Combination Of Risk Stratification Research Articles

Obstetric Anesthesia

Patient safety and reduction of possible complications are the top priorities for anesthesiologists in everyday clinical practice. Thus, interdisciplinary early assessment and optimization of patient specific medical conditions and risk factors are crucial. In obstetrics, regional anesthesia and general anesthesia are routinely being performed. To ensure maternal and fetal safety, knowledge regarding physiological changes during pregnancy is highly important. Regional anesthesia, particularly epidural analgesia, has its main field of application in the context of natural birth in the delivery room. Spinal anesthesia, as well as epidural and combined spinal-epidural anesthesia (CSE) are widely used for caesarean section. In this context, special attention should be paid to possible bleeding disorders. The combination of risk stratification and strategies to improve the patient's preoperative medical status is capable to reduce maternal and fetal complications.

Preoperative Assessment and Improvement of Patient's Medical Conditions

Patient safety and reduction of postoperative complications are the top priorities for anaesthesiologists in everyday clinical practice. Therefore, preoperative assessment and optimization of patient specific risk factors are crucial for reduction of postoperative morbidity and mortality. Understanding the patient's medical history and clinical examination represent the two most important aspects of preoperative patient evaluation by the anaesthesiologist. In addition, there are several clinical scores to specify the patient's individual perioperative risk according to the existing comorbidities. These specific assessment tools are easily accessible and have proven effective in everyday clinical practice. Special attention should be paid to preoperative cardiac, respiratory and metabolic conditions. The combination of risk stratification and strategies to improve the patient's preoperative medical status are capable to reduce complications in the postoperative period.

Introduction of a novel telescopic pathway to streamline 2-week-wait suspected head and neck cancer referrals and improve efficiency: A prospective service evaluation.

ObjectivesThis study summarizes the introduction of a novel telescopic pathway, which streamlines 2‐week‐wait suspected head and neck cancer referrals to our unit, describes the logistics of the pathway, and analyzes referral numbers and outcomes. We also discuss wider issues surrounding remote assessment in head and neck cancer.MethodsData were collected prospectively between January and May 2021, capturing all 2‐week‐wait referrals to our unit following the introduction of a telescopic pathway which utilized a nurse‐led clinic for nasendoscopic examination of selected patients and consultant‐led remote assessment using store and forward technology. Information on referral numbers, waiting times and outcomes was recorded.ResultsThree hundred and forty (185 high risk, 155 low risk) patients entered the telescopic pathway with the remaining 74 patients seen on the conventional standard of care pathway. Cancer conversion rates were 17%, <1%, and 5.4% for the high‐risk telescopic, low‐risk telescopic and standard of care pathways respectively. No patients discharged from the telescopic pathway were re‐referred within 3 months. Review capacity for endoscopic examination was higher per consultant on the telescopic pathway versus the standard of care (p = .01).ConclusionA combination of risk stratification and asynchronous telescopic assessment shows promise for the management of suspected head and neck cancer referrals. Potential benefits include consultant‐led care for all patients and enhanced documentation. Digital communication with patients may also assist with adherence to the new NHS 28‐day diagnostic standard for cancer referrals. Ongoing data collection is required to assess how the pathway functions over a longer period.Level of Evidence2c

Transcranial doppler re-screening of subjects who participated in STOP and STOP II.

In children with Sickle Cell Disease, the combination of risk stratification with Transcranial Doppler Ultrasound (TCD) and selective chronic red cell transfusion (CRCT-the STOP Protocol) is one of the most effective stroke prevention strategies in medicine. How fully it is being implemented is unclear. Nineteen of 26 sites that conducted the two pivotal clinical trials (STOP and STOP II) participated in Post STOP, a comprehensive medical records review assessing protocol implementation in the 10-15 years since the trials ended. Professional abstractors identified medical records in the Post STOP era in 2851 (74%) of the 3,840 children who took part in STOP and/or STOP II, and documented TCD rescreening, maintenance of CRCT in those at risk, and stroke. Among 1,896 children eligible for TCD rescreening (target group), evidence of any rescreening was found in 1,090 (57%). There was wide site variation in TCD rescreening ranging from 18% to 91% of eligible children. Both younger age and having a conditional TCD during STOP/II were associated with a higher likelihood of having a TCD in Post STOP. Sixty eight new abnormal, high risk cases were identified. Despite clear evidence of benefit the STOP protocol is not fully implemented even at experienced sites. Site variation suggests that system improvements might remove barriers to implementation and result in even greater reduction of ischemic stroke in children with SCD. Am. J. Hematol. 91:1191-1194, 2016. © 2016 Wiley Periodicals, Inc.

Developing potential biomarkers for preeclampsia: Why is the current strategy failing?

During the last decade major progress has been achieved in identifying new predictive biomarkers as well as setting up screening strategies for preeclampsia. A number of biochemical markers in combination with biophysical markers coupled to patients' demography and clinical history were identified and have been used in a number of studies. The combination of independent markers with various demographic and multivariate algorithms should have led to stratification of the risk to develop preeclampsia. However, today studies are still ongoing mostly focusing on a single marker and its performance for the early subtype of preeclampsia, which makes up only about 20% of all preeclampsia cases. While it is hard to forecast how medicine will progress, it has been the hope that a combination of risk stratification with large international randomised studies validating various prediction methods would enable new studies to identify preventive methods as well. This would have led to a significant revolution in the way pregnancy is managed to prevent preeclampsia. However, looking back on all the studies on markers such as soluble endoglin, placental protein 13 (PP13), placental growth factor (PlGF), vascular endothelial growth factor (VEGF) and soluble VEGF receptor-1 (sVEGF-R1 or sFlt-1) today pregnant women destined to develop preeclampsia are still suffering from the lack of any commonly accepted preventive therapy. Putative reasons for this failure of predictive biomarkers will be discussed in this talk.

Non-Invasive Vascular Function Tests:

The arterial wall has 3 layers (ie, the intima, including the endothelium, the media, and the adventitia); each of these layers has individual roles in systemic circulation. The vascular endothelium regulates the vascular tone, hemostasis and/or vascular permeability, and the media is the major determinant of arterial elasticity, which regulates the conduit function (delivery of blood to tissues) and cushioning effect (for generation of continuous blood flow). Failure of these functions results in organ/vascular damage. Several non-invasive methods are currently used to assess vascular dysfunction, including measurement of flow-mediated vasodilatation of the brachial artery induced by reactive hyperemia (FMD), pulse wave velocity (PWV), the augmentation index (AI), and central blood pressure. Endothelial dysfunction, which is assessed by FMD, contributes to the initiation/progression of atherosclerosis. Increased arterial stiffness, which is assessed by the PWV and/or AI, causes increased cardiac afterload, impaired coronary arterial blood supply, atherogenesis and/or microvascular damage. The combination of risk stratification by assessment of conventional risk factors for cardiovascular disease (CVD) with not only a morphological assessment of vascular damage, such as carotid ultrasound examination, but also vascular function tests, may be a useful strategy for the management of CVD and its related risk factors. (Circ J 2010; 74: 24 - 33).