Who,when and where? Identification of patients at risk of an in‐hospital adverse event: Implications for nursing practice

Patients who suffer an adverse event (AE) are more likely to die or suffer permanent disability. Many AEs are preventable. Nurses have long played a pivotal role in the prevention of AEs. Much of the literature to date pertains to the role of nurses in the prevention of AEs such as falls, pressure areas and deep vein thrombosis. Prominent risk factors for AEs are the presence of physiological abnormality, failure to recognize or correct physiological abnormality, advanced patient age and location of patient room. Ongoing physiological assessment of patients is a nursing responsibility and the assessment findings of nurses underpin many patient care decisions. The early recognition and correction of physiological abnormality can improve patient outcomes by reducing the incidence of AEs, making nurses' ability to identify, interpret and act on physiological abnormality a fundamental factor in AE prediction and prevention. This paper will examine the role of nurses in AE prevention, using cardiac arrest as an example, from the perspective of physiological safety; that is, accurate physiological assessment and the early correction of physiological abnormality.     

Do selective COX‐2 inhibitors increase the risk of cerebrovascular events? A meta‐analysis of randomized controlled trials

ABSTRACT OBJECTIVES: To evaluate the risk of cerebrovascular events (CVEs) associated with selective cyclooxygenase-2 inhibitors (coxibs). METHOD: Systematic review and meta-analysis of randomized controlled trials (RCTs). A fixed-effect model was used to estimate the odds ratios (ORs) for risk of CVE associated with coxibs compared against placebo, non-selective non-steroidal anti-inflammatory drugs (NSAIDs) and other coxibs. RESULTS: Forty trials (88 116 patients) were included in the meta-analysis. The overall pooled OR for CVE for any coxib against placebo was 1.03 (95% CI: 0.71, 1.50). Comparing individual coxibs against placebo, we found that celecoxib, rofecoxib, etoricoxib and lumiracoxib were associated with higher CVE risks and valdecoxib was associated with a lower CVE risk, although there were no significant differences detected. There was also no significant difference in risk of CVE when comparing coxibs against any non-selective NSAIDs; the corresponding pooled OR was 0.86 (95% CI: 0.64, 1.16). CONCLUSION: On the basis of a detailed analysis of available RCTs, there does not appear to be any significant difference in risk of CVEs associated with coxibs when compared against placebo or non-selective NSAIDs. It is likely that the increased risk of thrombotic vascular events associated with coxibs is largely attributable to an increased risk of myocardial infarction, rather than CVEs.     

The success of precaution? Managing the risk of transfusion transmission of variant Creutzfeldt‐Jakob disease

The precautionary principle has emerged as an important new paradigm influencing decision making in the blood system. The principle has influenced decision making in several nations leading to the institution of policies to protect their blood supplies form variant Creutzfeldt-Jakob disease (vCJD). Increasingly evidence has emerged to support the institution of these policies, which were introduced in advance of clear evidence of risk. These vCJD decisions serve as an example of the successful application of precaution and provide lesions as to how the principle should be applied in future transfusion safety decisions.     

Controlling invasive pneumococcal disease: is vaccination of at‐risk groups sufficient?

Risk factors for invasive pneumococcal disease (IPD) include young and old age, comorbidities (such as splenic dysfunction, immunodeficiencies, chronic renal disease, chronic heart or lung disease or cerebral spinal fluid leak), crowded environments or poor socioeconomic conditions. Universal use of the 7-valent pneumococcal conjugate (7vPncCRM) vaccine for infants and young children has led to significant decreases in IPD in the vaccinated population (direct protection), and there has also been a decrease in the incidence of IPD among the nonvaccinated population (indirect immunity; herd protection). While 7vPncCRM vaccine is administered universally to children in USA, many countries of the European Union have chosen to target children with comorbidities. This review aims to highlight individual risk factors for IPD, describe studies that evaluated pneumococcal conjugate vaccines in at-risk groups and estimate the proportion of at-risk children who may have been vaccinated in the European Union since the 7vPncCRM vaccine was introduced, using UK as an example. Although immunisation targeting only children with comorbidities may achieve satisfactory results for a few, many otherwise healthy children at risk simply because of their age will be neglected, and herd protection might not be established.     

Narrative minireview of the spatial epidemiology of substance use disorder in the United States: Who is at risk and where?

Drug overdose is the leading cause of death by injury in the United States. The incidence of substance use disorder (SUD) in the United States has increased steadily over the past two decades, becoming a major public health problem for the country. The drivers of the SUD epidemic in the United States have changed over time, characterized by an initial heroin outbreak between 1970 and 1999, followed by a painkiller outbreak, and finally by an ongoing synthetic opioid outbreak. The nature and sources of these abused substances reveal striking differences in the socioeconomic and behavioral factors that shape the drug epidemic. Moreover, the geospatial distribution of the SUD epidemic is not homogeneous. The United States has specific locations where vulnerable communities at high risk of SUD are concentrated, reaffirming the multifactorial socioeconomic nature of this epidemic. A better understanding of the SUD epidemic under a spatial epidemiology framework is necessary to determine the factors that have shaped its spread and how these patterns can be used to predict new outbreaks and create effective mitigation policies. This narrative minireview summarizes the current records of the spatial distribution of the SUD epidemic in the United States across different periods, revealing some spatiotemporal patterns that have preceded the occurrence of outbreaks. By analyzing the epidemic of SUD-related deaths, we also describe the epidemic behavior in areas with high incidence of cases. Finally, we describe public health interventions that can be effective for demographic groups, and we discuss future challenges in the study and control of the SUD epidemic in the country.     

Could bystander first‐aid prevent trauma deaths at the scene of injury?

Objective: To identify potentially preventable prehospital deaths following traumatic cardiac arrest. Methods: Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first‐aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times. Results: We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS <50. Twelve patients received first‐aid from bystanders. Ambulance response times >10 min might have contributed to five deaths with an ISS <25. Conclusion: Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first‐aid at scene following major trauma.     

Are lipid‐lowering drugs associated with a risk of cataract? A pharmacovigilance study

Some reports have raised concerns regarding a potential risk of cataracts associated with statins. However, clinical and observational studies evaluating the risk led to conflicting results. We assessed whether lipid‐lowering drugs (LLD) use is associated with an increased risk of cataract using the WHO's Individual Case Safety Reports database, VigiBase^®. We performed a disproportionality analysis with all reports between 1/1/1988 and 12/31/2018 to measure the reporting risk of ‘cataract’ in patients ≥45 years. Primary analysis compared LLD users to non‐users. To mitigate some potential confounding bias, we performed several sensitivity analyses excluding reports (i) with an association of at least two LLD, (ii) with antidiabetic and glucocorticoids and (iii) with lovastatin. We also analyzed the data according to the different classes of age limiting the period of study to years 2002–2012. We identified 14 664 reports of cataract (3 049 in LLD users, 66% women, 66 ± 20 years). Statins (84%, atorvastatin, simvastatin, rosuvastatin and lovastatin) were mostly reported, followed by fibrates (5.7%), nicotinic acid (3%), bile acid sequestrants (2%), herbal cholesterol and triglyceride reducers (2%) and others (ezetimibe, PCSK9 inhibitors, 15%). LLD users were associated with a greater risk of reports than non‐users (ROR 2.47, 95% CI 2.37–2.57). This association was also found for statins in general, fibrates, bile sequestrants, nicotinic acid, herbal drugs and others. Similar trends were observed in sensitivity analyses (except for fibrates and nicotinic acid after exclusion of reports with at least two LLD or in older patients ≥75 years). Using a large real‐life database (>18.5 million reports), we found a signal of cataract for LLD as a whole and statins, bile sequestrants and herbal drugs in particular. The signal disappeared for fibrates and nicotinic acid in older patients. No definite conclusions can be made for ezetimibe or PCSK9 inhibitors (evolocumab and alirocumab). This suggests that a decrease in cholesterol could be important in the pathophysiology of cataract in patients exposed to the main LLD.     

An ABC of apolipoprotein C‐III: a clinically useful new cardiovascular risk factor?

Background: Hypertriglyceridaemia, commonly found in subjects with obesity and type 2 diabetes mellitus, is associated with increased risk of coronary heart disease (CHD). Apolipoprotein C‐III (apoC‐III) plays an important role in regulating the metabolism of triglyceride‐rich lipoproteins (TRLs) and may provide a new approach to assessing hypertriglyceridaemia. Aims: We review the role of apoC‐III in regulating TRL metabolism and address the potential importance of apoC‐III in clinical practice. Discussion: Hypertriglyceridaemia is chiefly a consequence of alterations in the kinetics of TRLs, including overproduction and delayed clearance of very‐low density lipoprotein (VLDL). ApoC‐III is an inhibitor of lipoprotein lipase and of TRLs remnant uptake by hepatic lipoprotein receptors. Elevated apoC‐III, usually resulting from hepatic overproduction of VLDL apoC‐III, may cause accumulation of plasma TRLs leading to hypertriglyceridaemia. The results from recent observational studies demonstrate that apoC‐III is a strong predictor of risk for CHD, but this chiefly relates to apoC‐III in apoB‐containing lipoproteins. Lifestyle and pharmacological intervention can correct hypertriglyceridaemia by a mechanism of action that regulates apoC‐III transport. Conclusions: Targeting apoC‐III metabolism may therefore be an important, new therapeutic approach to managing dyslipidaemia and CHD risk in obesity, insulin resistance and type 2 diabetes mellitus. However, further work is required to establish the practical aspects of measuring apoC‐III in routine laboratory service and the precise therapeutic targets for serum total apoC‐III and/or apoC‐III in apoB‐containing lipoproteins. While showing much promise as a potentially useful cardiovascular risk factor, apoC‐III is not yet ready for prime time use in clinical practice.     

Are there really specific risk factors for heterotopic ossifications? A case report of ‘non-risk factor’ after total hip replacement

Femoral neck fractures are one of the most common fractures in the elderly population. Due to frequent complications of the fixation of these fractures, patients are more and more often eligible for hip replacement surgery. One of the most frequently mentioned postoperative complication is the formation of heterotopic ossification. This case report describes as a 70-year-old male patient that presented with an old hip fracture accompanied by a mild craniocerebral trauma. The patient underwent total cementless hip arthroplasty followed by rehabilitation. At 8 months after surgery, the patient was diagnosed with Brooker IV° heterotopic ossification in the area of the operated hip joint. Due to the persistent pain and complete loss of mobility in the operated joint, computed tomography imaging was performed and the patient was recommended for a revision surgery. The procedure was performed 14 months after the original surgical treatment, resulting in a significant improvement in the range of motion and reduction of pain.