scholarly journals LO29: Unexplained variation in ‘to-go’ opioid prescribing across emergency departments in a large Canadian cohort

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S17
Author(s):  
J. Hayward ◽  
G. Innes
Keyword(s):  
Pain Score ◽  
Multivariable Analysis ◽  
Unintended Consequences ◽  
Administrative Databases ◽  
Opioid Prescribing ◽  
Patient Demographics ◽  
Short Course ◽  
Observational Cohort ◽  
Opioid Medications ◽  
Cardiac Pain

Introduction: Emergency Department (ED) opioid prescribing has been linked to long-term use and dependence. Small packets of opioid medications are sometimes prescribed at discharge, i.e. ‘To-Go’, in an attempt to treat pain but avoid unintended consequences. The extent of this practice and its associated risks are not fully understood. This study's objective was to describe the use of ‘To-Go’ opioids in a large urban center. Methods: Multicenter linked administrative databases were used to recruit an observational cohort. The referral population was comprised of all patients discharged from a Calgary ED in 2016 (four hospitals) with an arrival pain score greater than 0. We first described this population and then performed a multivariable analysis to assess for predictors of ‘To-Go’ opioids. ‘To-Go’ opioids were either Tylenol-Codeine or Tylenol-Oxycodone. Results: A total of 88,855 patients were recruited. The majority were female (57%) and the average age was 44.5 yrs. Abdominal pain was the most frequent complaint (22.1%) followed by extremity (18.3%) and cardiac pain (8.0%). Overall, 2,736 patients (3.1%) received an opioid ‘To-Go’ with significant variation in prescribing rates across hospitals (1.8-5% Chi2 p < 0.05). Logistic regression (covariates: age, sex, CTAS, pain score, type of pain, hospital, ED opioid, length of stay) revealed that receiving an opioid (IV or PO) prior to discharge was the strongest predictor of ‘To-Go’ opioid (OR 6.4 [5.9-7.0]). Hospital (OR 1.4 [1.3-1.4]) and male sex (OR 1.2 [1.1-1.3]) also emerged as predictors, whereas age over 65 decreased the odds of ‘To-Go’ opioid (OR 0.8 [0.6-0.9]). Hospital-specific ORs ranged from 1.3-2.7. Conclusion: In comparable patient populations some hospitals are more likely than others to provide a short course of opioids at discharge. This difference is not explained by patient demographics, pain profiles, or medications prior to discharge. The reasons for this variation are unclear but it underscores the need to determine the risks of ED opioid exposures and develop clear evidence-based prescribing guidelines.

scholarly journals Infections after pediatric ambulatory surgery: Incidence and risk factors

2019 ◽  
Vol 40 (2) ◽  
pp. 150-157 ◽  
Author(s):  
Jeffrey S. Gerber ◽  
Rachael K. Ross ◽  
Julia E. Szymczak ◽  
Rui Xiao ◽  
A. Russell Localio ◽  
...  
Keyword(s):  
Ambulatory Surgery ◽  
Multivariable Analysis ◽  
Surgical Site Infections ◽  
Patient Demographics ◽  
Additional Burden ◽  
Observational Cohort ◽  
Parental Interviews ◽  
Pediatric Healthcare ◽  
Surgery Incidence

AbstractObjectiveTo describe the epidemiology of surgical site infections (SSIs) after pediatric ambulatory surgery.DesignObservational cohort study with 60 days follow-up after surgery.SettingThe study took place in 3 ambulatory surgical facilities (ASFs) and 1 hospital-based facility in a single pediatric healthcare network.ParticipantsChildren <18 years undergoing ambulatory surgery were included in the study. Of 19,777 eligible surgical encounters, 8,502 patients were enrolled.MethodsData were collected through parental interviews and from chart reviews. We assessed 2 outcomes: (1) National Healthcare Safety Network (NHSN)–defined SSI and (2) evidence of possible infection using a definition developed for this study.ResultsWe identified 21 NSHN SSIs for a rate of 2.5 SSIs per 1,000 surgical encounters: 2.9 per 1,000 at the hospital-based facility and 1.6 per 1,000 at the ASFs. After restricting the search to procedures completed at both facilities and adjustment for patient demographics, there was no difference in the risk of NHSN SSI between the 2 types of facilities (odds ratio, 0.7; 95% confidence interval, 0.2–2.3). Within 60 days after surgery, 404 surgical patients had some or strong evidence of possible infection obtained from parental interview and/or chart review (rate, 48 SSIs per 1,000 surgical encounters). Of 306 cases identified through parental interviews, 176 cases (57%) did not have chart documentation. In our multivariable analysis, older age and black race were associated with a reduced risk of possible infection.ConclusionsThe rate of NHSN-defined SSI after pediatric ambulatory surgery was low, although a substantial additional burden of infectious morbidity related to surgery might not have been captured by standard surveillance strategies and definitions.

scholarly journals Prostatic urethral lift (UroLift): a real-world analysis of outcomes using hospital episodes statistics

BMC Urology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Toby Page ◽  
Rajan Veeratterapillay ◽  
Kim Keltie ◽  
Julie Burn ◽  
Andrew Sims
Keyword(s):  
Real World ◽  
Hazard Analysis ◽  
Attendance Rate ◽  
Day Case ◽  
Patient Demographics ◽  
Kaplan Meier ◽  
Accident And Emergency ◽  
Case Surgery ◽  
Observational Cohort ◽  
Rate Requirement

Abstract Background To determine real-world outcomes of prostatic urethral lift (UroLift) procedures conducted in hospitals across England. Methods A retrospective observational cohort was identified from Hospital Episode Statistics data including men undergoing UroLift in hospitals in England between 2017 and 2020. Procedure uptake, patient demographics, inpatient complications, 30-day accident and emergency re-attendance rate, requirement for further treatment and catheterization were captured. Kaplan–Meier and hazard analysis were used to analyse time to re-treatment. Results 2942 index UroLift procedures from 80 hospital trusts were analysed; 85.3% conducted as day-case surgery (admitted to hospital for a planned surgical procedure and returning home on the same day). In-hospital complication rate was 3.4%. 93% of men were catheter-free at 30 days. The acute accident and emergency attendance rate within 30 days was 12.0%. Results of Kaplan Meier analysis for subsequent re-treatment (including additional UroLift and endoscopic intervention) at 1 and 2 years were 5.2% [95% CI 4.2 to 6.1] and 11.9% [10.1 to 13.6] respectively. Conclusions This real-world analysis of UroLift shows that it can be delivered safely in a day-case setting with minimal morbidity. However, hospital resource usage for catheterization and emergency hospital attendance in the first 30 days was substantial, and 12% required re-treatment at 2 years.

scholarly journals Predictors of brain infarction in adult patients on extracorporeal membrane oxygenation: an observational cohort study

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Riccardo Iacobelli ◽  
Alexander Fletcher-Sandersjöö ◽  
Caroline Lindblad ◽  
Boris Keselman ◽  
Eric Peter Thelin ◽  
...  
Keyword(s):  
Cohort Study ◽  
Extracorporeal Membrane Oxygenation ◽  
Brain Infarction ◽  
Multivariable Analysis ◽  
Group Analysis ◽  
Observational Cohort Study ◽  
Adult Patients ◽  
Membrane Oxygenation ◽  
Observational Cohort ◽  
Va Ecmo

AbstractNon-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excluding patients who did not undergo a head CT scan during ECMO treatment. The incidence of BI in adult ECMO patients may be higher than previously believed and is independently associated with VA ECMO mode. Larger prospective trials are warranted to validate these findings and ascertain their clinical significance.

scholarly journals Army and Navy ECHO Pain Telementoring Improves Clinician Opioid Prescribing for Military Patients: an Observational Cohort Study

2018 ◽  
Vol 34 (3) ◽  
pp. 387-395 ◽  
Author(s):  
Joanna G. Katzman ◽  
Clifford R. Qualls ◽  
William A. Satterfield ◽  
Martin Kistin ◽  
Keith Hofmann ◽  
...  
Keyword(s):  
Cohort Study ◽  
Observational Cohort Study ◽  
Opioid Prescribing ◽  
Observational Cohort ◽  
Military Patients

scholarly journals Treatment Duration for Uncomplicated Staphylococcus aureus Bacteremia To Prevent Relapse: Analysis of a Prospective Observational Cohort Study

2012 ◽  
Vol 57 (3) ◽  
pp. 1150-1156 ◽  
Author(s):  
Yong Pil Chong ◽  
Song Mi Moon ◽  
Kyung-Mi Bang ◽  
Hyun Jung Park ◽  
So-Youn Park ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Cohort Study ◽  
Antibiotic Therapy ◽  
Treatment Failure ◽  
Practice Guidelines ◽  
Observational Cohort Study ◽  
Care Hospital ◽  
Prospective Observational Cohort Study ◽  
Short Course ◽  
Observational Cohort

ABSTRACTPractice guidelines recommend at least 14 days of antibiotic therapy for uncomplicatedStaphylococcus aureusbacteremia (SAB). However, these recommendations have not been formally evaluated in clinical studies. To evaluate the duration of therapy for uncomplicated SAB, we analyzed data from our prospective cohort of patients with SAB. A prospective observational cohort study was performed in patients with SAB at a tertiary-care hospital in Korea between August 2008 and September 2010. All adult patients with SAB were prospectively enrolled and observed over a 12-week period. Uncomplicated SAB was defined as follows: negative results of follow-up blood cultures at 2 to 4 days, defervescence within 72 h of therapy, no evidence of metastatic infection, and catheter-related bloodstream infection or primary bacteremia without evidence of endocarditis on echocardiography. Of 483 patients with SAB, 111 met the study criteria for uncomplicated SAB. Fifty-three (47.7%) had methicillin-resistant SAB. When short-course therapy (<14 days) and intermediate-course therapy (≥14 days) were compared, the treatment failure rates (10/38 [26.3%] versus 16/73 [21.9%]) and crude mortality (7/38 [18.4%] versus 16/73 [21.9%]) did not differ significantly between the two groups. However, short-course therapy was significantly associated with relapse (3/38 [7.9%] versus 0/73;P= 0.036). In multivariate analysis, primary bacteremia was associated with a trend toward increased treatment failure (P= 0.06). Therefore, in the treatment of uncomplicated SAB, it seems reasonable to consider at least 14 days of antibiotic therapy to prevent relapse, as practice guidelines recommend. Because of its poor prognosis, primary bacteremia, even with a low risk of complication, should not be treated with short-course therapy.

scholarly journals Shared Decision-Making for Pain Management After Third Molar Extractions in Adolescents: A Qualitative Study

2021 ◽  
Author(s):  
Shannon Mitchell ◽  
Anjali Truitt ◽  
Lauryn Davin ◽  
D. Brad Rindal
Keyword(s):  
Decision Making ◽  
Pain Management ◽  
Shared Decision Making ◽  
Third Molar ◽  
Administrative Databases ◽  
Shared Decision ◽  
Opioid Prescription ◽  
Over The Counter ◽  
Adolescent Patients ◽  
Opioid Medications

Abstract Background: Understanding how adolescent patients and their parents make decisions about pain management after complex dental procedures could help reduce the use of opioid medications in this population. This study explored how adolescent patients and their parents make decisions about pain management after third molar extractions.Methods: Participants were identified from administrative databases based on age (15-17 years) and a dental extraction performed in the last 8 days. Structured interviews were conducted by phone, with interview guides tailored separately to patients and parents. De-identified interview transcripts were analyzed using qualitative analysis software using a directed content analysis approach.Results: A total of 15 patient/parent dyads were interviewed. There was high concordance in terms of shared decision-making and pain management views in this dyadic sample. In addition to conversations with their dentist, most patients and their parents discussed pain management plans that included non-medication options, over-the-counter medications, and opioid medications to be taken as needed. All participants reported that the adolescent received an opioid prescription for post-extraction pain management but most only took it the day of the extraction and up to 2 days following, usually based on the patient’s reported pain levels and perceptions of over-the-counter medication adequacy. Participants said they did not receive guidance from their provider concerning disposal of unused opioid medications. Conclusions: Shared decision-making concerning pain management was common for adolescents and their parents following third molar extractions. Providers may have an opportunity to reduce the number of opioids prescribed, since respondents reported little to no use of opioids that they were prescribed. Providers should educate patients and their parents about safe disposal of opioids to mitigate the potential for diversion.Trial registration: not applicable

scholarly journals Obesity and smoking as risk factors for invasive mechanical ventilation in COVID-19: A retrospective, observational cohort study

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0238552
Author(s):  
Ana C. Monteiro ◽  
Rajat Suri ◽  
Iheanacho O. Emeruwa ◽  
Robert J. Stretch ◽  
Roxana Y. Cortes-Lopez ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Cohort Study ◽  
Smoking Status ◽  
Univariate Analysis ◽  
Invasive Mechanical Ventilation ◽  
Multivariable Analysis ◽  
Observational Cohort Study ◽  
Smoking History ◽  
Observational Cohort ◽  
Retrospective Observational Cohort Study

Purpose To describe the trajectory of respiratory failure in COVID-19 and explore factors associated with risk of invasive mechanical ventilation (IMV). Materials and methods A retrospective, observational cohort study of 112 inpatient adults diagnosed with COVID-19 between March 12 and April 16, 2020. Data were manually extracted from electronic medical records. Multivariable and Univariable regression were used to evaluate association between baseline characteristics, initial serum markers and the outcome of IMV. Results Our cohort had median age of 61 (IQR 45–74) and was 66% male. In-hospital mortality was 6% (7/112). ICU mortality was 12.8% (6/47), and 18% (5/28) for those requiring IMV. Obesity (OR 5.82, CI 1.74–19.48), former (OR 8.06, CI 1.51–43.06) and current smoking status (OR 10.33, CI 1.43–74.67) were associated with IMV after adjusting for age, sex, and high prevalence comorbidities by multivariable analysis. Initial absolute lymphocyte count (OR 0.33, CI 0.11–0.96), procalcitonin (OR 1.27, CI 1.02–1.57), IL-6 (OR 1.17, CI 1.03–1.33), ferritin (OR 1.05, CI 1.005–1.11), LDH (OR 1.57, 95% CI 1.13–2.17) and CRP (OR 1.13, CI 1.06–1.21), were associated with IMV by univariate analysis. Conclusions Obesity, smoking history, and elevated inflammatory markers were associated with increased need for IMV in patients with COVID-19.

scholarly journals Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study

BMJ ◽  
2020 ◽  
pp. m3249 ◽  
Author(s):  
Olivia V Swann ◽  
Karl A Holden ◽  
Lance Turtle ◽  
Louisa Pollock ◽  
Cameron J Fairfield ◽  
...  
Keyword(s):  
Critical Care ◽  
Cohort Study ◽  
Young People ◽  
Clinical Features ◽  
Multivariable Analysis ◽  
Case Definition ◽  
Observational Cohort Study ◽  
Children And Young People ◽  
High Dependency ◽  
Observational Cohort

Abstract Objective To characterise the clinical features of children and young people admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK and explore factors associated with admission to critical care, mortality, and development of multisystem inflammatory syndrome in children and adolescents temporarily related to coronavirus disease 2019 (covid-19) (MIS-C). Design Prospective observational cohort study with rapid data gathering and near real time analysis. Setting 260 hospitals in England, Wales, and Scotland between 17 January and 3 July 2020, with a minimum follow-up time of two weeks (to 17 July 2020). Participants 651 children and young people aged less than 19 years admitted to 138 hospitals and enrolled into the International Severe Acute Respiratory and emergency Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK study with laboratory confirmed SARS-CoV-2. Main outcome measures Admission to critical care (high dependency or intensive care), in-hospital mortality, or meeting the WHO preliminary case definition for MIS-C. Results Median age was 4.6 (interquartile range 0.3-13.7) years, 35% (225/651) were under 12 months old, and 56% (367/650) were male. 57% (330/576) were white, 12% (67/576) South Asian, and 10% (56/576) black. 42% (276/651) had at least one recorded comorbidity. A systemic mucocutaneous-enteric cluster of symptoms was identified, which encompassed the symptoms for the WHO MIS-C criteria. 18% (116/632) of children were admitted to critical care. On multivariable analysis, this was associated with age under 1 month (odds ratio 3.21, 95% confidence interval 1.36 to 7.66; P=0.008), age 10-14 years (3.23, 1.55 to 6.99; P=0.002), and black ethnicity (2.82, 1.41 to 5.57; P=0.003). Six (1%) of 627 patients died in hospital, all of whom had profound comorbidity. 11% (52/456) met the WHO MIS-C criteria, with the first patient developing symptoms in mid-March. Children meeting MIS-C criteria were older (median age 10.7 (8.3-14.1) v 1.6 (0.2-12.9) years; P<0.001) and more likely to be of non-white ethnicity (64% (29/45) v 42% (148/355); P=0.004). Children with MIS-C were five times more likely to be admitted to critical care (73% (38/52) v 15% (62/404); P<0.001). In addition to the WHO criteria, children with MIS-C were more likely to present with fatigue (51% (24/47) v 28% (86/302); P=0.004), headache (34% (16/47) v 10% (26/263); P<0.001), myalgia (34% (15/44) v 8% (21/270); P<0.001), sore throat (30% (14/47) v (12% (34/284); P=0.003), and lymphadenopathy (20% (9/46) v 3% (10/318); P<0.001) and to have a platelet count of less than 150 × 10 9 /L (32% (16/50) v 11% (38/348); P<0.001) than children who did not have MIS-C. No deaths occurred in the MIS-C group. Conclusions Children and young people have less severe acute covid-19 than adults. A systemic mucocutaneous-enteric symptom cluster was also identified in acute cases that shares features with MIS-C. This study provides additional evidence for refining the WHO MIS-C preliminary case definition. Children meeting the MIS-C criteria have different demographic and clinical features depending on whether they have acute SARS-CoV-2 infection (polymerase chain reaction positive) or are post-acute (antibody positive). Study registration ISRCTN66726260.

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