geoffrey modest medical blogs

A recent international study found that a structured questionnaire, Duke Activity Status Index (DASI) outperformed other measures in predicting p re- operative risk for high risk patients undergoing major noncardiac surgery ( see  medical clearance for surgery lancet2018 in dropbox, or Wijeysundera DM. Lancet 2018; 391: 2631–40​ ). Details: -- 25 hospitals (5 in Canada, 7 in the UK, to Australia, 3 in New Zealand) with 1401 patients were included in this prospective cohort study, from 2013 to 2016 -- patients all had one or more risk factors for cardiac complications in surgery: history of heart failure, stroke, diabetes, or coronary artery disease -- median age 65 years, 39% female, 91% reclassified as American Society of Anesthesiologists Physical Status (ASA-PS) 2 or 3 (mild or severe systemic illness, but not one that is a constant threat to life) -- comorbidities: CAD 12%, diabetes 19%, hypertension 56%, current or recent smoker 15%, COPD 13%...

two new recommendations for perioperative cardiovascular disease evaluation and management for patients undergoing noncardiac surgery were just released, one from the US and one from Europe  (will limit review to common pre-operative primary care issues ) ​. The US guidelines ( see  preop cardiovasc eval management noncard surgery AHA 2014  in dropbox, or  doi:10.1016/j.jacc.2014.07.944) : the guideline reviews the risk factors for perioperative cardiovasc mortality, including the traditional ones (see paper for details):         --MI within the past 6 months, and esp within the past 2 months         --heart failure, esp decompensated, and more so in those with reduced ejection fraction         --cardiomyopathies present special management issues, though data on postoperative outcomes is limited and with mixed results ...

agency for healthcare research and quality (AHRQ) just came out with their synthesis of the data on routine preoperative testing (see link:  http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1846  ).  assessed literature on kids and adults of routine testing vs no testing or ad hoc testing, and routine vs per-protocol testing (per-protocol testing is testing a subset, eg EKG for those > 50yo, or hct in premenopausal women).  57 studies reviewed (14 comparative and 43 cohort). results: good  news:  data for cataract surgery is the best: routine pre-op testing (EKG, metabolic panel or glucose, cbc) has no effect on total perioperative complications. bad  news:  insufficient evidence for all other procedures and insufficient evidence comparing routine and per-protocol testing. no evidence regarding quality of life or satisfaction, resource utilization, or harms of testing. ...