Accuracy of automated computer-aided risk scoring systems to estimate the risk of COVID-19: a retrospective cohort study.

BACKGROUND: In the UK National Health Service (NHS), the patient's vital signs are monitored and summarised into a National Early Warning Score (NEWS) score. A set of computer-aided risk scoring systems (CARSS) was developed and validated for predicting in-hospital mortality and sepsis in unplanned admission to hospital using NEWS and routine blood tests results. We sought to assess the accuracy of these models to predict the risk of COVID-19 in unplanned admissions during the first phase of the pandemic. METHODS: Adult ( > = 18 years) non-elective admissions discharged (alive/deceased) between 11-March-2020 to 13-June-2020 from two acute hospitals with an index NEWS electronically recorded within ± 24 h of admission. We identified COVID-19 admission based on ICD-10 code 'U071' which was determined by COVID-19 swab test results (hospital or community). We assessed the performance of CARSS (CARS_N, CARS_NB, CARM_N, CARM_NB) for predicting the risk of COVID-19 in terms of discrimination (c-statistic) and calibration (graphically). RESULTS: The risk of in-hospital mortality following emergency medical admission was 8.4% (500/6444) and 9.6% (620/6444) had a diagnosis of COVID-19. For predicting COVID-19 admissions, the CARS_N model had the highest discrimination 0.73 (0.71 to 0.75) and calibration slope 0.81 (0.72 to 0.89) compared to other CARSS models: CARM_N (discrimination:0.68 (0.66 to 0.70) and calibration slope 0.47 (0.41 to 0.54)), CARM_NB (discrimination:0.68 (0.65 to 0.70) and calibration slope 0.37 (0.31 to 0.43)), and CARS_NB (discrimination:0.68 (0.66 to 0.70) and calibration slope 0.56 (0.47 to 0.64)). CONCLUSIONS: The CARS_N model is reasonably accurate for predicting the risk of COVID-19. It may be clinically useful as an early warning system at the time of admission especially to triage large numbers of unplanned admissions because it requires no additional data collection and is readily automated.

Development and validation of automated computer-aided risk scores to predict in-hospital mortality for emergency medical admissions with COVID-19: a retrospective cohort development and validation study.

OBJECTIVES: There are no established mortality risk equations specifically for unplanned emergency medical admissions which include patients with SARS-19 (COVID-19). We aim to develop and validate a computer-aided risk score (CARMc19) for predicting mortality risk by combining COVID-19 status, the first electronically recorded blood test results and the National Early Warning Score (NEWS2). DESIGN: Logistic regression model development and validation study. SETTING: Two acute hospitals (York Hospital-model development data; Scarborough Hospital-external validation data). PARTICIPANTS: Adult (aged ≥16 years) medical admissions discharged over a 24-month period with electronic NEWS and blood test results recorded on admission. We used logistic regression modelling to predict the risk of in-hospital mortality using two models: (1) CARMc19_N: age+sex+NEWS2 including subcomponents+COVID19; (2) CARMc19_NB: CARMc19_N in conjunction with seven blood test results and acute kidney injury score. Model performance was evaluated according to discrimination (c-statistic), calibration (graphically) and clinical usefulness at NEWS2 thresholds of 4+, 5+, 6+. RESULTS: The risk of in-hospital mortality following emergency medical admission was similar in development and validation datasets (8.4% vs 8.2%). The c-statistics for predicting mortality for CARMc19_NB is better than CARMc19_N in the validation dataset (CARMc19_NB=0.88 (95% CI 0.86 to 0.90) vs CARMc19_N=0.86 (95% CI 0.83 to 0.88)). Both models had good calibration (CARMc19_NB=1.01 (95% CI 0.88 to 1.14) and CARMc19_N:0.95 (95% CI 0.83 to 1.06)). At all NEWS2 thresholds (4+, 5+, 6+) model, CARMc19_NB had better sensitivity and similar specificity. CONCLUSIONS: We have developed a validated CARMc19 scores with good performance characteristics for predicting the risk of in-hospital mortality. Since the CARMc19 scores place no additional data collection burden on clinicians, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.

Predictive accuracy of enhanced versions of the on-admission National Early Warning Score in estimating the risk of COVID-19 for unplanned admission to hospital: a retrospective development and validation study.

BACKGROUND: The novel coronavirus SARS-19 produces 'COVID-19' in patients with symptoms. COVID-19 patients admitted to the hospital require early assessment and care including isolation. The National Early Warning Score (NEWS) and its updated version NEWS2 is a simple physiological scoring system used in hospitals, which may be useful in the early identification of COVID-19 patients. We investigate the performance of multiple enhanced NEWS2 models in predicting the risk of COVID-19. METHODS: Our cohort included unplanned adult medical admissions discharged over 3 months (11 March 2020 to 13 June 2020 ) from two hospitals (YH for model development; SH for external model validation). We used logistic regression to build multiple prediction models for the risk of COVID-19 using the first electronically recorded NEWS2 within ± 24 hours of admission. Model M0' included NEWS2; model M1' included NEWS2 + age + sex, and model M2' extends model M1' with subcomponents of NEWS2 (including diastolic blood pressure + oxygen flow rate + oxygen scale). Model performance was evaluated according to discrimination (c statistic), calibration (graphically), and clinical usefulness at NEWS2 ≥ 5. RESULTS: The prevalence of COVID-19 was higher in SH (11.0 %=277/2520) than YH (8.7 %=343/3924) with a higher first NEWS2 scores ( SH 3.2 vs YH 2.8) but similar in-hospital mortality (SH 8.4 % vs YH 8.2 %). The c-statistics for predicting the risk of COVID-19 for models M0',M1',M2' in the development dataset were: M0': 0.71 (95 %CI 0.68-0.74); M1': 0.67 (95 %CI 0.64-0.70) and M2': 0.78 (95 %CI 0.75-0.80)). For the validation datasets the c-statistics were: M0' 0.65 (95 %CI 0.61-0.68); M1': 0.67 (95 %CI 0.64-0.70) and M2': 0.72 (95 %CI 0.69-0.75) ). The calibration slope was similar across all models but Model M2' had the highest sensitivity (M0' 44 % (95 %CI 38-50 %); M1' 53 % (95 %CI 47-59 %) and M2': 57 % (95 %CI 51-63 %)) and specificity (M0' 75 % (95 %CI 73-77 %); M1' 72 % (95 %CI 70-74 %) and M2': 76 % (95 %CI 74-78 %)) for the validation dataset at NEWS2 ≥ 5. CONCLUSIONS: Model M2' appears to be reasonably accurate for predicting the risk of COVID-19. It may be clinically useful as an early warning system at the time of admission especially to triage large numbers of unplanned hospital admissions.

PCA3 in Prostate Cancer.

Prostate cancer antigen 3 (PCA3) is a urinary biomarker for prostate cancer and has demonstrated a good specificity and sensitivity representing a minimally invasive test.PCA3 assay could be useful in combination with PSA to suggest an eventual rebiopsy in men who have had one or more previous negative prostate biopsies.Combination of multiple tumor biomarkers will be the trend in the near future to achieve the goal of evaluate the aggressiveness of cancer and at the same time reducing the number of unnecessary biopsies.

Use of the first National Early Warning Score recorded within 24 hours of admission to estimate the risk of in-hospital mortality in unplanned COVID-19 patients: a retrospective cohort study.

OBJECTIVES: Although the National Early Warning Score (NEWS) and its latest version NEWS2 are recommended for monitoring deterioration in patients admitted to hospital, little is known about their performance in COVID-19 patients. We aimed to compare the performance of the NEWS and NEWS2 in patients with COVID-19 versus those without during the first phase of the pandemic. DESIGN: A retrospective cross-sectional study. SETTING: Two acute hospitals (Scarborough and York) are combined into a single dataset and analysed collectively. PARTICIPANTS: Adult (≥18 years) non-elective admissions discharged between 11 March 2020 and 13 June 2020 with an index or on-admission NEWS2 electronically recorded within ±24 hours of admission to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) in COVID-19 versus non-COVID-19 admissions. RESULTS: Out of 6480 non-elective admissions, 620 (9.6%) had a diagnosis of COVID-19. They were older (73.3 vs 67.7 years), more often male (54.7% vs 50.1%), had higher index NEWS (4 vs 2.5) and NEWS2 (4.6 vs 2.8) scores and higher in-hospital mortality (32.1% vs 5.8%). The c-statistics for predicting in-hospital mortality in COVID-19 admissions was significantly lower using NEWS (0.64 vs 0.74) or NEWS2 (0.64 vs 0.74), however, these differences reduced at 72hours (NEWS: 0.75 vs 0.81; NEWS2: 0.71 vs 0.81), 48 hours (NEWS: 0.78 vs 0.81; NEWS2: 0.76 vs 0.82) and 24hours (NEWS: 0.84 vs 0.84; NEWS2: 0.86 vs 0.84). Increasing NEWS2 values reflected increased mortality, but for any given value the absolute risk was on average 24% higher (eg, NEWS2=5: 36% vs 9%). CONCLUSIONS: The index or on-admission NEWS and NEWS2 offers lower discrimination for COVID-19 admissions versus non-COVID-19 admissions. The index NEWS2 was not proven to be better than the index NEWS. For each value of the index NEWS/NEWS2, COVID-19 admissions had a substantially higher risk of mortality than non-COVID-19 admissions which reflects the increased baseline mortality risk of COVID-19.

The role of intraoperative ultrasound in small renal mass robotic enucleation.

INTRODUCTION: As a result of the growing evidence on tumor radical resection in literature, simple enucleation has become one of the best techniques associated to robotic surgery in the treatment of renal neoplasia, as it guarantees minimal invasiveness and the maximum sparing of renal tissue, facilitating the use of reduced or zero ischemia techniques during resection. The use of a robotic ultrasound probe represents a useful tool to detect and define tumor location, especially in poorly exophytic small renal mass. MATERIALS AND METHODS: A total of 22 robotic enucleations were performed on < 3 cm renal neoplasias (PADUA score 18 Pz 6/7 e 4 Pz 8) using a 12-5 MHz robotic ultrasound probe (BK Drop-In 8826). RESULTS: Once kidney had been isolated from the adipose capsule at the site of the neoplasia (2), the exact position of the lesion could be easily identified in all cases (22/22), even for mostly endophytic lesions, thanks to the insertion of the ultrasound probe through the assistant port. Images were produced and visualized by the surgeon using the TilePro feature of the DaVinci surgical system for producing a picture-in-picture image on the console screen. The margins of resection were then marked with cautery, thus allowing for speedy anatomical dissection. This reduced the time of ischemia to 8 min (6-13) and facilitated the enucleation technique when performed without clamping the renal peduncle (6/22). No complications due to the use of the ultrasound probe were observed. CONCLUSIONS: The use of an intraoperative robotic ultrasound probe has allowed for easier identification of small, mostly endophytic neoplasias, better anatomical approach, shorter ischemic time, reduced risk of pseudocapsule rupture during dissection, and easier enucleation in cases performed without clamping. It is noteworthy that the use of intraoperative ultrasound probe allows mental reconstruction of the tumor through an accurate 3D vision of the hidden field during surgical dissection.

Impact of preoperative biofeedback on incontinence in cancer patients undergoing radical prostatectomy.

OBJECTIVE: Post-radical prostatectomy incontinence is mainly attributable to iatrogenic verify the importance of preoperative biofeedback (BFB) in an attempt to identify a strategy to improve postoperative urinary incontinence. MATERIALS AND METHODS: Ninety candidates (median age 68 years: range 49-75) for radical retropubic prostatectomy were evaluated. Forty-five patients underwent preoperative pelvic floor training (PFT) and BFB, whereas the remaining 45 (control group) had preoperative PFT only. Patients started PFT exercises two weeks before surgery and continued during the immediate postoperative period, after catheter removal (6-7 days after surgery), and thereafter at home. No adjuvant therapy was administered and all 90 patients were assessed at follow up visits timed 1, 3 and 6 months post surgery. RESULTS: Patients who were completely dry and without use of pads were defined as continent. At the 1-month follow-up, 6.6% (3/45) of both the PFT+BFB group and the PFT only arm were continent. After 3 months, the continence rate had increased to 33.3% (15/45) and 26.6% (12/45), respectively, and at 6-month follow-up, this percentage had further risen to 71.1% (32/45) in the former group and 66.6% (30/45) in the latter group. No significant differences were observed between the two arms during follow-up, but there was a statistically significant correlation between follow-up time and continence improvement in each group. CONCLUSIONS: Preoperative BFB associated with PFT does not significantly influence urinary continence recovery after radical prostatectomy.

Immunosuppression in renal cancer: differential expression of signal transduction molecules in tumor-infiltrating, near-tumor tissue, and peripheral blood lymphocytes.

Alterations in the expression of signal activation molecules, such as the T-cell receptor (TCR) zeta and epsilon chains and p56lck tyrosine kinase, are described in tumor-infiltrating lymphocytes (TIL). The aim of this study was to ascertain if such molecules were present in near-tumor-tissue lymphocytes (NTTL) and peripheral blood lymphocytes (PBL), as well as TIL, of renal cell carcinoma patients, to verify whether this tumor induces immunosuppression only locally or affects distant lymphocytes as well. Tissue from the tumor and from healthy nearby sites, as well as blood samples, were obtained from 27 consecutive patients who had undergone radical nephrectomy for renal cell carcinoma. Phenotype analysis and immunohistochemical staining of the TCR zeta and epsilon chains and p56lck were performed with standard techniques on TIL, NTTL, and PBL, and values were compared for each patient. Low expression of the TCR zeta chain and an almost complete absence of TCR epsilon chain and p56lck expression was observed in TIL (median values: 10% for zeta chain and 0% for epsilon and p56lck). In NTTL, these signal transduction molecules were expressed by a higher percentage of cells (60%, 50%, and 60%, respectively; p=0.000 vs. TIL), whereas PBL showed an almost normal expression of zeta and epsilon chains (80% and 90%, respectively; p=0.000 vs. TIL). Conversely, p56lck was detected in a greater proportion of NTTL than PBL (50% vs. 10%; p=0.001). The absence or the very low expression of signaling activation molecules in TIL compared with NTTL and PBL in renal cancer patients suggest that tumor-induced immunosuppression generally occurs or starts locally.

[Echo-dynamic study of female urinary incontinence: our experience with the use of tridimensional ultrasonography]. / Lo studio eco-dinamico dell'incontinenza urinaria femminile: nostra esperienza nell'utilizzo dell'ecografia tridimensionale (3D).

Traditional 2-D ultrasound is a fast, inexpensive, non-invasive procedure and may be used routinely for the pre and post-operative evaluation of patients with various grade of cystocele, but a new tool in ultrasound investigation is recently available: the 3D scan. Our aim is to assess the real usefulness of 3D scan in the evaluation of cystocele grade. 15 women with clinical and urodynamic findings of genuine stress incontinence and grade 2-3 cystocele (in accord to Baden-Walker grading) underwent both ultrasonographic 3D imaging and traditional 2D trans labial scan with Convex probe (3.5 Mh). Correct evaluation of the relationships between the bladder, urethrovesical junction, urethra and pubic bones at rest and when straining was correctly evaluated by 2D scan in all the women underwent the examination, whereas 3D scan did not let us exactly quantify the same anatomical defect. 3D ultrasound did not prove to be as useful as traditional trans-labial 2D ultrasound procedure to provide an objective demonstration of the mobility of the urethrovesical junction. A possible explanation is that the lack of reliability of 3D investigation is due to the impossibility of real-time scanning that make approximate the choice of the image to evaluate. In conclusion traditional ultrasound is up to now an important complementary evaluation for the study of female urinary incontinence which allows not only morphological documentation but can also improve our knowledge of function and anatomy of lower urinary tract. Finally it is basic to stress that a worldwide standardisation will be the starting point for the real success of this technique and, especially for the new 3D scan, it will be important to achieve this goal together a large amount of data to compare for defining the real importance of this investigation.

[Imaging of the prostate: traditional methods]. / L'imaging della prostata: metodi tradizionali.

Transrectal prostatic ultrasonography is an inexpensive, non-invasive procedure which permits an accurate evaluation of the dimensions and echostructure of the prostate and seminal vesicles. Prostatic tumors may present as hypoechogenic (60-80%) or isoechogenic nodules (30%), the latter requiring the use of specific techniques, which increase the sensitivity and specificity of the procedure (contrast-enhanced color-power Doppler), to identify and characterize focal lesions. The color Doppler increases the predictive value of TRUS (62-75%) but has a low sensitivity, while the power Doppler enables us to study vessels with slow blood flow. The recent introduction of contrast medium could lead to an enhancement of the Doppler signal, thus increasing sensitivity of the exam; it is also, however, an expensive, invasive and time-consuming method. Improved test sensitivity has also increased the problems relating to the identification of very small prostatic lesions which are probably of low clinical significance.

[Morbidity, tolerability, and number of samples in prostatic biopsy: our experience]. / Morbidità, tollerabilità e numero dei prelievi nella biopsia prostatica: nostra esperienza.

Transrectal prostatic ultrasonography with biopsy is a fundamental step in the diagnosis of prostate cancer. The number of bioptic samples taken has a direct influence on the sensitivity of the diagnostic procedure. We compared the degree of acceptance of the biopsy, using visual analogue scale, with the appearance of complications in two groups of 250 patients: group A (sextant biopsy) and group B (traditional transrectal prostatic biopsy + 2 additional lateral samples from each lobe). 21% of group A patients reported slight pain, 63% tolerable pain and 16% severe pain, while pain intensity of group B patients was 18%, 65% e 17%, respectively. The appearance and degree of painful symptomatology, and the frequency of serious complications were not significantly different in either group. The extensive prostatic biopsy is well tolerated by patients and is associated with modest local complications.