The measurement of D-dimer can provide useful information to aid in the diagnosis of patients with suspected venous thromboembolism. D-dimer measurement in conjunction with adequate estimation of ...pretest probability can facilitate the safe discharge of patients with suspected pulmonary embolism and limit unnecessary investigation or anticoagulation. We review clinical decision-making strategies in the diagnosis of pulmonary embolism and propose means to minimize diagnostic error that might arise from knowledge of the D-dimer result prior to clinical assessment.
Aortic arch geometry changes with age, including an increase in aortic arch width (AAW). High AAW is a predictor of incident adverse cardiovascular disease (CVD) events, but its distribution and ...determinants are unknown. We hypothesized that traditional CVD risk factors, in addition to age, are associated with increased AAW in community-dwelling adults.
Framingham Offspring and Third Generation cohort participants (N = 3026, 52 % men) underwent thoracic multidetector computed tomography (MDCT). A referent group (733M, 738W) free of clinical CVD, hypertension, dyslipidemia, smoking, and diabetes was used to generate sex and 10-year age-group specific upper 90th percentile (P90) cut-points for AAW. AAW was measured as the distance between the cross-sectional centroids of the ascending and descending thoracic aorta. Multivariable logistic regression models were used to identify clinical correlates of high AAW (≥referent P90) in the overall study group.
Among referent participants, AAW increased with greater age-group, p for trend <0.0001 in each sex. Overall and within each age group, AAW was greater in men than women, p < 0.0001 all comparisons. Across all participants, high AAW was associated with greater age (odds ratio, OR = 1.34/10 years; 95 % confidence interval 1.20–1.50), body surface area (OR = 1.97/SD; 1.62–2.40), diastolic blood pressure (OR = 1.59/10 mm Hg; 1.40–1.81), pack-years smoked (OR = 1.07; 1.02–1.13), and prevalent CVD (OR = 1.64; 1.08–2.49).
AAW increases with greater age, body size, diastolic blood pressure and burden of smoking. High AAW (≥referent P90) is also associated with prevalent (clinically apparent) CVD. AAW is often seen on and easily measured from tomographic thoracic images and has prognostic value.
Many of the adverse outcomes experienced by mothers and babies are directly related to the health of the woman prior to pregnancy. This preconception period is a unique window of opportunity when ...women are often more motivated to optimise health and change their lifestyle in preparation for pregnancy. Several risk factors in the preconception period can contribute to adverse perinatal outcomes. These risk factors can be divided into three broad areas: biomedical, social and environmental. Mobile phone applications as a behaviour change intervention have the potential to address these risks through supporting the provision of information, healthier lifestyles and informed decision-making. The aim of this systematic review is to assess the effectiveness of mobile phone applications in promoting behaviour change and improving long-term outcomes for mother and babies, in women of reproductive age.
This review will include trials that assess any mobile phone application (app) that assist women of reproductive age to optimise health behaviours. Randomised controlled trials, quasi-randomised controlled trials and cluster-randomised trials will be included. The search strategy will use both MeSH and keyword combinations to search databases including the WHO Global Health Library, CINHAL, The Cochrane Library, Embase and MEDLINE for relevant studies. Retrieved citations will be screened independently by two authors to assess eligibility. Studies will be selected only if the intervention was commenced prior to pregnancy. Comparisons will be made including mobile phone applications versus text messaging-based communications or paper-based, face-to-face or telephone conversations and standard care or no specific intervention. The Cochrane Handbook for Systematic Reviews of Interventions will be utilised to assess the quality of included randomised studies. Primary and secondary outcomes will be compared and analysed. Results of the review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines.
This systematic review is the first to assess the effects of preconception mobile phone app behaviour change and educational interventions in improving future pregnancy and maternal and child outcomes, in women of reproductive age.
PROSPERO 2017: CRD42017065903 .
We sought to determine whether increased aortic arch width (AAW) adds to standard Framingham risk factors and coronary artery calcium (CAC) for prediction of incident adverse cardiovascular disease ...(CVD) events in community-dwelling adults.
A total of 3026 Framingham Heart Study Offspring and Third Generation cohort participants underwent noncontrast multidetector computed tomography from 2002 to 2005 to quantify CAC. We measured AAW as the distance between the centroids of the ascending and descending thoracic aorta, at the level of main pulmonary artery bifurcation or the right pulmonary artery. We determined sex, age group, and body size specific cut points for high (≥90th percentile) AAW from a healthy referent group (N=1471) and dichotomized AAW as high or not high across all study participants. Clinical covariates were obtained at Offspring cycle 7 (1998-2001) or Third Generation cycle 1 (2002-2005) examinations. The primary CVD outcome was a composite of myocardial infarction, coronary insufficiency, cerebrovascular accident, first hospitalization for heart failure, or CVD death. Cox proportional hazards models were used to estimate hazard ratio of high AAW on time-to-incident CVD after adjustment for Framingham risk factors and CAC. Net reclassification improvement was used to assess the effect of adding AAW to the baseline Framingham risk factor+CAC model. A total of 2826 participants (aged 51±11 years, 48% women) had complete covariates and were free of CVD at multidetector computed tomography. Over a median 8.9 years of follow-up, there were 135 incident CVD events. High AAW was independently predictive of CVD events (hazard ratio, 1.55;
=0.032) and appropriately reclassified participants at risk: net reclassification improvement, 0.31 (95% confidence interval, 0.15-0.48).
AAW augments traditional CVD risk factors and CAC for prediction of incident adverse CVD events among community-dwelling adults.
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•Cancer-associated thrombosis (CAT) is a leading cause of death in cancer patients.•Introduction of direct oral anticoagulants has made treatment decisions complex.•An expert working ...group of clinicians met virtually to define consensus guidelines.•A practical colour-coded algorithm was produced to guide complex clinical decisions.
Cancer-associated thrombosis (CAT) is a leading cause of death amongst people with cancer. Treatment decisions have become increasingly complex with the introduction of direct oral anticoagulants and existing guidelines are limited to evidence from patients meeting stringent trial-entry criteria.
To assist decision making for healthcare professionals managing CAT in challenging ‘real-world’ situations, an expert working group of clinicians from oncology, haematology and pharmacology convened over a series of virtual meetings between September 2020 and January 2021 to catalogue the most challenging clinical problems and define consensus recommendations. Clinical problems were divided amongst the group members according to their areas of expertise, with each reviewing the literature and writing their recommendations. Using a web-based file-sharing platform, each contribution was reviewed until consensus was reached.
Each clinical problem is discussed; these include managing gastrointestinal impairment, renal impairment, liver impairment, increased risk of bleeding, extremes of body weight, drug interactions, anticoagulation beyond the initial six months and managing recurrent thrombosis.
A user-friendly, practical, colour-coded algorithm was produced to help guide clinical decision-making in CAT. Red highlights decision steps where shared decision making, such as with the multi-disciplinary team, is recommended. Amber steps reflect uncertainty of existing evidence. Multiple amber steps per patient warrant increased caution.
Making anticoagulation decisions in people with cancer is challenging; it is important that healthcare providers can discuss where there is a lack of evidence and ensure that patient preference is given priority. This algorithm and consensus recommendations are a useful tool to guide these complex discussions.
There is limited guidance available to clinicians regarding the management of antithrombotic therapy during epistaxis, whilst there has been an increase in the use of anticoagulation and antiplatelet ...therapy. In addition, the introduction of direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, over the last decade has significantly increased the complexity of managing the anticoagulated epistaxis patient. We undertook a systemic literature review investigating potential management strategies for each class of anti-thrombotic therapy during epistaxis. A PubMED and Cochrane Library search was performed on 10/03/16 using, but not limited to, the search terms epistaxis, nosebleed, nose bleeding, nasal haemorrhage, nasal bleeding AND each of the following search terms: antithrombotic, anticoagulant, antiplatelet, aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, apixaban and tranexamic acid. This yielded 3815 results, of which 29 were considered relevant. Other sources such as national and international guidelines related to the management of anti-thrombotics were also utilised. We present the findings related to the management of each class of anti-thrombotic therapy during epistaxis. Overall we found a lack of evidence regarding this topic and further high quality research is needed. This is an area growing in complexity and the support of colleagues in Haematology and Cardiology is increasingly important.
Women are increasingly turning to mobile health platforms to receive health information and support in pregnancy, yet the content of these platforms vary. Although there is great potential to ...influence health behaviors, little research has assessed the quality of these platforms or their ability to change behavior. In recent years, validated tools to assess app quality have become available.
To identify and assess the quality and ongoing popularity of the top 10 freely available pregnancy apps in Australia using validated tools.
A systematic search on app stores to identify apps was performed. A Google Play search used subject terms pregnancy, parenting, and childbirth; the iTunes search used alternative categories medical and health and fitness. The top 250 apps from each store were cross-referenced, and the top 100 found in both Google Play and iTunes were screened for eligibility. Apps that provided health information or advice for pregnancy were included. Excluded apps focused on nonhealth information (eg, baby names). The top 10 pregnancy apps were assessed using the Mobile App Rating Scale (MARS). A comparative analysis was conducted at 2 time points over 2 years to assess the ongoing popularity of the apps. The MARS score was compared to the download and star rating data collected from iTunes and Google Play in 2017 and 2019. Health behaviors including breastfeeding, healthy pregnancy weight, and maternal awareness of fetal movements were reviewed for apparent impact on the user's knowledge, attitudes, and behavior change intentions using the MARS perceived impact section and the Coventry, Aberdeen, and London-Refined (CALO-RE) taxonomy.
A total of 2052 free apps were screened for eligibility, 1397 were excluded, and 655 were reviewed and scored. The top 10 apps were selected using download numbers and star ratings. All 10 apps were suboptimal in quality, practicality, and functionality. It was not possible to identify a primary purpose for all apps, and there was overlap in purpose for many. The mean overall MARS app quality score across all 10 apps was 3.01 (range 1.97-4.40) in 2017 and 3.40 (range 2.27-4.44) in 2019. A minority of apps scored well for perceived impact on health behavior using the MARS tool. Using the CALO-RE 40 item taxonomy, the number of behavior change techniques used was low. The mean number of behavior change techniques for breastfeeding was 5 (range 2-11), for pregnancy weight was 4 (range 2-12), and for maternal awareness of fetal movements was 5 (range 2-8).
This review provides valuable information to clinicians and consumers about the quality of apps currently available for pregnancy in Australia. Consideration is needed regarding the regulation of information and the potential opportunity to incorporate behavior change techniques to improve maternal and fetal outcomes.
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