Browsing by Subject "Risk Assessment"
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Item ACUTE Heart Failure Risk Stratification: A Step Closer to the Holy Grail?(American Heart Association, 2019-02-26) Collins, Sean P.; Pang, Peter S.; Emergency Medicine, School of MedicineItem Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction(Silverchair, 2019-10-10) Fancy, Tanya; Huang, Andrew T.; Kass, Jason I.; Lamarre, Eric D.; Tassone, Patrick; Mantravadi, Avinash V.; Alwani, Mohamedkazim M.; Subbarayan, Rahul S.; Bur, Andrés M.; Worley, Mitchell L.; Graboyes, Evan M.; McMullen, Caitlin P.; Azoulay, Ofer; Wax, Mark K.; Cave, Taylor B.; Al-khudari, Samer; Abello, Eric H.; Higgins, Kevin M.; Ryan, Jesse T.; Orzell, Susannah C.; Goldman, Richard A.; Vimawala, Swar; Fernandes, Rui P.; Abdelmalik, Michael; Rajasekaran, Karthik; L’Esperance, Heidi E.; Kallogjeri, Dorina; Rich, Jason T.; Otolaryngology -- Head and Neck Surgery, School of MedicineImportance Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes. Objectives To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes. Design, Setting, and Participants This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019. Main Outcomes and Measures Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation–27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system. Results Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system. Conclusions and Relevance Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.Item Derivation and Validation of a Scoring System to Stratify Risk for Advanced Colorectal Neoplasia in Asymptomatic Adults: A Cross-sectional Study(American College of Physicians, 2015-09-01) Imperiale, Thomas F.; Monahan, Patrick O.; Stump, Timothy E.; Glowinski, Elizabeth A.; Ransohoff, David F.; Department of Medicine, IU School of MedicineBACKGROUND: Several methods are recommended equally strongly for colorectal cancer screening in average-risk persons. Risk stratification would enable tailoring of screening within this group, with less invasive tests (sigmoidoscopy or occult blood tests) for lower-risk persons and colonoscopy for higher-risk persons. OBJECTIVE: To create a risk index for advanced neoplasia (colorectal cancer and adenomas or serrated polyps ≥1.0 cm, villous histology, or high-grade dysplasia) anywhere in the colorectum, using the most common risk factors for colorectal neoplasia. DESIGN: Cross-sectional study. SETTING: Multiple endoscopy units, primarily in the Midwest. PATIENTS: Persons aged 50 to 80 years undergoing initial screening colonoscopy (December 2004 to September 2011). MEASUREMENTS: Derivation and validation of a risk index based on points from regression coefficients for age, sex, waist circumference, cigarette smoking, and family history of colorectal cancer. RESULTS: Among 2993 persons in the derivation set, prevalence of advanced neoplasia was 9.4%. Risks for advanced neoplasia in persons at very low, low, intermediate, and high risk were 1.92% (95% CI, 0.63% to 4.43%), 4.88% (CI, 3.79% to 6.18%), 9.93% (CI, 8.09% to 12.0%), and 24.9% (CI, 21.1% to 29.1%), respectively (P < 0.001). Sigmoidoscopy to the descending colon in the low-risk groups would have detected 51 of 70 (73% [CI, 61% to 83%]) advanced neoplasms. Among 1467 persons in the validation set, corresponding risks for advanced neoplasia were 1.65% (CI, 0.20% to 5.84%), 3.31% (CI, 2.08% to 4.97%), 10.9% (CI, 8.26% to 14.1%), and 22.3% (CI, 16.9% to 28.5%), respectively (P < 0.001). Sigmoidoscopy would have detected 21 of 24 (87.5% [CI, 68% to 97%]) advanced neoplasms. LIMITATIONS: Split-sample validation; results apply to first-time screening. CONCLUSION: This index stratifies risk for advanced neoplasia among average-risk persons by identifying lower-risk groups for which noncolonoscopy strategies may be effective and efficient and a higher-risk group for which colonoscopy may be preferred. PRIMARY FUNDING SOURCE: National Cancer Institute, Walther Cancer Institute, Indiana University Simon Cancer Center, and Indiana Clinical and Translational Sciences Institute.Item Discounting a surgical risk: data, understanding, and gist(http://virtualmentor.ama-assn.org//2012/07/ecas1-1207.html, 2012-07-01) Schwartz, Peter H.Excerpt: A few days after the surgery, Ms. Reid came in for an emergency appointment with Dr. Feng. It was obvious that she was irate,but her voice could barely be heard above the noise of the clinic. "I thought you said this was rare," she said, shaking a printout of a journal article on the subject. My recurrent laryngeal nerve was injured. I'm a teacher, and I have children! I need my voice. I would have never done the surgery if I knew there was a 4 percent risk that I would lose my voice!" Was Dr. Feng negligent in explaining the risks of surgery to Ms. Reid? Was she required to use precise percentages of risk?Item The ethics of information: absolute risk reduction and patient understanding of screening(Journal of General Internal Medicine, 2008-06) Meslin, Eric M.; Schwartz, Peter H.Some experts have argued that patients should routinely be told the specific magnitude and absolute probability of potential risks and benefits of screening tests. This position is motivated by the idea that framing risk information in ways that are less precise violates the ethical principle of respect for autonomy and its application in informed consent or shared decision-making. In this Perspective, we consider a number of problems with this view that have not been adequately addressed. The most important challenges stem from the danger that patients will misunderstand the information or have irrational responses to it. Any initiative in this area should take such factors into account and should consider carefully how to apply the ethical principles of respect for autonomy and beneficence.Item Frailty in Surgical Patients: Is it Relevant to Sexual Medicine?(Elsevier, 2022-03) Burns, Ramzy T.; Bernie, Helen L.; Urology, School of MedicineBACKGROUND: As the age of our surgical population continues to rise, there is an increased need for adequate preoperative evaluation and risk stratification to ensure the best possible surgical outcomes for patients. AIM: We sought to describe the 3 main models currently used to evaluate patient frailty and explore how they are being utilized in the field of surgery and sexual medicine. METHODS: We reviewed online resources including Pubmed with relevant search criteria centered around frailty, surgery, sexual medicine, and prosthetics. OUTCOMES/RESULTS: All relevant studies were reviewed and several models for patient frailty emerged; the Phenotype Model, the Frailty Index, the Clinical Frailty Scale, and the modified Frailty Index. Worse frailty indices were seen to be linked to higher rates of complications and mortalities postoperatively. CLINICAL IMPLICATIONS: Although the adoption of patient frailty in the field of sexual medicine has been sluggish, few studies have shown that its use could help predict which patients are at increased risk of complications and may require more support when it comes to postoperative care and teaching. STRENGTH & LIMITATIONS: Overall there is a paucity of literature as it relates to sexual medicine and patient frailty and this paper provides a limited look at the usage of patient frailty in sexual medicine. CONCLUSION: We implore all sexual health providers to begin to incorporate frailty metrics when caring for this population to help reduce postoperative complications and help better predict surgical success.Item Improving the validity of activity of daily living dependency risk assessment(SAGE Publications, 2015-04) Clark, Daniel O.; Stump, Timothy E.; Tu, Wanzhu; Miller, Douglas K.; Department of Medicine, IU School of MedicineOBJECTIVES: Efforts to prevent activity of daily living (ADL) dependency may be improved through models that assess older adults' dependency risk. We evaluated whether cognition and gait speed measures improve the predictive validity of interview-based models. METHOD: Participants were 8,095 self-respondents in the 2006 Health and Retirement Survey who were aged 65 years or over and independent in five ADLs. Incident ADL dependency was determined from the 2008 interview. Models were developed using random 2/3rd cohorts and validated in the remaining 1/3rd. RESULTS: Compared to a c-statistic of 0.79 in the best interview model, the model including cognitive measures had c-statistics of 0.82 and 0.80 while the best fitting gait speed model had c-statistics of 0.83 and 0.79 in the development and validation cohorts, respectively. CONCLUSION: Two relatively brief models, one that requires an in-person assessment and one that does not, had excellent validity for predicting incident ADL dependency but did not significantly improve the predictive validity of the best fitting interview-based models.Item Measuring dispositional cancer worry in China and Belgium: a cross-cultural validation(Taylor & Francis, 2014) Bernat, Jennifer Kim; Jensen, Jakob D.; IU School of NursingDispositional cancer worry (DCW) is the uncontrollable tendency to dwell on cancer independent of relevant stimuli (e.g., diagnosis of the disease). Past research has suggested that DCW has two underlying dimensions: severity and frequency. Available measures of DCW severity and frequency were translated and validated in two countries: China and Belgium. Participants (N = 623) completed translated scales, as well as measures of general dispositional worry, cancer fear, and perceived risk. In both locations, DCW measures were reliable (Cronbach's alphas ranged from .78 - .93) and demonstrated strong convergent, divergent, and concurrent validity. Severity and frequency factors loaded as expected in exploratory factor analysis. Future research should pursue longitudinal tests of DCW's predictive validity and explore DCW in theoretical models predicting the relationship between worry and cancer prevention and early detection behaviors.