A model to estimate survival in ambulatory patients with hepatocellular carcinoma: Can it predict the natural course of hepatocellular carcinoma?

BackgroundSeveral hepatocellular carcinoma (HCC) staging systems are available including the newly developed staging system, the Model to Estimate Survival in Ambulatory HCC patients (MESIAH); however, whether these staging systems could predict the natural course of HCC is largely unknown.Methods1013 patients with history of HCC treatment and 111 patients without any history of treatment till death or last follow-up at a single tertiary hospital were included.ResultsThe MESIAH score showed a better discrimination ability, with a C-statistic of 0.835 [95% confidence interval (CI), 0.810–0.861] in the group of treated patients compared to the Barcelona Clinic Liver Cancer (BCLC) staging system [0.739 (95% CI, 0.709–0.769)] before propensity score matching. However, the MESIAH score failed to stratify patients according to their risk of death in the group of untreated patients unlike the BCLC staging system. Propensity score matching analysis confirmed that the MESIAH score was most strongly influenced by whether treatment was given or not.ConclusionsAlthough the MESIAH score provided better prognostic stratification than other staging systems in treated HCC patients, it was not helpful in predicting the natural course of HCC. Since the treatment affects patient outcome and prognosis, it is necessary to develop a new staging system that can also reflect the natural course of HCC.     

Cognitive impairment in diabetic patients: Can diabetic control prevent cognitive decline?

It is well recognized that the prevalence of dementia is higher in diabetic patients than non‐diabetic subjects. The incidence of diabetes has been increasing because of dramatic changes in lifestyles, and combined with longer lifespans as a result of advances in medical technology, this has brought about an increase in the number of elderly diabetic patients. Together, aging and diabetes have contributed to dementia becoming a serious problem. Progression to dementia reduces quality of life, and imposes a burden on both patients themselves and the families supporting them. Therefore, preventing the complication of dementia will become more and more important in the future. Although many mechanisms have been considered for an association between diabetes and cognitive dysfunction, glucose metabolism abnormalities such as hyperglycemia and hypoglycemia, and insulin action abnormalities such as insulin deficiency and insulin resistance can be causes of cognitive impairment. Recent large‐scale longitudinal studies have found an association between glycemic control and cognitive decline, although it is still unclear how cognitive decline might be prevented by good glycemic control. However, at an early stage, it is necessary to detect moderate cognitive dysfunction and try to reduce the risk factors for it, which should result in prevention of dementia, as well as vascular events. In the present review, in addition to outlining an association between diabetes and cognitive function, we discuss how glycemic control and cognitive decline are related.     

Atherosclerotic renovascular disease and renal impairment: Can we predict the effect of intervention?

Atherosclerotic renal artery stenosis (ARAS) is associated with hypertension, ischemic nephropathy, and high cardiovascular risk. We review the data on revascularization of the renal artery by percutaneous transluminal renal angioplasty (PTRA) and pharmacological therapy. In patients with severe ARAS and poorly controlled hypertension, PTRA can improve blood pressure control. In patients with rapid renal function loss and severe ARAS, PTRA can improve short-term renal function, but there is no evidence for long-term renoprotection. Recent evidence indicates that ARAS, and incidental renal artery stenosis, considerably increases cardiovascular risk, independent of blood pressure, renal function, and prevalent risk factors. This suggests that revascularization might potentially improve overall prognosis, but no data are available currently. The high cardiovascular risk warrants aggressive pharmacological treatment to prevent progression of the generalized vascular disorder. Ongoing trials will show whether revascularization has added, long-term effects on blood pressure, renal function, and cardiovascular prognosis.     

Can we predict the occurrence of atrial fibrillation?

Atrial fibrillation (AF) is a complex disease with increasing prevalence in an aging population and longer survival with cardiovascular diseases. Whereas most clinical efforts have been aimed at predicting risk of AF sequelae such as stroke and heart failure, little is known on primary prevention. AF risk assessment is complicated by the existence of distinct subtypes of AF, such as lone AF or postoperative AF, in contrast to common AF in the elderly. Due to its often intermittent nature, diagnosing AF can be a challenge. Risk prediction becomes reasonable when specific interventions arise. Due to our limited understanding of AF pathophysiology and substantial lack of specific preventive strategies in the population, modification of the general cardiovascular risk profile has largely remained the only option. Initial attempts at combining established risk factors for AF such as age, sex, hypertension, body mass index, electrocardiographic characteristics, and cardiovascular disease in a risk-prediction instrument have produced a robust algorithm. However, known risk factors only explain a fraction of the population-attributable risk of AF, and the search for novel risk indicators is ongoing. More efficient monitoring for electrocardiographic precursors of AF and the field of genomics are evolving areas of AF risk factor research. A better understanding of the underlying substrate of AF will provide targets for prevention. In the future, clinical trials will be needed to establish risk categories, interventions, and their efficacy. Despite a relevant public-health impact, knowledge on risk prediction and primary prevention of AF is still limited today. There are no conflicts of interest to disclose.     

Can mean platelet volume levels of trauma patients predict severity of trauma?

Abstract

In this study, we aimed to evaluate the mean platelet voulme (MPV) levels of trauma patients who were admitted to our emergency department. Of the total 232 trauma patients, 40 females and 192 males over the age of 18 years were included in this study. Of them, 102 patients were mild trauma [Glasgow Coma Scale (GCS) 15–13)], 40 patients were moderate (GCS 12–9) and 90 patients were severe trauma (GCS 8–3) patients. We also calculated the Revised Trauma Score (RTS) of the patients. MPV levels were evaluated with GCS and RTS values. The control group was constituted of 100 healthy adults. Mean initial MPV value of GCS 15–13 patients was 8.25 fL, 8.25 fL in GCS 12–9 patients and 8.47 fL, in GCS 8–3 patients. Trauma severity was significantly related with initial MPV (iMPV) levels (p?<?0.05), initial Hb (iHb) levels (p?<?0.05), initial white blood count (iWBC) (p?<?0.05) and initial platelet (iPlt) levels (p?<?0.05). Severity of trauma was related with control MPV (kMPV) levels (p?<?0.05), control Hb (kHb) (p?<?0.05), control WBC (kWBC) (p?<?0.05), control Plt (kPlt) levels (p?<?0.05). MPV levels (p?<?0.05), Hb levels (p?<?0.05), WBC levels (p?<?0.05), Plt levels (p?<?0.05) were significantly different between trauma group and healthy group. IMPV and control kMPV levels were not related (p?=?0.149). But kHb – iHb levels (p?<?0.05), kWBC – iWBC levels (p?<?0.05), kPlt – iPlt levels (p?<?0.05), kGCS – iiGCS (p?<?0.05) were related to each other. We found a correlation between iMPV and iWBC levels (p?<?0.05, r?=??0.342). Similarly, there was a correlation between severity of trauma and iMPV level (p?<?0.05, r?=??0.224). We determined a significant correlation between iMPV and iPlt levels (p?<?0.05, r?=??0.246). There was not a correlation between kMPV and kWBC (p?>?0.05, r?=?0.124). kMPV and kPlt levels (p?<?0.05, r?=??0.174) were correlated. RTS was statistically related with GCS (p?<?0.05). Similarly, RTS was related with iMPV (p?<?0.05), iWBC(p?<?0.05) and iPlt (p?<?0.05) values, but there was not a relation with iHb (p?>?0.05). We found correlations between iMPV– trauma severity (p?<?0.05, r?=??0.224), iMPV – RTS (p?<?0.05, r?=?0.134), iMPV – iWBC (p?<?0.05 r?=??0.342), iMPV – iPlt (p?<?0.05, r?=??0.246). Control RTS (seventh day of hospitalization) values were not related to kMPV (p?>?0.05), kHB (p?>?0.05), kWBC (p?>?0.05) and kPlt(p?>?0.05). There was a correlation between kRTS and kMPV (p?<?0.05, r?=??0.169). Similarly, kMPV – kHb (p?<?0.05, r?=??0.141), kMPV – kPlt (p?<?0.05, r?=??0.174) were correlated. KMPV and kPlt were not correlated (p?<?0.05, r?=?0.124). Initial RTS and seventh day RTS values were significantly different (p?<?0.05). MPV may be helpful for emergency physicians for predicting the severity of trauma.     

Can composite performance measures predict survival of patients with colorectal cancer?

AIM: To assess the relationship between long-term colorectal patient survival and methods of calculating composite performance scores.METHODS: The Taiwan Cancer Database was used to identify patients who underwent bowel resection for colorectal adenocarcinoma between 2003 and 2004. Patients were assigned to one of three cohorts based on tumor staging: cohort 1, colon cancer stage < III; cohort 2, colon cancer stage III; cohort 3, rectal cancer. A composite performance score (CPS) was calculated for each patient using five different aggregating methods, including all-or-none, 70% standard, equal weight, analytic hierarchy process (AHP), and principal component analysis (PCA) algorithms. The relationships between CPS and five-year overall, disease-free, and disease-specific survivals were evaluated by a Cox proportional hazards model. A goodness-of-fit analysis for all five methods was performed using Akaike’s information criterion.RESULTS: A total of 3272 colorectal cancer patients (cohort 1, 1164; cohort 2, 790; cohort 3, 1318 patients) with a mean age of 65 years were enrolled in the study. Bivariate correlation analysis showed that CPS values from the equal weight method were highly correlated with those from the AHP method in all cohorts (all P < 0.05). Multivariate Cox hazards analysis showed that CPS values derived from equal weight and AHP methods were significantly associated with five-year survivals of patients in cohorts 1 and 2 (all P < 0.05). In these cohorts, higher CPS values suggested a higher probability of five-year survival. However, CPS values derived from the all-or-none method did not show any significant process-outcome relationship in any cohort. Goodness-of-fit analyses showed that CPS values derived from the PCA method were the best fit to the Cox proportional hazards model, whereas the values from the all-or-none model showed the poorest fit.CONCLUSION: CPS values may highlight process-outcome relationships for patients with colorectal cancer in addition to evaluating quality of care performance.     

Can ARFI elastography predict the presence of significant esophageal varices in newly diagnosed cirrhotic patients?

Aim. To establish an algorithm which includes the liver stiffness (LS) and/or spleen stiffness (SS) assessed by ARFI for the prediction of significant esophageal varices-EV (at least grade 2).Material and methods. Our study included 145 newly diagnosed cirrhotic patients admitted in our Department between September 2009-August 2011. 62 patients (42.7%) had significant EV. We performed 10 ARFI measurements in each patient, both in the liver and in the spleen; median values were calculated, expressed in meters/second. In 24 consecutive newly diagnosed cirrhotic patients admitted between September 2011-December 2011, we prospectively analyzed the value of the new score for predicting significant EV.Results. The LS and SS assessed by ARFI elastography, and the percentage of patients with ascites were stastically significant higher in patients with significant EV as compared with those without EV or grade 1 EV. By multiple regression analysis we obtained the following formula for predicting significant EV: prediction of significant EV (Pred EV_2-3) score: -0.572 + 0.041 × LS (m/s) + 0.122 × SS (m/s) + 0.325 × ascites (1-absent, 2-present). The best Pred EV_2-3 cut-off value for predicting significant EV was > 0.395 (AUROC = 0.721, accuracy = 69.6%). The accuracy in the group of patients in which the value of this score was prospectively analyzed was similar with that obtained in the first cohort of patients (70.8 vs. 69.6%). In conclusion, the proposed Pred EV_2-3 score had a enough good value for predicting significant EV.     

Can patients determine the level of their dysphagia?

AIM To determine if patients can localise dysphagia level determined endoscopically or radiologically and association of gender, age, level and pathology.METHODS Retrospective review of consecutive patients presenting to dysphagia hotline between March 2004 and March 2015 was carried out. Demographics, clinical history and investigation findings were recorded including patient perception of obstruction level (pharyngeal, mid sternal or low sternal) was documented and the actual level of obstruction found on endoscopic or radiological examination (if any) was noted. All patients with evidence of obstruction including oesophagealcarcinoma, peptic stricture, Schatzki ring, oesophageal pouch and cricopharyngeal hypertrophy were included in the study who had given a perceived level of dysphagia. The upper GI endoscopy reports (barium study where upper GI endoscopy was not performed) were reviewed to confirm the distance of obstructing lesion from central incisors. A previously described anatomical classification of oesophagus was used to define the level of obstruction to be upper, middle or lower oesophagus and this was compared with patient perceived level.RESULTS Three thousand six hundred and sixty-eight patients were included, 42.0% of who were female, mean age 70.7 ± 12.8 years old. Of those with obstructing lesions, 726 gave a perceived level of dysphagia: 37.2% had oesophageal cancer, 36.0% peptic stricture, 13.1% pharyngeal pouches, 10.3% Schatzki rings and 3.3% achalasia. Twenty-seven point five percent of patients reported pharyngeal level (upper) dysphagia, 36.9% mid sternal dysphagia and 25.9% lower sternal dysphagia (9.5% reported multiple levels). The level of obstructing lesion seen on diagnostic testing was upper (17.2%), mid (19.4%) or lower (62.9%) or combined (0.3%). When patients localised their level of dysphagia to a single level, the kappa statistic was 0.245 (P 0.001), indicating fair agreement. 48% of patients reporting a single level of dysphagia were accurate in localising the obstructing pathology. With respect to pathology, patients with pharyngeal pouches were most accurate localising their level of dysphagia(P 0.001). With respect to level of dysphagia, those with pharyngeal level lesions were best able to identify the level of dysphagia accurately (P 0.001). No association (P 0.05) was found between gender, patient age or clinical symptoms with their ability to detect the level of dysphagia.CONCLUSION Patient perceived level of dysphagia is unreliable in determining actual level of obstructing pathology and should not be used to tailor investigations.     

Does the metabolic syndrome predict mobility impairment in the elderly?

The predictive importance of the metabolic syndrome and its components for declining mobility were tested in a 5-year follow-up study of four elderly birth cohorts (65, 75, 80 and 85 years of age; n=946). In the age group of 65 years, the subjects with mobility decline were more often diabetics (24.6 vs. 15.5%, P=0.060), had higher blood glucose (6.2 vs. 5.8 mmol/l, P<0.05), higher fasting plasma insulin (13.2 vs. 11.4 IU/l, P<0.01), and higher body mass index (28.4 vs. 27.2 kg/m(2), P<0.05) than the others. In the 75 year-old group, the mobility decline was associated with lower HDL-cholesterol (1.4 vs. 1.6 mmol/l, P<0.05) and higher insulin (15.9 vs. 12.8 IU/l, P<0.10). In the 80 year-old group, insulin was higher in subjects whose mobility declined (11.3 vs. 17.9 IU/l, P<0.05) but in the oldest group insulin tended to be lower in the subjects with declining mobility. In non-diabetic subjects, blood glucose and plasma insulin were associated with declining mobility in the 65 year-old cohort, only. After controlling for gender and baseline mobility, one quartile of both insulin and BMI increased the probability of mobility decline by 35%, mainly of difficulties in walking up stairs. Of the components of metabolic syndrome, obesity and hyperinsulinemia as its consequence appear causal of declining mobility.     

Can platelet function tests predict the clinical efficacy of aspirin?

"Aspirin resistance" and "aspirin nonresponsiveness" are terms used both to describe both the failure of aspirin to protect subgroups of individuals from severe vascular events and to evoke an appropriate inhibition of platelet function. Several studies utilizing a broad range of platelet function tests have shown that some subgroups of individuals exhibit a reduced or completely missing antiplatelet response to aspirin. The clinical significance of aspirin nonresponsiveness for the prediction of clinical endpoints remains, however, to be determined. Thus far, only three prospective clinical trials have demonstrated a possible relationship between aspirin nonresponsiveness and subsequent vascular events. Most platelet function tests used in respective clinical studies cannot be reliably performed in clinical routine and are not interchangeable for monitoring antiplatelet treatment. There is a need for a simple and reliable assay for predicting the clinical efficacy of antiplatelet therapy. Recent data demonstrate that none of the currently developed assays, including the PFA-100 system, are presently able to accomplish these objectives.