Uptake and detection rate of a stepwise cardiometabolic disease detection program in primary care—a cohort study

Abstract Background Early detection and treatment of cardiometabolic diseases (CMD) in high-risk patients is a promising preventive strategy to anticipate the increasing burden of CMD. The Dutch guideline ‘the prevention consultation’ provides a framework for stepwise CMD risk assessment and detection in primary care. The aim of this study was to assess the outcome of this program in terms of newly diagnosed CMD. Methods A cohort study among 30 934 patients, aged 45–70 years without known CMD or CMD risk factors, who were invited for the CMD detection program within 37 general practices. Patients filled out a CMD risk score (step 1), were referred for additional risk profiling in case of high risk (step 2) and received lifestyle advice and (pharmacological) treatment if indicated (step 3). During 1-year follow-up newly diagnosed CMD, prescriptions and abnormal diagnostic tests were assessed. Results Twelve thousand seven hundred and thirty-eight patients filled out the risk score of which 865, 6665 and 5208 had a low, intermediate and high CMD risk, respectively. One thousand seven hundred and fifty-five high-risk patients consulted the general practitioner, in 346 of whom a new CMD was diagnosed. In an additional 422 patients a new prescription and/or abnormal diagnostic test were found. Conclusions Implementation of the CMD detection program resulted in a new CMD diagnosis in one-fifth of high-risk patients who attended the practice for completion of their risk profile. However, the potential yield of the program could be higher given the considerable number of additional risk factors—such as elevated glucose, blood pressure and cholesterol levels—found, requiring active follow-up and presumably treatment in the future.

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Survival in Patients with Newly Diagnosed Myeloma Undergoing Therapy with Lenalidomide and Dexamethasone: Impact of High-Risk Cytogenetic Risk Status on Outcome

Blood ◽

10.1182/blood.v112.11.95.95 ◽

2008 ◽

Vol 112 (11) ◽

pp. 95-95 ◽

Cited By ~ 1

Author(s):

Prashant Kapoor ◽

Shaji Kumar ◽

Rafael Fonseca ◽

Martha Q. Lacy ◽

Thomas E Witzig ◽

...

Keyword(s):

High Risk ◽

Risk Stratification ◽

Plasma Cell ◽

Risk Groups ◽

Newly Diagnosed ◽

High Risk Patients ◽

Risk Patients ◽

The Impact ◽

Standard Risk

Abstract Background: Multiple myeloma (MM) is a heterogeneous disease with very divergent outcomes that are dictated in a large part by specific cytogenetic abnormalities, as well as other prognostic factors such as the proliferative rate of marrow plasma cells. Prognostic systems incorporating these factors have shown clinical utility in identifying high-risk patients, and are increasingly being utilized for treatment decision-making. However, the prognostic relevance of these factors may change with the application of novel therapies. The objective of this study was to determine the impact of risk-stratification (incorporating plasma cell metaphase cytogenetics, interphase fluorescent in-situ hybridization (FISH) and the slide-based plasma cell labeling index (PCLI)) in a cohort of patients with newly diagnosed MM treated initially with lenalidomide + dexamethasone (Rev-Dex). Methods: From March 2004 to November 2007, 100 consecutive patients treated with Rev (25mg/day) on days 1 through 21 of a 4-week cycle in combination with dexamethasone as initial therapy for newly diagnosed myeloma, were identified. High-risk MM was defined as presence of any one or more of the following: hypodiploidy, monoallelic loss of chromosome 13 or its long arm (by metaphase cytogenetics only), deletion of p53 (locus 17p13) or PCLI ≥ 3% or immunoglobulin heavy chain (IgH) translocations, t(4;14) (p16.3;q32) or t(14;16)(q32;q23) on FISH. PFS and OS survival estimates were created using the Kaplan Meier method, and compared by log-rank tests. Results: The median estimated follow-up of the entire cohort (N=100) was 36 months. The median PFS was 31 months; the median OS has not been reached. The 2- and 3-year OS estimates were 93% and 83%, respectively. 16% patients were deemed high-risk by at least one of the 3 tests (cytogenetics, FISH or PCLI). Response rates (PR or better) were 81% versus 89% in the high-risk and standard risk groups, respectively, P=NS; corresponding values for CR plus VGPR rates were 38% and 45% respectively. The median PFS was 18.5 months in high-risk patients compared to 37 months in the standard-risk patients (n=84), P<0.001(Figure). Corresponding values for TTP were 18.5 months and 36.5 months, respectively, P=<0.001. OS was not statistically significant between the two groups; 92% 2-year OS was noted in both the groups. Overall, 95 patients had at least one of the 3 tests to determine risk, while 55 patients could be adequately stratified based on the availability of all the 3 tests, or at least one test result that led to their inclusion in the high-risk category. The significant difference in PFS persisted even when the analysis was restricted to the 55 patients classified using this stringent criterion; 18.5 months vs. 36.5 months in the high-risk and standard- risk groups respectively; P<0.001. In a separate analysis, patients who underwent SCT before the disease progression were censored on the date of SCT to negate its effect, and PFS was still inferior in the high-risk group (p=0.002). Conclusion: The TTP and PFS of high-risk MM patients are inferior to that of the standard-risk patients treated with Rev-Dex, indicating that the current genetic and proliferation-based risk-stratification model remains prognostic with novel therapy. However, the TTP, PFS, and OS obtained in high-risk patients treated with Rev-Dex in this study is comparable to overall results in all myeloma patients reported in recent phase III trials. In addition, no significant impact of high-risk features on OS is apparent so far. Longer follow-up is needed to determine the impact of risk stratification on the OS of patients treated with Rev-Dex. Figure Figure

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Surgical treatment of valve endocarditis in high-risk patients and predictors of long-term outcomes

Scientific Reports ◽

10.1038/s41598-021-03602-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Giuseppe Nasso ◽

Giuseppe Santarpino ◽

Marco Moscarelli ◽

Ignazio Condello ◽

Angelo Maria Dell’Aquila ◽

...

Keyword(s):

Risk Factors ◽

Infective Endocarditis ◽

High Risk ◽

Aortic Valve ◽

Hospital Mortality ◽

Long Term Outcomes ◽

High Risk Patients ◽

Risk Patients

AbstractInfective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients. We retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis. Preoperative renal failure, an elevation EuroSCORE II and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% vs. 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135 ± 65 min in dead patients vs. 76 ± 32 min in surviving patients; p = 0.0005). Mean follow up was 57.94 ± 30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis). Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI 97–100%), 96% (95% CI 92–100%), 85.9% (95% CI 76–97%), and 74% (95% CI 60–91%) respectively. Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

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Genomic classifier (ColoPrint) to predict outcome and chemotherapy benefit in stage II and III colon cancer patients.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.3612 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 3612-3612

Author(s):

Scott Kopetz ◽

Zhi-Qin Jiang ◽

Michael J. Overman ◽

Robert Rosenberg ◽

Ramon Salazar ◽

...

Keyword(s):

Risk Factors ◽

High Risk ◽

Adjuvant Chemotherapy ◽

Additional Treatment ◽

Low Risk ◽

Stage Ii ◽

Nccn Guidelines ◽

High Risk Patients ◽

Risk Patients

3612 Background: Although benefit of chemotherapy in stage II and III colorectal cancer patients is significant, many patients might not need adjuvant chemotherapy because they have a good prognosis even without additional treatment. ColoPrint is a gene expression classifier that distinguish patients with low or high risk of disease relapse. It was developed using whole genome expression data and validated in independent validation studies (JCO 2011, Ann Surg 2013). Methods: In this study, ColoPrint was validated in stage II (n=96) and III patients (n=95) treated at the MD Anderson Cancer Center. Frozen tissue specimen, clinical parameters and follow-up data (median follow-up 64 months) were available. Stage II patients from this study were pooled with patients from previous studies (n=416) and ColoPrint performance was compared to clinical risk factors described in the NCCN Guidelines 2013. Results: In the MDACC patient cohort, ColoPrint classified 56% of stage II and III patients as being at Low Risk. The 3-year Relapse-Free-Survival (RFS) was 90.5% for Low Risk and 78.1% for High Risk patients with a HR of 2.42 (p=0.025). In uni-and multivariate analysis, ColoPrint and stage were the only significant factors to predict outcome. Low Risk ColoPrint patients had a good outcome independent of stage or chemotherapy treatment (91% 3-year RFS for treated patients, 90% for untreated patients) while ColoPrint High Risk patients treated with adjuvant chemotherapy had 3-year RFS of 84%, compared to 70% 3-year RFS in untreated patients (p=0.037). In the pooled stage II dataset, ColoPrint identified 63% of patients as Low Risk with a 3-year RFS of 93% while High Risk patients had a 3-year RFS of 82.3% with a HR of 2.7 (p=0.001). In the univariate analysis, no clinical factor reached statistical significance. Using clinical high risk factors as described in the NCCN guidelines as classification, 56% of patients were classified as low risk with a 3-year RFS of 90.3% while high risk patients had a 3-year RFS of 87.7% with a HR of 0.6 (p=0.63). Conclusions: ColoPrint significantly improves prognostic accuracy, thereby facilitating the identification of patients at higher risk who might be considered for additional treatment.

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Registered Dietitian Nutritionists Are Associated with Improved Long-Term Clinical Outcomes in High-Risk Patients

Current Developments in Nutrition ◽

10.1093/cdn/nzaa059_010 ◽

2020 ◽

Vol 4 (Supplement_2) ◽

pp. 1293-1293

Author(s):

Erika Cavanaugh ◽

Heather Zeman ◽

Elizabeth Metallinos-Katsaras ◽

Shelley Strowman ◽

Kathy Ireland ◽

...

Keyword(s):

Primary Care ◽

High Risk ◽

Repeated Measures ◽

Registered Dietitian ◽

High Risk Patients ◽

Significant Difference ◽

Risk Patients ◽

Registered Dietitian Nutritionists

Abstract Objectives Treatment from registered dietitian nutritionists (RDNs) has been shown to improve weight and hemoglobin A1c in high-risk patients, yet little is known about these outcomes long term. The current study investigated the association between RDN care and changes in weight and HbA1c compared to primary care in high-risk patients (BMI ≥35 kg/m2 or HbA1c ≥7%) long term up to 24 months. Methods This was a retrospective cohort study of high-risk adults. Electronic medical records were reviewed for participants who were 18 years or older with BMI ≥35 kg/m2 or HbA1c ≥7.0% at first visit to a patient centered medical home in Boston, MA. Mean change in weight (kg) and HbA1c (%) at six, 12, and 24 months were compared between patients who saw an RDN and patients who received primary care only. Paired sample t-tests and repeated measures ANOVA adjusting for age, sex, gender, days from baseline at follow-up visit, and number of clinic visits at follow-up were used to analyze outcomes. Results 1902 patients with BMI >35 and 1240 patients with a HbA1c >7.0% were included. There was no significant difference in 24-month weight loss between RDN care and standard primary care. HbA1c decreased significantly with RDN care at all time points (P < 0.001). Patients with at least one RDN visit had a significantly greater mean change in HbA1c of −0.8 ± 0.2 (95% CI −1.0 to −0.5) and −0.6 ± 0.1 (95% CI −0.8 to −0.3) after 12 and 24 months from baseline, respectively (P < 0.001). Conclusions RDN care resulted in statistically and clinically significant improvements in HbA1c at 12 and 24 months compared to standard primary care alone. Funding Sources The authors received no specific funding for this work.

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Results from the International Silver Graft Registry for high-risk patients treated with a metallic-silver impregnated vascular graft

Vascular ◽

10.1177/1708538113478773 ◽

2013 ◽

Vol 21 (3) ◽

pp. 137-147 ◽

Cited By ~ 12

Author(s):

Max Zegelman ◽

Gisela Guenther ◽

Matthias Waliszewski ◽

Fryderyk Pukacki ◽

Michal Goran Stanisic ◽

...

Keyword(s):

Risk Factors ◽

High Risk ◽

De Novo ◽

Graft Infection ◽

Graft Patency ◽

Metallic Silver ◽

High Risk Patients ◽

Co Morbidity ◽

Risk Patients

The purpose of this postmarket surveillance registry was to document the efficacy of a vascular prosthesis coated with metallic silver in high-risk patients undergoing vascular reconstructions. Patency (primary endpoint) and freedom from graft infection (secondary endpoint) data were assessed at a minimum of 12 months in patients with significant co-morbidity and/or confirmed graft infections or infected native vessels. Between November 2006 and December 2009, 230 patients with high-risk factors underwent aortic, peripheral and/or extra-anatomic reconstructions with Silver Graft® (SG) in six German, one French and one Polish vascular center. All participating centers used the metallic silver-coated polyester graft (SG) in various diameters and lengths including tubular and bifurcate vascular grafts. Doppler ultrasound follow-ups to determine graft patency were planned at 12 months or done at an earlier time in case the patient became symptomatic. A total of 230 patients were studied. Ten of these 230 patients had graft infections at baseline whereas the remaining 220 subjects had significant risk factors such as coronary artery disease (62.7%, 138/220), vascular access in scar tissue (27.3%, 60/220), Fontaine III/IV (38.2%, 84/220), chronic renal insufficiency (26.8%, 59/220) and diabetes (21.0%, 46/220). The long-term follow-up at 15.5 ± 8.3 months revealed a secondary patency rate of 93.2% (205/220) and an ‘all cause’ mortality rate of 18.6% (41/220). There was a freedom from de novo graft infection rate of 95.9% (211/220) in the high-risk group without graft infections at baseline. One regraft infection occurred distal of the revisional reconstruction in the 10 patients with graft infection at baseline. The presence of perigraft fluid at follow-up and Fontaine III/IV at baseline were found to be predictors for graft patency whereas perigraft fluid presence was the only predictor for de novo graft infections. This registry revealed favorable patency and freedom from de novo infections rates in a ‘high-risk’ population with significant co-morbidities.

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Innovative 12 months ticagrelor virtual clinic – supporting appropriate extended dual anti-platelet therapy in post MI

European Heart Journal ◽

10.1093/ehjci/ehaa946.1448 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Khatib ◽

S Awan ◽

F Wilson ◽

A Barrowcliff ◽

S Wheatcroft ◽

...

Keyword(s):

Risk Factors ◽

Primary Care ◽

High Risk ◽

Funding Source ◽

Close Monitoring ◽

Index Point ◽

High Risk Patients ◽

Risk Of Bleeding ◽

Risk Patients ◽

Virtual Clinic

Abstract Background The ESC and NICE guidelines recommend extended dual antiplatelet therapy (DAPT) with Ticagrelor 60mg twice a day for 3 years after 12 months of a myocardial infarction (MI) among high risk patients with low risk of bleeding. As those patients in our health system are not routinely reviewed by a cardiologist, we introduced a 12 months Virtual Review clinic to support primary care in ensuring that appropriate patients are offered extended DAPT. Methods Working with primary care, a group for cardiologists and cardiology pharmacists established a clear guidance and pathway for identifying patients who are suitable for extended DAPT with Ticagrelor 60mg twice a day for 3 years inline with ESC guidelines. A virtual review clinic was established where primary care can refer potential candidates to be considered for extended DAPT. Patients needed to have had an MI approximately 12 months before the referral, have uptodate full blood counts and creatinine. Patients were reviewed virtually by a cardiology pharmacist against an agreed protocol. Patient risk factors and eligibility were identified and their risk of bleeding was assessed using the PRECISE-DAPT scoring. Complicated patients were discussed with a cardiologist and the final recommendation was sent to primary care electronically. Results 201 patients were reviewed in the virtual clinic; Mean age 69, 58% were males. 60% had NSTEMI, 37% STEMI, and the rest had either Unstable Angina or Type II MI. 28% had diabetes, 22% had prior MI, 60% had multivessel disease, and 22% were anaemic. 93% of patients had at least one high risk factor according to PEGASUS trial. 33% (n=67) of all patients reviewed were high risk of bleeding according to PRECISE-DAPT. Of these 78% (n=52) were not suitable to extended DAPT despite 71% (n=37) having risk factors. The virtual clinic recommended extended DAPT for 40% (n=81) of patients referred. In the case of 15 patients extended DAPT was recommended despite High risk of bleeding as deemed appropriate by the MDT with close monitoring. At discharge post index point, 18% (n=37) had recommendations to extend DAPT or not by the interventionist. 11% (n=4) of those recommendations were reversed at the 12 months review. 40% (n=80) of patients reviewed in clinic were inappropriately on Ticagrelor 90mg twice a day (with aspirin) beyond 12 months post MI. That is a total of 556 months of excess ticagrelor. 19 patients were HIGH risk of bleeding Discussion and conclusion The multidisciplinary innovative 12 months virtual review clinic improved appropriate initiation of extended DAPT in high risk patients and reduced risk of bleeding by stopping inappropriate antiplatelet dosing (90mg vs. 60mg). The clinic supported the low levels of recommendations made by the interventionist at index point and assured safety when actioning these recommendations. The virtual review clinic improved levels of extended DAPT prescribing and improved patient safety. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): This is a service development project funded by the Leeds NHS Community Commissioning Group

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Surgical Treatment of Valve Endocarditis in High-Risk Patients: Predictors of Long Term Outcome

10.21203/rs.3.rs-468101/v2 ◽

2021 ◽

Author(s):

Giuseppe Nasso ◽

Giuseppe Santarpino ◽

Marco Moscarelli ◽

Ignazio Condello ◽

Angelo Maria Dell'Aquila ◽

...

Keyword(s):

Risk Factors ◽

Infective Endocarditis ◽

High Risk ◽

Aortic Valve ◽

Hospital Mortality ◽

High Risk Patients ◽

Cross Clamp Time ◽

Risk Patients

Abstract IntroductionInfective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients.MethodsWe retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis.ResultsPreoperative renal failure, an elevation of all types of EuroSCORE (EuroSCORE I, II and logistic) and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% versus 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135±65 min in dead patients versus 76±32 min in surviving patients; p = 0.0005). Mean follow up was 57.94±30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis).Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI: 97%-100%), 96% (95% CI: 92%-100%), 85.9% (95% CI: 76%-97%), and 74% (95% CI: 60%-91%) respectively.Conclusion Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

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