IMPORTANCE The increased risk of hemorrhage associated with anticoagulant therapy following traumatic brain injury creates a serious dilemma for medical management of older patients: Should ...anticoagulant therapy be resumed after traumatic brain injury, and if so, when? OBJECTIVE To estimate the risk of thrombotic and hemorrhagic events associated with warfarin therapy resumption following traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of administrative claims data for Medicare beneficiaries aged at least 65 years hospitalized for traumatic brain injury during 2006 through 2009 who received warfarin in the month prior to injury (n = 10 782). INTERVENTION Warfarin use in each 30-day period following discharge after hospitalization for traumatic brain injury. MAIN OUTCOMES AND MEASURES The primary outcomes were hemorrhagic and thrombotic events following discharge after hospitalization for traumatic brain injury. Hemorrhagic events were defined on inpatient claims using International Classification of Diseases, Ninth Revision, Clinical Modification codes and included hemorrhagic stroke, upper gastrointestinal bleeding, adrenal hemorrhage, and other hemorrhage. Thrombotic events included ischemic stroke, pulmonary embolism, deep venous thrombosis, and myocardial infarction. A composite of hemorrhagic or ischemic stroke was a secondary outcome. RESULTS Medicare beneficiaries with traumatic brain injury were predominantly female (64%) and white (92%), with a mean (SD) age of 81.3 (7.3) years, and 82% had atrial fibrillation. Over the 12 months following hospital discharge, 55% received warfarin during 1 or more 30-day periods. We examined the lagged effect of warfarin use on outcomes in the following period. Warfarin use in the prior period was associated with decreased risk of thrombotic events (relative risk RR, 0.77 95% CI, 0.67-0.88) and increased risk of hemorrhagic events (RR, 1.51 95% CI, 1.29-1.78). Warfarin use in the prior period was associated with decreased risk of hemorrhagic or ischemic stroke (RR, 0.83 95% CI, 0.72-0.96). CONCLUSIONS AND RELEVANCE Results from this study suggest that despite increased risk of hemorrhage, there is a net benefit for most patients receiving anticoagulation therapy, in terms of a reduction in risk of stroke, from warfarin therapy resumption following discharge after hospitalization for traumatic brain injury.
ABSTRACT
The purpose of this study was to compare the prevalence of pressure ulcers among newly hospitalized nursing home residents and among newly hospitalized patients from nonnursing home ...settings. Study participants were at least 65 years old and admitted through the emergency department to one of two study hospitals. Research nurses ascertained the presence of pressure ulcers (stage 1–4) by visual skin assessment on the third day following admission to the hospital unit. Other data were collected by clinical examination, interview, and medical record review. The prevalence of preexisting pressure ulcers at the time of admission was 26.2% among those admitted from a nursing home and 4.8% among those admitted from another living situation (odds ratio 5.5, 95% confidence interval 4.3–7.1). After adjustment for confounders, the association between admission from a nursing home and pressure ulcer prevalence on admission was reduced (odds ratio 1.51, 95% confidence interval 1.03–2.23). These results indicate that admission from a nursing home is a potent marker for pressure ulcer risk and that the excess risk is largely mediated by the higher prevalence of pressure ulcer risk factors among patients admitted from a nursing home. The results highlight the importance of continuity of care across transitions between care settings.
Quasi-experimental study designs, sometimes called nonrandomized, pre-post-intervention study designs, are ubiquitous in the infectious diseases literature, particularly in the area of interventions ...aimed at decreasing the spread of antibiotic-resistant bacteria. Little has been written about the benefits and limitations of the quasi-experimental approach. This article outlines a hierarchy of quasi-experimental study design that is applicable to infectious diseases studies and that, if applied, may lead to sounder research and more-convincing causal links between infectious diseases interventions and outcomes.
Objectives: To compare rates of falling between nursing home residents with and without dementia and to examine dementia as an independent risk factor for falls and fall injuries.
Design: Prospective ...cohort study with 2 years of follow‐up.
Setting: Fifty‐nine randomly selected nursing homes in Maryland, stratified by geographic region and facility size.
Participants: Two thousand fifteen newly admitted residents aged 65 and older.
Measurements: During 2 years after nursing home admission, fall data were collected from nursing home charts and hospital discharge summaries.
Results: The unadjusted fall rate for residents in the nursing home with dementia was 4.05 per year, compared with 2.33 falls per year for residents without dementia (P<.0001). The effect of dementia on the rate of falling persisted when known risk factors were taken into account. Among fall events, those occurring to residents with dementia were no more likely to result in injury than falls of residents without dementia, but, given the markedly higher rates of falling by residents with dementia, their rate of injurious falls was higher than for residents without dementia.
Conclusion: Dementia is an independent risk factor for falling. Although most falls do not result in injury, the fact that residents with dementia fall more often than their counterparts without dementia leaves them with a higher overall risk of sustaining injurious falls over time. Nursing home residents with dementia should be considered important candidates for fall‐prevention and fall‐injury‐prevention strategies.
ABSTRACT
Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between ...repositioning and pressure ulcer incidence among bed‐bound elderly hip fracture patients, using data from a 2004–2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥65 years, underwent hip fracture surgery, and were bed‐bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person‐day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5–2.4). No association was found between frequent repositioning of bed‐bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.
Defining long‐term outcomes in chronic inflammatory demyelinating polyneuropathy (CIDP) has been complicated by varying definitions of treatment response and differing scales measuring impairment or ...disability. An expert panel was convened to devise a CIDP Disease Activity Status (CDAS) and to classify long‐term outcome by applying it to 106 patients with a consensus diagnosis of CIDP. Sixty of these cases were graded blindly by three independent reviewers to assess inter‐rater reliability. The mean duration of follow‐up was 6.4 years (range, 3 months–23 years). Eleven percent of patients were classified as cured (stable examination and off treatment for ≥5 years), 20% were in remission (stable and off treatment for <5 years), 44% had stable active disease but required ongoing therapy for at least 1 year, 7% were improving after recent initiation of therapy, and 18% had unstable active disease (treatment naïve or treatment refractory). Excellent inter‐rater reliability was observed (kappa scores: 0.93–0.97; p < 0.0001). The CDAS is considered a simple and reproducible tool to classify patients with CIDP according to disease activity and treatment status that can be applied easily in practice and potentially to select patients for clinical trials.
ABSTRACT
The purpose of this study was to evaluate the validity of digital photographs for the assessment of the presence of pressure ulcers stage 2 or higher. Participants were 48 patients (28 white ...and 20 black) with pressure ulcers identified in the course of a wound specialist's routine clinical practice at the University of Maryland Medical Center. One pressure ulcer and one unaffected skin area were photographed on each participating patient. The gold standard diagnosis (stage 2 pressure ulcer vs. stage 1 or no pressure ulcer) was recorded by the wound specialist based on bedside examination. The photographs were reviewed blindly by another wound expert. The sensitivity of the blinded assessment was 97% (95% confidence interval CI 91–100%). The specificity was 97% (95% CI 92–100%). The sensitivity and specificity were both 100% in the white patients. In black patients, the sensitivity and specificity were 92% (95% CI 75–100%) and 93% (95% CI 82–100%), respectively. These results suggest that the use of photographic images to assess the presence or absence of a pressure ulcer stage 2 or higher has a high degree of validity. Since blinded outcome assessment is one of the cornerstones of good clinical trial design, photography offers the potential to strengthen future studies.
Objective To evaluate the hypothesis that cytokine levels are associated with miscarriage risk using serum samples collected before report of miscarriage. Design A nested case-control study. Setting ...Biospecimens from the multisite Collaborative Perinatal Project, University of Florida, laboratory assessment of interleukin (IL)-1 receptor antagonist, IL-1β, IL-4, IL-6, interferon (IFN)-γ, tumor necrosis factor (TNF)-α, thrombopoietin (TPO), and granulocyte colony-stimulating factor (G-CSF). Patient(s) Cases of miscarriage (n = 439) were matched to controls (n = 373) by gestational age at sample collection. Intervention(s) None. Main Outcome Measure(s) Miscarriage. Result(s) Increased risk of miscarriage was associated with elevated TPO (adjusted odds ratio OR 1.16, 95% confidence interval CI 1.00–1.36) and decreased G-CSF (adjusted OR 0.78, 95% CI 0.64–0.95). When analysis was restricted to samples collected more than 35 days before miscarriage, the effect of G-CSF was not observed (adjusted OR 0.96, 95% CI 0.72–1.28), whereas increased risk related to higher TPO remained. Conclusion(s) Circulating levels of TPO may be associated with increased risk of miscarriage.
Objective:
To determine factors associated with increased risk of developing cardiovascular disease in a high-risk patient population.
Design:
Cross-sectional analysis of a retrospective cohort ...study.
Methods:
One-hundred patients at an inner city HIV clinic in 2008 were reviewed. The atherosclerotic vascular disease risk score was calculated using the Pooled Cohort Equation. Chi-square test was performed to identify associations of potential risk factors with elevated atherosclerotic vascular disease risk.
Results:
Eighty-one participants were included in the final analysis. In total, 95.1% were African American, and 38.3% were women. The median atherosclerotic vascular disease risk score was 8.8% and 8.1% in 2008 and 2012, respectively. The medical co-morbidities associated with increased atherosclerotic vascular disease risk were hepatitis C infection (X2 = 3.93; p value = 0.048), elevated triglycerides levels (X2 = 4.0; p value = 0.046), and low albumin (X2 = 4.65; p value = 0.031). There were a higher number of women with known atherosclerotic vascular disease despite lower median atherosclerotic vascular disease risk score compared to men.
Conclusion:
An elevated risk of developing cardiovascular disease persists in high-risk demographic groups of the HIV epidemic even in the current HIV era. There is an unexplained gender disparity and some non-traditional risk factors not accounted for in the Pooled Cohort Equation may be contributing to the excess cardiovascular disease risk observed among HIV-infected patients.
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