Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans

Background: The goal of cardiac evaluation of patients awaiting orthotopic liver transplantation (OLT) is to identify the patients at risk for cardiovascular events (CVEs) in the peri- and postoperative periods by opportunistic evaluation of coronary artery calcium (CAC) in non-gated abdominal computed tomographs (CT). Methods: We hypothesized that in patients with OLT, a combination of Lee’s revised cardiac index (RCRI) and CAC scoring would improve diagnostic accuracy and prognostic impact compared to non-invasive cardiac testing. Therefore, we retrospectively evaluated 169 patients and compared prediction of CVEs by both methods. Results: Standard workup identified 22 patients with a high risk for CVEs during the transplant period, leading to coronary interventions. Eighteen patients had a CVE after transplant and a CAC score > 0. The combination of CAC and RCRI ≥ 2 had better negative (NPV) and positive predictive values (PPV) for CVEs (NPV 95.7%, PPV 81.6%) than standard non-invasive stress tests (NPV 92.0%, PPV 54.5%). Conclusion: The cutoff value of CAC > 0 by non-gated CTs combined with RCRI ≥ 2 is highly sensitive for identifying patients at risk for CVEs in the OLT population.

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Non-invasive detection of bladder cancer through the analysis of driver gene mutations and aneuploidy

10.1101/203976 ◽

2017 ◽

Cited By ~ 3

Author(s):

Simeon Springer ◽

Maria Del Carmen Rodriguez Pena ◽

Lu Li ◽

Christopher Douville ◽

Yuxuan Wang ◽

...

Keyword(s):

At Risk ◽

Bladder Cancer ◽

Gene Mutations ◽

Urine Samples ◽

Driver Gene ◽

Low Grade ◽

Invasive Approach ◽

Non Invasive ◽

Patients At Risk ◽

Copy Number Changes

AbstractCurrent non-invasive approaches for bladder cancer (BC) detection are suboptimal. We report the development of non-invasive molecular test for BC using DNA recovered from cells shed into urine. This “UroSEEK” test incorporates assays for mutations in 11 genes and copy number changes on 39 chromosome arms. We first evaluated 570 urine samples from patients at risk for BC (microscopic hematuria or dysuria). UroSEEK was positive in 83% of patients that developed BC, but in only 7% of patients who did not develop BC. Combined with cytology, 95% of patients that developed BC were positive. We then evaluated 322 urine samples from patients soon after their BCs had been surgically resected. UroSEEK detected abnormalities in 66% of the urine samples from these patients, sometimes up to 4 years prior to clinical evidence of residual neoplasia, while cytology was positive in only 25% of such urine samples. The advantages of UroSEEK over cytology were particularly evident in low-grade tumors, wherein cytology detected none while UroSEEK detected 67% of 49 cases. These results establish the foundation for a new, non-invasive approach to the detection of BC in patients at risk for initial or recurrent disease.

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Non Invasive Assessment of Hepatic Fibrosis by Measurement of Liver Stiffness in Post Transfusional Iron Overload: Preliminary Results in 15 Patients.

Blood ◽

10.1182/blood.v108.11.3740.3740 ◽

2006 ◽

Vol 108 (11) ◽

pp. 3740-3740

Author(s):

T. Mirault ◽

D. Lucidarme ◽

B. Turlin ◽

Y. Deugnier ◽

P. Brissot ◽

...

Keyword(s):

At Risk ◽

Liver Fibrosis ◽

Iron Overload ◽

Predictive Value ◽

Liver Stiffness ◽

Liver Iron ◽

Preliminary Results ◽

Non Invasive ◽

Patients At Risk ◽

Severe Fibrosis

Abstract Background: The prognosis of liver iron overload is highly dependent on liver iron content (LIC) and the extent of liver fibrosis. Liver biopsy is the invasive reference method for fibrosis evaluation but with several limitations. Non-invasive biological methods (FibroTest, APRI) are not applicable in blood diseases. Transient elastography (TE) is a new non-invasive and rapid bedside method used to measure liver stiffness.This technique has been extensively studied with success in evaluation of liver fibrosis in HCV infection (Ziol, Hepatology 2005; Castera, Gastroenterology 2005). Until now, no data are available on evaluation of liver fibrosis by TE in highly transfused patients with iron overload. Methods: We assessed liver stiffness (kPa) by elastography measurement (Fibroscan; Echosens, Paris, France). Ishak’s and Metavir’s scales were used to stage fibrosis and hepatitis activity; LIC was measured by atomic absorption spectometry in a central laboratory (Rennes, France) and by MRI procedure according to Gandon (Lancet 2004). Cardiac MRI T2* (indirect estimation of iron heart content) was also measured by MRI according to Anderson (Eur Heart J 2001). Serum ferritin level and HCV serology were assayed in all cases. Correlation statistical analysis used Spearman’s Rho and Pearson tests and mean comparisons were done by a non-parametric Mann-Whitney test. Results: 15 liver samples (weight >1mg except 1) from monthly transfused patients (13 major beta Thalassemia, 1 sickle cell disease, 1 myelodysplastic syndrome) were analyzed. Median age was 37 years (7–75). Histological results were: 3 cirrhosis (METAVIR F=4 (F4), or Ishak’s Staging =6 (IS6)) among 5 patients with severe fibrosis (F3,F4) or (IS4-6) and 10 patients with no or mild fibrosis (F0-2) or (IS0-3). Mean ferritin was 2579 ng/ml CI 95% [1372–3786]. 2 patients were HCV positive. Correlation between LIC and ferritin was 0.82 (p<0,05); between LIC and MRI LIC: 0.88 (p<0,05); LIC and MRI Heart T2*: 0.72(p<0,05); METAVIR F score and Ishak’s grading score: 0.86 (p<0,05). A correlation was also observed between METAVIR F and elastography: 0.60(p<0,05); and mean values of elastography were significally different in patients with severe fibrosis: 9.1kPa CI95% [4.5–13.7] vs 5.9kPa CI95% [4.6–7.2] in those without sever fibrosis (p<0,05) (fig). A value of elastography above 6.25kPa (Se=80%; Sp=70%; AUROC=0.820) identified patients at risk for severe fibrosis (F3,F4 or IS 4–6) (Negative Predictive Value = 88%; Positive Predictive Value = 57%). Conclusion: A significant correlation between Metavir Fibrosis scale and elastography values was found. This new non-invasive method would be helpful to evaluate liver fibrosis and to determine patients who could avoid invasive procedures in particular in regularly transfused low risk myelodysplastic patients at risk of bleeding due to abnormal platelet function. These preliminary results will have to be confirmed in a larger population. Figure Figure

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Differentially methylated regions in T cells identify kidney transplant patients at risk for de novo skin cancer

Clinical Epigenetics ◽

10.1186/s13148-018-0519-7 ◽

2018 ◽

Vol 10 (1) ◽

Cited By ~ 5

Author(s):

Fleur S. Peters ◽

Annemiek M. A. Peeters ◽

Pooja R. Mandaviya ◽

Joyce B. J. van Meurs ◽

Leo J. Hofland ◽

...

Keyword(s):

At Risk ◽

T Cells ◽

Skin Cancer ◽

Kidney Transplant ◽

De Novo ◽

Differentially Methylated Regions ◽

Transplant Patients ◽

Patients At Risk ◽

Kidney Transplant Patients

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Bone marrow transplant patients at risk for bone loss

Oncology Times ◽

10.1097/01434893-200509000-00013 ◽

2005 ◽

Vol 2 (9) ◽

pp. 18

Author(s):

Ed Susman

Keyword(s):

At Risk ◽

Bone Marrow ◽

Bone Loss ◽

Bone Marrow Transplant ◽

Marrow Transplant ◽

Transplant Patients ◽

Patients At Risk

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Identification of Kidney Transplant Patients at Risk for Skin Cancer by Differentially Methylated Regions in T Cells

Transplantation Journal ◽

10.1097/01.tp.0000520362.08810.3f ◽

2017 ◽

Vol 101 ◽

pp. S42

Author(s):

Fleur Peters ◽

Annemiek MA Peeters ◽

Pooja R. Mandaviya ◽

Jacqueline van de Wetering ◽

Michiel GH Betjes ◽

...

Keyword(s):

At Risk ◽

T Cells ◽

Skin Cancer ◽

Kidney Transplant ◽

Differentially Methylated Regions ◽

Transplant Patients ◽

Patients At Risk ◽

Kidney Transplant Patients

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Towards Prevention of Acute Syndromes

Applied Clinical Informatics ◽

10.4338/aci-2013-07-ra-0045 ◽

2014 ◽

Vol 05 (01) ◽

pp. 58-72 ◽

Cited By ~ 10

Author(s):

C. Thongprayoon ◽

B.W. Pickering ◽

A. Akhoundi ◽

G. Wilson ◽

D. Pieczkiewicz ◽

...

Keyword(s):

At Risk ◽

Acute Pancreatitis ◽

Hospital Admission ◽

Data Extraction ◽

Secondary Analysis ◽

Reference Standard ◽

Predictive Values ◽

Derivation Cohort ◽

Automated Algorithm ◽

Patients At Risk

SummaryBackground: Identifying patients at risk for acute respiratory distress syndrome (ARDS) before their admission to intensive care is crucial to prevention and treatment. The objective of this study is to determine the performance of an automated algorithm for identifying selected ARDS predis-posing conditions at the time of hospital admission.Methods: This secondary analysis of a prospective cohort study included 3,005 patients admitted to hospital between January 1 and December 31, 2010. The automated algorithm for five ARDS pre-disposing conditions (sepsis, pneumonia, aspiration, acute pancreatitis, and shock) was developed through a series of queries applied to institutional electronic medical record databases. The automated algorithm was derived and refined in a derivation cohort of 1,562 patients and subsequently validated in an independent cohort of 1,443 patients. The sensitivity, specificity, and positive and negative predictive values of an automated algorithm to identify ARDS risk factors were compared with another two independent data extraction strategies, including manual data extraction and ICD-9 code search. The reference standard was defined as the agreement between the ICD-9 code, automated and manual data extraction.Results: Compared to the reference standard, the automated algorithm had higher sensitivity than manual data extraction for identifying a case of sepsis (95% vs. 56%), aspiration (63% vs. 42%), acute pancreatitis (100% vs. 70%), pneumonia (93% vs. 62%) and shock (77% vs. 41%) with similar specificity except for sepsis and pneumonia (90% vs. 98% for sepsis and 95% vs. 99% for pneumonia). The PPV for identifying these five acute conditions using the automated algorithm ranged from 65% for pneumonia to 91 % for acute pancreatitis, whereas the NPV for the automated algorithm ranged from 99% to 100%.Conclusion: A rule-based electronic data extraction can reliably and accurately identify patients at risk of ARDS at the time of hospital admission.Citation: Ahmed A, Thongprayoon C, Pickering BW, Akhoundi A, Wilson G, Pieczkiewicz D, Herasevich V. Towards prevention of acute syndromes: Electronic identification of at-risk patients during hospital admission. Appl Clin Inf 2014; 5: 58–72http://dx.doi.org/10.4338/ACI-2013-07-RA-0045

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Development and Performance of Electronic Acute Kidney Injury Triggers to Identify Pediatric Patients at Risk for Nephrotoxic Medication-associated Harm

Applied Clinical Informatics ◽

10.4338/aci-2013-12-ra-0102 ◽

2014 ◽

Vol 05 (02) ◽

pp. 313-333 ◽

Cited By ~ 38

Author(s):

W.L. Spires ◽

T.A. Mottes ◽

J.K. Schaffzin ◽

C. Barclay ◽

S.L. Goldstein ◽

...

Keyword(s):

At Risk ◽

Acute Kidney Injury ◽

Pediatric Patients ◽

Data Entry ◽

Kidney Injury ◽

Clinical Work ◽

Web Based ◽

Predictive Values ◽

Patients At Risk ◽

And Performance

Summary Background: Nephrotoxic medication-associated acute kidney injury (NTMx-AKI) is a costly clinical phenomenon and more common than previously recognized. Prior efforts to use technology to identify AKI have focused on detection after renal injury has occurred. Objectives: Describe an approach and provide a technical framework for the creation of risk-stratifying AKI triggers and the development of an application to manage the AKI trigger data. Report the performance characteristics of those triggers and the refinement process and on the challenges of implementation. Methods: Initial manual trigger screening guided design of an automated electronic trigger report. A web-based application was designed to alleviate inefficiency and serve as a user interface and central workspace for the project. Performance of the NTMx exposure trigger reports from September 2011 to September 2013 were evaluated using sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV). Results: Automated reports were created to replace manual screening for NTMx-AKI. The initial performance of the NTMx exposure triggers for SN, SP, PPV, and NPV all were 0.78, and increased over the study, with all four measures reaching 0.95 consistently. A web-based application was implemented that simplifies data entry and couriering from the reports, expedites results viewing, and interfaces with an automated data visualization tool. Sociotechnical challenges were logged and reported. Conclusion: We have built a risk-stratifying system based on electronic triggers that detects patients at-risk for NTMx-AKI before injury occurs. The performance of the NTMx-exposed reports has neared 100% through iterative optimization. The complexity of the trigger logic and clinical work-flows surrounding NTMx-AKI led to a challenging implementation, but one that has been successful from technical, clinical, and quality improvement standpoints. This report summarizes the construction of a trigger-based application, the performance of the triggers, and the challenges uncovered during the design, build, and implementation of the system. Citation: Kirkendall ES, Spires WL, Mottes TA, Schaffzin JK, Barclay C, Goldstein SL. Development and performance of electronic acute kidney injury triggers to identify pediatric patients at risk for nephrotoxic medication-associated harm. Appl Clin Inf 2014; 5: 313–333 http://dx.doi.org/10.4338/ACI-2013-12-RA-0102

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Abstract 19477: Transthoracic Bioimpedance Monitoring Predicts Readmission After Hospitalization for Heart Failure: Preliminary Results From the SENTINEL-HF Study

Circulation ◽

10.1161/circ.132.suppl_3.19477 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Chad E Darling ◽

Silviu Dovancescu ◽

Jarno Riistama ◽

Jane Saczynski ◽

Nisha Kini ◽

...

Keyword(s):

Heart Failure ◽

At Risk ◽

Acute Decompensated Heart Failure ◽

Decompensated Heart Failure ◽

Detection Algorithm ◽

Fluid Accumulation ◽

Predictive Values ◽

Preliminary Results ◽

Patients At Risk

Introduction: Patients and health systems are focused on reducing readmissions for patients with acute decompensated heart failure (ADHF). Readmission after hospitalization is often secondary to HF decompensation, but it remains challenging to identify patients at-risk. Bioimpedance is a validated marker of thoracic fluid accumulation. We examined whether changes in bioimpedance, measured using a Fluid Accumulation Vest (FAV), predicted subsequent HF decompensation in patients discharged after ADHF. Methods: Participants included 83 patients hospitalized for ADHF. Subjects were trained on the use of a FAV-smartphone dyad to obtain and transmit a 5-minute bioimpedance measurement once daily for 45-days after discharge.(see Figure) The outcome of interest, HF-related readmission was assessed using participant report and medical records. Sensitivity, specificity, negative and positive predictive values were calculated to describe the efficacy of the bioimpedance alert algorithm as a predictor of HF readmission. Results: Subject characteristics: mean age 68 ± 11 years, 36% female, 92% white, mean ejection fraction of 44 ± 19%. 49 participants completed the 45-day follow-up and had sufficient, daily FAV data for analysis. Our main outcome of HF-related rehospitalization occurred in 8% of patients during follow-up. The decompensation detection algorithm demonstrated a sensitivity of 75%, specificity of 47%, positive/negative predictive values of 11% and 96%, respectively. Conclusions: The preliminary results of this ongoing study suggest that HF readmissions may be predicted with modest sensitivity by our current decompensation detection algorithm. Further refinement of our transthoracic bioimpedance system may offer possibilities for reducing HF readmissions by enabling identification and treatment of outpatients at risk for readmission.

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Validation of Serum Aspergillus Galactomannan Index as a Surrogate Endpoint for Outcome of Invasive Aspergillosis: Clinical and Research Implications.

Blood ◽

10.1182/blood.v108.11.2861.2861 ◽

2006 ◽

Vol 108 (11) ◽

pp. 2861-2861 ◽

Cited By ~ 3

Author(s):

Gail Woods ◽

Marisa Miceli ◽

Monica Grazziutti ◽

Somashekar Krishna ◽

Nayyar Syed ◽

...

Keyword(s):

At Risk ◽

Clinical Outcome ◽

Invasive Aspergillosis ◽

Composite Endpoint ◽

Surrogate Endpoint ◽

Laboratory Findings ◽

Hematological Cancer ◽

Non Invasive ◽

Patients At Risk ◽

Neutropenic Patients

Abstract Background: Assessing clinical outcome of aspergillosis with conventional clinical and laboratory criteria is difficult. A composite “global outcome response” (clinical, radiologic, pathologic and microbiologic criteria) is frequently used but suffers from poor sensitivity and specificity, and has not been standardized or validated. A reliable, quantitative, non-invasive, and easy to measure laboratory test than can substitute for this composite endpoint, i.e. serve as a surrogate endpoint for aspergillosis outcome is highly desirable. Galactomannan (GM) is an Aspergillus-specific polysaccharide released during aspergillosis and detected by the serum GM test. The test which is reported as an index of optical density (OD) is an accepted diagnostic marker for aspergillosis and preliminary data suggest a correlation between GM index (GMI) and outcome. Purpose: To evaluate serum GMI as a surrogate endpoint for outcome of invasive aspergillosis in patients with hematological cancer. Patients and Methods: patients at risk for aspergillosis (11/03-2/06) underwent GMI screening during periods at risk. The clinical and laboratory findings of patients with ≥ 2 (+) GMI (OD ≥ 0.5) were reviewed. To validate GMI as a surrogate endpoint for aspergillosis, a k correlation concordance coefficient test between GMI and an objective clinical outcome of aspergillosis (death) was applied. The correlation is considered perfect when k is 1.0; excellent when ≥ 0.75. Results: 30 patients had GMI (+) aspergillosis of the respiratory tract [myeloma 92%; median age: 59 years (27–75); 15 males]. Aspergillosis developed following stem cell transplantation [autologous (11), allogeneic (1)], or after conventional chemotherapy (18). Among 25 neutropenic patients (<1000/ml), persistent GMI elevation was associated with death (5/5 patients) while return to negative values predicted survival (20/20 patients). Among 5 non-neutropenic patients, 1 with persistently elevated GMI died compared to no death among the remaining 4 whose GMI became negative. Overall, the GMI correlated with clinical outcome in all 30 patients with a perfect 1.0 k correlation concordance coefficient. Conclusion: we have validated GMI as an excellent surrogate endpoint for the outcome of invasive aspergillosis among patients with hematological cancer. This FDA-approved test is reproducible, quantitative, non-invasive, easy to measure and widely available. These findings have important implications for patient care and for the design of clinical trials of mould-active antifungal agents.

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