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Cardiology Clinics Feb 2021Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical... (Review)
Review
Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.
Topics: Female; Heart Failure; Heart Valve Diseases; Hemodynamics; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Prognosis; Risk Adjustment; Risk Assessment
PubMed: 33222810
DOI: 10.1016/j.ccl.2020.09.010 -
Postgraduate Medical Journal Jul 2021Many drug therapies are associated with prolongation of the QT interval. This may increase the risk of Torsades de Pointes (TdP), a potentially life-threatening cardiac... (Review)
Review
Many drug therapies are associated with prolongation of the QT interval. This may increase the risk of Torsades de Pointes (TdP), a potentially life-threatening cardiac arrhythmia. As the QT interval varies with a change in heart rate, various formulae can adjust for this, producing a 'corrected QT' (QTc) value. Normal QTc intervals are typically <450 ms for men and <460 ms for women. For every 10 ms increase, there is a ~5% increase in the risk of arrhythmic events. When prescribing drugs associated with QT prolongation, three key factors should be considered: patient-related risk factors (eg, female sex, age >65 years, uncorrected electrolyte disturbances); the potential risk and degree of QT prolongation associated with the proposed drug; and co-prescribed medicines that could increase the risk of QT prolongation. To support clinicians, who are likely to prescribe such medicines in their daily practice, we developed a simple algorithm to help guide clinical management in patients who are at risk of QT prolongation/TdP, those exposed to QT-prolonging medication or have QT prolongation.
Topics: Humans; Long QT Syndrome; Patient Care Management; Practice Patterns, Physicians'; Risk Adjustment; Torsades de Pointes
PubMed: 33122341
DOI: 10.1136/postgradmedj-2020-138661 -
Advances in Chronic Kidney Disease Nov 2020End-stage kidney disease is associated with low fertility, with rates of conception in women on dialysis estimated at 1/100th of the general population. However, live... (Review)
Review
End-stage kidney disease is associated with low fertility, with rates of conception in women on dialysis estimated at 1/100th of the general population. However, live birth rates are increasing over time in women on hemodialysis, whereas they remain lower and static in women on peritoneal dialysis. Intensification of hemodialysis, targeting a serum blood urea nitrogen <35 mg/dL or 36 hours of dialysis per week in women with no residual kidney function, is associated with improved live birth rates and longer gestational age. Even in intensively dialyzed cohorts, rates of prematurity and need for neonatal intensive care are high, upwards of 50%. Although women on peritoneal dialysis in pregnancy do not appear to be at increased risk of delivering preterm compared with those on hemodialysis, their infants are more likely to be small for gestational age. As such, hemodialysis has emerged as the preferred dialysis modality in pregnancy. Provision of specialized nephrology, obstetric, and neonatal care is necessary to manage these complex pregnancies and family planning counseling should be offered to all women with end-stage kidney disease.
Topics: Female; Humans; Kidney Failure, Chronic; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Pregnancy, High-Risk; Renal Dialysis; Risk Adjustment
PubMed: 33328064
DOI: 10.1053/j.ackd.2020.06.001 -
Journal of Perinatal Medicine Mar 2021During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful... (Review)
Review
During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful physical diagnosis and the ability to translate the acquired information into meaningful prognostic decision-making. We describe a coordinated approach to the assessment of labor. Graphing of serial measurements of cervical dilatation and fetal station creates "labor curves," which provide diagnostic and prognostic information. Based on these curves we recognize nine discrete labor abnormalities. Many may be related to insufficient or disordered contractile mechanisms. Several factors are strongly associated with development of labor disorders, including cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity. Clinical cephalopelvimetry involves assessing pelvic traits and predicting their effects on labor. These observations must be integrated with information derived from the labor curves. Exogenous oxytocin is widely used. It has a high therapeutic index, but is easily misused. Oxytocin treatment should be restricted to situations in which its potential benefits clearly outweigh its risks. This requires there be a documented labor dysfunction or a legitimate medical reason to shorten the labor. Normal labor and delivery pose little risk to a healthy fetus; but dysfunctional labors, especially if stimulated excessively by oxytocin or terminated by complex operative vaginal delivery, have the potential for considerable harm. Conscientiously implemented, the approach to the evaluation of labor outlined in this review will result in a reasonable cesarean rate and minimize risks that may accrue from the labor and delivery process.
Topics: Delivery, Obstetric; Female; Fetal Monitoring; Humans; Labor, Obstetric; Obstetric Labor Complications; Pelvimetry; Pregnancy; Risk Adjustment; Uterine Monitoring
PubMed: 33068385
DOI: 10.1515/jpm-2020-0256 -
American Family Physician Jul 2020Millions of units of blood products are transfused annually to patients in the United States. Red blood cells are transfused to improve oxygen-carrying capacity in...
Millions of units of blood products are transfused annually to patients in the United States. Red blood cells are transfused to improve oxygen-carrying capacity in patients with or at high risk of developing symptomatic anemia. Restrictive transfusion thresholds with lower hemoglobin levels are typically clinically equivalent to more liberal thresholds. Transfusion of plasma corrects clinically significant coagulopathy in patients with or at high risk of bleeding. Mildly abnormal laboratory coagulation values are not predictive of clinical bleeding and should not be corrected with plasma. Transfused platelets prevent or treat bleeding in patients with thrombocytopenia or platelet dysfunction. Cryoprecipitate is transfused to treat hypofibrinogenemia. Many adverse reactions can occur during or after blood product transfusion. Transfusion-associated circulatory overload (i.e., volume overload) is the most common cause of mortality associated with blood products. Modifications to blood products can prevent or decrease the risks of transfusion-related adverse reactions. It is critical to quickly recognize when a reaction is occurring, stop the transfusion, assess, and support the patient. Reporting a reaction to the blood bank is part of ensuring patient safety and supporting hemovigilance efforts.
Topics: Blood Component Transfusion; Hematologic Diseases; Humans; Patient Safety; Practice Guidelines as Topic; Risk Adjustment; Risk Assessment; Transfusion Reaction
PubMed: 32603068
DOI: No ID Found -
BMJ (Clinical Research Ed.) Jan 2020To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.
DESIGN
Systematic review and network meta-analysis.
DATA SOURCES
Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS
We included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee ( Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.
RESULTS
Seventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).
CONCLUSIONS
For higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42019126656.
Topics: Critical Illness; Gastrointestinal Hemorrhage; Histamine H2 Antagonists; Humans; Patient Selection; Proton Pump Inhibitors; Risk Adjustment
PubMed: 31907166
DOI: 10.1136/bmj.l6744 -
Clinical Oncology (Royal College of... Sep 2020Oncologists should recognise the need to move beyond the Eastern Cooperative Oncology Group Performance Status (ECOG PS) score. ECOG PS is a longstanding and ubiquitous... (Review)
Review
Oncologists should recognise the need to move beyond the Eastern Cooperative Oncology Group Performance Status (ECOG PS) score. ECOG PS is a longstanding and ubiquitous feature of oncology. It was evolved 40 years ago as an adaption of the 70-year-old Karnofsky performance score. It is short, easily understood and part of the global language of oncology. The wide prevalence of the ECOG PS attests to its proven utility and worth to help triage patient treatment. The ECOG PS is problematic. It is a unidimensional functional score. It is mostly physician assessed, subjective and therefore open to bias. It fails to account for multimorbidity, frailty or cognition. Too often the PS is recorded only once in wilful ignorance of a patient's changing physical state. As modern oncology offers an ever-widening array of therapies that are 'personalised' to tumour genotype, modern oncologists must strive to better define patient phenotype. Using a wider range of scoring and assessment tools, oncologists can identify deficits that may be reversed or steps taken to mitigate detrimental effects of treatment. These tools can function well to identify those patients who would benefit from comprehensive assessment. This overview identifies the strengths of ECOG PS but highlights the weaknesses and where these are supported by other measures. A strong recommendation is made here to move to routine use of the Clinical Frailty Score to start to triage patients and most appropriately design treatments and rehabilitation interventions.
Topics: Aged; Humans; Medical Oncology; Neoplasms; Outcome Assessment, Health Care; Patient Care Planning; Physicians; Risk Adjustment; Severity of Illness Index; Symptom Assessment
PubMed: 32684503
DOI: 10.1016/j.clon.2020.06.016 -
Health Affairs (Project Hope) Jan 2023The objective of risk adjustment is not to predict spending accurately but to support the social goals of a payment system, which include equity. Setting...
The objective of risk adjustment is not to predict spending accurately but to support the social goals of a payment system, which include equity. Setting population-based payments at accurate predictions risks entrenching spending levels that are insufficient to mitigate the impact of social determinants on health care use and effectiveness. Instead, to advance equity, payments must be set above current levels of spending for historically disadvantaged groups. In analyses intended to guide such reallocations, we found that current risk adjustment for the community-dwelling Medicare population overpredicts annual spending for Black and Hispanic beneficiaries by $376-$1,264. The risk-adjusted spending for these populations is lower than spending for White beneficiaries despite the former populations' worse risk-adjusted health and functional status. Thus, continued movement from fee-for-service to population-based payment models that omit race and ethnicity from risk adjustment (as current models do) should result in sizable resource reallocations and incentives that support efforts to address racial and ethnic disparities in care. We found smaller overpredictions for less-educated beneficiaries and communities with higher proportions of residents who are Black, Hispanic, or less educated, suggesting that additional payment adjustments that depart from predictive accuracy are needed to support health equity. These findings also suggest that adding social risk factors as predictors to spending models used for risk adjustment may be counterproductive or accomplish little.
Topics: United States; Humans; Health Equity; Risk Adjustment; Medicare; Fee-for-Service Plans; Ethnicity
PubMed: 36623215
DOI: 10.1377/hlthaff.2022.00916 -
Chest Jul 2016Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and... (Review)
Review
Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and associated complications, but common to all of them is the risk of hemorrhage. Central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture constitute a majority of the procedures performed in patients who are hospitalized. In this article, the authors will discuss the risk factors for bleeding complications from each of these procedures and methods to minimize risk. Physicians often correct coagulopathy prior to procedures to decrease bleeding risk, but there is minimal evidence to support this practice.
Topics: Critical Illness; Diagnostic Techniques and Procedures; Hemorrhage; Humans; Risk Adjustment; Risk Factors
PubMed: 26836937
DOI: 10.1016/j.chest.2016.01.023 -
Medicine Apr 2018Renal angiomyolipoma (AML) is a common benign tumor of the kidney. The main complication of AML is retroperitoneal hemorrhage caused by AML rupture, which can be severe... (Review)
Review
BACKGROUND
Renal angiomyolipoma (AML) is a common benign tumor of the kidney. The main complication of AML is retroperitoneal hemorrhage caused by AML rupture, which can be severe and life threatening. The risk of AML rupture used to be determined by tumor size. However, these criteria have been challenged by series of clinical studies and case reports, suggesting prediction AML rupture based on tumor size is not always reliable.
METHODS
The authors searched PubMed using "angiomyolipoma," "AML," and "rupture" and reviewed relevant studies. The authors investigated the risk factors of AML rupture using the retrieved literature. The authors also summarized current modalities to evaluate and manage AML.
RESULTS
It is established that risk of AML rupture is associated with lesion size. However, genetic abnormality, aneurysm formation, and pregnancy are also risk factors for tumor rupture. Thus, the prediction of AML rupture should be based on a more comprehensive risk assessment system. The management of renal AML and tumor rupture was also discussed in the present paper.
CONCLUSION
The risk of AML rupture is associated with but not exclusive to lesion size. Any decision to intervene AML must be based on multiple factors including risk, symptoms, and auxiliary findings.
Topics: Angiomyolipoma; Hemorrhage; Humans; Kidney Neoplasms; Retroperitoneal Space; Risk Adjustment; Risk Assessment; Risk Factors; Rupture, Spontaneous
PubMed: 29668633
DOI: 10.1097/MD.0000000000010497