Download the Free Unbound MEDLINE PubMed App to your smartphone or tablet.
Available for iPhone, iPad, iPod touch, and Android.
risk management [keywords]
- Effect of implementation of Integrated Management of Neonatal and Childhood Illness programme on treatment seeking practices for morbidities in infants: cluster randomised trial. [JOURNAL ARTICLE]
- BMJ 2014.:g4988.
To determine the effect of implementation of the Integrated Management of Neonatal and Childhood Illness strategy on treatment seeking practices and on neonatal and infant morbidity.Cluster randomised trial.Haryana, India.29 667 births in nine intervention clusters and 30 813 births in nine control clusters.The pre-specified outcome was the effect on treatment seeking practices. Post hoc exploratory analyses assessed morbidity, hospital admission, post-neonatal infant care, and nutritional status outcomes.The Integrated Management of Neonatal and Childhood Illness intervention included home visits by community health workers, improved case management of sick children, and strengthening of health systems. Outcomes were ascertained through interviews with randomly selected caregivers: 6204, 3073, and 2045 in intervention clusters and 6163, 3048, and 2017 in control clusters at ages 29 days, 6 months, and 12 months, respectively.In the intervention cluster, treatment was sought more often from an appropriate provider for severe neonatal illness (risk ratio 1.76, 95% confidence interval 1.38 to 2.24), for local neonatal infection (4.86, 3.80 to 6.21), and for diarrhoea at 6 months (1.96, 1.38 to 2.79) and 12 months (1.22, 1.06 to 1.42) and pneumonia at 6 months (2.09, 1.31 to 3.33) and 12 months (1.44, 1.00 to 2.08). Intervention mothers reported fewer episodes of severe neonatal illness (risk ratio 0.82, 0.67 to 0.99) and lower prevalence of diarrhoea (0.71, 0.60 to 0.83) and pneumonia (0.73, 0.52 to 1.04) in the two weeks preceding the 6 month interview and of diarrhoea (0.63, 0.49 to 0.80) and pneumonia (0.60, 0.46 to 0.78) in the two weeks preceding the 12 month interview. Infants in the intervention clusters were more likely to still be exclusively breast fed in the sixth month of life (risk ratio 3.19, 2.67 to 3.81).Implementation of the Integrated Management of Neonatal and Childhood Illness programme was associated with timely treatment seeking from appropriate providers and reduced morbidity, a likely explanation for the reduction in mortality observed following implementation of the programme in this study.Trial registration Clinical trials NCT00474981; ICMR Clinical Trial Registry CTRI/2009/091/000715.
- Role of novel anticoagulants for patients with mechanical heart valves. [Journal Article]
- Curr Atheroscler Rep 2014 Nov; 16(11):448.
The introduction of the target-specific oral anticoagulants (TSOACs) has led to a major shift in the management of patients at risk for thrombosis. The landscape continues to evolve as the evidence regarding their efficacy and safety in various clinical situations emerges. Antithrombotic therapy for thromboprophylaxis in patients with mechanical heart valves is challenging. To date, the RE-ALIGN trial comparing dabigatran etexilate to warfarin is the only randomized controlled study in this patient population. The higher risk of thromboembolic and bleeding events in the group of patients who received dabigatran compared with warfarin reinforced current guidelines recommending against the use of TSOACs in patients with mechanical heart valves. However, additional studies are needed to find suitable alternatives to vitamin K antagonists in this unique patient population.
- Physiologic and Management Implications of Obesity in Critical Illness. [JOURNAL ARTICLE]
- Ann Am Thorac Soc 2014 Aug 29.
Obesity is highly prevalent in the United States and is becoming increasingly common worldwide. The anatomic and physiologic changes that occur in obese individuals may have an impact across the spectrum of critical illness. Obese patients may be more susceptible to hypoxemia and hypercapnea. During mechanical ventilation, elevated end-expiratory pressures may be required to improve lung compliance and prevent ventilation-perfusion mismatch due to distal airway collapse. Several studies have shown an increased risk of organ dysfunction such as the acute respiratory distress syndrome and acute kidney injury in obese patients. Predisposition to ventricular hypertrophy and increases in blood volume should be considered in fluid management decisions. Obese patients have accelerated muscle losses in critical illness making nutrition essential, though the optimal predictive equation to estimate nutritional needs or formulation for obese patients is not well established. Many common intensive care unit medications are not well-studied in obese patients, necessitating understanding of pharmacokinetic concepts and consultation with pharmacists. Obesity is associated with higher risk of deep venous thrombosis and catheter-associated blood stream infections, likely related to greater average catheter dwell times. Logistical issues such as blood pressure cuff sizing, ultrasound assistance for procedures, diminished quality of some imaging modalities, and capabilities of hospital equipment such as beds and lifts are important considerations. Despite the physiologic alterations and logistical challenges involved, it is not clear whether obesity has an effect on mortality or long-term outcomes from critical illness. Effects may vary by type of critical illness, obesity severity, and obesity-associated comorbidities.
- Partner testing, linkage to care, and HIV-free survival in a program to prevent parent-to-child transmission of HIV in the Highlands of Papua New Guinea. [JOURNAL ARTICLE]
- Glob Health Action 2014.:24995.
Background: To eliminate new pediatric HIV infections, interventions that facilitate adherence, including those that minimize stigma, enhance social support, and mitigate the influence of poverty, will likely be required in addition to combination antiretroviral therapy (ART). We examined the relationship between partner testing and infant outcome in a prevention of parent-to-child transmission of HIV program, which included a family-centered case management approach and a supportive environment for partner disclosure and testing. Design: We analyzed routinely collected data for women and infants who enrolled in the parent-to-child transmission of HIV program at Goroka Family Clinic, Eastern Highlands Provincial Hospital, Papua New Guinea, from 2007 through 2011. Results: Two hundred and sixty five women were included for analysis. Of these, 226 (85%) had a partner, 127 (56%) of whom had a documented HIV test. Of the 102 HIV-infected partners, 81 (79%) had been linked to care. In adjusted analyses, we found a significantly higher risk of infant death, infant HIV infection, or loss to follow-up among mother-infant pairs in which the mother reported having no partner or a partner who was not tested or had an unknown testing status. In a second multivariable analysis, infants born to women with more time on ART or who enrolled in the program in later years experienced greater HIV-free survival. Conclusions: In a program with a patient-oriented and family-centered approach to prevent vertical HIV transmission, the majority of women's partners had a documented HIV test and, if positive, linkage to care. Having a tested partner was associated with program retention and HIV-free survival for infants. Programs aiming to facilitate diagnosis disclosure, partner testing, and linkage to care may contribute importantly to the elimination of pediatric HIV.
- Clinical characteristics and risk factors for low dose methotrexate toxicity: A cohort of 28 patients. [REVIEW]
- Autoimmun Rev 2014 Aug 27.
Low dose (10-25mg/week) methotrexate is widely used for the management of systemic inflammatory diseases, and is considered to be relatively safe. Toxicity due to low dose MTX has been reported but is poorly characterized. We describe the clinical features, risk factors, and outcomes of low dose MTX toxicity in a large case series at our center.We conducted a retrospective case series of all adult (>18years) patients hospitalized at Sheba Medical Center, between 2005 and 2012 for low dose MTX toxicity.We identified 28 patients (age: 70.4±13.7years, range: 33-88; 20 (71%) females) hospitalized for low dose MTX toxicity. Indications for MTX therapy included: rheumatoid arthritis (39.2%), psoriasis±arthritis (21.5%), polymyalgia rheumatica (10.8%) and other inflammatory conditions (28.5%). Pancytopenia was the most common manifestation of low dose MTX toxicity detected in 78.5% of the patients. Potential risk factors included acute renal failure, hypoalbuminemia, concurrent use of drugs known to interact with MTX, and dose errors. Serum MTX concentrations (n=20, mean 0.04±0.07μg/mL range: 0-0.3) did not correlate with the degree of either neutropenia (r=-0.36; p=0.18) or thrombocytopenia (r=0.44; p=0.10). Seven (25%) patients died, all from pancytopenia followed by sepsis. Serum MTX concentrations did not differ between the patients who died from MTX toxicity (n=6; mean: 0.05±0.04μg/mL) and those who survived the toxicity (n=14 mean 0.04±0.08; p=0.45).Low-dose MTX toxicity can be life threatening, mainly due to myelosuppression. There is no rationale for MTX therapeutic drug monitoring in the setting of low-dose toxicity.
- Percutaneous biliary interventions through the gallbladder and the cystic duct: What radiologists need to know. [REVIEW]
- Clin Radiol 2014 Aug 26.
Percutaneous cholecystostomy is an established drainage procedure for the management of high-risk patients with acute cholecystitis. However, percutaneous image-guided access to the gallbladder may not be limited to the simple placement of a drain, but may also be used as an alternative approach to the biliary tree through the catheterization of the cystic duct, for a variety of other more complicated conditions. Percutaneous transcholecystic interventions may be performed in both malignant and benign disease. In the case of malignant jaundice, the transcholecystic route may be used when the liver parenchyma is occupied by metastatic lesions and transhepatic access is not possible. In benign conditions, access through the gallbladder may offer a solution if the biliary tree is not dilated. The transcholecystic access may then be route of insertion of large sheaths, internal drainage catheters, lithotripsy devices, stone retrieval baskets, and stents. The purpose of this review is to illustrate the techniques and to discuss the indications, complications, and technical difficulties of this alternative access to the biliary tree.
- The Effects of Medical Management on the Progression of Diabetic Retinopathy in Persons with Type 2 Diabetes: The Action to Control Cardiovascular Risk in Diabetes Eye Study. [JOURNAL ARTICLE]
- Ophthalmology 2014 Aug 26.
To report additional ocular outcomes of intensive treatment of hyperglycemia, blood pressure, and dyslipidemia in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study.Double 2×2 factorial, multicenter, randomized clinical trials in people with type 2 diabetes who had cardiovascular disease or cardiovascular risk factors. In the glycemia trial, targets of intensive and standard treatment were: hemoglobin A1c <6.0% and 7.0% to 7.9%, respectively, and in the blood pressure trial: systolic blood pressures of <120 and <140 mmHg, respectively. The dyslipidemia trial compared fenofibrate plus simvastatin with placebo plus simvastatin.Of the 3472 ACCORD Eye Study participants enrolled, 2856 had 4-year data (85% of survivors).Eye examinations and fundus photographs were taken at baseline and year 4. Photographs were graded centrally for retinopathy severity and macular edema using the Early Treatment Diabetic Retinopathy Study (ETDRS) methods.Three or more steps of progression on the ETDRS person scale or treatment of retinopathy with photocoagulation or vitrectomy.As previously reported, there were significant reductions in the primary outcome in the glycemia and dyslipidemia trials, but no significant effect in the blood pressure trial. Results were similar for retinopathy progression by 1, 2, and 4 or more steps on the person scale and for ≥2 steps on the eye scale. In the subgroup of patients with mild retinopathy at baseline, effect estimates were large (odds ratios, ∼0.30; P < 0.001), but did not reach nominal significance for participants with no retinopathy or for those with moderate to severe retinopathy at baseline.Slowing of progression of retinopathy by intensive treatment of glycemia was observed in ACCORD participants, whose average age and diabetes duration were 62 and 10 years, respectively, and who had cardiovascular disease or cardiovascular risk factors. The effect seemed stronger in patients with mild retinopathy. Similar slowing of progression was observed in patients treated with fenofibrate, with no effect observed with intensive blood pressure treatment. This is the second study to confirm the benefits of fenofibrate in reducing diabetic retinopathy progression, and fenofibrate should be considered for treatment of diabetic retinopathy.
- Umbilical cord accidents and legal implications. [REVIEW]
- Semin Fetal Neonatal Med 2014 Aug 26.
Umbilical cord accidents (UCA) are a significant cause of stillbirth. Although infrequent, litigation may occur when there is a poor outcome associated with UCA. With advances in imaging, the ability to identify UCA by ultrasound and magnetic resonance imaging raises awareness of the risk of a poor outcome. Management of a pregnancy with an identified UCA may require more fetal surveillance by both the mother and caregiver. This is especially important if there is a previous history of UCA with or without stillbirth. UCA should be an acknowledged risk which is part of prenatal screening. In the event of a poor outcome associated with UCA, it is recommended that the patient be fully informed of all prenatal information including images. Excellent communication with parents who are looking for answers after a tragic outcome may help to decrease litigation risk.
- Dengue and dengue vectors in the WHO European region: past, present, and scenarios for the future. [REVIEW]
- Lancet Infect Dis 2014 Aug 26.
After 55 years of absence, dengue has re-emerged in the WHO European region both as locally transmitted sporadic cases and as an outbreak in Madeira, driven by the introduction of people infected with the virus and the invasion of the vector mosquito species Aedes aegypti and Aedes albopictus. Models predict a further spread of A albopictus, particularly under climate change conditions. Dengue transmission models suggest a low risk in Europe, but these models too rarely include transmission by A albopictus (the main established vector). Further information gaps exist with regard to the Caucasus and central Asian countries of the WHO European region. Many European countries have implemented surveillance and control measures for invasive mosquitoes, but only a few include surveillance for dengue. As long as no dengue-specific prophylaxis or therapeutics are available, integrated vector management is the most sustainable control option. The rapid elimination of newly introduced A aegypti populations should be targeted in the European region, particularly in southern Europe and the Caucasus, where the species was present for decades until the 1950s.
- Attention-deficit hyperactivity disorder increases the risk of deliberate self-poisoning: A population-based cohort. [JOURNAL ARTICLE]
- Eur Psychiatry 2014 Aug 26.
Children with attention-deficit hyperactivity disorder (ADHD) may suffer marked impairment in early adulthood, increasing their risk for serious self-harmful behaviors. Deliberate self-poisoning (DSP) is the most common form of deliberate self-harm. An association may exist between ADHD diagnosis and subsequent DSP events. The purpose of study was to determine whether children and adolescents with ADHD are at a greater risk for DSP than are age-matched controls.Claims data from the Taiwan National Health Insurance Database were used to conduct a retrospective cohort analysis of emergency department visits. The study cohort contained 3685 patients with ADHD (<8years old). Each ADHD patient was frequency matched based on sex, age, urbanization, parental occupation, and index year to 10 control patients without ADHD. A Cox proportional-hazards regression model was used to estimate the risk of DSP in the ADHD and comparison cohorts.The risk of developing DSP was significantly higher in the ADHD cohort than in the comparison cohort (P<.0001 for log-rank test). After adjusting for potential confounders, the regression model showed that the ADHD patients were at a 4.65-fold greater risk of developing DSP than the control patients were (HR=4.65, 95% CI: 2.41-8.94).Children with ADHD are at greater risk of developing DSP. Identifying risk factors of DSP is crucial efforts to implement prevention strategies. The identification of the underlying cause of increased DSP among ADHD patients warrants further investigation.