Do frailty and comorbidity indices improve risk prediction of 28-day ED reattendance? Reanalysis of an ED discharge nomogram for older people

Background: In older people, quantification of risk of reattendance after emergency department (ED) discharge is important to provide adequate post ED discharge care in the community to appropriately targeted patients at risk. Methods: We reanalysed data from a prospective observational study, previously used for derivation of a nomogram for stratifying people aged 65 and older at risk for ED reattendance. We investigated the potential effect of comorbidity load and frailty by adding the Charlson or Elixhauser comorbidity index and a ten-item frailty measure from our data to develop four new nomograms. Model I and model F built on the original nomogram by including the frailty measure with and without the addition of the Charlson comorbidity score; model E adapted for efficiency in the time-constrained environment of ED was without the frailty measure; and model P manually constructed in a purposeful stepwise manner and including only statistically significant variables. Areas under the ROC curve of models were compared. The primary outcome was any ED reattendance within 28 days of discharge. Results: Data from 1357 patients were used. The point estimate of the respective areas under ROC were 0.63 (O), 0.63 (I), 0.68 (E), 0.71 (P) and 0.63 (F). Conclusion: Addition of a comorbidity index to our previous model improves stratifying elderly at risk of ED reattendance. Our frailty measure did not demonstrate any additional predictive benefit

An independently validated nomogram for isocitrate dehydrogenase-wild-type glioblastoma patient survival.

BackgroundIn 2016, the World Health Organization reclassified the definition of glioblastoma (GBM), dividing these tumors into isocitrate dehydrogenase (IDH)-wild-type and IDH-mutant GBM, where the vast majority of GBMs are IDH-wild-type. Nomograms are useful tools for individualized estimation of survival. This study aimed to develop and independently validate a nomogram for IDH-wild-type patients with newly diagnosed GBM.MethodsData were obtained from newly diagnosed GBM patients from the Ohio Brain Tumor Study (OBTS) and the University of California San Francisco (UCSF) for diagnosis years 2007-2017 with the following variables: age at diagnosis, sex, extent of resection, concurrent radiation/temozolomide (TMZ) status, Karnofsky Performance Status (KPS), O6-methylguanine-DNA methyltransferase (MGMT) methylation status, and IDH mutation status. Survival was assessed using Cox proportional hazards regression, random survival forests, and recursive partitioning analysis, with adjustment for known prognostic factors. The models were developed using the OBTS data and independently validated using the UCSF data. Models were internally validated using 10-fold cross-validation and externally validated by plotting calibration curves.ResultsA final nomogram was validated for IDH-wild-type newly diagnosed GBM. Factors that increased the probability of survival included younger age at diagnosis, female sex, having gross total resection, having concurrent radiation/TMZ, having a high KPS, and having MGMT methylation.ConclusionsA nomogram that calculates individualized survival probabilities for IDH-wild-type patients with newly diagnosed GBM could be useful to physicians for counseling patients regarding treatment decisions and optimizing therapeutic approaches. Free software for implementing this nomogram is provided: https://gcioffi.shinyapps.io/Nomogram_For_IDH_Wildtype_GBM_H_Gittleman/

Urinary CE-MS peptide marker pattern for detection of solid tumors

Urinary profiling datasets, previously acquired by capillary electrophoresis coupled to mass-spectrometry were investigated to identify a general urinary marker pattern for detection of solid tumors by targeting common systemic events associated with tumor-related inflammation. A total of 2,055 urinary profiles were analyzed, derived from a) a cancer group of patients (n = 969) with bladder, prostate, and pancreatic cancers, renal cell carcinoma, and cholangiocarcinoma and b) a control group of patients with benign diseases (n = 556), inflammatory diseases (n = 199) and healthy individuals (n = 331). Statistical analysis was conducted in a discovery set of 676 cancer cases and 744 controls. 193 peptides differing at statistically significant levels between cases and controls were selected and combined to a multi-dimensional marker pattern using support vector machine algorithms. Independent validation in a set of 635 patients (293 cancer cases and 342 controls) showed an AUC of 0.82. Inclusion of age as independent variable, significantly increased the AUC value to 0.85. Among the identified peptides were mucins, fibrinogen and collagen fragments. Further studies are planned to assess the pattern value to monitor patients for tumor recurrence. In this proof-of-concept study, a general tumor marker pattern was developed to detect cancer based on shared biomarkers, likely indicative of cancer-related features

Patients With Kidney Cancer

To develop a preoperative prognostic model in order to predict recurrence-free survival in patients with nonmetastatic kidney cancer.A multi-institutional data base of 1889 patients who underwent surgical resection between 1987 and 2007 for kidney cancer was retrospectively analyzed. Preoperative variables were defined as age, gender, presentation, size, presence of radiological lymph nodes and clinical stage. Univariate and multivariate analyses of the variables were performed using the Cox proportional hazards regression model. A model was developed with preoperative variables as predictors of recurrence after nephrectomy. Internal validation was performed by Harrells concordance index.The median follow-up was 23.6 months (1222 months). During the follow-up, 258 patients (13.7) developed cancer recurrence. The median follow-up for patients who did not develop recurrence was 25 months. The median time from surgery to recurrence was 13 months. The 5-year freedom from recurrence probability was 78.6. All variables except age were associated with freedom from recurrence in multivariate analyses (P 0.05). Age was marginally significant in the univariate analysis. All variables were included in the predictive model. The calculated c-index was 0.747.This preoperative model utilizes easy to obtain clinical variables and predicts the likelihood of development of recurrent disease in patients with kidney tumors

Injury Risk Estimation Expertise: Interdisciplinary Differences in Performance on the ACL Injury Risk Estimation Quiz

Background: Simple observational assessment of movement is a potentially low-cost method for anterior cruciate ligament (ACL) injury screening and prevention. Although many individuals utilize some form of observational assessment of movement, there are currently no substantial data on group skill differences in observational screening of ACL injury risk. Purpose/Hypothesis: The purpose of this study was to compare various groups’ abilities to visually assess ACL injury risk as well as the associated strategies and ACL knowledge levels. The hypothesis was that sports medicine professionals would perform better than coaches and exercise science academics/students and that these subgroups would all perform better than parents and other general population members. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 428 individuals, including physicians, physical therapists, athletic trainers, strength and conditioning coaches, exercise science researchers/students, athletes, parents, and members of the general public participated in the study. Participants completed the ACL Injury Risk Estimation Quiz (ACL-IQ) and answered questions related to assessment strategy and ACL knowledge. Results: Strength and conditioning coaches, athletic trainers, physical therapists, and exercise science students exhibited consistently superior ACL injury risk estimation ability (þ2 SD) as compared with sport coaches, parents of athletes, and members of the general public. The performance of a substantial number of individuals in the exercise sciences/sports medicines (approximately 40%) was similar to or exceeded clinical instrument-based biomechanical assessment methods (eg, ACL nomogram). Parents, sport coaches, and the general public had lower ACL-IQ, likely due to their lower ACL knowledge and to rating the importance of knee/thigh motion lower and weight and jump height higher. Conclusion: Substantial cross-professional/group differences in visual ACL injury risk estimation exist. The relatively profound differences in injury risk estimation accuracy and their potential implications for risk screening suggest the need for additional training and outreach

A nomogram to determine required seed air kerma strength in planar 131 Cesium permanent seed implant brachytherapy

Purpose: Intraoperatively implanted Cesium-131 ( 131 Cs) permanent seed brachytherapy is used to deliver highly localized re-irradiation in recurrent head and neck cancers. A single planar implant of uniform air kerma strength (AKS) seeds and 10 mm seed-to-seed spacing is used to deliver the prescribed dose to a point 5 mm or 10 mm perpendicular to the center of the implant plane. Nomogram tables to quickly determine the required AKS for rectangular and irregularly shaped implants were created and dosimetrically verified. By eliminating the need for a full treatment planning system plan, nomogram tables allow for fast dose calculation for intraoperative re-planning and for a second check method. Material and methods: TG-43U1 recommended parameters were used to create a point-source model in MATLAB. The dose delivered to the prescription point from a single 1 U seed at each possible location in the implant plane was calculated. Implant tables were verified using an independent seed model in MIM Symphony LDR™. Implant tables were used to retrospectively determine seed AKS for previous cases: three rectangular and three irregular. Results: For rectangular implants, the percent difference between required seed AKS calculated using MATLAB and MIM was at most 0.6%. For irregular implants, the percent difference between MATLAB and MIM calculations for individual seed locations was within 1.5% with outliers of less than 3.1% at two distal locations (10.6 cm and 8.8 cm), which have minimal dose contribution to the prescription point. The retrospectively determined AKS for patient implants using nomogram tables agreed with previous calculations within 5% for all six cases. Conclusions: Nomogram tables were created to determine required AKS per seed for planar uniform AKS 131 Cs implants. Comparison with the treatment planning system confirms dosimetric accuracy that is acceptable for use as a second check or for dose calculation in cases of intraoperative re-planning

A possible new approach in the prediction of late gestational hypertension: The role of the fetal aortic intima-media thickness

The aim was to determine the predictive role of combined screening for late-onset gestational hypertension by fetal ultrasound measurements, third trimester uterine arteries (UtAs) Doppler imaging, and maternal history. This prospective study on singleton pregnancies was conducted at the tertiary center of Maternal and Fetal Medicine of the University of Padua during the period between January 2012 and December 2014. Ultrasound examination (fetal biometry, fetal wellbeing, maternal Doppler study, fetal abdominal aorta intima-media thickness [aIMT], and fetal kidney volumes), clinical data (mother age, prepregnancy body mass index [BMI], and parity), and pregnancy outcomes were collected. The P value <0.05 was defined significant considering a 2-sided alternative hypothesis. The distribution normality of variables were assessed using Kolmogorov–Smirnoff test. Data were presented by mean (±standard deviation), median and interquartile range, or percentage and absolute values. We considered data from 1381 ultrasound examinations at 29 to 32 weeks’ gestation, and in 73 cases late gestational hypertension developed after 34 weeks’ gestation. The final multivariate model found that fetal aIMT as well as fetal umbilical artery pulsatility index (PI), maternal age, maternal prepregnacy BMI, parity, and mean PI of maternal UtAs, assessed at ultrasound examination of 29 to 32 weeks’ gestation, were significant and independent predictors for the development of gestational hypertension after 34 weeks’ gestation. The area under the curve of the model was 81.07% (95% confidence interval, 75.83%–86.32%). A nomogram was developed starting from multivariate logistic regression coefficients. Late-gestational hypertension could be independently predicted by fetal aIMT assessment at 29 to 32 weeks’ gestation, ultrasound Doppler waveforms, and maternal clinical parameters

Screening for QT Prolongation in the Emergency Department: Is There a Better “Rule of Thumb?”

Introduction: Identification of QT prolongation in the emergency department (ED) is critical for appropriate monitoring, disposition, and treatment of patients at risk for torsades de pointes (TdP). Unfortunately, identifying prolonged QT is not straightforward. Computer algorithms are unreliable in identifying prolonged QT. Manual QT-interval assessment methods, including QT correction formulas and the QT nomogram, are time-consuming and are not ideal screening tools in the ED. Many emergency clinicians rely on the “rule of thumb” or “Half the RR” rule (Half-RR) as an initial screening method, but prior studies have shown that the Half-RR rule performs poorly as compared to other QT assessment methods. We sought to characterize the problems associated with the Half-RR rule and find a modified screening tool to more safely assess the QT interval of ED patients for prolonged QT.Methods: We created graphs comparing the prediction of the Half-RR rule to other common QT assessment methods for a spectrum of QT and heart rate pairs. We then proposed various modifications to the Half-RR rule and assessed these modifications to find an improved “rule of thumb.”Results: When compared to other methods of QT correction, the Half-RR rule appears to be more conservative at normal and elevated heart rates, making it a safe initial screening tool. However, in bradycardia, the Half-RR rule is not sufficiently sensitive in identifying prolonged QT. Adding a fixed QT cutoff of 485 milliseconds (ms) increases the sensitivity of the rule in bradycardia, creating a safer initial screening tool.Conclusion: For a rapid and more sensitive screening evaluation of the QT interval on electrocardiograms in the ED, we propose combining use of the Half-RR rule at normal and elevated heart rates with a fixed uncorrected QT cutoff of 485 ms in bradycardia

Renal cell carcinoma: a nomogram for the CT imaging-inclusive prediction of indolent, non-clear cell renal cortical tumours

Aim To develop a nomogram from clinical and computed tomography (CT) data for pre-treatment identification of indolent renal cortical tumours. Patients and methods A total of 1201 consecutive patients underwent dedicated contrast-enhanced CT prior to nephrectomy for a renal cortical tumour between January 2000 and July 2011. Two radiologists evaluated all tumours on CT for size, necrosis, calcification, contour, renal vein invasion, collecting system invasion, contact with renal sinus fat, multicystic tumour architecture, nodular enhancement, and the degree of nephrographic phase enhancement. CT and clinical predictors (gender, body mass index [BMI], age) were incorporated into the nomogram. We employed multivariable logistic regression analysis to predict tumour type and internally validated the final model using the data from reader 1. External validation was performed by using all data from reader 2. We applied Wilcoxon rank sum test and Fisher's exact test to investigate for differences in tumour size, BMI, age, and differences in CT imaging features between patients with aggressive and those with indolent tumours. Results 63.6% (764/1201) of patients had clear-cell or other aggressive non-clear-cell RCC (i.e. papillary RCC type 2, unclassified RCC) and 36.4% (437/1201) had indolent renal cortical tumours (i.e. papillary RCC type 1, chromophobe RCC, angiomyolipoma, or oncocytoma). On CT, indolent tumours were significantly smaller (p &lt; 0.001) than aggressive tumours and significantly associated with well-defined tumour contours (p &lt; 0.001). Aggressive RCC were significantly associated with necrosis, calcification, renal vein invasion, collecting system invasion, contact with renal sinus fat, multicystic tumour architecture, and nodular enhancement (all, p &lt; 0.001). The nomogram's concordance index (C-index) was 0.823 after internal and 0.829 after external validation. Concluding statement We present a nomogram based on 1201 patients combining CT features with clinical data for the prediction of indolent renal cortical tumours. When externally validated, this nomogram resulted in a C-index of 0.829