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At-risk Patients (at-risk + patient)
Selected AbstractsRisk management with suicidal patientsJOURNAL OF CLINICAL PSYCHOLOGY, Issue 2 2006Alan L. Berman The patient who is at-risk for suicide is complex and is difficult to evaluate and treat effectively. Should suicidal behavior occur, the clinician faces the potential wrath of bereaved survivors and their externalized blame exercised through a malpractice suit. The clinician's duty of care to a patient is to act affirmatively to protect a patient from violent acts against self. A finding of malpractice is established if the court finds that this duty was breached, through an act of omission or commission relative to the standard of care, and that this breach was proximately related to the patient's suicidal behavior. This article discusses the standard of care and factors that determine liability in a suicide death of a patient. An extensive list of recommendations for competent caregiving for the at-risk patient and risk management guidelines are then presented. © 2005 Wiley Periodicals, Inc. J Clin Psychol: In Session 62: 171,184, 2006. [source] Death by midgut infarction: clinical lessons from 88 post-mortems in Auckland, New ZealandANZ JOURNAL OF SURGERY, Issue 1-2 2009O'Grady Gregory Abstract Background:, Mortality rates from acute arterial mesenteric ischaemia remain high. Early diagnosis is of prognostic importance; however, early features are often non-specific, necessitating a high index of suspicion and knowledge of the at-risk patient. This study reviewed three decades of fatal cases in Auckland, New Zealand, to identify risk factors and associated pathologies that might help guide early diagnosis. Diagnostic delay was also evaluated. Methods:, Cases were identified through a pathology database maintained from 1977 to 2006. Autopsy reports were assessed together with available clinical detail. Results:, Eighty-eight cases were recovered. Mean age was 75.4 years, with women predominating (57%). Thromboembolic occlusion was the leading cause, followed by thrombotic occlusion. Embolic sources included atrial disease, aortic disease and myocardial infarction. Patients routinely showed extensive comorbidities, especially cardiovascular. Pain was the most constant presenting symptom, but features were often subtle and clinicians frequently misdiagnosed more minor ailments. Of operated patients, 36% received operations within 6 h of admission, 33% within 24 h, 17% at between 1 and 2 days, and the remainder between 2 and 12 days. Conclusion:, Knowledge of risk factors defined here is important to guide early diagnosis of mesenteric ischaemia. Diagnostic delay is again shown to be significant and case experience gathered in this series may improve doctors' discernment when meeting this condition. [source] Acceptability of Emergency Department-based Screening and Brief Intervention for Alcohol ProblemsACADEMIC EMERGENCY MEDICINE, Issue 12 2000Daniel W. Hungerford DrPH Abstract. Objectives: To adapt screening and brief intervention for alcohol problems (SBI) to a high-volume emergency department (ED) setting and evaluate its acceptability to patients. Methods: Patients at a large public-hospital ED were screened with the Alcohol Use Disorders Identification Test (AUDIT). Screen-positive drinkers (AUDIT score , 6) were provided brief, on-site counseling and referral as needed. Three months later, project staff blinded to baseline measures reassessed alcohol intake, alcohol-related harm, alcohol dependence symptoms, and readiness to change. Results: Of 1,034 patients approached, 78.3% (810) consented to participate (95% CI = 75.5% to 81.2%), and 21.2% (172) screened positive (95% CI = 18.4% to 24.0%). Of 88 patients with complete intervention data, 94.3% (83) accepted an intervention (95% CI = 89.5% to 99.2%), with acceptance rates ranging from 93% to 100% across four alcohol-problem-severity levels (p = 0.7). A majority (59.0%) set goals to decrease or stop drinking (95% CI = 48.4% to 69.6%). The group recontacted (n= 23) experienced statistically significant decreases in alcohol intake, alcohol-related harm, and dependence symptoms, with measures decreasing for 68%, 52%, and 61% of the patients. Readiness to change also showed statistically significant improvement, with scores increasing for 43% of the patients. Moreover, two-thirds of the patients (15/23) reported at follow-up that SBI was a helpful part of their ED visit. Conclusions: High rates of consent and acceptance of counseling for alcohol problems by patients across a wide range of problem severity indicate that this protocol was acceptable to at-risk patients in a public-hospital ED. Improvements in alcohol-related outcome measures at follow-up were strong enough to warrant controlled studies of intervention efficacy. [source] Allergy-like reactions to iodinated contrast agents.FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 3 2005A critical analysis Abstract Allergy-like reactions may occur following administration of iodinated contrast media (CM), mostly in at-risk patients (patients with history of previous reaction, history of allergy, co-treated with interleukin-2 or beta-blockers, etc.) but remain generally unpredictable. Severe and fatal reactions are very rare events. All categories of CM may induce such reactions, although first generation (high osmolar CM) have been found to induce a higher rate of adverse events than low osmolar CM. However, no differences were found between the two categories of CM with respect to mortality. Delayed reactions can also occur. There are no differences between the various categories of CM except for non-ionic dimers, which are more likely to induce such effect. Numerous clinical studies have evaluated the prophylactic value of drugs (mostly antihistamines and corticosteroids). Results are unclear and highly variable. Any prevention depends upon the mechanism involved. However, the mechanism of CM-induced allergy-like reaction remains disputed. Relatively recent data revived the hypothesis of a type-I hypersensitivity mechanism. Positive skin tests to CM have been reported. However, the affinity of IgE towards CM has been found to be very low in the only study which actually evaluated it. Other pathophysiological mechanisms (involving direct secretory effects on mast cells or basophils, or activation of the complement system associated or not with the plasma contact system) are also much debated. Anaphylaxis and anaphylactoid reactions are, in the end, clinically undistinguishable. [source] First Fracture Project: addressing the osteoporosis care gapINTERNAL MEDICINE JOURNAL, Issue 10 2007J. Vaile Abstract Patients sustaining a low-trauma fracture are at greater risk of subsequent fracture, but as a group are poorly managed. We report the development of our ,First Fracture Project', in which we attempt to assess all patients over 50 years of age with a low-trauma fracture attending orthopaedic fracture clinics and treat osteopenia and osteoporosis. We found that the First Fracture Project has greatly increased our success in improving delivery of osteoporosis care to appropriate at-risk patients. [source] The medical emergency team: does it really make a difference?INTERNAL MEDICINE JOURNAL, Issue 11 2003M. Cretikos Abstract Hospital systems are failing the critically ill. This has been well documented in many countries around the world, with detailed reports of suboptimal care prior to intensive care and high rates of serious adverse events, including death. These events are potentially preventable, but insufficient attention has been directed towards developing solutions to these important problems to date. The medical emergency team (MET) is a system approach that promotes early and appropriate intervention in the care of critically ill hospital patients. The benefits of the MET in terms of absolute in-patient mortality and cardiac arrest rates are not yet well-defined, although preliminary studies are promising. The MET does provide a potentially beneficial impact on many other aspects of patient care. These benefits include: (i) facilitating an integrated and coordinated approach to patient care across the hospital, (ii) increasing awareness of at-risk patients, (iii) encouraging early referral of seriously ill patients to clinicians with expertise in critical care and (iv) providing a foundation for quality initiatives for hospital-wide care of the seriously ill. The MET also empowers nursing staff and junior medical staff to call for immediate assistance in cases where they are seriously concerned about a patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately. (Intern Med J 2003; 33: 511,514) [source] Refinement of an osteoporosis risk-assessment questionnaire for use in community pharmacyINTERNATIONAL JOURNAL OF PHARMACY PRACTICE, Issue 5 2008Lee Ser Poh pharmacy practice advanced student Objective To explore the influence of bone mineral density (BMD) tests in osteoporosis risk categorisation in community pharmacies, and to develop a simple tool for pharmacists to use as a pre-BMD test screen. Method A secondary data analysis was conducted on the responses of 193 participants to a risk-assessment questionnaire, used in previous osteoporosis research that included a BMD test. To explore the impact of the BMD test on pharmacists' categorisation of risk, the researchers made an independent assessment based on responses of the questionnaire. The influence of risk factors on BMD scores/bone status was explored using multiple and logistic regression respectively. Key findings A total of responses of 193 participants were available for study, with 113 in the BMD group and 80 from the non-BMD group. In the BMD group, both researchers and pharmacists identified a similar proportion of patients in the moderate/high-risk category when BMD results were incorporated in the risk assessments (X2 = 0.78, degrees of freedom (df) = 1, 0.3 < P < 0.5). A statistically significant difference in risk categorisation was found between the pharmacists and researchers in the non-BMD group (X2 = 23.9, df = 1, P < 0.001). Risk factors identified to be significantly affecting BMD and of use for identifying patients at high risk for osteopenia/osteoporosis were age, weight, postmenopause and absence of hormone replacement therapy (HRT). These four factors were used to construct a simple risk index to guide pharmacists' initial risk categorisation. Conclusion The findings of this study suggested that BMD testing may increase the effectiveness of risk assessments and enhance the screening procedures in the community pharmacy. The simple risk index could serve as a pre-BMD test screen, with a BMD test recommended when necessary. A refined risk-assessment questionnaire could serve to guide pharmacists in directing individualised counselling and advice for at-risk patients, through identification of modifiable risk factors and conditions. [source] Underutilization of gastroprotection for at-risk patients undergoing percutaneous coronary intervention: Spain compared with the United StatesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 5 2010R. Casado-Arroyo Aliment Pharmacol Ther 2010; 32: 689,695 Summary Background, Proton pump inhibitors (PPIs) are the preferred agents for the prevention of aspirin-associated upper gastrointestinal bleeding (UGIB). Data are limited to determine whether PPIs are being used to reduce UGIB risk. Aim, To evaluate the implementation of PPI treatment to reduce the GI risk in two cardiology centres from Europe and the United States. Methods, A retrospective cross-sectional study was carried out at the University of Michigan and University Hospital-Zaragoza in 429 consecutive patients hospitalized for percutaneous coronary intervention (PCI) on dual antiplatelet therapy. Results, Admission for PPI co-therapy was similar (34% vs. 30%) in both centres. At discharge, the proportion of high-risk patients receiving PPI therapy in the Spanish centre (75.4%) was higher than their American peers (55.6%) (OR: 2.5; 95% CI; 1.3,4.7). No differences in PPI prescription rates were found among Spanish patients with/without GI risk factors. The opportunity to initiate PPI co-therapy in high-risk patients was missed in 81.8% (36/44) of those not on PPI at admission in US patients vs. 24.1% (19/79) (P < 0.0001) in Spanish patients. Conclusions, There are important differences concerning PPI prescription and risk stratification in the two centres when managing PCI patients. Efforts to stratify risks and utilize appropriate strategies for UGIB prophylaxis in high-risk patients are warranted. [source] Clinical trial: the incidence of NSAID-associated endoscopic gastric ulcers in patients treated with PN 400 (naproxen plus esomeprazole magnesium) vs. enteric-coated naproxen aloneALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 3 2010J. L. Goldstein Aliment Pharmacol Ther 2010; 32: 401,413 Summary Background, Gastroprotective co-therapy may reduce the risk of nonsteroidal anti-inflammatory drug (NSAID)-associated gastric ulcers, but adherence is suboptimal. Aim, To compare the incidence of gastric ulcers with PN 400 [enteric-coated (EC) naproxen 500 mg and immediate-release esomeprazole 20 mg], or EC naproxen. Methods, Two randomized, double-blind, multicentre studies (PN400-301, PN400-302). Patients [stratified by low-dose aspirin (,325 mg) use] aged ,50 years or 18,49 years with a history of ulcer, received PN 400 BID (301, n = 218; 302, n = 210) or EC naproxen 500 mg BID (301, n = 216; 302, n = 210) for 6 months. The primary endpoint was the cumulative incidence of endoscopic gastric ulcers. Results, The cumulative incidence of gastric ulcers was significantly lower with PN 400 vs. EC naproxen (301: 4.1% vs. 23.1%, P < 0.001; 302: 7.1% vs. 24.3%, P < 0.001). PN 400 was associated with a lower combined incidence of gastric ulcers vs. EC naproxen in low-dose aspirin users (n = 201) (3.0% vs. 28.4%, P < 0.001) and non-users (n = 653) (6.4% vs. 22.2%, P < 0.001). The incidence of, and discontinuations due to, upper gastrointestinal (UGI) AEs was significantly lower with PN 400 relative to EC naproxen (P < 0.01, both studies). Conclusions, PN 400 significantly reduces the incidence of gastric ulcers, regardless of low-dose aspirin use, in at-risk patients, and is associated with improved UGI tolerability relative to EC naproxen (ClinicalTrials.gov, NCT00527782). [source] Prevalence, risk factors and causes of discordance in fibrosis staging by transient elastography and liver biopsyLIVER INTERNATIONAL, Issue 10 2010Robert P. Myers Abstract Background and aims: Liver stiffness measurement (LSM) by transient elastography (TE) is widely used for the noninvasive assessment of fibrosis. Our objectives were to examine the prevalence, risk factors and causes of discordance between fibrosis estimated by TE and liver biopsy. Methods: Two hundred and fifty-one patients with hepatitis B, C and nonalcoholic fatty liver disease underwent LSM by TE and liver biopsy. Predictors of discordance (,2 fibrosis stages) between measures, which occurred in 14% of patients (n=35), were identified by comparing patient, TE and biopsy characteristics of discordant and nondiscordant cases. Results: According to predefined criteria, 40% of discordances were attributed to TE error and 23% to biopsy error; 37% were indeterminate. In multivariate analysis, mild fibrosis (F0,2 vs. F3,4), and higher body mass index (BMI), ALT and LSM variability [assessed by the ratio of the interquartile range to median LSM (IQR/M)] were independently associated with discordance. Discordance was three-fold more common in patients with obesity (28 vs. 9%), ALT,60 U/L (20 vs. 7%) and IQR/M ,0.17 (22 vs. 7%; all P<0.005). Based on these variables, a discordance risk score assigning 1 point to each factor was developed. The prevalence of discordance in patients with 0, 1, 2 and 3 factors were 2, 7, 20, and 55% respectively (P<0.0005). Conclusions: Discordance between liver fibrosis estimated by TE and biopsy occurs in one in seven patients. In assessing the validity of TE results, clinicians must recognize risk factors for discordance and in at-risk patients, consider alternative measures including biomarkers and possibly biopsy. [source] Fluid challenge in patients at risk for fluid loading-induced pulmonary edemaACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 1 2004M. Matejovic Background:, This study evaluated the effects of protocol-guided fluid loading on extravascular lung water (EVLW) and hemodynamics in a group of patients at high risk for volume expansion-induced pulmonary and systemic edema. Methods:, Nine acutely admitted septic patients with acute lung injury (ALI) were prospectively studied. In addition to sepsis and ALI, the following criteria indicating increased risk for edema formation had to be fulfilled: increased vascular permeability defined as microalbuminuria greater than fivefold normal and hypoalbuminemia <30 g l,1. Two hundred-ml boluses of a 10% hydroxyethyl starch (HES) was titrated to obtain best filling pressure/stroke volume relation. Extravascular lung water and intrathoracic blood volume (ITBV) were measured using a transpulmonary double-indicator dilution technique. Baseline data were compared with data at the end of fluid loading and 3 h postchallenge. Results:, At study entry the mean EVLW was 13 ml kg,1, and the mean EVLW/ITBV ratio (indicator of pulmonary permeability) was 0.72 (normal range 0.20,0.30). To attain optimal preload/stroke volume relation 633 ± 240 ml of HES was needed. Fluid loading significantly increased preload (CVP, PAOP and ITBV), and stroke volume. Effective pulmonary capillary pressure (Pcap) rose only slightly. As a result, the Pcap,PAOP gradient decreased. Despite increased cardiac output, EVLW did not change by plasma expansion. Conclusion:, In this selected group of at-risk patients, the optimization of cardiac output guided by the concept of best individual filling pressure/stroke volume relationship did not worsen permeability pulmonary edema. [source] Latest news and product developmentsPRESCRIBER, Issue 7 2007Article first published online: 11 JUL 200 Poor asthma control with off-licence prescribing Children who are prescribed off-licence medications are more likely to have poor asthma control, according to an analysis from Dundee (Br J Gen Practice 2007;57:220-2). The review of 17 163 consultations identified 1050 (6.1 per cent) who received a prescription for an unlicensed use (defined as not licensed for children or the particular age group, or dose not licensed). High doses (4.5 per cent) were more frequent than unlicensed indications (1.9 per cent). Children who received off-label prescriptions reported statistically significantly more symptoms in the day or night, symptoms during activity, and increased use of daily short-acting beta2-agonists. The authors note that off-label prescribing appears to be increasing. Atkins diet most effective over one year? The ultra low-carbohydrate, high-protein Atkins diet achieved greater weight loss than other popular diets in overweight women over one year, say US investigators (J Am Med Assoc 2007;297:969-77). The study compared the Atkins diet with three diets designed as low- or very high-carbohydrate, or based on USA nutritional guidance, in 311 women with body mass index 27-40. After one year, mean weight loss was 4.7kg with the Atkins diet , significantly greater than with the low- carbohydrate diet (1.6kg) but not compared with very high-carbohydrate (2.2kg) or the nutrition-based diet (2.6kg). Metabolic endpoints were comparable or more favourable in women using the Atkins diet. Androgen therapy linked to gum disease The majority of men treated with androgen deprivation therapy for prostate cancer are more likely to have periodontal disease (J Urol 2007;177:921-4). After controlling for risk factors, the prevalence of periodontal disease was 80.5 per cent among treated men compared with 3.7 per cent in matched controls not receiving treatment. There was no difference in bone mineral density between the groups but plaque scores were significantly higher among treated men. Food Commission rebuts MHRA on additives An independent watchdog has not accepted the MHRA's justification for including certain additives in medicines for children. The Food Commission (www.foodcomm.org.uk) found that most medicines for children contained additives, some of which , including azo dyes and benzoates , are not permitted in food. The Commission called on the pharmaceutical industry to stop using ,questionable additives'. The MHRA stated that the licensing process takes into account the likely exposure to excipients that are considered essential to make medicines palatable to children. Colouring helps children to identify the correct medicine, and preservatives ensure a reasonable shelf-life. A list of additives is included in the product's summary of product characteristics and patient information leaflet. In response, the Commission states: , , it is quite possible to flavour medicines with natural oils or extracts, and natural colourings such as beetroot and beta-carotene can be used instead of azo dyes. If parents were advised to give these medicinal products at mealtimes the manufacturers could also add a little sugar to sweeten their products, rather than relying on artificial sweeteners.' All triptans the same? There is no economic case for choosing one triptan over another and no evidence for preferring a particular triptan for adults, a systematic review has concluded. The Canadian Agency for Drugs and Technologies in Health (www.cadth.ca) found that published trials had compared most triptans with sumatriptan but not with one another, and most economic evaluations were flawed. New drug for HIV Janssen-Cilag has introduced darunavir (Prezista), a new protease inhibitor for the treatment of HIV infection. Licensed for highly pre- treated patients in whom more than one other pro- tease inhibitor regimen has failed, darunavir must be co-administered with ritonavir (Norvir). A month's treatment at the recommended dose of 600mg twice daily costs £446.70. Variation in liquid captopril for children The NHS uses a wide range of liquid formulations of captopril to treat children with heart failure , with no assurance of their bioequivalence (Arch Dis Child 2007; published online 15 March. doi: 10.1136/adc.2006.109389). Specialists in Leicester surveyed 13 tertiary paediatric cardiac centres and 13 hospitals that referred patients to them. Only three tertiary centres supplied the same liquid for-mulation of captopril as their referring hospitals. Four hospitals supplied tablets for crushing and dissolving in water; the other hospitals and centres used a total of nine different formulations. The authors say the formulations had widely varying shelf-lives, determined empirically in all but one case, and were used interchangeably despite a lack of quality control data to establish their bioequivalence. QOF CVD targets not good enough for GPs Two-thirds of GPs want Quality Outcome Framework (QOF) targets for cardiovascular disease brought into line with those of the Joint British Societies latest guidance (JBS2), according to a survey by doctor.net.uk. The survey of 1000 GPs showed that 88 per cent were aware of the JBS2 guidelines and most were already implementing the targets for lipids, blood pressure and blood glucose in some form; however, only 55 per cent were implementing the JBS2 obesity target and 14 per cent were implementing screening for the over-40s. The JBS2 target for lipids in at-risk patients is <4mmol per litre total cholesterol and <2 mmol per litre LDL-cholesterol, compared with <5 and <3mmol per litre respectively in QOF and the NSF. The survey was commissioned by Merck Sharp & Dohme and Schering- Plough. Fracture warning Following warnings in the US that rosiglitazone (Avandia) is associated with an increased risk of fractures in women, Takeda has advised prescribers that pioglitazone (Actos) carries a similar risk. An analysis of the company's clinical trials database has revealed an excess risk of fractures of bones below the elbow and knee. The incidence was similar to the excess risk associated with rosiglitazone and also confined to women. Scottish approvals The Scottish Medicines Consortium (www.scottish medicines.org.uk) has approved for use within NHS Scotland the sublingual tablet formulation buprenorphine/naloxone (Suboxone) for the treatment of opioid dependence. It has also approved the combined formulation of valsartan and amlodipine (Exforge) and the restricted use of the If inhibitor ivabradine (Procoralan). [source] Detection of Undiagnosed Diabetes and Prediabetic States in High-risk Emergency Department PatientsACADEMIC EMERGENCY MEDICINE, Issue 5 2009Michelle A. Charfen MD Abstract Background:, Diabetes is often not diagnosed until complications appear, and one-third of those with diabetes may be undiagnosed. Prediabetes and diabetes are conditions in which early detection would be appropriate, because the duration of hyperglycemia is a predictor of adverse outcomes, and there are effective interventions to prevent disease progression and to reduce complications. Objectives:, The objectives were to determine the prevalence of diabetes mellitus and prediabetes in emergency department (ED) patients with an elevated random glucose or risk factors for diabetes but without previously diagnosed diabetes and to identify which at-risk ED patients should be considered for referral for confirmatory diagnostic testing. Methods:, This two-part study was composed of a prospective 2-year cohort study, and a 1-week cross-sectional survey substudy, set in an urban ED in Los Angeles County, California. A convenience sample was enrolled of 528 ED patients without previously diagnosed diabetes with either 1) a random serum glucose , 140 mg/dL regardless of the time of last food intake or a random serum glucose , 126 mg/dL if more than 2 hours since last food intake or 2) at least two predefined diabetes risk factors. Measurements included presence of diabetes risk factors, ED glucose, cortisol, insulin and glycosylated hemoglobin (HbA1c), and 2-hour oral glucose tolerance test results, administered at 6-week follow-up. Results:, Glycemic status was confirmed at follow-up in 256 (48%) of the 528 patients. Twenty-seven (11%) were found to have diabetes, 141 (55%) had prediabetes, and 88 (34%) had normal results. Age, ED glucose, HbA1c, cortisol, and random serum glucose , 140 mg/dL were associated with both diabetes and prediabetes on univariate analysis. A random serum glucose , 126 mg/dL after 2 hours of fasting was associated with diabetes but not prediabetes; ED cortisol, insulin, age , 45 years, race, and calculated body mass index (BMI) were associated with prediabetes but not diabetes. In multivariable models, among factors measurable in the ED, the only independent predictor of diabetes was ED glucose, while ED glucose, age , 45 years, and symptoms of polyuria and polydipsia were independent predictors of prediabetes. All at-risk subjects with a random ED blood glucose > 155 mg/dL had either prediabetes or diabetes on follow-up testing. Conclusions:, A substantial fraction of this urban ED study population was at risk for undiagnosed diabetes and prediabetes, and among the at-risk patients referred for follow-up, the majority demonstrated diabetes or prediabetes. Notably, all patients with two risk factors and a random serum glucose > 155 mg/dL were later diagnosed with prediabetes or diabetes. Consideration should be given to referring ED patients with risk factors and a random glucose > 155 mg/dL for follow-up testing. [source] Gene expression profiling in autoantibody-positive patients with arthralgia predicts development of arthritis,ARTHRITIS & RHEUMATISM, Issue 3 2010Lisa G. M. van Baarsen Objective To identify molecular features associated with the development of rheumatoid arthritis (RA), to understand the pathophysiology of preclinical development of RA, and to assign predictive biomarkers. Methods The study group comprised 109 anti,citrullinated protein antibody (ACPA), and/or rheumatoid factor,positive patients with arthralgia who did not have arthritis but were at risk of RA, and 25 patients with RA. The gene expression profiles of blood samples obtained from these patients were determined by DNA microarray analysis and quantitative polymerase chain reaction. Results In 20 of the 109 patients with arthralgia who were at risk of RA, arthritis developed after a median of 7 months. Gene expression profiling of blood cells revealed heterogeneity among the at-risk patients, based on differential expression of immune-related genes. This report is the first to describe gene signatures relevant to the development of arthritis. Signatures significantly associated with arthritis development were involved in interferon (IFN),mediated immunity, hematopoiesis, and chemokine/cytokine activity. Logistic regression analysis revealed that the odds ratio (OR) for developing arthritis within 12 months was 21.0 (95% confidence interval [95% CI] 2.8,156.1 [P = 0.003]) for the subgroup characterized by increased expression of genes involved in IFN-mediated immunity and/or cytokine/chemokine-activity. Genes involved in B cell immunology were associated with protection against progression to arthritis (OR 0.38, 95% CI 0.21,0.70 [P = 0.002]). These processes were reminiscent of those in patients with RA, implying that the preclinical phase of disease is associated with features of established disease. Conclusion The results of this study indicate that IFN-mediated immunity, hematopoiesis, and cell trafficking specify processes relevant to the progression of arthritis independent of ACPA positivity. These findings strongly suggest that certain gene signatures have value for predicting the progression to arthritis, which will pave the way to preventive medicine. [source] Dysfunctional proinflammatory high-density lipoproteins confer increased risk of atherosclerosis in women with systemic lupus erythematosusARTHRITIS & RHEUMATISM, Issue 8 2009Maureen McMahon Objective Women with systemic lupus erythematosus (SLE) have an increased risk of atherosclerosis. Identification of at-risk patients and the etiology underlying atherosclerosis in SLE remain elusive. The antioxidant capacity of normal high-density lipoproteins (HDLs) is lost during inflammation, and these dysfunctional HDLs might predispose individuals to atherosclerosis. The aim of this study was to determine whether dysfunctional proinflammatory HDL (piHDL) is associated with subclinical atherosclerosis in SLE. Methods Carotid artery ultrasound was performed in 276 women with SLE to identify carotid plaques and measure intima-media thickness (IMT). The antioxidant function of HDL was measured as the change in oxidation of low-density lipoprotein after the addition of HDL cholesterol. Two antiinflammatory HDL components, paraoxonase 1 and apolipoprotein A-I, were also measured. Results Among the SLE patients, 48.2% were determined to have piHDL on carotid ultrasound, while 86.7% of patients with plaque had piHDL compared with 40.7% of those without plaque (P < 0.001). Patients with piHDL also had a higher IMT (P < 0.001). After multivariate analysis, the only factors found to be significantly associated with plaque were the presence of piHDL (odds ratio [OR] 16.1, P < 0.001), older age (OR 1.2, P < 0.001), hypertension (OR 3.0, P = 0.04), dyslipidemia (OR 3.4, P = 0.04), and mixed racial background (OR 8.3, P = 0.04). Factors associated with IMT measurements in the highest quartile were the presence of piHDL (OR 2.5, P = 0.02), older age (OR 1.1, P < 0.001), a higher body mass index (OR 1.07, P = 0.04), a cumulative lifetime prednisone dose ,20 gm (OR 2.9, P = 0.04), and African American race (OR 8.3, P = 0.001). Conclusion Dysfunctional piHDL greatly increases the risk of developing subclinical atherosclerosis in SLE. The presence of piHDL was associated with an increased prevalence of carotid plaque and with a higher IMT. Therefore, determination of piHDL may help identify patients at risk for atherosclerosis. [source] Percutaneous renal artery intervention for preservation of renal function: Strategies for identification of "at-risk" patientsCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 4 2006FSCAI, Krishna Rocha-Singh MD First page of article [source] Development of a Brief Mental Health Screen for Intimate Partner Violence Victims in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 3 2007Debra Houry MD Background: Emergency physicians routinely treat victims of intimate partner violence (IPV) and patients with mental health symptoms, although these issues may be missed without routine screening. In addition, research has demonstrated a strong association between IPV victimization and mental health symptoms. Objectives: To develop a brief mental health screen that could be used feasibly in an emergency department to screen IPV victims for depressive symptoms, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation. Methods: The authors conducted a pretest/posttest validation study of female IPV victims to determine what questions from the Beck Depression Inventory II, Posttraumatic Stress Diagnostic Scale, and Beck Scale for Suicide Ideation would predict moderate to severe levels of depressive symptoms, PTSD symptoms, and suicidal ideation. A principal components factor analysis was conducted to determine which questions would be used in the brief mental health screen. Scatter plots were then created to determine a cut point. Results: Scores on the brief mental health screen ranged from 0 to 8. A cutoff score of 4 was used, which resulted in positive predictive values of 96% for the brief mental health screen for depression, 84% for PTSD symptoms, and 54% for suicidal ideation. In particular, four questions about sadness, experiencing a traumatic event, the desire to live, and the desire to commit suicide were associated with moderate to severe mental health symptoms in IPV victims. Conclusions: The brief mental health screen provides a tool that could be used in an emergency department setting and predicted those IPV victims with moderate to severe mental health symptoms. Using this tool can assist emergency physicians in recognizing at-risk patients and referring these IPV victims to mental health services. [source] A Study on Variances in Multivariate Analyses of Oral Implant OutcomeCLINICAL IMPLANT DENTISTRY AND RELATED RESEARCH, Issue 1 2007Irene Herrmann LDS, Odont Lic ABSTRACT Background:, Elaborate studies have shown that interdependency exists between implants being placed in the same patient/jaw. Therefore, interdependency ought to be an important aspect to address, whenever performing statistical analyses of oral implant outcomes. A Jackknife method could be an option when conducting statistical evaluations of oral implant failure prognoses. Purpose:, The aim of this study was to evaluate whether a statistical difference can be detected by using the Jackknife method in conjunction with life table analyses and/or a log rank test of four different combinations of jaw density and quantity. Materials and Methods:, Four multicenter studies were pooled and adjusted in order to create a research database consisting of 486 patients and 1,737 implants in preparation for the Jackknife resampling method. Combinations of jaw shapes and bone qualities were constructed to select at-risk patients. Statistical Methods:, Life tables with confidence intervals were calculated and a log rank test was used to determine whether a statistical difference between the combinations could be established. Results:, Both statistical analyses, after the Jackknife resampling method, showed that patients with poor bone quality and resorbed jaws (combination IV) had a statistically higher risk of implant failure. Conclusion:, By rearranging data using the Jackknife method, standardized statistical tests seem to work well even when the study population tested was affected by interdependency. [source] Cytomegalovirus in transplantation , challenging the status quoCLINICAL TRANSPLANTATION, Issue 2 2007Jay A Fishman Abstract:, Background:, Cytomegalovirus (CMV) infection of solid organ transplant (SOT) recipients causes both ,,direct'' and ,,indirect'' effects including allograft rejection, decreased graft and patient survival, and predisposition to opportunistic infections and malignancies. Options for CMV prevention include pre-emptive therapy, whereby anti-CMV agents are administered based on sensitive viral assays, or universal prophylaxis of all at-risk patients. Each approach has advantages and disadvantages in terms of efficacy, costs, and side effects. Standards of care for prophylaxis have not been established. Methods:, A committee of international experts was convened to review the available data regarding CMV prophylaxis and to compare preventative strategies for CMV after transplantation from seropositive donors or in seropositive recipients. Results:, Pre-emptive therapy requires frequent monitoring with subsequent treatment of disease and associated costs, while universal prophylaxis results in greater exposure to potential toxicities and costs of drugs. The advantages of prophylaxis include suppressing asymptomatic viremia and prevention of both direct and indirect effects of CMV infection. Meta analyses reveal decreased in mortality for patients receiving CMV prophylaxis. Costs associated with prophylaxis are less than for routine monitoring and pre-emptive therapy. The optimal duration of antiviral prophylaxis remains undefined. Extended prophylaxis may improve clinical outcomes in the highest-risk patient populations including donor-seropositive/recipient-seronegative renal transplants and in CMV-infected lung and heart transplantation. Conclusions:, Prophylaxis is beneficial in preventing direct and indirect effects of CMV infection in transplant recipients, affecting both allograft and patient survival. More studies are necessary to define optimal prophylaxis regimens. [source] Early cellular events in colorectal carcinogenesisCOLORECTAL DISEASE, Issue 2 2002A. G. Renehan Colorectal cancer develops through a multistage process recognizable at a histopathological level by progression from normal mucosa to invasive carcinoma (the adenoma-carcinoma sequence). For many years, it has been hypothesized that increased cell proliferation in the colonic crypt represents the earliest recognizable stage in this sequence. This perspective is now changing. While several human studies have reported increased crypt cell proliferation in samples from at-risk patients, there are many inconsistencies and paradoxes in their conclusions. In addition, it is appreciated that the process of apoptosis (programmed cell death) is vital for normal crypt homeostasis and its impairment may be an early event in the neoplastic process. It is now believed that aberrant crypt foci (ACFs) represent the earliest step in colorectal carcinogenesis. Two ACF types are identifiable: hypercellular and dysplastic. Increased proliferative activity may be seen in both, but the dysplastic entity is most relevant to carcinogenesis. Animal and human studies support the notion that ACFs grow by crypt fission leading to the formation of microadenomas. Adenomas are monoclonal expansions of an altered cell, but very early lesions may be polyclonal. There are outward and inward theories of polypoid growth, and evidence to support both mechanisms. The ACF assay has become a useful tool to detect carcinogens in animal studies but has been less frequently used in human studies. For future cancer chemopreventive and risk assessment studies in humans, the identification and quantification of ACFs should be considered a more effective intermediate marker of risk than the determination of crypt cell proliferation alone. [source] Readmissions: a primary care examination of reasons for readmission of older people and possible readmission risk factorsJOURNAL OF CLINICAL NURSING, Issue 5 2006Dip N, Linda Dobrzanska MSc, PG Cert HCE Aim., To identify the reasons that may have contributed to the emergency readmission of older people to a medical unit, within 28 days of hospital discharge. Background., The current UK Government has initiatives in place to monitor quality and service delivery of NHS organizations. This is achieved by setting, delivering and monitoring standards, one of which is ,emergency readmission to hospital within 28 days of discharge (all ages), as a percentage of live discharges'. Design/method., A year-long study examined reasons for unplanned readmission of patients (aged 77 and over) within 28 days of hospital discharge. The population was patients, registered with North Bradford PCT General Practitioners, readmitted to one of five care of older people wards in two local acute trust NHS hospitals. Patient records were scrutinized and data related to demography, diagnosis and readmission were collected using a structured extraction tool. Data analysis was undertaken using descriptive statistics and identification of differences and correlations within the data. Results., A pilot study indicated patients readmitted from home vs. other sources and patients discharged to home vs. other sources had a significantly shorter stay on readmission. The main study showed other significant findings. Patients who lived in care were readmitted sooner than those who lived at home: those discharged home vs. other sources and agreeing to increased social service provision had longer stays on readmission. Shorter length of stay on index admission (up to 72 hours) was associated with increased likelihood of earlier readmission. Conclusions., A framework of factors was identified and could be used to target resources to meet patients' needs more flexibly. Relevance to clinical practice., It is possible that the process of targeting resources to ,at-risk' patients might enable services to be delivered in a more cost-efficient and cost-effective way. [source] Review article: medication non-adherence in ulcerative colitis , strategies to improve adherence with mesalazine and other maintenance therapiesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 12 2008A. B. HAWTHORNE Summary Background, Significant number of patients with ulcerative colitis (UC) fail to comply with treatment. Aims, To review issues surrounding medication non-adherence in inflammatory bowel disease (IBD), including the clinical and health service implications in the UK, and discuss strategies for optimizing medication adherence. Methods, Articles cited were identified via a PubMed search, utilizing the words IBD, adherence, compliance, medication and UC. Results, Medication non-adherence is multifactorial involving factors other than dosing frequency. Male gender (OR: 2.06), new patient status (OR: 2.14), work and travel pressures (OR: 4.9) and shorter disease duration (OR: 2.1), among others are proven predictors of non-adherence in UC. These indicators can identify ,at-risk' patients and allow an individually tailored treatment approach to be introduced that optimizes medication adherence. A collaborative relationship between physician and patient is important; several strategies for improving adherence have been proven effective including open dialogue that takes into consideration the patient's health beliefs and concerns, providing educational (e.g. verbal/written information, self-management programmes) and behavioural interventions (e.g. calendar blister packs, cues/reminders). Conclusions, Educational and behavioural interventions tailored to individual patients can optimize medication adherence. Additional studies combining educational and behavioural interventions may provide further strategies for improving medication adherence rates in UC. [source] | ||||||||||