Lower gastrointestinal bleeding (LGIB) can result in serious adverse events. Appropriate risk stratification of LGIB patients can improve their care. Previous risk scores to identify severe LGIB patients have limitations, therefore we developed clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day adverse outcomes that would overcome these limitations. We conducted a health records review and compared two methods of regression analysis on our data in order to develop a clinical decision tool. We identified five risk factors that have a high sensitivity and good predictive value for identifying low risk LGIB patients: age ≥ 75 years, INR ≥2.0, hemoglobin ≤ 100 g/l, ongoing bleeding in the ED and a medical history of colorectal polyps. Future, large, prospective studies should be done to validate the results, after which implementation studies should be conducted.

Following colonoscopic polypectomy, US Multisociety Task Force (USMSTF) guidelines stratify patients based on risk of subsequent advanced neoplasia (AN) using number, size, and histology of resected polyps, but have only moderate sensitivity and specificity. We hypothesized that a state-of-the-art statistical prediction model might improve identification of patients at high risk of future AN and address these challenges. Data were pooled from seven prospective studies which had follow-up ascertainment of metachronous AN within 3-5 years of baseline polypectomy (combined n = 8,228). Pooled data were randomly split into training (n = 5,483) and validation (n = 2,745) sets. A prognostic model was developed using best practices. Two risk cut-points were identified in the training data which achieved a 10 percentage point improvement in sensitivity and specificity, respectively, over current USMSTF guidelines. Clinical benefit of USMSTF versus model-based risk stratification was then estimated using validation data. The final model included polyp location, prior polyp history, patient age, and number, size and histology of resected polyps. The first risk cut-point improved sensitivity but with loss of specificity. The second risk cut-point improved specificity without loss of sensitivity (specificity 46.2 % model vs. 42.1 % guidelines, p < 0.001; sensitivity 75.8 % model vs. 74.0 % guidelines, p = 0.64). Estimated AUC was 65 % (95 % CI: 62-69 %). This model-based approach allows flexibility in trading sensitivity and specificity, which can optimize colonoscopy over- versus underuse rates. Only modest improvements in prognostic power are possible using currently available clinical data. Research considering additional factors such as adenoma detection rate for risk prediction appears warranted.

No description available.

Recent large randomized controlled trials (RCTs) have shown that renal revascularization does not confer added benefit to unselected patients with atherosclerotic renovascular disease (ARVD) treated with multi-targeted medical therapy. Results suggest that contemporary medical vascular protection therapy has contributed to improved clinical outcomes in ARVD. However, patients with †̃high-riskâ€TM clinical features have largely been excluded from RCTs and there is consistent observational evidence that this specific patient subgroup may gain benefit from revascularization. Timely identification of these patients through risk stratification and prediction of outcomes post-revascularization remain important challenges. The main aims of this epidemiological research project were to explore how treatment and clinical end-points in ARVD have evolved over the past three decades, to identify the determinants of long-term end-points in ARVD, to investigate the effect of revascularization in a selected †̃high-riskâ€TM subgroup, to investigate novel biomarker association of key end-points and finally to develop a clinical risk prediction model that can aid risk stratification and patient selection for revascularization. These individual studies were all based on a local database that includes details of demographic and clinical data for patients with ARVD referred to our tertiary renal centre between 1986 and 2014. Primary end-point measures included death, progression to end-stage kidney disease, cardiovascular events and a composite end-point composed of the first of any of the above events. Management of ARVD has been influenced by RCT results, leading to a decline in the number of revascularization procedures performed. Traditional cardiovascular risk factors together with baseline renal function and proteinuria are the most important determinants of adverse events in ARVD thus advocating the use of multi-targeted medical therapy and aggressive risk factor control in all patients with ARVD. Nonetheless ARVD is a heterogenous condition and results of this research project show that revascularization can be of benefit in patients with rapidly deteriorating renal function, bilateral severe ARVD and/or < 1g/day baseline proteinuria. A panel of novel biomarkers may have incremental risk predictive value when used in conjunction with more traditional risk factors, and NT-proBNP levels may aid patient selection for revascularization. A simple clinical risk-prediction score based on easily obtainable variables may be used as a bedside tool to help risk stratification and facilitate patient selection for revascularization, thus encouraging a more patient-specific therapeutic approach.

Objective Formulation of a clinical practice guideline (CPG) for the use of thromboprophylaxis (TP) in pediatric patients with a central venous catheter (CVC). Participants The development team consisted of five experts and a doctoral candidate acting as the primary author. Evidence The guideline was developed utilizing the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework. A systematic review of the evidence was performed and evidence was graded using the American Academy of Pediatrics (2004) evidence classifications for CPG recommendations. An appraisal team evaluated the guideline quality utilizing the AGREE Plus platform rating the guideline as “highest quality.” Consensus Employing a modified Delphi methodology, members of the development team reviewed available evidence and voted on proposed Key Action Statements (KAS). Consensus is defined as 80% rating the KAS “usually appropriate.” Conclusion Five KAS are included in the final CPG. Each KAS indicates level of evidence, benefit-harm relationship, and level of recommendation. KAS 1. Providers of hospitalized children (0-18 years of age) may assess for VTE risk factors using the Skrocki VTE risk stratification tool if the patient has a CVC. (Evidence Quality:C, Rec. Strength: Option). KAS 2. Providers of hospitalized children should initiate targeted pharmacologic thromboprophylaxis (tpTP) at the time of CVC insertion or hospital admission (if CVC present on admission). (Evidence Quality: B, Rec. Strength: Strong Recommendation) KAS 3. Providers of hospitalized children with a CVC should implement mechanical thromboprophylaxis (mTP) if the child is immobile (Braden Q score <2) or moderate/ high risk for VTE using the Skrocki VTE risk stratification tool and have no contraindications to mTP. (Evidence Quality: B, Rec. Strength: Recommendation). KAS 4. Providers of hospitalized children with a CVC may prescribe systemic pharmacologic thromboprophylaxis (spTP) if the patient is found to be at high risk for VTE using Skrocki VTE risk stratification tool and the patient has no contraindications to spTP. (Evidence Quality: C, Rec. Strength: Option). KAS 5. Providers of hospitalized children should avoid femoral CVCs, multilumen CVCs and/or percutaneous insertion technique if their benefit does not clearly outweigh their risks. (Evidence Quality: B, Rec. Strength: Recommendation).

Objetivo: Este artigo tem como objetivo avaliar o impacto da implantação da estratégia de triagem com classificação de risco e da unidade vascular no processo assistencial dos pacientes atendidos no serviço de emergência do Hospital de Clínicas de Porto Alegre, HCPA. Método:Trata-se de um quasi-experimento em que 3.700 pacientes atendidos na emergência nos meses de março a maio de 2005 e 4.954 pacientes atendidos no mesmo período de 2007, após a implantação das novas tecnologias, tiveram seu processo de atendimento medidos e comparados.O impacto da reorganização do serviço com a implantação destas tecnologias foi avaliado através da comparação dos indicadores de “Tempo de Permanência”, “Tempo de espera para realização de Exames” e “Tempo de espera para realização Cirurgias e Procedimentos” de todos os pacientes atendidos e especificamente dos pacientes com doenças cardiovasculares. Resultados: O tempo mediano de triagem de todos os pacientes foi de 11,8 minutos (0-92,5) e de 6,3 minutos (0-53) dos pacientes com doenças cardiovasculares. Foi evidenciado aumento significativo da mediana de tempo de permanência: 2005: 12,3h (0-510,8) e 2007:15,5h.(0-388,9), P<0,001. O mesmo ocorreu com os pacientes cardiovasculares que passaram de uma mediana de tempo de permanência de 24,5h (0,5- 341) em 2005 para 74h (0,6 -287,h), P <0,001.O exame de tomografia de crânio apresentou redução significativa no tempo mediano de espera para todos os pacientes 2005: 4h (0,08-76,4), 2007: 3h (0,2-62,7), P =0,006,e para os pacientes com doenças cardiovasculares, 2005: 4,2h (0,5-15,9), 2007: 0,9h (0,5-7,9), P =0,001.O cateterismo cardíaco realizado pelos doentes cardiovasculares agudos apresentou uma redução significativa no tempo mediano de espera, 2005: 55,6h (31,2-90,4) e 2007 13,6h (0,6-97,6), P =0,025. Conclusão: Embora tenha havido aumento de 25,3% nos casos atendidos entre 2005 e 2007, acompanhado do aumento da mediana de idade, do escore de gravidade e de casos demandando procedimentos cirúrgicos, a implantação de estratégia de triagem com estratificação de risco e da unidade vascular em serviço de emergência de hospital universitário esteve associada à redução dos tempos de espera para procedimentos diagnósticos e terapêuticos considerados como essenciais em pacientes com síndrome vascular aguda. / Objective: This study assesses the impact of implementing a strategy of screening using risk rating and creating a vascular unit for patients admitted to the emergency department of Hospital de Clinicas de Porto Alegre. Method: This study describes a quasi-experiment in which 3700 patients treated at the emergency department from March to May 2005 (P1) and 4954 patients treated during the same months of 2007 (P2), after the introduction of new care technologies. The process of care was measured and compared. The impact of department reorganization with these technologies was evaluated comparing length of stay, length of stay to perform tests and length of stay to perform surgery or procedure, measured for all patients and specifically for cardiovascular disease patients. Results: Screening median time was 11.8 min (0-92.5) for all patients and 6.3 min (0- 53) for cardiovascular disease patients. Our results showed a significant increase in median length of stay from P1 to P2 for all patients, 12.3 min (0-510.8) and 15.5 hr (0-388.9) respectively, P < 0.001. Cardiovascular disease patients had a median length of stay of 24.5 min (0.5-341) and 74 hr (0.6-287) in 2005 and 2007 respectively. Cranial tomography scan had a significant time reduction for all patients from P1 to P2, 4 hr (0.08-76.4) and 3 hr (0.2-62.7) respectively, P = 0.006, and for cardiovascular disease patients 4.2 hr (0.5-15.9) and 0.9 hr (0.5-7.9) respectively, P = 0.001. Cardiac catheterization for acute cardiovascular disease patients showed a significant decrease in median waiting time, from 55.6 min (31.2- 90.4) in P1 to 13.6 min (0.6-97.6) in P2, P = 0.025. Conclusion: Although there was a 25.3 percent increase in admitted patients from 2005 to 2007 and an increase in age, severity score and surgical patients, the implementation of a screening strategy with risk stratification and creation of a vascular unit in the emergency department was associated with reduction of waiting times of diagnostic and therapeutic procedures for acute cardiovascular disease patients.

Background Chemotherapy-induced peripheral neuropathy (CIPN) is a common dose-limiting toxicity with significant sequelae impacting prognosis and quality of life. The natural history and pathophysiological mechanisms of CIPN are unclear. Equally, the lack of systematic approach to diagnosis and assessments contribute to difficulty identifying at risk patients with implications on symptom burden. Effective management of CIPN is also difficult due to limited treatment options. To try and address this challenging clinical problem, this thesis aimed to adopt a translational approach to: 1) characterisation and early identification of the development of CIPN in cancer patients receiving neurotoxic chemotherapy and 2) explore topical treatment options in patients with chronic peripheral neuropathic pain. Methodology In the CIPN study, a mixed cohort of colorectal, gynaecological and lung cancer patients receiving neurotoxic chemotherapy (platinum agents and taxanes) were assessed prospectively, at baseline (prior to initiating chemotherapy), during cycles (every 3 weeks) and post-treatment (every 3 months) for up to 12 months (cumulative 261 assessments). Comprehensive longitudinal clinical characterisation consisted of the integration of quantitative sensory testing (QST), objective measure of function (grooved pegboard test), patient-reported outcomes and in vivo confocal microscopy to provide insight into the clinical course and potential psychophysical biomarkers of CIPN during and after chemotherapy. In the pilot intervention study, patients with chronic, complex cancer treatment related peripheral neuropathic pain received a single application of high concentration 8% capsaicin patch. Assessments conducted at baseline, 4 weeks and 12 weeks included patient-reported outcomes and QST with an exploratory application of in vivo confocal microscopy in a case. Results In the CIPN study, 33 patients when compared to 33 age and gender matched healthy controls displayed thermal hyperalgesia, sensorimotor impairment and increased resting heart rate prior to initiating neurotoxic chemotherapy. Characterisation of somato-sensory profile demonstrated dysfunction of the various types of primary afferent nerves (Aβ, Aδ and C). Assessing the change over time from baseline to during cycles and post-treatment follow up, revealed signs and symptoms as early as cycle 2 with an increase in the later cycles and 3 months post-treatment follow up. A greater burden was observed at 12 months in comparison to baseline. Significant changes were observed in QST parameters indicating both small and large fibre deficits. Interesting associations were observed for example with tactile deficits in the upper and lower limb and patient-reported outcomes. The repeated measures model provided an opportunity to distil the relationship between subjective and objective measures of CIPN. The subclinical findings at baseline however did not translate to obvious predictors of CIPN development. The exploratory use of in vivo confocal microscopy (45 healthy controls, 9 patients) demonstrated correlation with current assessment tools (QST). Analysis from the pilot intervention study of 20 patients revealed clinically significant improvement in pain in a subset at 4 and 12 weeks post-treatment. Conclusion Overall the combination of subjective and objective measures utilised in the prospective characterisation of this mixed cohort of cancer patients provided a useful paradigm for qualifying and quantifying the trajectory of CIPN related peripheral nerve damage and symptom burden with additional contribution from the novel in vivo confocal microscopy work. In capturing the varied spectrum of phenotypes, this approach may provide insight into the complexities of the underlying neurobiological mechanisms. The baseline subclinical sensory, motor and autonomic nerve dysfunction implicate a cancer-mediated process possibly contributing to CIPN. Although the preliminary investigation of baseline predictors of CIPN was inconclusive, thermal pain threshold warrant further investigation. These findings highlight the need to further address prediction and risk stratification in larger studies. The exploratory intervention study suggests that patients with chronic neuropathic pain may receive some benefit in pain severity, function and mood with effect continuing at 12 weeks post-treatment. This research warrants further investigation in larger cohorts.

Atrial fibrillation (AF) confers an independent increased risk of stroke and death. The stroke risk is very heterogeneous and current risk stratification models based on clinical variables, such as the CHADS2 and CHA2DS2VASc score, only offer a modest discriminating value. The aims of this thesis were to study cardiac biomarkers, cardiac troponin and natriuretic peptides e.g. N-terminal prohormone-B-type natriuretic peptide (NT-proBNP), and describe levels in AF patients, investigate the association with stroke or systemic embolism, cardiovascular event, major bleeding and mortality, and to assess how levels of cardiac biomarkers change over time. Cardiac troponin was analyzed with contemporary assays and high sensitivity assays. The study populations consisted of patients with atrial fibrillation and one risk factor for stroke included in the RE-LY (n=6189) and the ARISTOTLE (n=14892) biomarker substudies. Median follow-up time was 2.2 years and 1.9 years, respectively. In a subset of participants (n=2514) data from repeated measurements was available at three months. Cardiac troponin was detectable in 57.0% with the contemporary assay and 99.4% with the high sensitivity assay. NT-proBNP was elevated in approximately three quarters of the participants. In Cox models adjusted for established risk factors the cardiac biomarkers levels was independently associated with stroke or systemic embolism, cardiovascular events, and mortality. Only cardiac troponin was associated with major bleeding. In ROC analyses the prediction of stroke or systemic embolism, cardiovascular events, and mortality increased significantly by addition of cardiac troponin or NT-proBNP to the models. Persistent detectable cardiac troponin (contemporary assay) and elevated NT-proBNP levels were found in a large number of participants. Persistent detectable or elevated levels conferred significantly higher risk for stroke or systemic embolism, cardiovascular events, and mortality. By using both cardiac biomarkers simultaneously the risk stratification improved even further for all outcomes. In conclusion the analyses for the first time display that elevation of troponin I and NT-proBNP are common in patients with AF and independently related to increased risks of stroke, cardiovascular events and mortality. Persistent elevation of troponin and NT-proBNP indicate a worse prognosis than transient elevations or no elevations of either marker. The cardiac biomarkers added substantial improvements to existing risk stratification models.

Objetivo: Este artigo tem como objetivo avaliar o impacto da implantação da estratégia de triagem com classificação de risco e da unidade vascular no processo assistencial dos pacientes atendidos no serviço de emergência do Hospital de Clínicas de Porto Alegre, HCPA. Método:Trata-se de um quasi-experimento em que 3.700 pacientes atendidos na emergência nos meses de março a maio de 2005 e 4.954 pacientes atendidos no mesmo período de 2007, após a implantação das novas tecnologias, tiveram seu processo de atendimento medidos e comparados.O impacto da reorganização do serviço com a implantação destas tecnologias foi avaliado através da comparação dos indicadores de “Tempo de Permanência”, “Tempo de espera para realização de Exames” e “Tempo de espera para realização Cirurgias e Procedimentos” de todos os pacientes atendidos e especificamente dos pacientes com doenças cardiovasculares. Resultados: O tempo mediano de triagem de todos os pacientes foi de 11,8 minutos (0-92,5) e de 6,3 minutos (0-53) dos pacientes com doenças cardiovasculares. Foi evidenciado aumento significativo da mediana de tempo de permanência: 2005: 12,3h (0-510,8) e 2007:15,5h.(0-388,9), P<0,001. O mesmo ocorreu com os pacientes cardiovasculares que passaram de uma mediana de tempo de permanência de 24,5h (0,5- 341) em 2005 para 74h (0,6 -287,h), P <0,001.O exame de tomografia de crânio apresentou redução significativa no tempo mediano de espera para todos os pacientes 2005: 4h (0,08-76,4), 2007: 3h (0,2-62,7), P =0,006,e para os pacientes com doenças cardiovasculares, 2005: 4,2h (0,5-15,9), 2007: 0,9h (0,5-7,9), P =0,001.O cateterismo cardíaco realizado pelos doentes cardiovasculares agudos apresentou uma redução significativa no tempo mediano de espera, 2005: 55,6h (31,2-90,4) e 2007 13,6h (0,6-97,6), P =0,025. Conclusão: Embora tenha havido aumento de 25,3% nos casos atendidos entre 2005 e 2007, acompanhado do aumento da mediana de idade, do escore de gravidade e de casos demandando procedimentos cirúrgicos, a implantação de estratégia de triagem com estratificação de risco e da unidade vascular em serviço de emergência de hospital universitário esteve associada à redução dos tempos de espera para procedimentos diagnósticos e terapêuticos considerados como essenciais em pacientes com síndrome vascular aguda. / Objective: This study assesses the impact of implementing a strategy of screening using risk rating and creating a vascular unit for patients admitted to the emergency department of Hospital de Clinicas de Porto Alegre. Method: This study describes a quasi-experiment in which 3700 patients treated at the emergency department from March to May 2005 (P1) and 4954 patients treated during the same months of 2007 (P2), after the introduction of new care technologies. The process of care was measured and compared. The impact of department reorganization with these technologies was evaluated comparing length of stay, length of stay to perform tests and length of stay to perform surgery or procedure, measured for all patients and specifically for cardiovascular disease patients. Results: Screening median time was 11.8 min (0-92.5) for all patients and 6.3 min (0- 53) for cardiovascular disease patients. Our results showed a significant increase in median length of stay from P1 to P2 for all patients, 12.3 min (0-510.8) and 15.5 hr (0-388.9) respectively, P < 0.001. Cardiovascular disease patients had a median length of stay of 24.5 min (0.5-341) and 74 hr (0.6-287) in 2005 and 2007 respectively. Cranial tomography scan had a significant time reduction for all patients from P1 to P2, 4 hr (0.08-76.4) and 3 hr (0.2-62.7) respectively, P = 0.006, and for cardiovascular disease patients 4.2 hr (0.5-15.9) and 0.9 hr (0.5-7.9) respectively, P = 0.001. Cardiac catheterization for acute cardiovascular disease patients showed a significant decrease in median waiting time, from 55.6 min (31.2- 90.4) in P1 to 13.6 min (0.6-97.6) in P2, P = 0.025. Conclusion: Although there was a 25.3 percent increase in admitted patients from 2005 to 2007 and an increase in age, severity score and surgical patients, the implementation of a screening strategy with risk stratification and creation of a vascular unit in the emergency department was associated with reduction of waiting times of diagnostic and therapeutic procedures for acute cardiovascular disease patients.

Objetivo: Este artigo tem como objetivo avaliar o impacto da implantação da estratégia de triagem com classificação de risco e da unidade vascular no processo assistencial dos pacientes atendidos no serviço de emergência do Hospital de Clínicas de Porto Alegre, HCPA. Método:Trata-se de um quasi-experimento em que 3.700 pacientes atendidos na emergência nos meses de março a maio de 2005 e 4.954 pacientes atendidos no mesmo período de 2007, após a implantação das novas tecnologias, tiveram seu processo de atendimento medidos e comparados.O impacto da reorganização do serviço com a implantação destas tecnologias foi avaliado através da comparação dos indicadores de “Tempo de Permanência”, “Tempo de espera para realização de Exames” e “Tempo de espera para realização Cirurgias e Procedimentos” de todos os pacientes atendidos e especificamente dos pacientes com doenças cardiovasculares. Resultados: O tempo mediano de triagem de todos os pacientes foi de 11,8 minutos (0-92,5) e de 6,3 minutos (0-53) dos pacientes com doenças cardiovasculares. Foi evidenciado aumento significativo da mediana de tempo de permanência: 2005: 12,3h (0-510,8) e 2007:15,5h.(0-388,9), P<0,001. O mesmo ocorreu com os pacientes cardiovasculares que passaram de uma mediana de tempo de permanência de 24,5h (0,5- 341) em 2005 para 74h (0,6 -287,h), P <0,001.O exame de tomografia de crânio apresentou redução significativa no tempo mediano de espera para todos os pacientes 2005: 4h (0,08-76,4), 2007: 3h (0,2-62,7), P =0,006,e para os pacientes com doenças cardiovasculares, 2005: 4,2h (0,5-15,9), 2007: 0,9h (0,5-7,9), P =0,001.O cateterismo cardíaco realizado pelos doentes cardiovasculares agudos apresentou uma redução significativa no tempo mediano de espera, 2005: 55,6h (31,2-90,4) e 2007 13,6h (0,6-97,6), P =0,025. Conclusão: Embora tenha havido aumento de 25,3% nos casos atendidos entre 2005 e 2007, acompanhado do aumento da mediana de idade, do escore de gravidade e de casos demandando procedimentos cirúrgicos, a implantação de estratégia de triagem com estratificação de risco e da unidade vascular em serviço de emergência de hospital universitário esteve associada à redução dos tempos de espera para procedimentos diagnósticos e terapêuticos considerados como essenciais em pacientes com síndrome vascular aguda. / Objective: This study assesses the impact of implementing a strategy of screening using risk rating and creating a vascular unit for patients admitted to the emergency department of Hospital de Clinicas de Porto Alegre. Method: This study describes a quasi-experiment in which 3700 patients treated at the emergency department from March to May 2005 (P1) and 4954 patients treated during the same months of 2007 (P2), after the introduction of new care technologies. The process of care was measured and compared. The impact of department reorganization with these technologies was evaluated comparing length of stay, length of stay to perform tests and length of stay to perform surgery or procedure, measured for all patients and specifically for cardiovascular disease patients. Results: Screening median time was 11.8 min (0-92.5) for all patients and 6.3 min (0- 53) for cardiovascular disease patients. Our results showed a significant increase in median length of stay from P1 to P2 for all patients, 12.3 min (0-510.8) and 15.5 hr (0-388.9) respectively, P < 0.001. Cardiovascular disease patients had a median length of stay of 24.5 min (0.5-341) and 74 hr (0.6-287) in 2005 and 2007 respectively. Cranial tomography scan had a significant time reduction for all patients from P1 to P2, 4 hr (0.08-76.4) and 3 hr (0.2-62.7) respectively, P = 0.006, and for cardiovascular disease patients 4.2 hr (0.5-15.9) and 0.9 hr (0.5-7.9) respectively, P = 0.001. Cardiac catheterization for acute cardiovascular disease patients showed a significant decrease in median waiting time, from 55.6 min (31.2- 90.4) in P1 to 13.6 min (0.6-97.6) in P2, P = 0.025. Conclusion: Although there was a 25.3 percent increase in admitted patients from 2005 to 2007 and an increase in age, severity score and surgical patients, the implementation of a screening strategy with risk stratification and creation of a vascular unit in the emergency department was associated with reduction of waiting times of diagnostic and therapeutic procedures for acute cardiovascular disease patients.