Cross-sectional survey describing general practitioners' absolute cardiovascular disease risk assessment practices and their relationship to knowledge, attitudes and beliefs about cardiovascular disease risk in Queensland, Australia.

OBJECTIVES: To describe general practitioners' (GPs') absolute cardiovascular disease risk (ACVDR) self-reported assessment practices and their relationship to knowledge, attitudes and beliefs about ACVDR. DESIGN: Cross-sectional survey with opportunistic sampling (October-December 2017). SETTING: Sunshine Coast region, Queensland, Australia. PARTICIPANTS: 111 GPs responded to the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of GPs reporting a high (≥80%) versus moderate (60%-79%)/low (<60%) percentage of eligible patients receiving ACVDR assessment; proportion agreeing with statements pertaining to knowledge, attitudes and beliefs about ACVDR and associations between these factors. RESULTS: Of the 111 respondents, 78% reported using the Australian ACVDR calculator; 45% reported high, 25% moderate and 30% low ACVDR assessment rates; >85% reported knowing how to use ACVDR assessment tools, believed assessment valuable and were comfortable with providing guideline-recommended treatment. Around half believed patients understood the concept of high risk and were willing to adopt recommendations. High assessment rates (vs moderate/low) were less likely among older GPs (≥45 vs ≤34 years, age-adjusted and sex-adjusted OR (aOR) 0.36, 95% CI 0.12 to 0.97). Those who answered knowledge-based questions about the guidelines incorrectly had lower assessment rates, including those who answered questions on patient eligibility (aOR 0.13, 95% CI 0.02 to 1.11). A high assessment rate was more likely among GPs who believed there was sufficient time to do the assessment (aOR 3.79, 95% CI 1.23 to 11.61) and that their patients were willing to undertake lifestyle modification (aOR 2.29, 95% CI 1.02 to 5.15). Over 75% of GPs agreed better patient education, nurse-led assessment and computer-reminder prompts would enable higher assessment rates. CONCLUSIONS: Although the majority of GPs report using the ACVDR calculator when undertaking a CVD risk assessment, there is a need to increase the actual proportion of eligible patients undergoing ACVDR assessment. This may be achieved by improving GP assessment practices such as GP and patient knowledge of CVD risk, providing sufficient time and nurse-led assessment.

Postoperative outcomes of kidney transplant recipients undergoing non-transplant-related elective surgery: a systematic review and meta-analysis.

BACKGROUND: Reliable estimates of the absolute and relative risks of postoperative complications in kidney transplant recipients undergoing elective surgery are needed to inform clinical practice. This systematic review and meta-analysis aimed to estimate the odds of both fatal and non-fatal postoperative outcomes in kidney transplant recipients following elective surgery compared to non-transplanted patients. METHODS: Systematic searches were performed through Embase and MEDLINE databases to identify relevant studies from inception to January 2020. Risk of bias was assessed by the Newcastle Ottawa Scale and quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations, assessment, development and evaluation). Random effects meta-analysis was performed to derive summary risk estimates of outcomes. Meta-regression and sensitivity analyses were performed to explore heterogeneity. RESULTS: Fourteen studies involving 14,427 kidney transplant patients were eligible for inclusion. Kidney transplant recipients had increased odds of postoperative mortality; cardiac surgery (OR 2.2, 95%CI 1.9-2.5), general surgery (OR 2.2, 95% CI 1.3-4.0) compared to non-transplanted patients. The magnitude of the mortality odds was increased in the presence of diabetes mellitus. Acute kidney injury was the most frequently reported non-fatal complication whereby kidney transplant recipients had increased odds compared to their non-transplanted counterparts. The odds for acute kidney injury was highest following orthopaedic surgery (OR 15.3, 95% CI 3.9-59.4). However, there was no difference in the odds of stroke and pneumonia. CONCLUSION: Kidney transplant recipients are at increased odds for postoperative mortality and acute kidney injury following elective surgery. This review also highlights the urgent need for further studies to better inform perioperative risk assessment to assist in planning perioperative care.

In patients with unilateral pleural effusion, restricted lung inflation is the principal predictor of increased dyspnoea.

BACKGROUND AND OBJECTIVE: The mechanism of dyspnoea associated with pleural effusion is uncertain. A cohort of patients requiring thoracoscopy for unilateral exudative effusion were investigated for associations between dyspnoea and suggested predictors: impaired ipsilateral diaphragm movement, effusion volume and restricted lung inflation. METHODS: Baseline Dyspnoea Index, respiratory function, and ultrasound assessment of ipsilateral diaphragm movement were assessed prior to thoracoscopy, when effusion volume was measured. Transitional Dyspnoea Index (change from baseline) was assessed 4 and 8 weeks after thoracoscopy. Pearson product moment assessed bivariate correlations and a general linear model examined how well total lung capacity (measuring restricted lung inflation), effusion volume and impaired diaphragm movement predicted Baseline Dyspnoea Index. Un-paired t tests compared the groups with normal and impaired diaphragm movement. RESULTS: 19 patients were studied (14 malignant etiology). Total lung capacity was associated with Baseline Dyspnoea Index (r = 0.68, P = 0.003). Effusion volume (r = -0.138, P = 0.60) and diaphragm movement (P = 0.09) were not associated with Baseline Dyspnoea Index. Effusion volume was larger with impaired diaphragm movement compared to normal diaphragm movement (2.16 ±SD 0.95 vs.1.16 ±0.92 L, P = 0.009). Total lung capacity was lower with impaired diaphragm movement compared to normal diaphragm movement (65.4 ±10.3 vs 78.2 ±8.6% predicted, P = 0.011). The optimal general linear model to predict Baseline Dyspnoea Index used total lung capacity alone (adjusted R2 = 0.42, P = 0.003). In nine participants with controlled effusion, baseline effusion volume (r = 0.775, P = 0.014) and total lung capacity (r = -0.690, P = 0.040) were associated with Transitional Dyspnoea Index. CONCLUSIONS: Restricted lung inflation was the principal predictor of increased dyspnoea prior to thoracoscopic drainage of effusion, with no independent additional association with either effusion volume or impaired ipsilateral diaphragm movement. Restricted lung inflation may be an important determinant of the dyspnoea associated with pleural effusion.

Population pharmacokinetic modelling of doxorubicin and doxorubicinol in children with cancer: is there a relationship with cardiac troponin profiles?

PURPOSE: Anthracyclines are a mainstay of the treatment of several childhood malignancies, but their utility is limited by dose-related cardiotoxicity. This study is aimed to explore the link between exposure of paediatric cancer patients to doxorubicin and its metabolite doxorubicinol, and cardiac troponin I (cTnI). METHODS: In a prospective pilot study plasma doxorubicin, doxorubicinol, and cTnI concentrations were measured in samples from children undergoing cancer chemotherapy. A mixed-effects population pharmacokinetic model for doxorubicin and doxorubicinol and in combination with a turn-over model for cTnI were developed. RESULTS: Seventeen patients, aged 3.4-14.7 year, treated for a variety of cancers had 99 doxorubicin and 119 doxorubicinol concentrations analysed from samples drawn between 0.5 and 336 h after the start of the infusion. Eleven patients had received previous doses of anthracyclines, with a median cumulative prior dose of 90 mg/m2 (range 0-225 mg/m2). The median administered doxorubicin dose was 30 mg/m2 (range 25-75 mg/m2). Doxorubicin disposition was described by a three-compartment model with first-order elimination and metabolism to doxorubicinol. Body surface area was related to all clearance and distribution parameters and age further influenced clearance (CL, 58.7 L/h/1.8 m2 for an average 8.4-year-old patient). Combined doxorubicin and metabolite exposure stimulated a temporary increase in cTnI in plasma, with a concentration of 11.8 µg/L required to achieve half-maximal effect. Prior cumulative anthracycline dosage received by patients was predictive of an increased cTnI baseline prior to a new doxorubicin dose. CONCLUSION: Prior anthracycline exposure increased baseline cTnI in a dose-dependent manner, consistent with the known cumulative risk of anthracycline exposure-induced cardiotoxicity.