OMPUTERIZED CLINICAL DECIs i o n s u p p o r t s y s t e m s (CDSSs) are information systems designed to improve clinical decision making. Characteristics of individual patients are matched to a computerized knowledge base, and software algorithms generate patientspecific recommendations. Practitioners, health care staff, or patients can manually enter patient characteristics into the computer system; alternatively, electronic medical records can be queried for retrieval of patient characteristics. Computer-generated recommendations are delivered to the clinician through the electronic medical record, by pager, or through printouts placed in a patient's paper chart. Such systems have been developed for a myriad of clinical issues, including diagnosis of chest pain, treatment of infertility, and timely administration of immunizations. These systems provide several modes of decision support, including alerts of critical val-See also pp 1197 and 1261.

No abstract

No abstract

Current guidelines identify people with chronic kidney disease (CKD) as being at high risk for cardiovascular and all-cause mortality. Because as many as 19 million Americans may have CKD, a comprehensive summary of this risk would be potentially useful for planning public health policy. A systematic review of the association between non-dialysis-dependent CKD and the risk for all-cause and cardiovascular mortality was conducted. Patient-and study-related characteristics that influenced the magnitude of these associations also were investigated. MEDLINE and EMBASE databases were searched, and reference lists through December 2004 were consulted. Authors of 10 primary studies provided additional data. Cohort studies or cohort analyses of randomized, controlled trials that compared mortality between those with and without chronically reduced kidney function were included. Studies were excluded from review when participants were followed for <1 yr or had ESRD. Two reviewers independently extracted data on study setting, quality, participant and renal function characteristics, and outcomes. Thirty-nine studies that followed a total of 1,371,990 participants were reviewed. The unadjusted relative risk for mortality in participants with reduced kidney function compared with those without ranged from 0.94 to 5.0 and was significantly more than 1.0 in 93% of cohorts. Among the 16 studies that provided suitable data, the absolute risk for death increased exponentially with decreasing renal function. Fourteen cohorts described the risk for mortality from reduced kidney function, after adjustment for other established risk factors. Although adjusted relative hazards were consistently lower than unadjusted relative risks (median reduction 17%), they remained significantly more than 1.0 in 71% of cohorts. This review supports current guidelines that identify individuals with CKD as being at high risk for cardiovascular mortality. Determining which interventions best offset this risk remains a health priority. I t has been known for many years that ESRD is associated with very high mortality and accelerated cardiovascular disease (1). Several recent studies suggest that the risk for death is increased independently in individuals who have less severe impairment of kidney function and are not dialysis dependent, compared with those who have preserved kidney function (2,3). However, other rigorously conducted studies have found little or no significant increase in all-cause or cardiovascular mortality in the setting of mild to moderate chronic kidney disease (CKD) (4,5). Even among studies that have demonstrated higher mortality rates in people with CKD, the magnitude of the increased risk has varied substantially for reasons that are unclear.Current guidelines identify individuals with CKD as being at high risk for cardiovascular disease and other adverse outcomes (6). Because non-dialysis-dependent CKD may affect as many as 19 million Americans (7), a summary of the risk for all-cause and cardiovascular mortality associated w...

Even short durations of an intraoperative MAP less than 55 mmHg are associated with AKI and myocardial injury. Randomized trials are required to determine whether outcomes improve with interventions that maintain an intraoperative MAP of at least 55 mmHg.