Should High Risk Patients with Hodgkin's Disease be Singled out for Heavier Therapeutic Regimens while Low Risk Patients are Spared such Therapies?

Abstract Introduction: After intensive treatment regimens have been established, the survival rate for patients with advanced Hodgkin’s disease is approximately 91 % after five years and 13 % of the patients have a relapse or have primary progressive disease (2 %) within the first five years. For patients with relapse after conventional chemotherapy +/− radiotherapy, however, there is a real chance of achieving remission again. Since it is often difficult to harvest autologous stem cells following an intensive pretreatment, our center embarks on the strategy to harvest autologous blood stem cells in high-risk patients, defined according to the risk stratification of the German Hodgkin Study Group, already as part of the initial polychemotherapy. Results: Between 9/2003 and 5/2005, we analyzed the results of the stem cell harvest of 12 consecutive patients with Hodgkin’s disease who were mobilized with the escalated BEACOPP regimen. There were 7 female and 5 male patients. Escalated BEACOPP was the primary therapy in ten patients and a relapse was treated in two patients; the previous treatment was 4 or 6 cycles of the ABVD regime + involved field radiation. The ten patients who did not receive previous treatment were classified as having Ann Arbor stage IIA/2 IIB/5, IIIB/2 and IVB/1 and all of them had a large mediastinal bulk as an additional risk factor. The two patients who did receive a previous treatment were classified as having an initial Ann Arbor stage IIA or IIB, without an additional risk factor. The stem cells were collected in 1 patient from cycle 2, in 8 patients from cycle 3 and in 3 patients from cycle 4 of the escalated BEACOPP regimen. A total of 11 patients received a standard dose of filgrastim, 5μg/kg body weight s.c., from day 8 up to the last apheresis and 1 patient received pegfilgrastim 6mg s.c. All aphereses were performed using an Amicus cell separator® (Baxter, MNC set, closed two-arm). 7 patients required only 1 apheresis and the remaining 5 patients required 2 aphereses. An apheresis result sufficient for a possible reinfusion could be achieved in all patients (4.26 – 14.4 x10e6 CD34 pos. cells/kg/body weight, mean: 7.7). Summary: According to our experience, escalated BEACOPP regimen is very suitable for the harvesting of stem cells in high-risk patients with Hodgkin’s disease even though they are receiving procarbazine. A sufficient quantity of stem cells can also be collected from pretreated patients. The stem cell mobilization can be integrated into the escalated BEACOPP regimen safely and without a delay in treatment and thus creates, already at an early stage, the pre-condition for a high-dose therapy, which might be required in high-risk patients.

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Dynamic risk stratification in low-risk vs high-risk patients

Endocrine Abstracts ◽

10.1530/endoabs.49.s19.3 ◽

2017 ◽

Author(s):

Miguel Melo

Keyword(s):

High Risk ◽

Risk Stratification ◽

Low Risk ◽

High Risk Patients ◽

Dynamic Risk ◽

Risk Patients

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Faculty Opinions recommendation of Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725256596.793523901 ◽

2016 ◽

Author(s):

Nawwar Al-Attar

Keyword(s):

High Risk ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Real World ◽

Low Risk ◽

Intermediate Risk ◽

Surgical Aortic Valve Replacement ◽

High Risk Patients ◽

Risk Patients

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Accuracy of upper endoscopies with random biopsies to identify patients with gastric premalignant lesions who can safely be exempt from surveillance

Gastric Cancer ◽

10.1007/s10120-020-01149-2 ◽

2021 ◽

Vol 24 (3) ◽

pp. 680-690

Author(s):

Michiel C. Mommersteeg ◽

Stella A. V. Nieuwenburg ◽

Wouter J. den Hollander ◽

Lisanne Holster ◽

Caroline M. den Hoed ◽

...

Keyword(s):

Gastric Cancer ◽

High Risk ◽

Low Risk ◽

Premalignant Lesions ◽

High Risk Patients ◽

European Guidelines ◽

Progression Of Disease ◽

Risk Patients ◽

Progression Risk

Abstract Introduction Guidelines recommend endoscopy with biopsies to stratify patients with gastric premalignant lesions (GPL) to high and low progression risk. High-risk patients are recommended to undergo surveillance. We aimed to assess the accuracy of guideline recommendations to identify low-risk patients, who can safely be discharged from surveillance. Methods This study includes patients with GPL. Patients underwent at least two endoscopies with an interval of 1–6 years. Patients were defined ‘low risk’ if they fulfilled requirements for discharge, and ‘high risk’ if they fulfilled requirements for surveillance, according to European guidelines (MAPS-2012, updated MAPS-2019, BSG). Patients defined ‘low risk’ with progression of disease during follow-up (FU) were considered ‘misclassified’ as low risk. Results 334 patients (median age 60 years IQR11; 48.7% male) were included and followed for a median of 48 months. At baseline, 181/334 (54%) patients were defined low risk. Of these, 32.6% were ‘misclassified’, showing progression of disease during FU. If MAPS-2019 were followed, 169/334 (51%) patients were defined low risk, of which 32.5% were ‘misclassified’. If BSG were followed, 174/334 (51%) patients were defined low risk, of which 32.2% were ‘misclassified’. Seven patients developed gastric cancer (GC) or dysplasia, four patients were ‘misclassified’ based on MAPS-2012 and three on MAPS-2019 and BSG. By performing one additional endoscopy 72.9% (95% CI 62.4–83.3) of high-risk patients and all patients who developed GC or dysplasia were identified. Conclusion One-third of patients that would have been discharged from GC surveillance, appeared to be ‘misclassified’ as low risk. One additional endoscopy will reduce this risk by 70%.

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A Novel Epigenetic Machine Learning Model to Define Risk of Progression for Hepatocellular Carcinoma Patients

International Journal of Molecular Sciences ◽

10.3390/ijms22031075 ◽

2021 ◽

Vol 22 (3) ◽

pp. 1075

Author(s):

Luca Bedon ◽

Michele Dal Bo ◽

Monica Mossenta ◽

Davide Busato ◽

Giuseppe Toffoli ◽

...

Keyword(s):

Machine Learning ◽

Hepatocellular Carcinoma ◽

High Risk ◽

Progression Free Survival ◽

Low Risk ◽

Functional Enrichment ◽

Free Survival ◽

High Risk Patients ◽

Risk Of Progression ◽

Risk Patients

Although extensive advancements have been made in treatment against hepatocellular carcinoma (HCC), the prognosis of HCC patients remains unsatisfied. It is now clearly established that extensive epigenetic changes act as a driver in human tumors. This study exploits HCC epigenetic deregulation to define a novel prognostic model for monitoring the progression of HCC. We analyzed the genome-wide DNA methylation profile of 374 primary tumor specimens using the Illumina 450 K array data from The Cancer Genome Atlas. We initially used a novel combination of Machine Learning algorithms (Recursive Features Selection, Boruta) to capture early tumor progression features. The subsets of probes obtained were used to train and validate Random Forest models to predict a Progression Free Survival greater or less than 6 months. The model based on 34 epigenetic probes showed the best performance, scoring 0.80 accuracy and 0.51 Matthews Correlation Coefficient on testset. Then, we generated and validated a progression signature based on 4 methylation probes capable of stratifying HCC patients at high and low risk of progression. Survival analysis showed that high risk patients are characterized by a poorer progression free survival compared to low risk patients. Moreover, decision curve analysis confirmed the strength of this predictive tool over conventional clinical parameters. Functional enrichment analysis highlighted that high risk patients differentiated themselves by the upregulation of proliferative pathways. Ultimately, we propose the oncogenic MCM2 gene as a methylation-driven gene of which the representative epigenetic markers could serve both as predictive and prognostic markers. Briefly, our work provides several potential HCC progression epigenetic biomarkers as well as a new signature that may enhance patients surveillance and advances in personalized treatment.

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Does socioeconomic status make a difference? A register-based study on the extent to which cardiovascular screening in patients with inflammatory arthritis leads to recommended follow-up in general practice

RMD Open ◽

10.1136/rmdopen-2019-000940 ◽

2020 ◽

Vol 6 (2) ◽

pp. e000940

Author(s):

Anette Hvenegaard Kjeldgaard ◽

Kim Hørslev-Petersen ◽

Sonja Wehberg ◽

Jens Soendergaard ◽

Jette Primdahl

Keyword(s):

Blood Pressure ◽

Socioeconomic Status ◽

High Risk ◽

Secondary Care ◽

Inflammatory Arthritis ◽

Low Risk ◽

Risk Screening ◽

High Risk Patients ◽

Eular Recommendations ◽

Risk Patients

ObjectiveTo investigate to what extent patients with inflammatory arthritis (IA) follow recommendations given in a secondary care nurse-led cardiovascular (CV) risk screening consultation to consult their general practitioner (GP) to reduce their CV risk and whether their socioeconomic status (SES) affects adherence.MethodsAdults with IA who had participated in a secondary care screening consultation from July 2012 to July 2015, based on the EULAR recommendations, were identified. Patients were considered to have high CV risk if they had risk Systematic COronary Risk Evaluation (SCORE) ≥5%, according to the European SCORE model or systolic blood pressure ≥145 mmHg, total cholesterol ≥8 mmol/L, LDL cholesterol ≥5 mmol/L, HbA1c ≥42 mmol/mol or fasting glucose ≥6 mmol/L. The primary outcome was a consultation with their GP and at least one action focusing on CV risk factors within 6 weeks after the screening consultation.ResultsThe study comprised 1265 patients, aged 18–85 years. Of these, 336/447 (75%) of the high-risk patients and 580/819 (71%) of the low-risk patients had a GP consultation. 127/336 (38%) of high-risk patients and 160/580 (28%) of low-risk patients received relevant actions related to their CV risk, for example, blood pressure home measurement or prescription for statins, antihypertensives or antidiabetics. Education ≥10 years increased the odds for non-adherence (OR 0.58, 95% CI 0.0.37 to 0.92, p=0.02).Conclusions75% of the high-risk patients consulted their GP after the secondary care CV risk screening, and 38% of these received an action relevant for their CV risk. Higher education decreased adherence.

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Changes in patient activation following cardiac rehabilitation using the Active+me digital healthcare platform during the COVID-19 pandemic: a cohort evaluation

BMC Health Services Research ◽

10.1186/s12913-021-07363-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Gabbi Frith ◽

Kathryn Carver ◽

Sarah Curry ◽

Alan Darby ◽

Anna Sydes ◽

...

Keyword(s):

Blood Pressure ◽

High Risk ◽

Cardiac Rehabilitation ◽

Group Analysis ◽

Patient Activation ◽

Low Risk ◽

Smart Device ◽

Face To Face ◽

High Risk Patients ◽

Risk Patients

Abstract Background Restrictions on face-to-face contact, due to COVID-19, led to a rapid adoption of technology to remotely deliver cardiac rehabilitation (CR). Some technologies, including Active+me, were used without knowing their benefits. We assessed changes in patient activation measure (PAM) in patients participating in routine CR, using Active+me. We also investigated changes in PAM among low, moderate, and high risk patients, changes in cardiovascular risk factors, and explored patient and healthcare professional experiences of using Active+me. Methods Patients received standard CR education and an exercise prescription. Active+me was used to monitor patient health, progress towards goals, and provide additional lifestyle support. Patients accessed Active+me through a smart-device application which synchronised to telemetry enabled scales, blood pressure monitors, pulse oximeter, and activity trackers. Changes in PAM score following CR were calculated. Sub-group analysis was conducted on patients at high, moderate, and low risk of exercise induced cardiovascular events. Qualitative interviews explored the acceptability of Active+me. Results Forty-six patients were recruited (Age: 60.4 ± 10.9 years; BMI: 27.9 ± 5.0 kg.m2; 78.3% male). PAM scores increased from 65.5 (range: 51.0 to 100.0) to 70.2 (range: 40.7 to 100.0; P = 0.039). PAM scores of high risk patients increased from 61.9 (range: 53.0 to 91.0) to 75.0 (range: 58.1 to 100.0; P = 0.044). The PAM scores of moderate and low risk patients did not change. Resting systolic blood pressure decreased from 125 mmHg (95% CI: 120 to 130 mmHg) to 119 mmHg (95% CI: 115 to 122 mmHg; P = 0.023) and waist circumference measurements decreased from 92.8 cm (95% CI: 82.6 to 102.9 cm) to 85.3 cm (95% CI 79.1 to 96.2 cm; P = 0.026). Self-reported physical activity levels increased from 1557.5 MET-minutes (range: 245.0 to 5355.0 MET-minutes) to 3363.2 MET-minutes (range: 105.0 to 12,360.0 MET-minutes; P < 0.001). Active+me was acceptable to patients and healthcare professionals. Conclusion Participation in standard CR, with Active+me, is associated with increased patient skill, knowledge, and confidence to manage their condition. Active+me may be an appropriate platform to support CR delivery when patients cannot be seen face-to-face. Trial registration As this was not a clinical trial, the study was not registered in a trial registry.

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P3609Temporal trends of the management and outcomes of patients after myocardial infarction according to the risk for recurrent cardiovascular events

European Heart Journal ◽

10.1093/eurheartj/ehz745.0468 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T Grinberg ◽

T Bental ◽

Y Hammer ◽

A R Assali ◽

H Vaknin-Assa ◽

...

Keyword(s):

Myocardial Infarction ◽

High Risk ◽

Cardiovascular Events ◽

Risk Group ◽

Temporal Trends ◽

High Risk Group ◽

Low Risk ◽

Intermediate Risk ◽

High Risk Patients ◽

Risk Patients

Abstract Background Following Myocardial Infarction (MI), patients are at increased risk for recurrent cardiovascular events, particularly during the immediate period. Yet some patients are at higher risk than others, owing to their clinical characteristics and comorbidities, these high-risk patients are less often treated with guideline-recommended therapies. Aim To examine temporal trends in treatment and outcomes of patients with MI according to the TIMI risk score for secondary prevention (TRS2°P), a recently validated risk stratification tool. Methods A retrospective cohort study of patients with an acute MI, who underwent percutaneous coronary intervention and were discharged alive between 2004–2016. Temporal trends were examined in the early (2004–2010) and late (2011–2016) time-periods. Patients were stratified by the TRS2°P to a low (≤1), intermediate (2) or high-risk group (≥3). Clinical outcomes included 30-day MACE (death, MI, target vessel revascularization, coronary artery bypass grafting, unstable angina or stroke) and 1-year mortality. Results Among 4921 patients, 31% were low-risk, 27% intermediate-risk and 42% high-risk. Compared to low and intermediate-risk patients, high-risk patients were older, more commonly female, and had more comorbidities such as hypertension, diabetes, peripheral vascular disease, and chronic kidney disease. They presented more often with non ST elevation MI and 3-vessel disease. High-risk patients were less likely to receive drug eluting stents and potent anti-platelet drugs, among other guideline-recommended therapies. Evidently, they experienced higher 30-day MACE (8.1% vs. 3.9% and 2.1% in intermediate and low-risk, respectively, P<0.001) and 1-year mortality (10.4% vs. 3.9% and 1.1% in intermediate and low-risk, respectively, P<0.001). During time, comparing the early to the late-period, the use of potent antiplatelets and statins increased among the entire cohort (P<0.001). However, only the high-risk group demonstrated a significantly lower 30-day MACE (P=0.001). During time, there were no differences in 1-year mortality rate among all risk categories. Temporal trends in 30-day MACE by TRS2°P Conclusion Despite a better application of guideline-recommended therapies, high-risk patients after MI are still relatively undertreated. Nevertheless, they demonstrated the most notable improvement in outcomes over time.

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