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Vanstone MG, Krewulak K, Taneja S, Swinton M, Fiest K, Burns KEA, Debigare S, Dionne JC, Guyatt G, Marshall JC, Muscedere JG, Deane AM, Finfer S, Myburgh JA, Gouskos A, Rochwerg B, Ball I, Mele T, Niven DJ, English SW, Verhovsek M, Cook DJ. Patient-important upper gastrointestinal bleeding in the ICU: A mixed-methods study of patient and family perspectives. J Crit Care 2024; 81:154761. [PMID: 38447306 DOI: 10.1016/j.jcrc.2024.154761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION The objective of this study was to create a definition of patient-important upper gastrointestinal bleeding during critical illness as an outcome for a randomized trial. DESIGN This was a sequential mixed-methods qualitative-dominant multi-center study with an instrument-building aim. In semi-structured individual interviews or focus groups we elicited views from survivors of critical illness and family members of patients in the intensive care unit (ICU) regarding which features indicate important gastrointestinal bleeding. Quantitative demographic characteristics were collected. We analyzed qualitative data using inductive content analysis to develop a definition for patient-important upper gastrointestinal bleeding. SETTING Canada and the United States. PARTICIPANTS 51 ICU survivors and family members of ICU patients. RESULTS Participants considered gastrointestinal bleeding to be important if it resulted in death, disability, or prolonged hospitalization. The following also signaled patient-important upper gastrointestinal bleeding: blood transfusion, vasopressors, endoscopy, CT-angiography, or surgery. Whether an intervention evinced concern depended on its effectiveness, side-effects, invasiveness and accessibility; contextual influences included participant familiarity and knowledge of interventions and trust in the clinical team. CONCLUSIONS Survivors of critical illness and family members described patient-important upper gastrointestinal bleeding differently than current definitions of clinically-important upper gastrointestinal bleeding.
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Affiliation(s)
- Meredith G Vanstone
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karla Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shipra Taneja
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sylvie Debigare
- Patient and Family Partnership Committee, Commission Scolaire Central Québec, Canadian Critical Care Trials Group, Canada
| | - Joanna C Dionne
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada; Department of Surgery, Unity Health Toronto, University of Toronto, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center
| | - Adam M Deane
- Department of Critical Care, University of Melbourne, Melbourne Medical School, Victoria, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; The George Institute for Global Health, School of Public Health, Imperial College London, London, England, United Kingdom
| | - John A Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee representative, FAST-NAWC Trial, University of Toronto, Canada
| | - Bram Rochwerg
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, Ontario, Canada.; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Tina Mele
- Department of Critical Care Medicine, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Madeleine Verhovsek
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, St. Joseph's Healthcare Hamilton.
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Chen Z, Lin W, Zhang F, Cao W. Risk Factors and Prognosis Analysis of Upper Gastrointestinal Bleeding in Patients With Acute Severe Cerebral Stroke. J Clin Gastroenterol 2024; 58:440-446. [PMID: 37341702 PMCID: PMC10994183 DOI: 10.1097/mcg.0000000000001877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/22/2023] [Indexed: 06/22/2023]
Abstract
GOALS We aim to explore the relationship between the use of proton pump inhibitors (PPIs) and upper gastrointestinal bleeding (UGIB). We develop a nomogram model to predict mortality in critically ill stroke patients. STUDY This is a retrospective study based on the MIMIC IV database. We extracted clinical information including demographic data, comorbidities, and laboratory indicators. Univariate and multivariable logistic regressions were used to assess and identify risk factors for the occurrence of UGIB and for the in-hospital mortality of critically ill stroke patients. The resulting model was used to construct a nomogram for predicting in-hospital mortality. RESULTS Five thousand seven hundred sixteen patients from the MIMIC-IV database were included in our analysis. UGIB occurred in 109 patients (1.9%), whereas the PPI use rate was as high as 60.6%. Chronic liver disease, sepsis, shock, anemia, and increased level of urea nitrogen were independent risk factors for the occurrence of UGIB in severe stroke patients. We identified age, heart failure, shock, coagulopathy, mechanical ventilation, continuous renal replacement therapy, antiplatelet drugs, anticoagulation, simplified acute physiology score-II, and Glasgow coma score as independent risk factors for in-hospital mortality in severe stroke patients. The C-index for the final nomograms was 0.852 (95% confidence interval: 0.840, 0.864). CONCLUSIONS We found that the overall rate of UGIB in severe stroke patients is low, whereas the rate of PPI usage is high. In our study, PPI was not identified as a risk factor for the occurrence of UGIB and UGIB was not associated with all-cause mortality. More clinical trials are needed to evaluate the benefits of using PPI in critically ill stroke patients.
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Wang Y, Heels-Ansdell D, Ge L, Parpia S, Ibrahim Q, Cook D, Deane A, Lauzier F, Hammond N, Møller MH, Krag M, Perner A, Guyatt GH. Proton pump inhibitors for gastrointestinal bleeding prophylaxis in critically ill patients: A systematic review protocol. Acta Anaesthesiol Scand 2024. [PMID: 38581102 DOI: 10.1111/aas.14426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for preventing upper gastrointestinal bleeding in critically ill patients. However, concerns have arisen about the possible harms of using PPIs, including potentially increased risk of pneumonia, Clostridioides difficile infection, and more seriously, an increased risk of death in the most severely ill patients. Triggered by the REVISE trial, which is a forthcoming large randomized trial comparing pantoprazole to placebo in invasively mechanically ventilated patients, we will conduct this systematic review to evaluate the efficacy and safety of PPIs versus no prophylaxis for critically ill patients. METHODS We will systematically search randomized trials that compared gastrointestinal bleeding prophylaxis with PPIs versus placebo or no prophylaxis in adults in the intensive care unit (ICU). Pairs of reviewers will independently screen the literature, and for those eligible trials, extract data and assess risk of bias. We will perform meta-analyses using a random-effects model, and calculate relative risks for dichotomous outcomes and mean differences for continuous outcomes, and the associated 95% confidence intervals. We will conduct subgroup analysis to explore whether the impact of PPIs on mortality differs in more and less severely ill patients. We will assess certainty of evidence using the GRADE approach. DISCUSSION This systematic review will provide the most up-to-date evidence regarding the merits and limitations of stress ulcer prophylaxis with PPIs in critically ill patients in contemporary practice.
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Francois Lauzier
- Population Health and Optimal Health Practice Research Unit (Trauma-Emergency-Critical Care Medicine) CHU de Québec-Université Laval Research Centre, Québec City, Québec, Canada
- Department of Medicine, Anesthesiology and Critical Care, Université Laval, Québec, Québec, Canada
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Morten H Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mette Krag
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Granholm A, Lange T, Harhay MO, Jensen AKG, Perner A, Møller MH, Kaas-Hansen BS. Effects of duration of follow-up and lag in data collection on the performance of adaptive clinical trials. Pharm Stat 2024; 23:138-150. [PMID: 37837271 PMCID: PMC10935606 DOI: 10.1002/pst.2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/07/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023]
Abstract
Different combined outcome-data lags (follow-up durations plus data-collection lags) may affect the performance of adaptive clinical trial designs. We assessed the influence of different outcome-data lags (0-105 days) on the performance of various multi-stage, adaptive trial designs (2/4 arms, with/without a common control, fixed/response-adaptive randomisation) with undesirable binary outcomes according to different inclusion rates (3.33/6.67/10 patients/day) under scenarios with no, small, and large differences. Simulations were conducted under a Bayesian framework, with constant stopping thresholds for superiority/inferiority calibrated to keep type-1 error rates at approximately 5%. We assessed multiple performance metrics, including mean sample sizes, event counts/probabilities, probabilities of conclusiveness, root mean squared errors (RMSEs) of the estimated effect in the selected arms, and RMSEs between the analyses at the time of stopping and the final analyses including data from all randomised patients. Performance metrics generally deteriorated when the proportions of randomised patients with available data were smaller due to longer outcome-data lags or faster inclusion, that is, mean sample sizes, event counts/probabilities, and RMSEs were larger, while the probabilities of conclusiveness were lower. Performance metric impairments with outcome-data lags ≤45 days were relatively smaller compared to those occurring with ≥60 days of lag. For most metrics, the effects of different outcome-data lags and lower proportions of randomised patients with available data were larger than those of different design choices, for example, the use of fixed versus response-adaptive randomisation. Increased outcome-data lag substantially affected the performance of adaptive trial designs. Trialists should consider the effects of outcome-data lags when planning adaptive trials.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
| | - Michael O. Harhay
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative
and Advanced Illness Research) Center, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, USA
- Department of Biostatistics, Epidemiology, and Informatics,
Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
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Cheng J, Cai LY, Tang QQ. Pathogenic mechanism and preventive and therapeutic strategies for secondary stress ulcers in patients with moderate to severe traumatic brain injury. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:97-101. [DOI: 10.11569/wcjd.v32.i2.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
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Fischbach W, Bornschein J, Hoffmann JC, Koletzko S, Link A, Macke L, Malfertheiner P, Schütte K, Selgrad DM, Suerbaum S, Schulz C. Update S2k-Guideline Helicobacter pylori and gastroduodenal ulcer disease of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:261-321. [PMID: 38364851 DOI: 10.1055/a-2181-2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
| | - Jan Bornschein
- Translational Gastroenterology Unit John, John Radcliffe Hospital Oxford University Hospitals, Oxford, United Kingdom
| | - Jörg C Hoffmann
- Medizinische Klinik I, St. Marien- und St. Annastiftskrankenhaus, Ludwigshafen, Deutschland
| | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum Munich, Munich, Deutschland
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Alexander Link
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lukas Macke
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Dieter-Michael Selgrad
- Medizinische Klinik Gastroenterologie und Onkologie, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Deutschland
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Sebastian Suerbaum
- Universität Munich, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Deutschland
- Nationales Referenzzentrum Helicobacter pylori, Pettenkoferstr. 9a, 80336 Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Christian Schulz
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
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Battaglini D, De Rosa S, Godoy DA. Crosstalk Between the Nervous System and Systemic Organs in Acute Brain Injury. Neurocrit Care 2024; 40:337-348. [PMID: 37081275 DOI: 10.1007/s12028-023-01725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
Organ crosstalk is a complex biological communication between distal organs mediated via cellular, soluble, and neurohormonal actions, based on a two-way pathway. The communication between the central nervous system and peripheral organs involves nerves, endocrine, and immunity systems as well as the emotional and cognitive centers of the brain. Particularly, acute brain injury is complicated by neuroinflammation and neurodegeneration causing multiorgan inflammation, microbial dysbiosis, gastrointestinal dysfunction and dysmotility, liver dysfunction, acute kidney injury, and cardiac dysfunction. Organ crosstalk has become increasingly popular, although the information is still limited. The present narrative review provides an update on the crosstalk between the nervous system and systemic organs after acute brain injury. Future research might help to target this pathophysiological process, preventing the progression toward multiorgan dysfunction in critically ill patients with brain injury.
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Affiliation(s)
- Denise Battaglini
- Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy.
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Casal GL, Bittner EA. Pump the Breaks on the Slide to Harm From Nonindicated Proton Pump Inhibitors After Critical Illness! Crit Care Med 2024; 52:334-337. [PMID: 38240512 DOI: 10.1097/ccm.0000000000006126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
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Gonzalez D, Dahiya G, Mutirangura P, Ergando T, Mello G, Singh R, Bentho O, Elliott AM. Post Cardiac Arrest Care in the Cardiac Intensive Care Unit. Curr Cardiol Rep 2024; 26:35-49. [PMID: 38214836 DOI: 10.1007/s11886-023-02015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. RECENT FINDINGS Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes.
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Affiliation(s)
- Daniel Gonzalez
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Garima Dahiya
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, USA
| | | | | | - Gregory Mello
- University of Minnesota Medical School, Minneapolis, USA
| | - Rahul Singh
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Oladi Bentho
- Department of Neurology, University of Minnesota, Minneapolis, USA
| | - Andrea M Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA.
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Palmowski L, von Busch A, Unterberg M, Bergmann L, Schmitz S, Schlüter A, Peters J, Adamzik M, Rahmel T. Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study. Crit Care Med 2024; 52:190-199. [PMID: 38240505 PMCID: PMC10793775 DOI: 10.1097/ccm.0000000000006104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVE Proton pump inhibitors (PPIs) are among the drugs most commonly used in critically ill patients. Although mainly applied temporarily for stress ulcer prophylaxis, their application is frequently not terminated. Potential adverse effects of PPI treatment could impact the outcome in case of unnecessary and, therefore, avoidable long-term continuation. We tested the hypotheses that nonindicated PPI therapy continued beyond hospital discharge is associated with increased morbidity, rehospitalization rate, and mortality. DESIGN Nationwide retrospective cohort study considering critically ill patients treated on German ICUs between January, 2017, and December, 2018 with a 2-year follow-up. SETTING A total of 591,207 patient datasets of a German healthcare insurer were screened. PATIENTS We identified 11,576 ICU patients who received PPI therapy for the first time during their index ICU stay without having an indication for its continuation. INTERVENTIONS The cohort was stratified into two groups: 1) patients without further PPI therapy and 2) patients with continuation of PPI therapy beyond 8 weeks after hospital discharge. MEASUREMENTS AND MAIN RESULTS Frequency of predescribed adverse events associated with PPI therapy, 1-year rehospitalization rate, and 2-year mortality were determined. The proportion of patients with continued PPI therapy without an objectifiable indication was 41.7% (4,825 of 11,576 patients). These patients had a 27% greater risk of pneumonia (odds ratio [OR] 1.27; 95% CI, 1.15-1.39; p < 0.001) and a 17% greater risk of cardiovascular events (OR 1.17; 95% CI, 1.08-1.26; p < 0.001). Continued PPI therapy was associated with a 34% greater risk of rehospitalization (OR 1.34; 95% CI, 1.23-1.47) and a nearly 20% greater 2-year mortality risk (hazard ratio 1.17; 95% CI, 1.08-1.27; p = 0.006). CONCLUSIONS These data demonstrate that an unnecessary continuation of PPI therapy after hospital discharge may significantly impact morbidity and mortality. To avoid potentially harmful overuse of a PPIs, intensivists should ensure timely cessation of a temporarily indicated PPI therapy.
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Affiliation(s)
- Lars Palmowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Alexander von Busch
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Matthias Unterberg
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Lars Bergmann
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Stefanie Schmitz
- Abteilung I - Kranken und Pflegeversicherung, Knappschaft, Bochum, Germany
| | - Andreas Schlüter
- Hauptverwaltung, Knappschaft Kliniken GmbH, Recklinghausen, Germany
| | | | - Michael Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tim Rahmel
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
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Jiang FF, Guo Y, Zhang Z, Yin SJ, Fan YX, Huang YH, Li YJ, Chen LR, Qian K, He GH. The benefit of omeprazole exposure on all-cause mortality and length of ICU/hospital stay might vary with age in critically ill pediatric patients: A cohort study. Eur J Clin Pharmacol 2024; 80:115-125. [PMID: 37932381 DOI: 10.1007/s00228-023-03588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE To investigate the association between proton pump inhibitors (PPIs) administration during hospitalization and mortality and length of stay in critically ill pediatric patients. MATERIALS AND METHODS This is a retrospective observational cohort study on pediatric ICU patients (0 to 18 years). Propensity score matching (PSM), Kaplan-Meier curves, Cox proportional hazards model and Linear regression model was applied for assessing the effects of PPIs on mortality and other outcomes during hospitalization. RESULTS A total of 2269 pediatric ICU patients were included, involving 1378 omeprazole (OME) users and 891 non-OME users. The results showed significant association between OME exposure and decreased ICU stay (β -0.042; 95% CI -0.073--0.011; P = 0.008) but prolonged non-ICU hospital stay (β 0.121; 95% CI 0.097-0.155; P = 0.040). No statistical significance was observed between OME exposure and reduced mortality, but the OME group had a slightly decreased tendency in 28-day mortality (HR 0.701; 95% CI 0.418-1.176) and in-hospital mortality (HR 0.726; 95% CI 0.419-1.257). Furthermore, subgroup analyses revealed that the decreased tendency of mortality were more obvious in patients less than 1 year old compared with older pediatric patients, although not statistically significant. In addition, we also observed that OME exposure was significantly associated with reduced mortality of general ICU subgroup. CONCLUSIONS This study provided a sign that PPIs used only in the ICU, rather than throughout hospital stay, might provide more benefit for critically ill pediatric patients. Additionally, younger pediatric patients might gain relatively more benefit than older children when receiving PPIs.
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Affiliation(s)
- Fang-Fang Jiang
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Yu Guo
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Zheng Zhang
- Medical Engineering Section, The 306th Hospital of PLA, Beijing, China
| | - Sun-Jun Yin
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
| | - Yu-Xin Fan
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Yan-Hua Huang
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Ya-Jia Li
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Li-Rong Chen
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Kai Qian
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China
- Dali University, Dali, 671000, China
| | - Gong-Hao He
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force, 212 Daguan Rd, Kunming, 650032, China.
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Schmoch T, Weigand MA, Brenner T. [Guideline-conform treatment of sepsis]. DIE ANAESTHESIOLOGIE 2024; 73:4-16. [PMID: 37950017 DOI: 10.1007/s00101-023-01354-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/12/2023]
Abstract
The time to administration of broad-spectrum antibiotics and (secondarily) to the initiation of hemodynamic stabilization are the most important factors influencing survival of patients with sepsis and septic shock; however, the basic prerequisite for the initiation of an adequate treatment is that a suspected diagnosis of sepsis is made first. Therefore, the treatment of sepsis, even before it has begun, is an interdisciplinary and interprofessional task. This article provides an overview of the current state of the art in sepsis treatment and points towards new evidence that has the potential to change guideline recommendations in the coming years. In summary, the following points are critical: (1) sepsis must be diagnosed as soon as possible and the implementation of a source control intervention (in case of a controllable source) has to be implemented as soon as (logistically) possible. (2) In general, intravenous broad-spectrum antibiotics should be given within the first hour after diagnosis if sepsis or septic shock is suspected. In organ dysfunction without shock, where sepsis is a possible but unlikely cause, the results of focused advanced diagnostics should be awaited before a decision to give broad-spectrum antibiotics is made. If it is not clear within 3 h whether sepsis is the cause, broad-spectrum antibiotics should be given when in doubt. Administer beta-lactam antibiotics as a prolonged (or if therapeutic drug monitoring is available, continuous) infusion after an initial loading dose. (3) Combination treatment with two agents for one pathogen group should remain the exception (e.g. multidrug-resistant gram-negative pathogens). (4) In the case of doubt, the duration of anti-infective treatment should rather be shorter than longer. Procalcitonin can support the clinical decision to stop (not to start!) antibiotic treatment! (5) For fluid treatment, if hypoperfusion is present, the first (approximately) 2L (30 ml/kg BW) of crystalloid solution is usually safe and indicated. After that, the rule is: less is more! Any further fluid administration should be carefully weighed up with the help of dynamic parameters, the patient's clinical condition and echo(cardio)graphy.
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Affiliation(s)
- Thomas Schmoch
- Klinik für Anästhesiologie und Intensivmedizin, Hôpitaux Robert Schuman, Hôpital Kirchberg, 9 , rue Edward Steichen, 2540, Luxemburg, Luxemburg.
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
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13
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Wichmann S, Lange T, Perner A, Gluud C, Itenov TS, Berthelsen RE, Nebrich L, Wiis J, Brøchner AC, Nielsen LG, Behzadi MT, Damgaard K, Andreasen AS, Strand K, Järvisalo M, Strøm T, Eschen CT, Vang ML, Hildebrandt T, Andersen FH, Sigurdsson MI, Thomar KM, Thygesen SK, Troelsen TT, Uusalo P, Jalkanen V, Illum D, Sølling C, Keus F, Pfortmueller CA, Wahlin RR, Ostermann M, Aneman A, Bestle MH. Furosemide versus placebo for fluid overload in intensive care patients-The randomised GODIF trial second version: Statistical analysis plan. Acta Anaesthesiol Scand 2024; 68:130-136. [PMID: 37691474 DOI: 10.1111/aas.14320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Fluid overload is associated with increased mortality in intensive care unit (ICU) patients. The GODIF trial aims to assess the benefits and harms of fluid removal with furosemide versus placebo in stable adult patients with moderate to severe fluid overload in the ICU. This article describes the detailed statistical analysis plan for the primary results of the second version of the GODIF trial. METHODS The GODIF trial is an international, multi-centre, randomised, stratified, blinded, parallel-group, pragmatic clinical trial, allocating 1000 adult ICU patients with moderate to severe fluid overload 1:1 to furosemide versus placebo. The primary outcome is days alive and out of hospital within 90 days post-randomisation. With a power of 90% and an alpha level of 5%, we may reject or detect an improvement of 8%. The primary analyses of all outcomes will be performed in the intention-to-treat population. For the primary outcome, the Kryger Jensen and Lange method will be used to compare the two treatment groups adjusted for stratification variables supplemented with sensitivity analyses in the per-protocol population and with further adjustments for prognostic variables. Secondary outcomes will be analysed with multiple linear regressions, logistic regressions or the Kryger Jensen and Lange method as suitable with adjustment for stratification variables. CONCLUSION The GODIF trial data will increase the certainty about the effects of fluid removal using furosemide in adult ICU patients with fluid overload. TRIAL REGISTRATIONS EudraCT identifier: 2019-004292-40 and ClinicalTrials.org: NCT04180397.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- The Faculty of Health Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Theis S Itenov
- Department of Anaesthesia, Copenhagen University Hospital-Bispebjerg, Copenhagen, Denmark
| | - Rasmus E Berthelsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Nebrich
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Jørgen Wiis
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
| | - Louise G Nielsen
- Department of Intensive Care, Odense University Hospital, Odense, Denmark
| | - Meike T Behzadi
- Department of Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kjeld Damgaard
- Department of Anaesthesia and Intensive Care, Regionshospital Nordjylland, Hjoerring, Denmark
| | - Anne S Andreasen
- Department of Intensive Care, Copenhagen University Hospital-Herlev, Herlev, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Mikko Järvisalo
- Department of Internal Medicine, Kanta-Häme Central Hospital, Hameenlinna, Finland
| | - Thomas Strøm
- Department of Anaesthesia and Intensive Care, Sygehus Soenderjylland, Aabenraa, Denmark
| | - Camilla T Eschen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Gentofte Hospital, Gentofte, Denmark
| | - Marianne L Vang
- Department of Intensive Care, Regionshospitalet Randers, Randers, Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Finn H Andersen
- Department of Intensive Care, Aalesund Hospital, Moere and Romsdal Health Trust, Aalesund, Norway
- Faculty of Medicine and Health Science, Department of Health Science, Norwegian University of Science and Technology, Aalesund, Norway
| | - Martin I Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Katrin M Thomar
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland
| | - Sandra K Thygesen
- Department of Anaesthesia and Intensive Care, Regionshospitalet Goedstrup, Herning, Denmark
| | - Thomas T Troelsen
- Department of Anaesthesia and Intensive Care, Regionshospitalet Goedstrup, Herning, Denmark
| | - Panu Uusalo
- Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Ville Jalkanen
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Dorte Illum
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Rebecka R Wahlin
- Department of Anaesthesia and Intensive Care, Sodersjukhuset AB, Stockholm, Sweden
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St. Thomas' Hospital, London, UK
| | - Anders Aneman
- Department of Intensive Care, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Khokher W, Kesireddy N, Iftikhar S, Beran A, Abuhelwa Z, Malhas SE, Saif T, Rashid R, Ali H, Malik A, Assaly R. Clinically Significant Gastrointestinal Bleeding Using Proton Pump Inhibitors or Histamine Type-2 Receptor Antagonists in Patients Intubated for over 48 Hours: A Systematic Review and Meta-Analysis. Am J Ther 2024; 31:e62-e66. [PMID: 35703440 DOI: 10.1097/mjt.0000000000001514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Waleed Khokher
- Department of Internal Medicine, University of Toledo Internal Medicine, Toledo, OH
| | - Nithin Kesireddy
- Department of Internal Medicine, University of Toledo Internal Medicine, Toledo, OH
| | - Saffa Iftikhar
- Department of Internal Medicine, University of Toledo Internal Medicine, Toledo, OH
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo Internal Medicine, Toledo, OH
| | - Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo Internal Medicine, Toledo, OH
| | - Saif-Eddin Malhas
- Department of Internal Medicine, University of Toledo Internal Medicine, Toledo, OH
| | - Talha Saif
- Department of Anesthesiology, University of Toledo Anesthesiology, Toledo, OH
| | - Rakin Rashid
- Department of Internal Medicine, Trinity Health-Mercy Catholic Medical Center, Darby, PA
| | - Hyder Ali
- Department of Internal Medicine, Rosalind Franklin University- McHenry Hospital, McHenry, IL
| | - Ahmad Malik
- Department of Medicine, Ross University School of Medicine, Bridgetown, Barbados and
| | - Ragheb Assaly
- Department of Pulmonary and Critical Care Medicine, University of Toledo Pulmonary and Critical Care Medicine, Toledo, OH
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15
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Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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16
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Leng ZY, Wang JH, Gao L, Shi K, Hua HB. Efficacy of pantoprazole plus perforation repair for peptic ulcer and its effect on the stress response. World J Gastrointest Surg 2023; 15:2757-2764. [PMID: 38222001 PMCID: PMC10784820 DOI: 10.4240/wjgs.v15.i12.2757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 11/25/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Peptic ulcer (PU) is an abnormal phenomenon in which there is rupture of the mucosa of the digestive tract, which not only affects patients' normal life but also causes an economic burden due to its high medical costs. AIM To investigate the efficacy of pantoprazole (PPZ) plus perforation repair in patients with PU and its effect on the stress response. METHODS The study subjects were 108 PU patients admitted between July 2018 and July 2022, including 58 patients receiving PPZ plus perforation repair [research group (RG)] and 50 patients given simple perforation repair [control group (CG)]. The efficacy, somatostatin (SS) concentration, stress reaction [malondialdehyde (MDA), lipid peroxide (LPO)], inflammatory indices [tumor necrosis factor (TNF)-α, C-reactive protein (CRP), interleukin (IL)-1β], recurrence, and complications (perforation, hemorrhage, and pyloric obstruction) were compared. RESULTS The overall response rate was higher in the RG than in the CG. Patients in the RG had markedly elevated SS after treatment, which was higher than that of the CG, while MDA, LPO, TNF-, CRP, and IL-1β were significantly reduced to lower levels than those in the CG. Lower recurrence and complication rates were identified in the RG group. CONCLUSION Therefore, PPZ plus perforation repair is conducive to enhancing treatment outcomes in PU patients, reducing oxidative stress injury and excessive inflammatory reactions, and contributing to low recurrence and complication rates.
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Affiliation(s)
- Zi-Yan Leng
- The Second Hospital of Traditional Chinese Medicine of Jiangsu Province, Affiliated to Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Jia-Hao Wang
- Institute of Literature in Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Lei Gao
- School of Chinese Medicine & School of Integrated, Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Ke Shi
- Department of Spleen and Gastroenterology, Jiangyin Hospital Affiliated to Nanjing University of Chinese Medicine, Jiangyin 214400, Jiangsu Province, China
| | - Hai-Bing Hua
- Department of Spleen and Gastroenterology, Jiangyin Hospital Affiliated to Nanjing University of Chinese Medicine, Jiangyin 214400, Jiangsu Province, China
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17
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Heels-Ansdell D, Billot L, Thabane L, Alhazzani W, Deane A, Guyatt G, Finfer S, Lauzier F, Myburgh J, Young P, Arabi Y, Marshall J, English S, Muscedere J, Ostermann M, Venkatesh B, Zytaruk N, Hardie M, Hammond N, Knowles S, Saunders L, Poole A, Al-Fares A, Xie F, Hall R, Cook D. REVISE: re-evaluating the inhibition of stress erosions in the ICU-statistical analysis plan for a randomized trial. Trials 2023; 24:796. [PMID: 38057875 PMCID: PMC10701941 DOI: 10.1186/s13063-023-07794-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/09/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The REVISE (Re-Evaluating the Inhibition of Stress Erosions in the ICU) trial will evaluate the impact of the proton pump inhibitor pantoprazole compared to placebo in invasively ventilated critically ill patients. OBJECTIVE To outline the statistical analysis plan for the REVISE trial. METHODS REVISE is a randomized clinical trial ongoing in intensive care units (ICUs) internationally. Patients ≥ 18 years old, receiving invasive mechanical ventilation, and expected to remain ventilated beyond the calendar day after randomization are allocated to either 40 mg pantoprazole intravenously or placebo while mechanically ventilated. RESULTS The primary efficacy outcome is clinically important upper GI bleeding; the primary safety outcome is 90-day mortality. Secondary outcomes are ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine concentration, and duration of mechanical ventilation, ICU, and hospital length of stay. Following an interim analysis of results from 2400 patients (50% of 4800 target sample size), the data monitoring committee recommended continuing enrolment. CONCLUSIONS This statistical analysis plan outlines the statistical analyses of all outcomes, sensitivity analyses, and subgroup analyses. REVISE will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION www. CLINICALTRIALS gov NCT03374800. November 21, 2017.
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Affiliation(s)
- Diane Heels-Ansdell
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, University of New South Wales Medicine & Health, Sydney, New South Wales, Australia
| | - Lehana Thabane
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Adam Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Gordon Guyatt
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - François Lauzier
- Division of Critical Care, Department of MedicineDepartment of Anesthesiology and Critical CareFaculty of Medicine, at l`Université LavalLaval UniversityUniversite Laval Faculte de medicine, Quebec, Canada
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Yaseen Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyad, Saudi Arabia
| | - John Marshall
- Department of Surgery and Critical Care Medicine, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Shane English
- Department of Medicine (Critical Care), Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queens University| Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | | | - Bala Venkatesh
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicole Zytaruk
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Academic Critical Care Office Room D176, Critical Care Medicine, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario, Canada
| | - Miranda Hardie
- The George Institute for Global Health, Newton, Australia
| | - Naomi Hammond
- University of New South Wales, Sydney, New South Wales, Australia
| | - Serena Knowles
- The George Institute for Global Health, Newton, Australia
| | - Lois Saunders
- Academic Critical Care Office Room D176, Critical Care Medicine, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario, Canada
| | | | - Abdulrahman Al-Fares
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Feng Xie
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Richard Hall
- Dalhousie University Faculty of Medicine, Halifax, Canada
| | - Deborah Cook
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
- Academic Critical Care Office Room D176, Critical Care Medicine, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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18
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Li L, Shen Y, Tang Z, Yang Y, Fu Z, Ni D, Cai X. Engineered nanodrug targeting oxidative stress for treatment of acute kidney injury. EXPLORATION (BEIJING, CHINA) 2023; 3:20220148. [PMID: 38264689 PMCID: PMC10742205 DOI: 10.1002/exp.20220148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 04/23/2023] [Indexed: 01/25/2024]
Abstract
Acute kidney injury (AKI) is a clinical syndrome characterized by a rapid decline in renal function, and is associated with a high risk of death. Many pathological changes happen in the process of AKI, including crucial alterations to oxidative stress levels. Numerous efforts have thus been made to develop effective medicines to scavenge excess reactive oxygen species (ROS). However, researchers have encountered several significant challenges, including unspecific biodistribution, high biotoxicity, and in vivo instability. To address these problems, engineered nanoparticles have been developed to target oxidative stress and treat AKI. This review thoroughly discusses the methods that empower nanodrugs to specifically target the glomerular filtration barrier and presents the latest achievements in engineering novel ROS-scavenging nanodrugs in clustered sections. The analysis of each study's breakthroughs and imperfections visualizes the progress made in developing effective nanodrugs with specific biodistribution and oxidative stress-targeting capabilities. This review fills the blank of a comprehensive outline over current progress in applying nanotechnology to treat AKI, providing potential insights for further research.
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Affiliation(s)
- Liwen Li
- Department of Ultrasound in MedicineShanghai Jiao Tong University School of Medicine Affiliated Sixth People's HospitalShanghaiPeople's Republic of China
| | - Yining Shen
- Department of Ultrasound in MedicineShanghai Jiao Tong University School of Medicine Affiliated Sixth People's HospitalShanghaiPeople's Republic of China
| | - Zhongmin Tang
- Departments of Radiology and Medical PhysicsUniversity of Wisconsin‐MadisonWisconsinUSA
| | - Yuwen Yang
- Department of Ultrasound in MedicineShanghai Jiao Tong University School of Medicine Affiliated Sixth People's HospitalShanghaiPeople's Republic of China
| | - Zi Fu
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiPeople's Republic of China
| | - Dalong Ni
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiPeople's Republic of China
| | - Xiaojun Cai
- Department of Ultrasound in MedicineShanghai Jiao Tong University School of Medicine Affiliated Sixth People's HospitalShanghaiPeople's Republic of China
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19
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Deane AM, Alhazzani W, Guyatt G, Finfer S, Marshall JC, Myburgh J, Zytaruk N, Hardie M, Saunders L, Knowles S, Lauzier F, Chapman MJ, English S, Muscedere J, Arabi Y, Ostermann M, Venkatesh B, Young P, Thabane L, Billot L, Heels-Ansdell D, Al-Fares AA, Hammond NE, Hall R, Rajbhandari D, Poole A, Johnson D, Iqbal M, Reis G, Xie F, Cook DJ. REVISE: Re- Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol. BMJ Open 2023; 13:e075588. [PMID: 37968012 PMCID: PMC10660838 DOI: 10.1136/bmjopen-2023-075588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE. METHODS AND ANALYSIS REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial. ETHICS AND DISSEMINATION All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION NUMBER NCT03374800.
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Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Waleed Alhazzani
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - John C Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lois Saunders
- Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Francois Lauzier
- Departments of Anesthesiology, Medicine & Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, Laval, Quebec, Canada
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shane English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | | | - Paul Young
- Intensive Care Department, Wellington Hospital, London, UK
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Abdulrahman A Al-Fares
- Departments of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Naomi E Hammond
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - R Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dorrilyn Rajbhandari
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Alexis Poole
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Johnson
- Departments of Critical Care and Anesthesia, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mobeen Iqbal
- Intensive Care Department, Maroof International Hospital, Islamabad, Pakistan
| | - Gilmar Reis
- Cardresearch-Cardiologia Assistencial e de Pesquisa LTDA, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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20
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Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R, Ahuja V, Berry N, Bhat N, Dutta U, Ghoshal UC, Jain A, Jalihal U, Jayanthi V, Kumar A, Nijhawan S, Poddar U, Ramesh GN, Singh SP, Zargar S, Bhatia S. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian J Gastroenterol 2023; 42:601-628. [PMID: 37698821 DOI: 10.1007/s12664-023-01428-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/10/2023] [Indexed: 09/13/2023]
Abstract
Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, 632 004, India.
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ramit Mahajan
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | | | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | | | - Richard Kirubakaran
- Center of Biostatistics and Evidence Based Medicine, Vellore, 632 004, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Neha Berry
- BLK Institute of Digestive and Liver Disease, New Delhi, 201 012, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Uday Chand Ghoshal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ajay Jain
- Choithram Hospital and Research Center, Indore, 452 014, India
| | | | - V Jayanthi
- Sri Ramachandra Medical College, Chennai, 600 116, India
| | - Ajay Kumar
- Institute of Digestive and Liver Diseases, BLK - Max Superspeciality Hospital, New Delhi, 201 012, India
| | | | - Ujjal Poddar
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Shivram P Singh
- Kalinga Gastroenterology Foundation, Cuttack, 753 001, India
| | - Showkat Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, 190 011, India
| | - Shobna Bhatia
- Sir H N Reliance Foundation Hospital, Mumbai, 400 004, India
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21
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Chilbert MR, Woodruff AE, Saber M, Goriacko P, Sinnet M, Jacobs D. Comparison of bleeding and ischemic events with apixaban vs. rivaroxaban in triple antithrombotic therapy regimens. Blood Coagul Fibrinolysis 2023; 34:370-376. [PMID: 37577874 DOI: 10.1097/mbc.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To compare the risk of readmissions for major bleeding within one year between apixaban and rivaroxaban as a component of triple antithrombotic therapy. METHODS This study was a multicenter, retrospective cohort study conducted at two academic medical centers in the Western New York and New York City region between July 1, 2011 and September 25, 2019. Adult patients were included if they were diagnosed with atrial fibrillation or venous thromboembolism and discharged on new triple antithrombotic therapy. The primary outcome compared the rates of 1-year readmission for major bleeding between apixaban and rivaroxaban groups. Secondary outcomes included rate of ischemic outcomes. Time to event analysis was determined with a Kaplan-Meier plot and Cox proportional hazard ratios (HR). RESULTS A total of 378 patients were included in the study, 212 in the apixaban group and 166 in the rivaroxaban group. Within 1 year, readmission for major bleeding events occurred in six (2.8%) patients in the apixaban group and four (2.4%) patients in the rivaroxaban group ( P = 1.000). After adjustment, the major bleeding event rate was not statistically significantly different between apixaban and rivaroxaban [adjusted hazard ratio (aHR) 0.68, 95% confidence interval (CI) 0.12-3.77; P = 0.6624]. Higher albumin levels were identified to be protective against major bleeding related readmission events (aHR 0.18, 95% CI 0.05-0.63; P = 0.0072). The ischemic outcome occurred in seven (3.3%) patients in the apixaban group and three (1.8%) in the rivaroxaban group ( P = 0.7368). CONCLUSION Use of apixaban or rivaroxaban in a triple antithrombotic regimen was not associated with bleeding or ischemic outcomes.
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Affiliation(s)
- Maya R Chilbert
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
- Buffalo General Medical Center, Buffalo
| | - Ashley E Woodruff
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
- Buffalo General Medical Center, Buffalo
| | - Marissa Saber
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
| | | | - Mark Sinnet
- Montefiore Medical Center, The Bronx, New York, USA
| | - David Jacobs
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences
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22
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Dennis BB, Thabane L, Heels-Ansdell D, Dionne JC, Binnie A, Tsang J, Guyatt G, Ahmed A, Lauzier F, Deane A, Arabi Y, Marshall J, Zytaruk N, Saunders L, Finfer S, Myburgh J, Muscedere J, English S, Ostermann M, Hardie M, Knowles S, Cook D. Proton pump inhibitors in critically ill mechanically ventilated patients with COVID-19: protocol for a substudy of the Re-EValuating the Inhibition of Stress Erosions (REVISE) Trial. Trials 2023; 24:561. [PMID: 37644556 PMCID: PMC10466724 DOI: 10.1186/s13063-023-07589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Critically ill patients commonly receive proton pump inhibitors (PPIs) to prevent gastrointestinal (GI) bleeding from stress-induced ulceration. Despite widespread use in the intensive care unit (ICU), observational data suggest that PPIs may be associated with adverse outcomes in patients with COVID-19 infection. This preplanned study is nested within a large randomized trial evaluating pantoprazole versus placebo in invasively ventilated patients. The 3 objectives are as follows: (1) to describe the characteristics of patients with COVID-19 in terms of demographics, biomarkers, venous thromboembolism, tracheostomy incidence and timing, and other clinical outcomes; (2) to evaluate the impact of COVID-19 infection on clinically important GI bleeding, 90-day mortality, and other outcomes compared to a propensity-matched non-infected cohort; and (3) to explore whether pantoprazole has a differential treatment effect on clinically important GI bleeding, 90-day mortality, and other outcomes in patients with and without COVID-19 infection. METHODS The ongoing trial Re-EValuating the Inhibition of Stress Erosions (REVISE) compares pantoprazole 40 mg IV to placebo on the primary efficacy outcome of clinically important GI bleeding and the primary safety outcome of 90-day mortality. The protocol described in this report is for a substudy focused on patients with COVID-19 infection that was not in the original pre-pandemic trial protocol. We developed a one-page case report form to characterize these patients including data related to biomarkers, venous thromboembolism, COVID-19 therapies, tracheostomy incidence and timing, duration of mechanical ventilation, and ICU and hospital stay. Our analysis will describe the trajectory of patients with COVID-19 infection, a propensity-matched analysis of infected and non-infected patients, and an extended subgroup analysis comparing the effect of PPI among patients with and without COVID-19 infection. DISCUSSION Prophylactic acid suppression in invasively ventilated critically ill patients with COVID-19 infection has unknown consequences. The results of these investigations will inform practice, guidelines, and future research. TRIAL REGISTRATION REVISE Trial [NCT03374800 December 15, 2017], COVID-19 Cohort Study [NCT05715567 February 8, 2023].
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Affiliation(s)
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Joanna C. Dionne
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - Alexandra Binnie
- Department of Critical Care Medicine, Niagara Health System, St. Catharines, ON Canada
| | - Jennifer Tsang
- Department of Medicine, McMaster University, Hamilton, ON Canada
- Department of Critical Care Medicine, Niagara Health System, St. Catharines, ON Canada
| | - Gordon Guyatt
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - Aijaz Ahmed
- Department of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA USA
| | - François Lauzier
- Departments of Anesthesiology and Medicine and Critical Care Medicine, Université Laval, Québec, Québec Canada
| | - Adam Deane
- Department of Critical Care Medicine, University of Melbourne, Melbourne Medical School, Parkville, VIC Australia
| | - Yaseen Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - John Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Lois Saunders
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
- Intensive Care Unit, St. George Hospital, Sydney, Australia
| | - John Muscedere
- Department of Critical Care Medicine, Queen’s University, Kingston, ON Canada
| | - Shane English
- Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Marlies Ostermann
- Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
| | - Deborah Cook
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - For the REVISE Investigators the Canadian Critical Care Trials Group
- Department of Medicine, McMaster University, Hamilton, ON Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Department of Critical Care Medicine, Niagara Health System, St. Catharines, ON Canada
- Department of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA USA
- Departments of Anesthesiology and Medicine and Critical Care Medicine, Université Laval, Québec, Québec Canada
- Department of Critical Care Medicine, University of Melbourne, Melbourne Medical School, Parkville, VIC Australia
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
- Intensive Care Unit, St. George Hospital, Sydney, Australia
- Department of Critical Care Medicine, Queen’s University, Kingston, ON Canada
- Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
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23
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Arabi YM, Al-Dorzi HM, Sadat M, Muharib D, Algethamy H, Al-Hameed F, Mady A, AlGhamdi A, Almekhlafi GA, Al-Fares AA, Kharaba A, Al Bshabshe A, Maghrabi K, Al Ghamdi K, Rasool G, Chalabi J, AlHumedi HI, Sakkijha MH, Alamrey NK, Alhutail RH, Sifaoui K, Almaani M, Alqahtani R, Qureshi AS, Hejazi MM, Arishi H, AlQahtani S, Ghazi AM, Baaziz ST, Azhar AO, Alabbas SF, AlAqeely M, AlOrabi O, Al-Mutawa A, AlOtaibi M, Aldibaasi O, Jose J, Starkopf J, Preiser JC, Perner A, Al-Dawood A. Replacing protein via enteral nutrition in a stepwise approach in critically ill patients: the REPLENISH randomized clinical trial protocol. Trials 2023; 24:485. [PMID: 37518058 PMCID: PMC10388494 DOI: 10.1186/s13063-023-07507-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/11/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Protein intake is recommended in critically ill patients to mitigate the negative effects of critical illness-induced catabolism and muscle wasting. However, the optimal dose of enteral protein remains unknown. We hypothesize that supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition formula to achieve high amount of enteral protein (range 2-2.4 g/kg/day) given from ICU day 5 until ICU discharge or ICU day 90 as compared to no supplemental enteral protein to achieve moderate amount enteral protein (0.8-1.2 g/kg/day) would reduce all-cause 90-day mortality in adult critically ill mechanically ventilated patients. METHODS The REPLENISH (Replacing Protein Via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial is an open-label, multicenter randomized clinical trial. Patients will be randomized to the supplemental protein group or the control group. Patients in both groups will receive the primary enteral formula as per the treating team, which includes a maximum protein 1.2 g/kg/day. The supplemental protein group will receive, in addition, supplemental protein at 1.2 g/kg/day starting the fifth ICU day. The control group will receive the primary formula without supplemental protein. The primary outcome is 90-day all-cause mortality. Other outcomes include functional and quality of life assessments at 90 days. The trial will enroll 2502 patients. DISCUSSION The study has been initiated in September 2021. Interim analysis is planned at one third and two thirds of the target sample size. The study is expected to be completed by the end of 2025. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04475666 . Registered on July 17, 2020.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Dina Muharib
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Haifa Algethamy
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fahad Al-Hameed
- Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed Mady
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
- College of Medicine, Tanta University, Tanta, Egypt
| | - Adnan AlGhamdi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ghaleb A Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman A Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Ayman Kharaba
- Pulmonary & Critical Care Departments, King Fahad Hospital, Medinah, Saudi Arabia
- Critical Care Units, Ministry of Health, Madinah, Saudi Arabia
| | - Ali Al Bshabshe
- Department of Critical Care Medicine, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Khalid Maghrabi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid Al Ghamdi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Ghulam Rasool
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Jamal Chalabi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Abdulaziz Hospital, Ministry of National Guard Health Affairs, AlAhsa, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, AlAhsa, Saudi Arabia
| | - Haifaa Ibrahim AlHumedi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Maram Hasan Sakkijha
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Norah Khalid Alamrey
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Rabeah Hamad Alhutail
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Kaouthar Sifaoui
- Pulmonary & Critical Care Departments, King Fahad Hospital, Medinah, Saudi Arabia
- Critical Care Units, Ministry of Health, Madinah, Saudi Arabia
| | - Mohammed Almaani
- Adult Critical Care Services, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Rakan Alqahtani
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad S Qureshi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, Madinah, Saudi Arabia
| | - Mohammed Moneer Hejazi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hatim Arishi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Samah AlQahtani
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amro Mohamed Ghazi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saleh T Baaziz
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abeer Othman Azhar
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sara Fahad Alabbas
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed AlAqeely
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ohoud AlOrabi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Aliaa Al-Mutawa
- Department of Nutrition, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Maha AlOtaibi
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Omar Aldibaasi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jesna Jose
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Joel Starkopf
- Clinic of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Tartu, Estonia
| | | | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Abdulaziz Al-Dawood
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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24
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Reynolds PM, Wells L, Powell M, MacLaren R. Associated Mortality Risk of Proton Pump Inhibitor Therapy for the Prevention of Stress Ulceration in Intensive Care Unit Patients: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023; 57:586-594. [PMID: 35648972 DOI: 10.1097/mcg.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/27/2022] [Indexed: 12/10/2022]
Abstract
GOALS The aim was to systematically evaluate risks and benefits of proton pump inhibitor (PPI) use for stress ulcer prophylaxis in the critically ill patient. BACKGROUND Whether PPIs increase mortality in the critically ill patient remains controversial. STUDY Systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies with trial sequential analysis, Bayesian sensitivity analysis, and fragility index analysis. RESULTS A total of 31 studies in 78,009 critically ill adults receiving PPIs versus any comparator were included. PPI use was associated with an increased mortality risk in all studies [19.6% PPI vs. 17.5% comparator; RR: 1.10; 95% confidence interval (CI): 1.02-1.20; P =0.01], in the subgroup of RCTs (19.4% vs. 18.7%; RR: 1.05; 95% CI: 1.0-1.09, P =0.04), but not cohort studies (19.9% vs. 16.7%; RR: 1.12; 95% CI: 0.98-1.28, P =0.09). Results were maintained with a Bayesian sensitivity analysis (RR: 1.13; 95% credible interval: 1.035-1.227) and a fragility index analysis, but not sequential analysis ( P =0.16). RCTs with a higher baseline severity of illness revealed the greatest mortality risk with PPI use (32.1% PPI vs. 29.4% comparator; RR: 1.09; 95% CI: 1.04-1.14; P <0.001). PPI use reduced clinically important bleeding in RCTs (1.4% PPI vs. 2.1% comparator; RR: 0.67; 95% CI: 0.5-0.9; P =0.009) but increased bleeding in cohort studies (2.7% PPI vs. 1.2% comparator; RR: 2.05; 95% CI: 1.2-3.52; P =0.009). PPI use was not associated with a lower incidence of clinically important bleeding when compared with histamine-2 receptor antagonists (1.3% vs. 1.9%; RR: 0.59; 95% CI: 0.28-1.25, P =0.09). CONCLUSIONS This meta-analysis demonstrated an association between PPI use and an increased risk of mortality.
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Affiliation(s)
- Paul M Reynolds
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO
| | - Lauren Wells
- PGY2 Emergency Medicine Pharmacy Resident, Froedtert and the Medical College of Wisconsin, Wauwatosa, WI
| | | | - Robert MacLaren
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO
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Cook DJ, Swinton M, Krewulak KD, Fiest K, Dionne J, Debigare S, Guyatt G, Taneja S, Alhazzani W, Burns KEA, Marshall JC, Muscedere J, Gouskos A, Finfer S, Deane AM, Myburgh J, Rochwerg B, Ball I, Mele T, Niven D, English S, Verhovsek M, Vanstone M. What counts as patient-important upper gastrointestinal bleeding in the ICU? A mixed-methods study protocol of patient and family perspectives. BMJ Open 2023; 13:e070966. [PMID: 37208143 DOI: 10.1136/bmjopen-2022-070966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Clinically important upper gastrointestinal bleeding is conventionally defined as bleeding accompanied by haemodynamic changes, requiring red blood cell transfusions or other invasive interventions. However, it is unclear if this clinical definition reflects patient values and preferences. This protocol describes a study to elicit views from patients and families regarding features, tests, and treatments for upper gastrointestinal bleeding that are important to them. METHODS AND ANALYSIS This is a sequential mixed-methods qualitative-dominant multi-centre study with an instrument-building aim. We developed orientation tools and educational materials in partnership with patients and family members, including a slide deck and executive summary. We will invite intensive care unit (ICU) survivors and family members of former ICU patients to participate. Following a virtual interactive presentation, participants will share their perspectives in an interview or focus group. Qualitative data will be analysed using inductive qualitative content analysis, wherein codes will be derived directly from the data rather than using preconceived categories. Concurrent data collection and analysis will occur. Quantitative data will include self-reported demographic characteristics. This study will synthesise the values and perspectives of patients and family members to create a new trial outcome for a randomised trial of stress ulcer prophylaxis. This study is planned for May 2022 to August 2023. The pilot work was completed in Spring 2021. ETHICS AND DISSEMINATION This study has ethics approval from McMaster University and the University of Calgary. Findings will be disseminated via manuscript and through incorporation as a secondary trial outcome on stress ulcer prophylaxis. TRIAL REGISTRATION NUMBER NCT05506150.
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Affiliation(s)
- Deborah J Cook
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karla D Krewulak
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kirsten Fiest
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joanna Dionne
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sylvie Debigare
- Patient and Family Partnership Committee, Canadian Critical Care Trials Group, Montreal, Quebec, Canada
| | - Gordon Guyatt
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shipra Taneja
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John C Marshall
- Surgery and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Muscedere
- Critical Care Medicine, Kingston Health Sciences Center, Queens University, Kingston, Ontario, Canada
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee Representative, Toronto, Ontario, Canada
| | - Simon Finfer
- Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Adam M Deane
- Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - John Myburgh
- Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bram Rochwerg
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ian Ball
- Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Tina Mele
- Surgery and Critical Care Medicine, Western University, London, Ontario, Canada
| | - Daniel Niven
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Aktualisierte S2k-Leitlinie Helicobacter
pylori und gastroduodenale Ulkuskrankheit der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – Juli 2022 – AWMF-Registernummer: 021–001. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:544-606. [PMID: 37146633 DOI: 10.1055/a-1975-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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27
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Katzenschlager S, Popp E, Wnent J, Weigand MA, Gräsner JT. Developments in Post-Resuscitation Care for Out-of-Hospital Cardiac Arrests in Adults-A Narrative Review. J Clin Med 2023; 12:jcm12083009. [PMID: 37109345 PMCID: PMC10143439 DOI: 10.3390/jcm12083009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
This review focuses on current developments in post-resuscitation care for adults with an out-of-hospital cardiac arrest (OHCA). As the incidence of OHCA is high and with a low percentage of survival, it remains a challenge to treat those who survive the initial phase and regain spontaneous circulation. Early titration of oxygen in the out-of-hospital phase is not associated with increased survival and should be avoided. Once the patient is admitted, the oxygen fraction can be reduced. To maintain an adequate blood pressure and urine output, noradrenaline is the preferred agent over adrenaline. A higher blood pressure target is not associated with higher rates of good neurological survival. Early neuro-prognostication remains a challenge, and prognostication bundles should be used. Established bundles could be extended by novel biomarkers and methods in the upcoming years. Whole blood transcriptome analysis has shown to reliably predict neurological survival in two feasibility studies. This needs further investigation in larger cohorts.
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Affiliation(s)
| | - Erik Popp
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan Wnent
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
- School of Medicine, University of Namibia, Windhoek 9000, Namibia
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Thorsten Gräsner
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
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Borthwick M, Granholm A, Marker S, Krag M, Lange T, Wise MP, Bendel S, Keus F, Guttormsen AB, Schefold JC, Wetterslev J, Perner A, Møller MH. Associations between enteral nutrition and outcomes in the SUP-ICU trial: Protocol for exploratory post hoc analyses. Acta Anaesthesiol Scand 2023; 67:481-486. [PMID: 36636785 DOI: 10.1111/aas.14194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/01/2023] [Indexed: 01/14/2023]
Abstract
Critically ill patients are at risk of gastrointestinal (GI) bleeding. Counter measures to minimise this risk include the use of pharmacological stress ulcer prophylaxis (SUP). The effect of enteral nutrition as SUP on GI bleeding event rates is unknown. There are conflicting data describing the effect of co-administration of enteral nutrition with pharmacological SUP, and there is substantial variation in practice. We aim to conduct an exploratory post hoc analysis to evaluate the association of enteral nutrition with clinically important GI bleed rates in ICU patients included in the SUP-ICU trial, and to explore any interactions between enteral nutrition and pharmacologic SUP on patient outcomes. The SUP-ICU trial dataset will be used to assess if enteral nutrition is associated with the outcomes of interest. Extended Cox models will be used considering relevant competing events, including treatment allocation (SUP or placebo) and enteral nutrition as a daily time-varying covariate, with additional adjustment for severity of illness (SAPS II). Results will be presented as adjusted hazard ratios for treatment allocation and enteral nutrition, and for treatment allocation and enteral nutrition considering potential interactions with the other variable, all with 95% confidence intervals and p-values for the tests of interaction. All results will be considered as exploratory only. This post hoc analysis may yield important insights to guide practice and inform the design of future randomised clinical trial investigating the effect of enteral nutrition on GI bleeding.
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Affiliation(s)
- Mark Borthwick
- Departments of Pharmacy and Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Søren Marker
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Mette Krag
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Centre for Statistical Science, Peking University, Beijing, China
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Stepani Bendel
- Department of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anne Berit Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Saruta Y, Watanabe K, Tsuji T, Takahashi Y, Matsuzawa H, Yoshida T, Takahashi S, Shimodaira Y, Matsuhashi T, Iijima K. Vonoprazan poses no additional risk of developing Clostridioides difficile infection compared to proton pump inhibitors. J Gastroenterol Hepatol 2023. [PMID: 36882162 DOI: 10.1111/jgh.16169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/30/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND AND AIM The use of proton pump inhibitors (PPIs) has been repeatedly reported as a trigger of Clostridioides difficile infection (CDI), a leading cause of nosocomial diarrhea. However, only a few studies have reported on the association between vonoprazan, a novel potassium-competitive acid blocker providing potent acid suppression, and CDI, with no studies having been conducted in a clinical setting. We therefore evaluated the association between various classes of acid suppressants and CDI with special attention paid to differences in the magnitudes of association between PPIs and vonoprazan. METHODS A retrospective hospital-based cohort from a secondary-care hospital in Japan (n = 25 821) was collected, wherein eligible CDI cases were defined as hospital-onset cases (n = 91). A multivariable adjusted logistic regression analysis for the entire cohort and propensity analyses for subgroups consisting of PPI and/or vonoprazan users at various doses (n = 10 306) were performed. RESULTS The overall CDI incidence rate was 1.42/10 000 patient-days, which was comparable with previous reports. A multivariable analysis showed that both PPIs and vonoprazan were positively associated with CDI (odds ratios [95% confidence intervals]: 3.15 [1.67-5.96] and 2.63 [1.01-6.88], respectively). In addition, matched subgroup analyses showed that PPIs and vonoprazan had equivalent magnitudes of association with CDI. CONCLUSIONS We found that both PPIs and vonoprazan were associated with CDI, and the magnitude of the association was comparable. Because vonoprazan is widely available in Asian countries, further studies on the association of its usage with CDI are warranted.
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Affiliation(s)
- Yohei Saruta
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan.,Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Kenta Watanabe
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tsuyotoshi Tsuji
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Yasutaka Takahashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Tatsuki Yoshida
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - So Takahashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yosuke Shimodaira
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
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30
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Klompas M. Progress in preventing non-ventilator-associated hospital-acquired pneumonia. THE LANCET. INFECTIOUS DISEASES 2023:S1473-3099(22)00867-2. [PMID: 36893782 DOI: 10.1016/s1473-3099(22)00867-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 03/08/2023]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02135, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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31
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Krag M, Alhazzani W, Møller MH. Prevention of upper gastrointestinal bleeding in critical illness. Intensive Care Med 2023; 49:334-336. [PMID: 36598546 DOI: 10.1007/s00134-022-06959-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/10/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Mette Krag
- Department of Intensive Care, Holbæk Hospital, Holbæk, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Critical Care, Prince Sultan Military Medical City, The General Directorate of Armed Forces Health Services, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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32
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Barletta JF. Prophylactic acid suppression and enteral nutrition. Curr Opin Clin Nutr Metab Care 2023; 26:174-178. [PMID: 36892963 DOI: 10.1097/mco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients who are at high-risk for clinically important gastrointestinal bleeding. Recent evidence however has highlighted adverse effects with acid suppressive therapy, particularly proton pump inhibitors where associations with higher mortality have been reported. Enteral nutrition may provide benefits in reducing the incidence of stress ulceration and may mitigate the need for acid suppressive therapy. This manuscript will describe the most recent evidence evaluating enteral nutrition for the provision of SUP. RECENT FINDINGS There are limited data evaluating enteral nutrition for SUP. The available studies compare enteral nutrition with or without acid suppressive therapy rather than enteral nutrition vs. placebo. Although data exist demonstrating similar clinically important bleeding rates in patients on enteral nutrition who receive SUP vs. no SUP, these studies are underpowered for this endpoint. In the largest placebo-controlled trial conducted to date, lower bleeding rates were observed with SUP and most patients were receiving enteral nutrition. Pooled analyses had also described benefit with SUP vs. placebo and enteral nutrition did not change the impact of these therapies. SUMMARY Although enteral nutrition may provide some benefit as SUP, existing data are not strong enough to validate their use in place of acid suppressive therapy. Clinicians should continue to prescribe acid suppressive therapy for SUP in critically ill patients who are at high risk for clinically important bleeding even when enteral nutrition is being provided.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University, College of Pharmacy - Glendale Campus, Glendale, Arizona, USA
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33
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Cascone AE, Sullivan J, Ackerbauer K, Patel S, Lindale DK, Tatro H, Feeney ME. Pharmacist-Initiated De-Prescribing Efforts Reduce Inappropriate Continuation of Acid-Suppression Therapy Initiated in the ICU. Am J Med 2023; 136:186-192. [PMID: 36170933 DOI: 10.1016/j.amjmed.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Stress ulcer prophylaxis initiated for intensive care unit (ICU)-specific indications is often continued upon transfer or discharge despite lack of indication. This quality improvement initiative aimed to achieve a 25% reduction from baseline in ICU-initiated acid suppression therapy prescriptions by May 2021. METHODS This initiative was conducted in adult ICU patients at Boston Medical Center from July 2020 through May 2021. A multidisciplinary approach to de-prescribing was utilized, including the implementation of formalized stress ulcer prophylaxis criteria and an electronic handoff tool used to identify patients appropriate for assessment of acid suppression therapy continuation post-ICU stay. The primary outcome measure was the number of discharge prescriptions for ICU-initiated acid suppression therapy. Secondary endpoints included incidence of de-prescribing workflow failures, percentage of acid suppression therapy discharge prescriptions with inappropriate indications, and incidence of stress ulcer-related gastrointestinal bleeding. RESULTS A 55% decrease in ICU-initiated acid suppression therapy discharge prescriptions occurred after implementing the multidisciplinary workflow. The decrease was sustained for 28 weeks through the completion of the study. CONCLUSIONS Implementation of a pharmacist-initiated electronic handoff tool along with provider education and creation of formalized stress ulcer prophylaxis criteria may reduce the number of ICU-initiated acid suppression therapy prescriptions inadvertently or inappropriately continued at discharge.
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Affiliation(s)
- Ava E Cascone
- Department of Pharmacy, Boston Medical Center, Mass.
| | | | | | - Shyam Patel
- Department of Pharmacy, Boston Medical Center, Mass
| | | | - Hayley Tatro
- William Jennings Bryan Dorn: VA Health Care System, Columbia, SC
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Xu X, Zhu H, Cai L, Liu L, Zhang F, Zhou H, Mei B, Zhu M, Dai L, Chen T, Xu K. Risk Assessment of Major Adverse Cardiovascular and Cerebrovascular Events and Bleeding for Acute Myocardial Infarction With or Without Active Tuberculosis. Clin Ther 2022; 44:1370-1379. [PMID: 36150925 DOI: 10.1016/j.clinthera.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The underlying ischemic and bleeding risks of acute myocardial infarction (AMI) with active tuberculosis (TB) are unknown. The goal of this study was to explore the ischemic and bleeding risks, as well as treatment strategies during hospitalization, in patients with AMI with or without active TB. METHODS Patients were recruited from a tuberculosis hospital from 2014 to 2021. The primary outcomes were major cardiovascular and cerebrovascular events (MACE) and Bleeding Academic Research Consortium (BARC)-defined type 3 or 5 bleeding. Multivariate logistic regression and propensity score matching were performed for risk adjustment. Subgroups were defined according to AMI with active pulmonary TB and AMI with active TB undergoing percutaneous coronary intervention (PCI). FINDINGS A total of 242 patients were enrolled. Compared with AMI without active TB, AMI with active TB had a higher risk of MACE and BARC type 3 or 5 bleeding (P < 0.001 and P = 0.002, respectively). Multivariate logistic regression analysis showed that, compared with AMI without active TB, the odds ratio (OR) was 6.513 (95% CI, 2.195-19.331) for MACE in patients with AMI with active TB, and the OR was 16.074 (95% CI 3.337-77.436) for BARC type 3 or 5 bleeding in patients with AMI with active TB. After propensity score matching, AMI with active TB tended to increase the risk of MACE, although not statistically significantly (P = 0.189), and increased BARC type 3 or 5 bleeding (P < 0.001), compared with AMI without active TB. Results of subgroup analyses showed that active TB had outcomes consistent with those of the total cohort. AMI patients with active pulmonary TB who underwent PCI had a lower risk of MACE without an increase in the risk of bleeding compared with those not undergoing PCI. IMPLICATIONS Patients with AMI with active TB have a higher risk of MACE (or severe MACE) and bleeding than patients with AMI without active TB. However, AMI patients with active TB are still advised to undergo PCI for a high net clinical benefit.
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Affiliation(s)
- Xiaoqun Xu
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Long Cai
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Libin Liu
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Fengwei Zhang
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Hongjuan Zhou
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Bin Mei
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Mingzhi Zhu
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Lingshan Dai
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Kan Xu
- Centre of Laboratory Medicine, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China.
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Basha NJ. Therapeutic Efficacy of Benzimidazole and Its Analogs: An Update. Polycycl Aromat Compd 2022. [DOI: 10.1080/10406638.2022.2118334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- N. Jeelan Basha
- Department of Chemistry, Indian Academy Degree College-Autonomous Bengaluru, India
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36
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Jones CA, Betthauser KD, Lizza BD, Juang PA, Micek ST, Kollef MH. Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study. Hosp Pharm 2022; 57:510-517. [PMID: 35898251 PMCID: PMC9310319 DOI: 10.1177/00185787211061371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Purpose Recent data highlight unclear efficacy and potential negative sequelae of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). Minimizing SUP exposure has pertinent clinical and other implications. This study assessed medication use and clinical outcomes before and after implementation of a practice guideline promoting early discontinuation of SUP in mechanically ventilated ICU patients. Methods Retrospective, single-center, pre-post cohort study within a medical ICU at a large, academic medical center. Adult patients requiring mechanical ventilation and receiving SUP via a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) were eligible for inclusion. The clinical practice guideline was implemented on January 1, 2020. The impact of implementation was assessed via percent of patient-days with inappropriate SUP. Incidence of clinically important GI bleed was the primary safety outcome. Results A total of 137 pre-guideline and 112 post-guideline patients were included. Comorbidity burden was similar between groups. A higher prevalence of baseline vasopressor receipt (39% vs 67%, P < .01) and acute kidney injury (56% vs 69%, P = .04) was observed in post-guideline patients. Post-guideline patients experienced a significantly lower percentage of patient-days of inappropriate SUP (25% vs 50%, P < .01) as well as higher rates of SUP discontinuation before extubation (71% vs 12%, P < .01) and during ICU stay (93% vs 50%, P < .01). Post-guideline patients observed a significantly lower incidence of SUP at hospital discharge (4% vs 35%, P < .01). No differences in bleeding outcomes were observed, though post-guideline patients experienced longer durations of mechanical ventilation, ICU stay, and hospital stay. Conclusions Implementation of an early SUP discontinuation guideline was associated with significant improvements in SUP prescribing practices. Baseline differences between groups likely explain observed differences in clinical outcomes.
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Affiliation(s)
| | | | | | - Paul A. Juang
- Barnes-Jewish Hospital, Saint Louis, MO, USA
- University of Health Sciences and Pharmacy, St. Louis- College of Pharmacy, Saint Louis, MO, USA
| | - Scott T. Micek
- Barnes-Jewish Hospital, Saint Louis, MO, USA
- University of Health Sciences and Pharmacy, St. Louis- College of Pharmacy, Saint Louis, MO, USA
| | - Marin H. Kollef
- Washington University School of Medicine, Saint Louis, MO, USA
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Wichmann S, Itenov TS, Berthelsen RE, Lange T, Perner A, Gluud C, Lawson-Smith P, Nebrich L, Wiis J, Brøchner AC, Hildebrandt T, Behzadi MT, Strand K, Andersen FH, Strøm T, Järvisalo M, Damgaard KAJ, Vang ML, Wahlin RR, Sigurdsson MI, Thormar KM, Ostermann M, Keus F, Bestle MH. Goal directed fluid removal with furosemide versus placebo in intensive care patients with fluid overload: a trial protocol for a randomised, blinded trial (GODIF Trial). Acta Anaesthesiol Scand 2022; 66:1138-1145. [PMID: 35898170 PMCID: PMC9541596 DOI: 10.1111/aas.14121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
Abstract
Background Fluid overload is a risk factor for mortality in intensive care unit (ICU) patients. Administration of loop diuretics is the predominant treatment of fluid overload, but evidence for its benefit is very uncertain when assessed in a systematic review of randomised clinical trials. The GODIF trial will assess the benefits and harms of goal directed fluid removal with furosemide versus placebo in ICU patients with fluid overload. Methods An investigator‐initiated, international, randomised, stratified, blinded, parallel‐group trial allocating 1000 adult ICU patients with fluid overload to infusion of furosemide versus placebo. The goal is to achieve a neutral fluid balance. The primary outcome is days alive and out of hospital 90 days after randomisation. Secondary outcomes are all‐cause mortality at day 90 and 1‐year after randomisation; days alive at day 90 without life support; number of participants with one or more serious adverse events or reactions; health‐related quality of life and cognitive function at 1‐year follow‐up. A sample size of 1000 participants is required to detect an improvement of 8% in days alive and out of hospital 90 days after randomisation with a power of 90% and a risk of type 1 error of 5%. The conclusion of the trial will be based on the point estimate and 95% confidence interval; dichotomisation will not be used. ClinicalTrials.gov identifier: NCT04180397. Perspective The GODIF trial will provide important evidence of possible benefits and harms of fluid removal with furosemide in adult ICU patients with fluid overload.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Theis S Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Rasmus E Berthelsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Pia Lawson-Smith
- Department of Intensive Care, Odense University Hospital, Odense, Denmark
| | - Lars Nebrich
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Jørgen Wiis
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Meike T Behzadi
- Department of Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Finn H Andersen
- Department of Intensive Care, Ålesund Hospital, Møre and Romsdal Health Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of medicine and health science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thomas Strøm
- Department of Anaesthesia and Intensive Care, Sygehus Sønderjylland, Aabenraa, Denmark
| | - Mikko Järvisalo
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Kjeld A J Damgaard
- Department of Anaesthesia and Intensive Care, Regionshospital Nordjylland, Hjørring, Denmark
| | - Marianne L Vang
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecka R Wahlin
- Department of Anaesthesia and Intensive Care, Södersjukhuset AB, Stockholm, Sweden
| | - Martin I Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Icelandi
| | - Katrin M Thormar
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St. Thomas' Foundation Trust, London, UK
| | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
| | - Morten H Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Bořilová Linhartová P, Zendulka O, Janošek J, Mlčůchová N, Cvanová M, Daněk Z, Kroupa R, Bartošová L, Lipový B. CYP2C19 Gene Profiling as a Tool for Personalized Stress Ulcer Prophylaxis With Proton Pump Inhibitors in Critically Ill Patients - Recommendations Proposal. Front Med (Lausanne) 2022; 9:854280. [PMID: 35899207 PMCID: PMC9309431 DOI: 10.3389/fmed.2022.854280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
To this date, there are no recommendations for personalized stress ulcer prophylaxis (SUP) in critical care that would take the patient's individual genetic predispositions into account. Of drugs used for this purpose, proton pump inhibitors (PPIs) are the first-choice drugs in intensive care unit patients. The degradation of proton pump inhibitors is mediated by cytochrome P450 (CYP) enzymes; in particular, CYP2C19 and, to a lesser extent, CYP3A4 are involved. Expression and metabolic activity of, namely in, CYP2C19 is significantly affected by single nucleotide polymorphisms, the drug metabolization rate varies greatly from ultrarapid to poor and likely influences the optimal dosage. As these CYP2C19 predictive phenotypes via CYP2C19 haplogenotypes (rs12248560/rs4244285) can be relatively easily determined using the current standard equipment of hospital laboratories, we prepared a set of recommendations for personalized PPI-based stress ulcer prophylaxis taking into account the patient's CYP2C19 predictive phenotype determined in this way. These recommendations are valid, in particular, for European, American and African populations, because these populations have the high representations of the CYP2C19*17 allele associated with the overexpression of the CYP2C19 gene and ultrarapid degradation of PPIs. We propose the CYP2C19 gene profiling as a tool for personalized SUP with PPI in critically ill patients.
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Affiliation(s)
- Petra Bořilová Linhartová
- RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
- Clinic of Maxillofacial Surgery, Faculty of Medicine, Institution Shared With University Hospital Brno, Masaryk University, Brno, Czechia
| | - Ondřej Zendulka
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jaroslav Janošek
- Faculty of Medicine, Center for Health Research, University of Ostrava, Ostrava, Czechia
| | | | - Michaela Cvanová
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czechia
| | - Zdeněk Daněk
- RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
- Clinic of Maxillofacial Surgery, Faculty of Medicine, Institution Shared With University Hospital Brno, Masaryk University, Brno, Czechia
| | - Radek Kroupa
- Department of Internal Medicine and Gastroenterology, Faculty of Medicine, Institution Shared With University Hospital Brno, Masaryk University, Brno, Czechia
| | - Ladislava Bartošová
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Břetislav Lipový
- Department of Burns and Plastic Surgery, Faculty of Medicine, Institution Shared With University Hospital BrnoMasaryk University, Brno, Czechia
- *Correspondence: Břetislav Lipový
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Fanning J, Panigada M, Li Bassi G. Nosocomial Pneumonia in the Mechanically Ventilated Patient. Semin Respir Crit Care Med 2022; 43:426-439. [PMID: 35714627 DOI: 10.1055/s-0042-1749448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.
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Affiliation(s)
- Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Nuffield Department of Population Health, Oxford University, United Kingdom
| | - Mauro Panigada
- Department of Anaesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Australia
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40
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Daou M, Dionne JC, Teng JFT, Taran S, Zytaruk N, Cook D, Wilcox ME. Prophylactic acid suppressants in patients with primary neurologic injury: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2022; 71:154093. [PMID: 35714455 DOI: 10.1016/j.jcrc.2022.154093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE Neurocritical care patients are at risk of stress-induced gastrointestinal ulceration. We performed a systematic review and meta-analysis of stress ulcer prophylaxis (SUP) in critically ill adults admitted with a primary neurologic injury. MATERIALS AND METHODS We included randomized controlled trials (RCTs) comparing SUP with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs) to placebo/no prophylaxis, as well as to each other. The primary outcome was in-ICU gastrointestinal bleeding (GIB). Predefined secondary outcomes were all-cause 30-day mortality, ICU length of stay (LOS), nosocomial pneumonia, and other complications. RESULTS We identified 14 relevant trials enrolling 1036 neurocritical care patients; 11 trials enrolling 930 patients were included in the meta-analysis. H2RAs resulted in a lower incidence of GIB as compared to placebo or no prophylaxis (Risk ratio [RR] 0.42, 95% CI 0.30-0.58; p < 0.001); PPIs with a lower risk of GIB compared to placebo/no prophylaxis (RR 0.37, 95% CI 0.23-0.59; p < 0.001). No significant difference was observed in GIB comparing PPIs with H2RAs (RR 0.53, 95% CI 0.26-1.06; p = 0.07; I2 = 0%). CONCLUSIONS In neurocritical care patients, the overall high or unclear risk of bias of individual trials, the low event rates, and modest sample sizes preclude strong clinical inferences about the utility of SUP.
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Affiliation(s)
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer F T Teng
- Department of Pharmacy, University Health Network, Toronto, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine (Respirology), University Health Network, Toronto, Canada
| | - Nicole Zytaruk
- St. Joseph's HealthCare Hamilton, Hamilton, Ontario, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; St. Joseph's HealthCare Hamilton, Hamilton, Ontario, Canada
| | - M Elizabeth Wilcox
- Toronto Western Hospital, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine (Respirology), University Health Network, Toronto, Canada.
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41
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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42
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Mao X, Yang Z. Association between hospital-acquired pneumonia and proton pump inhibitor prophylaxis in patients treated with glucocorticoids: a retrospective cohort study based on 307,622 admissions in China. J Thorac Dis 2022; 14:2022-2033. [PMID: 35813745 PMCID: PMC9264073 DOI: 10.21037/jtd-21-1886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/12/2022] [Indexed: 11/06/2022]
Abstract
Background Prophylaxis with proton pump inhibitor (PPI) in patients treated with glucocorticoid therapy is a common phenomenon in the general wards of Chinese hospitals. Many of these prescriptions are inappropriate and lead to overuse. Hospital-acquired pneumonia (HAP) is a possible adverse effect for this combination but remains controversial. Methods We designed a retrospective cohort study using electronic medical record databases from multiple hospitals to investigate whether PPI prophylaxis increases the risk of HAP in hospitalized patients receiving glucocorticoid therapy. The study population was adult patients who were not critical and treated with at least 1 dose of glucocorticoid during hospitalization and the exposure factor was PPIs prophylaxis. The odds ratio of HAP between the exposed and unexposed groups was calculated based on the cohort which was established by propensity score matching. The dose-effect relationship between PPI prophylaxis and HAP was also evaluated. Results Among the 307,622 admissions eligible for the study, a total of 217,460 (70.7%) admissions had a record of PPI prophylaxis. After reconstructed the cohort by propensity score matching, the exposed and unexposed groups both included 83,786 admissions. The incidence of HAP in the exposed group was higher than that in the unexposed group (2.1% vs. 1.5%, OR: 1.4, 95% CI: 1.3 to 1.5). The risk of HAP increased when the cumulative dose of PPI during hospital was more than 2 defined drug doses. Compared to the unexposed group, the adjusted odds ratio was 1.3 (95% CI: 1.2 to 1.4) in the medium-dose group (2-7 defined drug doses) and 1.9 (95% CI: 1.8 to 2.1) in the high-dose group (>7 defined drug doses). Conclusions PPI prophylaxis increased the risk of HAP in hospitalized patients treated with glucocorticoid therapy and the risk of HAP increased as the dose of PPIs accumulated.
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Affiliation(s)
- Xufeng Mao
- Department of Pharmacy, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhangwei Yang
- Department of Information, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
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43
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Y-site compatibility of intravenous medications commonly used in intensive care units: laboratory tests on 75 mixtures involving nine main drugs. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2022. [DOI: 10.1515/pthp-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Patients hospitalized in intensive care units often require multiple drug infusions. Due to limited intravenous accesses, concomitant administration of drugs in the same infusion line is often necessary. Compatibility studies of Y-site administration are available in the literature, but data of several combinations are lacking. Previous work from d’Huart et al. have performed an observation of the administration of injectable drugs in three adults ICUs and identified a list of Y-site administration without compatibility data. The objective of this study was to test the physical compatibility of the main drugs of this list used in pairs in Y-site infusions in critical care units, in order to provide new compatibility data to the literature, and to secure the administration of intravenous drugs.
Methods
The physical compatibility in Y-site of nine drugs with other drugs commonly used in intensive care units has been tested. Examinations were performed on 75 mixtures after their preparation, after 1 and 4-h storage. This evaluation included a visual examination with a search for precipitation formation, color change, gas formation, and a subvisual evaluation: absorbance measurements by UV-visible spectrophotometry at 350, 410 and 550 nm, and Light Obscuration Particle Count Test. The pH evaluation was performed at each time of analysis.
Results
Laboratory tests led to an overall compatibility of 68.0% for all mixtures obtained in this study. Nefopam was found to be quite compatible with other drugs (95.0%). Amiodarone hydrochloride (84.6%), acetylsalicylic acid (80.0%), clonidine hydrochloride (75.0%) and insulin (71.4%) were compatible with other drugs too. Atenolol (42.9%), furosemide (25.0%), heparin sodium (25.0%) showed less compatible results. Pantoprazole sodium (0.0%) was not at all compatible with the other drugs analyzed.
Conclusions
By the results of these laboratory tests, missing compatibility data are now available, providing additional information to the literature.
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Liu YH, Cao ZY, Dai YN, Zeng LH, Zhang YS, Fan HL, Duan CY, Tan N, He PC. Association of Proton Pump Inhibitor and Infection and Major Adverse Clinical Events in Patients With ST-Elevation Myocardial Infarction: A Propensity Score Matching Analysis. Front Med (Lausanne) 2022; 9:882341. [PMID: 35602509 PMCID: PMC9115470 DOI: 10.3389/fmed.2022.882341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Infections are not common but important in patients with acute myocardial infarction, and are associated with worse outcomes. Infection was proved to be associated with the use of proton pump inhibitor (PPI) in several cohorts. It remains unclear whether PPI usage affects infection in patients with acute myocardial infarction. Methods We consecutively enrolled patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) from January 2010 to June 2018. All patients were divided into the PPI group and non-PPI group according to whether the PPI was used. The primary endpoint was the development of infection during hospitalization. Results A total of 3027 patients were finally enrolled, with a mean age of 62.2 ± 12.6 years. 310 (10.2%) patients were developed infection during hospitalization. Baseline characteristics were similar between the PPI and non-PPI groups (n = 584 for each group) after propensity score analysis. PPI usage was significantly associated with infection based on the propensity score matching analysis (adjusted OR = 1.62, 95% CI = 1.02-2.57, P = 0.041). Comparing to patients with non-PPI usage, PPI administration was positively associated with higher risk of in-hospital all-cause mortality (adjusted OR = 3.25, 95% CI = 1.06-9.97, P = 0.039) and in-hospital major adverse clinical events (adjusted OR = 3.71, 95% CI = 1.61-8.56, P = 0.002). Subgroup analysis demonstrated that the impact of PPI on infection was not significantly different among patients with or without diabetes and patients with age ≥65 years or age <65 years. Conclusion PPI usage was related to a higher incidence of infection during hospitalization, in-hospital all-cause mortality, and in-hospital major adverse clinical events (MACE) in STEMI patients.
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Affiliation(s)
- Yuan-Hui Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhi-Yuan Cao
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yi-Ning Dai
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li-Huan Zeng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ye-Shen Zhang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hua-Lin Fan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chong-Yang Duan
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Ning Tan,
| | - Peng-Cheng He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Peng-Cheng He,
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Roberts AR, Roddy M, Wilsey MJ, McKinley SD, Sanchez-Teppa B, Sochet AA. Stress Ulcer Prophylaxis for Critical Asthma. Pediatrics 2022; 149:185230. [PMID: 35229158 DOI: 10.1542/peds.2021-054527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children hospitalized for critical asthma (CA) in the pediatric ICU (PICU) are commonly prescribed stress ulcer prophylaxis (SUP) to mitigate risk of gastrointestinal (GI) bleeding. We sought to describe trends for SUP prescribing and explore for differences in rates of GI bleeding, gastritis, and SUP-related complications for those with and without SUP exposure. METHODS We performed a retrospective, multicenter cohort study using the Pediatric Hospital Information System registry among 42 children's hospitals from 2010 to 2019 including children 3 to 17 years of age admitted to the PICU for CA. Primary outcomes were chronologic and regional variation in SUP prescribing assessed by Joinpoint regression and Pearson's correlation. Rates of GI bleeding, gastritis, enteric ulceration, and SUP-related complications (C. difficile colitis, necrotizing enterocolitis, and thrombocytopenia) were compared for those with and without SUP exposure. RESULTS Of 30 177 children studied, 10 387 (34.4%) received SUP. No episodes of GI bleeding were recorded. One subject developed gastric ulceration and 32 (0.1%) gastritis. Linear trends for SUP were observed with rates increasing from 25.5% in 2010 to 42.1% in 2019 (+1.9% annually). Prescribing varied by institution (range: 5.5% to 97.2%) without correlation to admission volumes. Extremely rare rates of SUP-related complications were noted. CONCLUSIONS Although children hospitalized for CA routinely receive SUP, no episodes of GI bleeding were noted over a 10-year period. SUP solely for corticosteroid exposure may be unwarranted. We advocate for a targeted approach to SUP considering alternative risk factors for GI bleeding.
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Affiliation(s)
| | - Meghan Roddy
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | | | | | - Anthony Alexander Sochet
- Pediatric Critical Care Medicine.,Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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46
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Clarke K, Adler N, Agrawal D, Bhakta D, Sata SS, Singh S, Gupta A, Pahwa A, Pherson E, Sun A, Volpicelli F, Cho HJ. Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients. Am J Med 2022; 135:313-317. [PMID: 34655535 DOI: 10.1016/j.amjmed.2021.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/11/2022]
Abstract
Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.
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Affiliation(s)
- Karen Clarke
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Ga.
| | - Nicole Adler
- Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Deepak Agrawal
- Division of Gastroenterology and Hepatology, Dell Seton Medical Center, Austin, Tex
| | - Dimpal Bhakta
- Division of Gastroenterology, New York University School of Medicine, New York, NY
| | - Suchita Shah Sata
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sarguni Singh
- Division of Hospital Medicine, University of Colorado, Aurora
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Amit Pahwa
- Division of General Internal Medicine, Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Emily Pherson
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Md
| | - Alexander Sun
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Frank Volpicelli
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hyung J Cho
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; New York City Health and Hospitals, New York, NY
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van Diepen S, Coulson T, Wang X, Opgenorth D, Zuege DJ, Harris J, Agyemang M, Niven DJ, Bellomo R, Wright SE, Young PJ, Bagshaw SM. Efficacy and safety of proton pump inhibitors versus histamine-2 receptor blockers in the cardiac surgical population: insights from the PEPTIC trial. Eur J Cardiothorac Surg 2022; 62:6537079. [PMID: 35213716 PMCID: PMC9334785 DOI: 10.1093/ejcts/ezac124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. METHODS The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. RESULTS We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55-1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66-1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02-1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85-1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99-1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. CONCLUSIONS In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. CLINICAL TRIAL REGISTRATION NUMBER anzctr.org.au identifier: ACTRN12616000481471.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada,Corresponding author. 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-11 St., Edmonton, AB T6G 2B7, Canada. Tel: +1-780-407-6948; fax: +1-780-407-7485; e-mail: (S. van Diepen)
| | - Tim Coulson
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Calgary, AB, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Danny J Zuege
- Department of Critical Care Medicine, University of Calgary, Alberta Health Services, Calgary, AB, Canada,Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
| | - Jo Harris
- eCritical Alberta, Alberta Health Services, Calgary, AB, Canada
| | - Malik Agyemang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Alberta Health Services, Calgary, AB, Canada,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia,Data Analytics Research & Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | | | - Paul J Young
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia,Medical Research Institute of New Zealand, Wellington, New Zealand,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada,Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
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Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support Over the Past Two Decades—Extracorporeal Life Support Organization Registry Analysis. Crit Care Med 2022; 50:e569-e580. [PMID: 35167502 PMCID: PMC9210715 DOI: 10.1097/ccm.0000000000005466] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Data about inhospital outcomes in bleeding complications during extracorporeal life support (ECLS) have been poorly investigated. DESIGN Retrospective observational study. SETTING Patients reported in Extracorporeal Life Support Organization Registry. PATIENTS Data of 53.644 adult patients (greater than or equal to 18 yr old) mean age 51.4 ± 15.9 years, 33.859 (64.5%) male supported with single ECLS run between 01.01.2000 and 31.03.2020, and 19.748 cannulated for venovenous (V-V) ECLS and 30.696 for venoarterial (V-A) ECLS. INTERVENTIONS Trends in bleeding complications, bleeding risk factors, and mortality. MEASUREMENT AND MAIN RESULTS Bleeding complications were reported in 14.786 patients (27.6%), more often in V-A ECLS compared with V-V (30.0% vs 21.9%; p < 0.001). Hospital survival in those who developed bleeding complications was lower in both V-V ECLS (49.6% vs 66.6%; p < 0.001) and V-A ECLS (33.9 vs 44.9%; p < 0.001). Steady decrease in bleeding complications in V-V and V-A ECLS was observed over the past 20 years (coef., -1.124; p < 0.001 and -1.661; p < 0.001). No change in mortality rates was reported over time in V-V or V-A ECLS (coef., -0.147; p = 0.442 and coef., -0.195; p = 0.139).Multivariate regression revealed advanced age, ecls duration, surgical cannulation, renal replacement therapy, prone positioning as independent bleeding predictors in v-v ecls and female gender, ecls duration, pre-ecls arrest or bridge to transplant, therapeutic hypothermia, and surgical cannulation in v-a ecls. CONCLUSIONS A steady decrease in bleeding over the last 20 years, mostly attributable to surgical and cannula-site-related bleeding has been found in this large cohort of patients receiving ECLS support. However, there is not enough data to attribute the decreasing trends in bleeding to technological refinements alone. Especially reduction in cannulation site bleeding is also due to changes in timing, patient selection, and ultrasound guided percutaneous cannulation. Other types of bleeding, such as CNS, have remained stable, and overall bleeding remains associated with a persistent increase in mortality.
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Granholm A, Schjørring OL, Jensen AKG, Kaas‐Hansen BS, Munch MW, Klitgaard TL, Crescioli E, Kjær MN, Strøm T, Perner A, Rasmussen BS, Møller MH. Health-related quality of life and days alive without life support or out of hospital: Protocol. Acta Anaesthesiol Scand 2022; 66:295-301. [PMID: 34811741 DOI: 10.1111/aas.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mortality is often the primary outcome in randomised clinical trials (RCTs) conducted in critically ill patients. Due to increased awareness on survivors after critical illness and outcomes other than mortality, health-related quality of life (HRQoL) and days alive without life support (DAWOLS) or days alive and out of hospital (DAAOOH) are increasingly being used. DAWOLS and DAAOOH convey more information than mortality, are easier to collect than HRQoL, and are usually assessed at earlier time points, which may be preferable in some situations. However, the associations between DAWOLS-DAAOOH and HRQoL are uncertain. METHODS We will assess associations between DAWOLS-DAAOOH at day 28 and 90 (independent variables/predictors) and HRQoL assessed using the EuroQol EQ-5D-5L questionnaire (EQ-VAS and EQ-5D-5L index values) at 6 or 12 months (dependent variables) in two RCTs: the COVID STEROID 2 RCT conducted in adult patients with COVID-19 and severe hypoxaemia and the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) RCT conducted in adult intensive care patients with acute hypoxaemic respiratory failure. We will describe associations using best-fitting fractional polynomial transformations separately in each dataset, with the resulting models presented and assessed in both datasets graphically and using measures of fit and prediction adequacy (i.e., internal performance and external validation). We will use multiple imputation if missingness exceeds 5%. DISCUSSION The outlined study will provide important knowledge on the associations between DAWOLS-DAAOOH and HRQoL in adult critically ill patients, which may help researchers and clinical trialists prioritise and select outcomes in future RCTs conducted in this population.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Olav Lilleholt Schjørring
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Benjamin Skov Kaas‐Hansen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | - Marie Warrer Munch
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Lass Klitgaard
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Elena Crescioli
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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Sadeghpour N, Vadi M, Bagheri N. Engineering delivery of pantaprazole drug using multi-walled carbon nanotubes: an experimental and theoretical study. Struct Chem 2022. [DOI: 10.1007/s11224-022-01883-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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