scholarly journals Hemoglobin A1c and preoperative glycemia as a decision tool to help minimise sternal wound complications: a retrospective study in OPCAB patients

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Jef Van den Eynde ◽  
Abel Van Vlasselaer ◽  
Annoushka Laenen ◽  
Delphine Szecel ◽  
Bart Meuris ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Hemoglobin A1c ◽  
Clinical Decision Making ◽  
Artery Bypass ◽  
Clinical Decision ◽  
Wound Complications ◽  
Minimal Risk ◽  
Off Pump ◽  
Increased Risk ◽  
Diabetes Patients

Abstract Background Poor glycemic control has been associated with an increased risk of wound complications after various types of operations. However, it remains unclear how hemoglobin A1c (HbA1c) and preoperative glycemia can be used in clinical decision-making to prevent sternal wound complications (SWC) following off-pump coronary artery bypass grafting (OPCAB). Methods We conducted a retrospective study of 1774 consecutive patients who underwent OPCAB surgery between January 2010 and November 2016. A new four-grade classification for SWC was used. The associations of HbA1c and preoperative glycemia with incidence and grade of SWC were analysed using logistic regression analysis and proportional odds models, respectively. Results During a median follow-up of 326 days (interquartile range (IQR) 21–1261 days), SWC occurred in 133/1316 (10%) of non-diabetes and 82/458 (18%) of diabetes patients (p < 0.001). Higher HbA1c was significantly associated with a higher incidence of SWC (odds ratio, OR 1.24 per 1% increase, 95% confidence interval, CI 1.04;1.48, p = 0.016) as well as a higher grade of SWC (OR 1.25, 95% CI 1.06;1.48, p = 0.010). There was no association between glycemia and incidence (p = 0.539) nor grade (p = 0.607) of SWC. Significant modifiers of these effects were found: HbA1c was associated with SWC in diabetes patients younger than 70 years (OR 1.41, 95% CI 1.17;1.71, p < 0.001), whereas it was not in those older than 70 years. Glycemia was associated with SWC in patients who underwent non-urgent surgery (OR 2.48, 95% CI 1.26;4.88, p = 0.009), in diabetes patients who received skeletonised grafts (OR 4.83, 95% CI 1.28;18.17, p = 0.020), and in diabetes patients with a BMI < 30 (OR 2.19, 95% CI 1.01;4.76, p = 0.047), whereas it was not in the counterparts of these groups. Conclusions Under certain conditions, HbA1c and glycemia are associated SWC following OPCAB. These findings are helpful in planning the procedure with minimal risk of SWC.

scholarly journals Choice of faecal immunochemical test matters: comparison of OC-Sensor and HM-JACKarc, in the assessment of patients at high risk of colorectal cancer

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Caroline J. Chapman ◽  
Ayan Banerjea ◽  
David J Humes ◽  
Jaren Allen ◽  
Simon Oliver ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Clinical Decision Making ◽  
Full Range ◽  
Clinical Decision ◽  
Detection Rates ◽  
Faecal Immunochemical Test ◽  
Specimen Collection ◽  
Increased Risk ◽  
Immunochemical Test

AbstractObjectivesCurrently, NICE recommends the use of faecal immunochemical test (FIT) at faecal haemoglobin concentrations (f-Hb) of 10 μg Hb/g faeces to stratify for colorectal cancer (CRC) risk in symptomatic populations. This f-Hb cut-off is advised across all analysers, despite the fact that a direct comparison of analyser performance, in a clinical setting, has not been performed.MethodsTwo specimen collection devices (OC-Sensor, OC-S; HM-JACKarc, HM-J) were sent to 914 consecutive individuals referred for follow up due to their increased risk of CRC. Agreement of f-Hb around cut-offs of 4, 10 and 150 µg Hb/g faeces and CRC detection rates were assessed. Two OC-S devices were sent to a further 114 individuals, for within test comparisons.ResultsA total of 732 (80.1%) individuals correctly completed and returned two different FIT devices, with 38 (5.2%) CRCs detected. Median f-Hb for individuals diagnosed with and without CRC were 258.5 and 1.8 µg Hb/g faeces for OC-S and 318.1 and 1.0 µg Hb/g faeces for HM-J respectively. Correlation of f-Hb results between OC-S/HM-J over the full range was rho=0.74, p<0.001. Using a f-Hb of 4 µg Hb/g faeces for both tests found an agreement of 88.1%, at 10 µg Hb/g faeces 91.7% and at 150 µg Hb/g faeces 96.3%. A total of 114 individuals completed and returned two OC-S devices; correlation across the full range was rho=0.98, p<0.001.ConclusionsWe found large variations in f-Hb when different FIT devices were used, but a smaller variation when the same FIT device was used. Our data suggest that analyser-specific f-Hb cut-offs are applied with regard to clinical decision making, especially at lower f-Hb.

Assessment of Aortic Stenosis Severity Using Pressure Drop Coefficient: A Retrospective Study in Humans

2013 ◽  
Author(s):  
Anup K. Paul ◽  
Mohamed Effat ◽  
Jason J. Paquin ◽  
Rupak K. Banerjee
Keyword(s):  
Retrospective Study ◽  
Pressure Drop ◽  
Aortic Stenosis ◽  
Clinical Decision Making ◽  
Dynamic Pressure ◽  
Clinical Decision ◽  
Diagnostic Parameters ◽  
Stenosis Severity ◽  
Preliminary Study ◽  
A Prospective Study

Accurate assessment of the stenosis severity is critical in patients with aortic stenosis (AS). The ambiguities and reduced sensitivities of the current diagnostic parameters can result in sub-optimal clinical decision making. In this preliminary study, we investigate the functional diagnostic parameter CDP (ratio of the transvalvular pressure drop to the proximal dynamic pressure) for the assessment of AS severity by correlating with the current diagnostic parameters. CDP was calculated using diagnostic parameters obtained from retrospective chart reviews. CDP values were calculated independently from Doppler and catheterization measurements. CDP exhibited better correlation with transvalvular pressure drop and jet velocity simultaneously, than when correlated independently with the same diagnostic parameters. CDP increases with increasing AS severity, which is consistent with hydrodynamic principles. This retrospective study is a prelude to a prospective study to evaluate CDP for AS severity assessment.

An emerging epidemic: cancer and heart failure

2016 ◽  
Vol 131 (2) ◽  
pp. 113-121 ◽  
Author(s):  
Paaladinesh Thavendiranathan ◽  
Mark T. Nolan
Keyword(s):  
Heart Failure ◽  
Cancer Therapy ◽  
Clinical Decision Making ◽  
Prediction Models ◽  
Clinical Decision ◽  
Prevention Strategies ◽  
Patients With Cancer ◽  
Increased Risk ◽  
Adult Cancer Survivors ◽  
Shared Risk

Heart disease and cancer are the two leading causes of mortality globally. Cardiovascular complications of cancer therapy significantly contribute to the global burden of cardiovascular disease. Heart failure (HF) in particular is a relatively common and life-threatening complication. The increased risk is driven by the shared risk factors for cancer and HF, the direct impact of cancer therapy on the heart, an existing care gap in the cardiac care of patients with cancer and the increasing population of adult cancer survivors. The clear relationship between cancer treatment initiation and the potential for myocardial injury makes this population attractive for prevention strategies, targeted cardiovascular monitoring and treatment. However, there is currently no consensus on the optimal strategy for managing this at-risk population. Uniform treatment using cardioprotective medications may reduce the incidence of HF, but would impose frequently unnecessary and burdensome side effects. Ideally we could use validated risk-prediction models to target HF-preventive strategies, but currently no such models exist. In the present review, we focus on evidence and rationales for contemporary clinical decision-making in this novel field and discuss issues, including the burden of HF in patients with cancer, the reasons for the elevated risk and potential prevention strategies.

scholarly journals NLP Methods for Extraction of Symptoms from Unstructured Data for Use in Prognostic COVID-19 Analytic Models

2021 ◽  
Vol 72 ◽  
pp. 429-474
Author(s):  
Greg M. Silverman ◽  
Himanshu S. Sahoo ◽  
Nicholas E. Ingraham ◽  
Monica Lupei ◽  
Michael A. Puskarich ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Clinical Decision Making ◽  
Quality Care ◽  
Vital Signs ◽  
Clinical Decision ◽  
Prognostic Models ◽  
P Value ◽  
Rule Based ◽  
Presenting Symptoms ◽  
Increased Risk

Statistical modeling of outcomes based on a patient's presenting symptoms (symptomatology) can help deliver high quality care and allocate essential resources, which is especially important during the COVID-19 pandemic. Patient symptoms are typically found in unstructured notes, and thus not readily available for clinical decision making. In an attempt to fill this gap, this study compared two methods for symptom extraction from Emergency Department (ED) admission notes. Both methods utilized a lexicon derived by expanding The Center for Disease Control and Prevention's (CDC) Symptoms of Coronavirus list. The first method utilized a word2vec model to expand the lexicon using a dictionary mapping to the Uni ed Medical Language System (UMLS). The second method utilized the expanded lexicon as a rule-based gazetteer and the UMLS. These methods were evaluated against a manually annotated reference (f1-score of 0.87 for UMLS-based ensemble; and 0.85 for rule-based gazetteer with UMLS). Through analyses of associations of extracted symptoms used as features against various outcomes, salient risks among the population of COVID-19 patients, including increased risk of in-hospital mortality (OR 1.85, p-value < 0.001), were identified for patients presenting with dyspnea. Disparities between English and non-English speaking patients were also identified, the most salient being a concerning finding of opposing risk signals between fatigue and in-hospital mortality (non-English: OR 1.95, p-value = 0.02; English: OR 0.63, p-value = 0.01). While use of symptomatology for modeling of outcomes is not unique, unlike previous studies this study showed that models built using symptoms with the outcome of in-hospital mortality were not significantly different from models using data collected during an in-patient encounter (AUC of 0.9 with 95% CI of [0.88, 0.91] using only vital signs; AUC of 0.87 with 95% CI of [0.85, 0.88] using only symptoms). These findings indicate that prognostic models based on symptomatology could aid in extending COVID-19 patient care through telemedicine, replacing the need for in-person options. The methods presented in this study have potential for use in development of symptomatology-based models for other diseases, including for the study of Post-Acute Sequelae of COVID-19 (PASC).

scholarly journals Association of low fasting C-peptide levels with cardiovascular risk, visit-to-visit glucose variation and severe hypoglycemia in the Veterans Affairs Diabetes Trial (VADT)

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Juraj Koska ◽  
Daniel S. Nuyujukian ◽  
Gideon D. Bahn ◽  
Jin J. Zhou ◽  
Peter D. Reaven
Keyword(s):  
Type 2 Diabetes ◽  
Clinical Decision Making ◽  
Severe Hypoglycemia ◽  
Clinical Decision ◽  
Veterans Affairs ◽  
Cvd Risk ◽  
C Peptide ◽  
Increased Risk ◽  
Control Patterns

Abstract Aims Low C-peptide levels, indicating beta-cell dysfunction, are associated with increased within-day glucose variation and hypoglycemia. In advanced type 2 diabetes, severe hypoglycemia and increased glucose variation predict cardiovascular (CVD) risk. The present study examined the association between C-peptide levels and CVD risk and whether it can be explained by visit-to-visit glucose variation and severe hypoglycemia. Materials and methods Fasting C-peptide levels at baseline, composite CVD outcome, severe hypoglycemia, and visit-to-visit fasting glucose coefficient of variation (CV) and average real variability (ARV) were assessed in 1565 Veterans Affairs Diabetes Trial participants. Results There was a U-shaped relationship between C-peptide and CVD risk with increased risk with declining levels in the low range (< 0.50 nmol/l, HR 1.30 [95%CI 1.05–1.60], p = 0.02) and with rising levels in the high range (> 1.23 nmol/l, 1.27 [1.00–1.63], p = 0.05). C-peptide levels were inversely associated with the risk of severe hypoglycemia (OR 0.68 [0.60–0.77]) and visit-to-visit glucose variation (CV, standardized beta-estimate − 0.12 [SE 0.01]; ARV, − 0.10 [0.01]) (p < 0.0001 all). The association of low C-peptide levels with CVD risk was independent of cardiometabolic risk factors (1.48 [1.17–1.87, p = 0.001) and remained associated with CVD when tested in the same model with severe hypoglycemia and glucose CV. Conclusions Low C-peptide levels were associated with increased CVD risk in advanced type 2 diabetes. The association was independent of increases in glucose variation or severe hypoglycemia. C-peptide levels may predict future glucose control patterns and CVD risk, and identify phenotypes influencing clinical decision making in advanced type 2 diabetes.

scholarly journals Mortality risk of surgically managing orthopaedic trauma during the COVID-19 pandemic

2021 ◽  
Vol 2 (5) ◽  
pp. 330-336
Author(s):  
Balasubramanian Balakumar ◽  
Rajpal S. Nandra ◽  
Hugo Woffenden ◽  
Benjamin Atkin ◽  
Ansar Mahmood ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Mortality Risk ◽  
Clinical Decision Making ◽  
Significant Risk ◽  
Resource Planning ◽  
Clinical Decision ◽  
Primary Outcome Measure ◽  
Neck Of Femur ◽  
Increased Risk ◽  
Multiple Variables

Aims It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site. Methods The primary outcome measure was 30-day mortality. Secondary measures included complications of surgery, COVID-19 infection, and length of stay. Multiple variables were assessed for their contribution to the 30-day mortality. In total, 433 patients were included with a mean age of 65 years; 45% were male, and 90% were Caucasian. Results Overall mortality was 7.6% for all patients and 15.9% for femoral neck fractures. The mortality rate increased from 7.5% to 44.2% in patients with fracture neck of femur and a COVID-19 infection. The COVID-19 rate in the 30-day postoperative period was 11%. COVID-19 infection, age, and Charlson Comorbidity Index were independent risk factor for mortality. Conclusion There was a significant risk of contracting COVID-19 due to being admitted to hospital. Using a site which was not treating COVID-19 respiratory patients for surgery did not identify a difference with respect to mortality, nosocomial COVID-19 infection, or length of stay. The COVID-19 pandemic significantly increases perioperative mortality risk in patients with fractured neck of femora but patients with other injuries were not at increased risk. Cite this article: Bone Jt Open 2021;2(5):330–336.

scholarly journals Development and Validation of a Simplified Risk Score for the Prediction of Critical COVID-19 Illness in Newly Diagnosed Patients

2021 ◽  
Author(s):  
Stanislas Werfel ◽  
Carolin E. M. Jakob ◽  
Stefan Borgmann ◽  
Jochen Schneider ◽  
Christoph Spinner ◽  
...  
Keyword(s):  
Critical Illness ◽  
Clinical Decision Making ◽  
Validation Cohort ◽  
Predictive Accuracy ◽  
Clinical Decision ◽  
Increased Risk ◽  
Risk Of Progression ◽  
Risk Of Disease ◽  
Development And Validation

AbstractScores for identifying patients at high risk of progression of the coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), are discussed as key instruments for clinical decision-making and patient management during the current pandemic.Here we used the patient data from the multicenter Lean European Open Survey on SARS-CoV-2 - Infected Patients (LEOSS) and applied a technique of variable selection in order to develop a simplified score to identify patients at increased risk of critical illness or death.A total of 1,946 patients, who were tested positive for SARS-CoV-2 were included in the initial analysis. They were split into a derivation and a validation cohort (n=1,297 and 649, respectively). A stability selection among a total of 105 baseline predictors for the combined endpoint of progression to critical phase or COVID-19-related death allowed us to develop a simplified score consisting of five predictors: CRP, Age, clinical disease phase (uncomplicated vs. complicated), serum urea and D-dimer (abbreviated as CAPS-D score). This score showed an AUC of 0.81 (CI95%: 0.77-0.85) in the validation cohort for predicting the combined endpoint within 7 days of diagnosis and 0.81 (CI95%: 0.77-0.85) during the full follow-up. Finally, we used an additional prospective cohort of 682 patients, who were diagnosed largely after the “first wave” of the pandemic to validate predictive accuracy of the score, observing similar results (AUC for an event within 7 days: 0.83, CI95%, 0.78-0.87; for full follow-up: 0.82, CI95%, 0.78-0.86).We thus successfully establish and validate an easily applicable score to calculate the risk of disease progression of COVID-19 to critical illness or death.

scholarly journals Skeletonisation contributing to a reduction of sternal wound complications: a retrospective study in OPCAB patients

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Jef Van den Eynde ◽  
Astrid Heeren ◽  
Delphine Szecel ◽  
Bart Meuris ◽  
Steven Jacobs ◽  
...  
Keyword(s):  
Overall Survival ◽  
Coronary Artery ◽  
Coronary Artery Bypass Grafting ◽  
Artery Bypass ◽  
Wound Management ◽  
Wound Complications ◽  
Diabetic Patients ◽  
Lower Grade ◽  
Bypass Grafting ◽  
Off Pump

Abstract Background Sternal wound complications (SWC) are a rare but potentially life-threatening complication after coronary artery bypass grafting (CABG) surgery. Especially the use of bilateral IMA (BIMA) grafts as opposed to single IMA (SIMA) grafts is associated with an increased risk of SWC. Skeletonised harvesting has been proposed to reduce this risk. The purpose of this study was to retrospectively investigate the effect of skeletonisation on SWC after off-pump coronary artery bypass grafting (OPCAB) in a centre with a high volume of off-pump procedures and high frequencies of BIMA. Methods From January 2010 to November 2016, 1900 consecutive patients underwent OPCAB surgery at the University Hospitals of Leuven. The first group (n = 1487) received non-skeletonised IMA grafts, whereas the second group (n = 413) received skeletonised grafts. Optimal wound management was pursued in all patients. A new four-grade classification for SWC was developed. Incidence and grade of SWC as well as overall survival were assessed. Results Analysis of diabetic patients showed a lower incidence of SWC in the skeletonised (12/141, 8.5%) compared to the non-skeletonised group (82/414, 19.8%) [odds ratio 0.46, 95% confidence interval (0.23;0.88), p = 0.019] as well as a lower grade [0.45 (0.24;0.871), p = 0.018]. There was no significant effect on overall survival [0.67 (0.19;2.32), p = 0.529]. Subanalysis of this population revealed that the observed effects were most prominent in patients receiving BIMA grafts, with 6/56 (10.7%) SWC in the skeletonised and 62/252 (24.6%) in the non-skeletonised group [0.37 (0.15;0.90), p = 0.028 for incidence], as well as a lower grade [0.36 (0.15;0.88), p = 0.025]. These advantages were not significant in diabetic patients receiving SIMA grafts nor in the full study population. Conclusions This study, using a more sensitive classification of SWC, shows in a large group of patients that, in combination with optimized wound management, the skeletonisation technique is associated with a clear reduction in the incidence and grade of SWC in diabetic patients receiving BIMA grafts. This encourages the extension of BIMA use in OPCAB to this risk population.

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