Comparison of the Framingham Risk Score, SCORE and WHO/ISH cardiovascular risk prediction models in an Asian population

AbstractBackgroundCardiovascular risk-prediction models are used in clinical practice to identify and treat high-risk populations, and to communicate risk effectively. We assessed the validity and utility of four cardiovascular risk-prediction models in an Asian population of a middle-income country.MethodsData from a national population-based survey of 14,863 participants aged 40 to 65years, with a follow-up duration of 73,277 person-years was used. The Framingham Risk Score (FRS), SCORE (Systematic COronary Risk Evaluation)-high and -low cardiovascular-risk regions and the World Health Organization/International Society of Hypertension (WHO/ISH) models were assessed. The outcome of interest was 5-year cardiovascular mortality. Discrimination was assessed for all models and calibration for the SCORE models.ResultsCardiovascular risk factors were highly prevalent; smoking 20%, obesity 32%, hypertension 55%, diabetes mellitus 18% and hypercholesterolemia 34%. The FRS and SCORE models showed good agreement in risk stratification. The FRS, SCORE-high and -low models showed good discrimination for cardiovascular mortality, areas under the ROC curve (AUC) were 0.768, 0.774 and 0.775 respectively. The WHO/ISH model showed poor discrimination, AUC=0.613. Calibration of the SCORE-high model was graphically and statistically acceptable for men (χ2 goodness-of-fit, p=0.097). The SCORE-low model was statistically acceptable for men (χ2 goodness-of-fit, p=0.067). Both SCORE-models underestimated risk in women (p<0.001).ConclusionsThe FRS and SCORE-high models, but not the WHO/ISH model can be used to identify high cardiovascular risk in the Malaysian population. The SCORE-high model predicts risk accurately in men but underestimated it in women

A comparison between performing value stream mapping on production and administration : Case study on ABB ROBOTICS Västerås

Value stream mapping is a tool that is frequently used by many different companies. It is a great tool used to achieve the work that follows the theories of lean production. The tool is used, however, only frequent on the factory floor and the method is also designed based on this type of use. An interest of applying the method on administrative parts of the company has occurred lately. Administrative parts of the company refers to the part that does all the planning such as purchasing, receiving orders, customer contact, contact with factory floor and other work that is made around the actual manufacturing. But the knowledge about applying value stream mapping on the planning part of the company is lacking because the method is relatively new. In this work, a comparison is made between the introduction of value stream analysis on production and planning. This has been done through a case study at ABB Robotics. On this case study a value stream analysis has been made on the planning part of ABB Robotics and the part of the factory floor manufacturing the control cabinets of the robots. The purpose of the performance was to create an understanding of the similarities and differences that exist in the application of value stream analysis on production and planning. The case study has been made based on the current literature available on the subject. The literature has then been reviewed critically, based on the differences and similarities shown by the performed case study. Based on an analysis of the results from the case study, several conclusions were drawn and reflected over taking into account the existing literature. Conclusions drawn from the study, questions the existing literature's critical attitude to the method. Critical review is important at this situation because it is a new method and much proof, that it is properly functioning, does not yet exist. The study mentions that value stream analysis of planning is not always relevant. The interest of the method depends on the type of business and its customers' needs. For a company where the lead time of the planning part of the company is not of great importance to the customer’s value stream mapping is not interesting to apply. The application of value stream analysis is much more complex and time-consuming according to the study and therefore it is not always worthwhile to use the method.Värdeflödesanalys är ett verktyg som används i stor utsträckning i dagsläget. Det är ett bra verktyg som används för att uppnå arbete som följer teorier kring lean produktion. Verktyget används däremot endast frekvent på producerande delar av en organisation och metoden är också framtagen begrundat på den typen av användning. På senare tid har ett intresse skapats för att applicera metoden även på administrativa delar av ett företag. Med administrativ del av företaget menas själva planerande delen av företaget som står för råvaruhemtagning, ordermottagning, kundkontakt, kontakt med produktion och andra steg som görs kring själva fabriksgolvet. Alltså det arbete som sker på företagets kontor. Eftersom att metoden att applicera värdeflödesanalys på planeringen är relativt ny är också kunskaperna kring området bristande. I detta arbete görs en jämförelse mellan att införa värdeflödesanalys på produktionen respektive planeringen. Det har gjorts genom en fallstudie på ABB Robotics. Under fallstudien har en värdeflödesanalys utförts på produktionen av styrskåp till robotar samt kontoret på ABB Robotics. Syftet med utförandet har varit att skapa en förståelse för de skillnader som finns vid appliceringen av värdeflödesanalys på produktion och planering. Fallstudien har utförts med hjälp av den litteratur som finns kring ämnet idag. Därefter har litteraturen granskats kritiskt utifrån de skillnader som visades genom den utförda fallstudien. Utifrån analys av fallstudiens resultat har flera slutsatser dragits och reflekterats över med hänsyn tagen till befintlig litteratur. Slutsatser som dragits utifrån det ifrågasätter den befintliga litteraturens kritiska förhållning till metoden. Kritisk granskning av metoden är viktig eftersom att den är ny och bevis på att den är väl fungerande ännu inte existerar i stor utsträckning. Studien nämner att införandet av värdeflödesanalys på planering inte alltid är relevant. Intresset för metoden beror på typ av företag och hur dess kunders behov ser ut. För ett företag där ledtiden på planeringen inte har någon större betydelse för kunden är värdeflödesanalys heller inte intressant att applicera. Appliceringen av värdeflödesanalys är mycket mer komplex och tidskrävande enligt studien och därför är det också inte alltid lönt att använda metoden

An Asian validation of the TIMI risk score for ST-segment elevation myocardial infarction.

BACKGROUND: Risk stratification in ST-elevation myocardial infarction (STEMI) is important, such that the most resource intensive strategy is used to achieve the greatest clinical benefit. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases. This study sought to validate the Thrombolysis In Myocardial Infarction (TIMI) risk score for STEMI in a multi-ethnic developing country. METHODS: Data from a national, prospective, observational registry of acute coronary syndromes was used. The TIMI risk score was evaluated in 4701 patients who presented with STEMI. Model discrimination and calibration was tested in the overall population and in subgroups of patients that were at higher risk of mortality; i.e., diabetics and those with renal impairment. RESULTS: Compared to the TIMI population, this study population was younger, had more chronic conditions, more severe index events and received treatment later. The TIMI risk score was strongly associated with 30-day mortality. Discrimination was good for the overall study population (c statistic 0.785) and in the high risk subgroups; diabetics (c statistic 0.764) and renal impairment (c statistic 0.761). Calibration was good for the overall study population and diabetics, with χ2 goodness of fit test p value of 0.936 and 0.983 respectively, but poor for those with renal impairment, χ2 goodness of fit test p value of 0.006. CONCLUSIONS: The TIMI risk score is valid and can be used for risk stratification of STEMI patients for better targeted treatment

Use of a Diagnostic Score to Prioritize Computed Tomographic (CT) Imaging for Patients Suspected of Ischemic Stroke Who May Benefit from Thrombolytic Therapy

BACKGROUND: A shortage of computed tomographic (CT) machines in low and middle income countries often results in delayed CT imaging for patients suspected of a stroke. Yet, time constraint is one of the most important aspects for patients with an ischemic stroke to benefit from thrombolytic therapy. We set out to assess whether application of the Siriraj Stroke Score is able to assist physicians in prioritizing patients with a high probability of having an ischemic stroke for urgent CT imaging. METHODS: From the Malaysian National Neurology Registry, we selected patients aged 18 years and over with clinical features suggesting of a stroke, who arrived in the hospital 4.5 hours or less from ictus. The prioritization of receiving CT imaging was left to the discretion of the treating physician. We applied the Siriraj Stroke Score to all patients, refitted the score and defined a cut-off value to best distinguish an ischemic stroke from a hemorrhagic stroke. RESULTS: Of the 2176 patients included, 73% had an ischemic stroke. Only 33% of the ischemic stroke patients had CT imaging within 4.5 hours. The median door-to-scan time for these patients was 4 hours (IQR: 1;16). With the recalibrated score, it would have been possible to prioritize 95% (95% CI: 94%-96%) of patients with an ischemic stroke for urgent CT imaging. CONCLUSIONS: In settings where CT imaging capacity is limited, we propose the use of the Siriraj Stroke Score to prioritize patients with a probable ischemic stroke for urgent CT imaging

Sex differences in stroke metrics among Southeast Asian countries: Results from the Global Burden of Disease Study 2015

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420Item not available in this repository.Background Sex differences in cardiovascular diseases generally disadvantage women, particularly within developing regions. Aims This study aims to examine sex-related differences in stroke metrics across Southeast Asia in 2015. Furthermore, relative changes between sexes are compared from 1990 to 2015. Methods Data were sourced from the Global Burden of Disease Study. Incidence and mortality from ischemic and hemorrhagic strokes were explored with the following statistics derived: (1) women-to-men incidence/mortality ratio and (2) relative percentage change in rate. Results Women had lower incidence and mortality from stroke compared to men. Notable findings include higher ischemic stroke incidence for women at 30–34 years in high-income countries (women-to-men ratio: 1.3, 95% CI: 0.1, 16.2 in Brunei and 1.3, 95% CI: 0.5, 3.2 in Singapore) and the largest difference between sexes for ischemic stroke mortality in Vietnam and Myanmar across most ages. Within the last 25 years, greater reductions for ischemic stroke metrics were observed among women compared to men. Nevertheless, women below 40 years in some countries showed an increase in ischemic stroke incidence between 0.5% and 11.4%, whereas in men, a decline from −4.2% to −44.2%. Indonesia reported the largest difference between sexes for ischemic stroke mortality; a reduction for women whereas an increase in men. For hemorrhagic stroke, findings were similar: higher incidence among young women in high-income countries and greater reductions for stroke metrics in women than men over the last 25 years. Conclusions Distinct sex-specific differences observed across Southeast Asia should be accounted in future stroke preventive guidelines.https://doi.org/10.1177/174749301983299514

Use of Antihypertensive Drugs and Ischemic Stroke Severity - Is There a Role for Angiotensin-II?

BACKGROUND: The increase in angiotensin II (Ang II) formation by selected antihypertensive drugs is said to exhibit neuroprotective properties, but this translation into improvement in clinical outcomes has been inconclusive. We undertook a study to investigate the relationship between types of antihypertensive drugs used prior to a stroke event and ischemic stroke severity. We hypothesized that use of antihypertensive drugs that increase Ang II formation (Ang II increasers) would reduce ischemic stroke severity when compared to antihypertensive drugs that suppress Ang II formation (Ang II suppressors). METHODS: From the Malaysian National Neurology Registry, we included hypertensive patients with first ischemic stroke who presented within 48 hours from ictus. Antihypertensive drugs were divided into Ang II increasers (angiotensin-I receptor blockers (ARBs), calcium channel blockers (CCBs) and diuretics) and Ang II suppressors (angiotensin-converting-enzyme inhibitors (ACEIs) and beta blockers). We evaluated stroke severity during admission with the National Institute of Health Stroke Scale (NIHSS). We performed a multivariable logistic regression with the score being dichotomized at 15. Scores of less than 15 were categorized as less severe stroke. RESULTS: A total of 710 patients were included. ACEIs was the most commonly prescribed antihypertensive drug in patients using Ang II suppressors (74%) and CCBs, in patients prescribed with Ang II increasers at 77%. There was no significant difference in the severity of ischemic stroke between patients who were using Ang II increasers in comparison to patients with Ang II suppressors (OR: 1.32, 95%CI: 0.83-2.10, p = 0.24). CONCLUSION: In our study, we found that use of antihypertensive drugs that increase Ang II formation was not associated with less severe ischemic stroke as compared to use of antihypertensive drugs that suppress Ang II formation

Prescription of secondary preventive drugs after ischemic stroke : Results from the Malaysian National Stroke Registry

Background: Evaluation of secondary stroke prevention in low and middle-income countries remains limited. This study assessed the prescription of secondary preventive drugs among ischemic stroke patients upon hospital discharge in Malaysia and identified factors related to the prescribing decisions. Methods: From Malaysian National Stroke Registry, we included patients with non-fatal ischemic stroke. Prescriptions of antiplatelet, anticoagulants, antihypertensive drugs and lipid-lowering drugs were assessed. Multi-level logistic regressions were performed to determine the relation between potential factors and drug prescriptions. Results: Of 5292 patients, 48% received antihypertensive drugs, 88.9% antiplatelet and 88.7% lipid-lowering drugs upon discharge. Thirty-three percent of patients with an indication for anticoagulants (n = 391) received it. Compared to patients <=50 years, patients above 70 years were less likely to receive antiplatelet (OR: 0.72, 95% CI: 0.50-1.03), lipid-lowering drugs (OR: 0.66, 95% CI: 0.45-0.95) and anticoagulants (OR: 0.27, 95% CI: 0.09-0.83). Patients with moderate to severe disability upon discharge had less odds of receiving secondary preventive drugs; an odds ratio of 0.57 (95% CI: 0.45-0.71) for antiplatelet, 0.86 (95% CI: 0.75-0.98) for antihypertensive drugs and 0.78 (95% CI: 0.63-0.97) for lipid-lowering drugs in comparison to those with minor disability. Having prior specific comorbidities and drug prescriptions significantly increased the odds of receiving these drugs. No differences were found between sexes and ethnicities. Conclusions: Prescription of antihypertensive drugs and anticoagulants among ischemic stroke patients in Malaysia were suboptimal. Efforts to initiate regular clinical audits to evaluate the uptake and effectiveness of secondary preventive strategies are timely in low and middle-income settings