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

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

Symptomatic intracranial hemorrhage in patients with admission hyperglycemia and diabetes after mechanical thrombectomy: A systematic review and meta-analysis

ObjectivesSymptomatic intracranial hemorrhage (sICH) is a severe complication of revascularization therapy. We aimed to investigate the association of admission hyperglycemia and sICH after mechanical thrombectomy in patients with acute ischemic stroke.MethodsWe systematically searched PubMed, EMBASE and Cochrane Library to identify studies that reported incidence of sICH in patients with admission hyperglycemia and normoglycemia, or with and without a history of diabetes, or glucose level in patients with sICH and non-sICH from inception to December 10, 2019. The estimate effects were pooled by random-effects model.ResultsTwelve eligible studies were included with 4892 patients enrolled. The risk of sICH was significantly higher in admission hyperglycemia patients than that in normoglycemia (OR 2.93, 95% CI 1.34–6.42, p = 0.007; adjusted OR1.95, 95% CI 1.22–3.13; p = 0.006). The admission glucose level was significantly higher in sICH patients than that in non-sICH with a mean difference of 37.49 (95% CI 3.03–71.94, p = 0.03). The risk of sICH increased with elevating glucose level (adjusted OR 1.06, 95% CI 1.01–1.11; p = 0.02). The risk of sICH was not significantly increased in patients with a history of diabetes than that of those without (OR 1.74, 95% CI 1.00–3.03, p = 0.05; adjusted OR 2.26, 95% CI 0.97–5.28; p = 0.06).ConclusionsIn patients of acute ischemic stroke treated with mechanical thrombectomy, the risk of sICH was associated with admission hyperglycemia but possibly not with a history of diabetes.     

Cardiometabolic Risk Reduction Through Recreational Group Sport Interventions in Adults: A Systematic Review and Meta-analysis

Objective

To estimate the pooled effects of community-based, recreational-level group sports on cardiometabolic risk factors and fitness parameters among adults.

Development and feasibility of the Help to Overcome Problems Effectively (HOPE) self-management intervention for people living with multiple sclerosis

Purpose: To describe the development and feasibility of a self-management intervention called the Help to Overcome Problems Effectively (HOPE: MS), aimed at improving the physical and psychological wellbeing of people living with Multiple Sclerosis (MS).

Method: HOPE: MS is an innovative, 6-week group-based, manualised self-management intervention combining positive psychology theory and practice, and cognitive behavioural therapy (CBT). Participants (N?=?21) recruited via a local East Midlands branch of the MS Society attended one of three HOPE: MS interventions and completed self-reported outcome measures in week 1 and week 6. The following outcome measures were used: The Multiple Sclerosis Impact Scale; Multiple Sclerosis Fatigue Severity Scale; The Multiple Sclerosis Self-Efficacy Scale; The Adult State Hope Scale; The Hospital Anxiety and Depression Scale; The Positive and Negative Affect Scale.

Results: Post-intervention (6 weeks) mean scores decreased in the physical impact (baseline M?=?65.6, SD?=?17.4; 6 weeks M?=?55.1, SD?=?17.9, 95% CI [?4.39, ?16.47] and the psychological impact of MS (baseline M?=?24.0, SD?=?7.3; 6 weeks M?=?18.9; SD?=?6.3, 95% CI [?2.54, ?7.66]). There was also a decrease mean fatigue severity scores (baseline 49.4, SD?=?13.3, 6 weeks M?=?41.1, SD?=?14.4, 95% CI [?2.65, ?13.44]). There was a mean decrease in depression scores (baseline M?=?6.9, SD?=?3.5; 6 weeks M?=?4.2, SD?=?2.8, 95% CI [?1.43, ?4.00]). There were smaller mean decreases in anxiety (baseline M?=?7.6, SD?=?3.4; 6 weeks M?=?6.7 (4.0), 95% CI [0.69, ?2.50]) and negative affect (baseline M?=?22.9, SD?=?6.8; 6 weeks M?=?20.8 (8.1), 95% CI [0.69, ?2.50]) refer Table 3). Mean MS self-efficacy scores (baseline 21.7, SD?=?4.2; 6 weeks M?=?24.1, SD?=?4.7, 95% CI [0.23, 4.53]), mean total hope scores (baseline M?=?23.3, SD?=?10.7; 6 weeks M?=?32.2 (10.6), 95% CI [4.91, 12.9]), hope agency scores (baseline M?=?10.5, SD?=?5.7; 6 weeks M?=?15.7 (6.2), 95% CI [2.37, 8.01]), hope pathways (baseline M?=?12.9, SD?=?6.0; 6 weeks M?=?16.6 (4.9), 95% CI [2.00, 5.43]) and positive affect scores increased (baseline M?=?27.3, SD?=?7.1; 6 months M?=?32.2, SD?=?8.4, 95% CI [0.42, 9.39]). Participants positively rated the intervention quality and delivery.

Conclusions: This feasibility study showed that the HOPE: MS was acceptable and useful to people living with MS. Further robust evaluations using a randomised controlled trial design with longer follow ups are needed to confirm early promising results of the HOPE: MS.

• Implications for rehabilitation

• Living with MS requires constant adjustments to cope with unpredictable symptoms.

• Self-management interventions have the potential to help people living with MS to improve their quality of life.

• A feasibility study of the HOPE: MS self-management group-based intervention showed that it was acceptable and useful to people living with MS.

     

Can Yoga or Physical Therapy for Chronic Low Back Pain Improve Depression and Anxiety Among Adults From a Racially Diverse,Low-Income Community? A Secondary Analysis of a Randomized Controlled Trial

ObjectiveTo determine and compare the effect of yoga, physical therapy (PT), and education on depressive and anxious symptoms in patients with chronic low back pain (CLBP).DesignSecondary analysis of a randomized controlled trial.SettingAcademic safety net hospital and 7 community health centers.ParticipantsA total of 320 adults with CLBP.InterventionYoga classes, PT sessions, or an educational book.Outcome MeasureDepression and anxiety were measured using the Patient Health Questionnaire and Generalized Anxiety Disorder 7-item Scale, respectively, at baseline, 12, and 52 weeks. We identified baseline and midtreatment (6-wk) factors associated with clinically meaningful improvements in depressive (≥3 points) or anxious (≥2 points) symptoms at 12 weeks.ResultsParticipants (female=64%; mean age, 46.0±10.7 years) were predominantly non-White (82%), low-income (<$30,000/year, 59%), and had not received a college degree (71%). Most participants had mild or worse depressive (60%) and anxious (50%) symptoms. At 12 weeks, yoga and PT participants experienced modest within-group improvements in depressive symptoms (mean difference [MD]=?1.23 [95% CI, ?2.18 to ?0.28]; MD=?1.01 [95% CI, ?2.05 to ?0.03], respectively). Compared with the education group, 12-week differences were not statistically significant, although trends favored yoga (MD=?0.71 [95% CI, ?2.22 to 0.81]) and PT (MD= ?0.32 [95% CI, ?1.82 to 1.18]). At 12 weeks, improvements in anxious symptoms were only found in participants who had mild or moderate anxiety at baseline. Independent of treatment arm, participants who had 30% or greater improvement in pain or function midtreatment were more likely to have a clinically meaningful improvement in depressive symptoms (odds ratio [OR], 1.82 [95% CI, 1.03-3.22]; OR, 1.79 [95% CI, 1.06-3.04], respectively).ConclusionsIn our secondary analysis we found that depression and anxiety, common in this sample of underserved adults with CLBP, may improve modestly with PT and yoga. However, effects were not superior to education. Improvements in pain and function are associated with a decrease in depressive symptoms. More research is needed to optimize the integration of physical and psychological well-being in PT and yoga.     

ED Crowding Is Associated with Variable Perceptions of Care Compromise

Objectives The authors measured the association between emergency department (ED) crowding and patient and provider perceptions about whether patient care was compromised. Methods This was a cross‐sectional study of patients admitted from the ED and their providers. Surveys of patients, nurses, and resident physicians were linked. The primary outcome was agreement or strong agreement on a five‐item scale assessing whether ED crowding compromised care. Logistic regression was used to determine the association between the primary outcome and measures of ED crowding. Results Of 741 patients approached, 644 patients consented (87%); 703 resident physician surveys (95%) and 716 nursing surveys (97%) were completed. A total of 106 patients (16%), 86 residents (12%), and 173 nurses (24%) reported that care was compromised by ED crowding. In 252 cases (35%), one or more respondents reported that care was compromised. There was poor agreement over whose care was compromised. For patients, independent predictors of compromised care were waiting room time (odds ratio [OR], 1.05 for each additional 10‐minute wait [95% confidence interval {CI} = 1.02 to 1.09]) and being surveyed in a hallway bed (OR, 2.02 [95% CI = 1.12 to 3.68]). Predictors of compromised care for nurses included waiting room time (OR, 1.05 for each additional 10‐minute wait [95% CI = 1.01 to 1.08]), number of patients in the waiting room (OR, 1.05 for each additional patient waiting [95% CI = 1.02 to 1.07]), and number of admitted patients waiting for an inpatient bed (OR, 1.08 for each additional patient [95% CI = 1.03 to 1.12]). For residents, predictors of compromised care were patient/nurse ratio (OR, 1.39 for a one‐unit increase [95% CI = 1.09 to 1.20]) and number of admitted patients waiting for an inpatient bed (OR, 1.14 for each additional patient [95% CI = 1.10 to 1.75]). Conclusions ED crowding is associated with perceptions of compromised emergency care. There is considerable variability among nurses, patients, and resident physicians over which factors are associated with compromised care, whose care was compromised, and how care was compromised.     

Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical,psychological, and family outcomes: A systematic review and meta-analysis

BackgroundDelirium is common in critically ill patients and may lead to severe complications, such as falls and injuries. Nonpharmacological interventions have been widely suggested to prevent delirium, yet the effects remain uncertain.ObjectivesThe aim of the study was to determine the effects of nonpharmacological interventions on preventing delirium and improving critically ill patients' clinical, psychological, and family outcomes.MethodsTen databases were searched from their inception to September 2020. Two reviewers assessed the methodological quality and extracted details of the included studies. The data were narratively or statistically pooled where appropriate. Dichotomous variables are presented as odds ratio (OR), and continuous variables are presented as mean difference (MD). The Grading of Recommendations Assessment, Development, and Evaluation criteria were used to assess the quality of evidence for each review outcome.ResultsThirty-four studies (10 randomised controlled trials, eight controlled clinical trials, and 16 before-and-after studies) were included in the analysis. Low-certainty evidence indicated that nonpharmacological interventions reduced delirium incidence (OR = 0.43, 95% confidence interval [CI] [0.33, 0.55]), delirium duration (MD = ?1.43 days, 95% CI [?1.94, 0.92]), and length of stay in the intensive care unit (MD = ?1.24 days, 95% CI [?2.05, ?0.43]). Moderate-certainty evidence demonstrated no effect on mortality. Narrative synthesis further implied improvements in patients' psychological recovery (two studies, very low-certainty evidence) and families' satisfaction with care (two studies, very low-certainty evidence) through nonpharmacological interventions. As for effective intervention types, moderate-certainty evidence demonstrates that early mobilisation (OR = 0.33, 95% CI [0.24, 0.46], five studies, 859 participants, I² = 24%), family participation (OR = 0.25, 95% CI [0.18, 0.34], four studies, 997 participants, I² = 21%), and use of multicomponent interventions (OR = 0.48, 95% CI [0.34, 0.69], 13 studies, 3172 participants, I² = 77%) are associated with reduced incidence of delirium.ConclusionsHealthcare professionals are recommended to apply early mobilisation, family participation, or multicomponent interventions in clinical practice to prevent delirium. Further studies investigating the effects of nonpharmacological interventions on patients' psychological and family outcomes are warranted.     

Effects of Perioperative Dexmedetomidine on Postoperative Mortality and Morbidity: A Systematic Review and Meta-analysis

Purpose

Major postoperative complications translate into increased health care resource utilization, prolonged hospital stays, and increased mortality. We aimed to assess the effects of perioperative dexmedetomidine use on postoperative mortality and the prevalence of major complications after cardiac and noncardiac surgery.

Predictors of minor versus major stroke during carotid artery stenting: results from the carotid artery stenting (CAS) registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

Background

Patient outcome, quality of life as well as health care costs differ between patients with minor versus major stroke during carotid artery stenting. Evaluation of predictors for both subtypes of strokes is of paramount importance.

Methods and results

We analyzed data from the prospective, web-based German carotid artery stenting (CAS) registry. All patients entered in this registry were included as of January 2011. During the periprocedural period (until patient discharge or transfer) 1.5 % of the patients (85/5,794) sustained a major and 1.3 % (75/5,784) a minor stroke (total periprocedural stroke rate 2.8 %). Mean age of all patients was 71 years, 72 % were male and 50 % had a symptomatic carotid stenosis. Regression analysis identified age (OR 1.44; 95 % CI 1.05–1.98), symptomatic stenosis (OR 3.17; 95 % CI 1.74–5.76) and procedural duration per 10 min (OR 1.22; 95 % CI 1.13–1.31) as independent predictors for major strokes. Age (OR 1.43; 95 % CI 1.03–1.98), diabetes (OR 1.75; 95 % CI 1.04–2.94), and procedural duration (OR 1.17; 95 % CI 1.08–1.27) predicted for minor strokes. The use of an embolic protection device significantly prevented both type of strokes (OR 0.31; 95?% CI 0.15–0.62 for major strokes; OR 0.40; 95?% CI 0.18–0.91 for minor strokes), female patients suffered less major strokes (OR 0.47; 95?% CI 0.24–0.92). Moreover, minor and major strokes were associated with death, contralateral embolism and a longer hospital stay more frequently.

Conclusion

Patients with one or more risk factors for periprocedural stroke seem to require special attention in terms of optimal preprocedural assessment of the carotid stenosis and vascular anatomy, as well as adequate patient preparation. Identifying these risk factors may help in patient selection, encourage further refinement in carotid artery stenting technique and avoid procedural complications. The use of an embolic protection device system was associated with less periprocedural minor and major strokes.     

Opioid prescriptions by U.S. primary care physicians from 1992 to 2001.

Little is known about primary care physicians' (PCPs) prescribing of opioids. We describe trends and factors associated with opioid prescribing during PCP visits over the past decade. Using the National Ambulatory Medical Care Survey, we found an opioid prescribed in 2,206 (5%) PCP visits from 1992 to 2001. The prevalence of visits where an opioid was prescribed increased from a low of 41 per 1000 visits in 1992-1993 to a peak of 63 per 1000 in 1998-1999 (P < .0001 for trend) and then stabilized (59 per 1000 in 2000-2001). Several factors increased the odds of receiving an opioid: having Medicaid (odds ratio [OR] 2.09 [95% confidence interval (CI) 1.82-2.40]) or Medicare (OR 2.00 [95% CI 1.68-2.39]); having a visit between 15 and 35 minutes (OR 1.16 [95% CI 1.05-1.27]); and receiving an NSAID (OR 2.27 [95% CI 2.04-2.53]). Patients of hispanic (OR .67 [95% CI .56-.81]) or other race/ethnicity (OR .68 [95% CI .52-.90]), patients in health maintenance organizations (OR .74 [95% CI .66-.84]), and those living in the northeast (OR .60 [95% CI .51-.69]) or midwest (OR .75 [95% CI .66-.85]) had lower odds of receiving an opioid. Substantial variation exists in opioid prescribing by PCPs. Now that pain management standards are advocated, understanding the dynamics of opioid prescribing is necessary. PERSPECTIVE: This study describes a decade-long increase in opioid prescribing by U.S. primary care physicians and identifies important geographic-, racial/ethnic-, and insurance-related differences in who receives these medications. Several underlying factors, including regulatory and legal pressures, attitudes and knowledge of opioids, and publicized opioid-related events, may contribute to these differences.     

Identifying Patient Characteristics Associated With the Occurrence of Post Treatment Non-serious Adverse Events After Cervical Spine Manual Therapy Treatment in Patients With Neck Pain

ObjectivesTo compare prevalence rates of serious and non-serious adverse events after manipulation and mobilization and to identify risk factors of serious and non-serious adverse events following 4 types of manual therapy treatment in patients with neck pain.DesignA prospective cohort study in primary care manual therapy practice.ParticipantsPatients with neck pain (N=686) provided data on adverse events after 1014 manipulation treatments, 829 mobilization treatments, 437 combined manipulation and mobilization treatments, and 891 treatments consisting of “other treatment modality”.InterventionsUsual care manual therapy.Main Outcome MeasuresA chi-square test was performed to explore differences in prevalence rates. Logistic regression analysis was performed within the 4 treatment groups. A priori we defined associations between patient-characteristics and adverse events of odds ratio (OR)>2 or OR<0.5 as clinically relevant.ResultsNo serious adverse events, such as cervical artery dissection or stroke, were reported. With regard to non-serious adverse events, we found that these are common after manual therapy treatment: prevalence rates are ranging from 0.3% to 64.7%. We found a statistically significant difference between the 4 types of treatments, detrimental to mobilization treatment. Logistic regression analysis resulted in 3 main predictors related to non-serious adverse events after manual therapy treatment: smoking (OR ranges from 2.10 [95% confidence interval [CI] 1.37-3.11] to 3.33 [95% CI 1.83-5.93]), the presence of comorbidity (OR ranges from 2.32 [95% CI 1.22-4.44] to 3.88 [95% CI 1.62-9.26]), and female sex (OR ranges from 0.22 [95% CI 0.11-0.46] to 0.49 [95% CI 0.28-0.86]).ConclusionThere is a significant difference in the occurrence of non-serious adverse events after mobilization compared with manipulation or a combination of manipulation and mobilization. Non-serious adverse events in manual therapy practice are common and are associated with smoking and the presence of comorbidity. In addition, women are more likely to report non-serious adverse events.     

Common biomarkers of physiologic stress and associations with delirium in patients with intracerebral hemorrhage

PurposeTo examine associations between physiologic stress and delirium in the setting of a direct neurologic injury.Materials and methodsWe obtained initial neutrophil-to-lymphocyte ratio (NLR), glucose, and troponin in consecutive non-comatose patients with non-traumatic intracerebral hemorrhage (ICH) over 1 year, then used multivariable regression models to determine associations between each biomarker and incident delirium. Delirium diagnoses were established using DSM-5-based methods, with exploratory analyses further categorizing delirium as first occurring <24 h (“early-onset”) or > 24 h after presentation (“later-onset”).ResultsOf 284 patients, delirium occurred in 55% (early-onset: 39% [n = 111]; later-onset: 16% [n = 46]). Patients with delirium had higher NLR (mean 9.0 ± 10.4 vs. 6.4 ± 5.5; p = 0.01), glucose (mean 146.5 ± 59.6 vs. 129.9 ± 41.4 mg/dL; p = 0.008), and a higher frequency of elevated troponin (>0.05 ng/mL; 21% vs. 10%, p = 0.02). In adjusted models, elevated NLR (highest quartile: OR 3.4 [95% CI 1.5–7.8]), glucose (>180 mg/dL: OR 3.1 [95% CI 1.1–8.2]), and troponin (OR 3.0 [95% CI 1.2–7.2]) were each associated with delirium, but only initial NLR was specifically associated with later-onset delirium and with delirium in non-mechanically ventilated patients.ConclusionsStress-related biomarkers corresponding to multiple organ systems are associated with ICH-related delirium. Early NLR elevation may also predict delayed-onset delirium, potentially implicating systemic inflammation as a contributory delirium mechanism.     

Pneumothorax diagnosis with lung sliding quantification by speckle tracking: A prospective multicentric observational study

IntroductionLung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician.MethodsWe conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan.ResultsWith a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69).ConclusionIn our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax.     

Efficacy and safety of empagliflozin in type 2 diabetes mellitus: a meta-analysis of randomized controlled trials

Objectives: The prevalence of diabetes has increased in the recent decades and optimum glycemic control is required to reduce morbidity and mortality. We meta-analyzed randomized controlled trials in order to assess the efficacy and safety of empagliflozin compared to placebo in type 2 diabetes mellitus patients.

Methods: We included double-blind, placebo controlled trials of empagliflozin that evaluated glycemic efficacy and safety (10 mg or 25 mg) either as monotherapy or as add-on to existing diabetes pharmacotherapy.

Results: The results demonstrated significant improvements in HbA1c (SMD ?0.929%, 95 % CI ?1.064 to ?0.793, for 10 mg and ?1.064%, 95 % CI ?1.184 to ?0.944, for 25 mg) and FPG (SMD ?0.929%, 95 % CI ?1.064 to ?0.793, for 10 mg and ?1.064%, 95 % CI ?1.184 to ?0.944, for 25 mg) with empagliflozin monotherapy (n = 609) compared to placebo. Significant improvements in HbA1c [SMD ?1.582%, 95% CI ?2.164 to ?1.000, for 10 mg (n = 1079) and ?1.668%, 95% CI ?2.260 to ?1.077, for 25 mg (n = 1070)] and FPG [SMD ?0.865 mmol/L, 95 % CI ?1.309 to ?0.420, for 10 mg (n = 854) and ?0.996 mmol/L, 95% CI ?1.456 to ?0.536, for 25 mg (n = 854)] were also observed in empagliflozin add-on therapy trials. Reductions in blood pressure and body weight were also seen in both monotherapy and add-on therapy. Empagliflozin was associated with increased risk of hypoglycemia, genital and urinary tract infections (OR 1.043, 2.814, 1.119 respectively).

Conclusion: This meta-analysis shows empagliflozin is safe and effective for the treatment of T2DM along with existing diabetes pharmacotherapy.     

Rate and Predictors of Serious Neurologic Causes of Dizziness in the Emergency Department

ObjectiveTo describe the rate and predictors of central nervous system (CNS) disease in emergency department (ED) patients with dizziness in the modern era of neuroimaging.Patients and MethodsWe retrospectively reviewed the medical records of all adults presenting between January 1, 2007, and December 31, 2009, to an academic ED for a primary triage complaint of dizziness, vertigo, or imbalance. The final diagnosis for the cause of dizziness was independently assigned by 2 neurologists, with a third neurologist resolving any disagreements. The primary outcome was a composite of ischemic stroke, intracranial hemorrhage, transient ischemic attack, seizure, brain tumor, demyelinating disease, and CNS infection. Univariate and multivariate logistic regression were used to assess the association between clinical variables and serious CNS causes of dizziness.ResultsOf 907 patients experiencing dizziness (mean age, 59 years; 58% women [n=529]), 49 (5%) had a serious neurologic diagnosis, including 37 cerebrovascular events. Dizziness was often caused by benign conditions, such as peripheral vertigo (294 patients [32%]) or orthostatic hypotension (121 patients [13%]). Age 60 years or older (odds ratio [OR], 5.7; 95% confidence interval [CI], 2.5-11.2), a chief complaint of imbalance (OR, 5.9; 95% CI, 2.3-15.2), and any focal examination abnormality (OR, 5.9; 95% CI, 3.1-11.2) were independently associated with serious neurologic diagnoses, whereas isolated dizziness symptoms were inversely associated (OR, 0.2; 95% CI, 0.0-0.7).ConclusionDizziness in the ED is generally benign, although a substantial fraction of patients harbor serious neurologic disease. Clinical suspicion should be heightened for patients with advanced age, imbalance, or focal deficits.     

Return to work during first year after intensive care treatment and the impact of demographic,clinical and psychosocial factors

ObjectivesTo describe work participation in survivors during first year after intensive care unit discharge and examine the impact of selected demographic, clinical and psychosocial factors on return to work 12 months after discharge.Research methodology/DesignA predefined sub-study (prospective cohort study) of a randomised controlled trial.SettingA Norwegian single-centre university hospital. Medical and surgical adult intensive care survivors, working/on sick leave before admission, in the intensive care unit ≥24 h, were included.Main outcome measuresReturn to work three, six and 12 months after discharge, and impact of age, pre-existing comorbidities, previous serious life events, coping ability, hope and social support on return to work 12 months after discharge.ResultsIncluded were 284 patients, with mean age 47 years (SD 13.9) and 47 % women. One year after discharge, 69 % were back at work. In the regression analysis, with working at 12 months (yes/no) as the dependent variable, 178 patients, completing questionnaires at three as well as 12 months, were included. Lower age (OR 0.96, 95 % CI [0.93–0.99]), lower pre-existing comorbidities (OR 0.65, 95 % CI [0.43–0.97]), previous serious life events (OR 6.53, 95 % CI [2.14–19.94]), and greater hope at three months (OR 1.09, 95 % CI [1.01–1.17]) were all independently associated with higher odds of returning to work.ConclusionFollowing intensive care, age, pre-existing comorbidities, experience of previous serious life events and hope all have a significant impact on return to work, and are important variables to consider during intensive care treatment and rehabilitation.Implications for clinical practiceAttention must be paid to patients with prior working capability to ensure return to work after intensive care treatment. Older adults with pre-existing comorbidities might benefit from early, individualised rehabilitation to regain previous working capacity. In addition, there is also a need to support patients’ hope during and after critical illness.     

Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies

BACKGROUNDAdverse associations of low- and no-calorie sweetened beverages (LNCSB) with cardiometabolic outcomes in observational studies may be explained by reverse causality and residual confounding.PURPOSETo address these limitations we used change analyses of repeated measures of intake and substitution analyses to synthesize the association of LNCSB with cardiometabolic outcomes.DATA SOURCESMEDLINE, Embase, and the Cochrane Library were searched up to 10 June 2021 for prospective cohort studies with ≥1 year of follow-up duration in adults.STUDY SELECTIONOutcomes included changes in clinical measures of adiposity, risk of overweight/obesity, metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease, and total mortality.DATA EXTRACTIONTwo independent reviewers extracted data, assessed study quality, and assessed certainty of evidence using GRADE. Data were pooled with a random-effects model and expressed as mean difference (MD) or risk ratio (RR) and 95% CI.DATA SYNTHESISA total of 14 cohorts (416,830 participants) met the eligibility criteria. Increase in LNCSB intake was associated with lower weight (5 cohorts, 130,020 participants; MD −0.008 kg/year [95% CI −0.014, −0.002]). Substitution of LNCSB for sugar-sweetened beverages (SSB) was associated with lower weight (three cohorts, 165,579 participants; MD, −0.12 [−0.14, −0.10,] kg/y) and lower incidence of obesity (OB) (one cohort, 15,765 participants; RR 0.88 [95% CI 0.88, 0.89]), coronary heart disease (six cohorts, 233,676 participants; 0.89 [0.81, 0.98]), cardiovascular disease mortality (one cohort, 118,363 participants; 0.95 [0.90, 0.99]), and total mortality (one cohort, 118,363 participants; 0.96 [0.94, 0.98]) with no adverse associations across other outcomes. Substitution of water for SSB showed lower weight (three cohorts, 165,579 participants; MD −0.10 kg/year [−0.13, −0.06]), lower waist circumference (one cohort, 173 participants; −2.71 cm/year [−4.27, −1.15]) and percent body fat (one cohort, 173 participants; −1.51% per year [−2.61, −0.42]), and lower incidence of OB (one cohort, 15,765 participants; RR 0.85 [0.75, 0.97]) and T2D (three cohorts, 281,855 participants; 0.96 [0.94, 0.98]). Substitution of LNCSB for water showed no adverse associations.LIMITATIONSThe evidence was low to very low certainty owing to downgrades for imprecision, indirectness, and/or inconsistency.CONCLUSIONSLNCSB were not associated with cardiometabolic harm in analyses that model the exposure as change or substitutions. The available evidence provides some indication that LNCSB in their intended substitution for SSB may be associated with cardiometabolic benefit, comparable with the standard of care, water.