Value of risk scores in the decision to palliate patients withruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48‐h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C‐statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48‐h mortality in the IMPROVE data was reasonable (C‐statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C‐statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life‐saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non‐intervention rates, while respecting the wishes of the patient and family

Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family

Exploring the trinity of risks in abdominal aortic aneurysms

This thesis explores the three main risks that are relevant in the management of patients with an abdominal aortic aneurysm (AAA). These risks are the risk of rupture, procedural risks and competing risks and will need to be weighed against each other to tailor the treatment decision to the individual patient. However, making this decision can sometimes be a challenge because it is often difficult to accurately estimate either of these risks. Therefore, any improvement in estimating these risks may help both the vascular surgeon and the patient in making this decision. The first part of this thesis is focused on evaluating biomechanical imaging markers that could potentially be used to estimate rupture risk. The existing literature was critically reviewed in order to determine potentially useful biomechanical imaging markers and a magnetic resonance imaging (MRI) study was undertaken to assess the reproducibility of 4D flow MRI. Part two of this thesis primarily consists out of retrospective cohort studies that evaluated whether certain determinants for procedural and competing risks could be relevant for clinical practice. The final part considers AAA research and the challenges regarding the three risks. It presents the design and protocol of the biobank ‘Pearl AAA’ which was initiated in order to address some of these challenges. Specifically, it is aimed to recruit patients with a small asymptomatic AAA of whom clinical data, imaging data and biomaterials are collected for future study

Exploring the trinity of risks in abdominal aortic aneurysms

This thesis explores the three main risks that are relevant in the management of patients with an abdominal aortic aneurysm (AAA). These risks are the risk of rupture, procedural risks and competing risks and will need to be weighed against each other to tailor the treatment decision to the individual patient. However, making this decision can sometimes be a challenge because it is often difficult to accurately estimate either of these risks. Therefore, any improvement in estimating these risks may help both the vascular surgeon and the patient in making this decision. The first part of this thesis is focused on evaluating biomechanical imaging markers that could potentially be used to estimate rupture risk. The existing literature was critically reviewed in order to determine potentially useful biomechanical imaging markers and a magnetic resonance imaging (MRI) study was undertaken to assess the reproducibility of 4D flow MRI. Part two of this thesis primarily consists out of retrospective cohort studies that evaluated whether certain determinants for procedural and competing risks could be relevant for clinical practice. The final part considers AAA research and the challenges regarding the three risks. It presents the design and protocol of the biobank ‘Pearl AAA’ which was initiated in order to address some of these challenges. Specifically, it is aimed to recruit patients with a small asymptomatic AAA of whom clinical data, imaging data and biomaterials are collected for future study

Pengenalan dan Klasifikasi Tulisan pada Nota Pembelian Material (Studi Kasus Proyek Konstruksi)

CV Bangun Karya Sejahtera merupakan Perusahaan yang aktif bergerak di bidang properti dan memiliki banyak arus kas masuk maupun keluar. Perusahaan telah memiliki sistem informasi untuk membantu memantau aliran dana. Namun, karyawan harus memasukkan data tersebut secara manual ke dalam sistem. Proses input ini seringkali memakan banyak waktu mereka. Oleh karena itu, tugas akhir ini bermaksud untuk menambahkan fitur pada sistem informasi yang ada untuk membantu karyawan dalam menginput data secara otomatis ke dalam sistem informasi Perusahaan yang ada. Fitur ini memanfaatkan teknologi Optical Character Recognition (OCR). Ini dikembangkan menggunakan kerangka Flask berdasarkan bahasa pemrograman Python. Klasifikasi dilakukan dengan menggunakan Support Vector Machine. Hasil penelitian menunjukkan bahwa fitur tambahan dapat melakukan pengenalan dan klasifikasi teks dengan SGDClassifier rata-rata 8,89 detik. Adanya fitur OCR pada sistem informasi ini diharapkan dapat membantu karyawan Perusahaan dalam menginput data ke dalam sistem informasi CV Bangun Karya Sejahtera

Inflammation as a Predictor of Abdominal Aortic Aneurysm Growth and Rupture: A Systematic Review of Imaging Biomarkers

Methods are required to identify abdominal aortic aneurysms (AAAs) at increased risk of rupture. Inflammatory characteristics of AAA can be visualised using advanced imaging techniques and have been proposed as potential predictors of aneurysm progression. The objective of this review was to determine which inflammatory imaging biomarkers are associated with AAA growth and rupture. A systematic review was carried out in accordance with the PRISMA guidelines. The electronic databases of Medline (PubMed), Embase, and the Cochrane Library were searched up to January 1, 2016 for studies to determine the potential association between inflammatory imaging biomarkers and AAA growth or rupture. Seven studies were included, comprising 202 AAA patients. (18)F-fluoro-deoxy-glucose positron emission tomography ((18)F-FDG PET-CT) was evaluated in six studies. Magnetic resonance imaging with ultrasmall superparamagnetic particles of iron oxide (USPIO-MRI) was evaluated in one study. Two of six (18)F-FDG PET-CT studies reported a significant negative correlation (r=.383, p = .015) or a significant negative association (p = .04). Four of six (18)F-FDG PET-CT studies reported no significant association between (18)F-FDG uptake and AAA growth. The single study investigating USPIO-MRI demonstrated that AAA growth was three times higher in patients with focal USPIO uptake in the AAA wall compared to patients with diffuse or no USPIO uptake in the wall (0.66 vs. 0.24 vs. 0.22 cm/y, p = .020). In the single study relating (18)F-FDG uptake results to AAA rupture, the association was not significant. Current evidence shows contradictory associations between (18)F-FDG uptake and AAA growth. Data on the association with rupture are insufficient. Based on the currently available evidence, neither (18)F-FDG PET-CT nor USPIO-MRI can be implemented as growth or rupture prediction tools in daily practice. The heterogeneous results reflect the complex and partially unclear relationship between inflammatory processes and AAA progressio

Biomechanical Imaging Markers as Predictors of Abdominal Aortic Aneurysm Growth or Rupture: A Systematic Review

Biomechanical characteristics, such as wall stress, are important in the pathogenesis of abdominal aortic aneurysms (AAA) and can be visualised and quantified using imaging techniques. This systematic review aims to present an overview of all biomechanical imaging markers that have been studied in relation to AAA growth and rupture. This systematic review followed the PRISMA guidelines. A search in Medline, Embase, and the Cochrane Library identified 1503 potentially relevant articles. Studies were included if they assessed biomechanical imaging markers and their potential association with growth or rupture. Twenty-seven articles comprising 1730 patients met the inclusion criteria. Eighteen studies performed wall stress analysis using finite element analysis (FEA), 13 of which used peak wall stress (PWS) to quantify wall stress. Ten of 13 case control FEA studies reported a significantly higher PWS for symptomatic or ruptured AAAs than for intact AAAs. However, in some studies there was confounding bias because of baseline differences in aneurysm diameter between groups. Clinical heterogeneity in methodology obstructed a meaningful meta-analysis of PWS. Three of five FEA studies reported a significant positive association between several wall stress markers, such as PWS and 99th percentile stress, and growth. One study reported a significant negative association and one other study reported no significant association. Studies assessing wall compliance, the augmentation index and wall stress analysis using Laplace's law, computational fluid dynamics and fluid structure interaction were also included in this systematic review. Although PWS is significantly higher in symptomatic or ruptured AAAs in most FEA studies, confounding bias, clinical heterogeneity, and lack of standardisation limit the interpretation and generalisability of the results. Also, there is conflicting evidence on whether increased wall stress is associated with growt