Risk of major bleeding associated with aspirin use in non-surgical critically ill patients receiving therapeutic anticoagulation

BackgroundWe aimed to evaluate the risk of major bleeding in non-surgical critically ill patients who received aspirin in conjunction with therapeutic anticoagulation (concomitant therapy) compared to those who received therapeutic anticoagulation alone.MethodsThis is a retrospective cohort study of critically ill patients initiated on therapeutic anticoagulation at a large academic medical center from 2007 to 2016. The exposure of interest was aspirin therapy during anticoagulation. The primary outcome was the incidence of major bleeding during hospitalization. Secondary outcomes included in-hospital mortality, hospital free days, and new myocardial infarction or stroke.Results5507 (73.2%) patients received anticoagulation alone and 2014 (26.8%) received concomitant therapy; major bleeding occurred in 19.0% and 22.2%, respectively. There was no increased risk of major bleeding [OR 1.10 (95% CI: 0.93–1.30); p = .27] or mortality [OR 0.93 (95% CI: 0.77–1.11); p = .43] with concomitant therapy. Patients receiving concomitant therapy had fewer hospital-free days (mean decrease of 0.73 [1.36, 0.09]; p = .03) and were more likely to experience new myocardial infarction or stroke [OR 2.61 (95% CI: 1.72–3.98); p < .001].ConclusionsIn non-surgical critically ill patients receiving therapeutic anticoagulation, concomitant use of aspirin was not associated with an increased risk of bleeding or in-hospital mortality.     

The patterns of anticoagulation control and the risk of stroke,bleeding and mortality in patients with non‐valvular atrial fibrillation

Summary. Background: Anticoagulation control is often summarized using the percentage of time spent in a therapeutic range (TTR). This method does not describe the timing and severity of fluctuations in the International Normalised Ratio (INR).Objective: To evaluate whether the TTR method can be improved by considering the patterns of INR over time.Methods: The cohort included adults aged 40+ years with atrial fibrillation (AF) and laboratory records of INR as recorded in the UK Clinical Practice Research Datalink. Statistical clustering techniques based on simple INR measures were used to describe the patterns of INR. Nested case–control studies calculated the odds ratios (ORs) for the risk of stroke, bleeding and mortality with TTR and different INR patterns. It was also evaluated whether cluster analyses improved the prediction of outcomes over TTR.Results: A number of 27 381 patients were studied with a mean age of 73 years. The OR for mortality was 3.76 (95% confidence interval [CI] 3.03–4.68) in patients with < 30% TTR compared with patients with 100% TTR. INR patterns were found to be best described by six different clusters. The cluster with the most unstable pattern was associated with the largest risk of mortality (OR 10.7, 95% CI 8.27–13.85) and stroke (OR 3.42, 95% CI 2.08–5.63). INR measures that predicted death independent of the TTR‐included absolute difference between two subsequent INR measurements and change relative to the mean over time.Conclusion: Cluster analysis of INR patterns improved the prediction of clinical outcomes over TTR and may help to identify warfarin users who need additional anticoagulation monitoring.     

Risk factors for bleeding during anticoagulation of atrial fibrillation in older and younger patients in clinical practice

Background: The prevalence of atrial fibrillation increases with age, affecting ∼5% of people aged >65 years and almost 10% of people aged >80 years.Objective: The goal of this study was to identify risk factors for bleeding during warfarin treatment of nonvalvular atrial fibrillation (NNVAF) in older patients (those aged ≥75 years) compared with younger patients (those aged <75 years) in clinical practice.Methods: All patients with NVAF newly started on warfarin at an anticoagulation clinic in a large university hospital were included in this prospective observational study. Patient details were recorded at their first visit; details of any bleeding events were recorded via telephone interview every 4 to 6 weeks for a minimum of 10 months. Patients were divided into 2 groups (ie, those ≥75 years old and those <75 years old). Logistic regression analysis was used to identify risk factors for bleeding.Results: A total of 402 patients were included in the study. Group I comprised 203 patients <75 years old (mean [SD] age, 64.33 [8.33] years) and group II comprised 199 patients ≥75 years old (mean [SD] age, 80.44 [3.99] years). Follow-up ranged from 1 to 31 months (mean [SD], 19 [8.11] months). For major bleeding, number of medications was a significant risk factor in older patients (odds ratio [OR], 3.0; 95% CI, 1.2–7.8 [P = 0.02 ]) and range of the international normalized ratio (INR) was a significant risk factor in both groups. For every unit increase in the range of INR, the odds of major bleeding increased by 0.6 (OR, 1.6; 95% CI, 1.2–2.4 [P = 0.03 ]) in younger patients and by 0.4 (OR, 1.4; 95% CI, 1.07–1.99 [P = 0.04 ])in older patients. For minor bleeding, history of hypertension was the only significant risk factor in older patients (OR, 3.3; 95% CI, 1.3–8.1 [P = 0.01 ]), while history of ischemic heart disease was the only risk factor in younger patients (OR, 1.9; 95% CI, 1.1–5.4 [P = 0.04 ]).Conclusions: Bleeding pattern was similar in both age groups regarding severity, onset, anatomic site of bleeding, and INR values during the bleeding event. Risk factors for episodes of major bleeding, which are more of a clinical concern, are potentially modifiable. They include quality of anticoagulation control in both groups and number of medications in the older age group.     

Relationship of Restraint Use,Patient Injury,andAssaults on Ems Personnel

Objective. We hypothesized that the assaults on EMS personnel by patients requiring restraints can be correlated with demographic information, patient condition, andother scene information such as presence the of law enforcement. Methods. The study was a one-year cross-sectional study of paramedic restraint use andassault on EMS personnel in an urban area. A data collection form was completed by EMS for each patient placed in restraints. Study outcome variable was “Assault on EMS personnel.” Predictor variables included demographic andEMS call information, patient condition, law-enforcement related variables, andthe paramedic's perception of the need for chemical restraints. To compare predictor andoutcome variables, a multivariable model with odds ratios and95% confidence intervals was used. Results. The study included 271 restrained patients over a 12-month period from April 2002 to April 2003. Seventy-seven (28%) cases were positive for assaults on EMS personnel. Multivariable analysis including 8 variables, indicated the following 6 variables were associated with assault on EMS personnel: time of day between midnight and6 am (OR = 4.4, 95% CI = 1.6–12.7); female patient (OR for males 0.6, 95% CI = 0.3–1.0); violent patient (OR = 10.1, 95%CI = 2.3–48.2); patient injured under supervision (OR = 3.9, 95% CI = 1.1–13.8); arrested patient (OR = 4.4, 95% CI = 1.1–18.5); andperceived need for chemical restraint (OR = 2.1, 95% CI = 1.2–3.9). Conclusion. Multiple factors are correlated with assaults on EMS personnel by patients requiring restraints. By specifically targeting patients exhibiting these factors, EMS providers can help prevent injury to themselves. Patients not exhibiting these factors may be less dangerous.     

Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries

Brede E, Mayer TG, Gatchel RJ. Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries.ObjectiveTo identify risk factors for work retention (a patients' ability to both obtain and retain employment) at 1 year after treatment for a chronic disabling occupational musculoskeletal disorder (CDOMD).DesignProspective cohort study.SettingConsecutive patients undergoing interdisciplinary functional restoration treatment in a regional rehabilitation referral center.ParticipantsA sample of 1850 consecutive CDOMD patients, who were admitted to and completed a functional restoration program, were subsequently classified as work retention or nonwork retention at a 1-year posttreatment evaluation.InterventionsNot applicable.Main Outcome MeasuresMeasures, including medical evaluations, demographic and occupational data, psychosocial diagnostic evaluation, and validated measures of pain, disability, and depressive symptoms, were obtained at admission to, and discharge from, the program.ResultsUsing a multivariate logistic regression analysis, the following variables were found to be significant predictors of failure to retain work: older age (odds ratio [OR]=1.84; 95% confidence interval [CI], 1.33–2.54), female sex (OR=1.46; 95% CI, 1.09–1.94), nonworking status at discharge (OR=1.65; 95% CI, 1.11–2.45), extreme disability at admission (OR=1.46; 95% CI, 1.06–2.00), antisocial personality disorder (OR=2.11; 95% CI, 1.09–4.08), receipt of government disability benefits at admission (OR=2.28; 95% CI, 1.06–4.89), and dependence on opiate pain medications (OR=1.43; 95% CI, 1.02–2.00). The final model improved prediction by 75% over assigning all patients to the larger (work retention) group.ConclusionsThis study identified demographic, psychosocial, and occupational factors that were predictive of failure to retain work. These risk factors may be used to individualize treatment plans for CDOMD patients in order to provide optimal functional restoration.     

Patient characteristics associated with oral anticoagulation control: results of the Veterans AffaiRs Study to Improve Anticoagulation (VARIA)

Summary. Background: In patients receiving oral anticoagulation, improved control can reduce adverse outcomes such as stroke and major hemorrhage. However, little is known about patient‐level predictors of anticoagulation control. Objectives: To identify patient‐level predictors of oral anticoagulation control in the outpatient setting. Patients/Methods: We studied 124 619 patients who received oral anticoagulation from the Veterans Health Administration from October 2006 to September 2008. The outcome was anticoagulation control, summarized using percentage of time in therapeutic International Normalized Ratio range (TTR). Data were divided into inception (first 6 months of therapy; 39 447 patients) and experienced (any time thereafter; 104 505 patients). Patient‐level predictors of TTR were examined by multivariable regression. Results: Mean TTRs were 48% for inception management and 61% for experienced management. During inception, important predictors of TTR included hospitalizations (the expected TTR was 7.3% lower for those with two or more hospitalizations than for the non‐hospitalized), receipt of more medications (16 or more medications predicted a 4.3% lower than for patients with 0–7 medications), alcohol abuse (? 4.6%), cancer (? 3.1%), and bipolar disorder (? 2.9%). During the experienced period, important predictors of TTR included hospitalizations (four or more hospitalizations predicted 9.4% lower TTR), more medications (16 or more medications predicted 5.1% lower TTR), alcohol abuse (? 5.4%), female sex (? 2.9%), cancer (? 2.7%), dementia (? 2.6%), non‐alcohol substance abuse (? 2.4%), and chronic liver disease (? 2.3%). Conclusions: Some patients receiving oral anticoagulation therapy are more challenging to maintain within the therapeutic range than others. Our findings can be used to identify patients who require closer attention or innovative management strategies to maximize benefit and minimize harm from oral anticoagulation therapy.     

Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies

Background: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital).Objective: The goal of this study was to describe the incidence, drug classes, and probable importance of hospital admission medication discrepancies and discharge regimen differences, and to determine whether factors such as age and specific hospital services were associated with greater frequency of medication discrepancies and differences.Methods: This was a retrospective cohort study of a random sample of adult patients admitted to the general medicine, cardiology, or general surgery services of a tertiary care academic teaching hospital between July 1, 2006, and August 31, 2006. A chart review was performed to collect the following information: patient demographic characteristics, comorbid conditions, number of preadmission medications, discrepant medications identified by the hospital's reconciliation process, reasons for the discrepancies, and discharge medications that differed from the home regimen. Potentially high-risk discrepancies and differences were identified by determining if the medications were included on either the Institute for Safe Medication Practices high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and multivariate logistic regression analyses were used to identify factors associated with medication discrepancies and differences.Results: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60% white) included in the study, 27 did not have any medications recorded on admission. Of the 178 patients who did have medications listed, 41 had ≥1 discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17–29); 19% (95% CI, 11–31) of these medications were considered to be potentially high risk. In the multivariate logistic regression model, age (odds ratio [OR] per 5-year increase = 1.16; 95% CI, 1.01–1.33; P = 0.035), presence of high-risk medications on admission (OR = 76.68; 95% CI, 9.13–643.76; P < 0.001), and general surgery service (OR = 3.31; 95% CI, 1.40–7.87; P < 0.007) were associated with a higher proportion of patients with discrepancies on admission. At discharge, 196 patients (96% [95% CI, 93<98]) had ≥1 medication change from their home regimen, with 1102 total differences for 205 patients. Less than half (44% [95% CI, 37–51]) of these patients were explicitly alerted at discharge to new medications or dose changes; 12% (95% CI, 7–18) were given written instructions to stop taking discontinued home medications. Cardiovascular drugs were the most frequent class involved at both admission (31%) and discharge (27%) in medication discrepancies or differences.Conclusions: Medication discrepancies on admission and medication differences at discharge were prevalent for adult patients admitted to the general medicine, cardiology, and general surgery services in this academic teaching hospital. Medication reconciliation processes have a high potential to identify clinically important discrepancies for all patients.     

Can increasing the prevalence of vegetable-based diets lower the risk of osteoporosis in postmenopausal subjects? A systematic review with meta-analysis of the literature

ObjectivesSeveral epidemiological investigations have assessed the association between vegetable-based diet intake (VDI) and risk of osteoporosis in postmenopausal subjects (OPS), but the outcomes have been inconsistent. We performed a review of the updated literature to evaluate this correlation.MethodsWe searched for relevant studies published in September 2018 or earlier. Two researchers conducted eligibility assessment and data extraction. Discrepancies were resolved through consultation with a third expert. Pooled odds ratios (ORs) were calculated with 95% confidence intervals (CIs).ResultsTen studies, which included 14,247 subjects, were identified. On comparing the highest category of VDI consumption with the lowest category of VDI consumption, the pooled OR for OPS was 0.73 (95% CI = 0.57–0.95), i.e., participants with a higher intake of vegetables had a 27% (95% CI = 5–43%) lower risk of OPS. Significant benefits were found on subgroup analyses of case-control studies (OR, 0.61 [95% CI, 0.48–0.78]), but not on subgroup analyses of cross-sectional studies (OR, 0.82 [95% CI, 0.57–1.16]). The synthesized effect estimates were in the direction of decreased risk of OPS on subgroup analyses of the femoral region (OR, 0.57, 95% CI = 0.41–0.80) and the lumbar spine (OR = 0.55, 95% CI = 0.38–0.81), but not on subgroup analyses of the calcaneus (OR = 0.85, 95% CI = 0.33–2.16) and the lumbar and/or femoral region (OR = 1.04, 95%CI = 0.79–1.38). Positive results were observed on pooled analyses of the Dual energy X-ray absorptiometry (DEXA) measurement method (OR, 0.72 [95% CI, 0.54–0.95]), but not on pooled analyses of the Standardized Quantitative Ultrasound (QUS) measurement method (OR, 0.85 [95% CI, 0.33–2.16]). This might have resulted from a type II error due to wide confidence intervals and less number of included studies.ConclusionThis meta-analysis seemingly confirms that higher consumption of VDI was associated with a lower risk of OPS. Taken together, these results highlight the need for future high-quality design-based trials on quantified vegetable intake and OPS.     

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study

ObjectiveAppendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED).MethodsIn this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013–2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses.ResultsDuring the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610–6.096); vomiting (OR: 2.346; 95% CI: 1.141–4.822); diarrhea (OR: 4.549; 95% CI: 1.850–11.181); fever (OR: 3.429; 95% CI: 1.765–6.663); elevated WBC (OR: 2.962; 95% CI: 1.491–5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267–7.396) were variables that predicted the PA in children.ConclusionOur data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.     

Risk factors and ambulatory outcome in ischemic stroke patients with pre-stroke depression

ObjectiveIt is well known that post-stroke depression might be a negative factor for stroke recovery, however there is limited evidence to establish the link between pre-stroke depression and stroke outcome such motor recovery. The objective is to determine clinical risk factors in ischemic stroke patients with pre-stroke depression that are associated functional ambulatory outcome.MethodsData from acute ischemic patients from a regional stroke registry were collected for consecutive recombinant tissue plasminogen activator(rtPA)-treated acute ischemic stroke patients between January 2010 and June 2016. Logistic regression model was used to predict risk factors that served as predictive variables, while the increase or reduce odds of improvement in ambulatory outcome was considered as the primary outcome. Multicollinearity and possible interactions among the independent variables were analyzed using the variance inflation factor.ResultsA total of 1446 patients were eligible for recombinant tissue plasminogen activator (rtPA) and 596 of these patients received rtPA. Of the 596 ischemic stroke patients, 286 patients presented with recent pre-stroke depression, 310 had no pre-stroke depression. Carotid artery stenosis (OR = 11.577, 95% CI, 1.281–104.636, P = 0.029) and peripheral vascular disease (OR = 18.040, 95% CI, 2.956–110.086, P = 0.002) were more likely to be associated with increase odds of improvement in ambulation in patients with no pre-stroke depression treated with rtPA, while antihypertensive medications (OR = 0.192, 95% CI, 0.035–1.067, P = 0.050),previous TIA (OR = 0.177, 95% CI, 0.038–0.818, P = 0.027), and congestive heart failure (OR = 0. 0.160, 95% CI, 0.030–0.846, P = 0.031) were associated with reduced odds of improvement in ambulation. In addition, carotid artery stenosis (OR = 0.078, 95% CI, 0.10-0.614, P = 0.015, congestive heart failure (OR = 0.217, 95% CI, 0.318–0.402, P = 0.030), previous TIA (OR = 0.444, 95% CI, 0.517–0.971, P = 0.012), higher NIHSS scores ((OR = 0.887, 95% CI, 0.830–0.948, P < 0.001), and antihypertensive medications (OR = 0.810, 95% CI, 0.401–0.529, P = 0.019) were associated with the reduced odd of improvement in ambulation in an ischemic stroke population with pre-stroke depression treated with rtPA.ConclusionOur findings indicate that more risk factors were associated with the decreased odds of an improvement in ambulation following thrombolytic therapy in an ischemic stroke population with pre-stroke depression when compared with those without pre-stroke depression. This finding maybe helpful in the development of management strategies to increase the use of thrombolytic therapy for pre-stroke depressed ischemic stroke to increased their eligibility for rtPA.     

Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study

BackgroundOral care of intubated patients is essential to the prevention of infection and patient discomfort. However, barriers to oral access and delivery of oral care have received little attention.ObjectiveTo determine prevalence and predictors of oral access difficulty.DesignA prospective, observational, multi-center study.SettingsFour intensive care units in Toronto, Canada.ParticipantsAdult patients orally intubated for ≥48 h.MethodsWe screened consecutive admissions once a week to identify eligible participants. We observed each patient and asked the patient’s nurse about presence or absence of difficulty accessing the mouth to deliver oral care across three categories: (1) visualizing inside the mouth; (2) obtaining patient cooperation, or (3) inserting instruments for delivery of oral care. We asked nurses to identify presence of patient behaviors contributing to oral access difficulty and perceived level of difficulty on a Likert response scale. We examined patient and treatment characteristics associated with extreme difficulty (i.e., difficulty in all 3 categories) using a generalized estimating equation regression model.ResultsA total of 428 patients were observed, 58% admitted with a medical diagnosis. More than half (57%) had ≥2 oral devices up to maximum of 4. Oral care difficulty was identified in 83% of patients and rated as moderate to high for 217 (51%). Difficulty concerned visibility (74%), patient cooperation (55%), and space to insert instruments (53%). Patient behaviors contributing difficulty included coughing/gagging (60%), mouth closing (49%), biting (45%) and localizing (27%) during care. Variables associated with extreme difficulty included neurological (OR 1.92, 95% CI 1.42–2.60) or trauma admission (OR 1.83, 95% CI 1.16–2.89), lack of pain assessment or treatment in the 4 h prior to oral care (OR 1.43, 95% CI 1.14–1.80), more oral devices (OR 1.40, 95% CI 1.05–1.87), and duration of intubation (OR 1.05, 95% CI 1.01–1.10). Absence of documented agitation in the 4 h prior to oral care was associated with less difficulty (OR 0.68, 95% CI 0.54–0.86).ConclusionsOral care is complex and difficulties are experienced in a vast majority of intubated patients. Some difficulties are amenable to correction such as pain management.     

Effects of Telestroke on Thrombolysis Times and Outcomes: A Meta-analysis

Objective: Telestroke systems are tools, used to provide an advanced stroke care in regions without sufficient neurologic services. We performed this meta-analysis to assess the effects of telemedicine on treatment times and clinical outcomes of acute stroke care. Methods: A literature search of PubMed, SCOPUS, and Cochrane CENTRAL was conducted for original studies investigating telemedicine applications in acute stroke care. Dichotomous data on treatment outcomes were pooled as odds ratios (ORs), while continuous data on thrombolysis times were pooled as mean differences (MDs) with 95% confidence interval (CI), using RevMan software (version 5.3). Results: Pooling data from 26 studies (6605 thrombolysed patients) showed no significant differences between the telestroke and control groups in terms of in-hospital mortality (OR = 1.21, 95% CI [0.98, 1.49]), 90-day mortality (OR = 1.08, 95% CI [0.85, 1.37]), symptomatic intracranial hemorrhage (sICH) (OR = 1.10, 95% CI [0.79, 1.53]), and favorable clinical outcome at discharge (OR = 1.03, 95% CI [0.69, 1.53]) and 90 days later (OR = 0.99, 95% CI [0.82, 1.18]). The onset-to-door (OTD) duration (MD = ?10.4 minutes, 95% CI [?14.79, ?.01]) and length of hospital stay (MD = ?0.55 days, 95% CI [?1.02, ?0.07]) were significantly shorter in the telestroke group, compared to the control group. Although the overall effect estimate (under the fixed-effect model) showed a significant decrease in the onset-to-treatment (OTT) duration in the telestroke group (MD = ?5.83 minutes, 95% CI [?8.57, ?3.09]), employing the random-effects model for between-study heterogeneity abolished this significance (MD = ?5.90 minutes, 95% CI [?13.23, 1.42]). Conclusion: Telestroke significantly reduced OTD and hospital stay durations in stroke patients without increasing the risk of mortality or sICH. Therefore, telemedicine can improve stroke care in regional areas with minor experience in thrombolysis. Further randomized controlled trials are needed to assess the benefits of telestroke systems, especially in terms of cost-effectiveness and quality of life outcomes.     

Same provider,different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments

BackgroundPatient satisfaction scores have become quality benchmarks for hospitals, are publicly reported, and are often tied to financial incentives. We determined whether patient satisfaction scores for individual emergency medicine providers varied according to the clinical setting.MethodsWe obtained patient satisfaction survey results from January 1, 2018 to December 31, 2018 for patients treated at 6 freestanding (FED) and 11 hospital-based emergency departments (HBED). Differences in mean score by ED facility were tested for significance. Mean score differences with 95% confidence intervals are presented. Univariate and multivariable logistic regression analysis was conducted to predict the odds of receiving different scores by type of ED facility and adjusted for patient and provider demographics and ED length of stay.ResultsSixty-six providers with 3743 total surveys were analyzed: FED (n = 1974) and HBED (n = 1769). Overall satisfaction scores were higher for FED compared to HBED surveys 1.13 [95% CI, 1.0–1.3]. In multivariable logistic regression, we found patients seen at the FEDs were 42% more likely to rate providers courtesy as “very good” compared to patients seen at a HBED [OR: 1.42, 95% CI (0.94–2.15)]. Similarly, patients from FEDs showed increased likelihood to rate providers as “very good” for keeping patients informed about treatment [OR: 1.70, 95% CI (1.21–2.39)], took time to listen to patients [OR: 1.66, 95% CI (0.72–1.60)] and concerned for patient's comfort [OR: 1.54, 95% CI (1.12–2.12)].ConclusionIndividual providers, who practice at both types of facilities, consistently received higher satisfaction ratings from patients at FEDs compared to HBEDs.     

Failed extubation in a tertiary-level hospital intensive care unit,Pretoria, South Africa

Background A prospective cohort study sought to measure the incidence and outcomes of failed extubation in Dr George Mukhari Academic Hospital intensive care unit (ICU), as well as to identify possible factors associated with failed extubation. Methods Data were collected over a 6-month period from 1 July 2015 to 31 December 2015. Pre-intubation parameters recorded on the data collection sheet included secretions, Glasgow Coma Scale (GCS), fluid balance, Tobin index, partial pressure of carbon dioxide (pCO₂ ), partial pressure of oxygen (PaO₂ ), comorbidities and weaning method. Results A total of 242 patients were enrolled over the 6-month study period. Of the 242 patients, 86 were excluded owing to pre-set exclusion criteria (death before extubation; tracheostomy before extubation; re-intubation >72 hours post extubation). An extubation failure rate of 16.7% (n=26) was observed. The incidence of ventilator-associated pneumonia in the failed extubation group was 19.23%, whereas death was recorded in 42.31% of patients who failed extubation. The average length of ICU stay in the reintubated group was 11.58 days, and 4.04 days for successfully extubated patients. Only low GCS had a statistically significant impact on failed extubation: p=0.0025; odds ratio (OR) for low v. normal 5.13 (95% confidence interval (CI) 1.78 - 14.79). Other predictor variables measured did not reach statistical significance. Weaning method: p=0.3737, OR for No T-piece v. T-piece 1.65 (95% CI 0.547 - 4.976); comorbidities: p=0.5914, OR for two or more comorbidities v. no comorbidities 2.079 (95% CI 0.246 - 17.539), no comorbidities v. single comorbidity 0.802 (95% CI 0.211 - 3.043); fluid balance: p=0.6625, OR for negative v. positive fluid balance 0.571 (95% CI 0.170 - 1.916), OR for neutral v. positive fluid balance <0.001 (95% CI <0.001 - >999.999); pCO₂ : p=0.7510, OR for high v. normal pCO₂ 1.344 (95% CI 0.346 - 5.213), OR for low v. normal pCO₂ 1.515 (95% CI 0.501 - 4.576); PaO₂ : p=0.4405, OR for high v. normal 1.156 (95% CI 0.382 - 3.494); OR for low v. normal PaO₂ 2.638 (95% CI 0.553 - 12.587); Tobin index (Fischer’s exact test): p=0.7476. Conclusion Low pre-extubation GCS is a predictor of failed extubation. Contributions of the study The study is a prospective observational study conducted in a high-volume referral hospital. It adds valuable scientific information to a growing body of data on the topic of extubation failure. It further reinforces the importance of extubation failure and the requirement for due diligence to be paid before a patient is extubated.     

Factors influencing lower respiratory tract infection in older patients after general anesthesia

ObjectivePulmonary complication is common in older patients after surgery. We analyzed risk factors of lower respiratory tract infection after general anesthesia among older patients.MethodsIn this retrospective investigation, we included older patients who underwent surgery with general anesthesia. Logistic regression analyses were performed to determine risk factors of lower respiratory tract infection.ResultsA total 418 postoperative patients with general anesthesia were included; the incidence of lower respiratory tract infection was 9.33%. Ten cases were caused by gram-positive bacteria, 26 cases by gram-negative bacteria, and 2 cases by fungus. We found significant differences in age, smoking, diabetes, oral/nasal tracheal intubation, and surgery duration. Logistic regression analysis indicated that age ≥70 years (odds ratio [OR] 2.028, 95% confidence interval [CI] 1.115–3.646), smoking (OR 2.314, 95% CI 1.073–4.229), diabetes (OR 2.185, 95% CI 1.166–4.435), nasotracheal intubation (OR 3.528, 95% CI 1.104–5.074), and duration of surgery ≥180 minutes (OR 1.334, 95% CI 1.015–1.923) were independent risk factors of lower respiratory tract infections.ConclusionsOlder patients undergoing general anesthesia after tracheal intubation have a high risk of lower respiratory tract infections. Clinical interventions should be provided to prevent pulmonary infections in patients with relevant risk factors.     

Patient Preferences and Perspectives on Accessing Their Medical Records

BackgroundPersonal health record platforms and patient portals have the potential to empower patients by providing access to health records, but not all patients may be interested in this. The purpose of this study was to explore inpatients' opinions on their hospital paper medical records after they had incidental access to them.MethodsA survey and observational study were conducted in the computed tomography department at a large academic hospital. Patients in the computed tomography hallway were left with their paper records and either started reading them or not.ResultsOf 174 patients receiving the survey, 102 returned the questionnaire (59% response rate); two were excluded. Among the 100 included patients, 65 read their records, and 35 did not; 37.1% (13/35) nonreaders indicated interest to access their records but did not know they had the legal right. The physician's notes was the section that most patients read (n = 35, 53.8%) followed by the laboratory reports (n = 31, 47.7%) and nurse's notes (n = 29, 44.6%). Overall, 70.8% (46/65) of readers found their records easy to understand, and most found their records correct (64.4%) or complete (58.5%) and did not find anything unexpected (63.1%) or distressing (66.2%). However, a significant minority found errors in their records (7.7%) including missing test results, medications, and a wrong birthday. According to multivariate analysis, being female (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.0–8.0), younger than 60 years (OR = 3.0; 95% CI, 1.2–8.0), and having a higher level of education (OR = 3.9; 95% CI, 1.4–10.8) predicted readership.ConclusionA surprisingly high number of patients are still unaware of their legal right to access their health record. Predictors for access suggest a “social divide” in motivation and ability to access health records.