Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents

Background

A concern with long-term opioid use is the increased risk arising when opioids are used concurrently with drugs that can potentiate their associated adverse effects. The drugs most often encountered are benzodiazepines (BZDs) and gabapentinoids. Our study objectives were to examine trends in the concurrent use of opioids and BZDs, or gabapentinoids, in a Canadian nursing home population over an 11-year period, and current resident-level correlates of this concurrent use.

Methods

We conducted a population-based, repeated cross-sectional study among Ontario nursing home residents (>65 years) dispensed opioids between April 2009 and February 2020. For the last study year, we examined cross-sectional associations between resident characteristics and concurrent use of opioids with BZDs or gabapentinoids. Linked data on nursing home residents from clinical and health administrative databases was used. The yearly proportions of residents who were dispensed an opioid concurrently with a BZD or gabapentinoid were plotted with percent change derived from log-binomial regression models. Separate modified Poisson regression models estimated resident-level correlates of concurrent use of opioids with BZDs or gabapentinoids.

Results

Over the study period, among residents dispensed an opioid there was a 53.2% relative decrease (30.7% to 14.4%) in concurrent BZD and a 505.4% relative increase (4.4% to 26.6%) in concurrent gabapentinoid use. In adjusted models, increasing age and worsening cognition were inversely associated with the concurrent use of both classes, but most other significantly related covariates were unique to each drug class (e.g., sex and anxiety disorders for BZD, pain severity and presence of pain-related conditions for gabapentinoids).

Conclusions

Co-administration of BZDs or gabapentinoids in Ontario nursing home residents dispensed opioids remains common, but the pattern of co-use has changed over time. Observed covariates of concurrent use in 2019/20 suggest distinct but overlapping resident populations requiring consideration of the relative risks versus benefits of this co-use and monitoring for potential harm.     

Staphylococcus aureus bacteremic pneumonia: differences between community and nosocomial acquisition.

OBJECTIVE: The aim of the study was to ascertain the clinical and epidemiologic characteristics of patients with nosocomial or community-acquired Staphylococcus aureus bacteremic pneumonia. METHODS: A prospective study of 134 cases diagnosed between January 1990 and December 1995 was performed. RESULTS: Fifty cases involved primary bacteremic pneumonias, of which 80% were nosocomial (the majority, 72%, in intensive care unit patients, of whom 57% were post-surgery). Of the 84 cases of secondary pneumonia, 36 were non-intravenous drug users (78% nosocomial, of whom 43% were in the intensive care unit), and 48 cases were intravenous drug users (98% community-acquired). CONCLUSIONS: Nosocomial S. aureus bacteremic pneumonia was especially frequent in intensive care unit patients (68.1%), and community-acquired pneumonia in intravenous drug users (72.3%). In non-intravenous drug users, clinical outcome and mortality were similar for nosocomial and community-acquired pneumonia.     

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions

PURPOSE: To identify the frequency and type of iatrogenic medical events requiring admission to an intensive care unit. To assess the consequences of iatrogenic medical events for patients and institutions. To assess the prevalence of disclosure of iatrogenic medical events to patients, surrogates, and institutions. METHODS: The project on Care Improvement for the Critically Ill enrolled 5727 patients to 8 intensive care units at 4 Boston teaching hospitals. To determine the nature, consequences, and disclosure of iatrogenic medical events, we did a retrospective chart review on all patients whose admission to an intensive care unit was precipitated by an iatrogenic event. RESULTS: Sixty-six patients (1.2 %) were identified by an intensive care unit's clinical team as having an iatrogenic medical event as the primary reason for admission to the unit. The majority (29, or 45%) of iatrogenic medical events were secondary to technical error, but a high percentage (21, or 33%) was due to iatrogenic drug events. Twenty-two (34%) cases were assessed by the investigators to have been preventable. In 60 (94%) cases there was no documentation in the patient's chart of communication to the patient regarding the reason for admission to the intensive care unit. In 11 (17%) cases there was documentation of a discussion with the surrogate about the reason for admission to the unit. In only 3 (5%) cases was there documentation that the patient or surrogate was informed that an iatrogenic medical event was the reason for admission to the intensive care unit. Incident reports or malpractice claims were filed in only 4 (6 %) cases. CONCLUSION: The frequency of iatrogenic medical events resulting in admission to intensive care units is lower than previous studies have reported. Iatrogenic drug events continue to be an important source of error. A considerable percentage of iatrogenic events may be preventable. Health care professionals rarely document disclosure of iatrogenic events to patients and surrogates.     

Benzodiazepines,Methadone and Buprenorphine: Interactions and Clinical Management

Benzodiazepines (BZDs) are widely used by heroin users not in treatment, and by patients in methadone and buprenorphine (BPN) treatment. This review examines the epidemiology of BZD use by opioid users, and the range of harms that are associated with BZD use in this group, including the association of BZD use with opioid‐related mortality. Preclinical and clinical data regarding pharmacokinetic and pharmacodynamic interactions between methadone, buprenorphine, and BZDs are reviewed. An overview of treatment approaches for managing BZD use in this population is presented, including strategies for minimizing abuse and addressing BZD dependence. (Am J Addict 2009;19:59–72)     

Prospective evaluation of the complications of anticoagulants in an intensive care unit

A prospective study was undertaken in a multidisciplinary intensive care unit to determine the proportion of complications due to anticoagulant therapy, to evaluate their severity and to estimate what proportion was potentially avoidable. Among 1911 hospitalized patients over a 3 year period, 30 patients had a complication of anticoagulant therapy (1,57 p. 100). The causality was definite in 14 cases, probable in 14 and possible in 2 cases. Nineteen p. 100 were hemorrhagic complications. These iatrogenic illnesses were fatal in 5 cases, life-threatening in 6, moderate in 15 and minor in 4 cases. Potentially avoidable complications accounted for 60 p. 100 of the cases and were due to biological overdosage or interaction between drugs. Our results indicate that some complications of anticoagulant therapy could be reduced or eliminated by medical education and increased information.     

Withdrawal of psychotropic drugs decreases the risk of falls requiring treatment

This non-randomized, controlled trial assessed the effects of ceasing fall-risk-increasing drugs (FRIDs) (psychotropics or opiates or potent anticholinergics) on the risk of falls requiring medical treatment as a sub-analysis of a randomized, controlled multifactorial fall prevention. The population in this 12-month study consisted of 528 community-dwelling subjects aged 65 years or older with a history of at least one fall. The subjects were divided retrospectively into three groups according to the use of any FRID, any psychotropic drug, and benzodiazepine or related drug (BZD/BZDRD). The subjects in the intervention group (IG) ceasing the drug use were compared with the subjects in IG and the control group (CG) not ceasing the use of the corresponding type of drugs during the intervention period. Falls were recorded from medical records. For the year after the 12-month intervention the relative risk ratio (with 95% confidence intervals = CI) for controls in CG compared with the withdrawal group in IG was 8.26 (1.07-63.73) among the users of psychotropics and 8.11 (1.03-63.60) among the users of BZDs/BZDRDs. Withdrawal of psychotropics, especially BZDs/BZDRDs may have played an important role by lowering the risk of falls requiring medical treatment during the year after the 12-month multifactorial intervention.     

Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature

Benzodiazepines (BZDs) constitute the most widely used symptomatic treatment of insomnia and anxiety. Many of these drugs are associated with adverse effects, such as daytime sedation and dependence with continued use. There is a concern about the rationale for and extent of benzodiazepine (BZD) use in the elderly. The sedation due to BZD use is a main risk factor for falls and other accidents. Impaired cognitive function with continuous use appears to be a major side effect. There is a general awareness that BZD use is inappropriate in many patients, and therefore discontinuation should be recommended whenever possible. Moreover, long-term use of these drugs should be actively discouraged. Although no unanimous recommendations concerning the optimal duration of the withdrawal process exist, BZDs may easily be withdrawn during a short period in most patients who are habituated to a low dose, if an initial phase with dose reduction and psychological support are provided. Alternative approaches involve sleep hygiene guidelines, behavioural treatment and psychotherapy tailored to the needs of the individual patient.     

严重气管软化症10例临床特点及文献复习

目的回顾性分析10例ICU中经机械通气等治疗措施干预的严重气管软化症（tracheomalacia,TM）患者的临床资料,以提高对该病的识别。方法回顾性分析我院ICU收治的10例严重TM患者的临床表现、胸部CT影像、纤维支气管镜检查资料及治疗转归。结果10例TM患者男女比例相等。主要症状为呼气困难突发或加重,可伴咳嗽、咳痰困难,严重者表现为发作性窒息。体征主要为气管听诊区闻及吸气相或双相喘鸣音。胸部CT示呼气相气管狭窄。全组患者气囊漏气试验阳性,纤维支气管镜下见用力呼气时气管壁向管腔内突出致气管狭窄或陷闭。结论TM的临床表现无特异性,易误诊为COPD和支气管哮喘。胸部CT及气囊漏气试验可作为TM的早期筛查方法,纤维支气管镜检查是诊断TM的金标准。     

Peripheral-type benzodiazepines influence ornithine decarboxylase levels and neurite outgrowth in PC12 cells.

A number of the benzodiazepines (BZDs) inhibit nerve growth factor (NGF)-induced neurite outgrowth in a dose-dependent manner in PC12 cell cultures. The rank order of potency of a series of BZDs for inhibition of neurite outgrowth does not correlate with the order of their affinity constants for the so-called peripheral BZD sites present on PC12 cells. Whereas the inhibition of neurite extension is stereospecific, the binding to the peripheral site is not. The inhibition of neurite outgrowth is not attributable to a blockade of NGF binding to either its fast or slow receptors. Additionally, several other characteristics of NGF stimulation of PC12 cells, such as autoadhesion and the induction of ornithine decarboxylase (OrnDCase), remain unaltered in the presence of BZDs. Many BZDs increase OrnDCase levels in PC12 cells in the absence of NGF. The OrnDCase response to BZDs is blocked by actinomycin D. Furthermore, the structural requirements of BZDs for induction of OrnDCase activity is not identical to that for the inhibition of NGF-induced neurite extension. Thus, unlike attenuation of neurite extension, BZD induction of OrnDCase is not stereospecific. Also, some BZDs block neurite growth but do not induce OrnDCase. We propose that there are at least three sites of action of BZDs on PC12 cells. The first is the well-characterized high-affinity peripheral site. The second distinct locus of action results in a blockade of NGF-induced neurite outgrowth. The structural requirements for the latter effect are essentially indistinguishable from those for BZD induction of hemoglobin synthesis in Friend erythroleukemia cells. The third site of action results in an induction of OrnDCase. Structural requirements for this activity are not identical to those for either the differentiation of Friend cells or the inhibition of neurite outgrowth.     

Spontaneous bacterial peritonitis--in-hospital mortality, predictors of survival, and health care costs from 1988 to 1998

OBJECTIVES: Spontaneous bacterial peritonitis (SBP) is a complication of end-stage liver disease with a reported mortality of 30-50%. In this study, we investigated the outcome of all patients admitted to Maryland hospitals with SBP from 1988 to 1998. Main outcomes considered included trends in survival rates over time, changes in the length of stay, total health care costs, and variables that predicted survival rates. METHODS: We used the Maryland Health Services Cost Review database of all patients admitted to Maryland hospitals with an International Classification of Diseases (Ninth Revision) code for both peritonitis and cirrhosis from 1988 to 1998. RESULTS: A total of 348 patients were admitted with an in-hospital mortality of 32.6%; there was no significant change in mortality rate during this period. The survival rate was similar in the university and community hospitals. In the logistic regression analysis, age (p = 0.001) and intensive care unit stay (p = 0.0001) were found to significantly influence the survival rates; those patients who had an intensive care unit stay were 2.8 times more likely to die than those who did not have an intensive care unit stay, controlling for age. The average length of hospital stay remained unchanged (13.5 +/- 12.7 days) during the study period. Although the median hospital charge (excluding professional fees) remained unchanged, mean inflation-adjusted charges increased from $7,897 in 1988 to $25,902 in CONCLUSIONS: The mortality rate associated with SBP has remained unchanged over an 11-yr period from 1988 to 1998. The mortality showed a strong correlation with age and intensive care unit stay. The median hospital stay and median charges remained unchanged during this period, but mean costs increased significantly because of increased use of resources by a few patients.     

Clinical features,management, and outcome of hemodialysis patients with SARS-CoV-2

The aim of the study was to evaluate the clinical features of the patients on HD with COVID-19 and determine the prognostic factors. In this single-center prospective study, a total of 58 chronic renal failure patients on HD and diagnosed COVID-19 infection were enrolled in the study. The patients were divided into two groups according to their need for intensive care unit referral. Demographic features of the patients, clinical manifestations, laboratory data, treatments, and clinical outcome were evaluated. The mean age of 58 HD patients was 63.2 ± 13.8 (30–93) years and female–male ratio was 0.34. SARS-CoV2-PCR positivity rate was 32.8%. 85.2% of patients (n = 46) had bilateral lesions and 14.8% (n = 8) had unilateral one lesion in chest CT. The most common symptoms were fatigue (in 44 patients, 80%) and dyspnea (in 31 patients, 56.4%). The most common comorbidity was HT (in 37 patients, 67.3%). The patients who need intensive care and died were older (p = 0.015). We observed lower platelet and eosinophil counts, potassium levels, higher AST, troponin and CRP levels in the group of patients who need intensive care and died than the group who survived (p = 0.043, 0.005, 0.033, 0.007, 0.001, <0.001, respectively). 15.5% of the patients (n = 9) were transferred to intensive care unit. Among them, two were discharged with cure and seven patients died. Mortality rate was 12.1%. Older age, lower platelet and eosinophil counts and higher AST, troponin and CRP levels were prognostic risk factors in our HD patients who needed intensive care.     

Cimetidine prophylaxis for gastrointestinal bleeding in an intensive care unit.

The efficacy of cimetidine in the prevention of gastrointestinal haemorrhage in a general intensive care unit was evaluated in 221 patients by a placebo controlled double blind randomised study. Criteria for bleeding were (i) haematemesis or gastric aspirate greater than 50 ml fresh blood, (ii) melaena or fresh blood per rectum with an upper source verified by endoscopy if the gastric aspirate was clear, (iii) a fall in haemoglobin level greater than 2 g/dl in a 24 hour period associated with either 4+ occult blood in stools, or coffee ground gastric drainage of at least 100 ml. The drug and placebo groups were similar for age, sex, duration of study and risk factors. One hundred and fourteen received cimetidine and 107 placebo. Only 8% of the patients bled with no significant difference between the two groups (6/114 cimetidine, 11/107 placebo; p = 0.16). There was no correlation between the frequency of bleeding and either the number of risk factors per patient or the duration of intensive care unit stay. Thirteen patients died in each study group, resulting in overall mortality of 12%. The low incidence of haemorrhage, the lack of statistical benefit from cimetidine and the similar mortality all argue against the routine use of this drug in intensive care unit patients.     

A n evaluation of D SM-III- R benzodiazepine dependence criteria Rasch m odelling and IC D-10 using

A bstract A im s. To evaluate the homogeneity of the elements of the Substance Dependence Syndrome (SDS) as applied to benzodiazepines (BZDs) by Rasch modelling. M easurem ents. The Rasch scaling model was applied to data obtained by administering the SCAN (Schedules for Clinical Assessments in Neuropsychiatry) substance dependence sections. Subsequently, Rasch-homogeneous sets of DSM-III-R and ICD-10 BZD dependence criteria were assessed for subject and item discriminability. To support their construct validity a theoretical rationale was formulated based on the Rasch scale values. Participants. A heterogeneous sample of 599 outpatient BZD users. Findings. Only particular subsets of the DSM-III-R and ICD-10 BZD dependence criteria met the requirements for Rasch-homogeneity, which appears to be due to medical aspects of BZD use. The subject and item discriminability results were sufficiently good. C onclusions. The DSM-III-R and ICD-10 BZD dependence constructs may need to be redefined. The use of a BZD dependence severity model based on a Rasch-homogeneous scale appears to have greater clinical value than a dichotomous diagnostic model based on an arbitrary cut-off point. We recommend Rasch modelling to investigate the homogeneity of the elements of the SDS across other psychoactive substances.     

Endemic nosocomial Acinetobacter calcoaceticus bacteremia. Clinical significance, treatment, and prognosis

The medical records of 27 patients with blood cultures positive for Acinetobacter calcoaceticus over a recent five-year period (0.7% of all positive blood cultures) were reviewed retrospectively to determine the epidemiologic and clinical significance of these isolates. Eighteen isolates represented true bacteremias, 16 of which were hospital acquired. Patients most frequently were located in an intensive care unit or on a surgical ward. A seasonal July-to-September peak incidence was noted. The most common site of primary infection was the respiratory tract. Aminoglycosides, alone or in combination with a second agent, were used to treat all but one infection. Bacteriologic cure was achieved in 15 cases (88%); six patients had polymicrobial sepsis that carried a higher mortality than pure A calcoaceticus bacteremia (50% vs 0%). Acinetobacter, a low-virulence opportunistic pathogen, may be an infrequent but potentially serious endemic agent of nosocomial bacteremia in some institutions. The prognosis of bacteremia, when appropriately treated, appears to be good.     

Prevalence and correlates of substance use among clinical nurses in Kaohsiung city

Though substance abuse and its deleterious health sequelae are a serious problem in Taiwan, licit and illicit substance use patterns among nurses are understudied. The purpose of this study was to investigate the prevalence of substance use and to identify its related factors among clinical nurses. A total of 907 registered nurses were recruited for this study via stratified-random sampling from hospitals in Kaohsiung city. Each participant was requested to reply to a structured questionnaire anonymously and a 98.1% response rate was achieved. Prevalence of substance use during the past year was estimated as follows: alcohol drinking (regular use-3.8%); coffee drinking (regular use-44.7%); cigarette smoking (regular use-0.2%); regular use of analgesics 21.1%; regular use of benzodiazepines 1.8%; use of narcotics (ever use-0.7%). Significant factors related to substance use were analyzed by logistic regression. This revealed that for regular alcohol use, the significant factor was a positive attitude toward substance use; for BZD drug use, they were poor mental health, positive attitude toward substance use, being unmarried, and used analgesics; for regular analgesics use, they were work in non-critical care unit, self-perceived poor health status, and BZD drug use. Results generated from this study may act as reference for nursing administration to develop an effective health promotion program of physical and mental health for the clinical nurses.     

Ineffectiveness of routine abdominal radiography in patients with gastrointestinal hemorrhage admitted to an intensive care unit

GOALS: To determine the utility of plain abdominal radiography in the initial evaluation of acute gastrointestinal (GI) hemorrhage in a medical intensive care unit. BACKGROUND: Plain abdominal radiographs are frequently used in the routine evaluation of patients with GI bleeding. The utility of these studies in the intensive care unit setting is unclear. STUDY: The study was a retrospective chart review of 71 adult subjects admitted to a medical intensive care unit with the diagnosis of GI bleeding. Subjects were excluded if they presented with peritoneal signs, received an abdominal CT scan in the 24 hours prior to admission, or were chronically treated with immunosuppressive medication. Subjects were divided into two cohorts based on whether or not they underwent plain abdominal radiography during the first hospital day. The primary study endpoints were hospital mortality, intensive care unit length of stay, and whether or not radiographic findings altered clinical management. RESULTS: Of the 71 patients admitted with a diagnosis of GI bleeding (mean age 65.8 +/- 14.5 years, 73.2% male), 56 (79%) had a plain abdominal radiograph performed. Subjects who had a plain film did not differ significantly from those who did not in age, gender, degree of anemia, degree of coagulopathy, or in severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE II) score. There was no statistically significant difference in hospital mortality or intensive care unit length of stay between patients who received plain films and those who did not. In no subject (0%; 95% confidence interval, 0%-5.4%) did abdominal radiography reveal an abnormality that altered clinical management. CONCLUSIONS: Based on our observations, plain films of the abdomen do not appear to alter clinical outcomes or management decisions for patients with GI bleeding and normal abdominal examinations who are admitted to the intensive care unit.     

肺结核并发呼吸机相关性肺炎病原菌特点及临床分析

目的 了解肺结核患者呼吸机相关性肺炎（VAP）病原菌菌谱构成和药敏情况,为临床经验性治疗提供参考。方法 选择2007年1月至2011年1月入住重症监护病房（ICU）接受机械通气治疗,确诊为VAP 的58例患者,采用一次性呼吸道吸引导管Ⅱ型或纤维支气管镜直接经气管插管或气管切开套管留取患者深部痰标本,镜检合格标本接种至培养基分离培养,普通细菌培养基采用血琼脂和麦康凯琼脂,真菌培养采用沙保罗培养基,培养后采用VITEK32全自动微生物分析仪进行细菌鉴定和药敏试验。分析并发VAP的肺结核患者的临床特点、病原菌分布、耐药情况和治疗结果。 结果 58例发生VAP肺结核患者共分离104株病原菌,其中革兰阴性(G^-)杆菌71株［占68.3%（71/104）］、革兰阳性(G⁺)球菌8株［占7.7%（8/104）］、真菌25株［占24.0%（25/104）］。肺结核并发VAP的主要病原菌为鲍曼不动杆菌［占26.0%（27/104）］、铜绿假单胞菌［占21.2%（22/104）］、白色念珠菌［占14.4%（15/104）］。2种及2种以上病原菌混合感染患者26例［占44.8%（26/58）］。结论 肺结核并发VAP的主要病原菌为G^-杆菌和真菌,混合感染率较高。     

A utilization management intervention to reduce unnecessary testing in the coronary care unit

BACKGROUND: There have been no studies of interventions to reduce test utilization in the coronary care unit. OBJECTIVE: To determine whether a 3-part intervention in a coronary care unit could decrease utilization without affecting clinical outcomes. METHODS: Practice guidelines for routine laboratory and chest radiographic testing were developed by a multidisciplinary team, using evidence-based recommendations when possible and expert opinion otherwise. These guidelines were incorporated into the computer admission orders for the coronary care unit at a large teaching hospital, and educational efforts were targeted at the house staff and nurses. Utilization during the 3-month intervention period was compared with utilization during the same 3 months in the prior year. The hospital's medical intensive care unit, which did not receive the specific intervention, provided control data. RESULTS: During the intervention period, there were significant reductions in utilization of all chemistry tests (from 7% to 40%). Reductions in ordering of complete blood counts, arterial blood gas tests, and chest radiographs were not statistically significant. After controlling for trends in the control intensive care unit, however, the reductions in arterial blood gas tests (P =.04) and chest radiographs (P<.001) became significant. The reductions in potassium, glucose, calcium, magnesium, and phosphorus testing, but not other chemistries, remained significant. The estimated reduction in expenditures for "routine" blood tests and chest radiographs was 17% (P<.001). There were no significant changes in length of stay, readmission to intensive care, hospital mortality, or ventilator days. CONCLUSION: The utilization management intervention was associated with significant reductions in test ordering without a measurable change in clinical outcomes.