Use Of Prophylactic Therapies Research Articles

Returning integrated genomic risk and clinical recommendations: The eMERGE study

PurposeAssessing the risk of common, complex diseases requires consideration of clinical risk factors as well as monogenic and polygenic risks, which in turn may be reflected in family history. Returning risks to individuals and providers may influence preventive care or use of prophylactic therapies for those individuals at high genetic risk. MethodsTo enable integrated genetic risk assessment, the eMERGE (electronic MEdical Records and GEnomics) network is enrolling 25,000 diverse individuals in a prospective cohort study across 10 sites. The network developed methods to return cross-ancestry polygenic risk scores, monogenic risks, family history, and clinical risk assessments via a genome-informed risk assessment (GIRA) report and will assess uptake of care recommendations after return of results. ResultsGIRAs include summary care recommendations for 11 conditions, education pages, and clinical laboratory reports. The return of high-risk GIRA to individuals and providers includes guidelines for care and lifestyle recommendations. Assembling the GIRA required infrastructure and workflows for ingesting and presenting content from multiple sources. Recruitment began in February 2022. ConclusionReturn of a novel report for communicating monogenic, polygenic, and family history-based risk factors will inform the benefits of integrated genetic risk assessment for routine health care.

Vascular thrombotic events in the era of modern myeloma therapy.

The treatment landscape in multiple myeloma (MM) has changed drastically in the past two decades with new treatment paradigms evolving. In this issue Sborov et al. provide the first study investigating the frequency, severity, onset of vascular thrombotic events (VTEs) and use of prophylactic therapies in a trial applying a contemporary myeloma treatment protocol and highlight that prevention of VTEs needs to be revisited in the era of modern myeloma treatment. Commentary on: Sborov et al. Daratumumab plus lenalidomide, bortezomib and dexamethasone in newly diagnosed multiple myeloma: Analysis of vascular thrombotic events in the GRIFFIN study. Br J Haematol. 2022;199:355-365.

Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention

BackgroundVenous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action—here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers.MethodsAll admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach).ResultsData from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90–95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis.DiscussionAn EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8–5% despite this mandated system. Further research is needed to assess the potential reasons for this.

Predicting Postoperative Atrial Fibrillation from Independent ECG Components

Postoperative atrial fibrillation (PAF) occurs in 10% to 65% of the patients undergoing cardiothoracic surgery. It is associated with increased post-surgical mortality and morbidity, and results in longer and more expensive hospital stays. Accurately stratifying patients for PAF allows for selective use of prophylactic therapies (e.g., amiodarone). Unfortunately, existing tools to stratify patients for PAF fail to provide clinically adequate discrimination. Our research addresses this situation through the development of novel electrocardiographic(ECG) markers to identify patients at risk of PAF. As a first step, we explore an eigen-decomposition approach that partitions ECG signals into atrial and ventricular components by exploiting knowledge of the underlying cardiac cycle. We then quantify electrical instability in the myocardium manifesting as probabilistic variations in atrial ECG morphology to assess therisk of PAF. When evaluated on 385 patients undergoing cardiac surgery, this approach of stratifying patients for PAF through an analysis of morphologic variability within decoupled atrial ECG demonstrated substantial promise and improved net reclassification by over 53% relative to the use of baseline clinical characteristics.

Epidemiology and outcome of childhood asthma: a clinical study in an Egyptian university medical centre

The prevalence of childhood asthma has increased recently. The aim of this study was to assess the epidemiology of asthma and risk factors for hospital admission among children attending the outpatient and emergency clinic in a university hospital in Sohag, Egypt. The prevalence of asthma over a 6-month period among children aged 3-12 years at this hospital was 1.4% (178/12,612). All the asthmatic children were enrolled in an observational, prospective questionnaire study. More of the asthmatics were males, living in rural areas, with recurrent upper respiratory tract infections, passive exposure to tobacco smoke and suffering attacks at night time; 38 children (21.3%) needed hospital admission for asthma. In multivariate regression analysis, significant risk factors for hospital admission were: both cough and dyspnoea as presenting symptoms; using prophylactic therapy; and complaining of continuous symptoms (during both day and night). Proper use of prophylactic therapies is recommended for better outcomes in our asthmatic children.

Cost of medication therapy in ambulatory HIV-infected patients.

To examine the use and cost associated with prescribed medications as well as the use of over-the-counter medications and nontraditional therapies among ambulatory HIV-infected patients at Ryan White Title IIIb grantee centers. Study participants (n = 223) were enrolled from eight centers across the US and Puerto Rico. Data were collected by a nurse, pharmacist, or physician through review of medical records and medication profiles. Information on the use of over-the-counter drugs and alternative therapies was obtained from the patients. Two hundred eleven (94.6%) patients received a mean +/- SD of 5.3 +/- 3.8 prescription medications during a consecutive 90-day period. The cost of medication was $1237.62 +/- $1751.49 per patient. Patients with a diagnosis of AIDS received a greater number of prescription drugs: an average of 6.6 compared with 3.4 among HIV-positive patients and 3.5 among asymptomatic patients. Antiretroviral agents were used by 143 (68.7%) patients. Zidovudine and stavudine had the highest cost ($611.81 +/- $254.10 and $596.96 +/- $352.80, respectively). Eighty-one (40.9%) patients reported the use of at least one over-the-counter product (range 0-11) and 11.8% reported use of alternative therapies. This study shows the cost of drug treatment for HIV-infected patients has remained stable since the early 1990s. However, it is anticipated this will change due to the introduction of new anti-HIV agents, greater use of combination therapies, greater use of prophylactic therapies, and increased survival times.

OVERVIEW OF PULMONARY COMPLICATIONS

Pulmonary diseases continue to be important causes of illness and death in patients with HIV infection, but changes in therapy and demographics of HIV-infected populations are changing their manifestations. The risk of developing specific disorders is related to the area of residence, degree of immunosuppressions, HIV risk group, and use of prophylactic therapies. Bronchitis and sinusitis occur commonly in the general population but more frequently in HIV-infected persons. The increasing population of HIV-infected drug users is reflected in the increasing incidence of bacterial pneumonia and tuberculosis. Antipneumocystis prophylaxis has reduced the incidence of and mortality rate from this infection, and adjunctive corticosteriod therapy has improved the outlook for respiratory failure. Increased longevity, however, carries the risk of developing other opportunistic infections and neoplasms, some previously rare in AIDS.

Incubation Period of Vertically Acquired AIDS in Europe Before Widespread Use of Prophylactic Therapies

European surveillance data on vertically acquired (VA) AIDS cases were used to investigate the incubation period of AIDS in the absence of widespread prophylactic treatment and to assess the uncertainty associated with parametric estimates based on retrospective data. Nonparametric and parametric analyses, taking into account the effects of data truncation, were based on a total of 792 children diagnosed with AIDS between July, 1982, and June, 1990, inclusive. Among HIV-infected children who develop AIDS within 8 years, the nonparametric estimate of the median age at diagnosis was 34 months. If 20% of children are assumed to develop AIDS by the age of 1 year (a plausible estimate on the basis of published cohort data), the estimated median among all maternally HIV-infected children is 4.4 years, with 26% of children expected to remain AIDS free by 8 years of age. Results from the parametric (double Weibull) model support the hypothesis of a bimodal distribution, with a subgroup of children progressing rapidly to AIDS at a median age of approximately 5 months. However, neither the relative size of this group nor the median age at which AIDS develops in the remaining children can yet be estimated with any reasonable precision.