR) is measured invasively using a coronary guidewire equipped with a pressure sensor. A non-invasive derived FFR would eliminate risk of coronary injury, minimize technical limitations, and potentially increase adoption. We aimed to evaluate the diagnostic performance of a computational pressure-flow dynamics derived FFR (caFFR), applied to coronary angiography, compared to invasive FFR. Methods and results The FLASH FFR study was a prospective, multicentre, single-arm study conducted at six centres in China. Eligible patients had native coronary artery target lesions with visually estimated diameter stenosis of 30–90% and diagnosis of stable or unstable angina pectoris. Using computational pressure-fluid dynamics, in conjunction with thrombolysis in myocardial infarction (TIMI) frame count, applied to coronary angiography, caFFR was measured online in real-time and compared blind to conventional invasive FFR by an independent core laboratory. The primary endpoint was the agreement between caFFR and FFR, with a pre-specified performance goal of 84%. Between June and December 2018, matched caFFR and FFR measurements were performed in 328 coronary arteries. Total operational time for caFFR was 4.54 ± 1.48 min. caFFR was highly correlated to FFR (R = 0.89, P = 0.76) with a mean bias of −0.002 ± 0.049 (95% limits of agreement −0.098 to 0.093). The diagnostic performance of caFFR vs. FFR was diagnostic accuracy 95.7%, sensitivity 90.4%, specificity 98.6%, positive predictive value 97.2%, negative predictive value 95.0%, and area under the receiver operating characteristic curve of 0.979. Conclusions Using wire-based FFR as the reference, caFFR has high accuracy, sensitivity, and specificity. caFFR could eliminate the need of a pressure wire, technical error and potentially increase adoption of physiological assessment of coronary artery stenosis severity. Clinical Trial Registration URL: http://www.chictr.org.cn Unique Identifier: ChiCTR1800019522.

scholarly journals Combine preoperative estimation of serum thyroglobulin and ACR-thyroid imaging reporting and data system scoring could accurately define malignant thyroid nodules

2020 ◽  
Vol 8 (1) ◽  
pp. 32
Author(s):  
Waseem A. Shoda
Keyword(s):  
Roc Curve ◽  
Predictive Value ◽  
Thyroid Nodules ◽  
Curve Analysis ◽  
Data System ◽  
Operating Characteristics ◽  
Roc Curve Analysis ◽  
Serum Thyroglobulin ◽  
Thyroid Imaging ◽  
Significant Difference

Background: Evaluation of diagnostic ability of preoperative estimation of serum thyroglobulin (TG) to detect malignant thyroid nodules (TN) in comparison to the American College of Radiology, Thyroid imaging reporting and data system (ACR-TIRADS), fine needle aspiration cytology (FNAC) and intraoperative frozen section (IO-FS).Methods: 34 patients with ACR-TIRADS 2-4 TN were evaluated preoperatively for identification of malignancy and all underwent total thyroidectomy with bilateral neck block dissection if indicated. Results of preoperative investigations were statistically analyzed using the Receiver operating characteristics (ROC) curve analysis as predictors for malignancy in comparison to postoperative paraffin sections.Results: Preoperative serum TG levels had 100% sensitivity and negative predictive value, while ACR-TIRADS scoring had 100% specificity and positive predictive value with accuracy rates of 95.35% and 97.67% for TG and TIRADS, respectively. ROC curve analysis defined preoperative ACR-TIRADS class and serum TG as highly diagnostic than FNAC for defining malignancy with non-significant difference between areas under curve for TIRADS and TG. For cases had intermediate risk of malignancy on TIRADS, IO-FS had missed 3, FNAC missed 4, while serum TG levels were very high in the 13 cases and were defined by ROC curve as the only significant predictor for malignancy.Conclusions: Preoperative estimation of serum TG showed higher diagnostic validity than FNAC, high predictability of cancer and ability to verify the intermediate findings on TIRADS. Combined preoperative TIRADS and TG estimation could accurately discriminate malignant TN with high accuracy and spare the need for preoperative FNAC or IO-FS. 

scholarly journals Spiral Flow Fube for Contrast Medium Reduction in Coronary CT Angiography

2017 ◽  
Vol 9 ◽  
Author(s):  
Nobuo Tomizawa ◽  
Yayoi Hayakawa ◽  
Shinichi Inoh ◽  
Takeshi Nojo ◽  
Satoshi Uemura ◽  
...  
Keyword(s):  
Contrast Medium ◽  
Predictive Value ◽  
Diagnostic Performance ◽  
Left Main ◽  
Spiral Flow ◽  
Flow Tube ◽  
Coronary Ct ◽  
Shaped Tube ◽  
Significant Difference ◽  
Sensitivity Specificity

<p align="left"><strong>Objectives</strong></p><p align="left">To assess the diagnostic performance and enhancement of coronary CT with reduced contrast medium using the spiral flow tube compared with the T-shaped tube.</p><p align="left"><strong>Methods</strong></p><p align="left">We retrospectively included 444 patients who underwent catheter examination within 2 months after coronary CT. The first 222 patients received 21.0 mgI/kg/s of contrast medium using the T-shaped tube and the injected contrast medium was reduced by 6% (19.8 mgI/kg/s) in the last 222 patients using the spiral flow tube. We compared the per vessel diagnostic performance for detecting obstructive stenosis (≥50%) by catheter examination and the enhancement of proximal coronary arteries.</p><p align="left"><strong>Results</strong></p><p align="left">The sensitivity, specificity, positive predictive value, negative predictive value and accuracy was 96%, 84%, 72%, 98% and 87% using the spiral flow tube and 93%, 83%, 68%, 97% and 86% using the T-shaped tube, respectively, without significance. The enhancement of left main (spiral flow vs T-shape, 407 ± 53 vs 407 ± 62 HU, <em>p</em> = 0.95) and right coronary (419 ± 58 vs 415 ± 61 HU, <em>p</em> = 0.49) arteries did not show significant difference.</p><p align="left"><strong>Conclusions</strong></p><p align="left">The spiral flow tube would maintain the diagnostic performance and coronary enhancement with reduced contrast medium compared with the T-shaped tube.</p>

scholarly journals Lung ultrasound for the diagnosis of cystic fibrosis pulmonary exacerbation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Maryam Hassanzad ◽  
Arda Kiani ◽  
Atefeh Abedini ◽  
Hoseinali Ghaffaripour ◽  
Habib Emami ◽  
...  
Keyword(s):  
Cystic Fibrosis ◽  
Predictive Value ◽  
Diagnostic Performance ◽  
Lung Ultrasound ◽  
Characteristic Curve ◽  
Cross Sectional Study ◽  
Pulmonary Exacerbation ◽  
High Resolution Computed Tomography ◽  
Cross Sectional ◽  
Pleural Thickening

Abstract Background High-resolution computed tomography (HRCT) is the gold standard for the evaluation of cystic fibrosis (CF) lung disease; however, lung ultrasound (LUS) is being increasingly used for the assessment of lung in these patients due to its lower cost, availability, and lack of irradiation. We aimed to determine the diagnostic performance of LUS for the evaluation of CF pulmonary exacerbation. Methods This cross-sectional study included patients with CF pulmonary exacerbation admitted to Masih Daneshvari Hospital, Tehran, Iran, from March 21, 2020 to March 20, 2021. Age, gender, and body mass index (BMI) of the patients were recorded. All patients underwent chest X-ray (CXR), HRCT, and LUS on admission. Pleural thickening, atelectasis, air bronchogram, B-line, and consolidation were noted in LUS and then compared with the corresponding findings in CXR and HRCT. Taking HRCT findings as reference, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) of LUS and CXR for the detection of each pulmonary abnormality were determined. Results Of the 30 patients included in this study, with a mean age of 19.62 ± 5.53 years, 14 (46.7%) were male. Of the 15 patients aged 2–20 years, BMI was below the 5th percentile in 10 (66.7%), within the 5–10 percentiles in 1 (6.7%), 10–25 percentiles in 3 (20%), and 25-50 percentiles in 1 (6.7%). The mean BMI for 15 patients > 20 years was 18.03 ± 2.53 kg/m2. LUS had better diagnostic performance compared to CXR for the detection of air bronchogram, consolidation, and pleural thickening (area under the receiver operating characteristic curve [AUROC]: 0.966 vs. 0.483, 0.900 vs. 0.575, and 0.656 vs. 0.531, respectively). Also, LUS was 100% and 96.7% specific for the diagnosis of pleural effusion and atelectasis, respectively. Conclusions LUS appears to be superior to CXR and comparable with HRCT for the evaluation of CF pulmonary exacerbation, especially in terms of air bronchogram and consolidation detection. LUS can be used to lengthen the HRCT evaluation intervals in this regard or utilized along with HRCT for better evaluation of CF pulmonary exacerbation.

Diagnostic Performance Of Radiology Residents In Thoracic Ct Imaging In Emergency Radiology During The Covid-19 Pandemic

2021 ◽  
Vol 17 ◽  
Author(s):  
Vefa Cakmak ◽  
Duygu Herek ◽  
Pinar Cakmak
Keyword(s):  
Sensitivity And Specificity ◽  
Predictive Value ◽  
Diagnostic Performance ◽  
High Sensitivity ◽  
Ct Images ◽  
Roc Curve Analysis ◽  
Thoracic Ct ◽  
Thoracic Computed Tomography ◽  
Radiology Residents ◽  
And Gender

Background: During the COVID-19 pandemic, the workload of all radiologists and radiology residents, as well as other clinical physicians, has increased. Introduction: This study aims to determine the diagnostic performance of radiology residents, who effectively contribute to the diagnosis of COVID-19. Methods: The thoracic computed tomography (CT) images of 135 patients aged 20–83 diagnosed with COVID-19 were evaluated retrospectively by five radiology residents and a radiologist with 10 years of experience. The diagnostic performance of the radiology residents in evaluating COVID-19 was assessed according to their year of residency and the patients’ age and gender. Receiver operating characteristic (ROC) curve analysis was performed to determine the sensitivity and specificity of radiology residents. Results: The radiology residents’ performance in determining COVID-19 using CT findings was evaluated as follows: sensitivity 97.22%, specificity 88.89%, positive predictive value 90.91%, negative predictive value 96.55%, and accuracy 93.33%. According to the year of residency, the sensitivity and specificity of the radiology residents in determining COVID-19 using CT images were between 92.3% and 100%, and 71.43% and 100%, respectively. Conclusion: The high sensitivity and specificity of radiology residents in evaluating thoracic CT images for COVID-19 diagnosis indicate that radiologists are as important as clinical physicians in the diagnosis of COVID-19.

Abstract 17034: Diagnostic Accuracy of Diastolic Pressure Ratio Using a Microcatheter: An Analysis of the ACIST-FFR Study

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Matthew Price ◽  
Jaden Yang ◽  
Jeffrey Chambers ◽  
Arnold Seto ◽  
Iam Sarembock ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Diastolic Pressure ◽  
Pressure Ratio ◽  
Aortic Pressure ◽  
Paired Data ◽  
System A ◽  
Pressure Wire ◽  
Stable Cad ◽  
Highly Correlated ◽  
Automated Software

Background: The diastolic pressure ratio (dPR) is a non-hyperemic index used to measure the ratio of distal coronary to aortic pressure during a diastolic portion of the cardiac cycle. dPR indices measured by a pressure wire have similar diagnostic accuracy as iFR for FFR. The accuracy of dPR using a microcatheter (MC) has not been defined. Methods: The ACIST-FFR study was a prospective, multicenter study of a pressure-monitoring MC in patients with stable CAD. Using an automated software algorithm, dPR with the MC was defined as the Pd/Pa at the location within the diastolic period that was 50% of the distance from the peak of one waveform to the peak of the next waveform, averaged over a 5-beat period. iFR with the MC was computed in the usual fashion by the core laboratory from the original pressure tracings. Results: A total of 161 paired data samples from 11 sites were analyzed. dPR was highly correlated with iFR (R 2 =0.992, AUC=0.998 with a mean bias of -0.0237 (95% CI, -0.0041 to -0.0011) and provided a sensitivity of 98%, specificity 96%, and diagnostic accuracy of 96.9%. The optimal cutpoint of dPR for FFR was 0.91 (AUC=0.886), which provided a sensitivity of 82%, specificity of 80%, and diagnostic accuracy of 81%. The diagnostic accuracy of iFR for FFR was 81%, with a sensitivity of 82%, and specificity 80%. Conclusions: With a MC system, a non-hyperemic diastolic pressure ratio is highly correlated with iFR, and provides similar diagnostic accuracy as iFR for FFR.

scholarly journals Association of Serum Uric Acid Concentration and Its Change with Cardiovascular Death and All-Cause Mortality

2020 ◽  
Vol 2020 ◽  
pp. 1-10 ◽  
Author(s):  
Ze-Xuan Dong ◽  
Ming Tian ◽  
Hua Li ◽  
Yang Wu ◽  
Xing-Guo Du ◽  
...  
Keyword(s):  
Uric Acid ◽  
Confidence Interval ◽  
Predictive Value ◽  
Cardiac Death ◽  
Characteristic Curve ◽  
Maintenance Hemodialysis ◽  
Uric Acid Concentration ◽  
Serum Uric Acid Concentration ◽  
Significant Difference ◽  
All Cause Mortality

Objective. There is no consensus on the role of abnormal uric acid (UA) levels in the prognosis of patients undergoing hemodialysis. We therefore aimed to investigate the effects of changes in UA concentration on the risk of all-cause death and cardiac death in such patients. Method. In this retrospective cohort study, patients admitted to two hemodialysis centers performing maintenance hemodialysis (MHD) in Wuhan First Hospital and Fourth Hospital Hemodialysis Center from January 1, 2007, to October 31, 2017, were included. Results. In all, 325 patients undergoing MHD aged 59.7±14.7 years, including 195 men (60%), were enrolled, with a median follow-up of 37 months. Serum UA (p<0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p=0.193) between the two groups. Patients were assigned Quartile 1-Quartile 4 (from lowest to highest) based on serum UA levels. A total of 45 of 81 (55.6%) patients in Quartile 1 experienced all-cause death; 19 of 82 (23.2%) in Quartile 4 had all-cause mortality (OR, 0.2; 95% confidence interval, 0.1 to 0.5; p for trend<0.001). 25 of 81 (30.9%) in Quartile 1 had cardiac death; and 11 of 82 (13.4%) in Quartile 4 had cardiac death (OR, 0.3; 95% confidence interval, 0.2 to 0.8; p for trend=0.003). After adjusting for age, primary renal disease, vascular access, serum albumin, and UA variability, the OR values and 95% CI for all-cause death and cardiac death were 0.3 and 0.1-0.7 (p=0.001) and 0.6 and 0.2-1.4 (p=0.101), respectively. Additionally, the receiver operating characteristic curve showed that UA concentration and its changes combined with age had a good predictive value for all-cause mortality in patients undergoing MHD (AUC=0.7517, 95% CI: 0.6677-0.811, p=0.0245). However, the predictive value of cardiac death was not improved (AUC=0.7394, 95% CI: 0.6677-0.811, p=0.2194). Conclusion. Low UA levels were closely related to all-cause mortality in patients undergoing MHD. Although UA levels had no significant effect on cardiac death, they had a good predictive value for long-term prognosis in patients on MHD.

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