Abstract 78: Risk Factors Associated with Failure of Aggressive Medical Therapy in the SAMMPRIS Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Michael F Waters ◽  
Brian L Hoh ◽  
Michael J Lynn ◽  
Tanya N Turan ◽  
Colin P Derdeyn ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Medical Therapy ◽  
Primary Endpoint ◽  
Univariate Analysis ◽  
Baseline Risk ◽  
Medical Group ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Background: The SAMMPRIS trial showed that aggressive medical therapy was more effective than stenting for preventing stroke in high-risk patients with symptomatic intracranial stenosis. However, 15% of patients in the medical group still had a primary endpoint (any stroke or death within 30 days of enrollment or stroke in the territory beyond 30 days) during a median follow-up of 32.7 months. We sought to determine baseline risk factors that were associated with a primary endpoint in the medical arm of SAMMPRIS. Methods: Data on 227 patients randomized to the medical group in SAMMPRIS were analyzed. Baseline demographic features, vascular risk factors, qualifying event, brain imaging and angiographic features were analyzed. The hazard ratio and p-value from a Cox proportional hazard regression model relating time until a primary endpoint to each factor were calculated. Results: Female gender, diabetes, stroke as the qualifying event (especially non-penetrator stroke), old infarct in the territory of the stenotic artery, and > 80% stenosis were associated (p < 0.10) with a higher risk of the primary endpoint on univariate analysis (see accompanying table) (multivariate analysis will be available by the time of ISC). Variables not associated with a higher risk of a primary endpoint in the medical arm included: age, race, antithrombotic therapy at the time of a qualifying event, time from qualifying event to enrollment (< 7 days vs. > 7 days), and location of stenosis. Conclusions: Several features were associated with an increased risk of the primary endpoint in the medical group in SAMMPRIS. On univariate analysis, the most important risk factors were an old infarct in the territory of the stenotic artery and stroke (especially non-penetrator stroke) as the qualifying event. These features will be useful for identifying particularly high-risk patients who should be targeted for future clinical trials testing alternative therapies to aggressive medical management.

scholarly journals Risks of forgotten double-J ureteric stents after ureterorenoscopic lithotripsy in Taiwan: a nationwide population-based study

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Weiming Cheng ◽  
Yi-Chun Chiu ◽  
Yu-Hua Fan ◽  
Shu-Yi Lin ◽  
Sheng-Wen Chen
Keyword(s):  
Risk Factors ◽  
Socioeconomic Status ◽  
High Risk ◽  
Low Socioeconomic Status ◽  
Univariate Analysis ◽  
Safety Data ◽  
X Ray ◽  
High Risk Patients ◽  
Alpha Blocker ◽  
Risk Patients

AbstractDelayed double-J ureteric stent (DJ) removal may cause severe morbidity. We aimed to identify high-risk patients for forgotten DJs to prevent iatrogenic injury and improve safety. Data of patients with DJs placed after ureterorenoscopic lithotripsy (URSL) between 2000 and 2013 from the National Health Insurance Database in Taiwan were included. Forgotten DJs were defined as indwelling DJs for > 6 months after URSL, which is approximately two times longer than the expiratory duration. Age at stenting, sex, socioeconomic status, specialty of stenting physician, comorbidities, postoperative emergency room visiting and abdominal plain x-ray filming frequencies, and alpha blocker use for > 7 days after stenting were analysed. Of 13,058 patients, 12,969 (99.31%) had timely removed DJs while 89 (0.68%) had forgotten DJs. Per a univariate analysis, patients with forgotten DJs were older, female, and of low socioeconomic status, and the use of more than one DJ for one URSL, placement by non-urologists, and less frequent postoperative abdominal plain x-ray filming and postoperative alpha blocker use were risk factors. Per a multivariate analysis, elderly patients (Odds ratio [OR] = 3.37, 95% confidence interval (CI) 1.36–8.32, p = 0.0085), DJ placement by non-urologists (OR = 9.63, 95% CI 6.09–15.24, p < 0.0001), more than two DJs for one URSL (OR = 2.93, 95% CI 1.58–5.42, p = 0.0006), and less frequent postoperative abdominal plain x-ray filming (OR = 0.66, 95% CI 0.51–0.86, p = 0.0016) were significantly associated with forgotten DJs. Forgotten URSL-related DJs are infrequent in Taiwan. Old age, complicated DJ insertion requiring more than two stents for one URSL, and stent placement by non-urologists are risk factors. Physicians should be aware of these high-risk patients.

scholarly journals The Risk of Stroke Using CHA2 DS2 -VASc Score in Hemodialysis Patients at a Tertiary Hospital in Riyadh, Saudi Arabia

2019 ◽  
Vol 4 (7) ◽  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Stroke Risk ◽  
Hemodialysis Patients ◽  
Low Risk ◽  
High Risk Patients ◽  
Stroke Risk Factors ◽  
Increased Risk ◽  
Risk Patients ◽  
History Of

Introduction: Patients undergoing hemodialysis are at increased risk of stroke. However, less known about the impact of some of the stroke risk factors, and the value of stroke risk scores in determining the risk in those patients. Our main goal. To assess the risk factors for stroke in hemodialysis patients and the use of the new CHA2DS2-VASc score for stroke assessment. Methods: Single center, retrospective cohort study of 336 patients undergoing hemodialysis from June 24, 2018, to September 6, 2018, was recruited. Baseline demographics, clinical, and laboratory data were collected. We calculated the CHA2 DS2 -VASc score for stroke assessment in all patients and categorized them into high, moderate and low risk patients according to CHA2 DS2 - VASc score and subcategorized them to two groups atrial fibrillation (AFib) and Non- Atrial fibrillation (Non AFib) patients. Results: 336 patients were included in our study; the majority of patients were at high risk with a CHA2 DS2 -VASc Score mean of 2.9± 1.5, although history of stroke was observed only in 15 patients (4.46%). According to CHA2 DS2 - VASc score, 280 patients were at high risk, 172 (51.19%) were high-risk patients on treatment (anticoagulant or antiplatelet) and 108(32.14%) patients were high risk patients not on treatment 48 were at moderate risk (14.28%) and 8 were at low risk (2.38 %). Patients were divided into subgroups as non-AFib and AFib. In non-AFib patients 320 (95.23%), high-risk patients 103 (32.18%) were not treated; high-risk patients with treatment are 162 (50.62%), moderate patients were 47 (14.68%), 8(2.5%) was in low risk. AFib patients were 16 with a mean CHA2 DS2 -VASc score of 4.4±1.1. Patients with AFib were all at high risk except 1 was at moderate risk (6.25%). There were 11 (68.75%) patients on treatment and 5 (31.25%) patients not on treatment. The risk factors for stroke that were statistically significant in increasing score risk for all patients were: age > 65 (95% CI, -2.04– -1.29; p = 0.000), being female (95% CI, -1.36– -0.68; p = 0.000) hypertension (95% CI, -2.59– -1.37; p = 0.000), diabetes (95% CI, -2.10– -1.50; p = 0.000), CVD (95% CI, -2.07– -1.24; p=0.000), history of stroke or TIA (95% CI, -3.70– -2.03; p = 0.000), CHF or LVEF (95% CI, -2.28– - 0.91; p = 0.000). Conclusions: The risk of stroke in hemodialysis patients is significant according to the use of CHA2 DS2 -VASc score in Non-AFib hemodialysis patients shows supportive evidence of increased risk of stroke in those patients, which suggest the importance of close monitoring of patients with stroke risk factors by the nephrologist and the stroke team which will lead to the initiation of early prophylaxis in those patients.

Final Analysis of MELISSE, a Large Multicentric Observational Study to Determine Risk Factors of Venous Thromboembolism in Patients with Multiple Myeloma Treated with Immunomodulator Drugs

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1235-1235 ◽  
Author(s):  
Xavier Leleu ◽  
Laurent Daley ◽  
Philippe Rodon ◽  
Cyrille Hulin ◽  
Charles Dauriac ◽  
...  
Keyword(s):  
Risk Factors ◽  
Multiple Myeloma ◽  
High Risk ◽  
Incidence Rate ◽  
Research Funding ◽  
Final Analysis ◽  
Vte Prophylaxis ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Abstract Abstract 1235 Background. Immunomodulator drugs (IMiDs) are associated with an increased risk of thromboembolic events (TE). Multiple Myeloma patients (MM) that can not benefit from novel agents, including IMiDs, only have 9 months survival. IMiDs must be stopped when TE occurs with the consequence of potential shortened life expectancy. MELISSE was designed to prospectively evaluate the incidence and risk factors of venous TE (VTE) associated with IMiDs in MM. We have presented the interim analysis of MELISSE at ASH 2010. A reduced incidence rate of early VTE was observed when a prophylaxis for VTE was started as compared to patients that had no prophylaxis. Interestingly, we also reported that most of the patients had received aspirin, while aspirin is not considered to exert any venous prophylactic effect. LMWH was primarily proposed to patients with high risk of TE according to physician's evaluation. We present the final analysis of MELISSE with updated results at 1 year. Method. A total of 524 MM treated with IMiDs-based therapy were included in 52 IFM centers. VTE prophylaxis was recommended prior to start IMiDs, the choice of which was left at the discretion of the investigator. Patients gave written informed consent according to the declaration of Helsinki. The physicians were to record the risk of VTE occurrence, categorized as low, moderate and high, based on guidelines and their own appreciation of the risk. Occurrence of any VTE was to be recorded along with the management of the event and the patient's outcome. The data were collected at entry in the study, and then after 4 and 12 months. Results. The median age was 70 years old, with 64.67% of patients >65 years old. Overall 36.0% had thalidomide-based and 64.0% had lenalidomide-based therapy, with 180 patients in first line and the remaining patients in 2nd and 3rd lines of therapy. The observed repartition of TE risk factors was as expected in a European population with myeloma. The risk of VTE was assessed as high in 14.2% patient and small or intermediate otherwise. Interestingly, approximately 70% of patients rated as low and intermediate risk received aspirin as a routine prophylaxis for VTE as compared to 20% in high risk patients. LMWH was primarily given to high risk patients, 45.8%. Surprisingly, 16.0% of patients had no VTE prophylaxis. Investigators recorded 29 (5.5% annual incidence rate) TE at 12 months, including 12 associated with PE. The incidence rate of TE was similar within the first 4 months (early occurrence, 3.5%) versus after 4 months (late, 2.5%). We have not identified any risk factor that would explain early versus late occurrence of VTE. Interestingly, the incidence of VTE was higher in patients that had no prophylaxis treatment, 8.5%, as compared to 4.4% and 5.9% in the LMWH and aspirin groups, respectively. There was no PE recorded in patients that were on LMWH prophylaxis. The VTE was equally breakdown across the 3 groups of risk factors. The bleeding adverse events were reported for 27 patients, mainly patients with aspirin. We isolated a model with 3 variables that independently predicted a higher risk to develop VTE in the multivariate model, and that comprised the male gender [OR 4.31 (95% CI 1.60 – 13.90)], the smoking habit [6.76 (1.73–22.42)] and the association to EPO [2.66 (1.04–6.58)]. Aspirin showed no significance, but with a p value at 0.55. The multivariate analysis is limited as certain subgroups with high risk factors might have received the optimal VTE prophylaxis, such as patients with bed rest and patients with prior history of VTE. These 2 groups rarely had aspirin. Survival data will be updated and presented at ASH 2011. Conclusion. This study further demonstrates that TE prophylaxis is required for MM treated with IMiDs-based therapy. There is a slight increase risk of VTE/PE with the use of aspirin as compared to LMWH, but a significant increase in bleeding events. Although we have identified risk factors of VTE in MM treated with IMiDs, for the first time, we could not identified VTE risk factors to guide investigators between LMWH and aspirin-based prophylaxis. The optimal dose and duration of LMWH remains to be determined. Disclosures: Leleu: LeoPharma: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding; Roche: Research Funding; Amgen: Honoraria; Novartis: Research Funding. Daley:LeoPharma: Employment. Hulin:Janssen: Honoraria; Celgene: Honoraria. Lamblin:LeoPharma: Employment. Natta:LeoPharma: Employment.

scholarly journals SARS, MERS, COVID-19: Identification of Patients at a Higher Risk: A Narrative Review

2021 ◽  
Vol 2 (1) ◽  
pp. 57-70
Author(s):  
Hussein Noureldine ◽  
Georges Chedid ◽  
Jad Gerges Harb ◽  
Wared Nour-Eldine ◽  
Mariam Nour Eldine ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Risk Factors ◽  
Cardiovascular Disease ◽  
High Risk ◽  
Pregnant Women ◽  
Early Identification ◽  
Factors Associated ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

The different presentations, comorbidities, and outcomes of COVID-19 highlight the importance of early identification and proper triage of patients. High-risk patients can be divided into patients with common comorbidities and patients with special categories. Common comorbidities include, but are not limited to, Cardiovascular Disease (CVD), Diabetes Mellitus (DM), immunosuppression, underlying respiratory disease, and obesity. Certain categories of COVID-19 patients are also at increased risk, including neonates and pregnant women.  In the present article, we delineate the reported risk factors for acquisition of infection, and for increased severity of the clinical disease. We also comparatively analyze those risk factors associated with COVID-19 and with the antecedent human acute respiratory syndrome-causing viruses, SARS-CoV-1 and MERS-CoV. We hypothesize that the structural similarities of the three viruses predict a similarity in the profile of high-risk patients. Several pathophysiological patterns have been detected to support this theory.

Behavioral Emergencies and Crises

2010 ◽  
pp. 739-762
Author(s):  
Phillip M. Kleespies ◽  
Justin M. Hill
Keyword(s):  
Mental Health ◽  
Risk Factors ◽  
High Risk ◽  
Work Environment ◽  
Emotional Impact ◽  
High Risk Patients ◽  
Risk Patients ◽  
Life Threatening ◽  
Behavioral Emergencies ◽  
And Training

This chapter illustrates the mental health clinician’s relationship with behavioral emergencies. The chapter begins by distinguishing the terms behavioral emergency and behavioral crisis, and underlying themes among all behavioral emergencies are identified. Given that most clinicians will face a behavioral emergency in their careers, the importance of enhancing the process of educating and training practitioners for such situations far beyond the minimal training that currently exists is highlighted. The chapter continues by exploring various aspects of evaluating and managing high-risk patients (i.e., those who exhibit violent tendencies toward themselves or others, and those at risk for victimization). It includes a discussion of the benefits and limitations to estimating life-threatening risk factors and specific protective factors. The chapter concludes by discussing the emotional impact that working with high-risk patients has on clinicians, and an emphasis is placed on the importance of creating a supportive work environment.

scholarly journals Prevention of Hypotension following Spinal Anaesthesia in Caesarean Section - then and now

2012 ◽  
Vol 8 (4) ◽  
pp. 415-419
Author(s):  
J K Mitra
Keyword(s):  
Risk Factors ◽  
Clinical Practice ◽  
High Risk ◽  
Caesarean Section ◽  
Spinal Anaesthesia ◽  
Limited Data ◽  
First Line ◽  
High Risk Patients ◽  
Risk Patients ◽  
Poor Efficacy

Hypotension during spinal anaesthesia for caesarean section remains a common scenario in our clinical practice. Certain risk factors play a role in altering the incidence of hypotension. Aortocaval compression counteraction does not help to prevent hypotension. Intravenous crystalloid prehydration has poor efficacy; thus, the focus has changed toward co-hydration and use of colloids. Phenylephrine is established as a first- line vasopressor, although there are limited data from high-risk patients. Ephedrine crosses the placenta more than phenylephrine and cause possible alterations in the foetal physiology.http://dx.doi.org/10.3126/kumj.v8i4.6242 Kathmandu Univ Med J 2010;8(4):415-19   

Abstract 1122‐000035: Is Age Critical in Determining Stroke Severity Within the Telestroke Network?

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Cassie A Simmons ◽  
Nicolas Poupore ◽  
Fernando Gonzalez ◽  
Thomas I Nathaniel
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Risk Factor ◽  
Univariate Analysis ◽  
Baseline Risk ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Stroke Risk Factor ◽  
Patients Âgés ◽  
Increased Risk

Introduction : Age is the single most important risk factor for stroke and an estimated 75% of all strokes occur in people >65 years of age. In addition, adults >75 years’ experience more hospitalization stays and higher mortality rates with an estimated 50% in the occurrence of all strokes. Several comorbidities have been linked to an increased risk and severity of acute ischemic stroke (AIS). How these factors differentially contribute to the severity of stroke in patients ages >65 and <75 as well as those ≥75 is not known. In this study, we aim to investigate how age, coupled with various clinical risk factors, affects AIS severity within these two age categories. Methods : This retrospective data analysis study was conducted using the data collected from the PRISMA Health Stroke Registry between 2010 and 2016. Baseline clinical and demographic data for patients ages >65 and <75 as well as those ≥75 was analyzed using univariate analysis. Receiver operating characteristic (ROC) curve analysis and multivariate regression models were used to examine the association of specific baseline risk factors or comorbidities associated with worsening or improving neurologic functions. The primary functions were risk factors associated with improving or worsening neurologic outcome in each age category. Results : Adjusted multivariate analysis showed that AIS population of patients >65 and <75 experiencing heart failure (OR = 4.398, 95% CI, 3.912 – 494.613, P = 0.002) and elevated HDL levels (OR = 1.066, 95% CI, 1.009 – 1.126, P = 0.024) trended towards worsening neurologic functions while patients experiencing obesity (OR = 0.177, 95% CI, 0.041 – 0.760, P = 0.020) exhibited improving neurologic functions. For the patients ≥75 years of age, direct admission (OR = 0.270, 95% CI, 0.085 – 0.856, P = 0.026) was associated with improvement of patients treated in the telestroke. Conclusions : Age is a strong risk factor for AIS, and aged stroke patients have higher morbidity and worsening functional recovery than younger patients. In this study, we observed differences in stroke risk factor profiles for >65 and <75 and ≥75 age categories. Heart failure and elevated HDL levels were significantly associated with worsening neurologic functions among AIS for patients aged >65 and <75. Obese patients and individuals ≥75 years who were directly admitted were most likely to exhibit improving neurologic functions. Most importantly, findings from this study reveal specific risk factors that can be managed to improve the care in older stroke patients treated in the telestroke network.

Abstract 14782: Sex Comparisons in Anticoagulation Treatment for Atrial Fibrillation in a Large Rural Healthcare System

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Macaela N Rudeck ◽  
Catherine P Benziger
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Atrial Flutter ◽  
Electronic Medical Record System ◽  
Record System ◽  
High Risk Patients ◽  
Occlusion Device ◽  
Increased Risk ◽  
Medical Record System ◽  
Risk Patients

Introduction: Atrial fibrillation (AF) and flutter lead to increased risk of thromboembolism (TE). The CHA 2 DS 2 -VASc score is used to determine the risk of TE. Objective: We aim to evaluate the anticoagulation use across CHA 2 DS 2 -VASc scores calculated using a validated automatic calculator. Methods: An AF registry was created for patients with AF or atrial flutter who had seen a primary care or cardiology provider within the past 2 years (5/28/2018-5/28/2020). An automatic CHA 2 DS 2 -VASc calculator was integrated into the electronic medical record system at Essentia Health on 10/1/2019. High-risk of TE was defined as a score of ≥3 for females and a score of ≥2 for males. AF registry included demographics, anticoagulation prescription, CHA 2 DS 2 -VASc and ATRIA bleed score, contraindications, and presence of left atrial appendage (LAA) occlusion device. Results: A total of 10992 patients with AF or atrial flutter were included in the registry (74.8 ±11.8 years, 41.7% female). A total of 6703 (61.0%) had a CHA 2 DS 2 -VASc score calculated (mean score 3.9 ± 1.5). Mean ATRIA bleed score was 3.0 ± 2.0. Within these patients, 90.7% of males and 93.0% of females were at high-risk of TE. Of these high-risk patients, anticoagulation use was 82.7% for females and 83.5% for males and increased with increasing score (p<0.01 for males, p<0.01 for females) (Figure 1). Overall, 36.9% were prescribed NOAC, 47.0% warfarin, and 0.8% heparin. There was no sex difference in the prescription of NOAC (37.7% male vs. 35.9% female, p=0.1). Fewer than 1% had WATCHMAN LAA device (0.3% male vs. 0.4% female, p=0.5). Conclusion: Four out of 5 patients at increased risk of TE are prescribed an anticoagulant. Interventions to improve anticoagulation use in high-risk patients are needed. Figure 1. Anticoagulation prescription use in atrial fibrillation patients by CHA 2 DS 2 -VASc score and sex between 5/28/2018-5/28/2020 at Essentia Health (N=6703).

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