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2021 ◽  
Vol 09 (10) ◽  
pp. E1504-E1511
Vincent Quentin ◽  
André-Jean Remy ◽  
Gilles Macaigne ◽  
Rachida Leblanc-Boubchir ◽  
Jean-Pierre Arpurt ◽  

Abstract Background and study aims Prognostic and risk factors for upper gastrointestinal bleeding (UGIB) might have changed overtime because of the increased use of direct oral anticoagulants and improved gastroenterological care. This study was undertaken to assess the outcomes of UGIB in light of these new determinants by establishing a new national, multicenter cohort 10 years after the first. Methods Consecutive outpatients and inpatients with UGIB symptoms consulting at 46 French general hospitals were prospectively included between November 2017 and October 2018. They were followed for at least for 6 weeks to assess 6-week rebleeding and mortality rates and factors associated with each event. Results Among the 2498 enrolled patients (mean age 68.5 [16.3] years, 67.1 % men), 74.5 % were outpatients and 21 % had cirrhosis. Median Charlson score was 2 (IQR 1–4) and Rockall score was 5 (IQR 3–6). Within 24 hours, 83.4 % of the patients underwent endoscopy. The main causes of bleeding were peptic ulcers (44.9 %) and portal hypertension (18.9 %). The early in-hospital rebleeding rate was 10.5 %. The 6-week mortality rate was 12.5 %. Predictors significantly associated with 6-week mortality were initial transfusion (OR 1.54; 95 %CI 1.04–2.28), Charlson score > 4 (OR 1.80; 95 %CI 1.31–2.48), Rockall score > 5 (OR 1.98; 95 %CI 1.39–2.80), being an inpatient (OR 2.45; 95 %CI 1.76–3.41) and rebleeding (OR 2.6; 95 %CI 1.85–3.64). Anticoagulant therapy was not associated with dreaded outcomes. Conclusions The 6-week mortality rate remained high after UGIB, especially for inpatients. Predictors of mortality underlined the weight of comorbidities on outcomes.

2021 ◽  
Vorawee Varavithya ◽  
Chayanee Tirapat ◽  
Penpitcha Rojpibulstit ◽  
Panadda Poovichayasumlit ◽  
Vanida Prasert ◽  

Background: Older adults are at risk of receiving potentially inappropriate medications (PIMs) because their incidence of medical conditions and diseases is higher than younger individuals. This situation is of particular concern because the biological and physiologic changes in older adults make them vulnerable to PIMs. Thailand has become an aging society since the year 2002, so it is essential to evaluate the effect of PIMs in this age group. Objectives: This study examined the association between PIM use and the hospitalization rate in Thai older patients, in addition to identifying the factors associated with the hospitalization rate. Methods: In this retrospective cohort study, the electronic medical data of patients aged 60 years and older who visited the outpatient department (OPD) in 2015 were collected. The patients were categorized into PIM and non-PIM users according to the Beers 2019 criteria. An association between PIM use and the hospitalization rate was examined. Data were analyzed through descriptive and analytic statistics to examine the association between PIM use and the hospitalization rate via relative risk. Log-binomial regression was conducted to explore factors that impacted the hospitalization rate. Results: A total of 32,261 patients were collected, with the majority being female (59.65%) and the mean age of 70.21 ± 7.88 years. Overall, 63.98% of the patients (20,641 patients) were PIM users and 49.45% (15,952 patients) received polypharmacy (≥5 medications). The most common PIM prescription was Proton-pump inhibitors, making 27.51% of all medications prescribed. The results showed that PIM use increased the risk of hospitalization by 1.31 times (adjusted RR 1.31 95% CI 1.21-1.41, p-values < 0.001). Other factors affecting the rate of hospitalizations included age, gender, polypharmacy, and the number of OPD visits. Conclusions PIMs were commonly prescribed to older patients in the OPD and were significantly associated with subsequent hospitalization. A provision of an alternative drug list can help physicians avoid prescribing PIMs to older patients. If PIMs prescription is unavoidable, physicians should closely monitor drug-related problems and deprescribe when PIMs are not indicated.

2021 ◽  
Vol 12 ◽  
Weiying Zhong ◽  
Hong Kuang ◽  
Ping Zhang ◽  
Xinjian Yang ◽  
Bin Luo ◽  

Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling.Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed.Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050).Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.

Stroke ◽  
2021 ◽  
Julia Pudar ◽  
Brent Strong ◽  
Virginia J. Howard ◽  
Mathew J. Reeves

Background and Purpose: When reporting primary results from randomized controlled trials, recommendations include reporting results by sex. We reviewed the reporting of results by sex in contemporary acute stroke randomized controlled trials. Methods: We searched MEDLINE for articles reporting the primary results of phase 2 or 3 stroke randomized controlled trials published between 2010 and June 2020 in one of nine major clinical journals. Eligible trials were restricted to those with a therapeutic intervention initiated within one month of stroke onset. Of primary interest was the reporting of results by sex for the primary outcome. We performed bivariate analyses using Fisher exact tests to identify study-level factors associated with reporting by sex and investigated temporal trends using an exact test for trend. Results: Of the 115 studies identified, primary results were reported by sex in 37% (n=42). Reporting varied significantly by journal, with the New England Journal of Medicine (61%) and Lancet journals (40%) having the highest rates ( P =0.03). Reporting also differed significantly by geographic region (21% Europe versus 48% Americas, P =0.03), trial phase (13% phase 2 versus 40% phase 3, P =0.05), and sample size (24% <250 participants versus 61% >750 participants, P <0.01). Although not statistically significant ( P =0.11), there was a temporal trend in favor of greater reporting among later publications (25% 2010–2012 versus 48% 2019–2020). Conclusions: Although reporting of primary trial results by sex improved from 2010 to 2020, the prevalence of reporting in major journals is still low. Further efforts are required to encourage journals and authors to comply with current reporting recommendations.

2021 ◽  
Vol 10 (1) ◽  
Adelaide Mariele Pereira da Silva ◽  
Brenda Fabiana dos Santos ◽  
Isabella Lima Pereira ◽  
Suely Aparecida Lima Cassiano ◽  
André Luiz Silva Alvim

Objetivo: Levantar os fatores de motivação e insatisfação da equipe de enfermagem no contexto do trabalho em saúde. Métodos: Estudo descritivo, realizado em um hospital particular da região metropolitana de Belo Horizonte, Minas Gerais, Brasil. Foram incluídos 100 profissionais de enfermagem que responderam a um questionário estruturado. As informações foram analisadas por estatística descritiva. Resultados: Destacam-se enfermeiros (57%), do sexo feminino (85%), que trabalham há 5 anos ou mais na profissão (76%). Os profissionais concordam parcialmente quanto a se sentirem motivados na profissão (39%) e possuirem autonomia no trabalho (32%). No entanto, discordam totalmente em relação a estarem satisfeitos com o salário atual (33%). Conclusão: Este estudo mostrou os aspectos que promovem a motivação e a insatisfação dos profissionais de enfermagem, sendo fundamentais para garantia das condições de trabalho que favoreçam uma boa prestação de serviços. O salário foi citado como a principal causa de descontentamento.

2021 ◽  
pp. 175319342110456
Paul H. C. Stirling ◽  
Paul J. Jenkins ◽  
Nathan Ng ◽  
Nicholas D. Clement ◽  
Andrew D. Duckworth ◽  

The primary aim of this study was to identify factors associated with nonresponse to routinely collected patient-reported outcome measures (PROMs) after hand surgery. The secondary aim was to investigate the impact of nonresponder bias on postoperative PROMs. We identified 4357 patient episodes for which the patients received pre- and 1-year postoperative questionnaires. The response rate was 55%. Univariate and regression analyses were undertaken to determine factors predicting nonresponse. We developed a predictive model for the postoperative Quick version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores for nonresponders using imputation. Younger age, increasing deprivation, higher comorbidity, worse preoperative QuickDASH scores and unemployment predicted nonresponse. No significant difference in mean postoperative QuickDASH score was observed between the responders, and the scores for the responders combined with the predicted scores for the nonresponders. Preoperative function was the primary predictor of postoperative outcome. These results challenge the dogma that ‘loss to follow-up’ automatically invalidates the results of a study. Level of evidence: III

Karla I Galaviz ◽  
Jonathan A Colasanti ◽  
Ameeta S Kalokhe ◽  
Mohammed K Ali ◽  
Igho Ofotokun ◽  

Abstract Integrating cardiovascular disease (CVD) prevention in routine HIV care remains a challenge. This study aimed to identify factors associated with adherence to guideline-recommended CVD preventive practices among HIV clinicians. Clinicians from eight HIV clinics in Atlanta were invited to complete an online survey. The survey was informed by the Consolidated Framework for Implementation Research and assessed the following: clinician CVD risk screening and advice frequency (never to always), individual characteristics (clinician beliefs, self-efficacy, and motivation), inner setting factors (clinic culture, learning climate, leadership engagement, and resources available), and outer setting factors (peer pressure and patient needs). Bivariate correlations examined associations between these factors and guideline adherence. Thirty-eight clinicians completed the survey (82% women, mean age 42 years, 50% infectious disease physicians). For risk screening, clinicians always check patient blood pressure (median score 7.0/7), while they usually ask about smoking or check their blood glucose (median score 6.0/7). For advice provision, clinicians usually recommend quitting smoking, controlling cholesterol or controlling blood pressure (median score 6.0/7), while they often recommend controlling blood glucose, losing weight, or improving diet/physical activity (median score 5.5/7). Clinician beliefs, motivation and self-efficacy were positively correlated with screening and advice practices (r = .55−.84), while inner setting factors negatively correlated with lifestyle-related screening and advice practices (r = −.51 to −.76). Peer pressure was positively correlated with screening and advice practices (r = .57–.89). Clinician psychosocial characteristics and perceived peer pressure positively influence adherence to guideline-recommended CVD preventive practices. These correlates along with leadership engagement could be targeted with proven implementation strategies.

Ali Coppola ◽  
Sarah Black ◽  
Ruth Endacott

Abstract Background Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity. Design and methods An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings. Results Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable. Conclusion Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.

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