Internal and emergency medicine
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Observational Study
Variation in opioid prescribing patterns between ED providers.
Abuse of opioid prescription drugs has become an epidemic across the developed world. Despite the fact that emergency physicians overall account for a small proportion of total opioids prescribed, the number of prescriptions has risen dramatically in the past decade and, to some degree, contributes to the available supply of opioids in the community, some of which are diverted for non-medical use. Since successfully reducing opioid prescribing on the individual level first requires knowledge of current prescribing patterns, we sought to determine to what extent variation exists in opioid prescribing patterns at our institution. ⋯ There was a variation on the individual provider level, with rates ranging from 33 per to 332 per 1000 visits. There was also substantial variation by provider in the number of pills written per prescription with coefficient of variation (standard deviation divided by mean) averaged over different opioids ranging from 16 to 40 %. There was significant variation in opioid prescribing patterns at the individual physician level, even when accounting for the number of patients seen.
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Observational Study
Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department.
Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. ⋯ In the multivariate logistic regression analysis the use of AP OX was associated with a reduced odds of desaturation (aOR 0.13; 95 % CI 0.03-0.53). Patients with ICH who received AP OX during RSI in the ED were seven times less likely to have an oxygen saturation of <90 % during the intubation compared to patients who did not receive AP OX. AP OX is a simple intervention that may minimize the risk of oxygen desaturation during the RSI of patients with ICH.
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Currently available anticoagulants have limitations for long-term treatment of venous thromboembolism (VTE). We have evaluated the efficacy and safety of direct oral anticoagulants (DOACs) for extended treatment of VTE. Four randomized controlled trials (RCTs) comparing DOACs (apixaban, rivaroxaban, and dabigatran) with placebo or warfarin for extended treatment of VTE were published. ⋯ Risk of major bleeding is not different with DOACs compared to placebo/warfarin. However, DOACs are associated with a significantly higher rate of the composite of major and clinically relevant bleeding compared to placebo. In conclusion, DOACs are effective and safe for the extended treatment of VTE, and may reduce the risk of all-cause mortality.
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Portal vein thrombosis (PVT) dramatically changes the prognosis of cirrhotic patients, especially those waiting for liver transplantation. However, the possible contribution to PVT of von Willebrand factor (VWF) and ADAMTS-13 is poorly documented. The aim of our study was to assess the presence of alterations of VWF and ADAMTS-13 serum levels in cirrhotic patients with PVT. ⋯ No correlation was found between the Child-Pugh score and ADAMTS-13 activity. In multivariable logistic regression analysis performed on data concerning both group PVT and without PVT, only the ADAMTS-13 activity (p = 0.007) was independently and inversely associated with PVT. In conclusion, ADAMTS-13 activity is independently associated with PVT in cirrhotic patients.