scholarly journals 926: Lack of postpartum follow-up is associated with an increased risk of postpartum readmission in high-risk patients.

2018 ◽  
Vol 218 (1) ◽  
pp. S548-S549
Author(s):  
Clara Ward ◽  
Mesk Alrais ◽  
Susan Hosseini Nasab ◽  
Baha M. Sibai ◽  
Sean C. Blackwell
Keyword(s):  
High Risk ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

scholarly journals Cardiovascular outcomes, bleeding risk, and achieved blood pressure in patients on long-term anticoagulation with the thrombin antagonist dabigatran or warfarin: data from the RE-LY trial

2020 ◽  
Vol 41 (30) ◽  
pp. 2848-2859 ◽  
Author(s):  
Michael Böhm ◽  
Martina Brueckmann ◽  
John W Eikelboom ◽  
Michael Ezekowitz ◽  
Mandy Fräßdorf ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Blood Pressure ◽  
High Risk ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Bleeding Events ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Abstract Aims A J-shaped association of cardiovascular events to achieved systolic (SBP) and diastolic (DBP) blood pressure was shown in high-risk patients. This association on oral anticoagulation is unknown. This analysis from RELY assessed the risks of death, stroke or systemic emboli, and bleeding according to mean achieved SBP and DBP in atrial fibrillation on oral anticoagulation. Methods and results RE-LY patients were followed for 2 years and recruited between 22 December 2005 until 15 December 2007. 18.113 patients were randomized in 951 centres in 54 countries and 18,107 patients with complete blood pressure (BP) data were analysed with a median follow-up of 2.0 years and a complete follow-up in 99.9%. The association between achieved mean SBP and DBP on all-cause death, stroke and systemic embolic events (SSE), major, and any bleeding were explored. On treatment, SBP >140 mmHg and <120 mmHg was associated with all-cause death compared with SBP 120–130 mmHg (reference). For SSE, risk was unchanged at SBP <110 mmHg but increased at 140–160 mmHg (adjusted hazard ratio (HR) 1.81; 1.40–2.33) and SBP ≥160 mmHg (HR 3.35; 2.09–5.36). Major bleeding events were also increased at <110 mmHg and at 110 to <120 mmHg. Interestingly, there was no increased risk of major bleeding at SBP >130 mmHg. Similar patterns were observed for DBP with an increased risk at <70 mmHg (HR 1.55; 1.35–1.78) and >90 mmHg (HR 1.88; 1.43–2.46) for all-cause death compared to 70 to <80 mmHg (reference). Risk for any bleeding was increased at low DBP <70 mmHg (HR 1.46; 1.37–1.56) at DBP 80 to <90 mmHg (HR 1.13; 1.06–1.31) without increased risk at higher achieved DBP. Dabigatran 150 mg twice daily showed an advantage in all patients for all-cause death and SSE and there was an advantage for 110 mg dabigatran twice daily for major bleeding and any bleeding irrespective of SBP or DBP achieved. Similar results were obtained for baseline BP, time-updated BP, and BP as time-varying covariate. Conclusion Low achieved SBP associates with increased risk of death, SSE, and bleeding in patients with atrial fibrillation on oral anticoagulation. Major bleeding events did not occur at higher BP. Low BP might identify high-risk patients not only for death but also for high bleeding risks. Clinical trial registration  ClinicalTrials.gov—Identifier: NCT00262600.

scholarly journals The LACE Score as a Tool to Identify Radical Cystectomy Patients at Increased Risk of 90-Day Readmission and Mortality

2018 ◽  
Vol 12 (1) ◽  
pp. 20-26 ◽  
Author(s):  
Jennifer L. Saluk ◽  
Robert H. Blackwell ◽  
William S. Gange ◽  
Matthew A. C. Zapf ◽  
Anai N. Kothari ◽  
...  
Keyword(s):  
Bladder Cancer ◽  
High Risk ◽  
Radical Cystectomy ◽  
Multivariable Analysis ◽  
Emergency Department Visits ◽  
High Risk Patients ◽  
Increased Risk ◽  
Patients At Risk ◽  
Risk Patients

Introduction: Radical cystectomy for bladder cancer is associated with high rates of readmission. We investigated the LACE score, a validated prediction tool for readmission and mortality, in the radical cystectomy population. Materials &amp; Methods: Patients who underwent radical cystectomy for bladder cancer were identified by ICD-9 codes from the Healthcare Cost and Utilization Project State Inpatient Database for California years 2007-2010. The LACE score was calculated as previously described, with components of L: length of stay, A: acuity of admission, C: comorbidity, and E: number of emergency department visits within 6 months preceding surgery. Results: Of 3,470 radical cystectomy patients, 638 (18.4%) experienced 90-day readmission, and 160 (4.6%) 90-day mortality. At a previously validated “high-risk” LACE score ≥ 10, patients experienced an increased risk of 90-day readmission (22.8 vs. 17.7%, p = 0.002) and mortality (9.1 vs. 3.5%, p < 0.001). On adjusted multivariable analysis, “high risk” patients by LACE score had increased 90-day odds of readmission (adjusted OR = 1.24, 95% CI: 0.99-1.54, p = 0.050) and mortality (adjusted OR = 2.09, 95% CI: 1.47-2.99, p < 0.001). Conclusion: The LACE score reasonably identifies patients at risk for 90-day mortality following radical cystectomy, but only poorly predicts readmission. Providers may use the LACE score to target high-risk patients for closer follow-up or intervention.

scholarly journals Accuracy of upper endoscopies with random biopsies to identify patients with gastric premalignant lesions who can safely be exempt from surveillance

2021 ◽  
Vol 24 (3) ◽  
pp. 680-690
Author(s):  
Michiel C. Mommersteeg ◽  
Stella A. V. Nieuwenburg ◽  
Wouter J. den Hollander ◽  
Lisanne Holster ◽  
Caroline M. den Hoed ◽  
...  
Keyword(s):  
Gastric Cancer ◽  
High Risk ◽  
Low Risk ◽  
Premalignant Lesions ◽  
High Risk Patients ◽  
European Guidelines ◽  
Progression Of Disease ◽  
Risk Patients ◽  
Progression Risk

Abstract Introduction Guidelines recommend endoscopy with biopsies to stratify patients with gastric premalignant lesions (GPL) to high and low progression risk. High-risk patients are recommended to undergo surveillance. We aimed to assess the accuracy of guideline recommendations to identify low-risk patients, who can safely be discharged from surveillance. Methods This study includes patients with GPL. Patients underwent at least two endoscopies with an interval of 1–6 years. Patients were defined ‘low risk’ if they fulfilled requirements for discharge, and ‘high risk’ if they fulfilled requirements for surveillance, according to European guidelines (MAPS-2012, updated MAPS-2019, BSG). Patients defined ‘low risk’ with progression of disease during follow-up (FU) were considered ‘misclassified’ as low risk. Results 334 patients (median age 60 years IQR11; 48.7% male) were included and followed for a median of 48 months. At baseline, 181/334 (54%) patients were defined low risk. Of these, 32.6% were ‘misclassified’, showing progression of disease during FU. If MAPS-2019 were followed, 169/334 (51%) patients were defined low risk, of which 32.5% were ‘misclassified’. If BSG were followed, 174/334 (51%) patients were defined low risk, of which 32.2% were ‘misclassified’. Seven patients developed gastric cancer (GC) or dysplasia, four patients were ‘misclassified’ based on MAPS-2012 and three on MAPS-2019 and BSG. By performing one additional endoscopy 72.9% (95% CI 62.4–83.3) of high-risk patients and all patients who developed GC or dysplasia were identified. Conclusion One-third of patients that would have been discharged from GC surveillance, appeared to be ‘misclassified’ as low risk. One additional endoscopy will reduce this risk by 70%.

scholarly journals Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

2021 ◽  
Author(s):  
Laura C. Blomaard ◽  
Bas de Groot ◽  
Jacinta A. Lucke ◽  
Jelle de Gelder ◽  
Anja M. Booijen ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Screening Program ◽  
Admission Rate ◽  
Older Patient ◽  
Hospital Admission Rate ◽  
High Risk Patients ◽  
Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease

2021 ◽  
Author(s):  
Grischa Hoffmann ◽  
Christine Friedrich ◽  
Katharina Huenges ◽  
Rainer Petzina ◽  
Astrid-Mareike Vogt ◽  
...  
Keyword(s):  
Coronary Artery ◽  
High Risk ◽  
Minimally Invasive ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Multivessel Disease ◽  
Complete Revascularization ◽  
High Risk Patients ◽  
Risk Patients

Abstract Background High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR). Methods A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated. Results Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2–6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%. Conclusion In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.

Abstract 14782: Sex Comparisons in Anticoagulation Treatment for Atrial Fibrillation in a Large Rural Healthcare System

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Macaela N Rudeck ◽  
Catherine P Benziger
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Atrial Flutter ◽  
Electronic Medical Record System ◽  
Record System ◽  
High Risk Patients ◽  
Occlusion Device ◽  
Increased Risk ◽  
Medical Record System ◽  
Risk Patients

Introduction: Atrial fibrillation (AF) and flutter lead to increased risk of thromboembolism (TE). The CHA 2 DS 2 -VASc score is used to determine the risk of TE. Objective: We aim to evaluate the anticoagulation use across CHA 2 DS 2 -VASc scores calculated using a validated automatic calculator. Methods: An AF registry was created for patients with AF or atrial flutter who had seen a primary care or cardiology provider within the past 2 years (5/28/2018-5/28/2020). An automatic CHA 2 DS 2 -VASc calculator was integrated into the electronic medical record system at Essentia Health on 10/1/2019. High-risk of TE was defined as a score of ≥3 for females and a score of ≥2 for males. AF registry included demographics, anticoagulation prescription, CHA 2 DS 2 -VASc and ATRIA bleed score, contraindications, and presence of left atrial appendage (LAA) occlusion device. Results: A total of 10992 patients with AF or atrial flutter were included in the registry (74.8 ±11.8 years, 41.7% female). A total of 6703 (61.0%) had a CHA 2 DS 2 -VASc score calculated (mean score 3.9 ± 1.5). Mean ATRIA bleed score was 3.0 ± 2.0. Within these patients, 90.7% of males and 93.0% of females were at high-risk of TE. Of these high-risk patients, anticoagulation use was 82.7% for females and 83.5% for males and increased with increasing score (p<0.01 for males, p<0.01 for females) (Figure 1). Overall, 36.9% were prescribed NOAC, 47.0% warfarin, and 0.8% heparin. There was no sex difference in the prescription of NOAC (37.7% male vs. 35.9% female, p=0.1). Fewer than 1% had WATCHMAN LAA device (0.3% male vs. 0.4% female, p=0.5). Conclusion: Four out of 5 patients at increased risk of TE are prescribed an anticoagulant. Interventions to improve anticoagulation use in high-risk patients are needed. Figure 1. Anticoagulation prescription use in atrial fibrillation patients by CHA 2 DS 2 -VASc score and sex between 5/28/2018-5/28/2020 at Essentia Health (N=6703).

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