Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis

BACKGROUND:

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown.

OBJECTIVE:

To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis.

METHODS:

Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs.

RESULTS:

Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]).

CONCLUSIONS:

Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.     

Predictors of mortality among patients undergoing colectomy for ischemic colitis: A population-based,United States study

BACKGROUND:

Ischemic colitis is a potentially life-threatening condition that can require colectomy for management.

OBJECTIVE:

To assess independent predictors of mortality following colectomy for ischemic colitis using a nationally representative sample of hospitals in the United States.

METHODS:

The Nationwide Inpatient Sample was used to identify all patients with a primary diagnosis of acute vascular insufficiency of the colon (International Classification of Diseases, Ninth Revision codes 557.0 and 557.9) who underwent a colectomy between 1993 and 2008. Incidence and mortality are described; multivariate logistic regression analysis was performed to determine predictors of mortality.

RESULTS:

The incidence of colectomy for ischemic colitis was 1.43 cases (95% CI 1.40 cases to 1.47 cases) per 100,000. The incidence of colectomy for ischemic colitis increased by 3.1% per year (95% CI 2.3% to 3.9%) from 1993 to 2003, and stabilized thereafter. The postoperative mortality rate was 21.0% (95% CI 20.2% to 21.8%). After 1997, the mortality rate significantly decreased at an estimated annual rate of 4.5% (95% CI −6.3% to −2.7%). Mortality was associated with older age, 65 to 84 years (OR 5.45 [95% CI 2.91 to 10.22]) versus 18 to 34 years; health insurance, Medicaid (OR 1.69 [95% CI 1.29 to 2.21]) and Medicare (OR 1.33 [95% CI 1.12 to 1.58]) versus private health insurance; and comorbidities such as liver disease (OR 3.54 [95% CI 2.79 to 4.50]). Patients who underwent colonoscopy or sigmoidoscopy (OR 0.78 [95% CI 0.65 to 0.93]) had lower mortality.

CONCLUSIONS:

Colectomy for ischemic colitis was associated with considerable mortality. The explanation for the stable incidence and decreasing mortality rates observed in the latter part of the present study should be explored in future studies.     

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

Background

The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones.

Methods

MEDLINE/PubMed and Science Citation Index databases (1990–2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1.

Results

Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65–1.21), mortality (OR, 1.2; 95% CI, 0.32–4.52), total morbidity (OR, 0.75; 95% CI, 0.53–1.06), major morbidity (OR, 0.95; 95% CI, 0.60–1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76–3.30).

Conclusions

Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.     

Factors associated with the appropriate use of asthma drugs

BACKGROUND:

When used properly, asthma drugs can reduce asthma-related morbidity and mortality.

OBJECTIVE:

To assess the use of asthma drugs, and to identify factors associated with appropriateness of use among patients 12 to 45 years of age.

METHODS:

Asthmatic patients were interviewed about their asthma drug(s) use and the factors potentially associated with appropriateness of use according to the 2003 Canadian Asthma Consensus Conference guidelines. To determine the factors associated with the appropriate use of asthma drugs, a multivariate logistic regression model was built using a stepwise procedure, and ORs and associated 95% CIs were calculated.

RESULTS:

Of the 349 study participants, 43 (12.3%) reported appropriate use of their asthma drugs. Respondents who were more likely to report appropriate use were patients with sound knowledge of their asthma drugs (OR 2.61 [95% CI 1.29 to 5.29]), those in good, very good or excellent self-perceived health (OR 3.37 [95% CI 1.31 to 8.71]), those who had consulted a specialist during the preceding year (OR 2.28 [95% CI 1.05 to 4.97]) and those who declared themselves short of drugs due to a lack of money (OR 2.78 [95% CI 1.26 to 6.17]).

CONCLUSIONS:

Results of the present study suggested that recommendations in the current guidelines regarding the appropriate use of asthma medications are being poorly implemented. Educational interventions with the aim of improving quality of care and knowledge about asthma drugs should be offered.     

Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: a meta-analysis

OBJECTIVE:

To conduct a meta-analysis of published, full-length, randomized controlled trials evaluating the efficacy of endoscopic band ligation (EBL) versus pharmacological therapy for the primary and secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.

METHODS:

Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases. Eighteen randomized clinical trials that fulfilled the inclusion criteria were further pooled into a meta-analysis.

RESULTS:

Among 1023 patients in 12 trials comparing EBL with beta-blockers for primary prevention, there was no significant difference in gastrointestinal bleeding (RR 0.79 [95% CI 0.61 to 1.02]), all-cause deaths (RR 1.06 [95% CI 0.86 to 1.30]) or bleeding-related deaths (RR 0.66 [95% CI 0.38 to 1.16]). There was a reduced trend toward significance in variceal bleeding with EBL compared with beta-blockers (RR 0.72 [95% CI 0.54 to 0.96]). However, variceal bleeding was not significantly different between the two groups in high-quality trials (RR 0.84 [95% CI 0.60 to 1.17]). Among 687 patients from six trials comparing EBL with beta-blockers plus isosorbide mononitrate for secondary prevention, there was no effect on either gastrointestinal bleeding (RR 0.95 [95% CI 0.65 to 1.40]) or variceal bleeding (RR 0.89 [95% CI 0.53 to 1.49]). The risk for all-cause deaths in the EBL group was significantly higher than in the medical group (RR 1.25 [95% CI 1.01 to 1.55]); however, the rate of bleeding-related deaths was unaffected (RR 1.16 [95% CI 0.68 to 1.97]).

CONCLUSIONS:

Both EBL and beta-blockers may be considered first-line treatments to prevent first variceal bleeding, whereas beta-blockers plus isosorbide mononitrate may be the best choice for the prevention of rebleeding.     

Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients?

Background

Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.

Objective

To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).

Design

Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.

Participants

All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.

Measurements and Main Results

We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).

Conclusions

ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.KEY WORDS: medical errors internship and residency, education, medical, graduate, personnel staffing and scheduling, continuity of patient care     

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding

BACKGROUND:

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source.

OBJECTIVE:

To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation.

METHODS:

A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding.

RESULTS:

The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]).

CONCLUSION:

Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.     

Prevalence of asthma and chronic obstructive pulmonary disease in Aboriginal and non-Aboriginal populations: A systematic review and meta-analysis of epidemiological studies

BACKGROUND:

Asthma and chronic obstructive pulmonary disease (COPD) have considerable potential for inequities in diagnosis and treatment, thereby affecting vulnerable groups.

OBJECTIVE:

To evaluate differences in asthma and COPD prevalence between adult Aboriginal and non-Aboriginal populations.

METHODS:

MEDLINE, EMBASE, specialized databases and the grey literature up to October 2011 were searched to identify epidemiological studies comparing asthma and COPD prevalence between Aboriginal and non-Aboriginal adult populations. Prevalence ORs (PORs) and 95% CIs were calculated in a random-effects meta-analysis.

RESULTS:

Of 132 studies, eight contained relevant data. Aboriginal populations included Native Americans, Canadian Aboriginals, Australian Aboriginals and New Zealand Maori. Overall, Aboriginals were more likely to report having asthma than non-Aboriginals (POR 1.41 [95% CI 1.23 to 1.60]), particularly among Canadian Aboriginals (POR 1.80 [95% CI 1.68 to 1.93]), Native Americans (POR 1.41 [95% CI 1.13 to 1.76]) and Maori (POR 1.64 [95% CI 1.40 to 1.91]). Australian Aboriginals were less likely to report asthma (POR 0.49 [95% CI 0.28 to 0.86]). Sex differences in asthma prevalence between Aboriginals and their non-Aboriginal counterparts were not identified. One study compared COPD prevalence between Native and non-Native Americans, with similar rates in both groups (POR 1.08 [95% CI 0.81 to 1.44]).

CONCLUSIONS:

Differences in asthma prevalence between Aboriginal and non-Aboriginal populations exist in a variety of countries. Studies comparing COPD prevalence between Aboriginal and non-Aboriginal populations are scarce. Further investigation is needed to identify and account for factors associated with respiratory health inequalities among Aboriginal peoples.     

Retrospective Study of the Clinical Profile and Prognostic Indicators in Patients of Alcoholic Liver Disease Admitted to a Tertiary Care Teaching Hospital in Western Nepal

Background/Aim:

Alcohol is the most common substance abused in Nepal. Liver disease caused by alcohol abuse, including its end stage, cirrhosis, is a major health care problem, which is difficult to treat.

Objectives:

To study the demographic profile, laboratory parameters, complications and their prognostic implications among patients of alcoholic liver disease (ALD).

Materials and Methods:

Records of all patients of ALD admitted from January 1'' 2005 to December 31'' 2006 were studied and followed up to December 31, 2007. A total of 181 patients were analyzed. Their clinical profile and laboratory parameters were noted and analyzed using SPSS-10.0 software.

Results:

Among the 181 patients, 80.7% were male, 30.9% were army/ex-army and 65.2% were documented smokers. The mean age of presentation was 52.08 years. Jaundice (57.5%) was the most common presentation followed by hepatomegaly (51.4%). Hypoalbuminemia (50.3) followed by ascites (48.1) were common complications. Death occurred in 19.1% of the patients, the most common cause being hepatic encephalopathy (72.2%) followed by variceal bleeding and hepatorenal syndrome. Jaundice, ascites and hepatic encephalopathy at presentation and female sex were significantly associated with increased mortality along with discriminant score >32, aspartate aminotransferase (AST): Alanine aminotranferase (ALT) ≥ 2, ultrasonography (USG)-proven cirrhosis, rise in prothrombin time ≥5 s, total bilirubin ≥ 4mg/dL and ESR ≥34.

Conclusion:

ALD was predominantly seen among the productive age group with a high morbidity and mortality. Jaundice, ascites, hepatic encephalopathy at presentation and female sex are poor prognostic indicators along with discriminant score > 32, AST:ALT ≥ 2, USG-proven cirrhosis, coagulopathy, hyperbilirubenemia and high ESR.     

Tuberculosis in the intensive care unit: A retrospective descriptive cohort study with determination of a predictive fatality score

BACKGROUND:

Despite effective treatments, tuberculosis-related mortality remains high among patients requiring admission to the intensive care unit (ICU).

OBJECTIVE:

To determine prognostic factors of death in tuberculosis patients admitted to the ICU, and to develop a simple predictive scoring system.

METHODS:

A 10-year, retrospective study of 53 patients admitted consecutively to the Hôpitaux de Paris, Hôpital Lariboisière (Paris, France) ICU with confirmed tuberculosis, was conducted. A multivariate analysis was performed to identify risk factors for death. A predictive fatality score was determined.

RESULTS:

Diagnoses included pulmonary tuberculosis (96%) and tuberculous encephalomeningitis (26%). Patients required mechanical ventilation (45%) and vasopressor infusion (28%) on admission. Twenty patients (38%) died, related to direct tuberculosis-induced organ failure (n=5), pulmonary bacterial coinfections (n=14) and pulmonary embolism (n=1). Using a multivariate analysis, three independent factors on ICU admission were predictive of fatality: miliary pulmonary tuberculosis (OR 9.04 [95% CI 1.25 to 65.30]), mechanical ventilation (OR 11.36 [95% CI 1.55 to 83.48]) and vasopressor requirement (OR 8.45 [95% CI 1.29 to 55.18]). A score generated by summing these three independent variables was effective at predicting fatality with an area under the ROC curve of 0.92 (95% CI 0.85 to 0.98).

CONCLUSIONS:

Fatalities remain high in patients admitted to the ICU with tuberculosis. Miliary pulmonary tuberculosis, mechanical ventilation and vasopressor requirement on admission were predictive of death.     

Effect of perioperative glucose-insulin-potassium infusions on mortality and atrial fibrillation after coronary artery bypass grafting: A systematic review and meta-analysis

BACKGROUND:

Glucose-insulin infusions (with potassium [GIK] or without [GI]) have been advocated in the setting of coronary artery bypass graft (CABG) surgery to optimize myocardial glucose use and to minimize ischemic injury.

OBJECTIVE:

To conduct a meta-analysis assessing whether the use of GIK/GI infusions perioperatively reduce in-hospital mortality or atrial fibrillation (AF) after CABG surgery.

METHODS:

Electronic databases (Medline, EMBASE and Cochrane Central Register of Controlled Trials [CENTRAL]) and references of retrieved articles were searched for randomized controlled trials that evaluated the effects of GIK or GI infusions, before or during CABG surgery, on in-hospital mortality and/or postoperative AF. Pooled ORs and 95% CIs were calculated for each outcome.

RESULTS:

Twenty trials were identified and eligible for review. The summary OR for in-hospital mortality was 0.88 (95% CI 0.56 to 1.40), based on 44 deaths among 2326 patients. While postoperative AF was a more frequent outcome (occurring in 519 of 1540 patients in the 10 trials reporting this outcome), the overall pooled estimate of effect was nonsignificant (OR 0.79, 95% CI 0.54 to 1.15). This latter finding needs to be interpreted cautiously because it is accompanied by significant heterogeneity across trials.

CONCLUSIONS:

Perioperative use of GIK/GI does not significantly reduce mortality or atrial fibrillation in patients undergoing CABG surgery. Unless future trial data in support of GIK/GI infusions become available, the routine use of these treatments in patients undergoing CABG surgery should be discouraged because the safety of these infusions has not been systematically examined.     

Does the level of reproductive knowledge specific to inflammatory bowel disease predict childlessness among women with inflammatory bowel disease?

BACKGROUND:

Women with inflammatory bowel disease (IBD) may choose to remain childless due to a lack of IBD-specific reproductive knowledge.

OBJECTIVES:

To examine the effects of IBD-specific reproductive knowledge and discussion of family planning with a physician on childlessness among women with IBD.

METHODS:

Female IBD patients 18 to 45 years of age completed the Crohn’s and Colitis Pregnancy Knowledge questionnaire (CCPKnow), and answered questions regarding reproductive history, plans to have children and discussion of family planning with a physician. CCPKnow scores were grouped according to poor (0 to 7), adequate (8 to 10), good (11 to 13) and very good (14 to 17).

RESULTS:

Of 434 eligible women, 248 (57.1%) completed the questionnaires. Of these 248 women, 51.6% were childless and, among these, 12.9% were voluntarily childless and 12.1% were trying to become pregnant. Childless women had a lower median CCPKnow score than women with children (6.0 versus 8.0; P=0.001). After adjusting for current age and marital status, each one point increase in the CCPKnow score corresponded to 8% lower odds of childlessness (OR 0.92 [95% CI 0.86 to 0.99]), 9% lower odds of voluntary child-lessness (OR 0.91 [95% CI 0.79 to 1.0]) and 20% higher odds of trying to become pregnant (OR 1.2 [95% CI 1.0 to 1.4]). Discussion of family planning with a gastroenterologist corresponded to 72% lower odds of a poor CCPKnow score (OR 0.28 [95% CI 0.15 to 0.53]) and of voluntary childlessness (OR 0.28 [95% CI 0.057 to 1.3]).

CONCLUSION:

In the present study, higher IBD-specific reproductive knowledge lowered the odds of childlessness among women with IBD. Discussion of family planning with a physician was associated with higher CCPKnow scores and lower odds of voluntary childlessness.     

A meta-analysis comparing hyperfractionated vs. conventional fractionated radiotherapy in non-small cell lung cancer

Background

Lung cancer is the leading cause of cancer-related mortality. Non-small cell lung cancer (NSCLC) accounts for most lung cancer and carries a 5-year survival rate of 15%. The squamous cell carcinoma, large cell carcinoma, and adenocarcinoma are the most common types of NSCLC. The data on long term use of hyperfractionated radiotherapy (HRT) in NSCLC treatment is lacking. We performed a meta-analysis, based on published randomized trials to compare HRT [continuous hyperfractionated accelerated radiotherapy (CHART)/continuous hyperfractionated accelerated radiotherapy weekend less (CHARTWEL)] vs. conventional fractionated (CF) radiotherapy in the treatment of NSCLC.

Methods

A systematic search through the bibliographic databases, PubMed, Google Scholar and Cochrane Library was performed till December 2013.

Results

Of 63 studies identified, 3 studies were analyzed. All were randomized studies and included 1,005 patients in total. The pooled results of the studies showed that HRT did not improve overall survival (OS) of patients suffering from NSCLC compared to CF after 2 years (OR, 1.29; 95% CI, 0.98-1.71; P=0.16) and 3 years (OR, 0.55; 95% CI, 0.34-0.87; P=0.22) which was statistically significant. HRT was no better than CF in controlling tumour (OR, 1.40; 95% CI, 1.03-1.91). No significant difference in metastasis free survival (OR, 1.08; 95% CI, 0.83-1.39) and late dysphagia (OR, 1.48; 95% CI, 0.75-2.92) were observed between the two groups.

Conclusions

The results of the present meta-analysis showed that HRT was not significantly better to conventional radiotherapy in NSCLC treatment.     

Low-dose acetylsalicylic acid use and the risk of upper gastrointestinal bleeding: A meta-analysis of randomized clinical trials and observational studies

BACKGROUND:

Low-dose acetylsalicylic acid (LDA, 75 mg/day to 325 mg/day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB).

OBJECTIVE:

To analyze the magnitude of effect of LDA use on UGIB risk.

METHODS:

The PubMed and Embase databases were searched for randomized controlled trials (RCTs) reporting UGIB rates in individuals receiving LDA, and observational studies of LDA use in patients with UGIB. Studies were pooled for analysis of UGIB rates.

RESULTS:

Eighteen studies were included. Seven RCTs reported UGIB rates in individuals randomly assigned to receive LDA (n=22,901) or placebo (n=22,923). Ten case-control studies analyzed LDA use in patients with UGIB (n=10,816) and controls without UGIB (n=30,519); one cohort study reported 207 UGIB cases treated with LDA only. All studies found LDA use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with LDA use in the RCTs was 1.2 per 1000 patients per year (95% CI 0.7 to 1.8). The number needed to harm was 816 (95% CI 560 to 1500) for RCTs and 819 (95% CI 617 to 1119) for observational studies. Meta-analysis of RCT data showed that LDA use was associated with a 50% increase in UGIB risk (OR 1.5 [95% CI 1.2 to 1.8]). UGIB risk was most pronounced in observational studies (OR 3.1 [95% CI 2.5 to 3.7]).

CONCLUSIONS:

LDA use was associated with an increased risk of UGIB.     

Prevalence and predictors of sleep disturbance among liver diseases in long-term transplant survivors

BACKGROUND:

Patients with cirrhosis are known to experience sleep disturbance, which negatively impacts health-related quality of life.

OBJECTIVE:

To assess the prevalence and predictors of sleep disturbance before and after liver transplantation (LT).

METHODS:

Both pre- and post-LT patients were administered the Basic Nordic Sleep Questionnaire. The primary outcome was overall sleep satisfaction; the secondary outcomes were sleep latency and sleep duration.

RESULTS:

Eighty-three patients participated pre-LT and 273 post-LT. Overall, participants having completed both pre- and post-LT questionnaires reported satisfactory sleep 61% of the time before LT and 65% of the time after LT. However, on review of all questionnaires, patients with alcoholic liver disease (ETOH) experienced dramatically less sleep disturbance (OR 0.13 [95% CI 0.03 to 0.60]) post-LT, whereas those with hepatitis C remained without improvement (OR 0.90 [95% CI [0.38 to 2.15]). On logistic regression, patients with ETOH had statistically less sleep satisfaction pre-LT (OR 5.8 [95% CI 1.0 to 40.5]) and significantly better sleep satisfaction post-LT (OR 0.50 [95% CI 0.20 to 1.00]) compared with those with hepatitis C. In addition, both ETOH and other conditions had significantly better sleep latency than hepatitis C patients.

CONCLUSIONS:

Sleep parameters for patients who undergo LT for hepatitis C do not improve following LT as much as they do in patients transplanted for ETOH. Following LT, patients transplanted for ETOH are significantly more satisfied with their sleep than those transplanted for hepatitis C. Physicians should address and manage sleep quality after LT, so as to ultimately improve quality of life.     

Initial thrombolysis treatment compared with anticoagulation for acute intermediate-risk pulmonary embolism: a meta-analysis

Background

The use of thrombolysis in patients with acute, intermediate-risk pulmonary embolism (PE) remains controversial. This meta-analysis compared the efficacy and safety of thrombolysis and anticoagulation treatments for intermediate-risk PE patients.

Methods

Two investigators independently reviewed the literature and collected data from randomized controlled trials (RCTs) of thrombolysis for intermediate-risk PE in the PubMed, MEDLINE, EMBASE, the Cochrane Library, and Chinese Biomedical Literature Databases (CBM).

Results

A total of 1,631 intermediate-risk PE patients from seven studies were included. Significant differences were not found regarding the 30-day, all-cause mortality rates between the thrombolytic and anticoagulant groups [odds ratio (OR), 0.60; 95% confident interval (CI), 0.34-1.06; P=0.08]. The rate of clinical deterioration in the thrombolytic group was lower than that in the anticoagulant group (OR, 0.27; 95% CI, 0.18-0.41; P<0.01). Recurrent PE in the thrombolytic group was also significantly lower than that in the anticoagulant group (OR, 0.34; 95% CI, 0.15-0.77; P=0.01). Comparing the thrombolytic and anticoagulation groups, the incidence of minor bleeding was significantly higher in the thrombolytic group (OR, 5.33; 95% CI, 2.85-9.97; P<0.00001), but there were no difference in the incidences of major bleeding events (OR, 2.07; 95% CI, 0.60-7.16; P=0.25).

Conclusions

Thrombolytic treatment for intermediate-risk PE patients, if not contraindicated, could reduce clinical deterioration and recurrence of PE, and trends towards a decrease in all-cause, 30-day mortality. Despite thrombolytic treatment having an increased total bleeding risk, there was no difference in the incidence of major bleeding events, compared with patients receiving anticoagulation treatment.     

Postoperative delirium in the intensive care unit predicts worse outcomes in liver transplant recipients

BACKGROUND:

Delirium is common in intensive care unit patients and is associated with worse outcome.

OBJECTIVE:

To identify early risk factors for delirium in patients admitted to the intensive care unit following orthotopic liver transplantation (OLT).

METHODS:

An observational study of patients admitted to the intensive care unit from January 2000 to May 2010 for elective or semi-elective OLT was conducted. The primary end point was delirium in the intensive care unit. Pre- and post-transplantation and intraoperative factors potentially associated with this outcome were examined.

RESULTS:

Of the 281 patients included in the study, 28 (10.03%) developed delirium in the intensive care unit at a median of two days (interquartile range one to seven days) after OLT. According to multivariate analysis, independent risk factors for delirium were intraoperative transfusion of packed red blood cells (OR 1.15 [95% CI 1.01 to 1.18]), renal replacement therapy during the pretransplantation period (OR 13.12 [95% CI 2.82 to 72.12]) and Acute Physiologic and Health Evaluation (APACHE) II score (OR per unit increase 1.10 [95% CI 1.03 to 1.29]). Using Cox proportional hazards models adjusted for baseline covariates, delirium was associated with an almost twofold risk of remaining in hospital, a fourfold increased risk of dying in hospital and an almost threefold increased rate of death by one year.

CONCLUSION:

Intraoperative transfusion of packed red blood cells, pretransplantation renal replacement therapy and APACHE II score are predictors for the development of delirium in intensive care unit patients post-OLT and are associated with increased hospital lengths of stay and mortality.     

The Simple Predictors of Pseudomembranous Colitis in Patients with Hospital-Acquired Diarrhea: A Prospective Observational Study

Background/Aims

As the incidence rate of and mortality from pseudomembranous colitis (PMC) are increasing worldwide, it is important to study the simple predictive risk factors for PMC among patients with hospital-acquired diarrhea (HAD). This study focused on identifying the clinical risk factors that can easily predict PMC.

Methods

The presumed HAD patients were prospectively recruited at the Hallym University Kangdong Sacred Heart Hospital.

Results

Age of 70 and older (adjusted odds ratio [OR], 1.76; 95% confidence interval [CI], 1.12 to 0.75), use of proton pump inhibitors (adjusted OR, 4.07; 95% CI, 2.512 to 6.57), use of cephalosporins (adjusted OR, 2.99; 95% CI, 1.82 to 4.94), and underlying cancer (adjusted OR, 1.72; 95% CI, 1.04 to 2.82) were independent risk factors for PMC in the multivariate logistic regression analysis. The prevalence of PMC was very low in the patients with HAD who exhibited no risk factors.

Conclusions

The risk factors for PMC in patients with HAD included cephalosporin use, proton pump inhibitor use, old age, and cancer. Considering the strongly negative predictive values of these risk factors, endoscopic evaluation can be delayed in patients with HAD without risk of developing PMC.     

Third-generation cephalosporin-resistant spontaneous bacterial peritonitis: A single-centre experience and summary of existing studies

BACKGROUND:

Spontaneous bacterial peritonitis (SBP) is the most prevalent bacterial infection in patients with cirrhosis. Although studies from Europe have reported significant rates of resistance to third-generation cephalosporins, there are limited SBP-specific data from centres in North America.

OBJECTIVE:

To evaluate the prevalence of, predictors for and clinical impact of third-generation cephalosporin-resistant SBP at a Canadian tertiary care centre, and to summarize the data in the context of the existing literature.

METHODS:

SBP patients treated with both antibiotics and albumin therapy at a Canadian tertiary care hospital between 2003 and 2011 were retrospectively identified. Multivariate logistic regression was used to determine independent predictors of third-generation cephalosporin resistance and mortality.

RESULTS:

In 192 patients, 25% of infections were nosocomial. Forty per cent (77 of 192) of infections were culture positive; of these, 19% (15 of 77) were resistant to third-generation cephalosporins. The prevalence of cephalosporin resistance was 8% with community-acquired infections, 17% with health care-associated infections and 41% with nosocomial acquisition. Nosocomial acquisition of infection was the only predictor of resistance to third-generation cephalosporins (OR 4.0 [95% CI 1.04 to 15.2]). Thirty-day mortality censored for liver transplantation was 27% (50 of 184). In the 77 culture-positive patients, resistance to third-generation cephalosporins (OR 5.3 [1.3 to 22]) and the Model for End-stage Live Disease score (OR 1.14 [1.04 to 1.24]) were independent predictors of 30-day mortality.

CONCLUSIONS:

Third-generation cephalosporin-resistant SBP is a common diagnosis and has an effect on clinical outcomes. In an attempt to reduce the mortality associated with resistance to empirical therapy, high-risk subgroups should receive broader empirical antibiotic coverage.     

Vaccine knowledge in students in Paris,France, and surrounding regions

INTRODUCTION:

In France, young adults are legally freed from parental authority at the age of 18 years and are, thus, responsible for their own vaccine record. This young adult population is more frequently exposed to vaccine-preventable infectious diseases.

OBJECTIVE:

To determine the factors associated with students’ knowledge of the interval between two antitetanus boosters and their report of having up-to-date vaccinations.

METHODS:

In April 2009, a survey was conducted involving a random sample of students between 18 and 25 years of age eating lunch at university dining facilities in Paris and its suburbs (Ile de France).

RESULTS:

Among the 677 students approached, 583 agreed to participate. Only 207 (36%) of respondents knew the recommended dosing interval between two doses of tetanus vaccine booster (10 years). The majority of students (69%) reported having up-to-date vaccinations. Declaring having up-to-date vaccinations was significantly associated with having a general practitioner (OR 3.03 [95% CI 1.69 to 5.55]). Health care students were significantly more likely to know the decennial interval between two antitetanus boosters (OR 2 [95% CI 1.28 to 3.25]). Most of responding students (n=519 [89%]) believed that vaccines were very useful.

CONCLUSIONS:

An overall lack of knowledge of vaccines was observed among this student population. Health care providers, such as GPs and university medical practice staff, who interact with these young individuals have an essential role to promote better vaccination coverage in this population.