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risk management [keywords]
- False-positive rates of provocative cardiac testing in chest pain patients admitted to an emergency department observation unit. [Journal Article]
- Crit Pathw Cardiol 2014 Sep; 13(3):104-8.
Emergency department observation units (EDOUs) typically perform routine cardiac stress testing or coronary computed tomography (CCTA) to rule out ischemic cardiac chest pain. Some have questioned the utility of routine stress testing and advanced anatomic imaging in the low-risk chest pain patients. EDOU chest pain patients undergoing stress testing or CCTA prior to cardiac catheterization between June 1, 2009 and May 31, 2012 were studied in a prospective, observational manner. Baseline data, EDOU-related outcomes, and testing results were recorded. Stress tests were treadmill echocardiogram or myocardial perfusion stress tests and were considered positive if a "positive" or "equivocal" interpretation by the reviewing cardiologist prompted cardiac catheterization. CCTA was considered positive if it led to subsequent cardiac catheterization. Cardiac catheterization was considered positive if subsequent stent placement, coronary artery bypass graft (CABG), or change in medical management occurred. Of 1276 patients evaluated, 112 (8.8%) underwent cardiac catheterization of which 56 underwent some modality of prior testing. Forty-two of 56 were subject to stress testing (30 stress echo and 12 myocardial perfusion) and 14 underwent CCTA prior to catheterization. False-positive rate overall was 62.5% (35/56, 95% CI, 48.5%-74.7%). False-positive rate for stress testing was 75% and 66.7% for perfusion and stress echo respectively. False-positive rate for CCTA was 42.9%. It must be acknowledged that while these findings do not directly impugn the utility of stress testing or CCTA, it may indicate the need for more appropriate patient selection to avoid unnecessary cardiac catheterization among EDOU chest pain patient cohorts.
- Randomized Comparison of Topical Prednisolone Acetate 1% Versus Fluorometholone 0.1% in the First Year After Descemet Membrane Endothelial Keratoplasty. [JOURNAL ARTICLE]
- Cornea 2014 Jul 24.
The aim of this study was to compare the efficacy and side effects of prednisolone acetate 1% versus fluorometholone 0.1% after Descemet membrane endothelial keratoplasty (DMEK).DMEK recipients used prednisolone acetate 1% for 1 month, and they were randomized to either prednisolone or fluorometholone for months 2 through 12. Dosing was 4 times daily in months 1 to 3, thrice daily in month 4, twice daily in month 5, and once daily in months 6 to 12. The main outcomes were immunologic rejection episodes and intraocular pressure (IOP) elevation (defined as ≥24 mm Hg or ≥10 mm Hg increase over the preoperative baseline level), assessed by the Kaplan-Meier survival analysis.The study included 325 eyes (99% were white, 96% had Fuchs dystrophy, and 9% had a previous glaucoma diagnosis). No eyes (0%) assigned to prednisolone versus 2 eyes (1.4%) assigned to fluorometholone experienced a possible (n = 1) or probable (n = 1) rejection episode (P = 0.17). Both rejection episodes resolved successfully with increased topical steroids. In the prednisolone arm, a significantly higher proportion exceeded the defined IOP elevation threshold (22% vs. 6%, P = 0.0005), and glaucoma medications were initiated or increased more often (17% vs. 5%, P = 0.0003). The most frequent reasons for discontinuing the assigned intervention were IOP management (n = 13 eyes assigned to prednisolone) or inflammation management (n = 3 eyes assigned to fluorometholone). One-year endothelial cell loss was comparable in both arms (30% vs. 31%, P = 0.50).DMEK has a remarkably low rejection episode rate (<1% through 1 year), as confirmed in this prospective randomized study. This provides a unique opportunity to reduce postoperative topical corticosteroid strength and thereby reduce the risk of steroid-associated complications.
- Preparedness for threat of chikungunya in the pacific. [Journal Article]
- Emerg Infect Dis 2014 Aug; 20(8)
Chikungunya virus (CHIKV) caused significant outbreaks of illness during 2005-2007 in the Indian Ocean region. Chikungunya outbreaks have also occurred in the Pacific region, including in Papua New Guinea in 2012; New Caledonia in April 2013; and Yap State, Federated States of Micronesia, in August 2013. CHIKV is a threat in the Pacific, and the risk for further spread is high, given several similarities between the Pacific and Indian Ocean chikungunya outbreaks. Island health care systems have difficulties coping with high caseloads, which highlights the need for early multidisciplinary preparedness. The Pacific Public Health Surveillance Network has developed several strategies focusing on surveillance, case management, vector control, laboratory confirmation, and communication. The management of this CHIKV threat will likely have broad implications for global public health.
- Cancer risk awareness and concern among women with a family history of breast or ovarian cancer. [JOURNAL ARTICLE]
- Behav Med 2014 Jul 25.:0.
Abstract Women with a documented deleterious mutation in BRCA1 or BRCA2 are at substantially elevated risk for ovarian cancer. To understand what percentage of women with high risk family histories know their risk is elevated we surveyed 1,885 women with a high or moderate risk family history and no personal history of breast or ovarian cancer, and asked about their perceived risk of breast and ovarian cancer. Among high-risk women, fewer than 20% reported use of genetic counseling, and knowledge of elevated risk of ovarian cancer was low. Prior genetic counseling was associated with greater perceived risk for ovarian cancer. Results suggest that most high-risk women (> 75%) do not know their risk for ovarian cancer. Identification of potentially high-risk women for referral to genetic counseling may improve informed ovarian cancer risk management.
- Screening-level Microbial Risk Assessment of Urban Water Locations: a Tool for Prioritization. [JOURNAL ARTICLE]
- Environ Sci Technol 2014 Jul 25.
People in urban areas are exposed to microbial hazards in urban waters. In this study, various hazards, diseases, and water systems, where different recreation activities take place, are compared in an integrated quantitative microbial risk assessment (QMRA). The event and annual probability of gastrointestinal illness (GI) and Legionnaires'disease (LD) were analyzed in QMRA models using selected literature data. Highest mean event probabilities of GI were found for playing in pluvial flood from a combined sewer overflow (34%), swimming (18%) and rowing (13%) in the river, swimming (8.7%) and rowing (4.5%) in the lake, and playing in a water playground (3.7%) and in the pluvial flood from stormwater sewers (4.7%). At these locations, the GI probability was above the EU Bathing Water Directive threshold for excellent water quality (3%). All the annual risk medians were below the national incidence of legionellosis of 0.002%. The illness probability was most sensitive to the pathogens concentration (particularly Campylobacter, Norovirus and Legionella) and exposure frequency. Therefore, site-specific pathogen data collection is the best next step to strengthen the certainty of the risk estimates. This study created an evidence-base that was used by water authorities to understand the health risks and set priorities for risk management.
- Pain management in ambulatory surgery-a review. [Journal Article]
- Pharmaceuticals (Basel) 2014; 7(8):850-65.
Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3-5 days after common day/ambulatory surgical procedures.
- Factors affecting the presence of human-associated and fecal indicator real-time quantitative PCR genetic markers in urban-impacted recreational beaches. [JOURNAL ARTICLE]
- Water Res 2014 Jul 9.:196-208.
Urban runoff can carry a variety of pollutants into recreational beaches, often including bacterial pathogens and indicators of fecal contamination. To develop complete recreational criteria and risk assessments, it is necessary to understand conditions under which human contamination could be present at beaches solely impacted by urban runoff. Accurately estimating risk requires understanding sources, concentrations, and transport mechanisms of microbial contaminants in these environments. By applying microbial source tracking methods and empirical modeling, we assessed the presence and level of human contamination at urban runoff impacted recreational beaches. We also identified environmental parameters and pollution sources that can influence the concentration and transport of culturable and molecular fecal indicator bacteria (FIB) in systems impacted solely by urban runoff. Water samples and physico-chemical parameters were collected from shoreline locations from three South Carolina (SC) beaches (five locations per beach) and two Florida (FL) beaches (three locations per beach). Each SC beach was directly impacted by swashes or tidal creeks receiving stormwater runoff from the urbanized area and therefore were designated as swash drain associated (SDA) beaches, while FL beaches were designated as non-swash drain associated (NSDA). Sampling in swash drains (SD; three sites per SD) directly impacting each SC beach was also conducted. Results indicate that although culturable (enterococci) and real-time quantitative polymerase chain reaction (qPCR) (EC23S857, Entero1, and GenBac3) FIB concentrations were, on average, higher at SD locations, SDA beaches did not have consistently higher molecular FIB signals compared to NSDA beaches. Both human-associated markers (HF183 and HumM2) were concomitantly found only at SDA beaches. Bacteroidales species-specific qPCR markers (BsteriF1 and BuniF2) identified differences in the Bacteroidales community, depending on beach type. The marker for general Bacteroidales was most abundant at SD locations and exhibited a high correlation with both culturable and other molecular markers. Combining molecular information with predictive modeling allowed us to identify both alongshore movement of currents and SD outflow as significant influences on the concentration of molecular and culturable indicators in the bathing zone. Data also suggests that combining methodologies is a useful and cost effective approach to help understand transport dynamics of fecal contamination and identify potential sources of contamination at marine beaches.
- Fundoplication in neonates and infants with primary gastroesophageal reflux. [Journal Article]
- Pediatr Gastroenterol Hepatol Nutr 2014 Jun; 17(2):93-7.
Gastroesophageal reflux in infant is a physiological process. However, surgery is performed in high risk infants with severe gastroesophageal reflux disease (GERD) when medical management fails. This study focuses on efficacy and safety of Nissen fundoplication for GERD in infants under age 12 months.This study was a retrospective case analysis of 11 neonates and infants under 12 months of age who underwent Nissen fundoplication following a failure of medical treatment between June 2010 and June 2013 at Pusan National University Children's Hospital. The records were reviewed to determine the effect of fundoplication on symptoms and post-operative complications.A total of 11 infants consist of four males and seven females. Mean birth weight was 2,305.5±558.6 g (1,390-3,130 g). They had some underlying disease, which are not related with GERD such as congenital heart disease (54.5%), prematurity (45.5%), neurologic disease (18.2%), respiratory disease (18.2%), and other gastrointestinal disease. Mean body weight at surgery was 3,803.6±1,864.9 g (1,938.7-5,668.5 g). Mean age at operation was 99.9±107.6 days (17-276 days). Duration from operation to full enteral feeding was 10.9 days. Symptoms related GERD disappeared in all patients including one who got reoperation. One infant died of congenital heart disease unrelated to surgery. There were no complications related to fundoplication.Fundoplication is effective and safe treatment in the neonates and infants with severe GERD.
- Dyslipidemia in children and adolescents: when and how to diagnose and treat? [Journal Article, Review]
- Pediatr Gastroenterol Hepatol Nutr 2014 Jun; 17(2):85-92.
Recently, the incidence and prevalence of obesity and dyslipidemia are increasing. Dyslipidemia is associated with significant comorbidities and complications, and with cardiovascular risk factors (obesity, diabetes mellitus, hypertension and smoking). The main objectives of this article are that describe the prevalence of dyslipidemia in Korean children and adolescents and review the diagnosis and management of dyslipidemia in children and adolescents.
- Clostridium difficile in Children: To Treat or Not to Treat? [Journal Article, Review]
- Pediatr Gastroenterol Hepatol Nutr 2014 Jun; 17(2):80-4.
Clostridium difficile infection has been increasing since 2000 in children and in adults. Frequent antibiotics use, comorbidity, and the development of hypervirulent strains have increased the risk of infection. Despite the high carriage rates of C. difficile, infants rarely develop clinical infection. Discontinuing antibiotics and supportive management usually leads to resolution of disease. Antibiotics use should be stratified depending on the patient's age and severity of the disease.