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Heart (British Cardiac Society) May 2018Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial... (Review)
Review
Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial fibrillation, pulmonary hypertension and left heart disease. There is an increasing recognition of a subgroup of patients with isolated TR in the absence of other associated cardiac abnormalities. Left untreated isolated TR significantly worsens survival. Stand-alone surgery for isolated TR is rarely performed due to an average operative mortality of 8%-10% and a paucity of data demonstrating improved survival. When surgery is performed, valve repair may be preferred over replacement; however, there is a risk of significant recurrent regurgitation after repair. Existing society guidelines do not fully address the management of isolated TR. We propose that patients at low operative risk with symptomatic severe isolated TR and no reversible cause undergo surgery prior to the onset of right ventricular dysfunction and end-organ damage. For patients at increased surgical risk novel percutaneous interventions may offer an alternative treatment but further research is needed. Significant knowledge gaps remain and future research is needed to define operative outcomes and provide comparative data for medical and surgical therapy.
Topics: Heart Valve Prosthesis Implantation; Humans; Patient Care Management; Risk Adjustment; Treatment Outcome; Tricuspid Valve Insufficiency
PubMed: 29229649
DOI: 10.1136/heartjnl-2017-311586 -
BMC Geriatrics Dec 2017Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of... (Review)
Review
BACKGROUND
Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.
METHODS
A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.
RESULTS
Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.
CONCLUSIONS
There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.
TRIAL REGISTRATION
This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
Topics: Aged; Benzodiazepines; Delirium; Humans; Postoperative Complications; Premedication; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29284416
DOI: 10.1186/s12877-017-0695-x -
PloS One 2018We propose a nonparametric risk-adjusted cumulative sum chart to monitor surgical outcomes for patients with different risks of post-operative mortality due to risk...
We propose a nonparametric risk-adjusted cumulative sum chart to monitor surgical outcomes for patients with different risks of post-operative mortality due to risk factors that exist before the surgery. Using varying-coefficient logistic regression models, we accomplish the risk adjustment. Unknown coefficient functions are estimated by global polynomial spline approximation based on the maximum likelihood principle. We suggest a bisection minimization approach and a bootstrap method to determine the chart testing limit value. Compared with the previous (parametric) risk-adjusted cumulative sum chart, a major advantage of our method is that the morality rate can be modeled more flexibly by related covariates, which significantly enhances the monitoring efficiency. Simulations demonstrate nice performance of our proposed procedure. An application to a UK cardiac surgery dataset illustrates the use of our methodology.
Topics: Cardiac Surgical Procedures; General Surgery; Humans; Logistic Models; Models, Statistical; Models, Theoretical; Outcome Assessment, Health Care; Risk Adjustment; Risk Factors; Statistics, Nonparametric; Treatment Outcome
PubMed: 30089109
DOI: 10.1371/journal.pone.0200915 -
American Family Physician Aug 2018Surgical outcomes are significantly influenced by patients' overall health, function, and life expectancy. A comprehensive geriatric preoperative assessment of older... (Review)
Review
Surgical outcomes are significantly influenced by patients' overall health, function, and life expectancy. A comprehensive geriatric preoperative assessment of older adults requires expanding beyond an organ-based or disease-based assessment. At a preoperative visit, it is important to establish the patient's goals and preferences, and to determine whether the risks and benefits of surgery match these goals and preferences. These discussions should cover the possibility of resuscitation and ventilator support, prolonged rehabilitation, and loss of independence. The assessment should include evaluation of medical comorbidities, cognitive function, decision-making capacity, functional status, fall risk, frailty, nutritional status, and potentially inappropriate medication use. Problems identified in any of these key areas are associated with an increased risk of postoperative complications, institutionalization, functional decline, and, in some cases, mortality. If a patient elects to proceed with surgery, the risks should be communicated to surgical teams to allow for inpatient interventions that lower the risk of postoperative complications and functional decline, such as early mobilization and limiting medications that can cause delirium. Alcohol abuse and smoking are associated with increased rates of postoperative complications, and physicians should discuss cessation with patients before surgery. Physicians should also assess patients' social support systems because they are a critical component of discharge planning in this population and have been shown to predict 30-day postoperative morbidity.
Topics: Aged; Clinical Decision-Making; Geriatric Assessment; Humans; Postoperative Complications; Preoperative Care; Risk Adjustment; Risk Factors
PubMed: 30215973
DOI: No ID Found -
Circulation Jan 2017
Review
Topics: Benchmarking; Cardiology Service, Hospital; Health Personnel; Hospitals; Humans; Outcome Assessment, Health Care; Risk Adjustment; Risk Assessment
PubMed: 28115411
DOI: 10.1161/CIRCULATIONAHA.116.025653 -
Journal of the American College of... Jan 2018The burden of atherosclerotic cardiovascular disease (ASCVD) in high-income countries is mostly borne by the elderly. With increasing life expectancy, clear guidance on... (Review)
Review
The burden of atherosclerotic cardiovascular disease (ASCVD) in high-income countries is mostly borne by the elderly. With increasing life expectancy, clear guidance on sensible use of statin therapy to prevent a first and potentially devastating ASCVD event is critically important to ensure a healthy aging population. Since 2013, 5 major North American and European guidelines on statin use in primary prevention of ASCVD have been released by the American College of Cardiology/American Heart Association, the UK National Institute for Health and Care Excellence, the Canadian Cardiovascular Society, U.S. Preventive Services Task Force, and the European Society of Cardiology/European Atherosclerosis Society. Guidance on using statin therapy in primary ASCVD prevention in the growing elderly population (>65 years of age) differs markedly. The authors discuss the discrepant recommendations, place them into the context of available evidence, and identify circumstances in which uncertainty may hamper the appropriate use of statins in the elderly.
Topics: Age Factors; Aged; Atherosclerosis; Cardiovascular Diseases; Global Health; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Practice Guidelines as Topic; Primary Prevention; Risk Adjustment
PubMed: 29301631
DOI: 10.1016/j.jacc.2017.10.080 -
International Journal of Environmental... May 2021Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care...
Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care organizations' (HCOs) performance. For fair comparisons, providers' QI rates must be risk-adjusted to control for different case-mix. The study's objectives were to develop a risk adjustment model for worsening or onset of urinary incontinence (UI), measured with the RAI-HC QI bladder incontinence, using the database HomeCareData and to assess the impact of risk adjustment on quality rankings of HCOs. Risk factors of UI were identified in the scientific literature, and multivariable logistic regression was used to develop the risk adjustment model. The observed and risk-adjusted QI rates were calculated on organization level, uncertainty addressed by nonparametric bootstrapping. The differences between observed and risk-adjusted QI rates were graphically assessed with a Bland-Altman plot and the impact of risk adjustment examined by HCOs tertile ranking changes. 12,652 clients from 76 Swiss HCOs aged 18 years and older receiving home care between 1 January 2017, and 31 December 2018, were included. Eight risk factors were significantly associated with worsening or onset of UI: older age, female sex, obesity, impairment in cognition, impairment in hygiene, impairment in bathing, unsteady gait, and hospitalization. The adjustment model showed fair discrimination power and had a considerable effect on tertile ranking: 14 (20%) of 70 HCOs shifted to another tertile after risk adjustment. The study showed the importance of risk adjustment for fair comparisons of the quality of UI care between HCOs in Switzerland.
Topics: Aged; Female; Home Care Services; Humans; Quality Indicators, Health Care; Quality of Health Care; Risk Adjustment; Switzerland
PubMed: 34063743
DOI: 10.3390/ijerph18115502 -
BMJ Open Aug 2021Adequate risk adjustment for factors beyond the control of the healthcare system contributes to the process of transparent and equitable benchmarking of trauma outcomes....
OBJECTIVES
Adequate risk adjustment for factors beyond the control of the healthcare system contributes to the process of transparent and equitable benchmarking of trauma outcomes. Current risk adjustment models are not optimal in terms of the number and nature of predictor variables included in the model and the treatment of missing data. We propose a statistically robust and parsimonious risk adjustment model for the purpose of benchmarking.
SETTING
This study analysed data from the multicentre Australia New Zealand Trauma Registry from 1 July 2016 to 30 June 2018 consisting of 31 trauma centres.
OUTCOME MEASURES
The primary endpoints were inpatient mortality and length of hospital stay. Firth logistic regression and robust linear regression models were used to study the endpoints, respectively. Restricted cubic splines were used to model non-linear relationships with age. Model validation was performed on a subset of the dataset.
RESULTS
Of the 9509 patients in the model development cohort, 72% were male and approximately half (51%) aged over 50 years . For mortality, cubic splines in age, injury cause, arrival Glasgow Coma Scale motor score, highest and second-highest Abbreviated Injury Scale scores and shock index were significant predictors. The model performed well in the validation sample with an area under the curve of 0.93. For length of stay, the identified predictor variables were similar. Compared with low falls, motor vehicle occupants stayed on average 2.6 days longer (95% CI: 2.0 to 3.1), p<0.001. Sensitivity analyses did not demonstrate any marked differences in the performance of the models.
CONCLUSION
Our risk adjustment model of six variables is efficient and can be reliably collected from registries to enhance the process of benchmarking.
Topics: Aged; Australia; Hospitals; Humans; Length of Stay; Male; Registries; Risk Adjustment
PubMed: 34426470
DOI: 10.1136/bmjopen-2021-050795 -
Deutsches Arzteblatt International Feb 2021
Topics: Colorectal Neoplasms; Digestive System Surgical Procedures; Humans; Morbidity; Risk Adjustment
PubMed: 33835008
DOI: 10.3238/arztebl.m2021.0055 -
The Journal of Thoracic and... Oct 2021Both congestive heart failure (HF) and atrial fibrillation (AF) are important and increasingly common forms of cardiovascular disease in the 21 century. Heart failure is...
Both congestive heart failure (HF) and atrial fibrillation (AF) are important and increasingly common forms of cardiovascular disease in the 21 century. Heart failure is often complicated by AF, and AF can exacerbate and, in some cases, cause HF, also known as tachycardia-induced cardiomyopathy (TIC). Restoration and maintenance of sinus rhythm in the majority of AF patients with TIC can lead to an improvement in left ventricular function and dramatic symptomatic relief. This can be accomplished by surgical ablation; specifically, the Cox-Maze IV procedure (CMP IV), in those refractory to medical and catheter-based ablation, and those patients undergoing concomitant cardiac operation. However, many surgeons are reluctant to perform stand-alone or concomitant CMP IV in this high-risk cohort of patients. In this review, the over three decades of experience with surgical ablation will be reviewed along with the essential information that surgeons need to be aware of as they participate in the team-based care of patients with AF and HF.
Topics: Atrial Fibrillation; Catheter Ablation; Heart Failure; Humans; Outcome Assessment, Health Care; Patient Selection; Prognosis; Quality of Life; Randomized Controlled Trials as Topic; Risk Adjustment; Stroke Volume; Ventricular Dysfunction, Left
PubMed: 32948298
DOI: 10.1016/j.jtcvs.2020.05.125