This study explored the associations between delivery hospital self-reported level of maternal service, as defined by the American Hospital Association, and both maternal and neonatal outcomes among ...women at high maternal risk, as defined by the Obstetric Comorbidity Index.
This was a secondary analysis of linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. The need for maternal transfer was defined using a sample-specific cut-off of the risk score calculated using the Obstetric Comorbidity Index. Outcomes included poor maternal outcome (severe maternal morbidity or death), maternal length of stay, preterm delivery, low birth weight, and perinatal death. The analysis was completed using hierarchical logistic regression with a two-level model considering hospital level of maternal service and controlling for maternal race and transfer status.
In these data, there was no difference in the odds of a poor maternal or neonatal outcome according to delivery hospital level of maternal care; however, delivery at a hospital with maternal service level III was associated with a higher odds of an extended length of stay.
For this group of pregnant women in need of maternal transfer, delivery hospital self-reported level of maternal care was not associated with the odds of poor maternal or neonatal outcomes. This study supports the need for improved definitions of hospital level of maternal services.
In population level studies, the conventional practice of categorizing women into low and high maternal risk samples relies upon ascertaining the presence of various comorbid conditions in ...administrative data. Two problems with the conventional method include variability in the recommended comorbidities to consider and inability to distinguish between maternal and fetal risks. High maternal risk sample selection may be improved by using the Obstetric Comorbidity Index (OCI), a system of risk scoring based on weighting comorbidities associated with maternal end organ damage. The purpose of this study was to compare the net benefit of using OCI risk scoring vs the conventional risk identification method to identify a sample of women at high maternal risk in administrative data.
This was a net benefit analysis using linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. We compared the value identifying a sample of women at high maternal risk using the OCI score to the conventional method of dichotomous identification of any comorbidities. Value was measured by the ability to select a sample of women designated as high maternal risk who experienced severe maternal morbidity or mortality.
The high maternal risk sample created with the OCI had a small but positive net benefit (+ 0.6), while the conventionally derived sample had a negative net benefit indicating the sample selection performed worse than identifying no woman as high maternal risk.
The OCI can be used to select women at high maternal risk in administrative data. The OCI provides a consistent method of identification for women at risk of maternal morbidity and mortality and avoids confounding all obstetric risk factors with specific maternal risk factors. Using the OCI may help reduce misclassification as high maternal risk and improve the consistency in identifying women at high maternal risk in administrative data.
Do Advance Directives Direct? Shapiro, Susan P.
Journal of health politics, policy and law,
06/2015, Letnik:
40, Številka:
3
Journal Article
Recenzirano
Resolution of long-standing debates about the role and impact of advance directives — living wills and powers of attorney for health care — has been hampered by a dearth of appropriate data, in ...particular data that compare the process and outcomes of end-of-life decision making on behalf of patients with and without advance directives. Drawing on a large ethnographic study of patients in two intensive care units in a large urban teaching hospital, this article compares aspects of the medical decision-making process and outcomes by advance-directive status. Controlling for demographic characteristics and severity of illness, the study finds few significant differences between patients without advance directives and those who claim to have them. Surprisingly, these few differences hold only for those whose directives are in their hospital chart. There are no significant differences between those with no directive and those claiming to have a copy at home or elsewhere. The article considers the implications if directives seemingly must be in hand to show even modest effects. Do advance directives direct? The intensive care unit data provide far more support for the growing body of literature that casts doubt on their impact than studies that promote the use of them.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, ODKLJ, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Summary
Heritable dysfibrinogenaemia (HD) is a rare qualitative disorder of fibrinogen (FGN). To better describe the clinical, laboratory and genotypic spectrum of HD, we evaluated 35 subjects ...identified at two UK centres using laboratory criteria. 12/35(34%) subjects with HD experienced bleeding (bleeding score >1 at any site), 3/35(9%) thrombosis and 20/35(57%) were asymptomatic. Amongst subjects with bleeding, symptoms were typically mild, at one anatomical site and seldom occurred after invasive procedures. All subject showed dry clot weight within or above laboratory reference interval (median 3·2 g/l; range 1·9–5·1), reduced Clauss fibrinogen (median 0·52 g/l; range 0·21–1·3), and prolonged thrombin (median 30·7 s; range 21·3–45·7) and reptilase (median 42·0 s; range 20·0–68·0) times. In all subjects, the prothrombin time ratio (PTR), determined by Sysmex CA‐1500 coagulometer and Innovin activator, was abnormal (median 1·42; range 1·22–1·61). The activated partial thromboplastin time ratio and PTR with other coagulometers and activators were comparatively insensitive to HD. All subjects with HD harboured heterozygous candidate nucleotide variations within known hotspots in the FGN genes. The HD variants identified in this cross‐sectional study seldom have significant clinical manifestations and show similar laboratory features irrespective of genotype. Selection of coagulometer and PT activator may markedly affect the detection of new HD cases using coagulation screening tests.
Haemophilia and ageing Shapiro, Susan; Makris, Mike
British journal of haematology,
March 2019, 2019-03-00, 20190301, Letnik:
184, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Summary
Advances in the development of effective and safe treatments for haemophilia over the last 50 years have resulted in a significant increase in the life expectancy of persons with haemophilia ...(PWH). The management of this new cohort of middle‐aged and elderly PWH is challenging because of the opposing risks of haemophilia and age‐related cardiovascular disease and malignancy. Furthermore, this cohort of ageing PWH has the additional comorbidities of human immunodeficiency virus/hepatitis C and chronic haemophilic arthropathy. This article reviews the prevalence, underlying mechanisms and treatment strategies for managing these comorbidities. International collaboration is essential for registry data and further prospective trials to inform optimal evidence‐based management for this rare disorder in the future.
Platelets are anucleate but contain a rich repertoire of mRNAs. In this issue of Cell Reports Medicine, Shen and colleagues1 present platelet transcriptomes from patients with myeloproliferative ...neoplasms to study disease mechanisms and generate a predictive algorithm for fibrotic progression.
Platelets are anucleate but contain a rich repertoire of mRNAs. In this issue of Cell Reports Medicine, Shen and colleagues1 present platelet transcriptomes from patients with myeloproliferative neoplasms to study disease mechanisms and generate a predictive algorithm for fibrotic progression.
Schools of nursing located within academic health centers have embraced expanded opportunities to lead in this era of rapid change and considerable uncertainty in US health care. These schools bear a ...unique responsibility to work with their clinical nursing partners to advance the care of patients, improve the health of communities and populations, and help steward the nation's health care resources. This article describes how the Emory University Nell Hodgson Woodruff School of Nursing has formed and sustained academic-practice partnerships in response to these imperatives. The structures and processes that have supported the partnerships are shared, as are the keys to success in a true partnership. The authors describe the work required to achieve mutually agreed-upon goals, along with the challenges that faculty and health care leaders have faced in their journey to system partnerships.
Multiple myeloma (MM) and its precursor states, smoldering myeloma (SM) and monoclonal gammopathy of undetermined significance (MGUS) are associated with increased incidence of thrombosis, however ...the cause of this is unknown. Lenalidomide treatment of MM substantially improves patient survival, although significantly increases thrombotic risk by an unknown mechanism. This pilot study aimed to establish the impact of MM and its treatment with Lenalidomide on platelet function. We analyzed platelet function in MGUS, SM and MM compared to healthy controls. We report an increase in platelet reactivity in MGUS, SM, and MM where increases in fibrinogen binding, P-selectin exposure, altered receptor expression, elevated levels of aggregation and enhanced sensitivity to agonist stimulation were observed. We also demonstrate an increase in patient platelet reactivity post Lenalidomide treatment compared to pre-treatment. We show Lenalidomide treatment of platelets
increased reactivity that was associated with formation of larger thrombi at arterial shear rates but not venous shear rates. This study demonstrates a clear increase in platelet reactivity and prothrombotic potential in patients with MGUS, SM and MM which is elevated further upon treatment with Lenalidomide. Our observations suggest that more detailed studies are warranted to determine mechanisms of thrombotic complications to enable the development of new preventative strategies that specifically target platelets.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Purpose of Review
This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon ...algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier.
Recent Findings
Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response.
Summary
We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for “protocol maxima” of IR appropriate to patient condition.
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