High-risk Medicine Research Articles

Breastfeeding and Tacrolimus

Women have traditionally been advised not to breastfeed while taking tacrolimus, based on theoretical risks of neonatal immunosuppression and assumed secretion into breast milk, rather than clinical data suggesting neonatal absorption. The aim of this study was to assess tacrolimus levels in breast milk and neonatal exposure during breastfeeding. An observational cohort study was performed in two tertiary referral high-risk obstetric medicine clinics. Fourteen women taking tacrolimus during pregnancy and lactation, and their 15 infants, 11 of whom were exclusively breast-fed, were assessed. Tacrolimus levels were analyzed by liquid chromatography-tandem mass spectrometry. Samples from mothers and cord blood were collected at delivery and from mothers, infants, and breast milk postnatally where possible. All infants with serial sampling had a decline in tacrolimus level, which was approximately 15% per day (ratio of geometric mean concentrations 0.85; 95% confidence interval, 0.82-0.88; P<0.001). Breast-fed infants did not have higher tacrolimus levels compared with bottle-fed infants (median 1.3 μg/L [range, 0.0-4.0] versus 1.0 μg/L [range, 0.0-2.3], respectively; P=0.91). Maximum estimated absorption from breast milk is 0.23% of maternal dose (weight-adjusted). Ingestion of tacrolimus by infants via breast milk is negligible. Breastfeeding does not appear to slow the decline of infant tacrolimus levels from higher levels present at birth. Women taking tacrolimus should not be discouraged from breastfeeding if monitoring of infant levels is available.

Insulin: a commonly used high‐risk medicine

AbstractType 2 diabetes is common and is associated with progressive beta cell loss, insulin deficiency, organ damage and effects on mental health and wellbeing. The current management focus is on stringent blood glucose control (HbA1c &lt;7% [53mmol/mol]) and early insulin initiation. Insulin is a high‐risk medicine and is associated with a high rate of errors, adverse events and admissions to hospital. An insulin high‐risk medicine alert and accompanying audit tool were developed and distributed to Australian hospitals in Victoria in 2009.The purpose of this paper is to outline the self‐reported impact of the insulin alert on hospital insulin management policies, discuss the lessons learned from the process, and suggest strategies that could be more effective when other medicine alerts are disseminated. The insulin alert, audit tool and an anonymous self‐complete questionnaire were mailed to the chief executive officers of 90 hospitals who distributed them to their relevant quality and safety governance committees for action.Only 26 hospitals responded (29%). Respondents reported that the insulin alert triggered them to review insulin policies and procedures, develop insulin education programmes and review hypoglycaemia management. They did not provide information about the impact on insulin errors. Respondents found the audit tool time consuming because the form was very long and not available in electronic form. Diabetes clinicians did not appear to have been involved.The key lessons learned were that relying on a passive implementation process, self‐report, and long, written audit tools are unlikely to engender change. Processes need to be tailored to suit individual organisations and engage key local clinical leaders. Outcomes/impact need to be measured objectively. Copyright © 2012 John Wiley &amp; Sons.

Lymphoma in Pregnancy: Excellent Fetal Outcomes and Maternal Survival in a Large Multicenter Analysis

Abstract 94▪▪This icon denotes a clinically relevant abstract Background:Lymphoma diagnosed during pregnancy is a rare occurrence. Further, there is heterogeneity in clinical presentation and a range of lymphoma histologies resulting in a continued deficiency of lymphoma-specific data in the literature regarding prognosis, optimal therapy, maternal complications, and fetal outcome. Methods:A comprehensive retrospective analysis was completed for patients (pts) diagnosed (dx) with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) during pregnancy at 9 large U.S. academic centers over a 13-year period (1998–2011). The vast majority of cases were co-managed with high-risk maternal fetal medicine. Data on maternal disease characteristics, treatment details, obstetric complications, and fetal outcomes were analyzed. Results:88 cases were identified with complete data available in 82. The median age of pts was 31 yrs (18–40). Lymphoma dx occurred at a median of 24 weeks (wks) gestation (5–40). 15% of pts were dx during the 1st trimester, 46% during the 2nd trimester, 35% during the 3rd trimester, while 4% (n=3) of pts had a pre-existing NHL dx (follicular lymphoma (FL)). 52% (n=43) of pts had NHL and 48% (n=39) HL. Of NHL cases, 83% (n=33) were B-cell and 17% (n=10) T-cell. B-cell histologies were DLBCL n=23 (including 2 primary CNS and 1 ’double hit’ NHL), FL n=5 (including 1 leukemic phase FL), Burkitt’s lymphoma n=3, and mixed histology n=1; T-cell histologies were anaplastic large cell n=6, PTCL not otherwise specified n=2, and T-cell/NK NHL n=2. Pts with B-cell NHL and HL were dx at a median age of 29 yrs (range, 18–40), while T-cell NHL pts were dx at a median of 34 years (19–37). MRI without gadolinium was the most common imaging modality utilized for staging. 63% of NHL and 19% of HL pts had stage III/IV disease (25% of HL with stage IIB). Pregnancy was terminated in 6 pts (n=4 aggressive NHL and n=2 HD) to enable immediate chemotherapy (five in the 1st trimester [at 5, 8, 10, 10, and 12 wks] and 1 pt in the early 2nd trimester who required high-dose methotrexate). 48 pts (63%) initiated anti-lymphoma therapy at a median of 25 wks gestation (range, 13–37) with 79% of pts initiating therapy in the 2nd trimester (see Table 1). The median gestation at time of lymphoma dx for pts who received intra-partum treatment was 20 wks vs 34 wks for pts who had therapy deferred to post-delivery (p<0.0001). The overall response rate among pts who received therapy was 87% (74% complete remission). Notably, gestation went to full-term in 54% with delivery occurring at a median of 37 wks (31–40). Therapy was deferred until post-delivery in 28 pts (37%) and the majority of these pregnancies were also carried to term (median delivery at 38 wks). At a median follow-up of 41 months (6–157), the 3-year PFS and OS for all pts were 79% and 89% respectively. Histology-specific 3-year PFS and OS were: B-cell NHL: 73% and 82%, respectively; T-cell NHL: 50% and 90%, respectively; and HL: 90% and 95%, respectively (Figure 1). Detailed obstetrical information was available in 59 pts. There were minimal pre-term complications, the most common being induction of labor in 45%. Perinatal events included spontaneous rupture of membranes in 5% and pre-eclampsia in 8%. Further, there were no differences in these events detected among pts who received intra-partum treatment vs deferred therapy. No episodes of chorioamnionitis or endometritis were noted. There was 1 stillbirth that occurred at 19 wks gestation in a 34-year-old pt with double-hit NHL following 1 cycle of R-CHOP. The median birth weight of infants was 2427 grams (1005–5262) with no difference among pts who received intra-partum chemotherapy vs not (2637 grams vs 2212 grams, respectively; p=NS). Microcephaly was reported in 1 case following 4 intra-partum cycles of CHOP for DLBCL; there were otherwise no malformations detected. [Display omitted] Conclusions:To our knowledge, this represents one of the largest experiences reported of lymphoma in pregnancy. Our data show that standard NHL and HL chemotherapeutic regimens (without anti-metabolites) administered during the 2nd and 3rd trimester, including as early as 13 wks gestation in select cases, is associated with minimal maternal complications or fetal detriment. In addition, pts with low risk clinical scenarios (e.g., indolent NHL and/or late gestational dx) had therapy safely deferred to post-partum. In our experience, this approach was associated with overall expected lymphoma-related survival. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy

BackgroundInsulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation ‘u’ is...

Low-density lipoprotein cholesterol goal attainment in high-risk family medicine patients

The Adult Treatment Panel III guideline recommends a low-density lipoprotein-cholesterol (LDL-C) goal of <100mg/dl for patients with coronary heart disease or risk equivalence (ie, other forms of atherosclerotic vascular disease [peripheral vascular disease, abdominal aortic aneurysm, cerebrovascular disease], diabetes). An optional LDL-C goal of <70mg/dl is recommended for patients considered "very high risk." This category is not well defined, and clinical interpretation of this category varies. To define this category and to determine eligibility for an LDL-C goal of <70mg/dl, 5 definitions of "very high risk" were developed. Patients with coronary heart disease or risk equivalence within the University of Colorado Family Medicine system over the course of 2 years were identified using International Classification of Diseases, 9th Revision codes (n=445). Their medical records were evaluated retrospectively. Patients characterized as "very high risk" according to the 5 definitions were assessed for LDL-C <70mg/dl goal attainment. Twenty-seven patients did not have LDL-C measurements and were excluded. Using the 5 definitions, we discovered that prevalence as "very high risk" was 10.8% (atherosclerotic vascular disease [AVD] plus smoking), 19.1% (AVD plus diabetes), 21.5% (AVD plus metabolic syndrome plus uncontrolled hypertension or smoking), 47.1% (AVD plus metabolic syndrome), and 67.2% (All AVD), P < .0001. LDL-C <70mg/dl was attained in 26.7%, 46.3%, 31.1%, 39.1%, and 35.2%, respectively (P=.13). Classifying patients as "very high risk" is highly variable depending on individual definitions, but this does not appear to alter the rates of attaining an LDL-C goal of <70mg/dl. When the Adult Treatment Panel IV guidelines are developed and issued, simplicity and clarity will be important in assisting clinicians in defining patient risk and developing LDL-C goals.

A Comparison Between a “Terror” Reaction and a“Nonchalant” Reaction to the Diagnosis of Gestational Diabetes

S.E., a 30-year-old woman who was gravida 2, para 1, was asked to take a 3-hour oral glucose tolerance test (OGTT) after her 1-hour 50-g glucose screen yielded a result of 150 mg/dl. She was 27 weeks pregnant and stated that this never happened in her first pregnancy and that she was extremely worried. Her OGTT results were: 1. Fasting: 78 mg/dl 2. 1 hour: 206 mg/dl 3. 2 hours: 173 mg/dl 4. 3 hours: 133 mg/dl Based on these results, she was diagnosed with gestational diabetes mellitus (GDM). Thus far in her pregnancy, she had gained 18 lb, and her blood pressure was normal. Her physician referred her to a high-risk perinatal medicine group for management of this diagnosis. S.E. terrified at the diagnosis, and the fact that she was now referred to a high-risk practice, intensified her concern. The consulting physician who saw her performed her usual new patient visit and related the risks of this disorder. These risks included macrosomia, earlier-than-term delivery, increased possibility of a cesarean birth, possibility of neonatal hypoglycemia, and potential need to inject insulin as the pregnancy progressed. She added that the mother's risk of developing GDM in a subsequent pregnancy was very high. S.E. was told she would be scheduled for weekly antenatal tests to ensure the health of the placenta and her baby starting at 36 weeks. She was also instructed about how to test her blood glucose, keep records, and fax in the results once per week. In addition, she was told to limit sugars and starches. S.E. left the office in …

Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective

While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1% among HRP and 65.8% among the rest. A total of 51.1% of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.

Critical incident reporting system in emergency medicine

This review summarizes the knowledge of error and of critical incident reporting systems in general and especially in emergency medicine. Medicine is a high-risk area and emergency medicine in particular needs consequent use of critical incident reporting systems. We need a safety culture to learn from our mistakes and we need to discuss all mistakes regardless of hierarchical structures in medicine. The first step in avoiding fatalities in emergency medicine is to accept that errors do occur. The next question is how to prevent errors in medicine and not to search for personal mistakes. We need a culture of error and not a culture of blame. Critical incidents occur in all ranges of medical hierarchical structures. We have to accept the presence of mistakes and we need to recognize them every day to protect our patients.

Early Childhood Diet, Overweight, and Cardiovascular Risk

Early Childhood Diet, Overweight, and Cardiovascular Risk

Improving Palliative Care For Patients In The Intensive Care Unit

Improving Palliative Care For Patients In The Intensive Care Unit

Palliative Care Outcomes Research: The Next Steps

Journal of Palliative MedicineVol. 8, No. 1 Guest EditorialsPalliative Care Outcomes Research: The Next StepsR. Sean MorrisonR. Sean MorrisonSearch for more papers by this authorPublished Online:20 Jan 2005https://doi.org/10.1089/jpm.2005.8.13AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byUse of Palliative Care Consultation for Patients with End-Stage Liver Disease: Survey of Liver Transplant Service Providers Kendall R. Beck, Steven Z. Pantilat, David L. O'Riordan, and Marion G. Peters1 August 2016 | Journal of Palliative Medicine, Vol. 19, No. 8Two Steps Forward, One Step Back: Changes in Palliative Care Consultation Services in California Hospitals from 2007 to 2011 Steven Z. Pantilat, David L. O'Riordan, and Kelly A. Bruno12 November 2014 | Journal of Palliative Medicine, Vol. 17, No. 11The Feasibility of Using Technology to Enhance the Transition of Palliative Care for Rural PatientsCIN: Computers, Informatics, Nursing, Vol. 32, No. 6Current State of Pain Care for Hospitalized Patients at End of Life2 May 2012 | American Journal of Hospice and Palliative Medicine®, Vol. 30, No. 2Health system characteristics of quality care delivery: A comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada10 August 2011 | Palliative Medicine, Vol. 26, No. 4Characteristics of Palliative Care Consultation Services in California Hospitals Steven Z. Pantilat, Kathleen M. Kerr, J. Andrew Billings, Kelly A. Bruno, and David L. O'Riordan11 May 2012 | Journal of Palliative Medicine, Vol. 15, No. 5Using A Quality Framework to Assess Rural Palliative Care19 December 2018 | Journal of Palliative Care, Vol. 26, No. 3Physician factors associated with outpatient palliative care referral21 May 2009 | Palliative Medicine, Vol. 23, No. 7Research in Pediatric Palliative Care: Closing the Gap Between What Is and Is Not Known10 September 2009 | American Journal of Hospice and Palliative Medicine®, Vol. 26, No. 5Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model7 April 2009 | Palliative Medicine, Vol. 23, No. 5A Framework for Generalizability in Palliative CareJournal of Pain and Symptom Management, Vol. 37, No. 3Review Article: End-of-Life Care for Old People: A Review of the Literature1 August 2008 | American Journal of Hospice and Palliative Medicine®, Vol. 25, No. 4Family Satisfaction Following the Death of a Loved One in an Inner City MICU1 August 2008 | American Journal of Hospice and Palliative Medicine®, Vol. 25, No. 4End-of-Life Medical Treatment Choices: Do Survival Chances and Out-of-Pocket Costs Matter?25 April 2008 | Medical Decision Making, Vol. 28, No. 4Specialized palliative care services are associated with improved short- and long-term caregiver outcomes25 October 2007 | Supportive Care in Cancer, Vol. 16, No. 6Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patientsCritical Care Medicine, Vol. 35, No. 6A Literature Review of Randomized Controlled Trials of the Organization of Care at the End of Life31 March 2010 | Canadian Journal on Aging / La Revue canadienne du vieillissement, Vol. 25, No. 3 Volume 8Issue 1Feb 2005 InformationCopyright 2005, Mary Ann Liebert, Inc.To cite this article:R. Sean Morrison.Palliative Care Outcomes Research: The Next Steps.Journal of Palliative Medicine.Feb 2005.13-16.http://doi.org/10.1089/jpm.2005.8.13Published in Volume: 8 Issue 1: January 20, 2005PDF download

DIAGNOSING ACUTE COMPARTMENT SYNDROME

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space”.1 It is most commonly seen after injuries to the leg2-5 and forearm6-8 but may also occur in the arm,9 thigh,10 foot,11-13 buttock,14 hand15 and abdomen.16 It typically follows traumatic injury, but may also occur after ischaemic reperfusion injuries,17 burns,18 prolonged limb compression after drug overdose19 or poor positioning during surgery.20-24 Furthermore, subclinical compartment syndromes may explain the occurrence of a variety of postoperative disabilities which have been identified after the treatment of fractures of long bones using intramedullary nails.25 Approximately 40% of all acute compartment syndromes occur after fractures of the tibial shaft26 with an incidence in the range of 1% to 10%.26-30 A further 23% of compartment syndromes are caused by soft-tissue injuries with no fracture and fractures of the forearm account for 18%.26 Acute compartment syndrome is seen more commonly in younger patients, under 35 years of age31 and therefore leads to loss of function and long-term productivity in patients who would otherwise contribute to the country’s workforce for up to 40 years.

Potential prevention of Alzheimer disease and dementia.

The prevention of dementia is of critical importance. The increasing population of high-risk older individuals will result in an increasing prevalence of dementia. Primary prevention of dementia and Alzheimer disease can take either a public health or high-risk preventive medicine approach. At the present time, there is little evidence to support a specific primary public health approach such as a specific nutrient. The possible association of vascular disease with dementia may offer the best preventive high-risk approach. The identification of individuals with clinical and subclinical vascular disease is possible. There is a very high prevalence of subclinical cerebral infarction in older individuals. Specific treatments can prevent clinical disease such as stroke and coronary heart disease. Whether therapies will prevent some dementia can be determined.