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risk management [keywords]
- Managing osteoporosis in ulcerative colitis: Something new? [REVIEW]
- World J Gastroenterol 2014 Oct 21; 20(39):14087-14098.
The authors revise the latest evidence in the literature regarding managing of osteoporosis in ulcerative colitis (UC), paying particular attention to the latest tendency of the research concerning the management of bone damage in the patient affected by UC. It is wise to assess vitamin D status in ulcerative colitis patients to recognize who is predisposed to low levels of vitamin D, whose deficiency has to be treated with oral or parenteral vitamin D supplementation. An adequate dietary calcium intake or supplementation and physical activity, if possible, should be guaranteed. Osteoporotic risk factors, such as smoking and excessive alcohol intake, must be avoided. Steroid has to be prescribed at the lowest possible dosage and for the shortest possible time. Moreover, conditions favoring falling have to been minimized, like carpets, low illumination, sedatives assumption, vitamin D deficiency. It is advisable to assess the fracture risk in all UC patient by the fracture assessment risk tool (FRAX(®) tool), that calculates the ten years risk of fracture for the population aged from 40 to 90 years in many countries of the world. A high risk value could indicate the necessity of treatment, whereas a low risk value suggests a follow-up only. An intermediate risk supports the decision to prescribe bone mineral density (BMD) assessment and a subsequent patient revaluation for treatment. Dual energy X-ray absorptiometry bone densitometry can be used not only for BMD measurement, but also to collect data about bone quality by the means of trabecular bone score and hip structural analysis assessment. These two indices could represent a method of interesting perspectives in evaluating bone status in patients affected by diseases like UC, which may present an impairment of bone quality as well as of bone quantity. In literature there is no strong evidence for instituting pharmacological therapy of bone impairment in UC patients for clinical indications other than those that are also applied to the patients with osteoporosis. Therefore, a reasonable advice is to consider pharmacological treatment for osteoporosis in those UC patients who already present fragility fractures, which bring a high risk of subsequent fractures. Therapy has also to be considered in patients with a high risk of fracture even if it did not yet happen, and particularly when they had long periods of corticosteroid therapy or cumulative high dosages. In patients without fragility fractures or steroid treatment, a medical decision about treatment could be guided by the FRAX tool to determine the intervention threshold. Among drugs for osteoporosis treatment, the bisphosphonates are the most studied ones, with the best and longest evidence of efficacy and safety. Despite this, several questions are still open, such as the duration of treatment, the necessity to discontinue it, the indication of therapy in young patients, particularly in those without previous fractures. Further, it has to be mentioned that a long-term bisphosphonates use in primary osteoporosis has been associated with an increased incidence of dramatic side-effects, even if uncommon, like osteonecrosis of the jaw and atypical sub-trochanteric and diaphyseal femoral fractures. UC is a long-lasting disease and the majority of patients is relatively young. In this scenario primary prevention of fragility fracture is the best cost-effective strategy. Vitamin D supplementation, adequate calcium intake, suitable physical activity (when possible), removing of risk factors for osteoporosis like smoking, and avoiding falling are the best medical acts.
- Multi-resistant bacteria in spontaneous bacterial peritonitis: A new step in management? [REVIEW]
- World J Gastroenterol 2014 Oct 21; 20(39):14079-14086.
Spontaneous bacterial peritonitis (SBP) is the most typical infection observed in cirrhosis patients. SBP is responsible for an in-hospital mortality rate of approximately 32%. Recently, pattern changes in the bacterial flora of cirrhosis patients have been observed, and an increase in the prevalence of infections caused by multi-resistant bacteria has been noted. The wide-scale use of quinolones in the prophylaxis of SBP has promoted flora modifications and resulted in the development of bacterial resistance. The efficacy of traditionally recommended therapy has been low in nosocomial infections (up to 40%), and multi-resistance has been observed in up to 22% of isolated germs in nosocomial SBP. For this reason, the use of a broad empirical spectrum antibiotic has been suggested in these situations. The distinction between community-acquired infectious episodes, healthcare-associated infections, or nosocomial infections, and the identification of risk factors for multi-resistant germs can aid in the decision-making process regarding the empirical choice of antibiotic therapy. Broad-spectrum antimicrobial agents, such as carbapenems with or without glycopeptides or piperacillin-tazobactam, should be considered for the initial treatment not only of nosocomial infections but also of healthcare-associated infections when the risk factors or severity signs for multi-resistant bacteria are apparent. The use of cephalosporins should be restricted to community-acquired infections.
- Differential Effects of Parental Controls on Adolescent Substance Use: For Whom Is the Family Most Important? [JOURNAL ARTICLE]
- J Quant Criminol 2013 Sep; 29(3):347-368.
Social control theory assumes that the ability of social constraints to deter juvenile delinquency will be invariant across individuals. This paper tests this hypothesis and examines the degree to which there are differential effects of parental controls on adolescent substance use.Analyses are based on self-reported data from 7,349 10th-grade students and rely on regression mixture models to identify latent classes of individuals who may vary in the effects of parental controls on drug use.All parental controls were significantly related to adolescent drug use, with higher levels of control associated with less drug use. The effects of instrumental parental controls (e.g., parental management strategies) on drug use were shown to vary across individuals, while expressive controls (e.g., parent/child attachment) had uniform effects in reducing drug use. Specifically, poor family management and more favorable parental attitudes regarding children's drug use and delinquency had stronger effects on drug use for students who reported greater attachment to their neighborhoods, less acceptance of adolescent drug use by neighborhood residents, and fewer delinquent peers, compared to those with greater community and peer risk exposure. Parental influences were also stronger for Caucasian students versus those from other racial/ethnic groups, but no differences in effects were found based on students' gender or commitment to school.The findings demonstrate support for social control theory, and also help to refine and add precision to this perspective by identifying groups of individuals for whom parental controls are most influential. Further, they offer an innovative methodology that can be applied to any criminological theory to examine the complex forces that result in illegal behavior.
- Clinical and psychological telemonitoring and telecare of high risk heart failure patients. [JOURNAL ARTICLE]
- J Telemed Telecare 2014 Oct 22.
We conducted a trial of telemonitoring and telecare for patients with chronic heart failure leaving hospital after being treated for clinical instability. Eighty patients were randomized before hospital discharge to a usual care group (n = 40: follow-up at the outpatient clinic) or to an integrated management group (n = 40: patients learned to use a handheld PDA and kept in touch daily with the monitoring centre). At enrolment, the groups were similar for all clinical variables. At one-year follow-up, integrated management patients showed better adherence, reduced anxiety and depression, and lower NYHA class and plasma levels of BNP with respect to the usual care patients (e.g. NYHA class 2.1 vs 2.4, P < 0.02). Mortality and hospital re-admissions for congestive heart failure were also reduced in integrated management patients (P < 0.05). Integrated management was more expensive than usual care, although the cost of adverse events was 42% lower. In heart failure patients at high risk of relapse, the regular acquisition of simple clinical information and the possibility for the patient to contact the clinical staff improved drug titration, produced better psychological status and quality of life, and reduced hospitalizations for heart failure.
- Cardiovascular disease and its relationship with chronic kidney disease. [Journal Article]
- Eur Rev Med Pharmacol Sci 2014 Oct; 18(19):2918-26.
Cardiovascular disease (CVD), the leading cause of death, is mostly precipitated by cardiometabolic risk and chronic kidney disease (CKD). CVD and kidney disease are closely interrelated and disease of one organ cause dysfunction of the other, ultimately leading to the failure of both organs. Patients with end-stage renal disease (ESRD) are at much higher risk of mortality due to CVD. Traditional CVD risk factors viz., hypertension, hyperlipidemia, and diabetes do not account for the high cardiovascular risk in CKD patients and also standard clinical interventions for managing CVD that are successful in the general population, are ineffective to lower the death rate in CKD patients. Nontraditional factors, related to disturbed mineral and vitamin D metabolism were able to provide some explanation in terms of vascular calcification, for the increased risk of CVD in CKD. Fibroblast Growth Factor 23, a bone-derived hormone that regulates vitamin D synthesis in renal proximal tubules and renal phosphate reabsorption, has been suggested to be the missing link between CKD and CVD. Acute Kidney Injury (AKI) is strongly related to the progress of CVD and its early diagnosis and treatment has significant positive effect on the outcomes of CVD in the affected patients. Besides this, non-dialysable protein-bound uraemic toxins such as indoxyl sulfate and p-cresyl sulfate, produced by colonic microbes from dietary amino acids, appear to cause renal dysfunction. Thus, therapeutic approaches targeting colonic microbiota, have led to new prospects in early intervention for CKD patients. Intervention targets for preventing CVD events in CKD patients ideally should include control of blood pressure and dyslipidemia, diabetes mellitus, lowering proteinuria, correction of anemia, management of mineral metabolism abnormalities and life style changes including smoking cessation, decreased consumption of salt, and achievement of normal body mass index. Use of β-blockers, renin-angiotensin blockers, diuretics, statins, and aspirin are helpful in the early stages of CKD. In this review, we will address the biological, pathological and clinical relationship between CVD and CKD and their therapeutic management.
- A STUDY OF GENOTYPING FOR THE MANAGEMENT OF HUMAN PAPILLOMAVIRUS-POSITIVE, CYTOLOGY-NEGATIVE CERVICAL SCREENING RESULTS. [JOURNAL ARTICLE]
- J Clin Microbiol 2014 Oct 22.
Objectives: Effective management of women with HPV-positive, cytology-negative results is critical to the introduction of HPV testing into cervical screening. HPV typing has been recommended for colposcopy triage, but it is not clear which combinations of high-risk HPV types provide clinically useful information. Methods: The study included 18,810 HC2-positive, cytology-negative women aged 30 and older from Kaiser Permanente Northern California. Median follow-up was 475 days (IQR 0-1077, maximum 2217). Baseline specimens from 482 cases of cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) and 3,517 random HC2-positive non-cases were genotyped using 2 PCR-based methods. Using the case-control sampling fractions, 3-year cumulative risks of CIN3+ for each individual high-risk HPV type were calculated. Results: The 3-year cumulative risk of CIN3+ among all HC2-positive, cytology-negative women was 4.7%. Knowing HPV16 status conferred the greatest type-specific risk stratification; HC2-positive/HPV16-positive women had a 10.6% risk of CIN3+ while HC-2 positive/HPV16-negative women had a much lower risk of 2.4%. The next most informative HPV types and their risks in HPV-positive women were: HPV33 (5.9%) and HPV18 (5.9%). With regard to etiologic fraction, 20 of 71 cases of cervical AIS and adenocarcinoma in the cohort were positive for HPV18. Conclusion: HPV16 genotyping provides risk stratification useful to guide management; the risk among HPV16-positive women clearly exceeds the US consensus "risk threshold" for immediate colposcopy referral. HPV18 is of particular interest because of its association with difficult-to-detect glandular lesions. There is less clear clinical value to distinguishing the other high-risk HPV types.
- An analysis of expectant management in women with early-onset preeclampsia in China. [JOURNAL ARTICLE]
- J Hum Hypertens 2014 Oct 23.
Preeclampsia is a pregnancy-specific disorder and a leading cause of morbidity and mortality in both women and fetus. Although women with early severe preeclampsia are generally considered to require expedious delivery, expectant management may benefit for pregnancy prolongation. We performed a retrospective analysis of expectant management in early-onset preeclampsia, with or without fetal grow restriction (FGR) over a 6-year period, to investigate whether these women benefit from expectant management. Data including clinical parameters and liver and renal function from 186 nulliparous women with early-onset preeclampsia were analysed. In women with early-onset preeclampsia, 76.8% were delivered after 48 h and the median pregnancy prolongation was 8 days, whereas 23.2% were delivered within 48 h. There was no difference in maternal parameters, liver or renal functions between women in these two groups, regardless of the severity of preeclampsia. However, the stillbirth number was higher in preeclamptic women delivered after 48 h compared with those delivered within 48 h. Our study demonstrates that the decision for immediate delivery or expectant management was not associated with clinical parameter or laboratory biomarker of liver and renal function. However, the risk of stillbirth should still be taken into consideration when making the decision for immediate delivery or expectant management in the clinic.Journal of Human Hypertension advance online publication, 23 October 2014; doi:10.1038/jhh.2014.92.
- Medical management of abdominal aortic aneurysms. [Journal Article]
- Vasa 2014 Nov; 43(6):415-21.
Abdominal aortic aneurysms (AAA) are the most common arterial aneurysms. Endovascular or open surgical aneurysm repair is indicated in patients with large AAA ≥ 5.5 cm in diameter as this prevents aneurysm rupture. The presence even of small AAAs not in need of immediate repair is associated with a very high cardiovascular risk including myocardial infarction, stroke or cardiovascular death. This risk by far exceeds the risk of aneurysm rupture. These patients therefore should be considered as high-risk patients and receive optimal medical treatment and life-style modificiation of their cardiovascular risk factors to improve their prognosis. In addition, these patients should be followed-up for aneurysm growth and receive medical treatment to decrease aneurym progression and rupture rate. Treatment with statins has been shown to reduce cardiovascular mortality in these patients, and also slows the rate of AAA growth. Use of beta-blockers, ACE inhibitors and AT1-receptor antagonists does not affect AAA growth but may be indicated for comorbidities. Antibiotic therapy with roxithromycin has a small effect on AAA growth, but this effect must be critically weighed against the potential risk of wide-spread use of antibiotics.
- Mental illness and intensification of diabetes medications: an observational cohort study. [JOURNAL ARTICLE]
- BMC Health Serv Res 2014 Oct 22; 14(1):458.
Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c >=8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status.Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
- Prediction of biochemical recurrence after robot-assisted radical prostatectomy: Analysis of 784 Japanese patients. [JOURNAL ARTICLE]
- Int J Urol 2014 Oct 22.
To examine biochemical recurrence after robot-assisted radical prostatectomy in Japanese patients, and to develop a risk stratification model for biochemical recurrence.The study cohort consisted of 784 patients with localized prostate cancer who underwent robot-assisted radical prostatectomy without neoadjuvant or adjuvant endocrine therapy. The relationships of biochemical recurrence with perioperative findings were evaluated. The prognostic factors for biochemical recurrence-free survival were evaluated using Cox proportional hazard model analyses.During the follow-up period, 80 patients showed biochemical recurrence. The biochemical recurrence-free survival rates at 1, 3, and 5 years were 92.2%, 85.2% and 80.1%, respectively. In univariate analysis, the prostate-specific antigen level, prostate-specific antigen density, biopsy Gleason score, percent positive core, pathological T stage, pathological Gleason score, lymphovascular invasion, perineural invasion and positive surgical margin were significantly associated with biochemical recurrence. In multivariate analysis, prostate-specific antigen density ≥0.4 (P = 0.0011), pathological T stage ≥3a (P = 0.002), pathological Gleason score ≥8 (P = 0.007) and positive surgical margin (P < 0.0001) were independent predictors of biochemical recurrence. The patients were stratified into three risk groups according to these factors. The 5-year biochemical recurrence-free survival rate was 89.4% in the low-risk group, 65.6% in the intermediate-risk group and 30.3% in the high-risk group.The prostate-specific antigen density, pathological T stage, pathological Gleason score and positive surgical margin were independent prognostic factors for biochemical recurrence. The risk stratification model developed using these four factors could help clinicians identify patients with a poor prognosis who might be good candidates for clinical trials of alternative management strategies.