2012 August 16

GFR Estimation Using Standardized Serum Cystatin C in Japan.

Aug 162012

GFR Estimation Using Standardized Serum Cystatin C in Japan.

Am J Kidney Dis. 2012 Aug 11;

Authors: Horio M, Imai E, Yasuda Y, Watanabe T, Matsuo S, Collaborators Developing the Japanese Equation for Estimated GFR

Abstract

BACKGROUND: Recently, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) developed glomerular filtration rate (GFR)-estimating equations based on standardized serum cystatin C (CKD-EPI(cys)) and standardized serum creatinine plus standardized serum cystatin C (CKD-EPI(cr-cys)). We developed new GFR-estimating equations based on standardized cystatin C for a Japanese population and compared their accuracy with the CKD-EPI equations. STUDY DESIGN: Accuracy of diagnostic test study. SETTING & PARTICIPANTS: 413 (development data set) and 350 individuals (validation data set). INDEX TEST: CKD-EPI(cys); CKD-EPI(cr-cys); modifications to CKD-EPI(cys) and CKD-EPI(cr-cys) using Japanese coefficients; and newly developed Japanese eGFR equations based on standardized serum cystatin C (Eq(cys)), cystatin C with a nonrenal factor reflecting hypothesized extrarenal elimination (Eq(cys+nonrenal)), and creatinine in combination with cystatin C (Eq(cr-cys)). Standardized cystatin C values were determined by a colloidal gold immunoassay traceable to the international certified reference material ERM-DA471/IFCC. REFERENCE TEST: Measured GFR by inulin renal clearance. RESULTS: In a development data set, we calculated Japanese coefficients for CKD-EPI(cys) and CKD-EPI(cr-cys) of 0.977 (95% CI, 0.853-1.002) and 0.908 (95% CI, 0.889-0.928), respectively. In a validation data set, we compared CKD-EPI(cys), Eq(cys), and Eq(cys+nonrenal) with each other. Bias and accuracy were not significantly different among the 3 equations. The precision of CKD-EPI(cys) was significantly better than for Eq(cys) (P = 0.007) and not significantly different from Eq(cys+nonrenal) (P = 0.6). We then compared 0.908 × CKD-EPI(cr-cys), Eq(cr-cys), and Eq(average) (the average value of Eq(cr) [previous Japanese equation based on standardized serum creatinine] and Eq(cys+nonrenal)) with each other in the validation data set. Bias and accuracy were not significantly different among the 3 equations. The precision of 0.908 × CKD-EPI(cr-cys) was significantly better than for Eq(cr-cys) (P = 0.004) and not significantly different from Eq(average) (P = 0.06). LIMITATIONS: Limited number of participants with measured GFR >90 mL/min/1.73 m(2). Extrarenal elimination of cystatin C was not measured. CONCLUSIONS: CKD-EPI(cys) performed well in Japanese individuals, suggesting that equations based on serum cystatin C could be used in patients with different races without modification. Accounting for extrarenal elimination of cystatin C may improve the performance of estimating equations.

PMID: 22892396 [PubMed - as supplied by publisher]

Link to Article at PubMed

How frequently are contraindicated or warned against combinations of drugs prescribed to patients receiving long-term opioid therapy for chronic pain?

Pharmacoepidemiol Drug Saf Start a Discussion »

Aug 162012

How frequently are contraindicated or warned against combinations of drugs prescribed to patients receiving long-term opioid therapy for chronic pain?

Pharmacoepidemiol Drug Saf. 2012 May;21(5):453-62

Authors: Richarz U, Jacobs A, Spina E

Abstract

PURPOSE: To analyse the proportion of patients treated with an opioid for chronic pain who were prescribed concomitant medications that are warned against or contraindicated in the German summary of product characteristics to determine if warnings on drug-drug interactions (DDIs) are observed.

METHODS: This retrospective analysis used longitudinal aggregated patient data from the Intercontinental Marketing Services Disease Analyzer in Germany. Patients with two or more prescriptions of morphine, hydromorphone, oxycodone or tramadol from 1 January 2006 to 31 December 2008 were included; drugs prescribed within 30 days of an opioid prescription were identified as concomitant medications. The frequency of concomitant treatment with drugs warned against or contraindicated in the German opioid summary of product characteristics was determined. Concomitant treatment with drugs metabolised by CYP3A4 inhibitors and inducers and CYP2D6 inhibitors was also considered.

RESULTS: The Intercontinental Marketing Services database contained 13,405 eligible patients; 72% had concomitant diseases which may increase the risk for DDIs (hypertension, diabetes mellitus, renal failure, renal glomerular disease or renal tubulointerstitial disease). Very few patients received concomitant prescriptions of an opioid with a contraindicated drug. Many patients were prescribed opioids concomitantly with drugs with potential for harmful safety-related DDIs or DDIs that alter the effectiveness of one or more of the opioids. A large proportion of all concomitant prescriptions with potential for DDIs were given to at-risk patients aged 65 years and older.

CONCLUSIONS: Many patients that received an opioid for chronic pain were prescribed concomitant medications with the potential for safety-related DDIs or interactions that would alter the effectiveness of the opioid.

PMID: 22081534 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Emergency department crowding and risk of preventable medical errors.

Intern Emerg Med Start a Discussion »

Aug 162012

Emergency department crowding and risk of preventable medical errors.

Intern Emerg Med. 2012 Apr;7(2):173-80

Authors: Epstein SK, Huckins DS, Liu SW, Pallin DJ, Sullivan AF, Lipton RI, Camargo CA

Abstract

The objective of the study is to determine the association between emergency department (ED) crowding and preventable medical errors (PME). This was a retrospective cohort study of 533 ED patients enrolled in the National ED Safety Study (NEDSS) in four Massachusetts EDs. Individual patients' average exposure to ED crowding during their ED visit was compared with the occurrence of a PME (yes/no) for the three diagnostic categories in NEDSS: acute myocardial infarction, asthma exacerbation, and dislocation requiring procedural sedation. To accommodate site-to-site differences in available administrative data, ED crowding was measured using one of three previously validated crowding metrics (ED Work Index, ED Workscore, and ED Occupancy). At each site, the continuous measure was placed into site-specific quartiles, and these quartiles then were combined across sites. We found that 46 (8.6%; 95% confidence interval, 6.4-11.3%) of the 533 patients experienced a PME. For those seen during higher levels of ED crowding (quartile 4 vs. quartile 1), the occurrence of PMEs was more than twofold higher, both on unadjusted analysis and adjusting for two potential confounders (diagnosis, site). The association appeared non-linear, with most PMEs occurring at the highest crowding level. We identified a direct association between high levels of ED crowding and risk of preventable medical errors. Further study is needed to determine the generalizability of these results. Should such research confirm our findings, we would suggest that mitigating ED crowding may reduce the occurrence of preventable medical errors.

PMID: 22009553 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Delirium in acute stroke: a systematic review and meta-analysis.

Stroke Start a Discussion »

Aug 162012

Delirium in acute stroke: a systematic review and meta-analysis.

Stroke. 2012 Mar;43(3):645-9

Authors: Shi Q, Presutti R, Selchen D, Saposnik G

Abstract

BACKGROUND AND PURPOSE: Delirium is common in the early stage after hospitalization for an acute stroke. We conducted a systematic review and meta-analysis to evaluate the outcomes of acute stroke patients with delirium.

METHODS: We searched MEDLINE, EMBASE, CINAHL, Cochrane Library databases, and PsychInfo for relevant articles published in English up to September 2011. We included observational studies for review. Two reviewers independently assessed studies to determine eligibility, validity, and quality. The primary outcome was inpatient mortality and secondary outcomes were mortality at 12 months, institutionalization, and length of hospital stay.

RESULTS: Among 78 eligible studies, 10 studies (n=2004 patients) met the inclusion criteria. Stroke patients with delirium had higher inpatient mortality (OR, 4.71; 95% CI, 1.85-11.96) and mortality at 12 months (OR, 4.91; 95% CI, 3.18-7.6) compared to nondelirious patients. Patients with delirium also tended to stay longer in hospital compared to those who did not have delirium (mean difference, 9.39 days; 95% CI, 6.67-12.11) and were more likely to be discharged to a nursing homes or other institutions (OR, 3.39; 95% CI, 2.21-5.21).

CONCLUSIONS: Stroke patients with development of delirium have unfavorable outcomes, particularly higher mortality, longer hospitalizations, and a greater degree of dependence after discharge. Early recognition and prevention of delirium may improve outcomes in stroke patients.

PMID: 22267831 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus.

J Clin Endocrinol Metab Start a Discussion »

Aug 162012

Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus.

J Clin Endocrinol Metab. 2012 Jun;97(6):2019-26

Authors: Griffith ML, Boord JB, Eden SK, Matheny ME

Abstract

OBJECTIVE: We examined the effect of hospital admissions on the medical treatment of poorly controlled diabetes mellitus among Veterans Affairs (VA) patients.

RESEARCH DESIGN AND METHODS: This retrospective cohort study included male patients admitted to one of three VA hospitals from July 1, 2002, to August 31, 2009, who were receiving medication therapy for diabetes with hemoglobin A1c (HgbA1c) greater than 8.0%. The primary outcome was a change in preadmission and outpatient prescriptions for diabetes at hospital discharge. Covariates for multivariable logistic regression analysis of the primary outcome were defined a priori and retrieved from the electronic health record.

RESULTS: Of 2025 admissions for 1359 patients, 454 had some change in diabetes medications at discharge (rate of change 22.4%). In an adjusted analysis, higher preadmission HgbA1c [odds ratio (OR) 1.12 per 1.0 U increase; 95% confidence interval (CI) 1.12-1.05; P < 0.001], higher mean blood glucose during admission (OR 1.07 per 10 mg/dl increase; 95% CI 1.05-1.10; P < 0.0001), occurrence of inpatient hypoglycemia (blood glucose < 50 mg/dl; OR 1.82, 95% CI 1.32-2.51, P < 0.001), and inpatient basal insulin therapy (OR 1.71; 95% CI 1.25-2.35; P < 0.001) were associated with higher odds of change in therapy. A total of 656 admissions (32%) demonstrated aggregate clinical inertia with no change in therapy, no documentation of HgbA1c within 60 d of discharge, and no follow-up appointment within 30 d of discharge.

CONCLUSIONS: In this multicenter, retrospective study of patients with poorly controlled diabetes and at least one hospitalization, less than a quarter received a change in outpatient diabetes therapy upon discharge, suggesting widespread clinical inertia. Nearly one third had no change in therapy or subsequent follow-up scheduled.

PMID: 22466346 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Risk of Elective Major Non-Cardiac Surgery After Coronary Stent Insertion: A Population-Based Study.

Circulation Start a Discussion »

Aug 162012

Risk of Elective Major Non-Cardiac Surgery After Coronary Stent Insertion: A Population-Based Study.

Circulation. 2012 Aug 14;

Authors: Wijeysundera DN, Wijeysundera HC, Yun L, Wasowicz M, Beattie WS, Velianou JL, Ko DT

Abstract

BACKGROUND: Guidelines recommend that non-cardiac surgery be delayed until 30 to 45 days after bare-metal stent implantation and one-year after drug-eluting stent implantation. METHODS AND RESULTS: We used linked registry data and population-based administrative healthcare databases to conduct a cohort study of 8116 patients (?40 years) who underwent major elective non-cardiac surgery in Ontario, Canada between 2003 and 2009, and received coronary stents within 10 years before surgery. Approximately 34% (n=2725) underwent stent insertion within two years before surgery, of whom 905 (33%) received drug-eluting stents. For comparison, we assembled a separate cohort of 341,350 surgical patients who had not undergone coronary revascularization. The primary outcome was 30-day major adverse cardiac events (mortality, readmission for acute coronary syndrome or repeat coronary revascularization). The overall rate of 30-day events in patients with coronary stents was 2.1% (n=170). When the interval between stent insertion and surgery was less than 45-days, event rates were high for bare-metal (6.7%) and drug-eluting (20.0%) stents. When the interval was 45 to 180 days, the event rate for bare-metal stents was 2.6%, approaching that of intermediate-risk non-revascularized individuals. Adjusted analyses suggested that event rates were increased if this interval exceeded 180 days. For drug-eluting stents, the event rate was 1.2% once the interval exceeded 180 days, approaching that of intermediate-risk non-revascularized individuals. CONCLUSIONS: The earliest optimal time for elective surgery is 46 to 180 days after bare-metal stent implantation or more than 180 days after drug-eluting stent implantation.

PMID: 22893606 [PubMed - as supplied by publisher]

Link to Article at PubMed

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