The Role of Revascularisation in Patients Undergoing Non-cardiac Surgery

2010 ◽  
Vol 5 (1) ◽  
pp. 104
Author(s):  
Daniel S Menees ◽  
Eric R Bates ◽  
◽  
Keyword(s):  
Cardiac Surgery ◽  
Prediction Models ◽  
Cardiovascular Complications ◽  
Weight Of Evidence ◽  
Beta Blockade ◽  
Cardiac Morbidity ◽  
Increased Risk ◽  
Reduction Strategies ◽  
Artery Disease ◽  
Risk Reduction Strategies

Coronary artery disease (CAD) affects millions of US citizens. As the population ages, an increasing number of people with CAD are undergoing non-cardiac surgery and face significant peri-operative cardiac morbidity and mortality. Risk-prediction models can be used to help identify those patients at increased risk of peri-operative cardiovascular complications. Risk-reduction strategies utilising pharmacotherapy with beta blockade and statins have shown the most promise. Importantly, the benefit of prophylactic coronary revascularisation has not been demonstrated. The weight of evidence suggests reserving either percutaneous or surgical revascularisation in the pre-operative setting for those patients who would otherwise meet independent revascularisation criteria.

Risk reduction strategies: perioperative management in patients on antithrombotic therapy

ESC CardioMed ◽  
2018 ◽  
pp. 2657-2659
Author(s):  
Steen D. Kristensen ◽  
Kurt Huber ◽  
Michael Maeng
Keyword(s):  
Cardiac Surgery ◽  
Risk Reduction ◽  
Antithrombotic Therapy ◽  
Perioperative Management ◽  
Antithrombotic Drugs ◽  
Reduction Strategies ◽  
Thrombotic Complications ◽  
Risk Reduction Strategies ◽  
Cardiac Diagnosis ◽  
Type Of Surgery

The choice of disruption or continuation of antithrombotic drugs prior to non-cardiac surgery is a challenging issue for surgeons and cardiologists. The type of surgery, cardiac diagnosis, and indication for antithrombotic therapy should be evaluated and discussed. This chapter provides some guidance for clinicians on how to balance bleeding and perioperative thrombotic complications.

scholarly journals The Influence of In-Season Training Loads on Injury Risk in Professional Rugby Union

2016 ◽  
Vol 11 (3) ◽  
pp. 350-355 ◽  
Author(s):  
Matthew J. Cross ◽  
Sean Williams ◽  
Grant Trewartha ◽  
Simon P.T. Kemp ◽  
Keith A. Stokes
Keyword(s):  
Generalized Estimating Equations ◽  
Injury Risk ◽  
Reference Group ◽  
Harmful Effect ◽  
Rugby Union ◽  
Time Loss ◽  
Risk Of Injury ◽  
Increased Risk ◽  
Reduction Strategies ◽  
Risk Reduction Strategies

Purpose:To explore the association between in-season training-load (TL) measures and injury risk in professional rugby union players.Methods:This was a 1-season prospective cohort study of 173 professional rugby union players from 4 English Premiership teams. TL (duration × session-RPE) and time-loss injuries were recorded for all players for all pitch- and gym-based sessions. Generalized estimating equations were used to model the association between in-season TL measures and injury in the subsequent week.Results:Injury risk increased linearly with 1-wk loads and week-to-week changes in loads, with a 2-SD increase in these variables (1245 AU and 1069 AU, respectively) associated with odds ratios of 1.68 (95% CI 1.05–2.68) and 1.58 (95% CI 0.98–2.54). When compared with the reference group (<3684 AU), a significant nonlinear effect was evident for 4-wk cumulative loads, with a likely beneficial reduction in injury risk associated with intermediate loads of 5932–8651 AU (OR 0.55, 95% CI 0.22–1.38) (this range equates to around 4 wk of average in-season TL) and a likely harmful effect evident for higher loads of >8651 AU (OR 1.39, 95% CI 0.98–1.98).Conclusions:Players had an increased risk of injury if they had high 1-wk cumulative loads (1245 AU) or large week-to-week changes in TL (1069 AU). In addition, a U-shaped relationship was observed for 4-wk cumulative loads, with an apparent increase in risk associated with higher loads (>8651 AU). These measures should therefore be monitored to inform injury-risk-reduction strategies.

scholarly journals 375. High Laboratory-confirmed SARS-CoV-2 Attack Rate in Lima Health Care Personnel During August 2020-March 2021 Suggests Role for Improved Infection Control

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S289-S290
Author(s):  
Matthew Westercamp ◽  
Giselle Soto ◽  
Rachel Smith ◽  
Eduardo Azziz-Baumgartner ◽  
Susan Bollinger ◽  
...  
Keyword(s):  
Attack Rate ◽  
Healthcare Workers ◽  
P Value ◽  
Risk Of Infection ◽  
Vaccine Introduction ◽  
Specimen Collection ◽  
Increased Risk ◽  
Reduction Strategies ◽  
Risk Reduction Strategies

Abstract Background Peru has one of the highest per capita SARS-CoV-2 death rates in Latin America. Healthcare workers (HCW) are a critical workforce during the COVID-19 pandemic but are themselves often at increased risk of infection. We evaluated SARS-CoV-2 attack rate and risk factors among frontline HCWs. Methods We performed a prospective cohort study of HCW serving two acute care hospitals in Lima, Peru from Aug 2020 to Mar 2021. Participants had baseline SARS-CoV-2 serology using the CDC ELISA, active symptom monitoring, and weekly respiratory specimen collection with COVID-19 exposure/risk assessment for 16-weeks regardless of symptoms. Respiratory specimens were tested by real-time reverse transcriptase PCR (rRT-PCR). Results Of 783 eligible, 667 (85%) HCW were enrolled (33% nurse assistants, 29% non-clinical staff, 26% nurses, 7% physicians, and 6% other). At baseline and prior to COVID-19 vaccine introduction, 214 (32.1%; 214/667) were reactive for SARS-CoV-2 antibodies. In total, 72 (10.8%; 72/667) HCWs were found to be rRT-PCR positive during weekly follow-up. Of the rRT-PCR positive HCWs, 37.5% (27/72) did not report symptoms within 1-week of specimen collection. During follow up, HCW without detectable SARS-CoV-2 antibodies at baseline were significantly more likely to be rRT-PCR positive (65/453, 14.3%) compared to those with SARS-CoV-2 antibodies at baseline (4/214, 1.9%) (p-value: &lt; 0.001). Three HCW were both serologically reactive and rRT-PCR positive at baseline. Looking only at HCW without SARS-CoV-2 antibodies, nurse assistants (rRT-PCR positive: 18.6%; 27/141) and non-clinical healthcare workers (16.5%; 21/127) were at greater risk of infection compared to nurses (8.5%; 10/118), physicians (7.9%; 3/38), and other staff (10.3%; 4/29) (RR 1.95;95%CI 1.2,3.3; p-value: 0.01). Conclusion Baseline SARS-CoV-2 prevalence and 16-week cumulative incidence were substantial in this pre-vaccination Peruvian HCW cohort. Almost 40% of new infections occurred in HCW without complaint of symptoms illustrating a limitation of symptom-based HCW screening for COVID-19 prevention. Nurse assistants and non-clinical healthcare workers were at greater risk of infection indicating a role for focused infection prevention and risk reduction strategies for some groups of HCW. Disclosures Fernanda C. Lessa, MD, MPH, Nothing to disclose

scholarly journals Cardiovascular mortality following liver transplantation: predictors and temporal trends over 30 years

2020 ◽  
Vol 6 (4) ◽  
pp. 243-253 ◽  
Author(s):  
Anoop N Koshy ◽  
Paul J Gow ◽  
Hui-Chen Han ◽  
Andrew W Teh ◽  
Robert Jones ◽  
...  
Keyword(s):  
Liver Transplantation ◽  
Retrospective Cohort ◽  
Cox Regression ◽  
Temporal Trends ◽  
Early Mortality ◽  
Cerebrovascular Events ◽  
Reduction Strategies ◽  
Artery Disease ◽  
Risk Reduction Strategies

Abstract Aims There has been significant evolution in operative and post-transplant therapies following liver transplantation (LT). We sought to study their impact on cardiovascular (CV) mortality, particularly in the longer term. Methods and results A retrospective cohort study was conducted of all adult LTs in Australia and New Zealand across three 11-year eras from 1985 to assess prevalence, modes, and predictors of early (≤30 days) and late (&gt;30 days) CV mortality. A total of 4265 patients were followed-up for 37 409 person-years. Overall, 1328 patients died, and CV mortality accounted for 228 (17.2%) deaths. Both early and late CV mortality fell significantly across the eras (P &lt; 0.001). However, CV aetiologies were consistently the leading cause of early mortality and accounted for ∼40% of early deaths in the contemporary era. Cardiovascular deaths occurred significantly later than non-cardiac aetiologies (8.8 vs. 5.2 years, P &lt; 0.001). On multivariable Cox regression, coronary artery disease [hazard ratio (HR) 4.6, 95% confidence interval (CI) 1.2–21.6; P = 0.04] and era of transplantation (HR 0.44; 95% CI 0.28–0.70; P = 0.01) were predictors of early CV mortality, while advancing age (HR 1.05, 95% CI 1.02–1.10; P = 0.005) was an independent predictors of late CV mortality. Most common modes of CV death were cardiac arrest, cerebrovascular events, and myocardial infarction. Conclusion Despite reductions in CV mortality post-LT over 30 years, they still account for a substantial proportion of early and late deaths. The late occurrence of CV deaths highlights the importance of longitudinal follow-up to study the efficacy of targeted risk-reduction strategies in this unique patient population.

scholarly journals Levothyroxine Therapy in Elderly Patients With Hypothyroidism

2021 ◽  
Vol 12 ◽  
Author(s):  
Grigoris Effraimidis ◽  
Torquil Watt ◽  
Ulla Feldt-Rasmussen
Keyword(s):  
Elderly Patients ◽  
Correct Diagnosis ◽  
Young Patients ◽  
The Elderly ◽  
Cardiovascular Complications ◽  
Cardiac Ischemia ◽  
Overt Hypothyroidism ◽  
Cardiac Morbidity ◽  
Background Population ◽  
Increased Risk

Levothyroxine (L-T4) treatment of overt hypothyroidism can be more challenging in elderly compared to young patients. The elderly population is growing, and increasing incidence and prevalence of hypothyroidism with age are observed globally. Elderly people have more comorbidities compared to young patients, complicating correct diagnosis and management of hypothyroidism. Most importantly, cardiovascular complications compromise the usual start dosage and upward titration of L-T4 due to higher risk of decompensating cardiac ischemia and -function. It therefore takes more effort and care from the clinician, and the maintenance dose may have to be lower in order to avoid a cardiac incidence. On the other hand, L-T4 has a beneficial effect on cardiac function by increasing performance. The clinical challenge should not prevent treating with L-T4 should the patient develop e.g., cardiac ischemia. The endocrinologist is obliged to collaborate with the cardiologist on prophylactic cardiac measures by invasive cardiac surgery or medical therapy against cardiac ischemic angina. This usually allows subsequent successful treatment. Management of mild (subclinical) hypothyroidism is even more complex. Prevalent comorbidities in the elderly complicate correct diagnosis, since many concomitant morbidities can result in non-thyroidal illness, resembling mild hypothyroidism both clinically and biochemically. The diagnosis is further complicated as methods for measuring thyroid function (thyrotropin and thyroxine) vary immensely according to methodology and background population. It is thus imperative to ensure a correct diagnosis by etiology (e.g., autoimmunity) before deciding to treat. Even then, there is controversy regarding whether or not treatment of such mild forms of hypothyroidism in elderly will improve mortality, morbidity, and quality of life. This should be studied in large cohorts of patients in long-term placebo-controlled trials with clinically relevant outcomes. Other cases of hypothyroidism, e.g., medications, iodine overload or hypothalamus-pituitary-hypothyroidism, each pose specific challenges to management of hypothyroidism; these cases are also more frequent in the elderly. Finally, adherence to treatment is generally challenging. This is also the case in elderly patients, which may necessitate measuring thyroid hormones at individually tailored intervals, which is important to avoid over-treatment with increased risk of cardiac morbidity and mortality, osteoporosis, cognitive dysfunction, and muscle deficiency.

Retrospective Quality Improvement Study of Insulin-Induced Hypoglycemia and Implementation of Hospital-Wide Initiatives

2021 ◽  
pp. 193229682110085
Author(s):  
Carter Shelton ◽  
Andrew P. Demidowich ◽  
Mahsa Motevalli ◽  
Sam Sokolinsky ◽  
Periwinkle MacKay ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Community Hospital ◽  
Statistical Significance ◽  
Hospital Setting ◽  
Cost Savings ◽  
Cost Of Care ◽  
Potential Cost ◽  
Increased Risk ◽  
Reduction Strategies ◽  
Risk Reduction Strategies

Background: Hospitalized patients who are receiving antihyperglycemic agents are at increased risk for hypoglycemia. Inpatient hypoglycemia may lead to increased risk for morbidity, mortality, prolonged hospitalization, and readmission within 30 days of discharge, which in turn may lead to increased costs. Hospital-wide initiatives targeting hypoglycemia are known to be beneficial; however, their impact on patient care and economic measures in community nonteaching hospitals are unknown. Methods: This retrospective quality improvement study examined the effects of hospital-wide hypoglycemia initiatives on the rates of insulin-induced hypoglycemia in a community hospital setting from January 1, 2016, until September 30, 2019. The potential cost of care savings has been calculated. Results: Among 49 315 total patient days, 2682 days had an instance of hypoglycemia (5.4%). Mean ± SD hypoglycemic patient days/month was 59.6 ± 16.0. The frequency of hypoglycemia significantly decreased from 7.5% in January 2016 to 3.9% in September 2019 ( P = .001). Patients with type 2 diabetes demonstrated a significant decrease in the frequency of hypoglycemia (7.4%-3.8%; P < .0001), while among patients with type 1 diabetes the frequency trended downwards but did not reach statistical significance (18.5%-18.0%; P = 0.08). Based on the reduction of hypoglycemia rates, the hospital had an estimated cost of care savings of $98 635 during the study period. Conclusions: In a community hospital setting, implementation of hospital-wide initiatives targeting hypoglycemia resulted in a significant and sustainable decrease in the rate of insulin-induced hypoglycemia. These high-leverage risk reduction strategies may be translated into considerable cost savings and could be implemented at other community hospitals.

Co-movement of Prices between Biofuel Co-products in Canada: Ethanol, Electricity, and Pellets

2020 ◽  
Author(s):  
Claire Doll ◽  
Grant Hauer ◽  
Feng Qiu ◽  
Martin K. Luckert
Keyword(s):  
Second Generation ◽  
Wood Pellets ◽  
Volatility Spillovers ◽  
Future Production ◽  
Increased Risk ◽  
Reduction Strategies ◽  
Production Technologies ◽  
Energy Products ◽  
Risk Reduction Strategies ◽  
Second Generation Ethanol

The potential emergence of a second-generation ethanol industry in Canada will depend on future production technologies and prices. Financial viability might be improved by producing cellulosic ethanol with co-products such as lignin pellets or electricity. Financial returns to ethanol production will depend on price variability and possible price spillovers among ethanol and its co-products. We use a multivariate BEKK-GARCH approach to investigate past mean price interactions and volatility spillovers between ethanol and electricity prices. Wood pellets are investigated in a univariate framework because of data constraints. Results show substantial price interactions and volatility spillovers among these products. If a second-generation ethanol industry emerges, co-production of products from common feedstocks may strengthen already established relationships between the prices of these energy products. These conditions could create increased risk and the clustering of high/low price fluctuations among co-products. For investors, results suggest that risk reduction strategies should protect against correlated volatility. For policy makers, results suggest that policies that target one commodity may lead to unintended impacts on co-product(s). In sum, understanding links between markets is important for designing future policies, and for insights into how a second-generation ethanol industry may emerge.

Risk reduction strategies: perioperative management of cardiovascular medication

ESC CardioMed ◽  
2018 ◽  
pp. 2652-2657
Author(s):  
Emmanuelle Duceppe ◽  
P. J. Devereaux
Keyword(s):  
Cardiovascular Events ◽  
Angiotensin Receptor Blockers ◽  
Perioperative Period ◽  
Beta Blockade ◽  
Converting Enzyme Inhibitors ◽  
Time Of Surgery ◽  
Intraoperative Hypotension ◽  
Increased Risk ◽  
Reduction Strategies ◽  
Clinically Significant

The perioperative period is associated with various physiological stressors that can predispose patients to major cardiovascular events. Clinically significant hypotension and major bleeding are also common during and after surgery and can further increase the risk of myocardial events, stroke, and mortality. The decision to continue or withhold antithrombotic therapy around the time of surgery should take into consideration the patient’s thrombotic risk and the increased risk of bleeding associated with antiplatelet therapy; in most cases, the bleeding risk outweighs the benefits and such agents should be withheld in the perioperative period. Continuing statins around the time of surgery may be beneficial, but further evidence is required to confirm this finding. Perioperative beta blockade has been shown to prevent myocardial infarction but at the expense of increasing mortality, stroke, hypotension, and bradycardia. Alpha-2 blockers have also been evaluated in a large non-cardiac surgery trial, and their initiation in the perioperative setting has failed to show benefit in preventing cardiovascular events. Moreover, similar to beta blockers, perioperative alpha-2 agonist administration increased the risk of significant hypotension. Although the evidence is more limited for calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, their administration around the time of surgery appears to increase the risk of intraoperative hypotension without any apparent benefit. Given the increased risk of mortality and stroke among patients developing clinically important hypotension in the perioperative setting, the current evidence does not support the initiation of such agents to prevent perioperative cardiovascular events.

Mammographic Density: Intersection of Science, the Law, and Clinical Practice

2013 ◽  
pp. e63-e69
Author(s):  
Scott Hollenbeck ◽  
Patricia Keely ◽  
Victoria Seewaldt
Keyword(s):  
Breast Cancer ◽  
Breast Cancer Risk ◽  
Cancer Risk ◽  
Mammographic Density ◽  
Menopausal Status ◽  
Increased Risk ◽  
Reduction Strategies ◽  
High Mammographic Density ◽  
Risk Reduction Strategies

High mammographic density is associated with a two- to sixfold increased risk of breast cancer. Mammographic density can be altered by endogenous and exogenous hormonal factors and generally declines with age. Mammographic density is affected by confounding factors such as age, parity, menopausal status, and body mass index (BMI), thus making interpretation of mammographic density challenging. None of the established means of measuring mammographic density are entirely satisfactory because they are time consuming and/or subjective. Although mammographic density has been shown to predict breast cancer risk, the role of mammographic density in precisely assessing a woman's breast cancer risk over her lifetime and evaluating response to risk-reduction strategies cannot be fully realized until we have a better understanding of the biology that links mammographic density to breast cancer risk.

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