Identifying diabetic patients at high risk for amputation.

Lower-extremity amputation is a much feared complication of diabetes mellitus; however, 40% to 50% of these amputations are preventable. Peripheral neuropathy has been implicated as a cause in some 82% of diabetic amputations. Patient education on foot care is often not enough to prevent foot ulceration and potential amputation. Health care providers can lower the incidence of lower extremity amputation by using a Semmes-Weinstein monofilament to identify protective sensation loss and quickly taking measures to prevent ulceration. Diabetes patients who have a history of foot deformity, ulceration, or amputation of any part of the foot should be referred for special shoes or orthotics. This article reviews the methods for identifying those patients with diabetes that are at high risk for amputation and preventive interventions.     

Identifying patients at risk of perinatal mood disorders

Perinatal mental illness influences obstetric outcomes, mother-baby interactions and longer term emotional and cognitive development of the child. Psychiatric disorders have consistently been found to be one of the leading causes of maternal deaths, often through suicide. Postnatal depression and puerperal psychosis are two disorders most commonly associated with the perinatal period. The most efficient strategy to identify patients at risk relies on focussing on clinically vulnerable subgroups: enquiries about depressive symptoms should be made at the usual screening visits. Attention should be paid to any sign of poor self-care, avoidance of eye contact, overactivity or underactivity, or abnormalities in the rate of speech. Particular care should be taken to ask about suicidal ideation and thoughts of harming others, including the baby. One of the most important risk factors is a previous history of depression. The degree of risk is directly correlated with severity of past episodes. Both antenatal and postnatal depression are being increasingly recognised in men. Puerperal psychosis is rare (1 to 2 per 1,000). Sixty per cent of women with puerperal psychosis already have a diagnosis of bipolar disorder or schizoaffective disorder. Women with a personal history of postpartum psychosis or bipolar affective disorder should be considered as high risk for postpartum psychosis. All pregnant women who are identified as being at high risk should have a shared care plan for their late pregnancy and early postnatal psychiatric management. Women with current mood disorder of mild or moderate severity who have a first-degree relative with a history of bipolar disorder or postpartum psychosis should be referred for psychiatric assessment.     

Identifying individuals at high risk for diabetes: The Atherosclerosis Risk in Communities study

OBJECTIVE: To develop and evaluate clinical rules to predict risk for diabetes in middle-aged adults. RESEARCH DESIGN AND METHODS: The Atherosclerosis Risk in Communities is a cohort study conducted from 1987-1989 to 1996-1998. We studied 7,915 participants 45-64 years of age, free of diabetes at baseline, and ascertained 1,292 incident cases of diabetes by clinical diagnosis or oral glucose tolerance testing. RESULTS: We derived risk functions to predict diabetes using logistic regression in a random half of the sample. Rules based on these risk functions were evaluated in the other half. A risk function based on waist, height, hypertension, blood pressure, family history of diabetes, ethnicity, and age was performed similarly to one based on fasting glucose (area under the receiver-operating characteristic curve [AUC] 0.71 and 0.74, respectively; P = 0.2). Risk functions composed of the clinical variables plus fasting glucose (AUC 0.78) and additionally including triglycerides and HDL cholesterol (AUC 0.80) performed better (P < 0.001). Evaluation of scores based on the metabolic syndrome as defined by the National Cholesterol Education Program or with slight variations showed AUCs of 0.75 and 0.78, respectively. Rules based on all these approaches, while identifying 20-56% of the sample as screen positive, achieved sensitivities of 40-87% and specificities of 50-86%. CONCLUSIONS: Rules derived from clinical information, alone or combined with simple laboratory measures, can characterize degrees of diabetes risk in middle-aged adults, permitting preventive actions of appropriate intensity. Rules based on the metabolic syndrome are reasonable alternatives to rules derived from risk functions.     

Identifying critically ill patients at risk of death from coronavirus disease

BACKGROUND: A pandemic of coronavirus disease (COVID-19) has been declared by the World Health Organization (WHO) and caring for critically ill patients is expected to be at the core of battling this disease. However, little is known regarding an early detection of patients at high risk of fatality.     

Engaging women at risk for poor perinatal mental health outcomes: A mixed‐methods study

Risk factors for poor perinatal mental health are well known. Psychosocial assessment and depression screening during the perinatal period aim to identify women at risk for poor perinatal outcomes. Early intervention programmes are known to improve the mental health outcomes of women and infants. Key to any intervention is initial and ongoing engagement in the therapeutic process. This mixed‐methods study reports the proportion of women who engage/do not engage with services and their characteristics, as well as the strategies clinicians use to engage women. Data were collected by reviewing medical records, interviewing perinatal and infant mental health (PIMH) clinicians, their managers, key stakeholders, and women service users. Analyses identified that most (71.3%) women referred engaged with the PIMH service. Themes related to non‐engagement are ‘time to rethink’ and ‘stigma’. Themes reflecting the engagement strategies used by PIMH clinicians are initial engagement: ‘back to basics’ and ‘building trust’, therapeutic engagement: ‘making myself useful’, engagement at discharge: ‘woman or clinician led’, and models that facilitate engagement.     

Medical patients at high risk for catastrophic deterioration

The objective of this study was to develop criteria to demarcate patients at risk for catastrophic deterioration (arrest or major decompensation) and those likely to require intensive care. From an inception cohort of patients admitted to the medical service, 544 patients were evaluated prospectively for severity of illness and stability by the admitting residents; the course of patients was reviewed blindly by observers. Patients admitted with acute dyspnea, particularly those with chronic pulmonary disease, were at a significantly greater (p less than .01) risk of arrest. All but one of the other arrests occurred in patients who were rated unstable on admission and who had further deterioration of pre-existing problems in the hospital (p less than .0001). The deterioration rates were highest among patients rated as unstable, particularly in patients with comorbid disease. Patients who are unstable on admission or who begin to deteriorate due to comorbid disease or the condition leading to admission, should be considered at extremely high risk for subsequent arrest and should be admitted to critical care units for early observation.     

Frailty评分预测老年多发性骨髓瘤的临床分析

目的:运用Frailty评分体系预测老年多发性骨髓瘤(multiple myeloma,MM)患者临床转归的研究分析。方法:对复旦大学附属中山医院血液科2015年1月1日至2016年2月29日收治的29例65岁以上老年MM患者进行Frailty评分,以分析其与患者临床转归的关系。结果:Frailty评分高危组13例(44.8%)、中危组5例(17.2%)、低危组11例(37.9%),3组患者在ISS分期(P=0.281)和化疗强度(P=0.475)上的差异无统计学意义。Frailty高危组患者不良反应较多,血液学3级及以上不良发生率(69.2%)显著高于低危组(18.2%,P=0.014)和中危组(0.0,P=0.011);高危组非血液学3级及以上不良反应发生率(84.6%)显著高于低危组(18.2%,P=0.001)和中危组(20.0%,P=0.011)。高危组中有69.2%的患者中断、延缓化疗或减小化疗强度,显著高于低危组(9.1%,P=0.004),与中危组差异无统计学意义(40.0%,P=0.268)。高危组患者化疗后获完全缓解(CR)及极好的部分缓解(VGPR)的患者占30.8%、部分缓解(PR)者占23.1%、无效(NR)者占46.2%,显著低于低危组(CR及VGPR 63.6%、PR 36.4%、NR 0.0,P=0.027),与中危组比较差异无统计学意义(CR及VGPR 40.0%、PR20.0%、NR 40.0%,P=0.751)。结论:Frailty评分体系可预测高危患者治疗的不良反应和疗效,高危患者预后差,但其对预后评估价值的大小有待更大样本量的阐明。     

Surveillance of patients at high risk for colorectal cancer

Colorectal cancer (CRC) mortality may be greatly reduced by clinically feasible screening programs. The benefits of surveillance of high-risk programs are evident. Cancer mortality can be dramatically reduced by eradication of precursor lesions and by detection of cancer at an early and highly curable stage. Available screening methods, recommended intervals, and screening for other associated cancers are reviewed for specific high-risk groups.