Risk stratification for radioactive iodine refractoriness using molecular alterations in distant metastatic differentiated thyroid cancer

Objective: Patients with radioactive iodine-refractory differentiated thyroid cancer(RAIR-DTC) are often diagnosed with delay and constrained to limited treatment options. The correlation between RAI refractoriness and the underlying genetic characteristics has not been extensively studied.Methods: Adult patients with distant metastatic DTC were enrolled and assigned to undergo next-generation sequencing of a customized 26-gene panel(Thyro Lead). Patients were classified into RAIR-DTC or non-RAIR groups to determine the differences in clinicopathological and molecular characteristics. Molecular risk stratification(MRS) was constructed based on the association between molecular alterations identified and RAI refractoriness, and the results were classified as high, intermediate or low MRS.Results: A total of 220 patients with distant metastases were included, 63.2% of whom were identified as RAIRDTC. Genetic alterations were identified in 90% of all the patients, with BRAF(59.7% vs. 17.3%), TERT promoter(43.9% vs. 7.4%), and TP53 mutations(11.5% vs. 3.7%) being more prevalent in the RAIR-DTC group than in the non-RAIR group, except for RET fusions(15.8% vs. 39.5%), which had the opposite pattern. BRAF and TERT promoter are independent predictors of RAIR-DTC, accounting for 67.6% of patients with RAIR-DTC. MRS was strongly associated with RAI refractoriness(P<0.001), with an odds ratio(OR) of high to low MRS of 7.52 [95%confidence interval(95% CI), 3.96-14.28;P<0.001] and an OR of intermediate to low MRS of 3.20(95% CI,1.01-10.14;P=0.041).Conclusions: Molecular alterations were associated with RAI refractoriness, with BRAF and TERT promoter mutations being the predominant contributors, followed by TP53 and DICER1 mutations. MRS might serve as a valuable tool for both prognosticating clinical outcomes and directing precision-based therapeutic interventions.

Magnetic resonance imaging-based radiomics model for preoperative assessment of risk stratification in endometrial cancer

BACKGROUND Preoperative risk stratification is significant for the management of endometrial cancer(EC)patients.Radiomics based on magnetic resonance imaging(MRI)in combination with clinical features may be useful to predict the risk grade of EC.AIM To construct machine learning models to predict preoperative risk stratification of patients with EC based on radiomics features extracted from MRI.METHODS The study comprised 112 EC patients.The participants were randomly separated into training and validation groups with a 7:3 ratio.Logistic regression analysis was applied to uncover independent clinical predictors.These predictors were then used to create a clinical nomogram.Extracted radiomics features from the T2-weighted imaging and diffusion weighted imaging sequences of MRI images,the Mann-Whitney U test,Pearson test,and least absolute shrinkage and selection operator analysis were employed to evaluate the relevant radiomic features,which were subsequently utilized to generate a radiomic signature.Seven machine learning strategies were used to construct radiomic models that relied on the screening features.The logistic regression method was used to construct a composite nomogram that incorporated both the radiomic signature and clinical independent risk indicators.RESULTS Having an accuracy of 0.82 along with an area under the curve(AUC)of 0.915[95%confidence interval(CI):0.806-0.986],the random forest method trained on radiomics characteristics performed better than expected.The predictive accuracy of radiomics prediction models surpassed that of both the clinical nomogram(AUC:0.75,95%CI:0.611-0.899)and the combined nomogram(AUC:0.869,95%CI:0.702-0.986)that integrated clinical parameters and radiomic signature.CONCLUSION The MRI-based radiomics model may be an effective tool for preoperative risk grade prediction in EC patients.

The effect of adjuvant transarterial chemoembolization for hepatocellular carcinoma after liver resection based on risk stratification

Background:There is currently no standard adjuvant treatment proven to prevent hepatocellular carcinoma(HCC)recurrence.Recent studies suggest that postoperative adjuvant transarterial chemoembolization(PA-TACE)is beneficial for patients at high risk of tumor recurrence.However,it is difficult to select the patients.The present study aimed to develop an easy-to-use score to identify these patients.Methods:A total of 4530 patients undergoing liver resection were recruited.Independent risk factors were identified by Cox regression model in the training cohort and the Primary liver cancer big data transarterial chemoembolization(PDTE)scoring system was established.Results:The scoring system was composed of ten risk factors including alpha-fetoprotein(AFP),albuminbilirubin(ALBI)grade,operative bleeding loss,resection margin,tumor capsular,satellite nodules,tumor size and number,and microvascular and macrovascular invasion.Using 5 points as risk stratification,the patients with PA-TACE had higher recurrence-free survival(RFS)compared with non-TACE in>5 points group(P<0.001),whereas PA-TACE patients had lower RFS compared with non-TACE in≤5 points group(P=0.013).In the training and validation cohorts,the C-indexes of PDTE scoring system were 0.714[standard errors(SE)=0.010]and 0.716(SE=0.018),respectively.Conclusions:The model is a simple tool to identify PA-TACE for HCC patients after liver resection with a favorable performance.Patients with>5 points may benefit from PA-TACE.

Relationship between multi-slice computed tomography features and pathological risk stratification assessment in gastric gastrointestinal stromal tumors

BACKGROUND Computed tomography(CT)imaging features are associated with risk stratification of gastric gastrointestinal stromal tumors(GISTs).AIM To determine the multi-slice CT imaging features for predicting risk stratification in patients with primary gastric GISTs.METHODS The clinicopathological and CT imaging data for 147 patients with histologically confirmed primary gastric GISTs were retrospectively analyzed.All patients had received dynamic contrast-enhanced CT(CECT)followed by surgical resection.According to the modified National Institutes of Health criteria,147 lesions were classified into the low malignant potential group(very low and low risk;101 lesions)and high malignant potential group(medium and high-risk;46 lesions).The association between malignant potential and CT characteristic features(including tumor location,size,growth pattern,contour,ulceration,cystic degeneration or necrosis,calcification within the tumor,lymphadenopathy,enhancement patterns,unenhanced CT and CECT attenuation value,and enhancement degree)was analyzed using univariate analysis.Multivariate logistic regression analysis was performed to identify significant predictors of high malignant potential.The receiver operating curve(ROC)was used to evaluate the predictive value of tumor size and the multinomial logistic regression model for risk classification.RESULTS There were 46 patients with high malignant potential and 101 with low-malignant potential gastric GISTs.Univariate analysis showed no significant differences in age,gender,tumor location,calcification,unenhanced CT and CECT attenuation values,and enhancement degree between the two groups(P>0.05).However,a significant difference was observed in tumor size(3.14±0.94 vs 6.63±3.26 cm,P<0.001)between the low-grade and high-grade groups.The univariate analysis further revealed that CT imaging features,including tumor contours,lesion growth patterns,ulceration,cystic degeneration or necrosis,lymphadenopathy,and contrast enhancement patterns,were associated with risk stratification(P<0.05).According to binary logistic regression analysis,tumor size[P<0.001;odds ratio(OR)=26.448;95%confidence interval(CI):4.854-144.099)],contours(P=0.028;OR=7.750;95%CI:1.253-47.955),and mixed growth pattern(P=0.046;OR=4.740;95%CI:1.029-21.828)were independent predictors for risk stratification of gastric GISTs.ROC curve analysis for the multinomial logistic regression model and tumor size to differentiate high-malignant potential from low-malignant potential GISTs achieved a maximum area under the curve of 0.919(95%CI:0.863-0.975)and 0.940(95%CI:0.893-0.986),respectively.The tumor size cutoff value between the low and high malignant potential groups was 4.05 cm,and the sensitivity and specificity were 93.5%and 84.2%,respectively.CONCLUSION CT features,including tumor size,growth patterns,and lesion contours,were predictors of malignant potential for primary gastric GISTs.

New scoring system for acute chest pain risk stratification: Is it worth SVEAT-ing it?

The emergency room is a very potent environment in the hospital.With the growing demands of the population,improved accessibility to health resources,and the onslaught of the triple pandemic,it is extremely crucial to triage patients at presentation.In the spectrum of complaints,chest pain is the commonest.Despite it being a daily ailment,chest pain brings concern to every physician at first.Chest pain could span from acute coronary syndrome,pulmonary embolism,and aortic dissection(all potentially fatal)to reflux,zoster,or musculoskeletal causes that do not need rapid interventions.We often employ scoring systems such as GRACE/PURSUIT/TIMI to assist in clinical decision-making.Over the years,the HEART score became a popular and effective tool for predicting the risk of 30-d major adverse cardiovascular events.Recently,a new scoring system called SVEAT was developed and compared to the HEART score.We have attempted to summarize how these scoring systems differ and their generalizability.With an increasing number of scoring systems being introduced,one must also prevent anchorage bias;i.e.,tools such as these are only diagnosis-specific and not organ-specific,and other emergent differential diagnoses must also be kept in mind before discharging the patient home without additional workup.

Long-Term Outcomes after Coronary Artery Bypass Grafting with Risk Stratification

Background: Risk stratification of long-term outcomes for patients undergoing Coronary artery bypass grafting has enormous potential clinical importance. Aim: To develop risk stratification models for predicting long-term outcomes following coronary artery bypass graft (CABG) surgery. Methods: We retrospectively revised the electronic medical records of 2330 patients who underwent adult Cardiac surgery between August 2016 and December 2022 at Madinah Cardiac Center, Saudi Arabia. Three hundred patients fulfilled the eligibility criteria of CABG operations with a complete follow-up period of at least 24 months, and data reporting. The collected data included patient demographics, comorbidities, laboratory data, pharmacotherapy, echocardiographic parameters, procedural details, postoperative data, in-hospital outcomes, and follow-up data. Our follow-up was depending on the clinical status (NYHA class), chest pain recurrence, medication dependence and echo follow-up. A univariate analysis was performed between each patient risk factor and the long-term outcome to determine the preoperative, operative, and postoperative factors significantly associated with each long-term outcome. Then a multivariable logistic regression analysis was performed with a stepwise, forward selection procedure. Significant (p < 0.05) risk factors were identified and were used as candidate variables in the development of a multivariable risk prediction model. Results: The incidence of all-cause mortality during hospital admission or follow-up period was 2.3%. Other long-term outcomes included all-cause recurrent hospitalization (9.8%), recurrent chest pain (2.4%), and the need for revascularization by using a stent in 5 (3.0%) patients. Thirteen (4.4%) patients suffered heart failure and they were on the maximum anti-failure medications. The model for predicting all-cause mortality included the preoperative EF ≤ 35% (AOR: 30.757, p = 0.061), the bypass time (AOR: 1.029, p = 0.003), and the duration of ventilation following the operation (AOR: 1.237, p = 0.021). The model for risk stratification of recurrent hospitalization comprised the preoperative EF ≤ 35% (AOR: 6.198, p p = 0.023), low postoperative cardiac output (AOR: 3.622, p = 0.007), and the development of postoperative atrial fibrillation (AOR: 2.787, p = 0.038). Low postoperative cardiac output was the only predictor that significantly contributed to recurrent chest pain (AOR: 11.66, p = 0.004). Finally, the model consisted of low postoperative cardiac output (AOR: 5.976, p < 0.001) and postoperative ventricular fibrillation (AOR: 4.216, p = 0.019) was significantly associated with an increased likelihood of the future need for revascularization using a stent. Conclusions: A risk prediction model was developed in a Saudi cohort for predicting all-cause mortality risk during both hospital admission and the follow-up period of at least 24 months after isolated CABG surgery. A set of models were also developed for predicting long-term risks of all-cause recurrent hospitalization, recurrent chest pain, heart failure, and the need for revascularization by using stents.

Cancer risk stratification system and classification of gastritis:Perspectives

Kyoto global consensus reports that the current ICD-10 classification for gastritis is obsolete.The Kyoto classification of gastritis states that severe mucosal atrophy has a high risk of gastric cancer,while mild to moderate atrophy has a low risk.The updated Kimura-Takemoto classification of atrophic gastritis considers five histological types of multifocal corpus atrophic gastritis according to stages C2 to O3.This method of morphological diagnosis of atrophic gastritis increases sensitivity by 2.4 times for severe atrophy compared to the updated Sydney system.This advantage should be considered when stratifying the high risk of gastric cancer.The updated Kimura-Takemoto classification of atrophic gastritis should be used as a reference standard(gold standard)in studies of morphofunctional relationships to identify serological markers of atrophic gastritis with evidence-based effectiveness.The use of artificial intelligence in the serological screening of atrophic gastritis makes it possible to screen a large number of the population.During serological screening of atrophic gastritis and risk stratification of gastric cancer,it is advisable to use the Kyoto classification of gastritis with updated Kimura-Takemoto classification of atrophic gastritis.

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction(NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention(PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed.

Frailty and cardiovascular disease： potential role of gait speed in surgical risk stratification in older adults

Frailty is a state of late life decline and vulnerability, typified by physical weakness and decreased physiologic reserve. The epidemiology and pathophysiology of frailty share features with those of cardiovascular disease. Gait speed can be used as a measure of frailty and is a powerful predictor of mortality. Advancing age is a potent risk factor for cardiovascular disease and has been associated with an increased risk of adverse outcomes. Older adults comprise approximately half of cardiac surgery patients, and account for nearly 80% of the major complications and deaths following surgery. The ability of traditional risk models to predict mortality and major morbidity in older patients being considered for cardiac surgery may improve if frailty, as measured by gait speed, is included in their assessment. It is possible that in the future frailty assessment may assist in choosing among therapies （e.g., surgical vs. percutaneous aortic valve replacement for patients with aortic stenosis）.

Oncological results, functional outcomes and health-related quality-of-life in men who received a radical prostatectomy or external beam radiation therapy for localized prostate cancer： a study on long-term patient outcome with risk stratification

Health-related quality-of-life （HRQOL） after a radical prostatectomy （RP） or extemal beam radiation therapy （EBRT） has not been studied in conjunction with oncological outcomes in relation to disease risk stratification. Moreover, the long-term outcomes of these treatment approaches have not been studied. We retrospectively analyzed oncological outcomes between consecutive patients receiving RP （n = 86） and EBRT （n = 76） for localized prostate cancer. HRQOL and functional outcomes could be assessed in 62 RP （79%） and 54 EBRT （79%） patients over a 3-year follow-up period （median： 41 months） using the Medical Outcomes Study Short Form-36 （SF-36） and the University of Califomia Los Angeles Prostate Cancer Index （UCLA PCI）. The 5-year biochemical progression-free survival did not differ between the RP and EBRT groups for low-risk （74.6% vs. 75.0%, P = 0.931） and intermediate-risk （61.3% vs. 71.1%, P = 0.691） patients. For high-risk patients, progression-free survival was lower in the RP group （45.1%） than in the EBRT group （79.7%） （P = 0.002）. The general HRQOL was comparable between the two groups. Regarding functional outcomes, the RP group reported lower scores on urinary function and less urinary bother and sexual bother than the EBRT group （P 〈 0.001, P 〈 0.05 and P 〈 0.001, respectively）. With risk stratification, the low- and intermediate-risk patients in the RP group reported poorer urinary function than patients in the EBRT group （P 〈 0.001 for each）. The sexual function of the high-risk patients in the EBRT group was better than that of the same risk RP patients （P 〈 0.001）. Biochemical recurrence was not associated with the UCLA PCI score in either group. In conclusion, low- to intermediate-risk patients treated with an RP may report relatively decreased urinary function during long-term follow-up. The patient＇s HRQOL after treatment did not depend on biochemical recurrence.

Risk stratification of patients with atrial fibrillation: Biomarkers and other future perspectives

Risk stratification of atrial fibrillation (AF) and adequate thromboembolism prophylaxis is the cornerstone of treatment in patients with AF. Current risk stratification schemes such as the CHADS 2 and CHA 2 DS 2 -VASc scores are based on clinical risk factors and suboptimally weight the risk/benefit of anticoagulation. Recently, the potential of biomarkers (troponin and NT-proBNP) in the RE-LY biomarker sub-analysis has been demonstrated. Echocardiography is also being evaluated as a possible approach to improve risk score performance. The authors present an overview on AF risk stratification and discuss future potential developments that may be introduced into our current risk stratification schemes.

Acute traumatic coagulopathy：Incidence, risk stratification and therapeutic options

Uncontrolled hemorrhage is responsible for over 50% of all trauma-related deaths within the first 48 hours after admission. Clinical observations together with recent research resulted in an appreciation of the central role of coagulopathy in acute trauma care. A synopsis is presented of different retrospective analyses based upon datasets from severe multiply injured patients derived from the TR-DGU database （Trauma Registry of the Deutsche Gesellschaft for Unfallchirurgie （DGU）/German Society of Trauma Surgery） with respect to frequency, risk stratification and therapeutic options of acute traumatic coagulopathy （ATC）. The synopsis of different analyses based upon the datasets from severe multiply injured patients derived from the TR-DGU database and development/validation of a scoring system （TASH-score = Trauma Associated Severe Hemorrhage） that allows an early and reliable estimation for the probability of massive transfusion as a surrogate for life-threatening hemorrhage after severe multiple injuries. The high frequency of ATC upon emergency room admission is associated with significant morbidity and mortality in multiply injured patients. The TASH-score is recognized as an easy-to-calculate and valid scoring system to predict the individual＇s probability for massive transfusion and thus ongoing life-threatening hemorrhage at a very early stage after severe multiple injuries. An early aggressive management of ATC including a more balanced administration of blood products to improve outcome is advocated.

MRD-directed and risk-adapted individualized stratified treatment of AML

Measurable residual disease(MRD)has been widely recognized as a biomarker for deeply evaluating complete remission(CR),predicting relapse,guiding pre-emptive interventions,and serving as an endpoint surrogate for drug testing.However,despite the emergence of new technologies,there remains a lack of comprehensive understanding regarding the proper techniques,sample materials,and optimal time points for MRD assessment.In this review,we summarized the MRD methods,sample sources,and evaluation frequency according to the risk category of the European Leukemia Net(ELN)2022.Additionally,we emphasize the importance of properly utilizing and combining these technologies.We have also refined the flowchart outlining each time point for preemptive interventions and intervention paths.The evaluation of MRD in acute myeloid leukemia(AML)is sophisticated,clinically applicable,and technology-dependent,and necessitates standardized approaches and further research.

Multi-slice spiral computed tomography in differential diagnosis of gastric stromal tumors and benign gastric polyps,and gastric stromal tumor risk stratification assessment

BACKGROUND The biological characteristics of gastric stromal tumors are complex,and their incidence has increased in recent years.Gastric stromal tumors(GST)have potential malignant tendencies,and the probability of transformation into malignant tumors is as high as 20%-30%.AIM To investigate the value of multi-slice spiral computed tomography(MSCT)in the differential diagnosis of GST and benign gastric polyps,and GST risk stratification assessment.METHODS We included 64 patients with GST(GST group)and 60 with benign gastric polyps(control group),confirmed by pathological examination after surgery in PLA General Hospital,from January 2016 to June 2021.The differences in the MSCT imaging characteristic parameters and enhanced CT values between the two groups before surgery were compared.According to the National Institutes of Health’s standard,GST is divided into low-and high-risk groups for MSCT imaging characteristic parameters and enhanced CT values.RESULTS The incidences of extraluminal growth,blurred boundaries,and ulceration in the GST group were significantly higher than those in the control group(P<0.05).The CT values and enhanced peak CT values in the arterial phase in the CST group were higher than those in the control group(P<0.05).The MSCT differential diagnosis of GST and gastric polyp sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,and areas under the curve(AUCs)were 73.44%,83.33%,26.56%,16.67%,0.784,respectively.The receiver operating characteristic curves were plotted with the arterial CT value and enhanced peak CT value,with a statistical difference.The results showed that the sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,and AUC value of arterial CT in the differential diagnosis of GST and gastric polyps were 80.18%,62.20%,19.82%,37.80%,and 0.710,respectively.The sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,and AUC value of the enhanced peak CT value in the differential diagnosis of GST and gastric polyps were 67.63%,60.40%,32.37%,39.60%,and 0.710,respectively.The incidence of blurred lesion boundaries and ulceration in the high-risk group was significantly higher than that in the low-risk group(P<0.05).The arterial phase and enhanced peak CT values in the high-risk group were significantly higher than those in the low-risk group(P<0.05).CONCLUSION Presurgical MSCT examination has important value in the differential diagnosis of GST and gastric benign polyps and can effectively evaluate the risk grade of GST patients.

Performance of risk stratification systems for gastrointestinal stromal tumors: A multicenter study

BACKGROUND Gastrointestinal stromal tumors(GISTs) are the most common mesenchymal tumor type in the gastrointestinal system. Presently, various classification systems to prognosticate GISTs have been proposed.AIM To evaluate the application value of four different risk stratification systems for GISTs.METHODS Patients who were diagnosed with GISTs and underwent surgical resection at four hospitals from 1998 to 2015 were identified from a database. Risk of recurrence was stratified by the modified National Institute of Health(NIH)criteria, the Armed Forces Institute of Pathology(AFIP) criteria, the Memorial Sloan Kettering Cancer Center(MSKCC) prognostic nomogram, and the contour maps. Receiver operating characteristic(ROC) curves were established to compare the four abovementioned risk stratification systems based on the area under the curve(AUC).RESULTS A total of 1303 patients were included in the study. The mean age of the patients was 55.77 ± 13.70 yr; 52.3% of the patients were male. The mean follow-up period was 64.91 ± 35.79 mo. Approximately 67.0% the tumors were located in the stomach, and 59.5% were smaller than 5 cm; 67.3% of the patients had a mitotic count ≤ 5/50 high-power fields(HPFs). Thirty-four tumors ruptured before and during surgery. Univariate analysis demonstrated that tumor size > 5 cm(P <0.05), mitotic count > 5/50 HPFs(P < 0.05), non-gastric location(P < 0.05), and tumor rupture(P < 0.05) were significantly associated with increased recurrence rates. According to the ROC curve, the AFIP criteria showed the largest AUC(0.754).CONCLUSION According to our data, the AFIP criteria were associated with a larger AUC than the NIH modified criteria, the MSKCC nomogram, and the contour maps, which might indicate that the AFIP criteria have better accuracy to support therapeutic decision-making for patients with GISTs.

Electrophysiologic testing guided risk stratification approach for sudden cardiac death beyond the left ventricular ejection fraction

Sudden cardiac death threats ischaemic and dilated cardiomyopathy patients. Anti- arrhythmic protection may be provided to these patients with implanted cardiac defibrillators(ICD), after an efficient risk stratification approach. The proposed risk stratifier of an impaired left ventricular ejection fraction has limited sensitivity meaning that a significant number of victims will remain undetectable by this risk stratification approach because they have a preserved left ventricular systolic function. Current risk stratification strategies focus on combinations of non invasive methods like T wave alternans, late potentials, heart rate turbulence, deceleration capacity and others, with invasive methods like the electrophysiologic study. In the presence of an electrically impaired substrate with formed post myocardial infarction fibrotic zones, programmed ventricular stimulation provides important prognostic information for the selection of the patients expected to benefit from an ICD implantation, while due to its high negative predictive value, patients at low risk level may also be detected. Clustering evidence from different research groups and electrophysiologic labs support an electrophysiologic testing guided risk stratification approach for sudden cardiac death.

Role of Immune Microenvironmental Factors for Improving the IPI-related Risk Stratification of Aggressive B Cell Lymphoma

Objective To investigate the risk stratification of aggressive B cell lymphoma using the immune microenvironment and clinical factors. Methods A total of 127 patients with aggressive B cell lymphoma between 2014 and 2015 were enrolled in this study. CD4, Foxp3, CDS, CD68, CD163, PD-1, and PD-L1 expression levels were evaluated in paraffin-embedded lymphoma tissues to identify their roles in the risk stratification. Eleven factors were identified for further evaluation using analysis of variance, chi-square, and multinomial logistic regression analysis. Results Significant differences in 11 factors （age, Ann Arbor stage, B symptom, ECOG performance status, infiltrating CD8＋ T cells, PD-L1 expression, absolute blood monocyte count, serum lactate dehydrogenase, serum iron, serum albumin, and serum l^2-microglobulin） were observed among patient groups stratified by at least two risk stratification methods [International Prognostic Index （IPI）, revised IPI, and NCCN-IPI models] （P 〈 0.05）. Concordance rates were high （81.4%-100.0%） when these factors were used for the risk stratification. No difference in the risk stratification results was observed with or without the Ann Arbor stage data. Conclusion We developed a convenient and inexpensive tool for use in risk stratification of aggressive B cell lymphomas, although further studies on the role of immune microenvironmental factors are needed.

Presepsin as a biomarker for risk stratification for acute cholangitis in emergency department: A single-center study

BACKGROUND Acute cholangitis is caused by bacterial infection and has high morbidity and mortality risk.The grade of cholangitis can guide clinical treatment from single antibiotic treatment to biliary drainage.With the introduction of white blood cell(WBC)count,C-reactive protein(CRP),and total bilirubin(T-Bil)into the diagnostic criteria and severity grading for acute cholangitis,the diagnosis rate and grading have significantly improved.However,early risk stratification assessments are challenging in the emergency department.Therefore,we hope to find an ideal predictive biomarker for cholangitis grade.Presepsin is a promising biomarker for the early diagnosis,severity,and prognosis of acute bacterial infections.AIM To assess the grading value of presepsin in patients with acute cholangitis.METHODS This clinical study was conducted at the Beijing Friendship Hospital,a 2000-bed teaching hospital with approximately 200000 emergency admissions per year.In this prospective observational study,336 patients with acute cholangitis meeting the Tokyo Guidelines 2018 diagnostic criteria in the emergency department from May 2019 to December 2020 were analyzed.WBC count,CRP,procalcitonin(PCT),presepsin,T-Bil,and blood culture results were collected.The values were compared using the Pearsonχ2 test,Fisher’s exact test,or Mann-Whitney U test.The area under the receiver operating characteristic curve(AUC)of the value was examined using the Delong test.The correlations among the key research indicators were determined using Pearson correlation.RESULTS In total,336 patients were examined,which included 107,106,and 123 patients classified as having mild,moderate,and severe cholangitis,respectively.WBC count,CRP,PCT,presepsin,T-Bil,direct bilirubin,and sequential organ failure assessment scores of moderate and severe cholangitis patients were higher than those of mild cholangitis patients(P=0.000).The AUC of presepsin in predicting moderate acute cholangitis was 0.728,which was higher than that of CRP(0.631,P=0.043)and PCT(0.585,P=0.002),and same as that of WBC count(0.746,P=0.713)and T-Bil(0.686,P=0.361).The AUC of presepsin in predicting severe acute cholangitis was 0.715,which was higher than that of WBC count(0.571,P=0.008),CRP(0.590,P=0.009),PCT(0.618,P=0.024),and T-Bil(0.559,P=0.006).The presepsin levels in the positive blood culture group were higher(2830.8pg/mLvs1987.8pg/mL,P=0.000),and the AUC of presepsin(0.688)proved that it was a good biomarker for predicting positive bacterial culture.CONCLUSION Presepsin can predict positive blood culture in patients with acute cholangitis.It is superior to WBC count,CRP,PCT,and T-Bil for the risk stratification of acute cholangitis.

Evaluation of high-risk factors and the diagnostic value of alpha-fetoprotein in the stratification of primary liver cancer

BACKGROUND Alpha-fetoprotein(AFP)is one of the diagnostic standards for primary liver cancer(PLC);however,AFP exhibits insufficient sensitivity and specificity for diagnosing PLC.AIM To evaluate the effects of high-risk factors and the diagnostic value of AFP in stratified PLC.METHODS In total,289 PLC cases from 2013 to 2019 were selected for analysis.First,the contributions of high-risk factors in stratifying PLC were compared according to the following criteria:Child–Pugh score,clinical stage of liver cirrhosis,tumor size,and Barcelona Clinic Liver Cancer(BCLC)stage.Then,the diagnostic value of AFP was evaluated in different stratifications of PLC by receiver operating characteristic curves.For PLC cases in which AFP played little role,the diagnostic values of carcinoembryonic antigen(CEA),carbohydrate antigen 19-9(CA 19-9),gamma-glutamyl transferase(GGT),and AFP were analyzed.RESULTS The roles of high-risk factors differed in stratified PLC.The incidence of smoking and drinking history was higher in PLC with Child–Pugh scores of C(P<0.0167).The hepatitis B virus(HBV)infection rate in PLC with cirrhosis was more than in PLC without cirrhosis(P<0.0167).Small tumors were more prone to cirrhosis than large tumors(P<0.005).BCLC stage D PLC was more likely to be associated with HBV infection and cirrhosis(P<0.0083).AFP levels were higher in PLC with cirrhosis,diffuse tumors,and BCLC stage D disease.In diagnosing PLC defined as Child–Pugh A,B,and C,massive hepatoma,diffuse hepatoma,BCLC stage B,C,and D,and AFP showed significant diagnostic value[all area under the curve(AUC)>0.700].However,these measures were meaningless(AUC<0.600)in small hepatomas and BCLC A stage PLC,but could be replaced by the combined detection of CEA,CA 19-9,GGT,and AFP(AUC=0.810 and 0.846,respectively).CONCLUSION Stratification of PLC was essential for precise diagnoses and benefited from evaluating AFP levels.

Effects of Preoperative Risk Stratification on Direct In-hospital Costs for Chinese Patients with Coronary Artery Bypass Graft:A Single Center Analysis

The purpose of this study was to analyze the components of inpatient costs for coronary artery bypass graft(CABG)according to preoperative risk stratification and to provide evidence for improvement of diagnosis-related groups(DRGs)payment.All patients(n=458)receiving an isolated CABG between January 2014 and December 2016 in a tertiary referral center,in southwest China,were analyzed.Hospital mortality was predicted by the EuroSCORE Ⅱ for each patient. The patients were subdivided into two groups according to the observed mortality(1.97%,9/458):a high-risk group(group H,predicted mortality≥1.97%)and a low-risk group(group L,predicted mortality<1.97%).Clinical outcomes,resource use,in-hospital direct costs,and reimbursement expenses were compared between the two groups.Significant differences existed between group L and group H in postoperative mortality(0.4% vs.3.4%;P=0.02),postoperative complications(10.6% vs.45.7%;P<0.001),postoperative length of hospital stay(17.5±4.9 days vs.18.8±6.5 days,P=0.01),in-hospital costs($20 256±3096vs.$23 334±6332;P<0.001),and reimbursement expenses($7775±2627 vs.$9639±3917;P<0.001).In general,a higher EuroSCORE Ⅱ was significantly associated with a worse clinical outcome and increased costs.The CABG cost data provide evidence for improvement of DRGs payment. Key words:coronary artery bypass graft;risk stratification;hospital costs;medical insurance