Risk-based management of dental procedures in patients with inherited bleeding disorders: Development of a Dental Bleeding Risk Assessment and Treatment Tool (DeBRATT)

Haemophilia ◽  
2017 ◽  
Vol 23 (2) ◽  
pp. 247-254 ◽  
Author(s):  
L. Rasaratnam ◽  
P. Chowdary ◽  
D. Pollard ◽  
B. Subel ◽  
C. Harrington ◽  
...  
2018 ◽  
Vol 5 (1) ◽  
pp. 42-49
Author(s):  
Allison Greig

Abstract People with Inherited Bleeding Disorders (IBD) are often prescribed a course of Tranexamic Acid (TXA) mouthwash for five to seven days following dental procedures to reduce the risk of bleeding. Informal discussions with patients suggested that many do not complete the prescribed course of treatment. A literature review indicated that TXA was prescribed inappropriately for procedures with a low bleeding risk, and that there are inconsistencies in the recommended dose, mode of administration and duration of TXA for this patient group. A new protocol was implemented in the haemophilia centre at St George’s University Hospital NHS Foundation Trust, London, to rationalise the prescribing of TXA in dental procedures. A study was conducted to explore patients’ experience of this new guideline in the form of a service evaluation. Structured telephone interviews were completed following 39 dental procedures to collect data on concerns about bleeding; whether TXA was taken as prescribed and reasons for non-adherence; and any unplanned post-operative treatment. The financial impact of the new guideline was also explored. Patients were supportive of the new regimen, although almost half (46%) did not complete the prescribed course of TXA. The majority (37/39) were prescribed tablets rather than mouthwash. No patients required additional unplanned haemostasis support to control haemorrhage. Cost savings were made by replacing a five- to seven-day course of TXA mouthwash with a three-day course of TXA tablets. Although the data collected from patient interviews supports the new guideline, patients appear to be making decisions about taking TXA based on their own experience rather than following the prescribed regimen. Prescribers should support patients to make informed decisions about their medicines and incorporate patient experience into individualised regimens. Given the lack of bleeding complications experienced in this cohort of patients, it is possible that TXA is being overprescribed. Further work exploring how patients with IBDs make decisions about taking medicines is needed.


2016 ◽  
Vol 35 (4) ◽  
pp. 247-248
Author(s):  
Albert Ariza-Solé ◽  
Francesc Formiga ◽  
Eva Bernal ◽  
Alberto Garay

2018 ◽  
Vol 24 (1) ◽  
pp. 37-45
Author(s):  
Jessica Yakeley ◽  
William Burbridge-James

SUMMARYRates of suicide and self-harm are rising in many countries, and it is therapeutically important to explore the personal stories and relationships that underlie this behaviour. In this article psychoanalytic and psychodynamic principles and concepts in relation to violence towards the self are introduced and the various unconscious meanings of suicide and self-harm are explored within a relational context and attachment framework. We describe how a psychodynamic approach may enhance the risk assessment and treatment of patients presenting with self-harm and suicidality, particularly examining the role of transference and countertransference within the therapeutic relationship.LEARNING OBJECTIVES•Understand historical and contemporary psychoanalytic theories and concepts regarding the aetiology of suicide and self-harm•Understand the different meanings and expressions of acts of suicide and self-harm•Understand the use of countertransference in the risk assessment and management of self-harm and suicide attemptsDECLARATION OF INTERESTNone.


Assessment ◽  
2018 ◽  
Vol 27 (8) ◽  
pp. 1886-1900 ◽  
Author(s):  
Richard B. A. Coupland ◽  
Mark E. Olver

The present study featured an investigation of the predictive properties of risk and change scores of two violence risk assessment and treatment planning tools—the Violence Risk Scale (VRS) and the Historical, Clinical, Risk–20, Version 2 (HCR-20)—in sample of 178 treated adult male violent offenders who attended a high-intensity violence reduction program. The cases were rated on the VRS and HCR-20 using archival information sources and followed up nearly 10 years postrelease. Associations of HCR-20 and VRS risk and change scores with postprogram institutional and community recidivism were examined. VRS and HCR-20 scores converged in conceptually meaningful ways, supporting the construct validity of the tools for violence risk. Receiver operating characteristic curve analyses demonstrated moderate- to high-predictive accuracy of VRS and HCR-20 scores for violent and general community recidivism, but weaker accuracy for postprogram institutional recidivism. Cox regression survival analyses demonstrated that positive pretreatment and posttreatment changes, as assessed via the HCR-20 and VRS, were each significantly associated with reductions in violent and general community recidivism, as well as serious institutional misconducts, after controlling for baseline pretreatment score. Implications for use of the HCR-20 and VRS for dynamic violence risk assessment and management are discussed.


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