Threshold For Treatment Initiation Research Articles

Standardized treatment protocols for hypertension: global availability, characteristics, and alignment with the hypertension guideline recommendations.

Hypertension control is suboptimal globally. Implementing evidence-based, simple, standardized treatment protocols (STPs) has been instrumental in effectively and efficiently improving treatment and control of hypertension. We aimed to identify, characterize, and critically appraise hypertension STPs. We defined STP as a series of steps for the pharmacological treatment of primary hypertension, with information on target population, BP threshold for treatment initiation, target BP, specific drugs/classes/doses, and follow-up frequency. STPs for adult patients were identified from the websites of relevant health organizations, Google search, and through expert consultations (until July 2023). STPs for secondary, gestational, or malignant hypertension or those that were templates/samples were excluded. Included STPs were critically appraised using HEARTS in the Americas Checklist for hypertension management in primary care and compared with the 2021 WHO hypertension management guideline recommendations. Fifty STPs were identified. All STPs had a stepwise treatment approach, involved guideline-recommended first-line drugs, and 98% consisted of at least four steps. Majority (54%) recommended monotherapy with calcium channel blockers as first-line treatment. Only 44% STPs recommended treatment initiation with combination therapy, and 16% recommended single-pill combinations. Most (62%) had dose-intensification as the second step. Most (74%) STPs did not provide complete dosing information. Only one STP mentioned a target time for achieving BP control. On average, STPs scored a performance of 68% on the HEARTS Checklist. Several STPs are available globally; however, most of them have enormous scope for improvement through interventions aimed at alignment with the latest evidence-based guidelines and multistakeholder engagement.

Management of late-onset hypogonadism: person-centred thresholds, targets, techniques and tools.

Late-onset hypogonadism (LOH) is a complex and highly debatable syndrome in ageing men, which is characterised by reduced testosterone levels associated with classical symptoms of androgen deficiency. This article discusses the complex issues surrounding its management related to patient-centric thresholds and therapeutic targets. It specifically highlights the need to consider symptoms as the starting point, the key milestones in the management and the target of treatment, while ensuring safety at all times. The diagnosis of LOH requires a high index of suspicion and early identification of symptoms followed by appropriate investigations. The threshold for initiation of treatment has to be person centric and requires individualised decisions. The dose, preparation, route and follow up after testosterone initiation also may vary among different people. A person-centred approach is key to the successful management of this complex, nebulous yet debilitating disease.

Minimum Bladder Reference Contour To Guide Patient Setup For Prostate Radiotherapy

To evaluate if a model—based approach for bladder matching at the time of treatment reduces imaging and treatment time for prostate SBRT patients treated with a full bladder protocol. Prospectively collected data from prostate SBRT patients consecutively treated between 9/2019 and 1/2020 was used to select patients who experienced at least one treatment delay due to perceived underfilling of their bladder on CBCT. At our institution, a full bladder protocol (1 cup of water 45 min prior) checked by CBCT is employed for all treatments. When the pre-treatment bladder volume is smaller than the simulated volume, patients are asked to either wait longer and/or drink more water. A minimum bladder reference contour [min_bladder] was calculated for each patient by deforming the bladder contour at simulation [sim_bladder] with decreasing margins (1, 1.5, 2, 2.5, 3, 3.5, 4.5, and 5 cm) and identifying the smallest contour that met the bladder planning constraints (Maximum < 105%, V20Gy < 50% and V 36Gy < 10%). To evaluate the accuracy and efficacy of a model-based approach where min_bladder was used as the threshold for treatment initiation, the bladder on initial rejected CBCT was contoured, dose calculated and compared to min_bladder dose. Furthermore, treatment setup time reductions were estimated retrospectively as if the model had been used in the clinic. 64 patients were included in this study, of which 23 (36%) had delays due to perceived bladder underfilling (35/115 fractions). The average ± standard deviation sim_bladder and min_bladder size were 321 ± 117 and 134 ± 53 cm3, respectively. Comparing the min_bladder to the actual rejected setup bladder volume [rej_bladder] on CBCT predicted that the bladder would have been large enough for 22 fractions (63%) while for 13 fractions (37%) additional filling would have been necessary. When reviewing the doses to the rej_bladder, we found a model accuracy of 82%. For 3 fractions, the model predicted the volume was too small, but the rej_bladder met the dose constraints. For one patient, the rej_bladder shape did not conform well to the model and even though the rej_bladder was larger than the min_bladder, it did not meet the bladder constraints. The average total treatment times as recorded in Aria for fractions without delays versus those with delays was 28.1 ± 18 vs 49.6 ± 15 min (p<0.0001) (Student's t-test). Average estimated time that could be saved using the minimum bladder reference was 25± 11 min per fraction and number of CBCTs reduced from 2 to 1 per fraction. We found 36% of our prostate SBRT patients were delayed at least once during their treatment due to underfilling of their bladder. We demonstrate that employing a patient-specific model-based approach using a minimum bladder reference created at the time of planning could prevent treatment delays in the majority of cases and reduce the number of CBCTs used to setup patients for prostate SBRT.

How varying CD4 criteria for treatment initiation was associated with mortality of HIV-patients? A retrospective analysis of electronic health records from Andhra Pradesh, India.

BackgroundHIV treatment and care services were scaled up in 2007 in India with objective to increase HIV-care coverage. CD4 count based criteria was mainly used for treatment initiation with increasing threshold in later years. Therefore, this paper aimed to evaluate the survival by varying CD4 criteria for antiretroviral treatment (ART) initiation among of HIV-positive patients, and independent factors associated with the mortality.MethodsThis retrospective cohort study included 127 949 HIV-positive patients aged ≥15 years, who initiated ART between 2007 and 2013 in Andhra Pradesh state, India. The patient’s demographic and clinical characteristics were extracted from the patient’s health records from electronic Computerized Management Information System Software (CMIS). Incidence of mortality/100 person-years was calculated for CD4 and treatment initiation categories. Kaplan-Meier and multivariable Cox-regression analyses were used to explore the association.ResultsMedian CD4 count was 172 (inter-quartile range (IQR) = 102-240) at the time of treatment initiation, and 19.3% of them had ≤ 100 CD4 count. Incidence of mortality for the period 2007-08 (CD4 ≤ 200 cells/mm3) was 8.5/100 person-years compared to 6.4/100 person-years at risk for the period 2012 onwards (CD4 ≤ 350 cells/mm3). Earlier thresholds for treatment initiation showed higher risk of mortality (2007-08 (CD4 ≤ 200 cells/mm3), adjusted hazard ratio (HR): 1.86, 95% confidence interval (CI): 1.68-2.07; 2009-11 (CD4 ≤ 250 cells/mm3), HR = 1.67, 95% CI = 1.51-1.85) compared to 2012 onwards (CD4 ≤ 350 cells/mm3) criteria for treatment initiation.ConclusionsIncreasing CD4 threshold for treatment initiation over time was independently associated with lower risk of mortality. More efforts are required to detect and treat early, monitoring of follow-ups, promote health education to improve ART adherence, and provide supportive environment that encourages HIV-infected patients to disclose their HIV status in confidence.

A Simpler Prediction Rule for Rebound Hyperbilirubinemia.

We previously reported a clinical prediction rule to estimate the probability of rebound hyperbilirubinemia using gestational age (GA), age at phototherapy initiation, and total serum bilirubin (TSB) relative to the treatment threshold at phototherapy termination. We investigated (1) how a simpler 2-variable model would perform and (2) the absolute rebound risk if phototherapy were stopped at 2 mg/dL below the threshold for treatment initiation. Subjects for this retrospective cohort study were infants born 2012-2014 at ≥35 weeks' gestation at 1 of 17 Kaiser Permanente hospitals who underwent inpatient phototherapy before age 14 days. TSB reaching the phototherapy threshold within 72 hours of phototherapy termination was considered rebound. We simplified by using the difference between the TSB level at the time of phototherapy termination and the treatment threshold at the time of phototherapy initiation as 1 predictor, and kept GA as the other predictor. Of the 7048 infants treated with phototherapy, 4.6% had rebound hyperbilirubinemia. The area under the receiver operating characteristic curve was 0.876 (95% confidence interval, 0.854 to 0.899) for the 2-variable model versus 0.881 (95% confidence interval, 0.859 to 0.903) for the 3-variable model. The rebound probability after stopping phototherapy at 2 mg/dL below the starting threshold was 2.5% for infants ≥38 weeks' GA and 10.2% for infants <38 weeks' GA. Rebound hyperbilirubinemia can be predicted by a simpler 2-variable model consisting of GA and the starting threshold-ending TSB difference. Infants <38 weeks' gestation may need longer phototherapy because of their higher rebound risk.

Stroke and thromboembolic event rates in atrial fibrillation according to different guideline treatment thresholds: A nationwide cohort study.

Contemporary guidelines suggest anticoagulant treatment decisions in atrial fibrillation (AF) patients to be based on risk stratification for stroke. However, guidelines do not agree on the threshold for treatment initiation. We explored the variation in thromboembolic event rates in a non-anticoagulated AF population, according to different guideline threshold and methodological approaches. AF patients between 1998 and 2014 free from anticoagulant treatment were identified. Event rates for ischemic stroke and ischemic stroke/systemic embolism were explored. The overall ischemic stroke rate was 3.20 per 100 person-years (‘formal rate assessment’). For patients with a CHA2DS2-VASc score of 1 the ischemic stroke rate was 0.97 when using a ‘formal rate assessment’, 0.62 when using a ‘conditioning on the future’ approach, and 0.93 when using a ‘censoring approach’. Rates for thromboembolism for the ‘European treatment threshold’ (CHA2DS2-VASc score of 1, males only) ranged 1.17 to 1.53. Rates for the ‘U.S. treatment threshold’ (CHA2DS2-VASc of 2) ranged from 1.95 to 2.33. Thromboembolic event rates differed markedly in non-anticoagulated AF patients according to the conflicting European and U.S. guideline treatment thresholds. Second, the choice of methodological approach has implications, thus we recommend using the censoring approach for event rate estimation among AF patients not on treatment.

Abstract P179: Systolic Blood Pressure and Risk for Cardiovascular Disease Among Adults 60 Years and Older without Diabetes or Chronic Kidney Disease

The 2014 Evidence-based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) raised the systolic blood pressure (SBP) threshold for treatment initiation and goal attainment to 150 mmHg in adults 60 years and older without a history of diabetes or chronic kidney disease (CKD). Using data from the nationwide Reasons for Geographic and Racial Difference in Stroke (REGARDS) study, we examined the association between SBP levels and cardiovascular disease (CVD), coronary heart disease (CHD), and stroke among adults ≥60 years of age. We excluded participants with a history of diabetes, CKD, and diastolic blood pressure (DBP) ≥90 mmHg. Baseline REGARDS data were collected during telephone interviews and in-home study visits in 2003 through 2007 and included two blood pressure measurements following a standardized protocol. SBP was categorized as &lt;140 mmHg, 140-149 mmHg, and ≥150 mmHg. Outcomes were identified through December 31, 2012 using primary data collection. Of the 4,618 REGARDS participants taking antihypertensive medication, 593 (12.8%) had SBP 140-149 mmHg and 343 (7.4%) had SBP ≥150 mmHg. After multivariable adjustment, SBP of 140-149 mmHg versus SBP &lt;140 mmHg was not associated with any of the outcomes (Table 1) whereas SBP ≥150 mmHg was associated with an increased risk for CVD and CHD, but not stroke. Of the 5,601 participants not taking antihypertensive medication, 417 (7.5%) had SBP 140-149 mmHg and 181 (3.2%) had SBP ≥150 mmHg. Compared with SBP &lt;140 mmHg, SBP140-149 mmHg but not SBP ≥150 mmHg was associated with an increased risk for CVD, CHD, and stroke. In summary, SBP between 140-149 mmHg was associated with CVD-related outcomes in untreated, but not treated individuals. These data suggest using different thresholds for antihypertensive treatment initiation and goal attainment among individuals ≥60 years of age without a history of diabetes or CKD, with DBP ≥90 mmHg may be safe.

Effect of gene polymorphism of ghrelin on the risk of essential hypertension in a japanese population

with a history of diabetes, CKD, and diastolic blood pressure 90 mm Hg. Baseline REGARDS data were collected during telephone interviews and in-home study visits in 2003 through 2007 and included two blood pressure measurements following a standardized protocol. SBP was categorized as < 140 mm Hg, 140-149 mm Hg, and 150 mm Hg. Outcomes were identified through December 31, 2011 using primary data collection and Medicare claims. Of the 2,279 REGARDS participants taking antihypertensive medications with Medicare linked data (mean age 72.2 years, 54.8% female), 309 (13.6%) had SBP of 140 to 149 mm Hg and 200 (8.8%) had SBP 150 mm Hg. After multivariable adjustment, SBP of 140 to 149 mm Hg versus SBP < 140 mm Hg was not associated with any of the outcomes (Table 1) whereas SBP 150 mm Hg was associated with an increased risk for CVD. In summary, SBP levels between 140 and 149 mm Hg were not associated with CVD-related outcomes or falls in comparison to SBP < 140 mm Hg among adults 65 years taking antihypertensive medication. These data suggest the higher SBP threshold for treatment initiation and goal attainment among individuals 65 years of age without a history of diabetes or CKD, with DBP 90 mm Hg may be safe.

PTH-078 Forward Progress Or Financial Extravagance? Counting The Cost Of Nice Guidelines For Chronic Hepatitis B

IntroductionAn estimated 180,000 people in the UK are chronically infected with hepatitis B (HBV). NICE guidelines published in 2013 advocate changes in the management of this patient group. Recommendation toward...

Achieving the National Strategic Plan: A practical calculator for local target setting in district health facilities

The South African HIV National Strategic Plan (NSP) aims to provide access to appropriate treatment, care and support to 80% of the HIV-infected population by 2011. By mid-2008, highly active antiretroviral treatment (HAART) was being dispensed to about half the HIV-infected population in need. Reaching the NSP targets will require full mobilisation of all of South Africa's health facilities. While the NSP has broad political and programmatic support from the Department of Health and civil society, and managers are able to recite the national targets, it has been difficult for these managers to relate the targets to their own geographical areas of responsibility. National, regional and district targets for HIV care have been set from South Africa's relatively good census, modelling and epidemiological data. However, few practical tools are available to help clinicians and managers understand their facility's actual contribution to the district regional and national NSP targets for each step of the HIV care pathway (HIV testing, CD4 testing, HAART referral and initiation). The calculation of HAART initiation targets is complicated by the anticipated additional demand for treatment that will be generated by a change in the recommended CD4-count threshold for initiation of treatment.4 Accordingly, we provide a data-based tool that is readily available, and that district and facility managers can use to calculate their annual steady-state HIV testing, CD4 testing and HAART initiation requirements. These calculated values can be used for local and regional planning and to assess and improve current performance at facility level.

Stigma and treatment delay in first‐episode psychosis: a grounded theory study

A longer duration of untreated psychosis (DUP) is associated with greater morbidity in the early course of schizophrenia. This formative, hypothesis-generating study explored the effects of stigma, as perceived by family members, on DUP. Qualitative interviews were conducted with 12 African American family members directly involved in treatment initiation for a relative with first-episode psychosis. Data analysis relied on a grounded theory approach. A testable model informed by constructs of Link's modified labelling theory was developed. Four main themes were identified, including: (i) society's beliefs about mental illnesses; (ii) families' beliefs about mental illnesses; (iii) fear of the label of a mental illness; and (iv) a raised threshold for the initiation of treatment. A grounded theory model was developed as a schematic representation of the themes and subthemes uncovered in the family members' narratives. The findings suggest that due to fear of the official label of a mental illness, certain coping mechanisms may be adopted by families, which may result in a raised threshold for treatment initiation, and ultimately treatment delay. If the relationships within the grounded theory model are confirmed by further qualitative and quantitative research, public educational programs could be developed with the aim of reducing this threshold, ultimately decreasing DUP.

Treatment of young-onset Parkinson's disease: role of dopamine receptor agonists

For mostly arbitrary reasons, the term “juvenile parkinsonism” is restricted to patients aged 20 years or younger, and “young-onset PD” (YOPD) is onset between ages 21 and 40 years. Previous studies suggest that YOPD has a slower disease progression and a greater incidence and earlier appearance of l-dopa-induced dyskinesias and motor fluctuations. Therefore, our therapeutic strategies have to respect the fact that YOPD patients face many years of gradual progression of disease and disability, a greater probability for developing various adverse effects of treatment, and worsening of quality of life. As an individually tailored treatment should be our primary goal, we must bear in mind that the needs and expectations of YOPD patients are different from those of their older counterparts. The therapeutic strategy for YOPD patients should include a relatively low threshold for initiation of treatment, and initiating treatment with a dopamine receptor agonist while maintaining an individually adjusted, moderately high threshold for switching to or adding l-dopa in cases where treatment response is suboptimal or if problematic adverse effects develop. It has been shown that some dopamine receptor agonists may also have antidepressive efficacy, thus potentially managing an additional problem associated with PD.

Impact of Ethics and Economics on End-of-Life Decisions in an Indian Neonatal Unit

The aim of this article was to describe how providers in an Indian NICU reach life-or-death treatment decisions. Qualitative in-depth interviews, field observations, and document analysis were conducted at an Indian nonprofit private tertiary institution that provided advanced neonatal care under conditions of resource scarcity. Compared with American and European units with similar technical capabilities, the unit studied maintained a much higher threshold for treatment initiation and continuation (range: 28-32 completed gestational weeks). We observed that complex, interrelated socioeconomic reasons influenced specific treatment decisions. Providers desired to protect families and avoid a broad range of perceived harms: they were reluctant to risk outcomes with chronic disability; they openly factored scarcity of institutional resources; they were sensitive to local, culturally entrenched intrafamilial dynamics; they placed higher regard for "precious" infants; and they felt relatively powerless to prevent gender discrimination. Formal or regulatory guidelines were either lacking or not controlling. In a tertiary-level academic Indian NICU, multiple factors external to predicted clinical survival of a preterm newborn influence treatment decisions. Providers adjust their decisions about withdrawing or withholding treatment on the basis of pragmatic considerations. Numerous issues related to resource scarcity are relevant, and providers prioritize outcomes that affect stakeholders other than the newborn. These findings may have implications for initiatives that seek to improve global neonatal health.

Use of Nonsteroidal Antiinflammatory Drugs

Clinical trial data have prompted questions about the degree to which patients and their physicians should consider an increased risk of cardiovascular or cerebrovascular events when selecting medications for pain relief. Since the 2005 publication of a Science Advisory on the use of nonsteroidal antiinflammatory drugs (NSAIDs) by the American Heart Association,1 several important events have occurred that have served as the catalyst for this update for clinicians. (1) Additional data from randomized controlled trials of cyclooxygenase (COX)-2–selective agents have been reported and summarized in meta-analyses, which has reinforced the concern about cardiovascular events with COX-2 inhibitors (coxibs; Figure 1). (2) Several reports have appeared that have identified an increased risk of cardiovascular events even with the nonselective NSAIDs, which has raised concern about the use of those agents as well (Table). (3) Regulatory authorities in several regions of the world have introduced warning statements and advisories to both healthcare professionals and the lay public about the use of various NSAIDs (Figures 2 and 3⇓). Figure 1. Comparison of effects of different selective COX-2 inhibitors vs placebo on myocardial infarction. Event numbers and person-years of exposure, with corresponding mean annual event rates in parentheses, are presented for patients allocated to selective COX-2 inhibitor or placebo. Event rate ratios for pooled data with 95% CIs are indicated by a diamond; rate ratios for individual selective COX-2 inhibitors, with 99% CIs, are indicated by a square and horizontal line. Diamonds to the right of the solid line indicate hazard with a selective COX-2 inhibitor compared with placebo. As noted, there was a significant increase in the rate ratio for myocardial infarction with COX-2 inhibitors compared with placebo. Similar analyses (data not shown) include rate ratios of 1.42 (1.13 to 1.78; P =0.003) for vascular events, 1.02 (0.71 to 1.47; P …

Standards of Proof, Standards of Practice, and Proof of Standards: A Tale of Two Trials

In this issue of the Journal of Clinical Oncology, Chang et al and Witzig et al report two randomized controlled trials evaluating the role of recombinant human erythropoietin (epoetin alfa) for the management of anemia in cancer patients receiving chemotherapy. Previous rigorous trials and systematic reviews of randomized trials have demonstrated the efficacy of this agent in maintaining hemoglobin levels and reducing transfusion requirements in cancer patients receiving chemotherapy. Recommendations from high-quality, evidence-based clinical practice guidelines confirm the role for epoetin alfa in anemia management in this clinical setting. The drug is already commonly used in practice. Furthermore, the public and patients welcome the availability of a therapeutic option that can reduce exposure to what they perceive as the risks of blood transfusion. Both trials reported in this issue confirm, yet again, that epoetin alfa works in achieving the objectives of maintaining hemoglobin levels and reducing transfusion requirements in cancer patients receiving myelosuppressive therapy. So, what do these trials add to our current knowledge, and how should they affect routine practice? Both trials indirectly address the issue of drug scheduling. Whereas virtually all previous randomized trials tested epoetin alfa using an inconvenient three-times-per-week schedule, clinicians had already migrated towards the more convenient weekly schedule, and the wording of recommendations from clinical practice guidelines reflected this situation. Now, as a result of these trials, we can confirm both the efficacy of weekly dosing in maintaining hemoglobin levels and the reduction of transfusion requirements across a spectrum of cancer patient populations undergoing chemotherapy. Considering the current clinical context of the usage of routine epoetin alfa and the total body of available evidence, it would seem appropriate for updates of current guidelines and for future guidelines to endorse the weekly schedule for hemoglobin maintenance without demanding the higher standard of proof, which would involve a direct comparison to three-times-per-week treatment. The trial by Witzig et al also addressed the clinical utility of a tool for better selection of patients who might benefit from epoetin alfa treatment. This is important because one of the practical difficulties of using epoetin alfa is that, once it is started, the clinical effect takes several weeks to be observed. This means that timing the initiation of therapy must be done carefully and proper selection of those patients who can truly benefit from treatment should be performed because not all patients will develop a degree of anemia requiring intervention. The secondary question posed by this trial is specifically targeted to a corrective intervention strategy for anemia. The trial by Chang et al addressed a clinical question with more far-reaching implications, involving an expanded indication for epoetin alfa as a preventative, as opposed to corrective, intervention to manage anemia. Waiting for significant decreases in hemoglobin after initiation of myelosuppressive therapy to determine a patient’s eligibility for treatment with epoetin alfa may unnecessarily expose patients to an increased amount of time with symptoms of anemia. The preventative approach can be expected to minimize the burden of anemia symptoms by reducing the time spent in a symptomatic state. The Chang et al study included a relatively homogeneous population of breast cancer patients (79% receiving adjuvant chemotherapy) who were randomly assigned to receive the experimental therapy (epoetin alfa once weekly) or best supportive care when the hemoglobin decreased to or just below 12 g/dL. This threshold for initiation of treatment is higher than that used in previous trials (and in the study by Witzig et al). Given this potential expansion of clinical indications for this relatively costly drug, it seems appropriate that the standard of proof for clinical benefit for any trial ought to meet two more stringent criteria. First, the trial should JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 12 APRIL 2

How to Manage Metabolic Syndrome

Metabolic syndrome (MS) is a complex clinical condition, initially described as ‘metabolic syndrome X’, characterised by the presence in the same individual of multiple metabolic and cardiovascular traits, typically high blood pressure, abdominal obesity, lipid profile abnormalities, insulin resistance and glucose intolerance. More recently, other features have been proposed; in particular, chronic pro-inflammatory and pro-thrombotic states seem to further characterise MS. Because of its multifactorial pathogenesis, a unitary clinical management of MS is still debated and physicians tend to make individual choices. In particular, the threshold for treatment initiation is rather heterogeneous. However, a large body of observational studies have demonstrated that patients with MS have an increased incidence of major cardiovascular events, such as acute myocardial infarction and ischemic stroke, particularly in those patients with a high-risk profile (hypertensive patients with target organ damage or diabetes mellitus). An aggressive therapeutic approach for reducing global cardiovascular risk is effective in these subgroups. On the other hand, the lack of specific international guidelines, consisting of a diagnostic and therapeutic algorithm with accurate cardiovascular risk stratification, makes the clinical management of patients with MS by primary physicians difficult and not uniform. In particular, while there is convincing evidence that the progressive addition of components of MS increases cardiovascular risk, there are no consistent indications regarding treatment priorities and strategies. In this article we propose a global risk-based stratification, aimed at identifying ‘low-risk’ and ‘high-risk’ patients within those presenting the MS. This approach may prove to be of particular efficacy in clinical practice to identify patients with MS with different degrees of cardiovascular disease risk profile. This approach may also be helpful to develop therapeutic strategies based on global cardiovascular risk profile.

Evaluation of point-of-care tests for diagnosis of disseminated intravascular coagulation in dogs admitted to an intensive care unit

Objective To evaluate the accuracy of point-of-care tests for the diagnosis of disseminated intravascular coagulation (DIC) in dogs and assess the correlation and agreement of results between point-of-care and laboratory tests in the evaluation of hemostatic function. Design Prospective case series. Animals 59 critically ill dogs (affected dogs) with clinical signs of diseases known to predispose to DIC and 52 clinically normal dogs. Procedures Accuracy of the point-of-care tests (activated clotting time [ACT], estimated platelet count and number of schizocytes from a blood smear, plasma total solids [TS] concentration, and the protamine sulfate test) was evaluated, using receiver operating characteristic curves and likelihood ratios. A strategy, using likelihood ratios to calculate a post-test probability of DIC, was tested with 65% used as a threshold for initiation of treatment. Results of laboratory tests (coagulogram and plasma antithrombin III activity) were used as the standard for comparison in each dog. Results ACT and estimated platelet count provided the best accuracy for detection of DIC. The plasma TS concentration, schizocyte number, and protamine sulfate test had poor accuracy. The strategy using post-test probability of DIC identified 12 of 16 affected dogs that had DIC. Estimated platelet count was correlated and had acceptable clinical agreement with automated platelet count (r = 0.70). The plasma TS (r = 0.28) concentration and serum albumin (r = 0.63) concentration were not accurate predictors of plasma antithrombin III activity. The ACT did not correlate with activated partial thromboplastin time (r = 0.28). Conclusions and Clinical Relevance Strategic use of likelihood ratios from point-of-care tests can assist clinicians in making treatment decisions for dogs suspected to have DIC when immediate laboratory support is unavailable. (J Am Vet Med Assoc 1999;215:805–810)