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.     

Predictors of Symptom Duration and Bacteriuria in Uncomplicated Urinary Tract Infection

Abstract

Objective: To identify baseline predictors of symptom duration after empirical treatment for uncomplicated urinary tract infection (UTI) and significant bacteriuria in a cohort of women treated for UTI.

Design: Prospective single-centre cohort study.

Setting: Outpatient clinic in Norway.

Patients: From September 2010 to November 2011, 441 women aged 16–55 years with symptoms of uncomplicated UTI were included.

Results: Dipstick findings of leukocyte esterase 1?+?(incidence rate ratio (IRR) 1.93, 95% confidence interval (CI) 1.23–3.01, p?<?0.01) and microbe resistant to mecillinam treatment (IRR 1.41, 95% CI 1.07–1.89, p?=?0.02) predicted longer symptom duration. More pronounced symptoms did not predict longer symptom duration (IRR 1.18, 95% CI 0.94–1.46, p?=?0.15) or significant bacteriuria (odds ratio [OR] 1.16, 95% CI 0.72–1.88, p?=?0.54). Leukocyte esterase 2?+?(OR 2.51, 95% CI 0.92–6.83, p?=?0.07) or 3?+?(OR 2.40, 95% CI 0.88–6.05, p?=?0.09) and nitrite positive urine dipstick test (OR 3.22, 95% CI 1.58–7.01, p?=?<0.01) were associated with bacteriuria.

Conclusion: More pronounced symptoms did not correlate with significant bacteriuria or symptom duration after empirical treatment for acute cystitis. One might reconsider the current practice of treating uncomplicated UTI based on symptoms alone.

• Key Points

• Treatment strategies for milder infectious diseases must consider ways of reducing antibiotic consumption to decelerate the increase in antibiotic resistance. Our findings suggest that more emphasis should be put on urine dipstick results and bacteriological findings in the clinical setting. One might reconsider the current practice of treating uncomplicated UTIs based on symptoms alone.

     

High‐risk injecting behaviour in hostel accommodation for the homeless in Glasgow 2001–02: a study combining quantitative and qualitative methodology

Aims: The aim of this study was to determine whether injecting drug users (IDUs) living in hostels for the homeless were more likely to engage in blood‐borne virus associated injecting risk behaviour than those living elsewhere.

Design: Four‐hundred‐and‐fifty‐three IDUs who had commenced injecting post‐1995 were recruited from community settings in Glasgow and interviewed during 2001–02 using a structured questionnaire (quantitative component). Respondents who had commenced injecting post‐1998 were also invited to participate in an in‐depth interview to explore contextual factors that influence injecting risk behaviour (qualitative component).

Results: Individuals interviewed during the qualitative component of the study reported witnessing prolific sharing of needles and syringes (n/s) in hostels. Multi‐factorial logistic regression found that hostel residence was independently associated with injecting with a n/s previously used by a friend, acquaintance or family member (OR 1.58, 95% CI 1.01–2.49), passing on used n/s (OR 1.70, 95% CI 1.08–2.69), borrowing used n/s in a ‘shooting gallery’ (OR 2.23, 95% CI 1.04–4.77), borrowing used n/s from multiple sharing partners (OR 2.33, 95% CI 1.17–4.64) and sharing spoons during drug preparation (OR 1.68, 95% CI 1.03–2.73) in the 6 months prior to interview.

Conclusions: The hostel environment appears to be conducive to high‐risk injecting behaviour.     

The effect of drug interactions on bleeding risk associated with warfarin therapy in hospitalized patients

Background. Bleeding is a serious adverse drug reaction associated with warfarin therapy, often induced by interacting co-medication.

Methods. We investigated the frequency and clinical consequences of warfarin drug interactions utilizing medical records of 6,772 warfarin-treated in-patients of Turku University Hospital.

Results. A total of 48% of warfarin-treated in-patients were exposed to interacting co-medication. Adjusted odds ratio (OR) for bleeding was highest for cytochrome P450 2C9 (CYP2C9) inhibitors (OR 3.6; 95% confidence interval (CI) 2.4–5.6). Non-selective non-steroidal anti-inflammatory drugs (NSAID) and coxibs were associated with a bleeding risk of a similar magnitude (OR 2.6; 95% CI 1.6–4.2 and OR 3.1; 95% CI 1.4–6.7, respectively). Selective serotonin re-uptake inhibitors (SSRI) were associated with a remarkably higher bleeding risk than non-SSRIs (OR 2.6; 95% CI 1.5–4.3 and OR 1.2; 95% CI 0.3–4.3, respectively). Odds ratio for bleeding in the platelet aggregation inhibitor group was 1.6 (95% CI 0.8–3.1).

Conclusion. We conclude that co-medication in warfarin-treated in-patients is common and should be carefully evaluated to decrease the bleeding risk associated with warfarin therapy.     

Glu298Asp and NOS4ab polymorphisms in diabetic nephropathy

Background and aims. The risk of diabetic nephropathy (DN) increases with increase in intraglomerular pressure, which may partly be regulated by nitric oxide (NO). NO‐production can be affected by polymorphisms in the endothelial NO‐synthase gene (NOS3), hyperglycaemia and smoking. We therefore studied association between DN and two polymorphisms in NOS3, Glu298Asp and NOS4ab, in Caucasian type 1 diabetes (T1D) patients.

Patients and methods. A total of 1510 Finnish and Swedish T1D patients were included in a cross‐sectional case‐control study. Incipient DN was defined as an albumin excretion rate (AER) of 20–200?µg/min (n = 336). Overt DN = AER>200?µg/min or renal replacement therapy (n = 619). All patients with DN were considered as cases. The controls were T1D patients with diabetes duration ?20 years, AER<20?µg/min and without antihypertensive treatment (n = 555). The genetic markers studied were a 27?bp repeat (NOS4ab) and Glu298Asp (rs1799983).

Results. Age at onset of diabetes, male sex, duration of diabetes, HbA1c, blood pressure and smoking were assessed as possible confounders in the logistic regression analysis, which showed that homozygosity for the Glu‐allele of the Glu298Asp‐polymorphism was independently associated with increased risk of DN (OR = 1.46; 95% CI = 1.12–1.91). The variables smoking (OR = 2.13; 95% CI = 1.63–2.78), male sex (OR = 1.61; 95% CI = 1.23–2.10), HbA1c (OR per % increase above upper limit of the normal reference range = 1.02; 95% CI = 1.02–1.03), systolic (OR = 1.05; 95% CI = 1.04–1.06) and diastolic blood pressure (OR = 1.04; 95% CI = 1.02–1.05) also significantly and independently increased the risk of DN when taking age at diabetes onset and diabetes duration into account. The NOS4 a‐allele was not associated with DN.

Conclusions. The Glu/Glu‐genotype of the NOS3 Glu298Asp polymorphism may increase the risk of developing DN independently of other known risk factors.     

Sedative use: its association with harmful alcohol use,harmful tobacco use and quality of life among health care workers in Thailand

Background: Health care workers (HCWs) may be at higher risk for sedative misuse due to potential access and self-medication behavior.

Objectives: To examine risk factors for harmful sedative use (HSedU) and its association with harmful alcohol use (HAlcU), harmful tobacco use (HTobU) and quality of life (QoL).

Methods: A survey was conducted in 2013 at an urban university hospital in Northern Thailand. Risk of harm was measured using The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Harmful substance use defined as having at least moderate risk of harm. QoL was measured using SF-36 questionnaire.

Results: A sample of 3204 HCWs (59.7% response) participated. The prevalence of HSedU in past 3 months was 4.2%. Health professionals involved with prescribing or dispensing medication were at higher risk of HSedU (OR 1.80, 95% CI 1.21–2.67). Adjusting for confounders, HSedU was associated with HAlcU (OR 3.35, 95% CI 1.81–6.20) but not associated with HTobU. HSedU was associated with lower QoL score which was 7.78 and 5.52 points lower for physical (95% CI ?10.4 to ?5.18) and mental QoL (95% CI ?7.11 to ?3.93), respectively.

Conclusions: HCWs were at higher risk of HSedU. HSedU was associated with HAlcU and associated with lower physical and mental health QoL.     

Exploring activity limitations and sick leave among patients with spinal pain participating in multidisciplinary rehabilitation

Purpose.?To describe limitations in 12 activities at baseline, after multidisciplinary rehabilitation and at a 6-month follow-up for patients with spinal pain and, further, to investigate whether low limitation in any of the activities or in the mean score at baseline might predict increased working time at follow-up.

Method.?A prospective cohort study of 302 patients, 22- to 63-years old, who participated in multidisciplinary rehabilitation because of chronic neck, thoracic and/or lumbar pain. Data from the Disability Rating Index questionnaire were obtained at baseline, after the 4-week rehabilitation programme, and at the 6-month follow-up. Two subgroups are described: patients who at baseline (1) worked full-time or (2) were on part- or full-time sick leave.

Results.?The degree of limitation in the 12 activities (items) showed large variations in median scores (7–91). Both subgroups showed significant improvements in most activities after rehabilitation, which remained at the follow-up. Nevertheless, in the sick-leave group, patients who had increased their working time at follow-up (62%) were still very limited in running, heavy work, and lifting heavy objects. In logistic regressions, low limitation in standing bent over a sink at baseline was the only single activity that predicted increased working time at the follow-up: odds ratio (OR) 1.93 (95% CI 1.1–3.5). OR for the mean score was 1.8 (1.0–3.3).

Conclusion.?A profile of the separate activities demonstrates the large variation in the degree of limitation, which is concealed in a mean score. The single items can be useful when evaluating interventions. However, to predict increased working time after rehabilitation, the mean score, as well as the activity standing bent over a sink, proved useful.     

Book review

Purpose.?To investigate the relationship between duration and intensity of physical activity and disability 10 years later, and to investigate the possible effect of selective mortality.

Method.?Longitudinal data of 560 men aged 70?–?89 years, without disability at baseline from the Finland, Italy and The Netherlands Elderly (FINE) Study was used. Physical activity in 1990 was based on activities like walking, bicycling and gardening. Disability severity (three categories) in 1990 and 2000 was based on instrumental activities, mobility and basic activities of daily living.

Results.?Men in the highest tertile of total physical activity had a lower risk of disability than men in the lowest tertile (odds ratio (OR) 0.46; 95% confidence interval (CI): 0.26?–?0.84). This was due to duration of physical activity (OR highest tertile 0.42; 95% CI: 0.23?–?0.78 compared to the lowest tertile). Intensity of physical activity was not associated with disability. Addition of deceased men as fourth category leaded to weaker associations between physical activity and disability (OR highest tertile 0.67; 95% CI: 0.44?–?1.02).

Conclusions.?Even in old age among relatively healthy men, a physically active lifestyle was inversely related to disability. To prevent disability duration of physical activity seems to be more important than intensity.     

Risk of obstetric and thromboembolic complications in family members of women with previous adverse obstetric outcomes carrying common inherited thombophilias

Summary. Background: Factor (F)V Leiden and the prothrombin 20210A mutation (PTm) are associated with the occurrence of obstetric complications, including pregnancy‐related venous thromboembolism (VTE). It is not known whether family members of women with FV Leiden or PTm and previous obstetric complications have a higher risk of VTE or adverse obstetric outcomes. Methods: A retrospective family study including 563 relatives of 177 women with previous adverse outcomes carrying FV Leiden or PTm, referred between April 1993 and June 2010. A history of obstetric complications and VTE was obtained. Prevalence of VTE and obstetric complications in relatives with and without inherited thrombophilias was compared. Adjusted odd ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression models that controlled for predictors (age, FV Leiden and PTm). Results: Relatives carrying FV Leiden had a significant and independent risk for obstetric complications (OR: 1.98, 95% CI 1.03–3.83); this risk was not observed in the presence of PTm (OR: 1.03, 95% CI 0.46–2.32). The presence of FV Leiden or PTm in heterozygosis was significantly and independently associated with the occurrence of VTE (OR: 5.2, 95% CI: 1.70–15.91). Severe thrombophilias were strong risk factors for VTE (OR: 23.2, 95% CI: 6.0–89.85). Male gender was a significant and independent risk factor for VTE (OR: 3.49, 95% CI: 1.51–8.05). The risk did not change when relatives of women with a previous pregnancy‐related VTE were excluded (OR: 3.49, 95% CI: 1.51–8.05). Conclusions: Knowledge of thrombophilia status may help to better define the obstetric and thromboembolic risks in asymptomatic family members of women who suffered from obstetric complications.     

Factors Associated with Transition Planning in Autism and Other Developmental Disabilities

Objective

To determine whether functional self-care skills and presence of behavior problems in youth with developmental disabilities are associated with parents planning for the youth’s transition to adulthood.

Methods

This multi-site study consisted of 167 parents of youth aged 10–22 years with autism spectrum disorder, ADHD and/or other developmental disabilities who completed a questionnaire on transition to adulthood. Parent-rated child self-care status was measured using a six-item scale that had excellent reliability (Cronbach’s alpha=0.90).

Results

Multivariable logistic regression models revealed that parents were less likely to plan for the youth’s transition to adulthood if their child needed more assistance with functional self-care skills (OR 0.78, 95% CI 0.63–0.96, p=.021). Despite this unexpected finding, greater child need for assistance with self-care was associated with lower parental expectations that their children would live independently by age 22 (OR 0.40, 95%CI 0.24–0.66, p<.001) and 35 (OR 0.47, 95%CI 0.35–0.63, p<.001). The presence of behavioral problems (aggression, sexual behaviors and safety issues) was also associated with lower odds of parental expectations that their child would live independently in adulthood.

Conclusions

Despite this unexpected finding, greater child need for assistance with self-care was associated with lower parental expectations that their children would live independently by age 22 (OR 0.40, 95%CI 0.24–0.66, p<.001) and 35 (OR 0.47, 95%CI 0.35–0.63, p<.001). The presence of behavioral problems (aggression, sexual behaviors and safety issues) was also associated with lower odds of parental expectations that their child would live independently in adulthood. Despite parents’ awareness of the difficulties their children will face, less youth independence with self-care skills was associated with lower odds of plans for transition to adulthood and expectations for independent living. Results support the need for continued interventions targeted at improving daily living skills to achieve functional independence in adulthood, as well as interventions focused on aggression, safety and sexuality of the individuals.

     

Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism: findings from the RIETE registry

Summary. Background: Fatal bleeding is a serious consequence of anticoagulant therapy, but factors associated with fatal bleeding during the first 3 months of treatment of venous thromboembolism (VTE) are uncertain. Methods: Using data from RIETE, an ongoing registry of consecutive patients with acute VTE, we assessed risk factors for fatal bleeding among all patients. We then used this information to derive a clinical model that would stratify a patient’s risk of fatal bleeding during the first 3 months of treatment. Results: Of 24 395 patients, 546 (2.24%) had a major bleed and 135 (0.55%) had a fatal bleed. The gastrointestinal tract was the most common site (40% of fatal bleeds), followed by intracranial bleeding (25%). Fatal bleeding was independently associated with the following factors at the time of VTE diagnosis: age >75 years (OR, 2.16), metastatic cancer (OR, 3.80), immobility ≥ 4 days (OR, 1.99), a major bleed within the past 30 days (OR, 2.64), an abnormal prothrombin time (OR, 2.09), a platelet count < 100 × 10⁹ L⁻¹ (OR, 2.23), creatinine clearance < 30 mL min⁻¹ (OR, 2.27), anemia (OR, 1.54), and distal deep vein thrombosis (OR, 0.39). INR at the time of bleeding is not known. A clinical prediction rule for risk of fatal bleeding that included nine baseline factors was derived. Fatal bleeding occurred in 0.16% (95% CI, 0.11–0.23) of the low‐risk, 1.06% (95% CI, 0.85–1.30) of the moderate‐risk, and 4.24% (95% CI, 2.76–6.27) of the high‐risk category. Conclusions: Patient characteristics and laboratory variables can identify patients at high risk for fatal bleeding during treatment of VTE.     

Initial diffusion-weighted MRI and long-term neurologic outcomes in charcoal-burning carbon monoxide poisoning

Context: This study assessed the results of diffusion-weighted imaging (DWI) at presentation for acute charcoal-burning carbon monoxide (CO) poisoning and investigated whether the initial DWI results can predict long-term neurologic outcomes.

Methods: The study included 128 patients who suffered from CO poisoning after burning charcoal and underwent DWI. These patients were divided into two groups based on imaging results: a normal DWI group and an abnormal DWI group. Data regarding clinical courses and long-term neurologic outcomes (persistent severe neurologic sequelae) were collected and compared.

Results: The rate of abnormal DWI findings at presentation was 23.4%, and the most common site of abnormalities was the globus pallidus. All lesions in abnormal DWI had decreased apparent diffusion coefficient (ADC) values. The long-term neurologic state was assessed at a median follow-up of 19.5 months, and the frequency of poor long-term neurologic outcome was significantly higher in the abnormal DWI group (40.0% in the abnormal DWI group vs. 1.0% in the normal DWI group; p?Conclusions: In cases involving CO poisoning due to charcoal burning, DWI at presentation may help predict the long-term neurological outcome after discharge.     

Examining the relationship between post-traumatic stress disorder and social participation among Veterans with spinal cord injuries and disorders

Abstract

Purpose: The objectives of this study were to examine differences in social participation among Veterans with spinal cord injuries/disorders with and without post-traumatic stress disorder, and determine if lower social participation was independently associated with having post-traumatic stress disorder.

Methods: A cross-sectional mailed national survey was sent to a national sample of Veterans with spinal cord injuries/disorders who received prior-year Veterans Affairs healthcare. Surveys provided data on: demographics, health conditions, injury characteristics, and social participation. Analyses included bivariate comparisons, and multivariate logistic regression to determine if lower social participation was independently associated with post-traumatic stress disorder.

Results: Veterans with (vs. without) post-traumatic stress disorder (n?=?896) reported lower social participation (40.2 vs. 43.9, p?<?0.0001). Multivariate analyses showed that longer duration of injury (OR?=?0.98, 95% CI: 0.97–1.00, p?=?0.04) and white race (OR?=?0.62, 95% CI: 0.38–1.01, p?=?0.05) were associated with lower odds of post-traumatic stress disorder, while a greater number of health conditions (OR?=?1.43, 95% CI: 1.25–1.64, p?<?0.0001) was associated with greater odds. When controlling for covariates, lower social participation was independently associated with post-traumatic stress disorder (OR?=?0.94, 95% CI: 0.90–0.98, p?=?0.003).

Conclusions: Results indicate post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. Efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation.

• Implications for Rehabilitation

• Individuals with spinal cord injuries/disorders often have post-traumatic stress disorder; in Veterans with spinal cord injuries/disorders this may be compounded by trauma incurred through military experiences.

• Social participation, an important aspect of rehabilitation and community integration following spinal cord injury or disorder, may be hindered by symptoms of post-traumatic stress disorder.

• Our data show that post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation.

• These results indicate that efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation in this patient population.

     

Clopidogrel 150 vs. 75 mg day−1 in patients undergoing percutaneous coronary intervention: a meta‐analysis

Summary. Background: Whether an increase in the daily oral maintenance dose of clopidogrel may improve clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) is still debated. Objectives: This meta‐analysis aimed to estimate the relative effect of a 150‐ vs. 75‐mg daily maintenance dosage of clopidogrel on clinical and laboratory end‐points in patients undergoing PCI. Methods: We searched electronic and printed sources (up to 14 December 2010) for both randomized control trials and observational studies satisfying the predefined inclusion criteria. Results: We retrieved 12 reports of studies including a total of 23 814 patients. Clopidogrel, 150 mg day^?1, was associated with significant reductions in major adverse cardiac and/or cerebrovascular events (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.48–0.94), myocardial infarction (OR, 0.72; 95% CI, 0.60–0.86), target vessel revascularization (OR, 0.27; 95% CI, 0.12–0.62) and stent thrombosis (OR, 0.64; 95% CI, 0.53–0.77) and decreased adenosine diphosphate‐induced maximal platelet aggregation. However, as compared with 75 mg day^?1, the 150‐mg daily maintenance dosage significantly increased the risk of minor bleeding (OR, 1.21; 95% CI, 1.08–1.36). Conclusion: As compared with the currently recommended 75‐mg day^?1 maintenance dosage of clopidogrel, the 150‐mg day^?1 dosage can reduce major adverse cardiac and/or cerebrovascular events but may increase the risk of minor bleeding.     

Prognostic significance of elevated troponin in non-cardiac hospitalized patients: A systematic review and meta-analysis

Abstract

Cardiac biomarker troponin can be elevated in patients without a primary cardiac diagnosis and may have prognostic value. We conducted a systematic review to estimate the prevalence and prognostic significance of elevated troponin levels in patients admitted to hospital without a primary cardiac diagnosis. Literature search was done using MEDLINE (1946 to November 2012), EMBASE (1974 to Week 45, 2012), and Cochrane Central Register of Controlled Trials (November 2012). Two independent investigators reviewed full-text studies for final inclusion. We included studies of patients admitted without a primary cardiac diagnosis. Eligible studies compared adverse outcomes in patients with normal versus elevated troponin levels. Twenty-seven studies were included in the meta-analysis. Elevated troponin was associated with increased in-hospital and 30-day mortality (25 studies, 7255 patients, OR 3.88, 95% CI 2.90–5.19, P < 0.0001). Elevated troponin was also associated with increased risk of long-term mortality at 6 months (9 studies, 5368 patients, OR 4.21, 95% CI 1.84–9.64, P < 0.00001). Troponin is an independent predictor of short-term mortality with a pooled adjusted OR of 2.36, 95% CI 1.47–3.76, P < 0.0003. In conclusion, elevated troponin in non-cardiac patients is independently associated with increased mortality.     

Factors associated with first-pass success of emergency endotracheal intubation

Study objectiveEndotracheal intubation is frequently performed in emergency departments (EDs). First-pass success is important because repeated attempts are associated with poor outcomes. We sought to identify factors associated with first-pass success in emergency endotracheal intubation.MethodsWe analyzed emergency orotracheal intubations on adult patients in an ED located in South Korea from Jan. 2013 to Dec. 2016. Various operator-, procedure- and patient-related factors were screened with univariable logistic regression. Using variables with P-values less than 0.2, a multiple logistic regression model was constructed to identify independent predictors.ResultsThere were 1154 eligible cases. First-pass success was achieved in 974 (84.4%) cases. Among operator-related factors, clinical experience (OR: 2.93, 5.26, 3.80 and 5.71; 95% CI: 1.62–5.26, 2.80–9.84, 1.81–8.13 and 2.07–18.67 for PGY 3, 4 and 5 residents and EM specialists, respectively, relative to PGY 2 residents) and physician based outside the ED (OR: 0.10; 95% CI: 0.04–0.25) were independently associated with first-pass success. There was no statistically or clinically significant difference for first-pass success rate as determined by operator's gender (83.6% for female vs. 84.8% for male; 95% CI for difference: −3.1% to 5.8%). Among patient-related factors, restricted mouth opening (OR: 0.47; 95% CI: 0.31–0.72), restricted neck extension (OR: 0.57; 95% CI: 0.39–0.85) and swollen tongue (OR: 0.46; 95% CI: 0.28–0.77) were independent predictors of first-pass success.ConclusionsOperator characteristics, including clinical experience and working department, and patient characteristics, including restricted mouth opening, restricted neck extension and swollen tongue, were independent predictors of first-pass success in emergency endotracheal intubation.     

Cyanide poisoning in Thailand before and after establishment of the National Antidote Project*

Context: Antidote shortage is a global problem. In Thailand, the National Antidote Project (NAP) has operated since November 2010 to manage the national antidote stockpile, educate the healthcare providers on appropriate antidote use, and evaluate antidote usage.

Objective: To evaluate the effect of NAP implementation on mortality rate and antidote use in cyanide poisoning cases arising from ingestion of cyanide or cyanogenic glycoside.

Methods: This is a retrospective cohort of poisoning cases involving cyanide or cyanogenic glycoside ingestion reported to Ramathibodi Poison Center from 1 January 2007 to 31 December 2015. Mortality rate, antidote use, and appropriateness of antidote use (defined as correct indication, proper dosing regimen, and administration within 90?min) before and after NAP implementation were compared. Association between parameters and fatal outcomes was analyzed.

Results: A total of 343 cases involving cyanide or cyanogenic glycoside ingestion were reported to Ramathibodi Poison Center. There were 213 cases (62.1%) during NAP (Project group) and 130 cases (37.9%) pre-NAP implementation (Before group). Implementation of NAP led to increased antidote use (39.9% in Project group versus 24.6% in Before group) and a higher rate of appropriate antidote use (74.1% in Project group versus 50.0% in Before group). All 30 deaths were presented with initial severe symptoms. Cyanide chemical source and self-harm intent were associated with death (OR: 12.919, 95% CI: 4.863–39.761 and OR: 10.747, 95% CI: 3.884–28.514, respectively). No difference in overall mortality rate (13 [10.0%] deaths before versus 17 [8.0%] deaths after NAP) was found. In subgroup analysis of 80 cases with initial severe symptoms, NAP and appropriate antidote use reduced mortality (OR: 0.327, 95% CI: 0.106–0.997 and OR: 0.024, 95% CI: 0.004–0.122, respectively). In the multivariate analysis of the cases with initial severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of death (OR: 0.122, 95% CI: 0.023–0.633 and OR: 0.034, 95% CI: 0.007–0.167, respectively), adjusted for intent of exposure, cyanide source, age, and sex.

Conclusions: After NAP implementation, both antidote use and appropriate antidote use increased. In cases presenting with severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of mortality.     

Prognostic factors for self-rated function and perceived health in patient living at home three months after a hip fracture

Purpose: To explore the relationship between prefracture sociodemographic and health characteristics, basic activities of daily living, instrumental activities of daily living and perceived health 3 months after a hip fracture aged 65 or older.Methods: Age, sex, living alone or not, use of walking aids and whether they had experienced another fall during the previous 6 months, were recorded in hospital and at a three-month follow-up. A total of 277 patients were included. The Barthel Index, the Nottingham Extended ADL Index, the Short Form-12 questionnaire, and the Mini Mental State Examination were used.Results: Prefracture use of a walking aid outdoors was a predictor of postfracture dependency in basic activities of daily living: odds ratio (OR) 2.0, 95% confidence intervals (CI 1.1–3.6), reduced score in instrumental activities of daily living (OR 1.8; 95% CI 1.0–3.2) and reduced perceived physical health (p?=?0.04). Prefracture instrumental activity of daily living was a predictor for dependency in basic activities of daily living (OR 3.3; 95% CI 1.7–6.3). Cognitive dysfunction was a risk factor for dependency in basic activities of daily living (OR 0.1; 95% CI 0.01–0.7).Conclusions: Prefracture use of outdoor walking aids, perceived physical health, cognitive function, instrumental activity of daily living and female gender were all predictors explaining the three-month outcomes for basic activities of daily living and instrumental activity of daily living.

Implications for Rehabilitation

• The use of a walking aid before hip fracture may be a poor prognostic factor affecting 3-months rehabilitation outcome of hip-fractured patients.

• It is of importance to having knowledge of the patient’s prefracture status when planning rehabilitation.