MO805CAUSAL PATHWAY-BASED PHYSIOLOGICAL MODELING OF VASCULAR CALCIFICATION IN HEMODIALYSIS PATIENTS

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Alhaji Cherif ◽  
Jakob Voelkl ◽  
Peter Kotanko
Keyword(s):  
Risk Factors ◽  
Vascular Calcification ◽  
Pulse Pressure ◽  
Kidney Diseases ◽  
Cardiac Insufficiency ◽  
Patient Specific ◽  
Physiological Modeling ◽  
Neutrophil Lymphocyte Ratio ◽  
Causal Pathway ◽  
The Impact

Abstract Background and Aims Vascular calcification (VC) is common sequelae in chronic and end-stage kidney diseases (CKD/ESKD), and is associated with multiple risk factors, including disturbed bone metabolism and mineral disorders (CKD-BMD), uremia, leading to increased morbidity and mortality. The mechanism involves multiple physiological processes and is not well understood. The study aims to develop a causal pathway-based physiological model describing patient-specific drivers of vascular calcification. Method We develop a causal pathway-based physiological modeling that utilizes clinical data to identify patients with high risks of progression of VC and cardiometabolic diseases to provide multifactorial intervention strategies targeting the risk factors. We investigate the response of pulse pressure (PP, a proxy for pulse wave velocity) to parathyroid hormones (PTH), calcium (Ca), phosphate (PO4), calcium-phosphate product (CaPO4), neutrophil-lymphocyte ratio (NLR), and albumin (Alb). Pulse pressure may account for both cardiac and vascular conditions (e.g., atrial fibrillation, aortic insufficiency, arterial stiffness or arteriovenous malformation, aortic valve stenosis, cardiac insufficiency or cardiac tamponade). Results We demonstrate the causal pathway of PTH, Ca, PO4, NLR, and Alb on PP, and find that there are likely paths from PTH, Ca, PO4, CaPO4, NLR to PP, where the strength of the relationships vary from patient to patient. Figure 1 shows a representative patient. Figure 1(a) shows the longitudinal data for the aforementioned clinical parameters. Using a subset of the data (1 year was used), we extracted causal relationships between the clinical (Fig. 1(b)). As shown in Fig. 1(c), some of the relationships are physiologically consistent with current knowledge of the PTH, Ca, and PO4 disturbances on CKD-BMD, vascular calcification being one of the axes. Also, NLR is a measure of inflammation, which is also known to promote vascular calcification. Further, potential pathways were also detected, namely the direct or mediated effects of Alb and PTH on PP (as shown in Figs. 1(b)-(c)). Using these pathways, a dynamic model describing these interactions can be used to prescriptive investigate the impact of the dynamics on the progression of calcification. Conclusion From the clinical variables, the method was able to extract both known and potential drivers for changes on PP for the representative patients. Additional study is needed to confirm these relationships both prospectively, clinical investigation of potential pathways, and to further observe the long-term clinical manifestation of vascular calcification.

Abstract 141: Impact of an Aggressive Medical Management Protocol on Early Risk Factor Measures in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) Trial

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tanya N Turan ◽  
Azhar Nizam ◽  
Michael J Lynn ◽  
Colin P Derdeyn ◽  
David Fiorella ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Medical Management ◽  
Intracranial Stenosis ◽  
Patient Specific ◽  
Early Risk ◽  
Aggressive Medical Management ◽  
The Impact ◽  
Early Risk Factor

Purpose: SAMMPRIS is the first stroke prevention trial to include protocol-driven aggressive management of multiple vascular risk factors. We sought to determine the impact of this protocol on early risk factor control in the trial. Materials and Methods: SAMMPRIS randomized 451 patients with symptomatic 70%-99% intracranial stenosis to aggressive medical management or stenting plus aggressive medical management at 50 USA sites. For the primary risk factor targets (SBP < 140 mm/Hg (<130 if diabetic) and LDL < 70 mg/dL), the study neurologists follow medication titration algorithms and risk factor medications are provided to the patients. Secondary risk factors (diabetes, non-HDL, weight, exercise, and smoking cessation) are managed with assistance from the patient’s primary care physician and a lifestyle modification program (provided). Sites receive patient-specific recommendations and feedback to improve performance. Follow-up continues, but the 30-day data are final. We compared baseline to 30-day risk factor measures using paired t-tests for means and McNemar tests for percentages. Results: The differences in risk factor measures between baseline and 30 days are shown in Table 1. Conclusions: The SAMMPRIS protocol resulted in major improvements in controlling most risk factors within 30 days of enrollment, which may have contributed to the lower than expected 30 day stroke rate in the medical group (5.8%). However, the durability of this approach over time will be determined by additional follow-up.

Acute Effects of an Inorganic Phosphorus Additive on Mineral Metabolism and Cardiometabolic Risk Factors in Healthy Subjects

2021 ◽  
Author(s):  
Christin Volk ◽  
Benjamin Schmidt ◽  
Corinna Brandsch ◽  
Tabea Kurze ◽  
Ulf Schlegelmilch ◽  
...  
Keyword(s):  
Risk Factors ◽  
Healthy Subjects ◽  
Kidney Diseases ◽  
Mineral Metabolism ◽  
Fibroblast Growth Factor 23 ◽  
Inorganic Phosphorus ◽  
Dihydrogen Phosphate ◽  
Double Blind ◽  
Dietary Phosphorus ◽  
The Impact

Abstract Context Hyperphosphatemia and high levels of fibroblast growth factor 23 (FGF23) are risk factors for cardiovascular events in patients with chronic kidney diseases. However, the impact of an inorganic phosphorus additive in healthy people is largely unknown. Objective We aimed to investigate the acute effect of excessive dietary phosphorus administered as sodium dihydrogen phosphate on the postprandial levels of Pi and FGF23 and the response to food. Methods This study was a double-blind placebo-controlled crossover study with 29 healthy male and female participants from the general community who were administered a single dose of either 700 mg phosphorus (NaH2PO4) or a sodium-adjusted placebo in combination with a test meal. Postprandial plasma levels of Pi and FGF23 were measured. Results Compared with placebo, oral phosphorus increased the plasma Pi level, which remained elevated during the ensuing 8 hours (at 480 minutes: 1.31 vs 1.16 mmol/l; P &lt; 0.001), increased urinary Pi (iAUC0-480 789 vs 95 mmol/mmol; P &lt; 0.001), reduced tubular Pi reabsorption (iAUC0-480 −31.5 vs −6.2; P &lt; 0.001), decreased urinary calcium (iAUC0-240 30.6 vs 53.0 mmol/mmol; P = 0.009), and stimulated the release of parathyroid hormone (iAUC0-480 2212 vs 768 ng/l; P &lt; 0.001). However, the FGF23 levels did not change. Postprandial levels of glucose, insulin, and lipids were not substantially affected by phosphorus vs placebo. Conclusion An oral phosphorus load can induce elevated postprandial levels of circulating Pi for hours in healthy subjects, despite rapid homeostatic counterreactions. FGF23 levels and the postprandial response to food were not affected.

scholarly journals SO083VASCULAR STIFFNESS ESTIMATED NON-INVASIVELY USING PULSE WAVE PROPAGATION CORRESPONDS TO VASCULAR BIOPSY FINDINGS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Malgorzata Debowska ◽  
Bengt Lindholm ◽  
Lu Dai ◽  
Jacek Waniewski ◽  
Abdul Rashid Tony Qureshi ◽  
...  
Keyword(s):  
Mathematical Model ◽  
Wave Propagation ◽  
Vascular Calcification ◽  
Pulse Pressure ◽  
Pulse Wave ◽  
Vascular Stiffness ◽  
Patient Specific ◽  
P Value ◽  
Pulse Wave Propagation ◽  
Pressure Profiles

Abstract Background and Aims Patients with chronic kidney disease (CKD) are at high risk of cardiovascular disease (CVD) due to complex processes in the uremic milieu linked to CKD - mineral and bone disorders (CKD-MBD). These processes alter structure and function of heart and vasculature e.g. by causing ectopic calcification that makes vessels stiffer thus affecting pulse (pressure) wave profiles. Our study aimed to derive patient-specific parameters using pulse wave propagation model including arterial stiffness and compare those parameters with cardiovascular status including biopsy proven severity of vascular calcification. Method In a group of 81 CKD (stage 5) patients undergoing living donor kidney transplantation, the degree of medial calcification in epigastric artery was histologically graded as 0 (n=22), 1 (n=31), 2 (n=21) and 3 (n=7) representing no, minimal, moderate and extensive signs of vascular calcification, respectively. Concomitantly 82 features were determined including demographic and anthropometric features, blood biomarkers related to CKD - MBD and other measurements. Pressure profiles (circles in Fig. 1) in radial artery were recorded using applanation tonometer (SphygmoCor, AtCor Medical, Australia) and used to derive patient-specific parameters from a mathematical model describing blood flow and pressure in 55 major arteries. Results The model was able to reproduce all recorded pressure profiles with high accuracy with average relative error less than 8% (compare solid line and circles in Fig. 1). Vascular stiffness, derived from the model, in arterial branches located in the area of artery for which calcification was histologically quantified, was significantly higher for higher calcification score (p-value &lt; 0.001). The estimated stiffness correlated with the level of troponin T (rho=0.65**), advanced glycation end-products (by skin autofluorescence, rho=0.55*), osteoprotegerin (rho=0.44**), hepcidin 25 (rho=0.32*, interleukin 6 (rho=0.29*) and choline (rho=0.28**), (‘**’ and ‘*’ denote p-value &lt; 0.01 and 0.05, respectively). Stiffer arteries were found in patients with diagnosed CVD (p-value &lt; 0.01). Conclusion We demonstrate that a mathematical model based on a single peripheral recording of pulse pressure profile has the potential to provide information about cardiovascular status in the individual patient. Also, the estimated stiffness correlates well with several well-established CVD risk factors. Our mathematical model of the arterial tree, if validated in larger cohorts of patients, may be used as computational tool to predict vascular stiffness without need of arterial biopsy.

scholarly journals 2203. Patient-Specific Risk Stratification to Identify Patients at High and Low Risk for P. aeruginosa in Community-Acquired Pneumonia

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S751-S751
Author(s):  
William Justin Moore ◽  
Caroline Cruce ◽  
Karolina Harkabuz ◽  
Shereen Salama ◽  
Sarah Sutton ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Risk Stratification ◽  
Antibiotic Use ◽  
Community Acquired Pneumonia ◽  
Low Risk ◽  
Patient Specific ◽  
Stepwise Logistic Regression ◽  
Case Status ◽  
The Impact

Abstract Background Pseudomonas aeruginosa (PsA) is an infrequent pathogen associated with poor outcomes in community-acquired pneumonia (CAP). Identifying patients at high and low-risk for PsA in CAP is necessary to reduce inappropriate and overly broad-spectrum antibiotic use. We evaluated the distribution of risk-factors in hospitalized CAP patients with and without PsA infection. Methods Design: retrospective, single-center, case–control study. Inclusion: hospitalized CAP patients admitted to the general medicine wards between January 1, 2014 and May 29, 2018. Exclusion: cystic fibrosis, ≥ 3 admissions within 30 days, CAP requiring ICU admission, and death within 48 hours of admission. Case patients had PsA in respiratory or blood cultures during the index CAP admission. Controls were randomly selected targeting a 3:1 ratio. Comorbidities, pneumonia severity index, and m-APACHE II were assessed. Gram-negative risk factors defined by Shindo et al. 2013 (PMID: 23855620) and validated by Kobayashi et al. (2018; PMID: 30349327) were scored for each patient. Stepwise logistic regression was used to identify covariates that distinguished cases from controls at a P < 0.2; these were then used to generate propensity weights (i.e., inverse-probability conditioned on covariates). Unadjusted and adjusted odds ratios for case status were estimated using logistic regression according to: the total number of risk factors present and threshold values, respectively. All analyses were conducted using IC Stata (v.14.2). Results 54 cases and 152 controls were included. The distribution of the patient-specific sum of risk factors for PsA is shown in Figure 1. The univariate OR for case status was 4.29 (95% CI:1.55–11.9) at n = 3 risk factors, which was similar after propensity weight adjustment [aOR = 4.64 (95% CI: 1.32–16.3)]. The univariate OR of case status was 2.98 among patients with ≥ 3 risk factors (95% CI: 1.34–6.62), which was similar after propensity weight adjustment [aOR = 2.8 (95% CI: 1.02–7.72)], and correct classification was 73.8%. Conclusion At a threshold of ≥ 3 PsA risk factors, cases and controls were well classified, even after adjusting for propensity weights. The impact of patient-specific PsA risk-stratification on CAP outcomes and appropriate antibiotic use should be evaluated. Disclosures All authors: No reported disclosures.

scholarly journals Total Ankle Arthroplasty: Risk Factors For Subsequent Flap Coverage

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0003
Author(s):  
Daniel J. Cunningham ◽  
Sean Ryan ◽  
Samuel B. Adams
Keyword(s):  
Risk Factors ◽  
Total Ankle Arthroplasty ◽  
Patient Specific ◽  
Wound Complications ◽  
Diabetes Diagnosis ◽  
Ankle Arthroplasty ◽  
Medical Comorbidities ◽  
Flap Coverage ◽  
Wound Breakdown ◽  
The Impact

Category: Ankle Arthritis; Ankle; Diabetes Introduction/Purpose: Total ankle arthroplasty (TAA) results in improved patient outcomes and preserved range of motion for patients with end-stage arthritis. Wound complications following these procedures, while rare, can have a significant impact on patient morbidity, particularly when they require return to the operating room and flap coverage. We sought to determine the risk factors associated with the need for flap coverage over TAA, and hypothesized that intraoperative variables such as additional procedures to provide angular correction would play a more important role than patient-specific variables. Methods: We performed a single center retrospective review of primary total ankle arthroplasties from April 2007 - February 2019. Patients demographics and medical comorbidities were collected in addition to concomitant procedures performed at the time of TAA such as tibial osteotomies, removal of hardware, and subtalar fusion. Multivariable, main effects logistic regression models were performed to evaluate the impact of specific concomitant procedures during primary TAA on the rate of subsequent flap coverage with adjustment for age, sex, and medical comorbidities. Results: 2,124 TAA resulted in 29 flaps after an average of 1.1 (range 0-5) surgeries and 89.7 (range 18-591) days after the index arthroplasty. The most common flap was a radial forearm free flap performed in 15 (51.7%) patients. Patients requiring flap coverage were significantly older (p=0.044), were more likely to be diabetic (p=0.029), and were more likely to present to the ED and be readmitted within 90-days of their surgery (p<0.001). In a multivariable model controlling for age, gender, and diabetes diagnosis, patients with flaps were more likely to have a concomitant osteotomy (OR 3.720, 95% CI 1.693-8.177; p=0.001) at the time of there TAA. Other concomitant procedures did not show a significant association with subsequent need for flap coverage. Conclusion: Simultaneous procedures during TAA may place patients at higher risk of wound breakdown, specifically requiring flap coverage. In particular, osteotomies, namely tibial osteotomies for realignment, carry a special risk for wound healing difficulty. This should be considered as the indications for TAA continue to expand. [Table: see text]

scholarly journals What drives mortality among HIV patients in a conflict setting? A prospective cohort study in the Central African Republic

2018 ◽  
Author(s):  
Thomas Crellen ◽  
Charles Ssonko ◽  
Turid Piening ◽  
Marcel Mbeko Simaleko ◽  
Diemer Henri St. Calvaire ◽  
...  
Keyword(s):  
Risk Factors ◽  
Central African Republic ◽  
Linear Models ◽  
Opportunistic Infections ◽  
Patient Specific ◽  
People Living With Hiv ◽  
Armed Groups ◽  
Conflict Setting ◽  
Hiv Patients ◽  
The Impact

AbstractBackgroundProvision of antiretroviral therapy (ART) during conflict settings is rarely attempted and little is known about the expected patterns of mortality. The Central African Republic (CAR) continues to have a low coverage of ART despite an estimated 120,000 people living with HIV and 11,000 AIDS-related deaths in 2013. We present results from a cohort in Zemio, Haut-Mboumou prefecture. This region had the highest prevalence of HIV nationally (14.8% in 2010) and was subject to repeated attacks by armed groups on civilians during the observed period.MethodsConflict from armed groups can impact cohort mortality rates i) directly if HIV patients are victims of armed conflict, or ii) indirectly if population displacement or fear of movement reduces access to ART. Using monthly counts of civilian deaths, injuries and abductions, we estimated the impact of the conflict on patient mortality. We also determine patient-level risk factors for mortality and how this varies with time spent in the cohort. Model-fitting was performed in a Bayesian framework, using generalised-linear models with terms accounting for temporal autocorrelation.ResultsPatients were recruited and observed from October 2011 to May 2017. Overall 1631 patients were enrolled, giving 4107 person-years and 148 deaths. Our first model shows that patient mortality did not increase during periods of heightened conflict. The monthly risk (probability) of mortality was markedly higher at the beginning of the program (0.047 in November 2011 [95% credible interval; CrI 0.0078, 0.21]) and had declined greater than ten-fold by the end of the observed period (0.0016 in June 2017 [95% CrI 0.00042, 0.0036]). Our second model shows the risk of mortality for individual patients was highest in the first five months spent in the cohort. Male sex was associated with a higher mortality (odds ratio; OR 1.7 [95% CrI 1.2, 2.8]) along with the severity of opportunistic infections at baseline.ConclusionsOur results show that chronic conflict did not appear to adversely affect rates of mortality in this cohort, and that mortality was driven predominantly by patient specific risk factors. In areas initiating ART for the first time, particular attention should be focussed on stabilising patients with advanced symptoms.FundingMédecins Sans Frontières

scholarly journals Differences in Risk Factors and Prevalence of Vascular Calcification between Pre-Dialysis and Hemodialysis Balkan Nephropathy Patients

Medicina ◽  
2018 ◽  
Vol 54 (1) ◽  
pp. 4 ◽  
Author(s):  
Nenad Petković ◽  
Siniša Ristić ◽  
Jelena Marinković ◽  
Radmil Marić ◽  
Marijana Kovačević ◽  
...  
Keyword(s):  
Risk Factors ◽  
Vascular Calcification ◽  
Serum Cholesterol ◽  
Kidney Diseases ◽  
Serum Triglyceride ◽  
Balkan Endemic Nephropathy ◽  
Serum Triglyceride Level ◽  
Dialysis Patients ◽  
Lower Systolic Blood Pressure ◽  
Significant Difference

Aims: The aim of this study was to compare the risk factors and prevalence of vascular calcification (VC) in pre-dialysis and hemodialysis (HD) patients with Balkan endemic nephropathy (BEN) or other kidney diseases (non-BEN). Materials and Methods: The study involved 115 patients, 32 pre-dialysis and 83 HD patients, separated into groups of BEN and non-BEN patients. In addition to interviews, objective examinations and laboratory analyses, VC was assessed using Adragao score. Results: Patients with BEN were significantly older in both groups, while pre-dialysis BEN patients had significantly lower systolic blood pressure, serum cholesterol and phosphorus levels, but higher urinary excretion of phosphorus than non-BEN patients. These differences were lost in HD groups. In pre-dialysis patients, prevalence of VC was lower in BEN than in non-BEN group and mean VC score differed significantly between them (2.8 (1.7) vs. 4.6 (1.8); p = 0.009). No significant difference in VC score was found between BEN and non-BEN patients on HD. Multivariate analysis showed that in pre-dialysis patients VC score >4 was associated with lower iPTH and higher serum cholesterol level, but in the HD group with higher serum triglyceride level and longer HD vintage. Conclusions: Lower prevalence of risk factors for VC in the BEN than non-BEN patients was found in pre-dialysis but not in HD group and this was reflected in the prevalence and severity of VC in the groups. Prevalence of VC and mean VC score were significantly lower in pre-dialysis BEN than in non-BEN patients but not for those on HD.

scholarly journals What drives mortality among HIV patients in a conflict setting? A prospective cohort study in the Central African Republic

2019 ◽  
Vol 13 (1) ◽  
Author(s):  
Thomas Crellen ◽  
Charles Ssonko ◽  
Turid Piening ◽  
Marcel Mbeko Simaleko ◽  
Karen Geiger ◽  
...  
Keyword(s):  
Risk Factors ◽  
Central African Republic ◽  
Patient Specific ◽  
People Living With Hiv ◽  
Armed Groups ◽  
Conflict Setting ◽  
Hiv Patients ◽  
Cell Counts ◽  
Risk Of Mortality ◽  
The Impact

Abstract Background Provision of antiretroviral therapy (ART) in conflict settings is rarely attempted and little is known about the expected patterns of mortality. The Central African Republic (CAR) continues to have a low coverage of ART despite an estimated 110,000 people living with HIV and 5000 AIDS-related deaths in 2018. We present results from a cohort in Zemio, Haut-Mboumou prefecture. This region had the highest prevalence of HIV nationally (14.8% in a 2010 survey), and was subject to repeated attacks by armed groups on civilians during the observed period. Methods Conflict from armed groups can impact cohort mortality rates i) directly if HIV patients are victims of armed conflict, or ii) indirectly if population displacement or fear of movement reduces access to ART. Using monthly counts of civilian deaths, injuries and abductions, we estimated the impact of the conflict on patient mortality. We also determined patient-level risk factors for mortality and how the risk of mortality varies with time spent in the cohort. Model-fitting was performed in a Bayesian framework, using logistic regression with terms accounting for temporal autocorrelation. Results Patients were recruited and observed in the HIV treatment program from October 2011 to May 2017. Overall 1631 patients were enrolled and 1628 were included in the analysis giving 48,430 person-months at risk and 145 deaths. The crude survival rate after 12 months was 0.92 (95% CI 0.90, 0.93). Our model showed that patient mortality did not increase during periods of heightened conflict; the odds ratios (OR) 95% credible interval (CrI) for i) civilian fatalities and injuries, and ii) civilian abductions on patient mortality both spanned unity. The risk of mortality for individual patients was highest in the second month after entering the cohort, and declined seven-fold over the first 12 months. Male sex was associated with a higher mortality (odds ratio 1.70 [95% CrI 1.20, 2.33]) along with the severity of opportunistic infections (OIs) at baseline (OR 2.52; 95% CrI 2.01, 3.23 for stage 2 OIs compared with stage 1). Conclusions Our results show that chronic conflict did not appear to adversely affect rates of mortality in this cohort, and that mortality was driven predominantly by patient-specific risk factors. The risk of mortality and recovery of CD4 T-cell counts observed in this conflict setting are comparable to those in stable resource poor settings, suggesting that conflict should not be a barrier in access to ART.

scholarly journals The Impact of Baseline Risk Factors on the Incidence of Febrile Neutropenia in Breast Cancer Patients Receiving Chemotherapy with Pegfilgrastim Prophylaxis: A Real-World Data Analysis

2021 ◽  
Vol 8 (1) ◽  
pp. 106-115
Author(s):  
Edward Li ◽  
Bridgette Kanz Schroader ◽  
David Campbell ◽  
Kim Campbell ◽  
Weijia Wang
Keyword(s):  
Breast Cancer ◽  
Risk Factors ◽  
Febrile Neutropenia ◽  
Real World ◽  
Primary Prophylaxis ◽  
Patient Specific ◽  
Myelosuppressive Chemotherapy ◽  
Comparative Analyses ◽  
Specific Risk ◽  
The Impact

Background: There are sparse data addressing whether standard risk factors for febrile neutropenia (FN) are relevant in patients receiving myelosuppressive chemotherapy and primary prophylaxis for FN, which would have implications for variables to consider during real-world comparative analyses of FN incidence. Objective: To assess the impact of baseline patient-specific risk factors and regimen risk on the incidence of FN in patients receiving pegfilgrastim primary prophylaxis. Methods: This was a retrospective observational study in patients with breast cancer (BC) who received myelosuppressive chemotherapy and prophylactic pegfilgrastim identified January 1, 2017-May 31, 2018 from MarketScan® research databases. The outcomes were defined as incidence of FN in the first cycle and among all cycles of chemotherapy using three different definitions for FN. Logistic regression and generalized estimating equations models were used to compare outcomes among patients with and without patient-specific risk factors and among those receiving regimens categorized as high-, intermediate-, or other-risk for FN (low-risk or undefinable by clinical practice guidelines). Results: A total of 4460 patients were identified. In the first cycle of therapy, patients receiving intermediate-risk regimens were at up to 2 times higher risk for FN across all definitions than those receiving high-risk regimens (P<0.01). The odds ratio for main FN among patients with ≥4 versus 0 risk factors was 15.8 (95% confidence interval [CI]: 1.5, 169.4; P<0.01). Patients with ≥3 FN risk factors had significantly greater risks for FN across all cycles of treatment than those with no risk factors; this was true for all FN definitions. Discussion: The choice of FN definition significantly changed the impact of risk factors on the FN outcomes in our study, demonstrating the importance of evaluating all proxies for true FN events in a database study. This is particularly important during real-world study planning where potential missteps may lead to bias or confounding effects that render a study meaningless. Conclusions: In patients with BC receiving chemotherapy with pegfilgrastim prophylaxis, patient-specific risk factors and regimen risk levels are determinants of FN risk. In real-world studies evaluating FN incidence, it is imperative to consider and control for these risk factors when conducting comparative analyses.

Delirium in Palliative Care Patients: Focus on Pharmacotherapy

2011 ◽  
Vol 28 (7) ◽  
pp. 501-510 ◽  
Author(s):  
Kristin Zimmerman ◽  
James Rudolph ◽  
Marci Salow ◽  
L. Michal Skarf
Keyword(s):  
Risk Factors ◽  
Palliative Care ◽  
Subsequent Treatment ◽  
Patient Specific ◽  
Medical Risk ◽  
Multiple Risk Factors ◽  
Medical Risk Factors ◽  
Neuropsychiatric Adverse Effects ◽  
The Impact

Patients receiving palliative care often possess multiple risk factors and predisposing conditions for delirium. The impact of delirium on patient care in this population may also be far-reaching: affecting not only quality of remaining life but the dying process experienced by patients, caregivers, and the medical team as well. As palliative care focuses on comfort and symptom management, the approach to assessment and subsequent treatment of delirium in palliative care patients may prove difficult for providers to navigate. This article summarizes the multifactorial nature, numerous predisposing medical risk factors, neuropsychiatric adverse effects of palliative medications, pharmacokinetic changes, and challenges complicating delirium assessment and provides a systematic framework for assessment. The benefits, risks, and patient-specific considerations for treatment selection are also discussed.

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