Risk Of Serious Adverse Outcomes Research Articles

Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study

SummaryBackgroundDischarged psychiatric inpatients are at elevated risk of serious adverse outcomes, but no previous study has comprehensively examined an array of multiple risks in a single cohort.MethodsWe used data from the Danish Civil Registration System to delineate a cohort of all individuals born in Denmark in 1967–2000, who were alive and residing in Denmark on their 15th birthday, and who had been discharged from their first inpatient psychiatric episode at age 15 years or older. Each individual in the discharged cohort was matched on age and sex with 25 comparators without a history of psychiatric admission. Data linked to each individual were also obtained from the Psychiatric Central Research Register, Register of Causes of Death, National Patient Register, and the National Crime Register. We used survival analysis techniques to estimate absolute and relative risks of all-cause mortality, suicide, accidental death, homicide victimisation, homicide perpetration, non-fatal self-harm, violent criminality, and hospitalisation following violence, until Dec 31, 2015.FindingsWe included 62 922 individuals in the discharged cohort, and 1 573 050 matched comparators. Risks for each of all eight outcomes examined were markedly elevated in the discharged cohort relative to the comparators. Within 10 years of first discharge, the cumulative incidence of death, self-harm, committing a violent crime, or hospitalisation due to interpersonal violence was 32·0% (95% CI 31·6–32·5) in the discharged cohort (37·1% [36·5–37·8] in men and 27·2% [26·7–27·8] in women). Absolute risk of at least one adverse outcome occurring within this timeframe were highest in people diagnosed with a psychoactive substance use disorder at first discharge (cumulative incidence 49·4% [48·4–50·4]), and lowest in those diagnosed with a mood disorder (24·4% [23·6–25·2]). For suicide and non-fatal self-harm, risks were especially high during the first 3 months post-discharge, whereas risks for accidental death, violent criminality, and hospitalisation due to violence were more constant throughout the 10-year follow-up.InterpretationPeople discharged from inpatient psychiatric care are at higher risk than the rest of the population for a range of serious fatal and non-fatal adverse outcomes. Improved inter-agency liaison, intensive follow-up immediately after discharge, and longer-term social support are indicated.FundingMedical Research Council, European Research Council, and Wellcome Trust.

Pneumonia and Risk of Serious Adverse Outcomes in Hospitalized Strokes in Thailand

Background: The impact of stroke associated pneumonia (SAP) on stroke complications is not well understood; we aimed to study the association between SAP and adverse outcomes including in-hospital mortality, prolonged length of stay and the risk of developing common serious complications (sepsis, respiratory failure, and convulsions). Methods: We retrospectively analyzed data from a cohort of 610,668 stroke patients drawn from the Universal Coverage Health Security Scheme (a national insurance database) in Thailand which covers ∼80% of the Thai population. Patients were hospitalized between October 2004 and January 2013. Results: Pneumonia was present in 9.6 % (n = 58,586) of patients. Aspiration pneumonia was present in 6.2% (n = 38,060) and nonaspiration pneumonia in 3.4% (n = 20,526). After adjusting for age, sex, stroke type, and comorbidities, patients with SAP had significantly higher odds of in-hospital mortality (odds ratio [OR] 2.90: 2.83-2.96), long length of stay (OR 13.11: 12.83-13.40), sepsis (OR 8.49: 8.22-8.76), respiratory failure (OR 4.37: 4.27-4.48), and convulsions (OR 2.09: 2.00-2.17). On subanalysis, patients with nonaspiration pneumonia were found to have higher odds of adverse outcomes compared to aspiration pneumonia; the corresponding ORs (95% confidence interval) for above outcomes were 1.25 (1.21-1.30), 2.40 (2.32-2.49), 1.34 (1.28-1.40), 1.80 (1.73-1.88), and 1.19 (1.11-1.28), respectively. Conclusions: SAP is associated with higher odds of inpatient mortality, long length of stay, and risk of developing serious stroke complications. Nonaspiration pneumonia is associated with significantly higher likelihood of adverse outcomes compared to aspiration pneumonia in this patient population. Early identification and treatment of SAP is vital in reducing adverse outcomes in acute stroke.

Accuracy of sonographic estimated fetal weight in suspected macrosomia: the likelihood of overestimating and underestimating the true birthweight

Objective: Macrosomia has increased risk of serious adverse outcomes for both infants and their mothers. As such, many providers recommend induction of labor or cesarean delivery (CD) based on sonographic estimated fetal weight (sonoEFW) cutoffs. It is known that sonoEFW is a poor predictor of birthweight (BW), especially at the extremes of weight. It is not clear, however, whether sonoEFWs tend to underestimate or overestimate the true BW among fetuses with suspected macrosomia. The objective of this study was to compare rates of overestimation of BW among women with suspected macrosomia by sonoEFW.Methods: This was a retrospective cohort study of women who presented to a single maternal–fetal medicine ultrasound unit within 2 weeks prior to delivery from January 2011 to November 2017. We identified women who received a sonoEFW ≥4000 g. The study sample was divided into four sonoEFW categories: 4000–4249, 4250–4499, 4500–4749, and ≥4750 g. Accuracy of sonoEFW was compared across groups, with the primary outcome being overestimation of BW.Results: A total of 502 patients were included, of whom 301 (60.1%) had a sonoEFW 4000–4249 g, 135 (26.9%) had a sonoEFW 4250–4499 g, 45 (9.0%) had a sonoEFW 4500–4749 g, and 21 (4.2%) had a sonoEFW ≥4750 g. In each sonoEFW group, the risk of overestimating BW was greater than 50%, and the likelihood of overestimation of BW increased significantly across sonoEFW groups (69.4, 76.3, 80.0, 95.2%, p < .001). This held true after adjusting for differences in baseline characteristics, including diabetes and amniotic fluid index. BW ≥4500 g was not accurately predicted. Among women with sonoEFW 4500–4749 g, only 28.9% delivered a neonate with a BW >4500 g; for women with a sonoEFW ≥4750 g, only 47.6% had a BW >4500 g. One hundred sixty-one (32.1%) women underwent CD for suspected macrosomia. Of these CDs, 48 (29.8%) of neonates had a BW <4000 g and 134 (83.2%) had a BW <4500 g.Conclusion: In patients undergoing sonoEFW within 2 weeks of delivery, sonoEFWs ≥4000 g are significantly more likely to overestimate than underestimate the true BW. Obstetricians should be cautious about intervening based on sonoEFW alone, given the high risk that this value is an overestimation of the true weight.

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis.

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%–15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%–4.9%), and death 1.4% (95% CI: 0.8%–2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Helping Older Adults Improve Their Medication Experience (HOME) by Addressing Medication Regimen Complexity in Home Healthcare.

In skilled home healthcare (SHHC), communication between nurses and physicians is often inadequate for medication reconciliation and needed changes to the medication regimens are rarely made. Fragmentation of electronic health record (EHR) systems, transitions of care, lack of physician-nurse in-person contact, and poor understanding of medications by patients and their families put patients at risk for serious adverse outcomes. The aim of this study was to develop and test the HOME tool, an informatics tool to improve communication about medication regimens, share the insights of home care nurses with physicians, and highlight to physicians and nurses the complexity of medication schedules. We used human computer interaction design and evaluation principles, automated extraction from standardized forms, and modification of existing EHR fields to highlight key medication-related insights that had arisen during the SHHC visit. Separate versions of the tool were developed for physicians/nurses and patients/caregivers. A pilot of the tool was conducted using 20 SHHC encounters. Home care nurses and physicians found the tool useful for communication. Home care nurses were able to implement the HOME tool into their clinical workflow and reported improved communication with physicians about medications. This simple and largely automated tool improves understanding and communication around medications in SHHC.

4 The risk of deterioration in CT identified mild traumatic brain injury: a systematic review and meta-analysis

BackgroundThe optimal management of minor head injured patients with brain injury identified by CT imaging is unclear. Some guidelines recommend routine hospital admission of GCS13–15 patients with traumatic brain (TBI)...

Accuracy of Modified Early Warning Scores for Predicting Mortality in Hospital: A Systematic Review and Meta-analysis

Background: Patients at risk of rapid deterioration and critical illness often have preceding changes in their physiological parameters. Use of Modified Early Warning Score (MEWS) allows distinguishing points-of-care of patients who are at increased risk of serious adverse outcomes. Objectives: To evaluate the prognostic accuracy of the MEWS to identify patients at risk of in-hospital death. Methods: The review process conformed to the recommendation form five steps to conduct a systematic review. Relevant studies from January 2000 to December 2015 were obtained from electronic databases. Standards for Reporting of Diagnostic accuracy (STARD) and Quality Assessment of Diagnostic Accuracy Studies instrument (QUADAS-2) were used to assess quality and bias of individual studies. MedCalc statistic software was used to merge the diagnostic accuracy data of recruited studies. The prognostic accuracy of predicting for in-hospital death was pooled on data from the diagnostic odds ratio and area under The ROC Curve (AUC) analysis. Results: A total of 402 citations were identiA¯Â¬Âed yielding 16 studies for inclusion in this systematic review. Studies were statistically significant heterogeneous in terms of age and sample size. For predicting in-hospital death, high risk group of MEWS that get the threshold equal 4 or more and equal 5 or more had the Diagnostic odds ratio (DOR) of 14.278 (95% Confidence Interval [CI] 12.185 to 16.730, I2=56.59%]) and 3.28 (95%CI:2.489 to 4.323, I2=48.64%). On pooled AUC analysis, there was a trend for MEWS to estimate fair at the discriminative power of test. AUC of MEWS > 4 was 0.778 (95% CI : 0.715 to 0.841, I2=89.54%) and of MEWS > 5 was 0.646 (95% CI : 0.611 to 0.682, I2=49.69%). Conclusions: The result showed a robust positive trend to predict in-hospital death. MEWS equal 4 or greater may be a favored threshold to alert to call for immediate appropriate action in hospitalized patients.

Overview and Summary: Care Coordination: Benefits of Interprofessional Collaboration

Care transitions are recognized as a time of significant vulnerability for children and adults with multiple chronic illnesses and complex health and social needs. Moving between settings or between providers requires comprehensive preparation and education of patients and families and accurate and timely flow of essential information. Lack of effective coordination on both sides of the transition leaves patients at risk for serious adverse outcomes influencing quality of life and function and substantial cost.This OJIN topic captures several important steps in the evolution of knowledge and practice of transitional care and care coordination. Together, the articles included in this topic reflect where we have been and where we still need to go to assure that patients and their families have safe and effective transitional care experiences. The articles range from a summary of over two decades of research on the nurse-led Transitional Care Model (TCM) to recent pilot studies developing new models and tools to expand transitional care and care coordination interventions to new settings and populations.In Continuity of Care: The Transitional Care Model, Hirschman and members of the multiprofessional Transitional Care Model (TCM) team at the University of Pennsylvania detail the evidence supporting the impact of their nurse-led transitional care model on quality and cost outcomes for older adults with multiple chronic illnesses. The TCM has undergone rigorous testing over the past two decades and has consistently demonstrated reductions in hospitalizations and costs for Medicare beneficiaries at high risk for adverse outcomes. This well-recognized model has been implemented in hospitals and health systems including patientcentered medical homes across the United States. The nine core TCM interventions and tools developed to measure them are described in the paper. This latest summary of the body of TCM research and its translation into real-world health care systems is a testament to the importance of rigorous and continuous programs of research for defining and improving care coordination for vulnerable populations with complex care needs.DelBoccio and colleagues describe one hospital's experience in becoming a top performer in transitional care in Successes and Challenges in Patient Care Transition Programming. Spurred to improve transitional care by changes in the Affordable Care Act, Indiana University Health North Hospital launched new programs to enhance patient activation and health team performance in medication management and communication with post-acute providers. Their experience reinforces the importance of effective teamwork and continuous quality improvement in making meaningful improvements in the care transition experience and subsequent performance outcomes.Nurses across academic and clinical settings in Minnesota describe the implementation of two models of care coordination for children with medical complexity (CMC) in their article Pediatric Care Coordination: Lessons Learned and Future Priorities. Cady and colleagues designed the TeleFamilies Model and PRoSPer models of pediatric care coordination to overcome current challenges of integrating complex care for children in healthcare homes (HCH) and to address key components of their state's healthcare reform legislation. Examining the implementation of new care coordination models within the context of unfolding state healthcare reform is a critical aspect of this article. Both the TeleFamilies and PRoSPer models incorporate nurses as drivers of care coordination processes in concert with members of interprofessional teams. They involve different team members and the use of different technologies according to the needs of children and families in rural and urban HCHs. The results of initial model tests show improved family perceptions of their health care experience and provider communication. The authors suggest several opportunities for further evaluation of In their article Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Muitimorbiditv. …

Nitric oxide donors for treating preterm labour.

A number of tocolytics have been advocated for the treatment of threatened preterm labour in order to delay birth. The rationale is that a delay in birth may be associated with improved neonatal morbidity or mortality. Nitric oxide donors, such as nitroglycerin, have been used to relax the uterus. This review addresses their efficacy, adverse effects and influence on neonatal outcome. To determine whether nitric oxide donors administered in threatened preterm labour are associated with a delay in birth, adverse effects or improved neonatal outcome. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013). Randomised controlled trials of nitric oxide donors administered for tocolysis. Two review authors independently assessed trial quality and extracted data. Twelve trials, including a total of 1227 women at risk of preterm labour, contributed data to this updated review. The methodological quality of trials was mixed; trials comparing nitric oxide donors with other types of tocolytics were not blinded and this may have had an impact on findings.Three studies compared nitric oxide donors (glyceryl trinitrate (GTN)) with placebo. There was no significant evidence that nitric oxide donors prolonged pregnancy beyond 48 hours (average risk ratio (RR) 1.19, 95% confidence interval (CI) 0.74 to 1.90, two studies, 186 women), and although for most adverse effects there was no significant difference between groups, women in the active treatment group in one study were at higher risk of experiencing a headache. For infant outcomes there was no significant evidence that nitric oxide donors reduced the risk of neonatal death or serious morbidity (stillbirth RR 0.36, 95% CI 0.01 to 8.59, one study, 153 infants; neonatal death RR 0.43, 95% CI 0.06 to 2.89, two studies, 186 infants). One study, using a composite outcome, reported a reduced risk of serious adverse outcomes for infants in the GTN group which approached statistical significance (RR 0.29, 95% CI 0.08 to 1.00, 153 infants). Overall, these studies were underpowered to identify differences between groups for most outcomes.When nitric oxide donors were compared with other tocolytic drugs there was no significant evidence that nitric oxide donors performed better than other tocolytics (betamimetics, magnesium sulphate, a calcium channel blocker or a combination of tocolytics) in terms of pregnancy prolongation, although nitric oxide donors appeared to be associated with a reduction in most adverse effects, apart from headache. There was no significant difference between groups for infant morbidity or mortality outcomes. There is currently insufficient evidence to support the routine administration of nitric oxide donors in the treatment of threatened preterm labour.

The Effect of Sleep Disordered Breathing on the Outcome of Stroke and Transient Ischemic Attack: A Systematic Review

The primary objective was to systematically review the literature on how sleep disordered breathing (SDB) affects recurrence and death among stroke or transient ischemic attack (TIA) patients. A secondary objective was to evaluate how treatment of SDB with continuous positive airway pressure (CPAP) affects the risk of recurrence and death in these patients. Adults (18+) with a stroke or TIA diagnosis were eligible for inclusion. Case groups consisted of patients with a sleep disorder. The outcomes of interest were all-cause mortality, recurrent vascular events, and case fatality. Ten articles covering 1,203 stroke and TIA patients were included in the review. The results generally support a dose-response relationship between severity of SDB and risk of recurrent events and all-cause mortality in stroke and TIA patients. Three small-scale articles with substantial risk of bias evaluated the effects of CPAP therapy, and the results are inconclusive. Data on case fatality is too sparse to be conclusive. Existing studies provide sufficient data to establish obstructive SDB as a negative predictor of all-cause mortality and recurrent vascular events following stroke or TIA. The ability of CPAP treatment to lower the risk of serious adverse outcomes after stroke remains controversial because of substantial risk of bias identified in most of the eligible studies addressing this relation. Additional studies are needed.

Trauma, Delinquency, and Substance Use: Co-Occurring Problems for Adolescent Girls in the Juvenile Justice System

Girls in the juvenile justice system are known to have high rates of co-occurring childhood abuse, trauma, and substance abuse. Girls with this constellation of problems are at high risk for serious adverse outcomes, including problems with drug dependence and abuse. The relationship among childhood sexual abuse, childhood physical abuse, other types of childhood trauma, and rates of substance use during adolescence were examined for girls in the juvenile justice system. As expected, childhood sexual abuse was significantly related to girls' substance use during adolescence. In contrast to prior research, no link was found between physical abuse, lifetime trauma, and substance use. Limitations and future directions are discussed.

Osteoarthritis & Obesity

Globally, there has been an unprecedented rise in the number of persons living with obesity and well into old age. Increasing age and obesity increase risk for metabolic syndrome (impaired fasting glucose, hypertension, and dyslipidemia) and thus risk for diabetes and cardiovascular disease. Less well recognized as a consequence of obesity and longevity is their impact on the numbers living with osteoarthritis (OA). OA is the most common form of arthritis, affecting approximately 10% of the adult population, and the leading cause of disability among Canadians. OA affects the hands, feet, lower back, hips and knees. Incidence and progression of OA has been causally linked with obesity through its effects on the biomechanics of weight-bearing joints and on joint tissues through inflammatory mediators, adipokines, secreted by adipose tissue. Among people with OA, obesity is associated with worse pain and disability in part due to the high prevalence of other obesity-related conditions, e.g., hypertension and diabetes, which may be preclude the safe use of OA therapies, such as non-steroidal anti-inflammatory drugs. Additionally, comorbid OA appears to increase risk for serious adverse outcomes among individuals with diabetes and heart disease. Thus, attaining and maintaining a healthy weight through diet and physical activity is a central focus of OA prevention and management. Modest weight loss reduces the incidence of knee OA and severity of pain and disability in the setting of symptomatic OA. Whether o not more substantial weight loss, e.g. with bariatric surgery, can reduce structural progression of OA is under investigation.

Elective Birth at 37 Weeks of Gestation Versus Standard Care for Women With an Uncomplicated Twin Pregnancy at Term

The majority of women with a twin pregnancy give birth preterm, but about 46% deliver after 37 weeks of gestation. Several population-based studies have reported that there is a higher risk of perinatal mortality and morbidity among women with a twin pregnancy continuing beyond 37 weeks of gestation with advancing gestational age. The Twins Timing of Birth Randomised Trial was a multicenter controlled study designed to determine whether elective timing of birth at 37 weeks of gestation among women with an uncomplicated twin pregnancy was associated with reduced risk of death or serious outcomes for babies, without increased harms in either the woman or the infants. All participants were at 36 6/7 weeks of gestation, dichorionic or monochorionic, with no contraindication to continuing their pregnancy. Eligible women were randomized to either an elective birth group (birth at 37 weeks, n = 116) or a standard care group (expectant management with birth planned from 38 weeks, n = 119). Outcome assessors were blinded to treatment allocation. The primary study outcome measure was a composite of serious adverse outcome for the infant. Among women with an uncomplicated twin pregnancy, there was a significantly reduced risk of serious adverse outcome for infants with elective birth at 37 weeks of gestation (elective birth: 4.7% [11/232] vs standard care: 12.2% [29/238]; the risk ratio [RR] was 0.39, with a 95% confidence interval [CI] of 0.20–0.75; P = 0.005). The only individual outcome that differed between the 2 groups was a reduced risk of birth weight less than the third centile for gestational age and infant sex (elective birth group: 3.0% [7/232] vs standard care group: 10.1% [24/238]; RR, 0.30; 95% CI, 0.13–0.67; P = 0.004). However, when they conducted a post hoc analysis using twin gestational age–specific growth charts, there was still a small difference in the primary composite of serious adverse infant outcome (elective birth group: 1.7% [4/232] vs standard care group: 5.0% [12/238]; the RR was 0.34, with a 95% CI of 0.11–1.05; P = 0.06), but it was no longer statistically significant.

Blood Components for Hemostasis

We present an overview of revised indications and doses for routinely transfused blood components. Targeted blood component therapy is one of the earliest models of personalized medicine, striving to achieve the tenets of the right dose at the right time for the right reason to the right patient. Despite rigorous quality assessment and federally mandated regulatory requirements, blood component therapy has fallen short of this goal. Transfusion support practices largely are dictated by expert opinion and tradition with few evidence-based recommendations. Blood component transfusions, while mostly regarded as safe, are not without risk for serious adverse outcomes. Pharmaceutical agents commonly used either in lieu of, or in addition to, transfusion support will also be discussed. * Abbreviation Key : RBCs : red blood cells HIV : human immunodeficiency virus TRALI : transfusion-related acute lung injury HTRs : hemolytic transfusion reactions HLA : human leukocyte antigen CMV : cytomegalovirus VWF : von Willebrand factor ADP : adenosine diphosphate TAS : transfusion-associated sepsis NSAID : nonsteroidal anti-inflammatory drug DDAVP : desmopressin acetate TTP : thrombotic thrombocytopenic purpura HELLP, hemolysis, elevated liver enzymes : and low platelet count HUS : hemolytic uremic syndrome HIT : heparin-induced thrombocytopenia ITP : immune thrombocytopenia PTP : post-transfusion purpura WHO : World Health Organization CCI : corrected count increment DIC : disseminated intravascular coagulation FFP : fresh frozen plasma TPE : therapeutic plasma exchange VKA : vitamin K antagonism PT : prothrombin time INR : international normalized ratio TACO : transfusion-associated circulatory overload FDA : US Food and Drug Administration PCC : prothrombin complex concentrate EACA : e-aminocaproic acid TXA : tranexamic acid rFVIIa : recombinant Factor VIIa

The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD

BackgroundPrehospital high concentration oxygen therapy leads to worse clinical outcomes in patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Less is known about the risks of hypoxaemia...

Comparison of Orbital Atherectomy Plus Balloon Angioplasty vs. Balloon Angioplasty Alone in Patients With Critical Limb Ischemia: Results of the CALCIUM 360 Randomized Pilot Trial

To evaluate the role of orbital atherectomy in calcified infrapopliteal arteries in patients with critical limb ischemia compared to balloon angioplasty (BA) alone. A randomized multicenter study was undertaken to evaluate short and 1-year outcomes in 50 patients (32 men; mean age 71 years, range 40-90) with confirmed calcified lesions using 1∶1 randomization to the Diamondback 360° Orbital Atherectomy System followed by BA vs. BA alone. All patients had severe (≥50% stenosis) peripheral artery disease (Rutherford classification 4-6) in the popliteal, tibial, and/or peroneal arteries. The primary endpoint was defined as restoration of a normal lumen (residual stenosis ≤30%) with no bailout stenting or dissection types C through F. Scheduled follow-up visits were conducted according to a common protocol at 1, 6, and 12 months. Procedural success was 93.1% (27/29 lesions) for atherectomy + BA patients and 82.4% (28/34 lesions) for BA alone (p = 0.27). Bailout stenting was needed in 2 (6.9%) of the 29 atherectomy + BA lesions and in 5 (14.3%) of the 35 BA-treated lesions (p = 0.44). At 1 year, there were no amputations in either group related to the index procedure. Estimates for freedom from target vessel revascularization and all-cause mortality were 93.3% and 100% in the atherectomy + BA group vs. 80.0% (p = 0.14) and 68.4% (p = 0.01) in the BA group, respectively. Proportional hazard models evaluating survival time vs. status of residual stenosis determined a hazard ratio for major adverse events of 5.6 for patients with an acute post-procedure residual stenosis >30% (p = 0.01). Debulking with orbital atherectomy appeared to increase the chance of reaching a desirable angioplasty result, with less acute need for bailout stenting and a higher procedure success. A negative association between procedure success and risk of serious adverse outcomes should encourage larger confirmatory studies.

Severity of comorbid osteoarthritis is not associated with increased risk for serious adverse outcomes in individuals with diabetes mellitus

Severity of comorbid osteoarthritis is not associated with increased risk for serious adverse outcomes in individuals with diabetes mellitus

This Month in Gastroenterology

This Month in Gastroenterology

Do Antisocial Females Exhibit Poor Outcomes in Adulthood? An Australian Cohort Study

Antisocial behaviour in young people is common and associated with adverse effects in adulthood. The question whether these effects are observed in both genders remains controversial. A typology of antisocial behaviour that captures childhood limited (CL), adolescent onset (AO) and life course persistent behaviour (LCP) through both developmental stages is utilized to examine young adult outcomes in both sexes. The Mater-University of Queensland Study of Pregnancy (MUSP) data set is a longitudinal study following up a cohort of 7223 infants and mothers from antenatal care to the child's 21st year. Data on child antisocial behaviour was collected at ages 5 and 14 years. At the 21-year follow up, self-reported outcomes were collected on antisocial behaviour, use of alcohol, tobacco and cannabis, physical and mental health functioning. The relationship between the three antisocial sub-types and negative young adult outcomes was examined for both males and females using a series of logistic regressions. Complete data across 21 years was available for 3173 participants. Males experienced higher levels of antisocial behaviour. In both males and females, AO and LCP groups exhibited elevated risk of negative outcomes including continuing antisocial behaviour, cannabis use, general health problems and depression/anxiety symptoms. The CL group exhibited poorer outcomes in physical and mental health but not in other domains. Both males and females exhibiting AO and LCP antisocial behaviour are at increased risk of serious adverse outcomes in young adulthood. The significant loss to follow up of high-risk groups suggests the important relationship between early antisocial behaviour and problems in adulthood have been underestimated. Further research is required to understand antisocial behaviour in adolescence, identify factors that reinforce its continuity into adulthood, and identify interventions which are able to modify adult outcomes.

Gene-Expression Profiling for Rejection Surveillance after Cardiac Transplantation

Endomyocardial biopsy is the standard method of monitoring for rejection in recipients of a cardiac transplant. However, this procedure is uncomfortable, and there are risks associated with it. Gene-expression profiling of peripheral-blood specimens has been shown to correlate with the results of an endomyocardial biopsy. We randomly assigned 602 patients who had undergone cardiac transplantation 6 months to 5 years previously to be monitored for rejection with the use of gene-expression profiling or with the use of routine endomyocardial biopsies, in addition to clinical and echocardiographic assessment of graft function. We performed a noninferiority comparison of the two approaches with respect to the composite primary outcome of rejection with hemodynamic compromise, graft dysfunction due to other causes, death, or retransplantation. During a median follow-up period of 19 months, patients who were monitored with gene-expression profiling and those who underwent routine biopsies had similar 2-year cumulative rates of the composite primary outcome (14.5% and 15.3%, respectively; hazard ratio with gene-expression profiling, 1.04; 95% confidence interval, 0.67 to 1.68). The 2-year rates of death from any cause were also similar in the two groups (6.3% and 5.5%, respectively; P=0.82). Patients who were monitored with the use of gene-expression profiling underwent fewer biopsies per person-year of follow-up than did patients who were monitored with the use of endomyocardial biopsies (0.5 vs. 3.0, P<0.001). Among selected patients who had received a cardiac transplant more than 6 months previously and who were at a low risk for rejection, a strategy of monitoring for rejection that involved gene-expression profiling, as compared with routine biopsies, was not associated with an increased risk of serious adverse outcomes and resulted in the performance of significantly fewer biopsies. (ClinicalTrials.gov number, NCT00351559.)