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

Mirror exposure to increase body satisfaction: Should we guide the focus of attention towards positively or negatively evaluated body parts?

Background and Objectives: Though there is some evidence that body exposure increases body satisfaction, it is still unclear why exposure works and how attention should be guided during exposure. This pilot study manipulates the focus of attention during body exposure. Methods: Female participants high in body dissatisfaction were randomly assigned to an exposure intervention that exclusively focused on self-defined attractive (n = 11) or self-defined unattractive (n = 11) body parts. Both interventions consisted of five exposure sessions and homework. Outcome and process of change were studied. Results: Both types of exposure were equally effective and led to significant improvements in body satisfaction, body checking, body concerns, body avoidance and mood at post-test. Improvements for body satisfaction and mood were maintained at follow-up while body shape concerns and body checking still improved between post-test and follow-up. Body avoidance improvements were maintained for the positive exposure while the negative exposure tended to further decrease long-term body avoidance at follow-up.. The 'positive' exposure induced positive feelings during all exposure sessions while the 'negative' exposure initially induced a worsening of feelings but feelings started to improve after some sessions. The most unattractive body part was rated increasingly attractive in both conditions though this increase was significantly larger in the negative compared to the positive exposure condition. Limitations: The sample size was small and non-clinical. Conclusions: Both types of exposure might be effective and clinically useful. Negative exposure is emotionally hard but might be significantly more effective in increasing the perceived attractiveness of loathed body parts and in decreasing avoidance behavior. (c) 2015 Elsevier Ltd. All rights reserved

Amsterdam Acute Aneurysm Trial: Background, design, and methods

The objective of the Amsterdam Acute Aneurysm Trial is to study the combined outcome of conventional emergency surgery versus endovascular treatment for ruptured abdominal aortic aneurysms. The design used was a multicenter randomized clinical trial conducted in two university hospitals and one teaching hospital in the Amsterdam region. The study included all patients with a ruptured abdominal aneurysm who were eligible for endovascular and conventional surgery. The primary end points were combined mortality and severe morbidity. The secondary end points were quality of life and cost-effectiveness. The background, design, and methods of this trial are presented, and the ethical and legal issues of this type of research are discussed