Post-exposure prophylaxis for human immunodeficiency virus after sexual assault in a Midwestern U.S. emergency department

BackgroundEmergency departments (EDs) play an essential role in the timely initiation of HIV post-exposure prophylaxis (PEP) for sexual assault victims.MethodsRetrospective analysis of sexual assault victims evaluated and offered HIV PEP in an urban academic ED between January 1, 2005 and January 1, 2018. Data on demographics, comorbidities, nature of sexual assault, initial ED care, subsequent healthcare utilization within 28 days of initial ED visit, and evidence of seroconversion within 6 months of the initial ED visit were obtained. Predictors of subsequent ED visit and follow-up in the infectious diseases clinic were evaluated using logistic regression analysis.ResultsFour hundred twenty-three ED visits met criteria for inclusion in this study. Median age at ED presentation was 25 years (IQR 21–34 years), with the majority of victims being female (95.5%), Black (63.4%), unemployed (66.3%) and uninsured (53.9%); psychiatric comorbidities (38.8%) and substance abuse (23.6%) were common. About 87% of the patients accepted HIV PEP (368 of 423 ED visits). Age (OR 0.97, 95% CI 0.94–0.99, p = 0.025) and sexual assault involving >1 assailant (OR 0.48, 95% CI 0.26–0.88, p = 0.018) were associated with lower likelihood of HIV PEP acceptance. Ten patients (2.7%) followed up with the infectious disease clinic within 28 days of starting HIV PEP; 70 patients (19%) returned to the ED for care during the same time period. Psychiatric comorbidity (OR 2.48, 95% CI 1.43–4.30, p = 0.001) and anal penetration (OR 2.02, 95% CI 1.10–3.70, p = 0.024) were associated with greater likelihood of repeat ED visit; female gender (OR 0.30, 95% CI 0.11–0.85, p = 0.023) was associated with lower likelihood of repeat visit. Completion of HIV PEP was documented for 14 (3.3%) individuals.ConclusionsWhile ED patient acceptance of HIV PEP after sexual assault was high, infectious disease clinic follow-up and documented completion of PEP remained low. Innovative care models bridging EDs to outpatient clinics and community support services are needed to optimize transitions of care for sexual assault victims, including those receiving HIV PEP.     

Changes in vital signs as predictors of bacterial infection in home care: a multi-center prospective cohort study

Objectives: To explore whether the combination of changes in heart rate and body temperature can predict bacterial infection in home care patients.

Methods: This multicenter, prospective cohort study was conducted in Japan from March 2012 through December 2013 and involved three clinics. The study population comprised all patients who received regular home visit services for at least 3 months and met one of the following inclusion criteria: 1) fever over 37.5°C at home visit, 2) physician’s clinical suspicion of fever, or 3) physician’s suspicion of bacterial infection. We collected temperature and heart rate data on the day of enrollment, and determined the probable causes of fever after treatment of febrile episodes. We defined the combination of changes in heart rate and body temperature as delta HR/BT. We calculated two types of delta HR/BT, averaged and assumed, using different baseline values for heart rate and body temperature.

Results: A total of 124 patients were enrolled and 194 episodes of fever were analyzed during the study period. The sensitivity, specificity, positive predictive value, and negative predictive value for the average delta HR/BT with a cut-off ≥ 20 were 20.4% (95% CI, 16.7–23.3), 84.2% (95% CI, 75.2–91.0), 75.7% (95% CI, 61.8–86.2), and 30.6% (95% CI, 27.3–33.0), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the assumed delta HR/BT with a cut-off ≥ 5 was 91.2% (95% CI, 89.2–94.0), 8.9% (95% CI, 4.1–15.7), 70.9% (95% CI, 69.3–73.0), and 29.4% (95% CI, 13.6–51.8), respectively.

Conclusions: The combination of changes in heart rate and body temperature could help physicians determine whether home care patients have bacterial infections.     

Factors associated with poor prognosis in patients with atrial fibrillation: An emergency department perspective the EMERG-AF study

ObjectiveWe sought to identify the factors associated with a worse prognosis in Emergency Department (ED) patients with atrial fibrillation (AF), crucial information to guide management decisions.MethodsThis is a secondary analysis of a prospective, multicenter, observational cohort of consecutive AF patients attended in 62 EDs in Spain. Clinical variables were collected on enrollment. Follow-up was performed at 30 days and one year. The primary composite outcome was all-cause mortality, major bleeding and/or stroke at one year. Secondary outcomes were each of these components considered separately, plus one-year cardiovascular mortality and the composite outcome at 30 days.ResultsWe analyzed 1107 patients. The primary outcome occurred in 209 patients (18.9%), one-year all-cause mortality in 151 (13.6%), major bleeding in 47 (4.2%), and stroke in 31 (2.8%). Disability (HR 2.064, 95% CI 1.478–2.882), previous known AF (HR 1.829, 95% CI 1.096–3.051), long duration of the AF episode (HR 1.849, 95% CI 1.052–3.252) and renal failure (HR 2.073, 95% CI 1.433–2.999) were independently associated with the primary outcome, whereas anticoagulation at discharge was inversely associated (HR 0.576, 95% CI 0.415–0.801). Disability was associated with mortality, cardiovascular mortality, and the composite at 30 days, and renal failure with mortality and major bleeding.ConclusionsComorbidities like renal failure, long AF duration and disability were related to adverse outcomes and should be decisive to guide management decisions in ED patients with AF.Anticoagulation had a positive impact on prognosis and should be the mainstay of therapy in AF patients attended in ED.     

An open label naturalistic study of predictors of retention and compliance to naltrexone maintenance treatment among patients with opioid dependence

Background: This study aimed at assessment of retention and compliance to naltrexone for long-term management among patients with opioid dependence syndrome over a follow-up period of 15 months. Additionally, it aimed to identify predictors of retention in naltrexone treatment.

Methods: The study was conducted at a tertiary care drug dependence treatment centre. The study involved patients with opioid dependence syndrome who were prescribed naltrexone for long-term management. Information was collected for socio-demographic variables, drug use history, diagnosis, retention and compliance to naltrexone treatment. Data were analysed using SPSS ver 21 (IBM Inc., New York, NY).

Results: One hundred fifty-three patients were enrolled in naltrexone maintenance treatment following an initial detoxification phase. Duration of retention was longer among those who did not report concurrent use of cannabis (z?=?2.06, p?=?0.03) or benzodiazepines (z?=?2.04, p?=?0.04) at the time of presentation to treatment centre. Marital status (OR 3.61, 95% CI 0.96–8.22), employment status (OR 8.18, 95% CI 1.68–16.53), age at onset of opioid use (OR 13.17, 95% CI 1.08–1.31), duration of opioid use (OR 11.56, 95% CI 0.97–0.99) and number of abstinence attempts in past (OR 7.49, CI 1.20–3.07) as predictors of retention at 90 days (Table 4). Similarly, marital status (OR 4.80, 95% CI 1.13–10.22), employment status (OR 4.90, 95% CI 1.20–21.61), duration of opioid use (OR 8.11, 95% CI 0.96–0.99) and number of abstinence attempts in past (OR 8.18, 95% CI 1.23–3.05) were predictors of retention at 180 days.

Conclusions: Certain socio-demographic and drug use related variables are predictors of longer retention in naltrexone treatment. These factors can guide the selection process for the patients suited for long-term maintenance with naltrexone for opioid dependence.     

Limited value of NT-proBNP as a prognostic marker of all-cause mortality in patients with heart failure with preserved and mid-range ejection fraction in primary care: A report from the swedish heart failure register

Abstract

Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.

Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100?±?687?days.

Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40–50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p?=?0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60–2.39) p?<?0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49–1.98) p?<?0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38–2.44), p?<?0.0001] and [HR 1.48 (95% CI 1.16–1.90), p?=?0.0001], HFmrEF and HFpEF, respectively.

Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.

• Key points

• It is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF?>?40%, HFpEF) managed in primary care.

• We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.

• The clinical use is however limited due to large standard deviations, many co-morbidities and high age.

• Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.

     

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services

ObjectivesRoutine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation.MethodsCross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017–July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care.ResultsThere were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%–8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%–23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services.ConclusionsPatients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.     

Characteristics of Family Physicians Delivering Home Visits: A Canadian Retrospective Cohort Study

ContextHome visits have become increasingly uncommon although evidence suggests they improve healthcare quality and reduce overall expenditures. This study identifies the primary care physicians delivering home visits at patients’ end of life in Ontario, Canada, describes characteristics of primary care physicians delivering end-of-life home visits, and explores associations with delivery.ObjectivesIdentify the primary care physicians delivering home visits at patients' end of life in Ontario, Canada, describe characteristics of primary care physicians delivering end-of-life home visits, and explore associations with delivery.MethodsA retrospective cohort design using population-level health administrative data housed at ICES. The cohort was composed of primary care physicians in Ontario, Canada between April 1, 2014 and March 31, 2019, who were registered in the College of Physicians and Surgeons of Ontario database dataset on or after January 1, 1990 and as of March 31, 2016.ResultsA total of 9884 physicians were identified, of which 2568 (25.7%) delivered at least one end-of-life home visit. Physician characteristics showing increased odds ratio (OR) of home visit delivery were older age (OR 1.01 [95% Confidence Interval (CI): 1.00–1.02]) international training (OR 1.28 [95% CI:1.04–1.59]), previous home visit experience (OR 1.02 [95% CI: 1.01–1.02]), capitation models of remuneration; namely enhanced fee-for-service models (OR 1.5 [95%CI: 1.17–2.00]) and mainly capitation model (OR 1.4 [95% CI:1.11–1.79]), and population size of practice location with highest odds in small rural or remote areas (<9000 residents) (OR 1.38 [95%CI: 1.02–1.88]) and large metropolitan areas (OR 1.84 [95%CI: 1.46–2.57]).ConclusionThis research confirms previous evidence and identifies novel primary care physicians’ characteristics associated with home visit practice patterns. Furthermore, it highlights characteristics amenable to policy or system-level changes (e.g., remuneration model, training, and experience) that could increase the provision of home visits which may greatly improve the dying experience of Canadians.     

Estimated proportion of an urban academic emergency department patient population eligible for HIV preexposure prophylaxis

ObjectivePre-exposure prophylaxis (PrEP) is a highly effective but underutilized method of HIV prevention. Emergency departments (EDs) have access to at-risk populations meeting CDC eligibility criteria for PrEP. Characterizing this population could help motivate, develop, and implement ED interventions to promote PrEP uptake.MethodsThis cross-sectional study explored the proportion of patients from an urban, academic ED who met CDC 2017 PrEP eligibility criteria using three existing datasets that mimic patient selection strategies for HIV screening: 1) study of consecutively approached ED patients from 2008 to 2009 (analogous to non-targeted screening), 2) patients of the ED's HIV screening program in 2017 (analogous to risk-targeted screening), and 3) electronic health record (EHR) diagnostic codes in 2017 (analogous to EHR selected screening). The primary outcome was the proportion eligible for PrEP referral. Secondary outcomes included proportion by risk group: men who have sex with men (MSM), heterosexual men and women (HMW), and persons who inject drugs (PWID).ResultsThe proportion eligible for PrEP was: 568/1970 (28.8%, 95% CI: 26.9–30.9) for consecutively approached patients, 552/3884 (14%, 95% CI: 13–15) for risk-targeted patients, and 605/66287 (0.9%, 95% CI: 0.8–1.0) for EHR diagnoses of all patients. For the two datasets with behavioral risk information, the proportion eligible was: MSM 1–2%, HMW 12–28%, and PWID 1–4%.ConclusionsA large subgroup of this ED population was eligible for PrEP referral. EDs are a compelling setting for development and implementation of HIV prevention interventions to assist in national efforts to expand PrEP.     

Real-world medication persistence among HIV-1 patients initiating integrase inhibitor-based antiretroviral therapy in Japan

IntroductionMedication persistence has rarely been studied for integrase strand transfer inhibitor (INSTI)-based regimens among patients living HIV (PLWH) in Asia. This study investigated medication persistence for newly prescribed INSTI-based regimens in Japan by comparing single-tablet regimens (STRs) versus multiple-tablet regimens (MTRs), based on the Medical Data Vision database.MethodsAdult PLWH with ≥2 claims for antiretroviral therapy (ART) of interest between 1 January 2017 and 30 June 2018 were included if they had a ≥3-month continuous enrolment prior to the index date and a ≥6-month follow-up after the index date. Medication persistence was measured as the duration from initiation to discontinuation of the prescribed INSTI-based regimen.ResultsOverall, 487 patients were included, with 220 in the STR cohort and 267 in the MTR cohort. Persistence was longer in the STR cohort than in the MTR cohort (mean days on the index regimens: 384.2 vs. 317.3, P < 0.001). MTRs were associated with a higher risk of discontinuation than STRs (hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.18–2.52; P = 0.005). Other factors that were associated with discontinuation were backbone (emtricitabine/tenofovir disoproxil fumarate vs. emtricitabine/tenofovir alafenamide: HR, 5.64; 95% CI, 3.68–8.66; P < 0.001), third agent (raltegravir vs. elvitegravir/cobicistat: HR, 2.06; 95% CI, 1.10–3.86; P = 0.024), age (HR, 1.02; 95% CI, 1.01–1.03; P = 0.007), and the number of non-ART index medications (HR, 1.16; 95% CI, 1.12–1.21; P < 0.001).ConclusionsAmong PLWH newly prescribed an INSTI-based regimen in Japan, STRs were associated with longer persistence than MTRs.     

Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital

ObjectiveDescribe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital.MethodsA retrospective longitudinal registry study based on all ED visits with adult patients during 2009–2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician’s ratios) were extracted from the hospital’s electronic health record. Non-parametric analyses were conducted.ResultsThe proportion of unstable patients (triage level 1–2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8–9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18–79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3–5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5–7.9) compared to 15.5 min/year (95% CI: 15.2–15.8) for those being admitted.ConclusionFewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.     

Association of Hospice Care Services With the Utilization of Life-Sustaining Treatments During End-of-Life Care Among Patients With Cancer: A Nationwide 11-Year Cohort Study

ContextThe impact of hospice care services on the utilization of life-sustaining treatments during end-of-life care in terminally ill patients has not been extensively studied.ObjectivesTo determine the impact of hospice care services on the utilization of life-sustaining treatments during the last three months of life among patients with cancer.MethodsThis nationwide population-based cohort study identified adults with cancer diagnosis from the Taiwan Registry for Catastrophic Illness, 2006–2016. Life-sustaining treatments included cardiopulmonary resuscitation, intubation, mechanical ventilation support, nasogastric tube feeding, and total parenteral nutrition. Hospice care services consisted of hospice inpatient care, hospice-shared care, and hospice home care. The association of hospice care services with the utilization of life-sustaining treatments was determined using multiple logistic regression.ResultsOf 516,409 patients with cancer, 310,722 (60.2%) patients used life-sustaining treatments during the last three months of life. After adjusting for covariates, patients with hospice care services were less likely to receive life-sustaining treatments during the last three months of life than those without the services (adjusted odds ratio [AOR]: 0.70; 95% CI: 0.69–0.71). While type of life-sustaining treatments were considered, hospice care services were associated with a lower likelihood of receiving cardiopulmonary resuscitation (AOR: 0.125; 95% CI: 0.118–0.131), endotracheal intubation (AOR: 0.204; 95% CI: 0.199–0.210), mechanical ventilation support (AOR: 0.265; 95% CI: 0.260–0.270), nasogastric tube feeding (AOR: 0.736; 95% CI: 0.727–0.744), and total parenteral nutrition (AOR: 0.86; 95% CI: 0.84–0.88).ConclusionHospice care services were associated with a lower likelihood of receiving life-sustaining treatments during the last three months of life in patients with cancer.     

Multiple comorbidities increase the risk of death from invasive pneumococcal disease under the age of 65 years

IntroductionRisk factors for death from invasive pneumococcal disease (IPD) have not been clearly established in patients aged under 65 years. We aimed to evaluate contributions of host and bacterial factors to the risk of death from IPD in patients aged under 65 years in Japan.MethodsIn this prospective, observational, multicenter cohort study, patients with IPD (n = 581) aged 6–64 years were enrolled between 2010 and 2017. We investigated the role of host and bacterial factors in 28-day mortality.ResultsThe mortality rate increased from 3.4% to 6.2% in patients aged 6–44 years to 15.5%–19.5% in those aged 45–64 years. Multivariable analysis identified the following risk factors for mortality: age 45–64 years (hazard ratio [HR], 3.4; 95% confidence interval [CI], 1.6–6.8, p = 0.001), bacteremia with unknown focus (HR, 2.0; 95% CI, 1.1–3.7, p = 0.024), meningitis (HR, 2.1; 95% CI, 1.1–4.0, p = 0.019), underlying multiple non-immunocompromising conditions (HR, 2.6; 95% CI, 1.1–7.4, p = 0.023), and immunocompromising conditions related to malignancy (HR, 2.4; 95% CI, 1.0–5.2, p = 0.039). Pneumococcal serotype was not associated with poor outcomes.ConclusionsHost factors, including age of 45–64 years and underlying multiple non-immunocompromising conditions, are important for the prognosis of IPD. Our results will contribute to the development of targeted pneumococcal vaccination strategies in Japan.     

2019年浙江省温州市艾滋病感染诊断治疗服务链特征分析

目的 分析2019年浙江省温州市艾滋病感染诊断治疗服务链中诊断发现率、链接率、保持率、登记治疗率、维持治疗率、病毒抑制率及相关因素,为精准防控提供参考依据。方法 通过中国疾病预防控制信息系统收集截至2019年温州市现存活艾滋病病毒感染者/艾滋病患者（HIV/AIDS）信息,采用Spectrum v5.753软件估计HIV/AIDS数,采用多因素logistic回归模型分析温州市艾滋病感染诊断治疗服务链各环节（链接、保持、登记治疗、维持治疗和病毒抑制）影响因素。结果 截至2019年底,温州市估计现存活HIV/AIDS 5 750(5 078～6 473)例,诊断发现率为76.2%(67.7%～86.2%)（“第一个90%”）。分别与服务链的上一环节相比,链接率、保持率及登记治疗率为99.1%、97.2%、98.9%。维持治疗率为91.5%（“第二个90%”）,病毒抑制率为95.9%（“第三个90%”）。多因素logistic回归分析显示,监管场所来源HIV/AIDS在各环节均容易脱失,OR值（95%CI）分别为0.23(0.08～0.64)、0.32(0.17～0.62)、0.33(0....     

New-onset atrial fibrillation in patients with acute kidney injury on continuous renal replacement therapy

PurposeThe mortality of critically ill patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT) remains high. We assessed the incidence and predictors of new-onset atrial fibrillation (NOAF) in this population and its impact on outcomes.Materials and methodsThis is a retrospective cohort study of adult intensive care units (ICU) patients who had AKI and received CRRT from December 2006 through November 2015 in a tertiary academic medical center. Cox proportional hazard model was used to evaluate the impact of NOAF on overall mortality.ResultsOut of 1398 screened patients, NOAF occurred in 193 (14%) cases. NOAF occurring on CRRT was independently associated with an increased hazard of death at follow-up (HR: 1.26; 95% CI: 1.03–1.56), compared to the group who did not have NOAF. In the multivariable analysis using time-dependent covariates, higher potassium (HR 1.24, 95%CI: 1.01–1.54) and bicarbonate (HR 0.95, 95%CI: 0.92–0.98) levels were associated with increased and decreased risk of NOAF on CRRT, respectively.ConclusionsNOAF in critically ill patients with AKI receiving CRRT is common and carries an unfavorable prognosis. Prospective studies are required to elucidate modifiable risk factors for NOAF occurring on CRRT.     

Resource utilization across the continuum of HIV care: An emergency department-based cohort study

BackgroundThe objective of this study was to determine the healthcare resource utilization for people living with HIV (PLWH) presenting to the emergency department (ED) across the HIV Care Continuum.MethodsThis prospective study enrolled PLWH presenting to an urban ED between June 2016 and March 2017. Subjects were categorized as being linked to care, retained in care, on antiretroviral therapy (ART), and virally suppressed (<200 copies/ml). Data on ED visit rates, duration of stay, and hospital admission rates were compared to local metrics.ResultsOverall, 94.3% of 159 enrollees had been linked to care, 75.5% retained in care, 81.1% on ART, and 62.8% virally suppressed. Compared to the general population of the city and of the ED, participants had a higher ED visit rate (3.0 v. 1.2 visits per person-per year) in the past two years, a higher median duration of ED stay (12.6 v. 7.6 h), and a higher hospital admission rate (36.5% v. 24.9%) during their index ED visit. Viral suppression was negatively associated with admission (OR = 0.35, 95% CI: 0.17, 0.72). Forty-eight (30.2%) participants who had at least eight ED visits in the past two years were more likely to have a diagnosed mental health disorder (79.2% v. 62.2%, p=0.036).ConclusionsOur results showed that PLWH use more ED resources than the general population and a better engagement in HIV care is linked to lesser ED resource utilization for PLWH, indicating the importance of improved HIV care engagement in healthcare utilization management.     

High Risk of Gastrointestinal Hemorrhage in Patients With Epilepsy: A Nationwide Cohort Study

ObjectiveTo examine the association between epilepsy and gastrointestinal hemorrhage.Patients and MethodsWe conducted a nationwide retrospective cohort study by using data from Taiwan’s National Health Insurance Research Database. Patients 20 years and older newly diagnosed as having epilepsy and nonepileptic adults were identified between January 1, 2000, and December 31, 2003, and were observed through December 31, 2008. Cox proportional hazards models were performed to calculate adjusted hazard ratios (HRs) and 95% CIs of gastrointestinal hemorrhage associated with epilepsy.ResultsCompared with the nonepileptic group (n=449,541), epileptic patients (n=1412) had a higher incidence of gastrointestinal hemorrhage (13.4 vs 2.9 per 1000 person-years), with an HR of 2.97 (95% CI, 2.49-3.53). The HRs of gastrointestinal hemorrhage for patients with generalized epilepsy, inpatient care, emergency care, and frequent outpatient visits for epilepsy were 3.50 (95% CI, 2.59-4.72), 3.96 (95% CI, 2.85-5.50), 4.35 (95% CI, 3.15-6.01), and 4.96 (95% CI, 3.97-6.21), respectively. Risks were significantly higher in epileptic patients with mental disorders (HR, 3.20; 95% CI, 2.55-4.01), aged 70 years and older (HR, 4.08; 95% CI, 2.89-5.77), and in the first year after epilepsy (HR, 4.81; 95%, CI, 3.14-7.34).ConclusionEpilepsy is an independent determinant for gastrointestinal hemorrhage in a chronological and severity-dependent pattern. We urge the development of an adequate surveillance policy and strategy for the early prevention of gastrointestinal hemorrhage in epileptic patients.     

Effect of yoga on the quality of life of patients with rheumatic diseases: Systematic review with meta-analysis

AimTo analyze the effects of yoga on the quality of life of patients with rheumatic diseases through a systematic review with meta-analysis.MethodsThis systematic review with meta-analysis was conducted following the recommendations of the Declaration of PRISMA. The searches were carried out on the databases PubMed, Web of Science, EBSCO, Scopus, and Cochrane until August 2018. Experimental studies evaluating the effect of yoga on the quality of life in patients with rheumatic diseases were included.ResultsAfter data searches, 483 studies were found, 23 of which were included in our analysis. We found that yoga improves the overall quality of life (d= −0.64; 95% CI: −0.91 to 0.038) of patients with rheumatic diseases, as well as the following domains: functional capacity (d = 16.43; 95% CI: 13.37–19.49), physical aspects (d = 27.11; 95% CI: 19.40–34.83), emotional aspects (d = 26.00; 95% CI: 18.87–33.13), general health (d = 16.61; 95% CI: 12.66–20.55), and social aspects (d = 7.01 ; 95% CI: 5.57–9.45).ConclusionEvidence suggests weak recommendations can be made for the use of yoga in the management of RD patients.