Adolescent medicine also known as adolescent and young adult medicine is a medical subspecialty that focuses on care of patients who are in the adolescent period of development. This period begins at puberty and lasts until growth has stopped, at which time adulthood begins. Typically, patients in this age range will be in the last years of middle school up until college graduation (some Importance The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue.. Objective To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality.. Design, Setting, and Participants Danish nationwide cohort study () including all patients aged 20 years or May 23, · Likes, 2 Comments - Dr Raymond C Lee MD (@drrayleemd) on Instagram: “What an amazing virtual aats. Congratulations to my chairman Dr Vaughn Starnes th AATS ”
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MACE indicates major adverse cardiac events acute myocardial infarction, ischemic stroke, or cardiovascular death. Adjusted for sex, age, body mass index, all comorbidities, all pharmacotherapy, surgery group, and surgery risk. Splines of the association of time elapsed between stroke and risk of major adverse cardiac events MACEmortality, and ischemic stroke, personal statements cardiology fellowship, respectively, among patients with prior stroke.
All splines were adjusted for sex, age, and surgical category. The median time between stroke and surgery days served as the reference. eFigure 1. Flowchart of Population Selection and Sensitivity Analyses. eFigure 2. Risk of day MACE Stratified by Surgery Risk for the Full Study Population. eFigure 3. eFigure 4. eFigure 5, personal statements cardiology fellowship. Sensitivity Analyses, Including Only the First Surgery per Patient.
eTable 2. All NOMESCO Three-Letter codes Present in Study Population. eTable 3. Frequency and Proportion of Three-Letter Surgery Codes stratified by Time between Stroke and Surgery, personal statements cardiology fellowship.
eTable 4. NOMESCO Codes Used for the 16 Surgical Categories and Surgical Risk Classification. eTable 5. eTable 6, personal statements cardiology fellowship. Surgeries Excluded for Selected Concomitant ICD Diagnoses. eTable 8. Analyses Including Elective Hip and Knee Replacement Only. Jørgensen ME, Torp-Pedersen C, Gislason GH, et al. Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery.
Importance The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue. Objective To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality.
Exposures Time elapsed between stroke and surgery in categories and as a continuous measure. Main Outcomes and Measures Risk of major adverse cardiovascular events MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality and all-cause mortality up to 30 days after surgery.
Odds ratios ORs were calculated by multivariable logistic regression models. Compared with patients without stroke, ORs for MACE were MACE risks were at least as high for low-risk OR, personal statements cardiology fellowship. Similar patterns were found for day mortality: ORs were 3. Cubic regression splines performed on the stroke subgroup supported that personal statements cardiology fellowship leveled off after 9 months, personal statements cardiology fellowship.
Conclusions and Relevance A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, personal statements cardiology fellowship, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may personal statements cardiology fellowship attention in future guidelines.
Previous studies have identified stroke as a major risk factor for adverse outcomes in noncardiac surgery. Stroke is also a major component in integrated perioperative risk evaluation schemes, such as the widely used revised cardiac risk index by Lee et al. These alterations are especially important for perioperative risks among patients with established cardiovascular disease, including cerebrovascular disease, and may pose a particular risk among individuals with unstable cardiovascular comorbidities.
Noncardiac surgeries performed in patients with a recent myocardial infarction or stent implantation have been associated with increased risk of perioperative cardiac events, stent thrombosis, and bleeding compared with patients with more distant myocardial infarction or personal statements cardiology fellowship implantation. Because the prevalence of stroke and the need for noncardiac surgery increase rapidly with age, it personal statements cardiology fellowship important to address this matter.
Ethical approval of register-based studies is not warranted in Denmark. The authors had full access personal statements cardiology fellowship encrypted raw data provided by Statistics Denmark Central Authority on Danish Statistics. The study was approved by the Danish data protection agency.
In Denmark, personal statements cardiology fellowship, medical care is tax-financed, free of personal charge, and equally available to all inhabitants. For administrative purposes, the government has kept nationwide registers on health care—related data for decades.
Moreover, all citizens are given a unique and permanent identification number at birth or upon immigration, which enabled us to link nationwide administrative registers.
Five registers were used to identify our population and retrieve information on different variables. Available data included admission and discharge dates and diagnoses coded according to the International Statistical Classification of Diseases, Tenth Revision ICD since Correct coding of surgeries and comorbidities is paramount for governmental reimbursement to the departments.
The National Population Register and the National Causes of Death Register hold information on vital status, date of birth, and death, including causes of death. Information on all drugs prescribed to the population was obtained from the Danish Register of Medicinal Product Statistics, which collects all prescriptions in Denmark according to the Anatomical Therapeutic Chemical Classification System.
The register is directly linked to the government for reimbursement and has been proven to be accurate. All elective noncardiac surgeries performed in patients aged 20 years or older during the period were included in the present study.
For patients having multiple surgeries performed during a day period, only the first in each period was included. We identified patients with prior ischemic stroke using ICD personal statements cardiology fellowship I63 or I Patients with a diagnosis of transient ischemic attack or hemorrhagic stroke were not included in this definition.
As with other comorbidities, the stroke diagnosis was considered obsolete if more than 5 years had passed between stroke and surgery. Our population was a priori divided into 5 subgroups based on time elapsed between stroke and surgery: patients with no prior stroke, patients with a stroke within less than 3 months, patients with a stroke within 3 to less than 6 months, patients with a stroke personal statements cardiology fellowship 6 to less than 12 months, and patients with a stroke 12 months or more prior to surgery.
Use of these cutoff points was inspired by a clinical impression and previous documented relations of time elapsed after myocardial infarction or stenting with risk of adverse outcomes. Use of specific drugs was defined as at least 1 claimed prescription for the following agents during the preceding days prior to surgery: statins Anatomical Therapeutic Chemical Classification C10Aβ-blockers C07angiotensin-converting enzyme inhibitors and angiotensin II antagonists ie, renin-angiotensin system inhibitors C09aldosterone blockers Personal statements cardiology fellowshipthiazides C03Acalcium channel blockers C08digoxin C01AA05personal statements cardiology fellowship, vitamin K antagonists B01AA0glucose-lowering agents A10loop diuretics C03CA01and antithrombotic therapy as low-dose acetylsalicylic acid B01AC06dipyridamole B01AC07clopidogrel B01AC04or a combination of acetylsalicylic acid and dipyridamole B01AC Records of discharge diagnoses defined by ICD codes up to 5 years prior to surgery were used to identify the following comorbidities: acute myocardial infarction, chronic obstructive pulmonary disease, anemia, cancer with metastases, personal statements cardiology fellowship, renal disease, rheumatic disease, peripheral artery disease, liver disease, diabetes, chronic heart failure, ischemic heart disease, and atrial fibrillation.
In addition to ICD codes, use of glucose-lowering agents was used as a proxy for diabetes and use of personal statements cardiology fellowship diuretics as a proxy for heart failure, as has been done previously. Frequency and proportion of 3-letter surgery codes stratified by time between stroke and surgery are shown in eTable 3 in the Supplement. As each category consisted of several types of surgery, absolute and relative risk estimates were calculated to ensure that no major discrepancies in risk were found between types of surgery within each category.
This classification has also been used in previous work. In this analysis we also excluded orthopedic surgeries that were preceded by a diagnosis of trauma to the surgical area, as well as abdominal surgeries preceded by a diagnosis of peptic ulcer and cholecystitis within 7 days prior to surgery eFigure 1 and eTable 6 in the Supplement.
As suggested by Boersma et al 19 and as specified in the European Society of Cardiology guidelines, 9 surgeries were stratified into 3 groups: low- intermediate- and high-risk surgeries. Coding details and allocation of surgeries are available in eTable 4 in the Supplement. Primary outcomes were all-cause mortality and MACE. We also identified recurrent ischemic strokes ICD codes I as a separate end point. The majority of perioperative strokes in noncardiac, personal statements cardiology fellowship, nonneurological surgery has shown to be of ischemic etiology.
Events during surgery and at day 30 were included in the respective end points. Fully adjusted models included sex, age, body mass index, and all comorbidities, pharmacotherapies, and surgical categories from Table 1as well as surgery risk level as defined above. Patients with no prior stroke were used as a reference.
Relevant interaction analyses were chosen a priori based on clinical relevance atrial fibrillation, antithrombotic therapy, use of statins, calendar year, and sex. Dose-response splines adjusted for sex, age, and surgical category were created by restricted cubic spline functions using the macro provided by Desquilbet et al.
Knots were placed at p10, p25, p50, p75, and p90; p50 was used as the reference. Because some patients had more than 1 surgery performed during the study period, we performed a sensitivity analysis including only the first surgery for each patient to ensure that the assumption of independence of observations was not violated. Odds ratios associated with prior stroke for the propensity score—matched cohort were calculated using conditional logistic regression models.
All calculations were performed with SAS, version 9. On average, patients with prior personal statements cardiology fellowship were 16 years older, were more often men, were more frequently treated with cardiovascular medications, and had a higher prevalence of comorbidities Table 1. The median number of surgeries per patient was 1 interquartile range, ; 95th percentile, 3. A total of patients with prior stroke Crude events, incidence rates, and unadjusted odds ratios for patients with no prior stroke, patients with personal statements cardiology fellowship any time prior to surgery, and stratified by time between stroke and surgery for day MACE, its components, and day all-cause mortality are personal statements cardiology fellowship in Table 2.
Incidence rates of day ischemic stroke were There was a stepwise decline in risk associated with prior stroke for longer time distances between stroke and surgery Figure 1. For the subgroup with stroke less than 3 months prior, the OR of day MACE was The odds ratios for MACE were the same or higher for low-risk surgery OR, 9.
The elevated risk of MACE associated with prior stroke were to a large personal statements cardiology fellowship driven by a high risk of recurrent stroke Figure 1with an adjusted OR of There was no significant association between prior stroke and risk of acute myocardial infarction eFigure 3 in the Supplement, personal statements cardiology fellowship.
The risk of cardiovascular death as a separate end point was also increased for patients with prior stroke OR, personal statements cardiology fellowship, 4. Analyses including imputed values on alcohol and smoking as covariates in the models did not change the estimates substantially ORs are shown in eTable 7 in the Supplement. Compared with no stroke, ORs associated with MACE were Adjusted ORs associated with MACE for the stroke groups were of similar magnitudes as those seen in the other analyses OR, Results for ischemic stroke and all-cause mortality are shown in eTable 8 in the Supplement.
There were no major differences between stroke patients and controls in propensity score—matched subgroups baseline characteristics are shown in eTable 9 in the Supplement.
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, time: 20:13Adolescent medicine - Wikipedia
May 23, · Likes, 2 Comments - Dr Raymond C Lee MD (@drrayleemd) on Instagram: “What an amazing virtual aats. Congratulations to my chairman Dr Vaughn Starnes th AATS ” Adolescent medicine also known as adolescent and young adult medicine is a medical subspecialty that focuses on care of patients who are in the adolescent period of development. This period begins at puberty and lasts until growth has stopped, at which time adulthood begins. Typically, patients in this age range will be in the last years of middle school up until college graduation (some Art and Images in Psychiatry Best of the JAMA Network Clinical Crosswords from JAMA Coronavirus Resource Center Digital Media Editorial Fellowship Evidence-Based Medicine: An Oral History Fishbein Fellowship Genomics and Precision Health Hypertension JAMA Forum Archive JAMA Network Audio JAMA Network Conferences Machine Learning Research Ethics
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