Improved malignancy prediction by B3 breast lesions subclassification

Core-needle biopsy (CNB) of breast lesions can be classified into 5 categories according to lesion type and associated risk of malignancy. B3 category (lesion of uncertain malignant potential) constitutes a challenging problem in clinical decision, with most ending in excisional biopsy. Therefore, the aim of this study was to establish the incidence of malignancy on excision biopsy of B3 lesions and assess if subclassification (in B3a and B3b categories) according to the presence of atypia in otherwise B3 lesions better predicts malignancy on excision. Forty-eight cases with diagnosis of B3 lesion on CNB and matched surgical excision specimen were included to evaluate the positive predictive value (PPV) and odds for malignancy in CNB. All cases were further subclassified into B3a and B3b categories. B3 category lesions had an overall PPV for malignancy of 12.5% and significant low odds of malignancy of 0.14. When subclassified, B3b (lesions with atypia) demonstrated a higher PPV for malignancy (36.36%) with a nonsignificant odds. Inversely, B3a (lesions without atypia) demonstrated a PPV for malignancy of only 5.41% and a significant low odds of malignancy of only 0.06. The described low rate of malignancy in some of B3 lesions additionally reinforces the practice of avoiding surgical excision in selected patients and provides data that additionally support B3 lesion subclassification according to the presence of atypia. Subclassification of B3 category can further refine the current classification of associated risk of malignancy with possible implications in clinical management.     

Multi-scale graph-based grading for Alzheimer’s disease prediction

The prediction of subjects with mild cognitive impairment (MCI) who will progress to Alzheimer’s disease (AD) is clinically relevant, and may above all have a significant impact on accelerating the development of new treatments. In this paper, we present a new MRI-based biomarker that enables us to accurately predict conversion of MCI subjects to AD. In order to better capture the AD signature, we introduce two main contributions. First, we present a new graph-based grading framework to combine inter-subject similarity features and intra-subject variability features. This framework involves patch-based grading of anatomical structures and graph-based modeling of structure alteration relationships. Second, we propose an innovative multiscale brain analysis to capture alterations caused by AD at different anatomical levels. Based on a cascade of classifiers, this multiscale approach enables the analysis of alterations of whole brain structures and hippocampus subfields at the same time. During our experiments using the ADNI-1 dataset, the proposed multiscale graph-based grading method obtained an area under the curve (AUC) of 81% to predict conversion of MCI subjects to AD within three years. Moreover, when combined with cognitive scores, the proposed method obtained 85% of AUC. These results are competitive in comparison to state-of-the-art methods evaluated on the same dataset.     

Nutrition integration across the nursing curriculum: A novel teaching model within a pre-licensure program

Across the healthcare spectrum, the provision of evidence-based nutrition education is critical in supporting optimal patient care and health outcomes. Nurses are uniquely positioned to deliver nutrition-focused patient education related to health promotion and disease management; yet widespread evidence of sufficient nutrition instruction in nursing curricula is not available. Although lifestyle and nutrition recommendations have historically been the domain of registered dietitians, interprofessional collaboration requires that nurses are prepared to reinforce and support the dissemination of accurate nutrition education. Interdisciplinary teaching approaches are therefore imperative for consistent communication and execution of nutrition guidance. At a private nursing college, an innovative model for nutrition integration across a nursing curriculum has been developed and implemented. This model features an ongoing instructional partnership between registered dietitian faculty and nurse educators. This integrative model enhances nutrition-related nursing competencies demonstrated by undergraduate nursing students and aims to produce graduates who are confident in the delivery of nutrition-related nursing care.     

Predictors of renal replacement therapy and mortality in children with chronic kidney disease

Objectives:

To study the epidemiology of chronic kidney disease (CKD) in children, and to look for risk factors to predict renal replacement therapy (RRT) and mortality.

Methods:

This is a retrospective cohort study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between 2006 and 2014, where the files of 1,000 children with CKD were reviewed. We determined the effect of consanguinity and hypertension, and being a Saudi indigene on mortality and RRT. We compared children with congenital versus non-congenital causes of CKD.

Results:

The mean±standard deviation age at presentation was 4.9±4.3 years. The median duration of follow up was 1.5 (interquartile range [IQR]: 0.4-4.0) years. Only 9.7% of children received RRT, and 8.3% died. The underlying etiology for CKD was congenital in 537 children. The congenital CKD group presented at a younger age group (3.5±4.0 versus 6.6±3.9 years, p<0.0001), had more advanced stages of CKD (p<0.0001), higher rates of consanguinity (75.4% versus 47.1%, p<0.0001), and RRT (p<0.004) than children with non-congenital CKD. Risk factors for RRT among children with CKD include being a Saudi indigene (relative risk [RR]=1.49, 95% confidence interval (CI): 1.01-2.21), and hypertensive (RR=5.29, 95% CI: 3.54-7.91). The risk factor for mortality was hypertension (RR=2.46, 95% CI: 1.66-3.65).

Conclusion:

Congenital causes of CKD represent the main etiology of CKD in children living in the western province of Saudi Arabia. Significant risk factors for RRT include congenital CKD, Saudi nationality, and hypertension. Hypertension is also a predictor of mortality in children with CKD.Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function, present for more than 3 months with implications for health.1 Children with CKD who are on renal replacement therapy (RRT) have higher mortality rate, which is at least 30-fold higher than their age-matched peers.2 Epidemiological information on the incidence and prevalence of pediatric CKD in children is currently limited,3 particularly in developing countries. Furthermore, most of the available epidemiological data are from end-stage kidney disease (ESKD) registries, and information on the earlier stages of pediatric CKD is still lacking.4 The early stages of CKD in the pediatric population are in most cases asymptomatic, and are therefore under-diagnosed and under-reported.4 Direct comparisons of the incidence and prevalence rate of pediatric CKD are complex since each pediatric CKD registries uses different definition; some depend on the estimated glomerular filtration rate (eGFR), while others use serum creatinine levels. The incidence in Europe was consistent between 11-12 per million of the age-related population (pmarp) for CKD stages 3-5, and 8 pmarp for CKD stages 4-5.4 Data available on the exact prevalence of various kidney diseases in the Arab world is very limited. Most of the data come from small studies and are of limited generalizability.5 In Kuwait, the mean incidence was found to be as high as 38 pmarp, while the prevalence was as also high at 329 pmarp in 2003.6 An incidence of 11 pmarp and a prevalence of 51 pmarp has been reported in Jordanian children.7 The epidemiological data of CKD in children is very scarce in Saudi Arabia. One study from Asir reported that the mean annual incidence of CRF of 15.6 per million children, the mean annual incidence of ESRF is 9.2 per million children, and congenital anomalies of the urinary system constitute the most common cause of chronic renal failure (CRF).8 Another study from Jeddah reported similar results.9 All these studies enrolled a small number of children (less that 100). In the light of a limited data available regarding the epidemiology of CKD in children in Saudi Arabia, we performed a retrospective study to examine the risk factors for RRT and mortality among children with CKD.     

Renal Denervation in the Management of Hypertension: A Meta-Analysis of Sham-Controlled Trials

IntroductionSympathetic renal denervation (RD) can potentially reduce blood pressure (BP) in people with resistant hypertension (RH) and uncontrolled hypertension (UH). While a large sham-controlled trial (SCT) showed similar outcomes of RD vs. sham control, in the recent trials, RD was effective in reducing BP in hypertensive people. We performed a meta-analysis of SCTs of RD vs. sham in hypertensive patients.MethodsMultiple electronic databases were searched since inception through September 2018 for SCTs that compared RD vs. sham. Change in 24-hour, daytime and nighttime ambulatory and office BP were efficacy outcomes. Various adverse events were safety outcomes.ResultsA total of 7 SCTs were included in the analysis. RD vs. sham significantly reduced 24-hour ambulatory SBP by 3.45 mmHg [95% CI (−5.01, −1.88); P < 0.0001] and DBP by 1.87 mmHg [(−3.59, −0.15); P = 0.01], office DBP by 2.97 mmHg [(−4.76, −1.18); P = 0.001] and daytime ambulatory SBP by 4.03 mmHg [(−6.37, −1.68); P = 0.0008] and DBP by 1.53 mmHg [(−2.69, −0.37); P = 0.01]. RD vs. sham caused non-significant reduction in office SBP by 3.99 mmHg [(−8.10, 0.11); P = 0.06] and nighttime ambulatory SBP by 3.05 mmHg [(−6.86, 0.75), P = 0.12] and DBP by 1.03 mmHg [(−3.01, 0.96); P = 0.31]. There was no difference in the risk of hypertensive crisis/emergency [0.62; 0.24–1.60; P = 0.33] between the two strategies.ConclusionsCurrent meta-analysis shows that RD reduces ambulatory BP and office DBP in patients with hypertension. Future trials with longer follow-up should confirm these findings.     

Association between early respiratory viral infections and structural lung disease in infants with cystic fibrosis

BackgroundInfants with cystic fibrosis (CF) develop structural lung disease early in life, and viral infections are associated with progressive lung disease. We hypothesized that the presence of respiratory viruses would be associated with structural lung disease on computed tomography (CT) of the chest in infants with CF.MethodsInfants with CF were enrolled before 4 months of age. Multiplex PCR assays were performed on nasal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent CT imaging at approximately 12 months of age. Associations between Perth–Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) CT scores and respiratory viruses and symptoms were assessed with Spearman correlation coefficients.ResultsSixty infants were included for analysis. Human rhinovirus was the most common virus detected, on 28% of tested nasal swabs and in 85% of participants. The median (IQR) extent of lung fields that was healthy based on PRAGMA-CF was 98.7 (0.8)%. There were no associations between PRAGMA-CF and age at first virus, or detection of any virus, including rhinovirus, respiratory syncytial virus, or parainfluenza. The extent of airway wall thickening was associated with ever having wheezed (ρ = 0.31, p = 0.02) and number of encounters with cough (ρ = 0.25, p = 0.0495).ConclusionsInfants with CF had minimal structural lung disease. We did not find an association between respiratory viruses and CT abnormalities. Wheezing and frequency of cough were associated with early structural changes.     

Angiographic and histopathological study on bronchial-to-pulmonary vascular anastomoses on explants from patients with cystic fibrosis after bronchial artery embolisation

Labelled backgroundHaemoptysis is a life-threatening complication of cystic fibrosis (CF). One treatment is bronchial artery embolisation (BAE) using embolic-microspheres (EMs). During BAE, pulmonary arteries can be seen on digital subtracted angiography while iodine containing contrast material injection is performed in the bronchial artery. This suggests that EMs could go from bronchial to nontarget pulmonary arteries. The aim was to evaluate if EMs could be found inside pulmonary arteries on lung explants after BAE in transplanted CF patients.MethodsRetrospective observational study including patients with CF who underwent lung transplantation and had previously needed BAE. Clinical, chest CT angiography, and angiographic data were reviewed from medical records. Pathology examination of lung explants was performed to analyze the EMs anatomical localisation.ResultsEight patients were included between 2013 and 2015, four males with a mean age of 29 (19-45) years. All patients had bronchial artery hypertrophy on CT and bronchial-to-pulmonary artery shunting during BAE. On pathology examination, EM ≤800 µm were found in the pulmonary arteries in all patients and were responsible for distal branch occlusions. Two pulmonary infarcts were observed on CT angiography after BAE and confirmed histopathologically.ConclusionsEM migration from the bronchial to pulmonary arteries is a common occurrence after BAE in patients with advanced stage CF. Although BAE is a highly effective means of controlling haemoptysis in CF, studies on the optimal particle size are needed to preserve pulmonary artery circulation, because these results suggest that low size EMs could lead to nontarget embolisation.     

Advanced but not mild liver disease is a predictor of decreased survival in children with cystic fibrosis,with far greater impact in females: A 27-year real-life cohort study

BackgroundImproved survival of children with CF has increased our need to understand the relevance of cystic fibrosis-associated liver disease (CFLD). We assessed the impact of liver disease and disease severity on the survival of children with cystic fibrosis.MethodsA real life, single center cohort study with 27 years follow up was conducted. Mild CFLD was diagnosed as children with abnormal serum liver function tests and abnormal ultrasound. Advanced CFLD was established by detection of cirrhosis or portal hypertension. A directed acyclic graph, Kaplan-Meier (KM) and Cox regression analysis were used to model survival.Results290 patients were enrolled, 48 (16.5%) had mild CFLD and 55 (19%) had advanced CFLD. Ten children with advanced CFLD and 1 with mild CFLD died. Based on the KM analysis, the mean (SE) overall survival age of all CF children was 29.1 years (0.50). The mean (SE) survival among females with advanced CFLD was 24.7 years (1.58) compared to 30.4 years (0.66) for females without advanced CFLD (p = 0.0027). Advanced CFLD was a predictor of decreased survival when adjusted for sex and diabetes (HR 2.54, 95%CI 1.05–6.15, p = 0.039). Mild CFLD was not associated with decreased survival. The effect of advanced CFLD on survival was mainly borne by females (HR = 6.37, 95%CI 1.62–25.06 vs. males, HR = 1.00, 95%CI 0.25–4.01).ConclusionAdvanced but not mild CFLD was associated with an increased risk of death when adjusted for sex and diabetes, and resulted in premature death in females with cystic fibrosis by approximately 6 years.