Knowledge Summary 27: Death reviews: maternal, perinatal and child

Many maternal, perinatal and child deaths are preventable and progress towards Millennium Development Goals 4&5, to reduce child mortality and improve maternal health, has been insufficient in many parts of the world. Well-implemented death reviews provide opportunities to examine the circumstances surrounding a woman’s or child’s death, and improve the delivery of health services to prevent such deaths in the future. Several types of review processes exist to evaluate deaths in diverse settings, given different data availability and levels of service delivery. Both consistent surveillance and effective response are needed to ensure that maternal, perinatal and child deaths are identified and reviewed, so that recommendations can be made, and action can be taken to prevent further deaths

Patients' self-assessed functional status in heart failure by New York Heart Association class: a prognostic predictor of hospitalizations, quality of life and death.

BACKGROUND: Clinician-assigned New York Heart Association (NYHA) class is an established predictor of outcomes in heart failure. This study aims to test whether patients' self-assessment of functional status by NYHA class predicts hospital admissions, quality of life, and mortality. METHODS AND RESULTS: This was an observational study within a randomized controlled trial. A total of 293 adult patients diagnosed with heart failure were recruited after an emergency admission at 3 acute hospitals in Norfolk, UK. Outcome measures included number of emergency admissions over 6 months, self-assessed quality of life measured with the Minnesota Living with Heart Failure questionnaire (MLHFQ) and EQ-5D at 6 months, and deaths up to 20 months' follow-up. Patients were grouped into 3 NYHA groups (I/II, III, and IV) based on patients' self-assigned NYHA class (SA-NYHA). A Poisson model indicated an increased readmission rate associated with higher SA-NYHA class (adjusted rate ratio 1.21; 95% CI 1.04-1.41; P=.02). Higher SA-NYHA class at baseline predicted worse quality of life at 6 months' follow-up (P=.002 for MLHFQ; P=.047 for EQ-5D), and was associated with higher mortality rate (adjusted hazard ratio 1.84; 95% CI 1.10-3.06; P=.02). CONCLUSIONS: SA-NYHA class is predictive of hospitalization, quality of life, and mortality among patients with heart failure

Effects of hemodialysis on circulating adrenomedullin concentrations in patients with end-stage renal disease

To characterize the determinants of circulating levels of adrenomedullin (AM), the plasma levels of this peptide were measured in 58 patients with end-stage renal disease on hemodialysis, Predialysis plasma levels of AM were more than twice as high in patients on hemodialysis as compared to controls. In hemodialysis patients with heart failure (NYHA classes II-IV) or hypertensive HD patients plasma levels of AM were significantly higher than in patients with end-stage renal disease only. Plasma levels of AM were clot altered immediately by hemodialysis but decreased significantly 14-20 h after hemodialysis, AM plasma levels before hemodialysis and 14-20 h after hemodialysis were correlated with the corresponding mean arterial pressure

Levels of von Willebrand factor antigen and von Willebrand factor cleaving protease (ADAMTS13) activity predict clinical events in chronic heart failure.

Decreased activity of ADAMTS13, the von Willebrand factor (VWF) cleaving protease, was recently reported in cardiovascular diseases and in hepatic failure. Chronic heart failure (CHF) is characterised by abnormalities of left ventricular function accompanied by the failure of the liver and dysregulation of endothelial activation. Therefore, the aim of our study was to measure ADAMTS13 activity in CHF, and determine the prognostic value of VWF and ADAMTS13 on major clinical events in CHF. ADAMTS13 activity (measured by FRETS-VWF73 substrate) was decreased in CHF (n = 152, left ventricular ejection fraction <45%), and it correlated negatively with B-type natriuretic peptide (BNP) NYHA (New York Heart Association) classes, markers of synthetic capacity of the liver and endothelial dysfunction (all p < 0.005). Both, high VWF:Ag levels (hazard ratio [HR] 1.52, 95% confidence interval [CI] 1.189-1.943), and low ADAMTS13/VWF:Ag ratios (HR 0.70, 95% CI 0.58-0.84) independently and significantly predicted short-term (1 year follow-up) clinical adverse events in heart failure (HF). Decreased activity of ADAMTS13 with concomitant high VWF:Ag levels is a significant independent predictor of clinical events in CHF. The levels of the two molecules may integrate the impaired synthetic capacity of the liver and the disturbed endothelial regulation and can therefore be a useful tool to predict clinical events in CHF

The systematic guideline review: method, rationale, and test on chronic heart failure

Background: Evidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources-especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development-the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF). Methods: A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline. Results: Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) - the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer. Conclusion: The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines